Adolescent Friendly Health Corners (AFHCs) in Selected Government Health Facilities in Bangladesh: An Early Qualitative Assessment

"In Bangladesh, regardless of socio-economic status or educational background, open discussion about sexual and reproductive health (SRH) remains a cultural taboo, particularly for adolescents and young people, and particularly among unmarried adolescents."

Bangladesh has limited experience providing adolescent friendly health services; only a few non-governmental organisations (NGOs) provide services for adolescents, and these tend to be limited to SRH awareness-raising activities and counseling. To address this gap, in early 2015, the Maternal and Child Health (MCH) Services Unit of the Directorate General of Family Planning (DGFP), with financial and technical assistance from development partners, began establishing Adolescent Friendly Health Corners (AFHCs) at selected government facilities at district and union levels. The Evidence Project/Population Council was asked to assess the implementation of the first of these AFHCs, including their performance and quality of services, to inform the effective scale-up of the AFHC model around the country. This report presents findings from a qualitative study of 10 AFHCs, with recommendations for improving the AFHC initiative going forward. In brief, the study found that unmarried adolescent girls are using AFHCs and that AFHC users expressed satisfaction with AFHC service providers. However, the study also noted limited awareness of AFHCs and a number of challenges associated with the physical set up of AFHCs.

Chapter 1 of the report provides context, such as the fact that, globally, providing AFHS to ensure sexual and reproductive health and rights for adolescents has been hindered by both service providers' bias and stigma and other barriers experienced by adolescents (Svanemyr et al., 2015). Confidentiality, respectful treatment, integrated services, culturally-appropriate care, free or low-cost services, and easy access are recognised as important components of appropriate services for adolescents. Furthermore, development partners and policymakers are increasingly advocating for comprehensive sexuality education (CSE) to improve adolescent health and wellbeing.

AFHCs are integrated into existing government health facilities - Maternal and Child Welfare Centers (MCWCs) at the district and upazila levels, Union Health and Family Welfare Centers (UHFWCs) at the union level, and through public hospitals at the district level - rather than constructed as separate stand-alone facilities. This integrated approach marks the AFHCs as a new initiative for expanding adolescent friendly health services (AFHS) and reducing stigma and other barriers that adolescents - especially unmarried girls - face when seeking SRH information and services. An AFHC is defined as either a separate room or a dedicated space separated by a screen so that audio-visual privacy for the adolescent client can be maintained. AFHCs are designed to maintain privacy and confidentiality so that adolescent clients can share their problems openly with the service providers and can receive counseling and services. AFHCs are intended to serve as a hub for SRH information and services for both unmarried adolescent boys and girls. They are a place where adolescents can access information, counseling, and services on a wide range of ASRH issues. While the cultural context of Bangladesh and the policy of the Government of Bangladesh (GOB) does not permit the provision of contraceptives to unmarried adolescents, information and counseling on menstruation, reproductive tract infections (RTIs)/sexually transmitted infections (STIs), safe sex, early marriage and pregnancy, family planning (FP), gender-based violence (GBV), puberty, and substance abuse are to be provided to unmarried adolescents through these AFHCs. This study focused on AFHCs supported by the United Nations Population Fund (UNFPA) in Moulvibazar, Thakurgaon, Sirajganj, Patuakhali, and Cox's Bazar districts, as the first AFHCs to open.

Between August and September 2016, this study collected qualitative data mainly through in-depth interviews (IDIs) and focus group discussions (FGDs) involving unmarried girls between the ages of 15-19. Here is a summary of the findings:

• AFHCs are reaching umarried adolescent girls with a range of health services, both general and SRH-related, in established health facilities. This supports the global evidence that integrating adolescent friendly services into existing health delivery systems is more effective than establishing separate or stand-alone youth and/or adolescent centres or clinics. It is also noteworthy that significantly few adolescent boys use the AFHCs and, based on the service statistics, appear to do so for general illness, rather than SRH services.
• AFHC users expressed satisfaction with AFHC service providers, which suggests that the AFHS training that AFHC service providers undergo is having a positive impact on how service providers interact with adolescent girls.
• Variation in the physical set-up of AFHCs impacts client access and privacy. According to world Health Organization (WHO) guidelines, having a separate room is an important criterion for ensuring quality AFHS.
• Adolescents and parents had limited awareness of AFHCs; more publicity and generating awareness about the centres in the community is recommended. Adolescents' use of health services is highly influenced by the social values, attitudes, and taboos (perceived or real) of their parents and other gatekeepers, including service providers. Ensuring that these gatekeepers are also involved in awareness generation efforts will be critical for increasing the likelihood that adolescents will use AFHCs. These efforts provide an opportunity to "rebrand" how AFHCs are viewed - as "information hubs", rather than as a place to go only if you have a problem. This shift of perspective may also reduce social stigma and barriers to adolescents accessing the centres.
• While generally happy with the way AFHC service providers treated them, AFHC users described several limitations in accessing services at AFHCs. For example, concerns were raised by both clients and AFHC service providers regarding the lack of behaviour change communication (BCC)/educational materials available in the AFHCs. There were strong recommendations for increased investment to ensure that posters, booklets, and leaflets be made available, and that they should address an expanded range of issues of concern to adolescents - e.g., mental health, substance abuse, early marriage prevention, and domestic violence. To cite another example: The AFHS-trained providers talked about the additional demands created by their new responsibilities serving adolescents, while continuing to meet the needs of their regular clients (mothers and children). Most service providers in MCWCs used outdoor service points to serve adolescent clients rather than using the designated AFHC, due to their workload. Service providers should be supported and motivated to use the AFHCs so that adolescents can be confident that the service provider will be available when they visit.

"This early assessment of the AFHC initiative of the Government of Bangladesh is encouraging and offers specific recommendations for improving access, availability, and quality of adolescent friendly health services as AFHCs are expanded in the country." For example, service providers offer in the report strategies for: collaborating with local schools to increase awareness, involving local leaders and other gatekeepers to generate support and demand for AFHC among the community, involving parents to address communication gaps, and involving field-level staff, including those who visit door to door to provide FP services, in publicising the AFHC.