1. Andrei USATÎI Minister of Health
Strategies to sustain and scale up quality health care services for adolescents in the Republic of Moldova
Andrei USATÎI
Minister of Health

2. HEALTH FOR THE WORLD'S ADOLESCENTS.
Progress toward universal health coverage requires a transition from adolescent-friendly projects to adolescent-responsive health systems.
HEALTH FOR THE WORLD'S ADOLESCENTS.
A second chance in the second decade. WHO 2014
Main approach of Ministry of Health of Republic of Moldova in area of adolescent health during the last years is focused on implementation of the sustainable evidence based system changes in order obtain important improvements in adolescent health . This approach is in line with the important statement of WHO Report in adolescent health presented on the slide.

3. Summary of the presentation
Rationale for strengthening the quality of health care services for adolescents in the Republic of Moldova
Strategies to sustain and scale up quality health care services for adolescents
Impact
Unresolved issues and ways forward
This presentation will be focused to point four main stages in this process:

4. Health status argument
Rationale for strengthening the quality of health care services for adolescents in the Republic of Moldova
Why better health services for adolescents in Moldova?
Demographic argument
Health status argument
Unsupportive environment
To answer on the question why are needed better health services for adolescents in Republic of Moldova, we take into consideration 3 main aspects – they demographic power, level of health problems faced by adolescent and existence of supportive environment for they health and development

5. Demography and health status
23,4% of total population are youth people (10-24 years), 1 January 2012 *
14 % of total population are adolescents (10-19 years), 1 January 2012 *
Health
Proportion of years old adolescents who had experience of sexual intercourse increase from 28,1% in 2003 to 36% in 2012**
Proportion of years old adolescents who used condom at the first sexual intercourse increase from 35,7% in 2003 to 52,3 % in 2012**
Proportion of years old adolescents who not use currently any contraceptive method increase from 5,6% in 2003 to 9% in 2012 and decrease proportion of those who use pills as contraception – from 17,4% in 2003 to 8,8% in 2012**
HIV incidence among youth – 18,4/ in 2011 (total HIV incidence was 13,9 / ) and 10,5/ in 2001*
The suicide rate among adolescents is increasing last years* (by 40% from 2007 to 2011) and boys is more than 10 time higher than in girls (see figures below)4.
Near one half of adolescents know somebody form peers involved in physical violence and one fifth - somebody involved in sexual violence**
Every eleventh adolescent (10-19 years) indicated that currently smoke, 15.4% - use alcohol in present 1-2 times in a month and more frequently and 3% of the adolescents indicated that they have experience of use narcotic substances.**
Thus, as you can see from this slide – yang people, including adolescent, represent a important part of country population - each fourth person in our country is yang person from 10 to 24 years old and each seventh person is an adolescent years old.
Analyze of they health status present a worrying situation, especially in area of sexual-reproductive health, mental health, violence etc. – some figures that reflect this situation are presented on the slide
sources: *National Statistics Office in Republic of Moldova, National Centre of Preventive Medicine
**KAP, Studies , Health for Youth Association

6. Adolescent grow and develop in unsupportive environment
- Near 1/3 from years old adolescent live without at least one parent and 10% of adolescent live without both parents **
Only 15% of them had access to YFHS yet**
Life skills development is not yet a mandatory course in school curricula
Also, actual generation of adolescents grow and develop in unsupportive environment.
Due to the fact of the massive travel migration of the mature population, each tenth adolescent live without both parent and each third – without one parent.
Also, in spite of the fact that last 2 years access to YFHS increase thrice, it is not enough – in 2013 it was assured for 15% of yang population yet
One other important factor is that complex programs for life skills development are not yet included in mandatory school curricula, though some optional and partial courses are existing
sources: *National Statistics Office in Republic of Moldova, National Centre of Preventive Medicine
**KAP, Studies , Health for Youth Association

7. Using a WHO 5S approach to inform strategic actions
Supportive policies & strategies
Services & commodities
Strategic information
Strategic resources:
Financing
HR capacity
To effectively solve the above problems, the Government and Ministry of Health are implementing a series of strategic actions to improve health and developmental potential of yang people in Republic of Moldova:
Development of the youth friendly health services
Development sustainable recourses to offer effective health services for adolescents – financing of the YFHS, human recourses increasing
This process was supported: by improving policy documents in the area
By the strategic data gathering process in the area and by
Strengthening cooperation with the other sectors
Strengthening & supporting other sectors

8. Services: the Youth Friendly Health Services initiative
The goal
To increase the access of young people to information and qualitative health services, as well as other services that correspond to the definition and criteria of “youth friendly” developed by the UN Interagency Group (YFHS National Conception, 2005)
Health priorities :
STI/HIV/AIDS.
Adolescent pregnancy.
Mental health problems as a result of substance abuse (alcohol, drug addiction).
Psycho-emotional and identity disorders.
Health problems occurred as a result of violence.
Nutritional deficiencies and malnutrition (I, Fe).
Development disorders during the puberty.
Development of youth friendly health services in Moldova have a goal to improve health and developmental potential of yang people by increase the access to health services adapted to they real needs.
These services has comprehensive approach for adolescent health and are focused in solving 7 health priority adolescent health problems presented on the slide.

9. Services & commodities: scaling up
pilot YFHC, with the support from UNICEF
2005 – creation of 12 YFHC Network with GF & WB and UNICEF support
all YFHC integrated into the public health system as a subdivision of PMSI in which they were created
was initiated YFHS scaling up process
YFHC were contracted by the National Health Insurance Company
Process of development of YFHS in Republic of Moldova stated in from creation of first 3 pilot YFHC with UNICEF support, followed by creation of a small network of 12 YFHC in 2005, supported by GF & WB, UNICEF and SDC.
In 2007 all these center were institutionalized in existing medical system as a subdivision of the primary health care institution were they acted initially only as a projects.
In 2011 the MoH began to scale up the YFHS based on the World Health Organization’s systemic approach to improving the quality of health services for adolescents. This process involves horizontal and vertical scaling-up actions.
Horizontal scaling-up actions include:
establishing a youth friendly health centre (YFHC) in each rayon (district)
improving the quality of service provision, including building the capacity of health-care providers from YFHCs and primary health care services.
Vertical scaling-up actions include:
improving the regulatory basis for YFHS
improving its monitoring and evaluation (M&E) system
improving its financing mechanisms and
revising the medical university curricula to include adolescent health care.
At the rayon level YHFCs are located under the Family Medicine Centres. At the national level the Department of Primary Health Care of the MoH coordinates the YFHS programme in cooperation with the M&E unit of National Mother and Child Centre and the YFHC Neovita, Chisinau (acting as a national resource centre in this field).

10. Strategic resources for sustainability
Financing
Human resources
YFHC began to be financed by the NHIC
In service Trainings
Curriculum Review (MFSU "N.Testimiţanu, NMC) including primary care providers’ curriculum
Guides (adaptation of WHO materials: WHO OP, JOB AID etc.)
To assure sustainability of these services, The national health insurance company CNAM started to provide financial support for the YFHCs in 2008, providing fixed amounts on a per capita basis).
In 2014 financing of YFHC started to take into consideration they performance too and was increased by 50% comparing with 2013, though it covered only 60% of financing needed to assure optimal level of efficiency and quality of these services yet. Here, we plan to go forward in improving financing mechanisms of these services, taking into consideration the actual situation in our country and the best international experiences.
In last years was done a lot to increase capacity of human resources in this area and this process will continue with support of SDC the next years:
O series of the training for YFHC staff, primary health care staff, school resource persons (school nurse, psychologist etc.)
Revision of medical University and College curricula. A post-graduate training course for service providers has been developed, approved and integrated into the university curriculum for continuous professional education. Adolescent health has not yet been included in the medical curriculum for undergraduates or for medical residents.
And elaboration/adaptation of series of guides.

11. Strategic information
Youth Health and Development KAP Study, 2003, UNICEF, HFY
MARA Study, 2007 (UNICEF)
Surveillance studies of HIV among young people, 2006, 2008, 2010, 2012 (UNAIDS, NCPH)
Adolescent Health and Development KAP Study, 2003 HFY
Epidemiological/ behavioral studies
mostly is not disaggregated by age
Demographic and medical statistics
YFHS Quality assessment, 2009 (WHO)
SHS Mapping Survey, 2011, UNFPA
Baseline YFHS coverage survey, 2012 CPS
Economic analysis study of YFHC, , UNICEF, CSRGM
Implementation research studies of access to health care:
We support our interventions in area of adolescent health with data generation process that serve as evidences base for better planning of them and as evaluation tool for impacts.
As you can see from this slide we used to this data from different sources – from:
Epidemiological/ behavioral studies (Youth Health and Development KAP Study, 2003, UNICEF, Health for Youth Association; Most at Risk Adolescents (MARA) Study, 2007, UNICEF; Surveillance studies of HIV among young people, 2006, 2008, 2010, 2012 ,UNAIDS, NCPH; Adolescent Health and Development KAP Study, 2012 HFY; MICS Study, UNICEF, 2012)
Demographic and medical statistics. One last example of improving medical statistics in this area is elaboration of the electronic monitoring system of Youth Friendly Health Services,
Access to health care evaluation studies: YFHS Quality assessment, 2009, MoH, WHO; School Health Services Mapping Survey, 2011, UNFPA; Baseline YFHS coverage survey, 2012 Health for Youth Association (HFY); Economic analysis study of YFHC, , UNICEF.

12. Supportive policies & strategies
National Reproductive Health Strategy,
National Conceptual Framework of YHFS, 2005
Regulation of Youth Friendly Health Centre, 2006
National Health Policy,
National Youth Strategy,
Quality Standards of Youth Friendly Health Services, 2009
YFHS Scaling up MoH Ordinance, 2011
Law in Reproduction Health, 2012
Regulation of activities of YFHC, 2013
A important role to ensure institutionalization and sustainability of these services was elaboration of a number of supportive policy and strategic documents which stated the priority of health and development of adolescents and youth (Low in Reproduction Health, 2012; National Health Policy for ; Strategy for Youth for ; National Strategy on Reproductive Health for the period ; National Strategy in Child and Adolescent Health and Development, for period (in process of elaboration); National Conceptual Framework of Youth Friendly Health Services, 2005; Quality Standards of Youth Friendly Health Services, 2009; Regulation of activities of Youth Friendly Health Centers, 2013)
Now MoH, in common with relevant ministries, with WHO support, finalize elaboration of the comprehensive Strategy in Child and Adolescent Health and Development, that will serve as important umbrella document for evidence based inter-sectoral interventions in the field for the next 10 years.
CAHD Strategy in final draft, 2014

13. Strengthening & supporting other sectors
- SHS reorganisation process, , WHO
- Peer programs, UNFPA
- Capacity building of school resource persons in adolescent health promotion , Health For Youth Association, SDC
- Piloting reviewed mandatory curricula of civic education with component of health promotion, Neovita YHFC
As you know, adolescent health and development potential can be improved not only by MoH interventions but also by other partners actions and MoH has a role to Strengthening & supporting other sectors in this process by actively involving in the:
- School Health Services reorganisation process, , WHO
- Peer programs, UNFPA
- Capacity building of school resource persons in adolescent health promotion , Health For Youth Association, SDC
- Piloting reviewed mandatory curricula of civic education with component of health promotion, Neovita YHFC

14. Main Impact
From 2011 to 2013 access to YFHS increased by 3 time from 5% to 15% for y.o. In 2014 we expect an increase in this figures.
Prevention of 9 cases of HIV by all YFHCs (1 case by 4 YFHC) per year, at least , providing full range of HIV prevention services (information, counseling, testing, condom provision) can be potentially cost saving for medical system.
Of course, is too early to have in 1-2 years after the start of the scaling up process, the essential changes in health statistics – we will look for them in 4-5 years of implementation of full package of YFHS in all centers.
But, already in 2013 was achieved increasing by 3 time of the access to YFHS comparing with 2011 that we consider main achievement at this stage of scaling up process and near the 5% of beneficiaries were most at risk yang people in 2013.
It is important to mention that achievements in scaling up process during the last years were obtained by MoH thanks to financial support of SDC, UNICEF and technical support of WHO and dedication of the YFHC staff.
Also, it is important, that economical evaluation of YFHS, done by UNICEF in 2013, demonstrate that prevention of 9 cases of HIV by all YFHCs (1 case by 4 YFHCs) per year, at least , providing full range of HIV prevention services (information, counseling, testing, condom provision) can be potentially cost saving for medical system. Now for us is important to assure provision of full package of services by all centers.

15. Unresolved issues and ways forward (1)
Areas for future actions
Health in all policies
Health laws and policies
Workforce capacity
Coverage
Quality
We achieve during the very short period of time a geographical scaling up of YFHS, but now is needed to pay more attention and do a lot of efforts to obtain real effectiveness of these services.

16. Unresolved issues and ways forward (2)
Improve the quality and expand the comprehensiveness of services
Assure continuous quality improvement and increase the efficiency of youth friendly health services, including implementation of the YFHC certification process
Assure the provision of the full package of YFHS, especially by improving and diversifying financing sources, with the special attention for vulnerable adolescents and youth at risk.
Coverage - continue scaling up
Scaling up YFHS to all districts and all primary care facilities
First of all we will focus to assure quality and provision of full package of services in created YFHC and to finalize Scaling up YFHS to all districts and all primary care facilities.

17. Unresolved issues and ways forward (3)
Further develop the legal and normative framework
assure a stable status of YFHC within primary care
develop amendments to the health legislation in order to remove barriers for adolescents’ autonomy in decision-making, in line with the international human rights standards (CRC) and with the principles of evolving capacity and best interests of the child
Workforce capacity
Assure the sustainability of professional development in adolescent health (finalize the revision of the universities’ curricula , develop evidence based protocols of care)
Health in all policies
Strengthen the inter-sectorial cooperation to increase safe environment and implementation of educational programs for adolescents
We will further develop the legal and normative framework, especially related to assure a stable status of YFHC within primary care and
develop amendments to the health legislation in order to remove barriers for adolescents’ autonomy in decision-making, in line with the international human rights standards (CRC) and with the principles of evolving capacity and best interests of the child
Also we will continue increase workforce capacity and strengthen the inter-sectorial cooperation to increase safe environment and implementation of educational programs for adolescents
MoH, supported by SDC, WHO, UNICEF, elaborated a plan of actions for next phase of YFHS scaling up process, that will start from September this year and will cover all unsolved issues.

18. THANK YOU FOR YOR ATTENTION