“At your age, you can’t access that!”

By Ana Fried, Youth Program Specialist, Peace Corps Return Volunteer with AgirPF, EngenderHealth

“Now I see that [contraception] is permitted for adolescents who may come alone or accompanied by their parents, that they are free to choose the method that is convenient for them. I am there to explain the advantages and inconveniences of thesemethods…it’s up to the client to choose the one that suits them.”

—Michel Datoma, Medical Assistant, Social Medical Center Atchambade

Michel is a provider at a health center in the Grand Nord region of Togo. In the past, he provided authoritative, disapproving, and biased services to youth if and when they went to see him.

“If a 16-year-old boy came into my office and said he had [a sexually transmitted infection], I wouldn’t just let him be, I would scold him. ‘You! At your age you can’t have that! You must go to school, you must study, your parents are sending you to school to study,” he said. “And a girl too, a young girl who came wanting contraception, I would say ‘No, at your age you can’t access that!’”

Michel’s attitude is not an isolated case, but reflects the service delivery environment that youth in Togo encounter when seeking family planning services—even though the population of most West African countries is rapidly growing and is characterized by a youth bulge (youth aged 10–24 represent 32% of the total population). A baseline survey carried out in Togo by Agir pour la Planification Familiale (AgirPF), a project managed by EngenderHealth and partners and supported by the United States Agency for International Development (USAID), revealed significant gaps in the effort to provide youth-friendly services.

Presented at this week’s International Conference on Family Planning (read full results here), the baseline in Togo measured provider training, access, and confidentiality as three key aspects of youth-friendly sexual and reproductive health services in 48 health centers. The results were striking, including that just 33% of health providers had been trained in the provision of youth-friendly services, 81% of providers reported that they ask about a client’s marital status before providing services, 84% of providers imposed barriers to services based on marital status, and nearly half (48%) did so for age.

According to providers interviewed, the greatest barriers are that providers believe boys and girls should not be sexually active and women should have had at least one child before accessing contraception. Not a single health center complied with all 10 characteristics of youth-friendly services (derived from: High-Impact Practices).

During the baseline assessment, youth (13–24) reported similar barriers to accessing sexual and reproductive health services. Some examples of barriers youth face include refusal by health center staff to provide services without a parent or spouse, or due to age restrictions; judgmental attitudes and practices among providers regarding sexual practices and gender norms; and inadequate infrastructure to ensure privacy and confidentiality.

As of December 2015, 57 health care providers had been trained in the provision of youth-friendly services in Lomé, Sokodé, and Kara. In 2016, 28 more health care providers, in addition to 48 health care managers, will receive this training, resulting in a total of 133 trained staff nationwide.

AgirPF trained six facilitators from the Association Togolaise pour le Bien Etre Familiale (the local affiliate of the International Planned Parenthood Federation) and from the Family Health Division of the Ministry of Health to lead this intensive five-day workshop. The curriculum is based on introspection, critical thinking, and reflection on such issues as gender norms, cultural taboos, and perceptions of sexual and reproductive health, as well as sexual and reproductive rights.

After being trained in youth-friendly service provision by the AgirPF project staff, Michel and others understood how to differentiate between personal beliefs and the responsibility to provide equitable and high-quality sexual and reproductive health services for youth and adolescents. At the workshop, Michel listened to youth’s experiences and needs, practiced role plays covering difficult questions regarding sexuality, sexual practices, and gender, and learned how to respond so that a client can make safe and healthy choices.

Conversations with both providers and youth indicated the profound effects that shifts in perception have in service provision for youth and adolescents: “With this training, providers will be able to get into the skin of young people. If a young person goes to a health center, he will not feel ashamed, because after this training… youth will have more clarity about their sexuality and about their problems concerning sex,” said Nikada, a youth group member and 23-year-old marketing student. “Now I know [providers] will improve the way they see things, because the world is evolving and we are evolving with the world too.”

Training providers in youth-friendly services not only improves the experience of young people when they access health services, but it also encourages them to do so in the first place. You can learn more about the AgirPF project, including access to the full baseline report, at www.engenderhealth.org/agirpf.