Unprecedented work has been undertaken in the Republic of Moldova to ensure that adolescents can access sexual and reproductive health services, following a systematic process outlined by WHO.
WHO/Europe carried out an assessment of sexual, reproductive, maternal, newborn, child and adolescent health in the context of universal health coverage in 6 countries of the WHO European Region. This assessment identified broad health system challenges that must be addressed to achieve universal health coverage in the area of sexual and reproductive health. It also pinpointed key interventions for countries to prioritize, including sexual and reproductive health services for adolescents.
During 20 and 22 October 2020 WHO and the United Nations Population Fund (UNFPA) will organize a sub-regional consultation on sexual and reproductive health in Central Asian countries. The outcomes of the country assessments on sexual, reproductive, maternal, newborn, child and adolescent health as well as how to ensure access to sexual and reproductive services in the context of the COVID-19 pandemic will be key topics of discussion during this online event.
Republic of Moldova sets an example
The Republic of Moldova was the only country included in the WHO/Europe assessment that offers comprehensive sexual and reproductive health services for young people. It established youth-friendly clinics in every district and municipality between 2002 and 2017.
These 41 clinics offer free counselling services to young people aged 10–24, and are staffed with multidisciplinary teams of specialists including gynaecologists, urologists/andrologists, internists, dermato-venereologists, midwives, nurses, psychologists and social workers. Adolescents also receive free contraceptives and HIV testing.
In addition to the network of clinics, efforts are underway to set up mobile teams to provide clinical outreach services to adolescents in villages.
Dr Galina Leșco, Head of the National Resource Centre on Youth-friendly Health Services Neovita in Chisinau, coordinates the national youth-friendly clinic network. She says that the Ministry of Health’s commitment along with donor support from the Global Fund to Fight AIDS, Tuberculosis and Malaria, the Swiss Agency for Development and Cooperation (SDC), the United Nations Children’s Fund (UNICEF) and WHO have been decisive in strengthening services specifically for teenagers.
“The first 3 pilot centres were opened with the financial support of UNICEF Moldova. The SDC played an essential role in extending the network during the past decade. Thanks to WHO’s technical support, a scaling-up concept for youth-friendly services was established,” explains Dr Leșco.
“We receive extraordinary support from WHO and appreciate how we are continuously guided in the development of service-quality standards and in implementing innovative approaches, such as collaborative learning.”
Positive trends, legislative challenges
According to the Health Behaviour in School-aged Children study in the Republic of Moldova, in the last 5 years the fertility rate of those aged 15–19 has decreased by 25%, and abortions in this age group have decreased by 20%. The number of abortions among minors has nearly halved in the last 3 years, from 243 in 2016 to 141 in 2018.
Another positive development is seen in several studies indicating that the proportion of 15-year-olds who have started having sex decreased from 18% in 2014 to 13.3% in 2018. Also, the use of the contraceptive pill among sexually active 15-year-olds increased from 6% in 2014 to 10% in 2018.
However, several challenges remain. The incidence of HIV among young people has stayed the same in recent years, and condom use among sexually active young people aged 15–17 is inconsistent. Insufficient financial support for youth clinics is an additional concern.
“Every year we have significant personnel losses due to the poor financial situation in the country,” says Dr Leșco. Many health workers from the Republic of Moldova migrate to other countries with the hope of securing higher pay and improved working conditions.
Dr Leșco is keen to review Moldovan legislation related to the age of consent to access health services. The current legislation requires parental consent for those aged 16 years and under. “The criteria for assessing the decision-making capacities of a young person should change so that, under certain conditions, young people can have easier access to quality services,” she says.
The WHO assessment also showed that not all health providers know about the relevant regulations or how to apply them in young people’s best interests. One of the assessment’s policy recommendations is that legislation on adolescents’ right to access to sexual and reproductive health services without parental consent be clearly communicated to all health workers to ensure that it is understood and applied uniformly across different levels of care. It is also essential that young people know their rights and entitlements.
Reaching every young person, in every village
“A big problem right now is that young people from small, remote villages are embarrassed to ask for the help they need in the regular local health services,” adds Dr Leșco. The plan to create mobile teams will address this issue and ensure privacy and confidentiality in small communities.
“The teams will consist of nurses and volunteers who regularly visit the communities based on an established programme. Like this, young people will benefit from more confidential services, for free,” she explains.
Ms Alina Racu, a young woman from Criuleni in the central part of the country, confirms that a lot of work remains to inform young people in small villages about sexual and reproductive health and the possibility of accessing services in the youth-friendly clinics.
“Many young people in villages don’t know about the basic methods of contraception and don’t know where to go for help,” she says. “Most of them look for solutions on social networks, like Facebook, Odnoklassniki or other sites. It’s totally different when you go to a qualified specialist, who explains in detail the risks, challenges and ways of protecting yourself. It’s very important for teens to know about these centres and not be afraid to ask for qualified help on time.”
Making a difference in young lives
Many health professionals at the youth-friendly clinics have modest working conditions and low salaries. Despite such challenges, they find gratification and great value in their work.
“I will never forget when our centre, Neovita, celebrated its 10-year anniversary. A young girl came to the reception and I saw from her clothes and appearance that she probably lived on the streets. She wanted to make an appointment with a gynaecologist at the recommendation of her friend, who had visited the centre earlier. This friend had a mental health issue and had needed an abortion when she was 14 years old,” remembers Dr Leșco.
“I realized that if this young girl convinced a friend to visit us now, it means that when she was here, she felt safe with us, thought of us as friends and received the help she needed. This makes us proud of our achievements, no matter how small they may be.”