Evaluating the implementation fidelity of national standards for adolescent- and youth-friendly sexual and reproductive health services in Tanzania: a descriptive cross-sectional survey – BioMed Central

Assessment of Adolescent and Youth Sexual and Reproductive Health Services in Tanzania: A Report on Alignment with Sustainable Development Goals

This report details findings from an assessment of 11 health facilities in the Dar es Salaam, Dodoma, and Kigoma regions of Tanzania, conducted between November 13th and 30th, 2022. The analysis focuses on the coverage and implementation fidelity of Adolescent- and Youth-Friendly Sexual and Reproductive Health (SRH) services, evaluating their contribution to achieving the Sustainable Development Goals (SDGs), particularly SDG 3 (Good Health and Well-being), SDG 5 (Gender Equality), and SDG 10 (Reduced Inequalities).

Facility Profile and Overall Implementation Fidelity

The assessment covered a range of healthcare delivery points, providing a cross-section of the public and private health sectors.

1. Facility Types:
   • Dispensaries: 27% (n=3)
   • Health Centers: 55% (n=6)
   • Hospitals: 18% (n=2)
2. Ownership Structure:
   • Government-owned: 82%
   • Faith-Based Organizations (FBOs): 18%

While all facilities (100%) reported offering Adolescent- and Youth-Friendly SRH services, a significant gap exists between policy and practice. No facility achieved full adherence to national standards, with an average implementation fidelity of only 60%. This shortfall directly impedes progress towards SDG Target 3.7, which calls for universal access to sexual and reproductive health-care services. Government-owned facilities, particularly health centers, demonstrated higher fidelity, suggesting that standardized protocols and training contribute positively to service quality. The highest fidelity was recorded at Tandale health center (73%), while the lowest was at Murufiti dispensary (43%).

Proportional Analysis of SRH National Standards and SDG Implications

The following sections disaggregate performance by specific national standards, highlighting strengths and weaknesses and their direct impact on the 2030 Agenda for Sustainable Development.

Standard I: Adolescent Health Literacy

This standard is fundamental to achieving SDG 3 (Good Health and Well-being) and SDG 4 (Quality Education) by empowering youth with the knowledge to make informed health decisions. The assessment revealed critical deficiencies.

• No facility achieved 100% implementation, with scores ranging from 54% to 77%.
• Weak Performance Areas:
  • Availability of adolescent-specific information, education, and communication materials: 35%
  • Adolescents’ basic health knowledge assessment: 47%
  • Existence of outreach programs led by trained personnel: 59%

These gaps indicate that adolescents lack sufficient information to navigate health services effectively, undermining their health outcomes and right to education on health and well-being.

Standard II: Parent and Community Support

Engaging community systems is crucial for creating a supportive environment for adolescent health, aligning with SDG 17 (Partnerships for the Goals). Findings show that services remain largely facility-centered, failing to leverage vital community partnerships.

• Implementation scores ranged from 47% to 78%.
• Weak Performance Areas:
  • Systematic engagement with parents, teachers, and religious leaders: 37% of facilities regularly informed stakeholders during school meetings.
  • Planned community outreach activities: 55%
  • Partnerships with local agencies: 59%

Standard III: Appropriate Package of Services

A comprehensive and accessible package of SRH services is the cornerstone of SDG Target 3.7. The assessment found significant inconsistencies and gaps in service delivery and referral systems.

• Implementation fidelity varied widely, from 27% (Murufiti dispensary) to 69% (Tandale health center).
• Weak Performance Areas:
  • Effective referral systems for appropriate levels of care: 4%
  • Provision of a complete package of SRH services, including outreach: 51%
  • Established referral procedures based on existing policies: 56%

The failure to provide comprehensive services and ensure continuity of care represents a major barrier to achieving universal health coverage for adolescents.

Standard IV: Provider Competencies

Competent and accountable providers are essential for building strong health institutions, as envisioned in SDG 16 (Peace, Justice and Strong Institutions). The findings point to systemic weaknesses in provider training and accountability.

• Scores ranged from 44% to 75%, with no facility in full compliance.
• Weak Performance Areas:
  • Continuing professional education on adolescent healthcare: 18%
  • Public display of adolescents’ rights and providers’ obligations: 41%
  • Supportive supervision mechanisms to improve performance: 44%

Standard V: Facility Characteristics

The physical environment of a health facility directly impacts service accessibility and quality, a key component of SDG 3. The assessment identified major deficiencies in infrastructure and resources.

• Fidelity scores ranged from 46% to 67%.
• Weak Performance Areas:
  • Availability of essential technology, equipment, and supplies: 5%
  • Ensuring privacy and confidentiality during consultations: 48%
  • Maintaining a welcoming facility environment: 50%
• Over half of the facilities (54%) lacked adequate resources, compromising service delivery and deterring adolescents from seeking care.

Standard VI: Equity and Non-Discrimination

This standard is central to SDG 10 (Reduced Inequalities) and SDG 5 (Gender Equality), ensuring that all adolescents, especially the most vulnerable, can access care without discrimination. The findings reveal a significant policy-to-practice gap.

• Scores ranged from a low of 25% to a high of 94%, with no facility achieving 100%.
• Weak Performance Areas:
  • Prominently displayed policy commitments to non-discrimination: 35%
  • Formal policies ensuring universal access regardless of age, marital status, or other factors: 41%
  • Policies for free or affordable services: 52%
• A critical gap was noted in the involvement of vulnerable adolescent groups in the planning and evaluation of health services, with several facilities unable to even identify these groups in their communities.

Standard VII: Data and Quality Improvement

Effective, accountable, and transparent institutions, as targeted by SDG 16, rely on data-driven decision-making for continuous improvement. This practice was found to be severely lacking.

• Implementation scores ranged from 49% to 87%.
• Weak Performance Areas:
  • Reward and recognition systems for high-performing staff: 12%
  • Self-monitoring mechanisms for service quality: 41%
  • Systems for recognizing provider excellence were present in only three facilities (48%).

The absence of robust quality improvement frameworks hinders accountability and prevents sustained enhancements in SRH service delivery.

Standard VIII: Adolescent Participation

Meaningful youth participation is a core principle for achieving inclusive societies under SDG 10 and SDG 16. This standard was the most under-implemented, indicating that adolescents are viewed as passive recipients of care rather than active partners.

• Scores ranged from 29% to 70%.
• Weak Performance Areas:
  • Policies supporting adolescent participation in service design, monitoring, and evaluation: 7% (three facilities).
  • Involvement of adolescents in planning or service delivery: This was absent in 8% of facilities (five facilities).
  • Preparedness of providers to support youth engagement: 27% (three facilities).

This lack of engagement fundamentally undermines the “youth-friendly” aspect of services and misses critical opportunities to design interventions that meet the actual needs of adolescents.

Analysis of Sustainable Development Goals in the Article

1. Which SDGs are addressed or connected to the issues highlighted in the article?

The article on Adolescent- and Youth-Friendly Sexual and Reproductive Health (SRH) services in Tanzania directly addresses and connects to several Sustainable Development Goals (SDGs). The primary focus on health services, education, equality, and institutional quality links the article’s findings to the following SDGs:

• SDG 3: Good Health and Well-being: This is the most central SDG discussed. The entire article is an evaluation of health services, specifically focusing on ensuring healthy lives and promoting well-being for adolescents and youth through access to sexual and reproductive healthcare.
• SDG 4: Quality Education: The article highlights significant gaps in “Adolescent health literacy” (Standard I). This connects to SDG 4, as providing comprehensive health education is a key component of a quality education that equips individuals with knowledge for life.
• SDG 5: Gender Equality: Ensuring access to SRH services is a fundamental aspect of achieving gender equality and empowering all women and girls. The article’s focus on equitable access to these services, regardless of gender or marital status, directly supports the objectives of SDG 5.
• SDG 10: Reduced Inequalities: The article explicitly assesses “Equity and non-discrimination” (Standard VI), investigating whether services are accessible to all adolescents, including vulnerable groups, irrespective of age, marital status, sexual orientation, or socioeconomic status. This directly aligns with the goal of reducing inequalities within and among countries.

2. What specific targets under those SDGs can be identified based on the article’s content?

Based on the issues discussed, several specific SDG targets can be identified:

1. Target 3.7: “By 2030, ensure universal access to sexual and reproductive health-care services, including for family planning, information and education, and the integration of reproductive health into national strategies and programmes.” The article’s core theme is the assessment of the coverage, fidelity, and quality of SRH services for adolescents in Tanzania. It directly measures the extent to which these services are available and adhere to national standards, which is the essence of this target. The finding that all facilities provided some services but none achieved full adherence highlights the challenge in achieving “universal access” in terms of quality.
2. Target 4.7: “By 2030, ensure that all learners acquire the knowledge and skills needed to promote sustainable development, including, among others, through education for… health and well-being…” The article’s evaluation of “Standard I: Adolescent health literacy” directly relates to this target. It points out deficiencies in the availability of “adolescent-specific information, education and communication materials” (35% availability) and low scores on “adolescents’ basic health knowledge” (47%), indicating a failure to provide the necessary health education.
3. Target 5.6: “Ensure universal access to sexual and reproductive health and reproductive rights…” This target is closely linked to 3.7 but with an emphasis on rights and empowerment. The article’s assessment of provider competencies, privacy, confidentiality, and non-judgmental care (Standard IV), as well as equity and non-discrimination (Standard VI), are all crucial components of ensuring reproductive rights are upheld in service delivery.
4. Target 10.3: “Ensure equal opportunity and reduce inequalities of outcome, including by eliminating discriminatory laws, policies and practices…” The article’s findings under “Standard VI: Equity and non-discrimination” directly measure progress towards this target. It reveals that many facilities lacked “formal policies and procedures ensuring universal access to SRH services regardless of age, marital status, education, ethnicity, sexual orientation or socioeconomic status” (only 41% had them), indicating that discriminatory practices may persist.

3. Are there any indicators mentioned or implied in the article that can be used to measure progress towards the identified targets?

Yes, the article is rich with specific, measurable indicators used in the study, which can serve as direct measures of progress towards the identified SDG targets.

• For Target 3.7 (Universal access to SRH):
  • Indicator: Percentage of health facilities providing a comprehensive package of SRH services. The article implies this by stating, “Only 51% offered a complete package of SRH services that fulfil the needs of all adolescents and youth.”
  • Indicator: Percentage of facilities with effective referral systems for SRH care. The article provides a stark measure: “only 4% of facilities effectively referred adolescents and youth to appropriate levels of care.”
  • Indicator: Average implementation fidelity score of national SRH standards. The article quantifies this as an “average implementation fidelity of… 60%.”
• For Target 4.7 (Health education and literacy):
  • Indicator: Availability of adolescent-specific information, education, and communication (IEC) materials in health facilities. The article measures this, finding only “35%” availability in waiting areas.
  • Indicator: Percentage of facilities with outreach programs led by trained personnel. The article states this was present in “59%” of facilities.
• For Target 10.3 (Equity and non-discrimination):
  • Indicator: Percentage of facilities with formal policies ensuring universal access regardless of background. The article found this in only “41%” of facilities.
  • Indicator: Percentage of facilities with policies for free or affordable services. This was measured at “52% of the facilities.”
  • Indicator: Percentage of facilities involving vulnerable groups in planning and monitoring. The article notes this was a major gap, with providers at some facilities not even knowing “who the vulnerable group(s) of adolescents in their community are.”

4. Summary of SDGs, Targets, and Indicators

Source: reproductive-health-journal.biomedcentral.com