Adolescent friendly health services:
Supervisory/Self-
assessment checklist
and User's guide
1
Adolescent friendly health services: Supervisory/Self-assessment checklist and User's guide ISBN 978-92-9022-832-5
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Adolescent friendly health services:
Supervisory/Self-
assessment checklist and
User's guide
3
Table of Content
I-Introduction ---4
• What is Supervisory/Self-Assessment Checklist for Adolescent Friendly Health Services?
• What is the purpose of the checklist?
• Who can use this checklist?
• What is the frequency of assessment and supervision/monitoring?
• What is the expected outcome of such an exercise?
II-Explanations for sections A-F ---5
• A - Provision of Services
• B - Facility Check
• C - Capacity of Service Providers
• D - Demand Creation for Services
• E - Feedback from Adolescent Clients
• F - Data on Client visits and outreach services in the last quarter
III-Directions for using the checklist---9
• Collecting the required information:
• Filling up the supervisory checklist:
IV. Scoring Method ---10
• Total score of observations
• Color-coding of Scores
• Interpretation of Scores and Color Code
• Problem solving and follow up
4
Adolescent friendly health services:
Supervisory/Self-assessment checklist and User's guide
I.INTRODUCTION
What is Supervisory/Self-Assessment Checklist for Adolescent Friendly Health Services?
This supervisory checklist is a simple form to assist the supervisors and health facility in- charges to carry out a periodic supervision or service providers in self-assessment for monitoring quality and utilization of adolescent friendly health services in a health centre. This checklist allows recording of the status of selected input and process criteria (indicators) related to the specific national standards of adolescent friendly health services (AFHS). For this checklist such criteria of measurement have been selected by consultation to understand the priority areas for monitoring and feasibility of doing it in routine supervisory visits and self-assessment. Hence, the checklist does not cover the entire list of criteria related to all national standards of AFHS.
Once the health facilities in an area have achieved and sustained a reasonable
compliance to these selected criteria (related to the specific standards) over a period of time, the authorities could consider revising the checklist by replacing these criteria with another set of criteria related to same or other standards of AFHS.
What is the purpose of the checklist?
A checklist will assist the supervisors and service providers in assessing whether the delivery of health services in a health centre is taking place in keeping with the national standards on adolescent friendly health services (AFHS). It will help to verify the availability of services, identify possible deficiencies, and provide clear directions for corrective measures to ensure sustained provision of good quality services to adolescent clients.
Who can use this checklist?
Facility in-charge and the service providers are encouraged to use this checklist as a self- monitoring tool to assess the quality of health services that they provide to the
adolescent clients and initiate necessary actions to improve the quality every time.
While some corrective measures would be possible at their level, they should notify their district management for further support on those interventions requiring decisions from higher authority.
Supervisors would use the checklist to monitor the availability and quality of adolescent friendly health services at a health centre during their scheduled supervisory visit to the facility. Based on the interactions and observations during the assessment, the
supervisors and facility in-charge / service providers need to discuss the gaps and jointly chart out the necessary remedial actions to address the identified gaps and sustain the positive observations.
5 What is the frequency of assessment and supervision/monitoring?
Facility in-charge / service provider should do a self-assessment periodically and identify any significant gaps and, wherever possible, rectify them. If some of the required
corrective actions are beyond their capacity and authority, the same should be conveyed to their supervisors or the district management, as necessary.
Supervisors would assess the status of adolescent friendly health services during one of their scheduled visits to the health centre, at least once in 3 months.
What is the expected outcome of such an exercise?
Such periodic assessment would assess the extent to which the selected national standards for AFHS are being implemented in the health center / facility. This is expected to subsequently result in corrective actions as may be required, and thus assure quality of services being offered to the adolescent clients.
The periodic self-assessment would set in the process of ongoing quality improvement and this will be supplemented and supported by regular supervisory process.
II. EXPLANATIONS FOR SECTIONS A - F
The information to be collected during each assessment is arranged in the checklist in sections A to F. These items represent input and process criteria related to the National Standards for AFHS.
The following tables provide brief explanations for each item in the checklist:
The National Standards require that a health facility provides the specified package of promotive, preventive, curative and referral health services and there are adequate supplies.
A - Provision of Services
Information/advice on sexual and reproductive health concerns is provided: It could include one or more of the following for each client
• Information and counseling for sexual concerns of adolescents
• Information and counseling for menstrual disorders
• Care during pregnancy, childbirth and postpartum
• Information on prevention of unwanted pregnancy and contraceptives
• Advice on early and safe termination of pregnancy and management of post abortion complications
• Preventive counseling on safe sex STIs/RTIs treatment: It includes
• Provision of medicines for treatment of common STIs/RTIs as per the national protocols
• Voluntary counseling and testing for HIV (on site or through referral), if
6 indicated
• Information on safe sex Provision of condoms free of cost:
• Provision of condoms to adolescents free of cost irrespective of their marital status
• Information provision on correct use of a condom
• No stock outs of condoms
Provision of contraceptives including emergency contraceptive pills free of cost:
• Contraceptive counseling for married adolescents and for unmarried adolescents who are sexually active.
• Provision of contraceptives and emergency contraceptive pills free of cost
• No stock outs of contraceptives Provision of iron folic acid (IFA) tablets:
• Distribution of IFA tablets to adolescent boys and girls free of cost
• No stock out of IFA tablets Provision of referral services:
• Referral for STI management
• Referral for VCTC
• Referral for PMTCT
• Referral for termination of pregnancy and post abortion complications
• Referral linkages are in place
Adolescent health services through outreach activities:
• Periodic health check-ups and camps in schools and communities
• Provision of IFA tablets, deworming tablets, condoms, contraceptives, and educational materials during outreach service
• Periodic health education activities on SRH
• Identification and facilitation of referral of adolescent clients to an adolescent friendly health center
The National Standard requires that a health facility creates conducive environment ensuring easy and comfortable access for adolescent clients to the services.
B - Facility Check
Signboard with clinic information and policy on confidentiality on display:
• A signboard is in place welcoming adolescents, informing about the AFHS and issues related to privacy and confidentiality
• It is put up at a prominent place like the entrance of the facility Consultation/examination room ensures privacy:
• Audio and visual privacy is ensured during consultation Records of adolescent clients kept under lock and key:
• Records of adolescent clients who visit the health centre are kept under lock and key
7
• No information on adolescent’s health conditions or treatment is shared with parents or others without consent of the adolescent client
Clean and functional toilets available:
• There is a toilet at the health centre that is clean, and functioning
The National Standards require that the service providers in a health facility are technically competent and motivated to provide services to adolescent clients.
C - Capacity of Service Providers Received trainings on AFHS/ASRH:
• Service providers (MO, Nurse, Counsellor) have received standard training Have confidence in dealing with adolescent clients:
• Service providers feel confident after the training to provide health services to adolescent clients
The National Standards require that the adolescents and community are aware of the value of providing sexual and reproductive health services to adolescents and enabling environment in the community is created for adolescents to seek services.
D - Demand Creation for Services Availability of IEC materials on AFHS/ASRH at the facility:
• Educational materials on ASRH are displayed and available for adolescents either to read or take home
• No stock outs of IEC materials Provision of AFHS/ASRH information in schools:
• Service providers periodically visit schools and disseminate educational materials on ASRH and inform about the availability of AFHS in their health centers.
Dissemination of AFHS/ASRH information to community members:
• Service providers periodically visit community to inform about availability of AFHS and the value of promoting use of AFHS by their adolescents.
Dissemination of AFHS/ASRH information to adolescents in community:
• Service providers periodically visit adolescents in community disseminate educational materials on ASRH and inform them about the availability of AFHS
The service utilization is directly proportional to the level of satisfaction that adolescent clients derived from the services they received. The extent of satisfaction will reflect the poor or high quality of services in a facility as perceived by the adolescents.
E - Feedback from Adolescent Clients Did the staff here treat you with warmth and friendly attitude?
• Service providers were friendly, respectful and non-judgmental towards the
8 adolescent clients
Are you satisfied with the services that you received here today?
• Services received met the expectation of the adolescent clients
• Services were of good quality in their perception
In order to keep track of all activities related to adolescent health services, it is imperative for a health facility to ensure recording information on facility visits by adolescent clients, and client’s profile (routine OPD register in which age and sex of the clients is recorded, or a separate register of the special adolescent clinic) and those adolescents reached by outreach sessions.
F - Data on Client visits and outreach services in the last quarter Number of adolescents attended routine clinics/OPD:
• Total number of male and female adolescents who attended routine clinics/OPD at the health centre in the last three months
Number of adolescents attended fixed day clinics:
• Total number of male and female adolescents who attended fixed day clinic at the health centre in the last three months
Number of adolescents attended outreach sessions:
• Total number of male and female adolescents who attended outreach sessions in the last three months
Number of schools visited:
• Number of times the service providers visited the schools in the last three months
Number of community outreach sessions conducted:
• Number of community outreach sessions the service providers conducted in the last three months for providing information, counseling and services including distribution of IFA tablets, IEC materials and contraceptives.
9 III.DIRECTIONS FOR USING THE CHECKLIST
Collecting the required information:
The required information is collected by asking specific questions to relevant persons/s, checking the records (registers) and by observation of the physical infrastructure of the adolescent clinic / health facility.
The Supervisor is expected to ask specific questions to the relevant persons:
1. Section A: Facility in-charge or the service provider 2. Section C: Service Provider
3. Section E: Adolescent client in the health center
In case of assessment by the facility in-charge, he / she would ask these questions to the service provider/s and in case of self-assessment by the service provider, he / she would fill in the responses himself/herself.
Filling up the supervisory checklist:
The checklist mainly consists of three columns, from left to right – i) Items, ii) Tick column and iii) Means of Verification.
The ‘Items’ column has six sections (A, B, C, D, E, F). Each section has items requiring either to tick ‘Yes/No’ or simply write down the ‘numbers’. There are, in total, twenty- four items distributed over six sections:
A - Provision of Services - seven items Yes or No B - Facility Check - four items Yes or No C - Capacity of Service Providers - two items Yes or No D - Demand Creation for Services - four items Yes or No E - Feedback from Adolescent Clients - two items Yes. or No, or Can’t say F - Data on client visits and outreach services - five items Numbers
The ‘Tick column’ has four sub-columns. Each sub-column represents one quarter of a year. The supervisory visits and self-assessment are expected to be once in a quarter of the year. The cells need to be filled either with √ or X. The supervisor must mark √ for
‘Yes’ and X for ‘No’. For example:
A - Provision of Services 1st Qtr 2nd Qtr 3rd Qtr 4th Qtr
Provision of condoms √ X X √
Provision of emergency contraceptive pills X X √ √
Please note that ‘Yes’ and ‘No’ labels do not indicate whether the interview or
verification was carried out. In fact, these represent affirmative or negative response to each item (question or observation).
10 For the items, in which means of verification include both interview (asking a question) and checking of the records or registers the finding from the records / registers would be taken as more definitive than the interview. That means if the records do not confirm what the providers report, the item will be recorded as ‘X’. For instance, service provider may inform that condoms are provided to adolescent clients but checking of the records / registers at the center does not indicate that condoms were provided, the item will be recorded as ‘X’ (meaning ‘No’).
Section E. is about the client’s satisfaction. The supervisor can ask at least one adolescent client (who happens to be there at the time of the supervisory visit) to express his/her views on the satisfaction of using services at the health centre. There are two questions on client’s satisfaction. The first question is on the adolescent client’s perception about service provider’s and staff’s attitude and friendliness, and it requires marking
(encircling) either ‘Yes’ and ‘No’. The second question pertains to whether the client feels satisfied the services he/she received, which has three options for marking (encircling) ‘Yes’, ‘Can’t say’, or ‘No’.
In the Section F one needs to write down the numbers of client visits and outreach services. The information on number of adolescent clients is to be filled as disaggregated by sex in each quarter.
IV.SCORING METHOD
Total score of observations
Only sections A, B, C and D are used for scoring. The section E provides qualitative information while section F records the absolute numbers. These two sections are not scored.
An item with ‘Yes’ (or √) gets one point and every ‘No’ (or X) gets zero point. There are all together seventeen items to be scored, and thus, the maximum possible score is 17. After the assessment, points from all sections are added up and measured against the maximum score (17) during each assessment.
A sample of calculated scores in each quarter of a year is as below:
Add up the points from A-D
(Total points = 17) 1 Qtr. 2 Qtr. 3 Qtr. 4 Qtr.
Section A- Provision of services
(Max. Score = 7) 3 4 5 6
Section B - Facility Check
(Max. Score = 4) 2 3 3 4
Section C - Capacity of Service Providers
(Max. Score = 2) 0 1 1 2
Section D - Demand Creation for Services
(Max. Score = 4)) 2 3 3 3
Total score earned out of 17 7 11 12 15
11 Total score for each section (A-D) regarding all the items is recorded for the quarter under consideration. For instance, section A can have maximum score of 7 and similarly the section D, a maximum score of 2. The scores of all the sections are to be added to arrive at the total score. Therefore, individual score for each section (A, B, C and D) and the total score would be available for each quarter of the year to see the trends over time. From the sample score sheet above, one could see that the score in the first quarter is low (7/17), but, gradually over the year, the score keeps on improving.
However, the trend could also be reverse or variable.
Color-coding of Scores
The scores obtained by a health centre are coded by three different colours. If a health centre gets the total score of 15 - 17, it gets green code, if the total score is between10- 14, it gets yellow code and in case the total score is less than 10 (9 and below), it gets red code.
Performance of the facility in the past 12 months Period
Major improvements needed (Yes = 9 & below)
Minor improvements needed (Yes = 10-14 )
No significant problems (Yes = 15-17)
1st qtr. 7
2nd qtr. 11
3rd qtr. 12
4th qtr. 15
Interpretation of Scores and Color Code:
The scores and colour codes are important measure of the status of implementation of the criteria for compliance with the National Standards of adolescent friendly health services, or ‘performance of the services’ in the health facility. Adherence to the national standards indicates the level of service quality that the adolescent clients
receive at a health center. Higher the score, better the quality of services for adolescent clients – green code being the best, indicating there are no significant problems, while yellow code indicates an average performance that requires minor improvements and the red code being the worst, indicates low performance requiring major efforts to improve the services.
The colour in the table gives a visual snapshot of the implementation status of the national standards on adolescent friendly health services at the health facility in the last quarter, and also trends over one-year time. It is desirable that score remains high, and green colour is maintained most of the time. This helps to monitor the performance of a health centre and make plans to sustain the high levels or further improve the services, as the case may be.
12 Sign off
The supervisor, health facility in-charge or the service provider will complete the
checklist with his/her name, signature and designation. The supervisory would thank the facility in-charge and service provider/s. The feedback from all the health facilities would be conveyed to the district management for records and necessary supportive actions.
PROBLEM SOLVING AND FOLLOW UP
The supervisor must use problem-solving approach during such supervisory visits and take opportunity to build capacity of the health service providers in resolving some of the gaps that have been noticed. Following the completion of the assessment and completing the checklist, the supervisor, facility in-charge and service providers should together spend adequate amount of time to discuss the findings. During such sessions, the supervisor / the facility in-charge must encourage open discussion and allow generation of new ideas and creative approaches for solving the identified problems.
The analysis of the findings of the assessment during a supervisory visit or a self-
assessment would be able to identify one or more of the following follow-up actions for improvement:
• Ensure that all elements of the specified package of service (especially, the sensitive issues of sexual and reproductive health) and commodities (IFA tablets, Contraceptives, Condoms, IEC materials etc.) are provided as per the needs of the adolescent clients (boys and girls)
• Strengthening of referral services: from outreach to health center and from primary center to higher center
• Improve record keeping tracking total number of adolescent clients (age and sex disaggregation), presenting complaints and outcome of the visit
• Improve physical infrastructure to ensure privacy, confidentiality, proper signboard, clean toilets etc. as per the national standards
• Organize appropriate periodic outreach activities in schools and community as per plan
• Further capacity building of staff as required
Some of these actions could be undertaken at local level and some would require action at higher (district or state / province) level. Depending on the nature and extent of problems, few realistic recommendations can be agreed upon with assigning
responsibility of action clearly, along with practical timelines. These agreements should be noted (in brief) in the space provided in the checklist.
Towards ensuring and fulfilling the health needs and rights of adolescents
Evaluation of Observations
Name and signature of facility in-charge / supervisor in each quarter
Add up the scores of Items A-D
(Yes = 1; No=0) 1 Qtr. 2 Qtr. 3 Qtr. 4 Qtr.
Provision of services
Facility Check
Capacity of Service Providers
Demand Creation for Services
Total scores
Performance of the facility in the past 12 months Period No significant
problems (Yes = 15-17)
Minor improve- ments needed (Yes = 10-14 )
Major improve- ments needed (Yes = 9 & below)
1st qtr.
2nd qtr.
3rd qtr.
4th qtr.
Problems
observed Follow up actions
recommended Responsible Officials
Time- Frame
Name of Facility: ………
District: …….………...…………
State: ……….………
Date of visits: 1st qtr. ………...
2nd qtr………...
3rd qtr……….
4th qtr……….
Adolescent Friendly Health Services Supervisory / Self-Assessment
Checklist
WHO-SEARO
South-East Asia Regional Office of WHO
General instruction: Each cell in the tick columns corresponds to a visit in each quarter of a year. Tick the cells as per the visits in respectiv
No. Items
A. Provision of Services [Instruction: Interview the providers, and verify the information through records ] 1 Information/advice on sexual and reproductive health concerns
2 STIs/RTIs treatment as per the national protocols 3 Provision of condoms free of cost
4 Provision of contraceptives incl. emergency contraceptive pills free of cost 5 Provision of iron folic acid (IFA) tablets
6 Provision of referral services
7 Adolescent Health services (like above) through outreach activities
B. Facility Check [Instruction: Directly observe the conditions of facilities, and tick the observation accordingly]
1 Signboard with clinic information and policy on confidentiality on display 2 Consultation/examination room ensures privacy
3 Records of adolescent clients kept under lock and key 4 Clean and functional toilets available
C. Capacity of Service Providers [Instruction: Interview the main service providers (MO/Nurse/Counsellor) 1 Received trainings on AFHS/ASRH
2 Have confidence in dealing with adolescent clients
D. Demand Creation for Services [Instruction: Observe and verify through records of activities maintained in the health facility]
1 Availability of IEC materials on AFHS/ASRH at the facility 2 Provision of AFHS/ASRH Information in schools
3 Dissemination of AFHS/ASRH Information to community members 4 Dissemination of AFHS/ASRH Information to adolescents in community
E. Feedback from Adolescent Clients [Instruction: Interview some adolescent clients in the facility]
1 Were you treated here with warmth, respect and a friendly attitude? (each quarter
2 Are you satisfied with the services that you received here today? Yes, Can't say, or No (each quarter)
F. Data on client visits and outreach services in the last quarter [Instruction: Write down the numbers from service registers and records]
(record disaggregated by sex) 1 Number of adolescents attended routine clinics/OPD
2 Number of adolescents attended fixed day clinics 3 Number of adolescents attended outreach sessions
4 Number of schools visited
5 Number of community outreach sessions conducted
Each cell in the tick columns corresponds to a visit in each quarter of a year. Tick the cells as per the visits in respective quarters Yes = √ : No= X Means of Verification
Instruction: Interview the providers, and verify the information through records ]
Interview and service (clinic) register Interview, service and stock registers Interview and distribution records Provision of contraceptives incl. emergency contraceptive pills free of cost Interview and service register
Interview, service and stock registers Interview and service register Records of school/community visits [Instruction: Directly observe the conditions of facilities, and tick the observation accordingly]
Observation Observation Observation Observation
[Instruction: Interview the main service providers (MO/Nurse/Counsellor) and note down any training needs]
Interview Interview
[Instruction: Observe and verify through records of activities maintained in the health facility]
Check if IEC materials displayed and distributed Records of school visits and activities
Records of community visits and activities Records of activities with adolescent groups [Instruction: Interview some adolescent clients in the facility]
Were you treated here with warmth, respect and a friendly attitude? (each quarter– encircle) Yes
No
Yes
No
Yes No
Yes No
Are you satisfied with the services that you received here today? Yes, Can't say, or No (each quarter)
Instruction: Write down the numbers from service registers and records]
(record disaggregated by sex) M F M F M F M F
Any remarks:
………
………
………
………
………
………
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