Copyright – YK volunteers in process of peer education sessions in schools and promotion of YFHS among peers, 2023

60 SECOND SUMMARY

Adolescents and youth in Moldova were particularly affected by the period of instability following the collapse of the Soviet Union in the 1990s. The Government of Moldova instituted several policy and legal initiatives to expand access to adolescent sexual and reproductive health and rights (ASRHR) services from the early 2000s onwards. The strong legislative and policy environment, coupled with strengthening data and interventions aimed at increasing service delivery, have led to improved ASRHR outcomes in the last decade, including increasing use of contraceptives and decreasing teens pregnancy rate. Adolescents played a crucial role in designing and delivering the interventions.

Sexual and Reproductive Health & Rights Challenge

Moldova has a universal health care system that aims to provide access to basic health services for all its citizens. The period following the dissolution of the Soviet Union in the 1990s led to significant social, economic, and health system disruptions in Moldova. Adolescents and youth were particularly affected with increases in sexually transmitted infections and early and unintended pregnancy. Between 1994 and 1996, one in five births were to mothers under the age of 20 years. The incidence of HIV among adolescents in Moldova has been rising and adolescents aged 15–19 years accounted for 14.4% of HIV-infected people in 2003. Since the early 2000s, the Ministry of Health of Moldova prioritized re-orienting the public health system, including prioritizing meeting ASRHR needs. The country introduced a mandatory health insurance (MHI) system in 2004 to improve the efficiency and transparency of health financing, prioritizing primary care. Approximately 88% of the population was covered by mandatory health insurance in 2021.

Intervention

To address ASRHR issues, the Republic of Moldova developed and implemented youth friendly health services (YFHS). This involved a multi-disciplinary approach with active involvement of youth. YFHS were implemented with specific actions in the health system building blocks:

• Leadership and governance: Adolescent health and access to YFHS was a priority in the National Strategy for Reproductive Health 2005-2015, National Health Policy 2007–2021, and continues to be a priority for the National Health Strategy 2030. According to health law and reproductive health law, adolescents can access health services, including SRH services, without parental consent from age 16 years, or younger in cases where parents cannot be reached, and life-saving services are needed.
• Health system financing: Health insurance for children, students, and pregnant women is paid for by the state. A basic package of services is available free for all. The national health insurance company has been funding Youth Friendly Health Centres (YFHC) since 2008 ensuring free access for all young people aged 10–24 years and for vulnerable youth up to 35 years of age.
• Service delivery: YFHS are provided by a network of 41 YFHC – Youth Klinics (YK) in public primary health care institutions in all municipalities and districts of Moldova, based on Youth Friendly Health Services Quality Standards with a special focus on rural youth, vulnerable and at-risk adolescents. Services include outreach (YK Mobile) and online counselling (YK Support line).
• Health workforce: Adolescent healthcare training courses/modules were incorporated into preservice curricula at the medical university and nursing and midwifery schools. Collaborative learning sessions are organized regularly by all YFHC/YKs.
• Health information systems: In addition to the national health management information system (HMIS), a separate confidential component – Youth Klinic-Informational System – was developed and implemented for YFHCs/YK to monitor activities of YFHS.
• Medical products: Since 2017, contraceptive products and rapid tests for HIV, syphilis, hepatitis are procured by the State and distributed by family doctors, reproductive health offices, YFHCs. It has been possible to procure medication for medical abortion for adolescents in one YFHC since 2012 and in all YFHCs since 2022–2023.

Outcomes

The strong legislative and policy environment, coupled with strengthening data and interventions aimed at increasing service delivery have led to improved ASRHR outcomes in the last decade. Access to YFHS for 10–24 year olds increased from 5% in 2011 to 38% in 2023. Outreach efforts resulted in a higher number of vulnerable service users and male beneficiaries accessing the services. Contraceptive pill use among sexually active adolescents increased from 6% in 2014 to 13% in 2022, and the majority of sexually active adolescents (74%) continue to use condoms. The adolescent fertility rate declined from 34.2 per 1000 women aged 15–19 years in 2015 to 23 per 1000 women in 2022. At the same time points, abortion rates declined from 11.7 per 1000 women aged 15–19 years to 5.9/1000. HIV incidence among 15–24 years olds remained unchanged during the last decade and is more than two times lower than HIV incidence in the general population.

Challenges

Challenges for YFHS include political, social and humanitarian instability, underfunding, limited access for young people from rural areas, and insufficient mechanisms to motivate medical staff in hospitals and family doctors to apply the friendly approach to adolescents seeking medical care. Furthermore, the underdevelopment of school health services and lack of implementation of a complex health education program present obstacles to ensuring universal access to friendly health services for adolescents in the Republic of Moldova.

Lessons

• Legislative and policy reforms expanded the range of services that adolescents and young people could access, removing critical structural barriers and expanding geographical coverage.
• Reduction of service charges for adolescents, specifically within financing and benefits packages, and accessing services without parental consent, help remove barriers to ASRHR.
• Integrating ASRHR into existing pre-service health training institutions helps build a large cadre of providers who could offer adolescents and young people seamless services without the need for specialized training.
• Integrating ASRHR into essential packages of YFHS created a ‘one-stop shop’ for key SRHR and mental health services for adolescents. Such cost-effective delivery models benefit adolescents, their families and the broader health system.
• Involving young people in planning, provision and evaluation of YFHS, implementing parenting programs, collaborative learning sessions with community professionals, and communication campaigns contributed to community support, especially for parents, and increased acceptability and demand for services from teenagers.

Authors

• Galina Lesco, Obstetrician-Gynaecologist, Head of Resourse Centre at the National Level în Youth Friendly Health Services NEOVITA, Moldova, galina.lesco@gmail.com

Sources

• https://learn-uhc.srhr.org/story/17

• Statistical data bank [online database]. Chisinau: National Bureau of Statistics Republic of Moldova; 2024: (https://statbank.statistica.md/PxWeb/pxweb/ro/20%20Populatia%20si%20procesele%20demografice/20%20Populatia%20si%20procesele%20demografice__POP030/POP030500.px/table/tableViewLayout2/?rxid=9a62a0d7-86c4-45da-b7e4-fecc26003802 (accessed 6 September 2024).