A Review of Literature and Projects 1995 - 2002
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Sexual and Reproductive Health of Adolescents and Youths in Mongolia
WHO Library Cataloguing in Publication Data Sexual and reproductive health of adolescents and youths in Mongolia: a review of literature and projects 1995-2002. 1. Sexuality 2. Reproductive medicine 3. Adolescent 4. Mongolia ISBN 978 92 9061 264 3 (NLM Classification: WS 462)
The World Health Organization welcomes requests for permission to reproduce or translate its publications, in part or in full. Applications and enquiries should be addressed to the Office of Publications, World Health Organization, Geneva, Switzerland or to the Regional Office for the Western Pacific, Manila, Philippines, which will be glad to provide the latest information on any changes made to the text, plans for new editions, and reprints and translations already available. © World Health Organization 2007 Publications of the World Health Organization enjoy copyright protection in accordance with the provisions of Protocol 2 of the Universal Copyright Convention. All rights reserved. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the Secretariat of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters.
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A Review of Literature, Projects and Case Study 2002
Table of Contents Acronyms .................................................................................... 7 Acknowledgement ...................................................................... 8 Preface ........................................................................................ 9 Executive summary ................................................................... 11 Part I 1. General country situation ..................................................... 13 1.1. Geography and climate ..................................................................................13 1.2. Population ........................................................................................................13 1.3. Administrative structure ................................................................................14 1.4. Lifestyles and culture ......................................................................................14 1.5. Health status ....................................................................................................15 1.6. Disease burden ................................................................................................16 1.7. Health expenditure .........................................................................................16
2. Adolescent health and development ..................................... 18 2.1. Adolescent population ...................................................................................18 2.2. Health status and health services ..................................................................18 2.3. Education .........................................................................................................30 2.4. Labour ..............................................................................................................32 2.5. Street children..................................................................................................34 2.6. Crime ................................................................................................................35
3. Programmes and projects in response to adolescent health and development issues ....................................................... 36 3.1 Government programmes ..............................................................................36 3.2 Projects of United Nations agencies ............................................................40 3.3. Programmes of nongovernmental organizations ......................................45
4. Rationale behind the development of selected policy options, particularly the national adolescent health and development policy....................................................... 50 3
Sexual and Reproductive Health of Adolescents and Youths in Mongolia
5. Development process of adolescent health and development policy....................................................... 51 6. Implementation of the policy ............................................... 61 7. Effect/impact of the adolescent health and development policy....................................................... 65 8. Lessons learned .................................................................... 69 Part II 1. Review of Health Services for Adolescents .......................... 74 1.1 Goal and objectives ........................................................................................74 1.2 Methodology .................................................................................................. 74
2. Findings of the Survey ......................................................... 78 2.1 Voices of 2.2 Voices of 2.3 Voices of 2.4 Voices of Adolescents.....................................................................................78 Parents and Key Informants ........................................................82 Service Providers ...........................................................................85 Managers and Policy-Makers........................................................91
3. Conclusions .......................................................................... 95 4. Recommendations ............................................................... 102 Annex 1. Complete list of Methods used for Collecting Data from Different Sources ............... 106 Annex 2. Responsibilities of the Adolescent Cabinet Doctor ...................................... 108 Annex 3. Selected AFSH Criteria for the Review .................... 109 Annex 4. List of Review Team members ................................ 112 Annex 5. Survey Instruments .................................................. 113 References ............................................................................... 127 Endnotes.................................................................................. 130
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A Review of Literature, Projects and Case Study 2002
Figures and Tables Figure 1. Demographic pyramid by age group and sex, 1989 and 2000 .......................................................................................................13 Figure 2. Health expenditure and outcomes, 1989-1998 ................................................................................................................17 Figure 3. The causes of adolescents’ death by percentage, 1997-2000 ................................................................................................................20 Figure 4. Adolescent deaths caused by injuries, accidents and external factors, 1997-2000 ................................................................................................................20 Figure 5. Percentage of abortions among women under 20 years, 1996-2000 ................................................................................................................24 Figure 6. Organizational structure for policy implementation at the national and provincial levels .....................................................................64 Figure 7. Comparison of adolescent reproductive health knowledge and practices ...........................................................................................................65 Table 1. Health indicators in Mongolia .....................................................................15 Table 2. Demographic indicators in Mongolia ........................................................18 Table 3. Protein energy malnutrition in adolescents, 1997 ....................................21 Table 4. Current adolescent daily nutrient intake, 1999 .........................................21 Table 5. NGO programmes and projects for adolescent health and development ..............................................................49
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Sexual and Reproductive Health of Adolescents and Youths in Mongolia
Table 6. Development of programmes for adolescent health and development ..............................................................51 Table 7. Main stakeholders/ participators/ organizations and their roles and functions in policy development ........................................56 Table 8. Service providers for adolescents and their training needs .....................63 Table 9. Main indicators of the National Programme on Health Education for School Pupils and Adolescents, 1997-2000..................................................67 Table 10. Review sample .............................................................................................76
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A Review of Literature, Projects and Case Study 2002
Acronyms AFHS ADH ARI CRC FGD HIV/AIDS HMIEC HRH HSDP IEC ILO MCHRC MCRC MMR MOH MOHSW NCC NCHD NGO NMUM NSO PHC RH SDC STD STI UNDP UNICEF UNFPA WHO adolescent-friendly health services adolescent development and health acute respiratory infection Children’s Rights Centre focus group discussions human immunodeficiency virus/ acquired immunodeficiency syndrome Health Management, Information and Education Centre Human resources for health Health Sector Development Programme information, education and communication International Labour Organization Mother and Child Health Research Centre Maternal and Child Research Center maternal mortality ratio Ministry of Health Ministry of Health and Social Welfare National Committee for Children National Centre for Health Development nongovernmental organization National Medical University of Mongolia National Statistical Office primary health care reproductive health Social Development Centre sexually transmitted diseases sexually transmitted infections United Nations Development Programme United Nations Children’s Fund United Nations Population Fund World Health Organization
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Sexual and Reproductive Health of Adolescents and Youths in Mongolia
Acknowledgement WHO is grateful to the Government and Ministry of Health of Mongolia for their contribution towards the review of literature and projects on the Sexual and Reproductive Health of Adolescents and Youths, the research on Improving Outlook of Adolescent Girls and Boys Sexual and Reproductive Health and in preparation of the case study for publication. Special gratitude is expressed to the Chairperson, Secretary and Members of the Task Force on Improving Outlook of Adolescent Girls and Boys in Mongolia and to the health staff of Arkhangai and Khuvsgul Aimags, Maternal and Child Health Research Centre, Chingeltei Health Centre, the Adolescent Future Centre, National Health Sciences Medical University of Mongolia, Officer -In charge of Division of Information, Analysis, Monitoring and Evaluation and the non-governmental organizations involved in the research. Thanks are also due to all the researchers who conducted the literature reviews, survey and contributed towards the case study and to those who provided information. The team of reviewers who contributed their time in reviewing the final documents also need special mention. We hope that by sharing the country experiences in planning, implementing and evaluating specific programmes and activities on adolescent sexual and reproductive health issues we will be able to further improve the health and well being of our adolescents in the Western Pacific Region and beyond.
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A Review of Literature, Projects and Case Study 2002
Preface
T
his is one of the reviews on the literature and projects of sexual and reproductive health of adolescents and youths in eight Asian countries.* Adolescents and youth make up onefourth of the population in the Western Pacific Region. At least 17 out of 37 countries and areas in the Region have a median age below 25 years. The health of adolescents is, therefore, a key element and an investment for social and economic progress in the Region. Many of the problems adolescents experience are inter-related and should be regarded in a comprehensive manner. However, adjusting to sexual development and protecting their reproductive health are the major challenges for adolescents. Adolescents are vulnerable because they lack knowledge and skills to avoid risky behaviour and lack access to acceptable, affordable and appropriate reproductive health information and services. This is often compounded with environmental disadvantages such as poverty and unemployment. Social nor ms of sexuality have also changed in the past two decades and puberty comes 2-3 years earlier over one century, but the environment to support adolescents has not changed. There is still much to be desired in terms of governments’ institutionalization and allocation of funds. Also families and communities are still unprepared to provide accurate reproductive health information and
* Cambodia, China, Lao People’s Democratic Republic, Malaysia, Mongolia, Philippines, Republic of Korea, Viet Nam
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Sexual and Reproductive Health of Adolescents and Youths in Mongolia
services necessary for adolescents. Risks of unwanted pregnancies, unsafe abortions, pregnancy-related complications, sexually transmitted infections and HIV/AIDS, all of which are important elements of Millennium Development Goals (MDG), continue to threaten adolescents. Since the International Conference on Population and Development (ICPD) in Cairo in 1994, where the importance of adolescent reproductive health was acknowledged, many studies and programmes have been carried out by various national and international agencies and nongovernmental organizations. In order to assist governments to achieve the objectives of ICPD and MDG, the WHO Western
Pacific Regional Office provided technical and financial support to several countries to conduct literature and programme reviews. As a result of these reviews, countries now have evidence-based information for the development of national policies and strategies for adolescent sexual and reproductive health. I appreciate the practical and cost-effective use of existing information for increasing awareness of adolescent reproductive health and for improving our work. Here, I also would like to express my thanks to the governments, the reviewers and researchers for your contributions to improving the reproductive health of adolescents and youths.
Shigeru Omi, MD, Ph.D Regional Director
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A Review of Literature, Projects and Case Study 2002
Executive Summary Adolescents represent more than one quarter of the total population of Mongolia and are a vast current and future national resource. The low population density, severe climate, poor transportation and communications, and inadequate infrastructure and facilities make the delivery of adolescent health and development services difficult and complex, particularly in rural areas. Health indicators reflect gross inequities in access to the basic prerequisites for health; there is a need to improve access to appropriate preventive and curative care and rehabilitation services. It is estimated that many premature deaths among adults are largely due to behaviour initiated during adolescence, and there is significant mortality and morbidity among adolescents due to accidents, suicide, violence, pregnancyrelated complications and illnesses. Many of these deaths and illnesses are preventable, which is an important reason to focus health prevention efforts on adolescents. Preventing risky behaviour, such as smoking, alcohol consumption and drug abuse, and promoting healthy choices among adolescents can yield positive health outcomes, not just during adolescence, but also during adulthood. Adolescents are not considered an independent group with specific needs, and there is no documented independent, comprehensive adolescent health and development policy. The parental and social attention given to adolescent health and development issues is still minimal. Service quality and access for adolescents, particularly boys, in remote areas is insufficient. Based on international trends and the specific needs of adolescents in Mongolia, the Government has developed its own adolescent policy, implemented through a national programme. In the national programme, adolescents’ issues are included in children’s problems. Currently, adolescent health and development policies do differentiate from other broad health policies, but they are still in the initial stage of development. One of the main policies on adolescent health and development is the National Programme of Action for the Development of Children by 2000, adopted in 1993. The National Programme on Health Education for School Pupils and Adolescents, which was approved in 1997, particularly addresses issues related to adolescent health and development. 11
Sexual and Reproductive Health of Adolescents and Youths in Mongolia
The primary goal of the programme is to strengthen the health of secondary school students and adolescents by encouraging government and public entities and parents to pay attention to their health and physiological development, and to create a sound health education programme. As a result of the programme, a special Health Education Programme has been included in the secondary school curriculum. Adolescent centres and school doctors’ units have also been established. In February 2002, the Ministry of Health, together with its partners in the Ministry of Education, Culture and Science, the Ministry of Social Welfare and Labour, and the Ministry of Justice and Internal Affairs, and various other government agencies and nongovernmental organizations, initiated a national programme, to run until 2010, to improve the outlook for children and adolescents. A working group is developing a policy on social
welfare and protection; health and nutrition; rights and participation; and education and development of children and adolescents. International organizations, NGOs and other donor agencies are making great financial and technical contributions towards the development of adolescent health and development policies. They have initiated many activities to address adolescents’ problems, aimed especially at the most vulnerable. Most NGO activities concentrate on reproductive health and sexually transmitted infections; issues related to a safe environment are less often considered. There is still a need for more collaboration, cooperation and coordination between government agencies, government and nongovernmental organizations, international and local NGOs, and the Government and the private sector.
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A Review of Literature, Projects and Case Study 2002
PART I 1. General country situation
1.1 Geography and climate Mongolia is a landlocked country in north-east Asia. The relatively small population is spread over a large geographical area of 1.56 million sq. km, which is half the size of India or three times the size of France, making the country one of the most sparsely populated in the world, with a population density of 1.4 persons per sq. km. The climate is defined as semi-arid continental, with long severe winters and short summers.
1.2 Population According to the 2000 census, the population of Mongolia is 2.4 million. It has increased by 16.1% within the last decade1 . Between 1989 and 1998, the population growth rate fell slowly from an average 2.5% to 1.4% due to a decrease in the birth rate. However, the birth rate seems to have stabilized since then. The Government’s population policy has a target growth rate of 1.8%2 .
Figure 1. Demographic pyramid by age group and sex, 1989 and 2000
1989
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Sexual and Reproductive Health of Adolescents and Youths in Mongolia (Continued) Figure 1. Demographic pyramid by age group and sex, 1989 and 2000
2000
1.3. Administrative structure Administratively, Mongolia is divided into 21 provinces and the capital city, Ulaanbaatar. The provincial populations range from 46 000 to 122 0003 . Each province has a provincial centre, surrounded by 15-21 soums or rural districts. Each soum has an average population of 3000 living in the soum centre and bags (villages). Each province and soum has a Governor and an elected assembly responsible for administration and budgeting4 . All health and education services for the population are organized through this structure.
1.4 Lifestyle and culture The largest ethnic group in the country is Khalkh Mongols (81%) and the smallest minority is Kazakhs (6.1%). At least 30% of the population lives in Ulaanbaatar and 58.6% of the population was urbanized by 2000. The population in urban areas has a tendency to increase due to increasing migration from rural areas to cities. In the last two years particularly, movement has increased due to natural disasters that have affected provincial households. Those who have lost their livestock have moved increasingly from district to provincial centres and/or from provinces to cities.
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A Review of Literature, Projects and Case Study 2002
Nearly 40% of the rural population are nomadic or semi-nomadic herdsmen, which presents a difficult challenge for the provision of social and health services. The average household size is 4.2 members. Around 36% of the population live in poor or extremely poor conditions, and there is no sign of the unemployement level declining. The majority of Mongolian poor households are headed by females and, regardless of household location, poor households usually have many family members.
Islam and, since 1990, an increasing number of Mongolians have become committed to Christianity.
1.5 Health status Mongolia has achieved many successes in the protection of the population’s health.
The crude mortality rate has declined remarkably from 2.8 per 1000 inhabitants between 1985 and 1995, to 1.01 per 1000 inhabitant in the last five years. The maternal death rate in rural areas is higher than in urban areas, 29 % of pregnant The official language is Mongolian. The women giving birth are herdswomen, literacy rate amongst those over 15 years with 49.3 % of the total mortality rate of age was 97.8 % in 2000. The adult being among this group of women. female literacy rate was 95% in 19985 . Around 43 % of deceased mothers lived There is still limited access to in bags, and 36.9% in soum centres. For information recourses and limited the last three years, 40.5 % of maternal opportunities to receive information in deaths have been in soum and bag rural areas. hospitals 6 . High maternal mortality remains a priority health problem. The most widely accepted religion is Buddhism, the Kazak minority practises Table 1. Health indicators in Mongolia Indicators Population growth rate (%) Life expectancy at birth Mortality rate (per 1000 population) Maternal mortality ratio (per 100 000 live births) Infant mortality rate (per 1000 live births) Under-5 mortality rate (per 1000 live births)
2000 1.4 65 5.99 158 31.2 42.4
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Sexual and Reproductive Health of Adolescents and Youths in Mongolia
incidence of hepatitis have caused an increase in the incidence of malignancies 8 In 2000, 23 562 cases of infectious among the population . diseases were registered, approximately 41.2% of them STIs (including syphilis, In the last few years, mental and oral gonococcal infection and health problems have also been trichomoniasis), 25% viral hepatitis, increasing, both in urban and rural areas. 2.5% measles, 4.19% rubella, Around 5% of Mongolians are physically 8 % tuberculosis, and 4.4% shigellosis disabled, and injuries and deaths due to and others. The incidence of vaccine- accidents at work, traffic accidents and preventable diseases has been reduced intentional violence are on the increase. as a result of the high priority given to Stress due to harsh socioeconomic the Expanded Programme for conditions is also adding to the toll of Immunization, which achieved over 92% mental suffering. immunization coverage for the underone-year age group for pertussis, 1.5 Health expenditure diphtheria, tetanus, poliomyelitis, measles and tuberculosis in 20007 . Only three The Ministry of Health and local cases of HIV/AIDS have been authorities emphasize a functioning registered in Mongolia. However, the STI referral system as a key strategy to rate has increased considerably in the last increase equity in the allocation of human resources for health while five years. decreasing health care expenditure. The The leading causes of morbidity for transition to a market economy in the inpatients and outpatients are respiratory early 1990s led to budgetary constraints, infections, gastrointestinal diseases and which forced “the government to cut diseases of the genitourinary system. back on real per capita expenditure on Cardiovascular diseases and cancer are health care by 42%”9 . the leading causes of death in Mongolia. The shift from a nomadic lifestyle to a As can be seen from Figure 2, the share sedentary one, the psychological stress of GDP spent on government health caused by changing living conditions, expenditure dropped from 5.4% in 1990 poor nutrition habits and smoking have to 3.6% in 1998. At the same time, MMR contributed to the increase in was 119 per 100 000 live births in 1990, cardiovascular diseases. Unhealthy but almost doubled in 199310 . However, nutrition, alcohol, smoking and the high the figure had dropped to 145 by 1997.
1.4 Disease burden
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A Review of Literature, Projects and Case Study 2002
Ministry of Health expenditure is divided into 86% recurrent and 14% capital. Recurrent expenditure in 1997 was broken down into 31% for personnel, 22% for drugs and the rest (47%) for other expenditures. In 1996, the total percentage of recurrent health expenditure by type of service was estimated to be about 60% for curative services and 40% for preventive and public health activities.
The percentage of health expenditure going to preventive and public health ser vices slowly increased from 1993 to1996 as a result of government policy to place greater emphasis on primary health care and preventive ser vices 11 . Capital investments in 1990 accounted for over 14% of the total expenditure on health, but since 1993 have fallen to 2.5%-4.5%.
Figure 2. Health expenditure and outcomes, 1989-1998
Sources: Mongolia-Health sector review 1999 and HMIEC1998
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Sexual and Reproductive Health of Adolescents and Youths in Mongolia
2. Adolescent health and development situation
2.1. Adolescent population According to the Mongolian Population Census of 2000, 581 186 members of the population were adolescents between the ages of 10 and 19 (see Table 1). The figure was 477 200 in 1989 and has increased by 4.5% during the last decade. The high percentage is the result of government policy to promote rapid population growth and improvements in health care, particularly in relation to women and children. Despite a decreasing fertility rate during the last 10 years, adolescents’ needs are going to be relatively stable for several years in the near future.
related complications and illnesses. Many of those deaths and illnesses are preventable. In addition, it is estimated that many premature deaths among adults are largely due to behaviour initiated during adolescence.
2.2.1. General health status
In comparison with the high percentage of adolescents in the population, there is still little parental and public attention given to adolescents’ health care. Only 21.7 % of adolescents are relatively healthy. Acute respiratory infections and diseases of the digestive system are as common among adolescents as other age groups. The incidence of acute 2.2. Health status and health respiratory infection is two times higher in the capital city, Ulaanbaatar, than in services rural areas12 . There is significant mortality and morbidity among adolescents due to One survey stated that 74.3% of accidents, suicide, violence, pregnancy- adolescents had chronic diseases, Table 2. Demographic indicators in Mongolia Indicators Total population (million) 10-19 adolescents (%) 15-24 youth (%) Adolescents sex ratio (10-19) Age dependency ratio Median age Population growth rate (%) 2000 2373 24.1 21.0 101.6 65 22 1.4
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A Review of Literature, Projects and Case Study 2002
including caries and gum inflammation, and noted that diseases of the oral cavity, ears, nose and throat diseases, allergies and gastrointestinal diseases were dominant among adolescents13 . During the last 10 years, the incidence of pollinosis among adolescents has doubled. Twenty five to thirty three per cent of adolescents were found to have two or more chronic diseases. The survey conducted in 1999 by the Mother and Child Health Research Centre in Ulaanbaatar city showed that 78.3% of schoolchildren had chronic diseases. Among them 38.1% were dental, 20.5% - ENT, 8.6 % - genitourinary tract, 7.8% - endocrinal, 7.4% - eye, 6.4% - gastrointestinal and, 4.85% - nervous system diseases14 . According to Health indicators-2000 , developed by NCHD in 2001, there were 193 497 incidences of disease in children aged 5-19 years and the five leading causes of their morbidity were: • diseases of the respiratory system (28 %); • diseases of the digestive system (19.57 %); • diseases of genitourinary tract (9.83 %);
• injuries, intoxication and external factors (9.16 %); and • infectious diseases (7.12 %). The main causes of adolescent death are injuries, accidents and external factors. In 2000, 387 adolescent deaths were registered, 47% of them caused by injuries, intoxication, accidents and external factors, 8.79% by diseases of the digestive system, 8.27 % by diseases of the nervous system, 7.75% by infectious diseases, and 6.2% by diseases of the circulatory system (figure 3). According to health statistic data the incidence of injuries, accidents, (figure 4) and diseases of the digestive system and diseases of the nervuos system increased year by year.
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Sexual and Reproductive Health of Adolescents and Youths in Mongolia Figure 3. Causes of adolescent deaths by percentage, 1997-2000
Figure 4. Adolescent deaths caused by injuries, accidents and external factors (%)
2.2.2. Nutrition Underweight, stunting and wasting About 60%-70% of adolescents have insufficient physiological growth for their 20
ages. Among school-aged children there is a high incidence of protein and iodine deficiency. Among adolescents, 16.3% are late in their physical development, 46.9% are below average weight, and 49.0% below average height15 .
A Review of Literature, Projects and Case Study 2002 Table 3. Protein energy malnutrition of adolescents, 1997 Age group 8-10 years 11-17 years Underweight 45.4% 48.0% Stunting 14.3% 17.4 Wasting 16.3 n/a Overweight 12.6% n/a n/a- not available Table 4. Current nutrient intake consumed daily by adolescents, 1999 Protein Calories Fat 8-10 years 11-14 years 15-17 years 86.2% 62.1% 56.2% 77.4% 52.8% 50.5% 30.2-49.9%
The Second National Nutrition Survey found that 45% of respondents did not eat regularly, eating only one meal a day, from which they were receiving only 44% of their necessary calories. The survey found that the respondents’ diets were only providing 74% of the daily protein, 40.7% of the fat, 71% of the carbohydrates and 69% of the calories needed. According to the respondents, nutritional deficiencies were being caused by their unhealthy behaviour, such as having irregular meal times, small and low quality meals, and eating meals prepared the previous day. They explained that situation was due to insufficient time, not having money and insufficient skill in food preparation.
responsibilities because of health problems (impaired vision, hearing difficulties, kidney problems, etc.) and 19% of them had insufficient physiological growth (insufficient height)16 . Micronutrient deficiencies
Every third adolescent has iodine deficiency and every fourth, anaemia (24.2%). Around 21.4% of children between the ages of 7 and 12 exhibit goitre, a reflection of iodine deficiency disorder17 , reflecting a significant public health problem. Among adolescents aged 12 to 18, 15% have anaemia, with anaemia being 29% higher among girls. Forty one percent of anaemia is caused During military mobilization, about by iron deficiency and 70.5 % of all cases 42% of the young people who were are first-degree anaemia18 . checked were excused from military 21
Sexual and Reproductive Health of Adolescents and Youths in Mongolia
Food standards and food safety A few secondary schools in Ulaanbaatar have cafeterias that meet hygiene standards, but they do not sell food that meets the requirements for children’s physiological growth. Candy, chocolate and soft drinks are sold, contrary to good oral health habits among adolescents. There are no developed standard menus or meal prescriptions in school cafeterias and there is a need to address that situation as a matter of urgency.
reproductive health19 , and fewer than half of the adolescents interviewed had some knowledge of STIs.
According to Mary Stopes International, a 1999 survey showed most of the girls and boys interviewed (80%) were unable to talk with their parents about reproductive health and sex. Even teachers did not have sufficient knowledge, and were therefore unable to discuss reproductive health with their students. Such a situation has led many adolescents to adopt risky sexual Standards of food quality and food safety behaviour and become vulnerable to are very difficult to monitor and control, STIs, including HIV. especially in the summer. Food is kept in unhygienic conditions for long The Adolescent Reproductive Health periods, and the lack of adequate water Survey, conducted in 1996, showed that and toilet facilities in schools, dormitories almost 26% of 17-18 year-old and homes makes proper food hygiene adolescents had experienced sexual difficult. In shops, there are many canned intercourse. However, by 1999 that figure and packaged products from abroad, had increased to 34.5%20 . which are purchased long after their safe “sell by” date. Statistical data and survey Contraceptive knowledge and use materials on adolescents’ nutrition are insufficient. Nearly 98% of married young women aged 15-19 know of modern contraceptive methods. Most of them 2.2.3. Reproductive health know of condoms, IUDs and calendar methods. Their basic sources of KAP on reproductive health information on contraception are books, Study findings illustrate the overall lack journals and friends. Seventy three per of knowledge on sexual issues among cent of adolescents do not receive adolescents. About 25% of adolescents information from TV or radio. Among do not have a basic knowledge of married women aged 15-19, 18.8% use 22
A Review of Literature, Projects and Case Study 2002
some kind of modern contraceptives and 4.7% use traditional methods21 . Age at marriage The official minimum age for marriage is 18 years. However, according to a reproductive health survey in 1998, about 1.1% of all married women up to the age of 49 were girls aged 15-19. The survey showed that only 6.6% of women aged 15-19 were registered as being married and living together with a spouse. Cohabitation was also popular before official registration. Official statistics reveal that 48% of registered couples live together for two or more years before marriage. The median age at first marriage for women is relatively young, about 20.8 years, and is lower for women with a low educational level than for those with more education. Research shows that the median age of marriage has increased gradually over time from 20.1 years for those now 45-49 years of age, to 20.8 for those now aged 25-29.
births is twice as large in provincial centres (11.5%) than in Ulaanbaatar (4.4%), and the highest rate is in rural areas in the south (26.3%) possibly due to reproductive health IEC activities being concentrated in urban areas with appropriate infrastructure22 . According to statistical data from 1996-1998, 8.3% of maternal deaths from pregnancy and delivery were adolescents between the ages of 15 and 19, which is twice as high as the percentage of deaths among the 20-29year-old age group. The large majority of those adolescent maternal deaths (81%) were in soums and bags in rural areas. Abortion
In 1998 , 6.3% of women aged 13-20 became pregnant. Of those, 43.3% were unwanted pregnancies and 18% had abortions23 . Those who had only received primary-school education had higher pregnancy rates than those who had attained the education level of grade 10. According to health statistics, Adolescent pregnancy and fertility the percentage of abortions among women less than 20 years of age has The birth rate among adolescents has increased significantly 24 (see Figure 5). increased in the last ten years. According to the 1998 reproductive health survey, in 1998 about 9% of 15-19 year-old girls gave birth. The percentage of adolescent 23
Sexual and Reproductive Health of Adolescents and Youths in Mongolia Figure 5. Percentage of abortion among women under 20 years, 1996-2000
In 1998, about 9135 women had induced abortions. Of those, 5.2% were under 20 years of age. That number does not include abortions carried out in private hospitals, which were estimated at 18% among women aged 15-24 and 2% among women aged 35-39. The rates were probably underestimated because abortions in private hospitals were neither registered nor reported to the health and statistics offices. Both parents and young women preferred to have induced abortions in private hospitals because of their confidentiality25 .
are unemployed and 49%-58% are under 25 years of age26 . According to health indicators, cases of syphilis, gonorrhoea and trichomoniasis increased from 39.5% of total STIs in 1998 to 42.2 % in 2000. In 1997, there were nine cases of congenital syphilis, 24 in 1998, increasing to 43 in 2000. At the soum level the capacity to treat STIs is still poor. About 70% of respondents who participated in the HIV/AIDS/STDs KAP survey of young people aged 15-25 claimed to have insufficient knowledge about STIs, and 65% about HIV/AIDS27 . Of 490 males examined, 6% had the first symptoms of STIs, 20% had had sexual intercourse with more than one partner, and 7% had been
2.2.4 STI/HIV/AIDS It is estimated that every year about 7000-8000 people are infected with STIs, increasing their vulnerability to HIV infection. About 50.4% of STI patients 24
A Review of Literature, Projects and Case Study 2002
infected with an STI by their first partner. Ten per cent of the respondents preferred to treat themselves for STIs instead of going to a clinic28 . Most of those actually infected did not go to a clinic, and half of them said that the symptoms of the disease disappeared on their own, indicating that adolescents do not have easy or direct access to clinics and do not openly seek their parents’ advice. A rising number of street children and teenage female prostitutes are at risk of contracting STIs. National AIDS Centre statistics reveal that 39% of prostitutes or sex workers began at ages 14-16, and that their knowledge about STIs was very limited. Thus, various training programmes on STIs should be developed and facilitated in the future.
Intoxication Treatment. Those who had tried to commit suicide had taken drugs, particularly sedative drugs. At the Maternal and Child Research Centre, 40 children aged 13-16 were treated for attempted suicide. One survey 29 indicated that adolescents aged 10-18 often considered themselves outsiders and 67.8% of them felt lonely. Children, especially girls, in urban areas appeared to be more affected than children in rural areas. Adolescents who were involved in the survey said that a serious problem is teenagers who become tired of life due to different kinds of depression, sometimes resulting in suicide. One in 20 adolescents involved in the survey had tried to commit suicide because of depression, with more girls (60%) being affected than boys. The suicide attempts had occurred more often among children and young people who had run away from home and had no job or school place. According to the Centre for Pathology and Forensic Medicine, in the last five years, 745 people have died as a result of suicide, 5% of them adolescents.
2.2.5 Mental health
In recent years, children and adolescents have been confronting mental health problems such as neuroses, pathological behaviour, substance abuse, suicide, and running away from difficult circumstances at home. This situation is seen as the result of negative societal 2.2.6 Oral health influences and anxiety. Surveys have been carried out on the oral In 2000, 170 (56%) adolescents and health of younger children, but young people aged 16-25 were treated information about adolescent oral health for acute intoxication at the Centre for is rare. According to a survey carried out
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Sexual and Reproductive Health of Adolescents and Youths in Mongolia
by the Maternal and Child Research among schoolchildren that had chronic Centre, 38.1% of adolescents aged diseases than healthy children. 12-18 have dental problems and 94% of The average starting age for smoking was adolescents have gingivitis 30 . 16.7 years for boys and 17.2 for girls. Dental pathology is more common However, the average starting age among among children from urban areas than young people in Ulaanbaatar was lower. from rural areas. Six in ten children aged Forty per cent of high-school students 7-12 years have teeth caries. who smoked indicated that they had smoked their first cigarettes between the Overconsumption of sugar and sweet ages of 12 and 13, and 34.4 % between food products is common among 14 and 15 32 . There used to be a law children, and 16.7 % of adolescents do banning the sale of tobacco products to not clean their teeth regularly and do not adolescents, but it was repealed in use adequate toothpaste. This problem 1998 and has not been re-introduced in is more common in rural areas and, to spite of appeals by the Ministry of some extent, depends on living Health. In 1997, the Government of standards. Mongolia also reduced the import tax on tobacco. The Tobacco Law is now being 2.2.7 Smoking, alcohol and drug discussed in Parliament and the tobacco tax issue will be reviewed. abuse Smoking According to the report of the 1997 survey on health-conscious behaviour, habits and attitudes among adolescents, 16.4% (334) of the adolescent respondents smoked, although 65.6% of those wanted to quit31 . Given the availability and price, cigarettes are more often used than either drugs or alcohol. Of the respondents who smoked, 78.7% came from a family with smokers. The number of families with smokers was 2.4 times higher 26 Alcohol The 1998 assessment of alcoholism in Mongolia 33 found that 51.2% of the population were drinking alcohol regularly and were involved in various legal violations. Seventy one per cent of adolescents below the age of 20 and 54.7% under 16 had begun to use alcohol. The reasons for alcoholism include growing unemployment and poverty, a widening gap between rich and poor, and
A Review of Literature, Projects and Case Study 2002
a fall in living standards among the population in general. Those economic factors, combined with a lack of discipline and loss of spiritual values, which have not yet been replaced by new ones, have created conditions conducive to possible reliance on alcohol, with very serious implications for the future of Mongolian society.
vulnerable to their negative influence35 . Injection of drugs
There is little information about the use of injectable drugs, but it does not seem to be a problem among adolescents. However, according to newspaper information, some adolescents and young people are interested in injecting The 2000 Adolescents’ Needs drugs. Assessment Survey found that, among respondents, the average starting age for 2.2.8 Adolescent groups with drinking alcohol was 17.6 years, plus or specific care needs minus 2-3 years, for both urban and rural areas, but urban adolescents were Disabled adolescents drinking twice as much as rural adolescents. Poverty, infectious diseases, malnutrition, social stress and unsafe environments In the 1997 Ministry of Health and Social that are not conducive to health are Welfare/WHO Survey, 22.4 % of those leading to physical and mental disabilities sampled who consumed alcohol came among adolescents. There are no survey from families with drinking problems, data on the health status, causes and and 18.5% of the respondents were health needs of disabled children and scared that one of their family members adolescents, and it is impossible to show was drinking too often. the percentage of disabled adolescents because the statistical information on Drug abuse disabled people from the National Statistics Office only includes social Among adolescents, 2.2%-2.3% use welfare data. However, a 2002 survey of drugs of some kind, including pain- disabled children under 15 years of age36 relieving drugs. The younger ones mostly found that: sniff petrol, polish or glue, and 10.1% of 17-20 year-olds have tried • 24.7% of the children were blind drugs34 . One in seven street children use or partially sighted; drugs of some kind, and are especially 27
Sexual and Reproductive Health of Adolescents and Youths in Mongolia
• 20.5% had hearing difficulties; • 16.4% had physical disabilities;
Children living in ver y poor households
There are 24 100 families and • 4.9% had learning difficulties; 116 000 people living below the poverty and line; 40% of those are very poor families, representing 57 301 children under • 5.0% were mentally disabled. 15 years of age39 . According to 1997 statistics, 8% or 34 000 of all school-aged children are handicapped. Of those, 37% are outside the school system, 5.8% are in special schools, and 50% are enrolled in ordinary secondary schools. Ministry of Education, Culture and Science statistics indicate that there are eight special schools, which cater to 1757 disabled pupils. Special schools for children with hearing difficulties and for those who are blind or partially sighted were established in 1954. The schools cover 80% of 7-18-year-old children with hearing difficulties37 . Many disabled children and adolescents are socially isolated due to boredom, shyness and fear.
2.2.9 Health services and IEC activities Health care for adolescents in Mongolia is provided through a multi-layered system, including government and private clinics and hospitals. As stated in the Health Law approved on 7 May 1998, the health of mothers and children must be under the constant attention of the State and medical care must be rendered free of charge. However, that is implemented only in State-run health organizations.
According to the Health Insurance Law of Mongolia, all young people under 16 years of age (or high-school students up to age 18) are covered by a health Orphans insurance scheme. However, street children and young people who have According to statistical documents, in migrated to cities may not have health 1996 there were 4197 orphans and certificates, making it difficult for them 57 395 children who had lost one to access health services. parent38 . 28
A Review of Literature, Projects and Case Study 2002
Current health services for adolescents focus on curative rather than preventive and promotive health care, and issues related to lifestyle health problems, such as reproductive health, substance abuse, mental health and nutrition, are not well addressed. Thanks to the joint efforts of the Ministry of Health and Social Welfare, the Ministry of Finance and the Ministy of Education, order number A/ 41/63/33 was passed in 1998, establishing the adolescent health bureau. By 2001, most provinces had an adolescent health bureau, but the majority were established based on former girls’ or gynaecological centres, so only the name changed and activities continued as previously. It is clear that physicians working in the adolescent health bureau are not clear about their own job descriptions. Around 34% of adolescents believe that health services are inadequate 40 and 57.3% that health care workers are inattentive to adolescents’ health concerns and problems, that they are often treated disrespectfully, and that they are given poor health services41 . It is clear that current health services for adolescents are inadequate and that there is poor appreciation of adolescent health issues.
access to information on reproductive health and sexuality. However, many adolescents receive some related information from television and newspapers or from school-based reproductive health programmes. In 1998, under the School-Based Health Education Programme, a training curriculum and training manuals for teachers were developed for the following health-related subjects42 : 1. Hygiene and sanitation (13 hours); 2. Infectious diseases (13.5 hours); 3. Reproductive health (21.5 hours); 4. Prevention of smoking, alcohol and drug abuse (11 hours); 5. Nutrition (24 hours); 6. Mental health (11 hours); 7. Oral health (16.5 hours); 8. Primary medical care (9.5 hours).
In 2000, the training curriculum was reviewed to improve integration and the relationship between subjects; 200 teachers were trained, but that Most adolescents (66%) receive number is still insufficient. Handbook information from friends due to limited quality does not meet requirements, with 29
Sexual and Reproductive Health of Adolescents and Youths in Mongolia
the exception of the Reproductive health handbook . A working group was organized to improve the quality of handbooks, with participation by the Ministry of Health; the National Centre for Health Development; the Ministry of Education, Culture and Science; the medical, pedagogical and the agricultural universities; and the Adolescent Future Centre. This group is presently active. Current health services for adolescents are insuffiecent. According to joint order A\41\63\33 issued by the Ministry of Health and the Ministry of Education, since 1998, schools with more than 901 students should employ a school doctor. Currently 144 schools have more than 901 students, but only 30% of those schools have school doctors. Most school doctors are retired doctors, as well as some feldshers and nurses. Young physicians working as school doctors often come and go, which has a negative impact on efforts to provide health information and services to adolescetns through school doctors. There is little or no outreach to marginalized sectors of society who may not be able to access health services easily. This includes migrant adolescents, street children and disabled adolescents. Mr. N. Tsogtsaikhan, Executive Director of the Association for Parents with 30
Disabled Children, expressed his feeling that there is a need to establish a rehabilitation centre for disabled children and adolescents, but also his fear that lack of coordination between the Ministry of Health and the Ministry of Education, Culture and Science made this impossible.
2.3 Education School enrolment rate The educational level of the population in Mongolia is high in comparison with other developing countries. According to the population census conducted by the National Statistical Office in 2000, the basic education enrolment rate was 86.5 % for children aged 8-15, and the completion rate was 66.3 %. The school enrolment rate for children among the lowest 20% of extremely poor households was 25% lower for primary and secondary schools and 65% lower for higher education institutions than those among the highest 20% of wealthy households43 . The recently introduced tuition fees for school programmes has put tremendous pressure on vulnerable groups of the population. In 2001, the teacher /pupil ratio in secondary schools was 25.4% and the completion rate at grade 5 was 85.9 %44 .
A Review of Literature, Projects and Case Study 2002
School dropout rate In 2000, 10.1% of children dropped out of school. Of these, 10.3% were aged 8-15 and 54.2% were adolescents aged 16-17. Nearly 46.5% were girls, and 12.7% were from provincial centres and rural areas. The school dropout rate was higher in rural areas than in urban areas and about 45% of those who left school went to work in livestock breeding or factories, and 26% did not wish to study for non-stated reason. According to the Population Census in 2000 the number of out–of-school children aged 8-15 was 68 155 and 89% of them lived in rural areas. School drop out rates are high for school-aged children of very poor households. In the early 1990s, the dropout rate was very high (8.8% in 1993), but in the last five years it has tended to decrease (3.8% in 1997 and 2.8% in 2001). Many schools throughout Mongolia are still using the old style of teaching, and success is monitored by academic performance rather than by personal progress and achievement that focuses on the learning process. As a result, many children are required to repeat grades if they have not reached the accepted standard, which results in a loss of confidence and decreased motivation. Between 1990 and 1998, 0.7%-0.9% of
students had to repeat a year, a very high proportion coming from the first grade. Social circumstances and the current structure of the education system have caused a sex ratio in favour of women among the students in the middle to higher grades of general education institutions. Child- and adolescent-friendly environment in school By 2000, there were 683 primary and secondary schools. Six of them have been working under the HealthPromoting Model School Project according to WHO standards. Only 6% (40 schools) of all schools are targeted for the Health-Promoting Model School Project nationwide. Recently the Health-Promoting School Project has not certified any school officially. Eighty four per cent of secondary schools with more than 901 students have school doctors. The Health Authority of Ulaanbaatar has developed its own standards for healthpromoting schools, and one secondary school has been certified through them. Many things contribute towards the high drop-out rate in schools, including financial constraints on families with school-age children; children being required to help with herding; bullying 31
Sexual and Reproductive Health of Adolescents and Youths in Mongolia
in school; lack of interest in school; lack of adequate textbooks and equipment; few or no libraries or sports facilities; no extracurricular activities; and a deterioration in facilities, including dormitory accommodation, and grim and uncomfortable classrooms, often inadequate heating, no hygienic toilet facilities and sometimes no electricity.
deteriorated even further. To some extent, children from poor families both in urban and rural areas are labouring in order to survive.
By 1998, 47.9% of children aged 0-15 were living with unemployed parents and in vulnerable groups of poor or very poor families that general poverty is not decreasing; indeed, it generally has Most secondary schools have lesson in increased. 2-3 shifts, increasing the capacity of school buildings. Only 31.7% of all Official data provided by the National schools are connected with the central Statistical Office suggest that in total water supply system, 28.2% use river there are 5271 working children 47 water and 46.5% of them have no pans including 46 girl prostitutes who are in which to keep water. Only 67.5% of registered by the Children’s Police all schools have ordinary toilets45 . The Department of Ulaanbaatar city48 . This toilets in schools often do not meet group represents 0.6% of the total child hygiene requirements. There are population and 3.48% of insufficient substances for sterilizing and 13-15 years-olds. cleaning due to the overloaded use of toilets, therefore cleaners close the toilets A study conducted by the Policy for and no one can use them. Juveniles Unit indicates that 14% of the girls living in the cities’ sewers and in Roughly two out of 100 students are building stairwells are involved in involved in after-school programmes, on prostitution 49 ; 66.7% of the girls average less than one in 100 participate answered that they became sex workers in music or other arts 46 . Thus, the to earn money and 38.9% because it was environment for adolescent health and part of street life or following rape development is limited. (33.3%) 50 . According to the survey, 57%-80% of young people up to the age of 16, and 42.9%-54.4% of 2.4 Labour 16-17 years-olds work full days. The Decreasing living standards over the last situation does not comply with labour 10 years has meant that the situation has laws, which state that 30 hours per week 32
A Review of Literature, Projects and Case Study 2002
is the maximum working period for health. This kind of labour in rural areas 14-15 years-olds, and 36 hours per week is not measured in terms of wages; it for 16-17 years-olds51 . contributes significantly to household income generation, helping parents to Data on herders’ children are more sustain the family. difficult to obtain. A large proportion of the active labour force is unemployed, The most common work activities of which may suggest that the employment urban children are selling sweets and of children as a labour force is juice on busy streets, at bus stops and in insignificant. A growing number of public places; washing cars; shining children are engaged in the informal shoes; gathering and selling fruits and sector, particularly in street trading, nuts; and doing odd-jobs in markets. In contributing to household income. ger (small traditional house) areas, However, as yet, child labour in the children are also found selling coal and formal sector is virtually non-existent. firewood, often obtained by illegal means from heating stations, train stations and Child labour in rural Mongolia is difficult other places where coal is stored. to appraise and the issue is largely ignored by government agencies and The most exploitative and hazardous NGOs. At the household level, the form of child labour, which requires hidden abuse of child labour is immediate action, is child prostitution. widespread. The participants in the Such children are severely exploited, both contract are mainly ‘employers’ and the by adults and their peers, being violently parents of the children. The majority of coerced into prostitution and living the children hired by wealthy families are under physical threat if they try to escape school dropouts, mostly from provincial or resist. Often they receive no money centres and soums or rural settlements. or salary, but in-kind payment in the form Child labour in rural areas can be of gang membership and protection, or considered traditional. It is usual for girls accomodation, food and clothing. to look after younger brothers and sisters, and to milk cows and clean homes, work The other highly hazardous form of not requiring physical strength. Boys, child labour is coal mining. Children’s however, graze cattle, prepare the supply involvement in mining as an (illegal) of fodder and hay and build cattle barns family activity is widespread and and sheds, work which requires a lot of represents a serious threat to their safety physical strength. These jobs are and health. considered to be hazardous to their
33
Sexual and Reproductive Health of Adolescents and Youths in Mongolia
Seven hundred children were involved in the survey carried out by the National Centre for Children and the Maternal and Child Resarch Centre, and 72.4% of those who worked had some disease. The highest percentage of morbidity was from diseases of the respiratory and urinary tracts, probably related to working in severe conditions and climates. Girls who worked had higher morbidity than boys in the survey52 .
poverty (39.6%), and general conflict between adolescents and parents; 72.1% of the children came from Ulaanbaatar and 53.4 % had left home for 1 to 12 months. It is necessary, first of all, to survey the children who are living on the streets and to take measures to return them to their families. According to the information provided by the Police Department, 14% of the girls who live in heating ducts and doorways are involved in prostitution. Several international and local NGOs conduct activities directed towards protecting street children, including Save the Children Fund of the United Kingdom, World Vision, Adventist Development and Relief Agency, the Damost Center, the Japanese Peace Wind and the Cristina Noble Fund. There are about 20 children’s care centres, with a capacity for about 1000 children, but only 750 children are living there. During the period from 1995 to 2000, a total of 6472 children were involved in health examinations, and 58% of them had some form of disease, the most prevalent being acute respiratory infection; trauma; STIs; skin infections; disease of the ear, nose and throat; and dental caries. Most of them had lost or had never had a health insurance card due to their non-permanent residency,
2.5 Street children There are many figures related to the number of street children, and there is no general methodology and concept defining street children. According to information from the National Centre for Children, 700 children spend the night in the streets of Ulaanbaatar. The information from the Police Department puts the figure at 400, and the Registration Department, which determines the address of children, at 90053 . A survey conducted by the Mongolian Child Right Centre 54 involved 79 children from 8-18 years of age who had left home, and 156 children aged 3-18 who were living at the Children’s Care Centre. The main reasons given for leaving home were domestic violence (49.5%), aggressive and abusive parents when they were drunk (24.7%), 34
A Review of Literature, Projects and Case Study 2002
non-registration etc. Without health insurance coverage, they did not receive medical care and were not able to be hospitalized.
Crimes committed by adolescents throughout Mongolia are usually the same as those committed by adults, including, in 1997, murder (20), robbery (1079), rape (47), fraud and violence (87). Thirty five per cent of street children are While crimes committed by adolescents always hungry and therefore beg represent only about 7.6% of all crimes, (20.2%), pick up rubbish (13.9%), and they involve more than 1500 teenagers find food in other ways in the 12-18 year-old age group57 . (20.2 %), particularly stealing. A survey55 , involving children aged 6-18 living in the Another area of juvenile crime that Children’s Protection Centre, determined seems to be increasing is crime the health status of 109 children: committed by groups. Crimes committed 64% had toothache, 23% otitis, by groups of adolescents increased from 41.8% sore throat, 19.3 % chronic skin 325 in 1999 to 656 in 2000, and inflammation, and 6.4% severe 75.8% (453) of them involved malnutrition; 77% had been smoking for adolescents from rural areas. 1-5 years; 14.8% used an opiate drug; and 12% drank alcohol. Thus, street children In children’s prisons, hygiene, food have already adopted lifestyles which will quality and availability of supplies needed impact negatively on their lives as future for children’s health and growth are citizens. In addition, the high number of inadequate. street children alone means there will be numerous illiterate and uneducated adults in the future.
2.6 Crime In 2000, 14 234 persons were sentenced, 990 of them adolescents, and 109 adolescents were jailed. The majority of juvenile offenders are school dropouts and unemployed. For example, in 2000, 71% of juvenile offenders were school dropouts and unemployed56 . 35
Sexual and Reproductive Health of Adolescents and Youths in Mongolia
3. Programmes and projects in response to adolescent health and development issues
3.1. Government programmes
and protection of children. According to the law, the State and families are not to consider children as outsiders or 3.1.1. Legal environment equals, but are to place the rights of The Government of Mongolia is party children first, and to provide for their to the Convention on the Rights of the rights to life and healthy growth, as well Child, which was adopted by the United as participation in social life. Nations General Assembly in 1989. In th 1996, Mongolia joined the Convention In the 7 paragraph ¹ 16 in the and internationally confirmed the rights Constitution of Mongolia, it is declared of children to a healthy life, as well as that basic education is provided free of th their defence and their active charge. In the 6 paragraph ¹ 8 of the participation in social life. Mongolia Law of Health Insurance, which was joined the World Declaration to approved in 1997, it is pointed out that “Provide conditions for healthy growth, the State will be responsible for health defense and development“, which was insurance fees for children up to 16 years adopted by the World Summit in New of age (if they study at secondary school up to age 18). Orphans come under the York in 1990. Law of Social Welfare and Care. The Law A law on Children’s Rights was approved of Labour, which was approved on 7 May 1996. According to this law, in 1999, defines the labour rights of the central organization for children under 18. They should only implementing state policy and defending work at a reduced number of hours and the rights of children is the National are prohibited from working in Centre for Children (current name is poisonous or hazardous conditions. National Committee for Children), while at the local level, the Governor is 3.1.2 National Programme on responsible for children’s rights issues. Health Education for School The National Committee for Children Pupils and Adolescents, 1997-2005 works as an agency under the supervision of the Ministry of Social The National Programme on Health Welfare and Labour, and its activities are Education for School Pupils and mostly directed towards social welfare Adolescents was adopted through 36
A Review of Literature, Projects and Case Study 2002
and develop teaching materials Government Resolution No.30 in for teachers and students; and January 1997. The primary goal of the programme is to strengthen student and • to organize seminars and adolescent health. The Ministry of consultations for decisionHealth, the Ministry of Education, makers from local authorities, Culture and Science, and other health organizations and others. organizations are responsible for coordinating and monitoring the programme. The National Council of Highlights of actual results attained by Programmes is in charge of the project: implementing and coordinating the • A formal education system on programme at the national level. At the health has been established for local level, the subprogramme on adolescents. adolescents was elaborated and adopted by the Provincial Governors. Health and • Trained teachers are teaching educational organizations in provinces health education lessons using a and the capital city should be part of the developed training curriculum subprogramme. and materials. The trainers for health education were trained Ten priorities for health education for from among secondary school secondary schools were identified as a biology teachers, and training of result of the collaboration between trainers was conducted in all health and educational institutions and provinces. public and international organizations. The main objectives of the programme are: • to improve health education programmes for students; • to encourage integration of health-related projects and programmes; • to train school health advocates • Adolescents have become intrested in health education and they understand its usefulness for them. • The project is being implemented with the support of WHO. The teaching programme contents were defined and developed, and some of them were printed with support from UNFPA, the Soros 37
Sexual and Reproductive Health of Adolescents and Youths in Mongolia
Foundation and the United Nations Development Programme (project on Water and Sanitation) agencies. Lessons learned: • There is a need to review existing health education materials, improve their quality and publish them in sufficient quantities. • There is a need to train more teachers/trainers on health education and to retrain them as needed. • There is a need to improve the assessment of health education programmes in secondary schools.
3.1.3 National Reproductive Health Programme, 1998-2000 This programme was approved through Government Resolution No. 126 in May 1997, and was implementated during 1998-2000. The current state of teenage pregnancy, abortion and contraceptive knowledge was brought into discussion under this programme. During the programme, 210 000 women gave birth, 299 maternal rest homes were restored, and model comprehensive reproductive health service clinics were 38
established in the capital city, Nalaikh district, and Selenge, Tuv and Umnogobi provinces. Reproductive health was included in the secondary school curriculum and relevant teachers were trained. However, the expected improvement in the main indicators was not achieved, and levels of STIs and maternal mortality had not decreased consistently by the end of the programme. There is still weak programme management; a poor guarantee of programme implementation, data collection, national capacity-building, monitoring and evaluation; and insufficient linkages within the sector, between sectors and between the central and local levels. It was also observed that the quality and the number of professionals trained in reproductive health services are insufficient, and that education and communication activities on adolescent reproductive health are only at the initial stages of development. The challenges that occured during the past few years due to changes in economic and social life and reproductive health issues in the population created a need to revise the National Programme. Thus, the National Programme on Reproductive Health was newly developed and approved by Government Resolution No 288, dated 28 December 2001.
A Review of Literature, Projects and Case Study 2002
The newly developed Programme aims to support the sustainable growth of the population by improving reproductive health status. The main objectives of the programme are: (1) to provide accessible, high quality and client-respected reproductive health services, in particular safe motherhood services, which meet the needs of men, women and adolescents;
(2) to improve knowledge and develop healthy behaviour in families and individuals to protect and prevent travellers A National Reproductive Heath Subfrom unwanted pregnancy, STDs Committee will be established with the and HIV/AIDS; following objectives: to lead and manage programme implementation nationwide; (3) to improve reproductive health to develop partnerships and coordinate knowledge among adolescents, and monitor implementing agencies’ to enable them to practice safe activities; to present a mid-term review sexual behaviour and make of the programme to the Government; responsible sexual decisions and and to submit proposals to the choices; Government for programme change. The Sub-Committee will be part of the (4) to strengthen the National Public Health Council. The institutionalized management National Public Health Council will and coordination framework, approve the rules and structure of the and to improve national capacity Sub-Committee. Branches of the through increased cooperation Reproductive Health Sub-Committees between the agencies will be established in provinces and the implementing the Reproductive city of Ulaanbaatar. The Ministry of Health Programme and Health will be responsible for providing participatory organizations; and professional leadership and the 39
(5) to create a favorable legal, economic and social environment for sustainable development of reproductive health through extensive involvement in decision-making on all levels by political leaders, policy-makers, administrative officers, mass media and NGOs, involving information dissemination, advocacy, training and advertisements that include issues related to reproductive health rights, gender equity and male involvement.
Sexual and Reproductive Health of Adolescents and Youths in Mongolia
management implementation.
of
programme
the Population will be elaborated and adopted by the Provincial Governors.
The following outcomes are expected at The aim of the programme is to form a pleasant environment for protecting and the end of the programme: strengthening citizens’ health by • A system for official and developing knowledge, correct attitudes unofficial training in and and practices, and supporting general improvement of reproductive health. One of the main reasons for health knowledge among implementing the programme was the adolescents will be created, poor habits and knowledge about health teaching methodology will be among adolescents. Under this developed, and trained teachers programme, offices for health training will be provided in health centres, with and materials will be available. the necessary up-to-date techniques and • Professional reproductive health instruments and trained professionals. offices, which will provide The National Centre for Health services for boys and girls, will Development is the leading agency for be opened in cities and implementing the programme nationally, and health educators from aimag/city provinces. health centres make up the main human 3.1.4 National Programme of resources for the project.
Health Education Population, 1998-2005
for
the
This programme was approved through Government Resolution No. 05 in 3.2.1 Improving the Outlook of January 1998 for implementation from Adolesent Girls/ Boys in 1998 to 2005. Mongolia The National Council of Programmes is in charge of implementing and coordinating the programme at the national level, led by the Minister of Health. At the local level, the Subprogramme on Health Education for 40
3.2 Projects of United Nations agencies
The project, Improving the Outlook for Adolescent Girls/Boys in Mongolia, was designed by United Nations agencies (UNESCO, UNICEF, UNDP, UNFPA and WHO) in collaboration with the
A Review of Literature, Projects and Case Study 2002
Government of Mongolia (Ministry of Health and Social Welfare and Ministry of Education). The Scout Association of Mongolia, the Mongolian Child Rights Centre, the Adolescents Future Centre, the One World NGO and the Mongolian Youth Development Centre actively cooperate in the project.
adolescent health, education and participation status. It is expected to impact on a significant number of direct and indirect beneficiaries in the piloting of a model framework for action. It welcomes and takes pride in the new enthusiasm for adolescent development and participation that the Adolescent Programme has fueled. Dialogue at all levels must continue to explore areas that may have been missed or inadequately analysed. Responsibilities and ways of working together must be identified among the many partners involved – the Government, civil society organizations, private enterprises, the media, United Nations agencies and, most importantly, adolescents themselves.
The aim of the project is to assist the United Nations to develop and execute an integrated, sustainable, multisectoral programme to respond to priority adolescent concerns in health, education, participation and communication/ media, as identified in the Mongolian adolescent needs assessment survey report, in collaboration with adolescents, communities, the Government and NGOs. The programme aims to increase knowledge, awareness and promotion of Highlights of actual results attained and child rights in the areas of education, success of the project: health, participation and development among adolescents, their caretakers and • An interministerial decree on the policy-makers, and to institutionalize Adolescents Project has been adolescent participation in the decisionsigned by the Ministers of making processes which affect them. It Education, Health and Social is a pilot programme to be implemented Welfare and Labour. The decree in a limited number of sites at central, approves the project’s provincial, and local district (soum) levels, implemention structure, which including urban and peri-urban consists of an Interministerial settlements. Coordinating Committee (later called Task Force), a United The programme is expected to achieve Nations Theme Group on a number of qualitative and quantitative Adolescents, and a Board of improvements in key indicators reflecting Adolescents to advise and
41
Sexual and Reproductive Health of Adolescents and Youths in Mongolia
contribute to the monitoring of working on each component according project implementation. to their mandates. • The Intersectoral Task Force was UNICEF component: established and included three deputy ministers, four United • Adolescent Development Nations agencies (UNESCO, Centres (ADC) are being UNICEF, UNFPA and WHO), established in 17 pilot schools, the National Committee for which have been provided with Children and the Chief extracurricular activities. The Commissioner of the Scout centres are connected to the Association of Mongolia. Non-formal Education (NFE) Subsequently, instead of the Learning Centres in the United Nations Theme Group provinces. They are staffed by on Adolescents, the United social workers trained to work Nations Country Team decided with disadvantaged adolescents, to establish a new United and they are open after school Nations Theme Group on hours to be accessible to all Young People. adolescents. The ADCs work with out-of-school adolescents • In July 2001, an Adolescent to tutor them back into the Board was established and, in formal education system. consultation with the members of the Board, its structure and a • Encouragement is being given to working plan for 2001 were capacity-building of youth determined. associations and NGOs. The NGO guidelines will develop • Student councils and school local initiatives and leadership. management boards were The central NGOs will be established in 17 project schools. available to guide newly founded One of the aims is to include NGOs or branches of central parents more closely in school NGOs in efforts to support local management. governments in their policies and mandates to improve education, The project has four components and health, child rights and other four United Nations agencies are issues supported by the United 42
A Review of Literature, Projects and Case Study 2002
Nations Country Team at pilot UNESCO component: sites. • A total of 73 distance education • The ‘My Passport’ adolescent facilitators (visiting teachers) participation campaign was were chosen and prepared. They established to increase then developed the distance adolescents’ civic participation, education parent-child sexuality reduce school absenteeism and education textbook, Are you increase adolescents’ desire, in listening? , as well as general, to play an active part in administrators’ and facilitators’ their communities. Areas of civic manuals. participation include health, communication, cultural • The ‘Kid-to-Kid’ media initiative development, self-development, (TV programme) was launched. volunteerism (ser vice), and youth participation in the UNFPA component: community. The campaign covers adolescents in secondary • Student books on reproductive schools, children’s councils, health and sex education were clubs, dormitories, shelters, etc. developed for students in Parents and teachers are 3rd to 6th grade and 7th to 10th encouraged to participate and grade. take an active interest. It is part of the mandate of the NCC to • The Uerkhel (Love) newspaper, develop and strengthen all editions 12 and 13, were adolescents’ rights to produced and disseminated to participation, and the ‘My adolescents aged 10-19. The Passport’ campaign is under the newspapers describe types and supervision of the Chairperson signs of child sexual abuse, as of the National Council for well as information about sexual Children, the Prime Minister of orientation. Mongolia. • Posters and booklets on sexuality and reproductive health were provided, including such topics as love, healthy and unhealthy 43
Sexual and Reproductive Health of Adolescents and Youths in Mongolia
relationships and relationship Problems encountered by the project: skills (communication, decisionmaking and responsibility in • As a result of the delay, most of relationships). the project activities have only just been set up, leaving only two WHO component: years for project action and impact. • A review was carried out of existing health education • The ministerial working groups materials and health services for have now developed an adolescents in ter ms of adolescent participation availability and accessibility, as component to contribute to the well as quality of service. groups. While this has been done and close consultations are now • Support is being given to taking place on project implementation of the implementation, the process is adolescent-friendly health still in its infancy. service in pilot areas. • Although the Adolescent Board • There is a focus on provision of is initiating many activities, they health education materials need to be allocated funding if produced within the project they are to continue their (dissemination of two series of activities effectively. posters, pamphlets and stickers for adolescents on tobacco and • The members of the Adolescent alcohol), and dissemination to Board feel that they should meet health facilities. more regularly with the Task Force to enable them to express • Education messages are being their views and exchange established through information opinions. and communication technologies, such as websites Lessons learned from the project: and CD-ROMs (1000). • The project inputs and outputs and its indicators were all clear; it is important to allocate and 44
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manage extra resources and activities, and to avoid duplication. • There is a need for consistent and participatory management from government counterparts, some of whom are, as yet, not very familiar with the project documents, processes and objectives. • There is a need for consistent integrated approaches throughout such a project and a need to include, in a more active manner, all the major NGOs who work with and for adolescent rights. • There is a need for more communication with the provincial level task forces to maintain the momentum established during training, and to continue to plan project activities with adolescents in order to reduce a tendency towards top-down planning and implementation. • The project, from the very beginning, employed a collaborative process between United Nations agencies and government counterparts,
national and international NGOs and adolescents themselves at every stage of planning and implementation. The project provided an excellent framework for all those agencies to work together in a consultative atmosphere, while developing a united vision. A harmonious working relationship has still to be developed with new government counterparts who have had less experience in the process that gave rise to the project, and who have less time to devote to the project and less experience in shared decision-making.
3.3. Programmes of NGOs Various NGOs have carried out different kinds of training, advocacy and surveys on adolescent reproductive and sexual health. The NGOs include: The Mongolian Family Welfare Association, the Scout Association of Mongolia, the Adolescent Future Centre, the National Centre Against Violence, the Women’s Movement for Social Progress, the Good Neighbour Association, the Family Planning Association and the National Centre for Children.
45
Sexual and Reproductive Health of Adolescents and Youths in Mongolia
3.3.1. Adolescent Reproductive Health Project (supported by UNFPA)
The number of unemployed persons, school dropouts and street children are • a workshop and survey on sexual increasing. As a result, non-formal life and sexual education; and education or training is very important in meeting the needs of those groups as • production of advocacy regards adolescent reproductive health. materials-pamphlets, leaflets, and The wide range of such training, posters. conducted through assistance and collaboration with local NGOs, has some advantages compared with the limited The Margeret Sanger Center International executed the project and curriculum of formal education. the implementing agencies were the The objectives of the project were to Ministry of Education, Culture and improve adolescent reproductive and Sciences and the Ministry of Health. The sexual health, help adolescents make the project was implementated in correct reproductive rights decisions, and June 1998 for a period of 3.5 years, develop reproductive health education finishing in 2002. that meets adolescents’ demands and requirements. The following general Highlights of actual results attained activities were conducted in the sphere through the project: of non-formal training: • The sexuality education curriculum was developed and • skills-based family life/human approved by the the Ministry of sexuality curriculum for Health and the Ministry of secondary schools; Education, Culture and Science for printing and pilot testing • training parents and adolescents during the 1999-2000 school through radio and television; year. The final official curriculum included 36 hours of lessons (22 • drawing up syllabi, serial lessons reproductive health, 11 mental, and books for parents; and 3 infectious diseases). The background materials were also
• non-formal and distance training, in collaboration with UNESCO and other NGOs, for unemployed, out-of-school and marginalized adolescents;
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edited, and 12 posters were developed as visual aids. The project printed 3500 copies of the lesson plan book, 1200 copies of background materials and 1035 sets of posters.
attitudes regarding reproductive health. • The Mongolian Family Welfare Association, the Scout Association of Mongolia, and Adolescent Future Centre were assessed and selected for inclusion in project training activities.
• Under the UNFPA project, 15 master trainers were trained in psychological counselling on sexuality attitudes, knowledge Lessons learned from the project: and practices, as well as training skills. The project developed • The project team did not share training programmes on systematically all reports or other sexuality for schools and NGOs project outputs either with the involved in the design of related Government or with all other educational materials. It also partners. facilitated one-day training programmes for mass media • In 1999, some activities were professionals and officials of the postponed to 2000 or 2001 due Ministry of Education, Culture to staff movement. and Science, the Ministry of Health and the Ministry of Social • The project gave a lot of Welfare and Labour. attention to producing quality work. The high quality • Uerkhel , the first newspaper achievements of this project dedicated to the topic of were indeed most encouraging reproductive health in Mongolia, and led the way to more quality was disseminated to young and creative actions to address people with the support of the the needs of adolescents in the project. Six 20-minute radio area of reproductive health programmes and messages were ser vices for out-of-school aired, two per month. These adolescents. were the first steps towards changing public perceptions and 47
Sexual and Reproductive Health of Adolescents and Youths in Mongolia
3.3.2 Other NGO projects
The names of the projects/programmes, their duration, the areas targeted for improvement their, audiences/ location Lessons learned: and implementing agencies and their • The NGOs did not share outcomes are described in the table systematically all reports or other below. project inputs/outputs either with the Government or with all Highlights of actual results of the other partners. projects: • A total of 325 children recieved social ser vices and were protected by the Hot ail Education and Shelter for Street Children project through Save the Children Fund support. • Many adolescents and young people who participated in the Smoking Free Youth project by ADRA-Mongolia gave up smoking. • Approximately 1000 adolescents received counselling and health services on reproductive health/ STIs free of charge from the Adolescent and Future Centre. UNFPA is supporting the centre. • Save the Children Fund developed two kinds of peer educator handout and a training curriculum on HIV/AIDS/STI 48 • The Peer Educator project showed that the adolescent-toadolescent approach is an easier way to communicate to a group of people with specific needs. • There is a need to promote the training of social workers, with emotional and financial support, especially in rural remote areas. • Counselling on reproductive health and sexuality education should be expended through a hotline in both urban and rural areas. • The formal health education curriculum and training manuals should be printed and distributed in sufficient quantity.
for students and social workers, and trained 35 peer educators under the Peer Educator project.
A Review of Literature, Projects and Case Study 2002 Table 5. NGO programmes and projects for adolescents health and development Name of the Duration project/programme Hot ail-Education Since November and Shelter for Street 1996 Children project Smoking Free Youth project Health Education project Reproductive health/STD counseling and health services Peer Educator project Audiences/ location 4-17 year-old children teachers at shelters and volunteers Since 2000 Training and IEC activities to 10-24 year-old prevent smoking youth 1998-2000 Formal health education Schoolchildren and curriculum and training adolescents manuals Since January Training on reproductive Adolescents and 1998 health, prevention of STI and youth free reproductive health services April, 1997 Teaching materials on Street children, HIV/AIDS and peer staff of orphanages educators' handouts. Training curriculum on HIV/AIDS/STI for students and social workers. Training for street children and staff of orphanages Since 1996 Preparation of school social School social workers, prevention of school workers and drop-out and capacity students building for them Since April 1998 Counseling on reproductive Adolescents and health and sexuality education youth (The project is implemented in urban areas only) Since March 1998 Training and IEC activities on Adolescents and prevention of youth STI/HIV/AIDS. Peer educators' training Since 1997 Treatment and prevention. Adolescents and Counselling on reproductive street children health and STI prevention Since 1999 Participation in political mini- Adolescents parliament. Social mobilization Areas targeted for improvement Life skills, child protection Implementing agencies National Committee for Children, with Save the Children Fund support ADRA Open Society Institute, SOROS Foundation Adolescent and Future Centre, with UNFPA support Save the Children Fund
School social workers programme Hotline for adolescents Hos bagana centre
Save the Children Fund Adolescent Future Centre with UNFPA Mongolian Youth Federation Mongolian Child Right's Centre One World NGO, with support from UNDP
Hot ail project One World project
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Sexual and Reproductive Health of Adolescents and Youths in Mongolia
4. Rationale behind the development of selected policy options, particularly the national adolescent and youth health and development policy The rationale of the policy may be divided into two parts, as follows: (1) Duty, as laid down internationally: • Protect the adolescents58 . rights of • good health habits at the national level. Adolescent health and development is low due to insufficient parental attention to the problems, inadequate intersectoral collaboration on adolescent health, and insufficient development and education, and the environment is not conducive to adolescent health.
• Support the development of healthy lifestyles through promotion of education, supportive and safe environments for health, and healthy behaviour during childhood and adolescence to establish lifelong healthy practices59 . • Invest in adolescents to promote equity and social justice60 . (2) Specific national needs of adolescents: • There needs to be a focus on preventive efforts rather than curative activities and on reducing the factors negatively affecting health, to improve the quality and environment of life, to follow the policy directed at social health, and to develop 50
• There is an increasing need for health education for adolescents to improve their physical and mental development. • Adolescents’ tendency to have selected lifestyle diseases and their risk of STIs is increasing. Preventing risky behaviour and promoting healthy choices among adolescents can give them a better chance of becoming healthy, responsible and productive adults and increase their productivity and the country’s progress. • Insufficient emphasis is being
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given to determining a system for controlling the health of adolescents, giving them health education and counselling,
treating disease and pathology, and ensuring good nutrition.
5. Development process of adolescent health and development policy The Health Policy of Mongolia is adolescents were not considered as an implemented through national independent population group until the programmes. In the development of end of the 1990s. policies for those national programmes, Table 6. Development of programmes for adolescent health and development Name of the programme 1. National Programme of Action for the Development of Children by the year 2000 Duration 1996-2000 When adopted Government Resolution No.30, May 1993 Initiating and leading organization National Centre for Children Budget allocation 2148.05 million tugrugs from the government budget and US$97.48 million from external resources Not clear
2. National 1997-2005 Programme on Health Education for School Pupils and Adolescent Health 3. National 1997-2001 Programme on Reproductive Health Second National 2002-2006 Programme on Reproductive Health 4. National 2002-2010 Programme for Improving the Mode of Living of Children and Adolescents until 2010
Government Resolution No.30, January 1997 Government Resolution No.126, May 1997 Government Resolution No.288, December 2001 In processing since February 2002
Ministry of Health and Ministry of Education, Culture and Science Ministry of Health
5 million tugrugs from the government budget and US$ 9.3 million from UNFPA
Ministries of Health; Education, Culture and Science; Social Welfare and Labour; Justice
Donor assistance
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Sexual and Reproductive Health of Adolescents and Youths in Mongolia
At present, there are no clearly stated several times to: overall policies relating to the needs and • analyse and review the situation problems of adolescent health, and areas of development for education, social welfare, etc. However, children; there are some programmes equivalent to policy for adolescent health and • discuss suggestions and development, most of them initiated by comments, highlighting the main the Ministry of Health and the Ministry issues; of Education, Culture and Science. Adolescent health and development policies are reflected in the four government documents (see Table 6). National Programme of Action for the Development of Children by the year 2000 One of the main policy documents on adolescent health and development is the National Programme of Action for the Development of Children by the year 2000. The Ministry of Labour and Social Welfare initiated the programme, establishing a Prime Ministerial Task Force (1992) and involving representatives from many different stakeholders. Several working groups were established and functioned within four ministries (the Ministr y of Population Policy and Labour, the Ministry of Health, the Ministry of Education, and the Ministry of Finance), the National Statistical Office and the National Development Office. The working groups and task forces met 52 • develop a draft programme of action document ; and • discuss the draft with specialists, senior programme managers and heads of provincial governors’ cabinets. The Prime Minister approved the Programme of Action in May 1993. The programme was intended to provide direction in the for mulation of multisectoral activities to achieve the goals for children in the 1990s, in accordance with the Declaration and Plan of Action of the World Summit for Children, a convention of the United Nations General Assembly. The programme stated, “… The National Programme of Action reflects the active care and concern of the Government for the welfare of children and women, to ensure health, education and productive prosperity. It will become an integral component of the social welfare and development policy under the country’s
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newly-prevailing circumstances…”. The framework of the programme was developed according to the Convention on the Rights of the Child (adolescent) and the Law Protecting Children’s Rights in Mongolia Main principles of adolescent health and development were stated as: • Involvement of governmental and nongovernmental organizations; • Establishment of multisectoral partnerships; • Domestic mobilization; • International cooperation and collaboration; • Selection and prioritization of goals; • Utilization of the potential of mass media and other effective forms of social communication. The programme covered the following priority areas: • Health and nutrition of infants, preschool children and schoolchildren;
• Early childhood development; • Primary education; • Adult literacy; • Children with mental and physical disabilities; • Children in difficult circumstances (orphans, street children, child victims); • Women’s welfare; • Water supply and sanitation. A Programme Coordinating and Implementing Committee was established under the National Children’s Council, chaired by the Prime Minister. The Minister of Population Policy and Labour headed the Programme Coordinating and Implementing Committee. Under the Committee, by which state policy was developed and implemented, the National Centre for Children organized and coordinated dayto-day activities among citizens and organizations using social resources. Programme documentation was supplemented with a detailed action plan. The National Centre for Children was designed as an intersectoral body to monitor and implement the policy. Since government restructuring, the Centre has 53
Sexual and Reproductive Health of Adolescents and Youths in Mongolia
been part of the Ministry of Social Welfare and Labour. The Programme was published in Mongolian and English with the support of UNICEF, and was widely circulated among stakeholders such as ministries, agencies, NGOs and the general public. The programme had budgeted 2148.05 million tugrugs (local currency) from the Government budget and US$97.48 million from external resources for programme implementation. However, no expenditure report was found during the review. National Programme on Health Education for School Pupils and Adolescents
The National Programme of Action for the Development of Children by the year 2000 did not consider adolescents as an independent specific population group, but included them with children because The specific objectives af the Article 3 of the Law Protecting programme are: Children’s Rights in Mongolia (May of 1996) mentions that the law protects • to improve the content and children from birth to 18 years of age. methodology of training systems Adolescents were deter mined an to strengthen student and independent population group in the adolescent health education and Population and Development physiological development; International Conference, held in Cairo, September 1994, when it was pointed out • to reduce common diseases that society should consider their health among adolescents and to 54
needs, particularly reproductive health and services. Mongolia supported the Cairo Declaration and it was felt that the country should implement programmes of action developed by the Conference. Thus, the Ministry of Health and Social Welfare initiated the National Programme on Health Education for School Pupils and Adolescents near the end of 1995 as a means of paying attention to adolescent health issues and problems. The National Programme on Health Education for School Pupils and Adolescents was adopted through Government Resolution No.30 in January 1997. Its implementation period is from 1997-2005. The primary goal of the programme is to strengthen student and adolescent health by encouraging government and public entities and parents to pay attention to adolescent health issues, create a sound and sufficient health education programme and improve physiological development.
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improve activities to prevent disabilities and impairment; • to create and promote a healthy environment for adolescents by increasing the role and participation of communities, organizations, families and volunteers; • to encourage Health-Promoting Schools; and • to train professionals in raising the awareness and understanding of adolescent health among teachers, school principals and the general public. The National Task Force takes the lead role in coordinating, implementing and monitoring the programme. However, the professional control and management lies with the Ministry of Health, the Ministry of Education, Culture and Science and other related organizations. In rural areas, branch councils implemented the programme with the support of provincial and city organizations in the areas of health and education, as well as other related organizations. By the end of 2005, the programme should have achieved the following objectives:
• to increase the percentage of adolescents with normal height and weight by 5% above the level in 1995; • to increase the percentage of adolescents involved in formal and informal health education training to 90%-95%; • to increase the percentage of Health-Promotiing Schools to 50%; • to increase the percentage of health facilities and adolescent doctors/specialists who provide health services for adolescents to 80%; • to reduce adolescent morbidity from 743 to 595 per 1000; • to reduce the percentage of teenage pregnancies from 9.0% to 3.0%; • to reduce the percentage of adolescents among STI patients from 16.0% to 10.0%; and • to increase the percentage of young people who join the army from 68.2 to 80%.
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Sexual and Reproductive Health of Adolescents and Youths in Mongolia Table 7. Main stakeholders/ participators/ organizations and their roles and functions in policy development Main stakeholders/ participators/ organizations 1. National Committee of Student and Adolescent Health Programme 2. Standing Committee of Social Policy in Parliament 3. Department of Public Health, the Ministry of Health 4. Department of Primary and Secondary Education, Ministry of Education, Culture and Science 5. Subcommittee of province/city for Adolescent Health programme 6. National Committee for Children 7. Mongolian Youth Federation 8. Adolescents Level National National Main roles and functions - Coordination - Monitoring
- Creation of legal environment Intersectoral - Assessment and analysis of adolescent health needs and identification of trends - Professional consultation - Implementation - Monitoring and evaluation Provincial - Coordination at the provincial level - Monitoring of activities implemented - Assessment and analysis of adolescent health needs and identification of trends - Implemention of policy Sharing of resources - Participation in needs assessment
National
National
The National Programme on Health Education for School Pupils and Adolescents was published in the Mongolian language. No information about budget allocation for the programme was found during the review.
from UNICEF and in collaboration with the Ministry of Health, the Ministry of Education, Culture and Science, the State Policy Department and the NCC. The survey provides accurate and systematic information on the National Programme of Action for Children 1990-2000 and National Programme of Action for baseline data for future actions. The Improving the Mode for Living of evaluation identified the next necessary Children and Adolescents until 2010 actions as designing and planning a new National Programme of Action for In 2000, the Child and Development Children and Adolescents for the next Survey-2000 was conducted by the decade. National Statistical Office, with support 56
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By joint order of the Ministries of Health; Education, Culture and Science; Labour and Social Welfare; and Justice and Internal Affairs, Order No 08/19/10/17, dated 16 January 2002, established a working group for the development of the National Programme of Action for Improving Child and Adolescent Status. Since February 2002, The Ministry of Health, together with its partners in the Ministries of Health; Education, Culture and Science; Labour and Social Welfare; and Justice and Internal Affairs, and various other government agencies and nongovernmental organizations, have initiated the formulation of a National Programme of Action for Improving the Mode for Living of Children and Adolescents until 2010.
(1) social welfare and protection; (2) health and nutrition; (3) rights and participation; (4) education and development. It was decided to continue the activities of the National Council for Children, headed by the Prime Minister, to coordinate intersectoral implementation of the programme. The goal of an adolescent health and development policy, which is implemented through government programmes, is to promote and protect the needs and rights of adolescents to access information, basic life skills, comprehensive health services and a safe and supportive environment. The plan of action provides a framework for focused action and resource mobilization for the comprehensive promotion of healthy development of adolescents through provision of a pleasant environment and needed services.
A working group, headed by the Deputy Minister, was established in every ministry involved, and they had several meetings during February and March 2002. They developed a draft programme after comprehensive collection and analysis of information. The working group, with representatives from four ministries and headed by the The programme will be based on the NCC, after discussing the draft, reported following guiding principles: to the Prime Minister on the progress of programme development. The • a rights-based approach; working group has worked to formulate • gender sensitivity; policy in the following areas:
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Sexual and Reproductive Health of Adolescents and Youths in Mongolia
• an adolescent-friendly participation and involvement has environment; increased in the last few years. • privacy and confidentiality; and • participation and consultation. Major stakeholders
Programmes of many kinds exist to promote health, prevent problems and The National Programme will be focused provide care and rehabilitation for on the following elements: adolescents. Stakeholders in the health and development of adolescents come • accessible, available and from all sectors of government and acceptable health information; nongovernmental organizations. There are around 40 stakeholders in the • ensuring the equity and quality adolescent health policy development of health services for process: adolescents; Health: • promotion of friendly, safe and supportive environments for (1) Department of Public Health, adolescents; the Ministry of Health • improvement and promotion of the capacity of health care providers for adolescents; and • development of multisectoral partnerships and collaboration with NGOs, international agencies, donors and the community. Adolescents’ participation in developing policy, strategies and integrated interventions is in the initial stage. Under the UNICEF and UNDP projects for adolescents and young people, their 58 (2) Department of Medical Service, the Ministry of Health (3) Health Departments in provinces and City Health Authorities (4) Adolescent Health Cabinet Doctors in provinces/cities (5) Soum/ family doctors (6) Maternal and Child Research Centre
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(7) Department of Paediatrics, the Mongolian National Medical University (8) Nutrition Research Centre (9) Health Promotion Department of the National Centre for Health Development (10)National Centre for AIDS/ STIs (11) Health centres and hospitals (12) Adolescents/young people and their parents. Social Welfare Services: (13)National Children Committee for
(18) Schools and colleges (19) School doctors and nurses Local NGOs: (20) Child Right Centre (21) Mongol Vision (22) Mongolian Youth Federation (23) Mongolian Women’s Federarion (24)Mongolian Family Welfare Association (25) Scout Association of Mongolia (26) Adolescent Future Centre International NGOs:
(14) Child Care Centres Education: (15) Department of Primary and Secondary Education, Ministry of Education, Culture and Science (16) Education and culture centres in provinces/ cities (17) Education Development Centre of the Pedagogical University 59 (27)Margeret Sanger International Center
(28) Soros Foundation-Mongolia (29) World Vision-Mongolia (30) WASH-21 (31) ADRA-Mongolia
Sexual and Reproductive Health of Adolescents and Youths in Mongolia
Police: (32) Children Police Department of Ulaanbaatar city and provinces United Nations agencies: (33) WHO (34) UNICEF (35) UNFPA (36) UNESCO (37) UNDP Politicians: (38) Social Policy Advisor to the President (39) Social Policy Advisor to the Prime Minister (40) Standing Committee of Public Policy of Parliament (41) Prime Minister’s Cabinet
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6. Implementation of the policy A national policy for adolescent health requires structures to implement that policy and ensure it is carried out in a consistent, coherent and coordinated way. These structures will vary from country to country but could involve the creation of: schoolchildren. However, several surveys have been carried out to create an information database, determine policy on adolescent reproductive health and develop a rationale for policy change, such as on reproductive health behaviour and the condition of reproductive health ser vices; the sexual behaviour of • interdepartmental or adolescents (with UNFPA support); and multisectoral committees for a KAP survey on health and health adolescent health; service delivery for adolescents (with WHO support). • joint task forces on specific adolescent health policy issues; The opportunities for organizations to discuss each other’s work, duplication of and resources and what problems require the • the appointment of elected most urgent attention are limited. Such members or senior government a lack of coordination affects the officials to oversee the implementation of activities to protect adolescent health policy and be the health of adolescents, as pointed out accountable for its planning, in the Instruction of an adolescent doctors’ implementation, monitoring, performance, approved by appendix ¹ 7 in evaluation and further the joint of order A¹\41\63\33 of the Ministers of Health and Social Welfare, development. Finance and Education in 1998. There are no surveys or materials that Adolescent health doctors are specialists evaluate health conditions and the causes who have the responsibility for of morbidity and mortality, and there is controlling the health of children up to no proper information about the 20 years of age; rendering primary measures needed for implementing medical care, providing health education improvements in the health and and prophylactics for disease, developing development of adolescents and habits for living healthy, and leading 61
Sexual and Reproductive Health of Adolescents and Youths in Mongolia
doctors of schools and colleges in the promotion of professional methodologies related to adolescent health. Adolescent health doctors have the following duties:
and to manage health promotion activities. (5) To organize the work of encouraging participation by international and public organizations and to help coordinate efforts for the protection and improvement of adolescent health.
(1) To conduct health education training to enable health care providers to give children up to 20 years of age, as well as (6) To report annually on joint secondary-school and work with other organizations. kindergarten students in their areas, the knowledge needed for According to order A-¹\41\63\33, every healthy living province and district of Ulaanbaatar should have at least one adolescent (2) To organize working teams, cabinet. Currently, 83% of health consisting of training doctors facilities have an adolescent cabinet, and advocates, health centre 77% of facilities have doctors, 30% of family doctors, nutritionists, them gynaecologists, 50% paediatricians hygienists and school doctors, to and 10% health educators. Most of them arrange joint work programmes have attended some training, but not and interconnected activities. sufficient to meet the requirements of the functions and duties mentioned (3) To organize specialist above (Table 7). examinations annually, to determine the level of health, to There are around 200 school doctors carry out treatment and capacity- employed by the Ministry of Education, building, and to pass on results Culture and Science. The Ministry of to the joint working group in Health is responsible for their order to decrease morbidity professional development, only but a among adolescents small percentage of them have attended training on adolescent health and (4) To organize the development development issues. of health promotion in schools 62
A Review of Literature, Projects and Case Study 2002 Table 8. Service providers for adolescents and their training needs Main health service providers for adolescents 1. Adolescent cabinet in province and city Person who provides health service to adolescent Main services for adolescents Provided Should be provided - Psychosocial risk assessment Main training for service providers Attended - Adolescent reproductive health - Substance abuse and health education No specific training on adolescent health Needed training
2. Family practitioner group
3. School doctors
Paediatrician, - Curative services gynaecologist or - Drug prescription health educator - Counselling - Screening - Health education and control of health lesson provision in school Family doctor - Curative services or general - Drug prescription practitioner - Referral to hospital/next level health care - Growth monitoring - Counselling - Health education General - Primary medical aid practitioner - Vaccination or - Screening Paediatrician - Health education - Control of health lesson provision in school
- Primary health care - Screening - Health education
- Health education
Training on Healthpromoting schools
- Basic Medical services - Medical social work - Screening - Communication and counseling skills - Psychosocial risk assessment and counseling - Behaviour change - Teaching methodology - Health education - Peer educator training - Community development - Social mobilization
General - Curative services practitioner and - Vaccination feldsher - Drug prescription - Referral to hospital or next level health care - Growth monitoring - Screening - Control of health lessons in school - Curative services 5. The Maternal Paediatrician - Screening and Child Research Centre 4. Soum hospitals
- Counseling - Health education
No specific training on adolescent health
- Counseling - Health education - Training for providers of adolescent services
Monitoring of the content, methodology and implementation of the health education programmes taught in secondary schools is the responsibility of the NCHD (previous name is HMIEC)
and the School of Educational Development, Pedagogical University. However, the ongoing activity has not yet reached required levels.
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Sexual and Reproductive Health of Adolescents and Youths in Mongolia
It has been shown that, to improve the quality of adolescent health services and to improve the skills and attitudes of service providers for adolescent health and development successfully,
development of human resources for health, particularly the clarification of job descriptions and broad systematic training, needs to be given a higher priority.
Figure 6. Organizational structure for policy implemention at the national and provincial levels
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7. Effect/impact of adolescent health and development policy Adolescent health programmes in support from UNFPA has helped this Mongolia have shown some positive effort greatly. results, including: However, although adolescents’ (1) Adolescents’ knowledge of their knowledge regarding reproductive health own health, particularly has increased, application of that reproductive health, has knowledge for decision-making is still weak, and must be considered a priority improved. for the Reproductive Health Programme One successful programme is the for the next five years (see Figure 7)61 62 . Reproductive Health Programme. Many organizations are working successfully on One of the main results of the National adolescent reproductive health. As a Programme on Health Education for result of programmes, adolescents’ School Pupils and Adolescents is the knowledge and attitudes towards school-based Health Education reproductive health and STIs have Programme, included in the curriculum improved markedly, despite an increasing of secondary schools. Through this number of pregnancies among teenagers curriculum, adolescents receive basic and cases of STI. Financial and policy knowledge and messages on hygiene and Figure 7. Comparision of reproductive health knowledge and practices of adolescents
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school doctors and doctors of adolescent cabinets, as well as standards of service for adolescents, are not defined clearly and thus it is difficult to control and evaluate their activities. However, the working group responsible for Knowledge, attitudes and skills of developing the standards for health care students in grades 9 and 10 are improved and services for adolescents has been set through school-based sex education63 . up, and is working at the Ministry of The students like to get information Health. from teachers who have been specially trained in sex education and those By 2000, there were 683 primary and teachers are very supportive of the secondary schools, six working under the implementation of the school-based Health-Promoting Model School curriculum and the positive impact of Project 66 , 6% (40 schools) of all the their training. However, the present schools targeted for the project at the hours allotted to the health curriculum national level. Presently no school is a are not enough for students to learn all certified Health-Promoting School the reproductive health information that nationally, because the criteria and might be useful to them64 65 . indicators, which were developed by NCHD in 2001, have still not been (2) The health care service system approved by the the Ministry of Health. for adolescents has been established. The Health Authority of Ulaanbaatar has developed its own standards for HealthThe network of adolescent health Promoting Schools and one secondary services has been established in every school has been certified through them. stage of the health service referral system. However, quality and access need Family doctors work to deliver health to be improved as adolescents’ care to the general population to improve satisfaction, feelings and utilization of their health by providing primary health health services are insufficent. care and coordinating the required specialized professional care. Therefore, Approximately 84% of secondary as part of their duties, they render help schools with more than 901 students and services to adolescents following have school doctors. Job descriptions for definite standards. sanitation, infectious diseases, reproductive health, prevention of smoking, alcohol and dr ug abuse, nutrition, mental health, oral health and primary medical care. 66
A Review of Literature, Projects and Case Study 2002 Table 9. Main indicators of the national programme on health education for school pupils and adolescents Measurement indicators Baseline data 1995 1. Percentage of adolescents Boys 91.7% with adequate weight and Girls 87.9% height for their age 2. Coverage of formal and informal health education for adolescents 3. Percentage of schools that are certified as a Health-promoting school 4. Percentage of health staff and facilities that provide adolescent health services 5. Morbidity of adolescents 743 per 1000 6. Percentage of births to 9.0% adolescents under 20 years of age per total births 7. Percentage of adolescent 16.0% with STD under 20 per total cases 8. Percentage of young 68.2% people who are accepted to military services Current 2000/2001 n/a n/a 0% Not clear* 210 (5-15 yrs)** 254 (16-19 yrs)** 9% 14.2% n/a Goal 2005 Increase by 5% each 90-95% 50% 80% 595 3% 10.0% 80.0%
Note: n/a - not available * Estimation of this figure is difficult and not clear. According to order A-¹\41\63\33, every province and district of Ulaanbaatar should have at least one adolescent cabinet. 83% of health facilities have an adolescent cabinet, but only 77% of facilities have doctors. However 30% of them are obstetricians/gynecologists, 50% are paediatrician and 10% are health educators. ** Based on registered cases of morbidity
(3) Generally there has been an population group, with specific needs. increase in participation by adolescents in decision-making concerning their own problems The National Programme of Action for and some initial activities have the Development of Children by the year been launched. 2000 (May 1993) did not consider adolescents as an independent, specific (4) At the decision-making level, population group and adolescents were adolescents are now being included with children. considered as an independent 67
Sexual and Reproductive Health of Adolescents and Youths in Mongolia
In Public Health Policy of November, 2001, National Programme on Reproductive Health (December 2001) and the draft of the National Programme of Action for Improving the Mode of Living for Children and Adolescents till 2010 (February 2002) it was agreed that adolescents are an independent group of the population and that they would benefit from a special programme that provides for their health and development issues. (5) Information about adolescent health and development has been collected and analysed for policy development and decision-making. Between 1995-2000 the following surveys on adolescent health and development were carried out: • Survey report on morbidity of adolescents (1995)
• Smoking in Mongolia: prevalence, knowledge, and attitudes in urban areas (2000) • Smoking among high school students in Ulaanbaatar (2000) • Needs assessment survey on reproductive health (2000) • Mongolian adolescents needs assessment (2000) • Children and women in Mongolia-situation analysis report-2000 (2000) • Reproductive health: evaluation of school-based sexual education in Mongolia (2001) • Health behaviour of adolescents (2002)
Morbidity and mortality data on adolescents are available to decision• Adolescent Reproductive Health makers and policy developers through Survey (1996) the national health management information system. However, • KAP survey on adolescents’ information about health care and health (1997) services and the number of adolescents aged 10-19 who use the health care • Girls as sex workers-situation and system is limited to that available from trends in Mongolia, sur vey the reports of family doctors concerning results (1998) the information-gathering process and the results of the National Programme 68
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of Health. The reporting data are classified according to two groups: 5-15 years and 16-60 years. National health indicators (e.g morbidity), which are analysed by National Centre for Health Development and the Ministry of Health, classify the population as 5-15 year age group or 16-19 year age group. It is difficult, therefore, to identify the morbidity of adolescents.
supported by United Nations agencies (UNICEF, UNFPA, UNESCO, WHO, etc.) and other NGOs and are intended for improving adolescent health and development, contribute to the formulation and implementation of adolescent health and development policies and programmes in Mongolia. Budget allocations from the Government may have been approved when a programme was developed, but (6) Financial support from donor during the implemention period, the agencies has played a big role in planned budget may or may not be implementing health available, depending on the social and economic conditions of the country. programmes and projects. Budget shortfalls are more common at Projects/ programmes that are the local level.
8. Lessons learned (1) Clear legal environment and (2) Advocacy for adolescent health legislation for adolescent health and and development development Advocacy for adolescent health and Adolescents need to be assessed as an development is important to the people independent population group in policy who develop policy, such as higher-level documents and statistical data. decision-makers, planners and finance According to the law, the legal age of officers in local areas. In particular, timely marriage is 18 years and there is a social involvement of the Government and bias to consider pregnancy among local authorities in terms of budget has unmarried women aged 18-19 years as a great contribution to make in legal. Implementing international implementing policy direction. projects in Mongolia directed at adolescent issues gives an opportunity to (3) Building technical capacity determine adolescents as an independent population group. Efforts to address adolescent 69
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reproductive health issue have resulted in a growing technical capacity at the national level. A system for adolescent health and development services has been established through the health education programme in the secondary school curriculum, school doctors and the adolescent cabinet network. There is a need to develop this system for adolescents, to clarify the job descriptions of school and adolescent cabinet doctors, and to develop and review the content and teaching methodolog y of health education programmes in secondary schools. There is also a need to increase communication between parents, teachers, health workers and adolescents on health issues, their future, education, ethics, values and social life. Adolescents’ doctors address the problems of adolescence only from the medical side. They cannot see the overall problem. Adolescents’ doctors and teachers of health education programmes seem to have little ability to communicate. The quality of the health education programme is poor because health lessons are not assessed. It may be that teaching methods are poor or lesson plans may not be optimal. It is necessary to increase awareness and promote the rights to survival, education, participation and development among 70
adolescents, caretakers and policymakers. The environment affects the mortality and morbidity of children and adolescents. The rights of children to live in unhealthy and unsafe environments are being violated, as is pointed out in the Law of Children’s Rights. For example, the increase in mortality due to mental disorders may be connected with social anxiety and oppression. (4) Proper systems for information, surveys, reporting and registration Health indicators are not reported for the adolescent age group because there is no legal definition of adolescence, making it difficult to determine adolescent health status, particularly morbidity. According to the joint sur vey of NSO and UNICEF, the under-five mortality rate is 62 %; that rate differs from official statistics, so it is necessary to improve the reporting system. There is also no general definition of street children. There are different figures from the many studies that have been undertaken on adolescents, some of them duplicated. Therefore it is necessary to improve relations, integrate the results of surveys and create a database or information system.
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(5) Developing integrated supportive interventions Adolescents’ participation in the development of national policy, strategies and integrated interventions is crucial in meeting their needs. One example of the activities being initiated in Mongolia was the One World-Adolescent National Assembly on the New Generation, held in June 2001with support from UNICEF, UNDP and the National Committee for Children. During the Assembly, adolescents determined the constraints they must deal with, what they could do and what they would like the Government to do to overcome those barriers: What can adolescents do themselves? • Promote social mobilization • Organize IEC activities on reproductive health • Make correct life decisions and healthy choices • Contribute to building a green and healthy environment • Take responsibility for their own health
What kind of constraints affect adolescents’ health? • Low quality of health education programmes • Insufficient service by family doctors • Limited reproductive health services • High prices for imported quality medicines • Insufficient numbers qualified doctors in soums of
• Stress due to a high incidence of divorce What should the Government do to improve adolescents’ health and development ? • Widen services through new government organizations • Increase workshops and training for adolescents • Consider special education programmes for disabled adolescents • Work to decrease the number of pregnancies among teenagers
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• Organize monthly health examinations • Improve the supply of diagnostic and curative equipment and facilities • Supply healthy food • Increase the supply adolescents’ doctors. of
It is necessary to involve all people interested in solving adolescents’ health problems in all stages of planning, implementing, controlling and evaluating efforts aimed at improving their health, development and welfare. The needs of adolescents are often determined by medical professionals, so it is necessary to clarify or determine communityperceived needs. While projects and programmes are developed and approved by people and organizations at the mid or higher levels, who perceive the needs of the community, the people who must implement them do not participate in the preparation process, which negatively influences their implementation. Community-perceived needs are not reflected well in the development process. Therefore efforts are often criticized and results poor.
Multisectoral and intersectoral collaboration to address the problems of adolescent health and development is very important and much needed. It is necessary to improve the coordination of activities of projects and programmes developed for the health and welfare of adolescents, as well as the activities of organizations that work in the same fields of adolescent health and development. Experience shows that it is important to organize coordinating councils and committees under the direct supervision of the Prime Minister to coordinate the planning and financing activities of the ministries addressing adolescents’ problems. Many organizations are working successfully on adolescent reproductive health, but other health-related problems, such as mental health and rehabilitation, are ignored. Therefore, coordination of activities and proper distribution and reallocation of resources is necessary. Relationships between NGOs and service organizations are very strong and provide the impetus to promote and continue adolescent programmes in many non-funded sectors.
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(6) Strengthening health systems to There is also a need to enhance the improve services for adolescents effectiveness of existing health interventions and services. More efforts to provide expanded access and quality health services to adolescents, especially within the county health systems, are urgently needed. The job descriptions of adolescents’ doctors and school doctors need to be clarified. Improvements also need to be made in the knowledge, skills and attitudes of health ser vice providers, such as adolescents’ doctors, school doctors and family and soum doctors to enable them to provide comprehensive adolescentfriendly services. Systematic training of health staff needs to include counselling skills and ethics concerning patient security and privacy. (7) Gender equity It is important to highlight the imbalance between boys and girls in Mongolia in level of education. Boys are becoming marginalized, particularly in rural areas. In urban areas, they are catching up and may surpass girls if the present trend continues. At the tertiary level of education, more than 70% of students are girls. Gender equity in services is important because most activities of adolescent cabinets are directed towards girls, and boys have limited access to services. 73
Sexual and Reproductive Health of Adolescents and Youths in Mongolia
PART II 1. Review of health services for adolescents Mongolia is making a systematic effort to improve health ser vices for adolescents with a two-fold aim: first, to strengthen the existing curative services, and second, to complement the latter with health promotion and disease prevention services.As the first step towards achieving this aim, the Ministry of Health, in collaboration with WHO and other partners, has reviewed the existing health services for adolescents to identify the strengths and weaknesses of the system and its ability to respond to needs. • to explore ways of strengthening health promotion, disease prevention and curative health services for adolescents; and • to provide evidence for further policy review.
1.2 Methodology Development of review criteria The review began with a literature review of existing research and practices in adolescent health service provision in both developed and developing countries. Based on the literature review, a set of criteria describing a number of elements essential to adolescent-friendly health service (AFHS) provision was developed. The criteria can be classified into four main categories: (1) health service characteristics; / facility
1.1 Goal and objectives The main goal of the review was to assess the existing health services for adolescents in terms of their accessibility and quality. The specific objectives were: • to develop criteria for adolescentfriendly health services; • to conduct an in-depth review to identify the strengths of the existing system and the barriers to the provision of preventive and curative ser vices for adolescents; 74
(2) service provider characteristics; (3) adolescents’ psychosocial and behavioural characteristics; and
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(4) characteristics of the overall social and health system context. (See Annex 3 for list of AFHS criteria.) These criteria were then used to develop a set of review protocols to collect information and to measure the degree of “adolescent-friendliness” of current service provision to adolescents in Mongolia. Review methodology The review employed qualitative methods to collect in-depth, systematic information from service providers, managers, adolescents and community members. The methodology was based in part on the model of the WHO Rapid Assessment and Response (RAR) tools 67 , which allowed for gathering systematic, in-depth, qualitative data in a short period of time. The RAR tools use a participatory and interactive approach that actively involves consumers (adolescents and community members) and providers of health services in identifying key problems, issues and areas for intervention. A variety of data collection tools were developed and used including:
• a service manager interview schedule for service managers at aimag and district levels, and the Maternal and Child Research Centre (MCRC provides tertiarylevel health ser vices at the national level (Services at the district and aimag levels are provided by district and aimag health centres and hospitals. Service managers at both MCRC and aimag/district levels have similar job responsibilities and were therefore given the same questionnaire. Since service managers do not directly provide services to the customers, but coordinate and manage the ser vice providers, separate interview schedules were designed for service managers and providers.); • a service provider focus group discussion (FGD) schedule (a list of questions for the FGD); • an adolescent FGD schedule (a list of questions for the FGD); • a key informants and parents FGD schedule (a list of questions for the FGD); and 75
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• an observation checklist – three adolescent cabinets at Chingeltei District of Ulaanbaatar City, and Arkhangai and Khuvsgul aimags were observed. (See Annex 5 for a copy of the tools.) In addition, existing data and information regarding adolescent health status, service provision and service utilization by adolescents was collected and analysed. A desk review of government policies and legislation, relevant reports and research findings was also conducted. (See Annex 1 for a complete list of methods used for collecting data from different sources.)
Review sample and sites A total of 314 sample respondents participated in the review. They were: (1) adolescents; (2) service providers at hospitals, the MCRS and adolescent cabinets, and school doctors; (3) bag feldshers; (4) health service managers; (5) parents; (6) policy-makers and (7) key informants (NGO representatives from Marie Stopes International, the Adolescent Future Centre, and a health volunteer from Chingeltei District Health Centre). The review was conducted at the following sites: (1) Chingeltei District in Ulaanbaatar and the MCRC, (2) Tsetserleg aimag centre and Khashaat soum in Arkhangai aimag; and (3) Murun aimag centre and Tarialan soum in Khuvsgul aimag (see the Table 10 for details).
Table 10. Review sample Service managers FGD II 6* 1** 0 8 0 Service Adolescents Parents providers FGD II FGD II FGD II 16 6 64 14 16 0 16 8 8 12 8 64 18 11 0 8 0 0 Key informant FGD II 16 0 0 0 2 Policymakers FGD II 0 0 0 2 Total 159 36 111 8 314
Aimag 2 aimags Soum 2 soums Districts MCRC Total
* only in Arkhangai ** only in Khuvsgul FGD – focus group discussion II – individual interview
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Review team The review was conducted by a team of researchers from the National Centre for Health Development (NCHD), the Maternal and Child Research Centre (MCRC), the Adolescent Future Centre (AFC) and Chingeltei District Health Centre. WHO provided technical support. The review was carried out during October and November 2001 at three project sites (see Annex 2).
• Approaches to data analysis and report writing. Workshop to share review findings
A workshop was conducted at the NCHD in Ulaanbaatar to provide feedback to participants on the main findings of the review, and to involve the participants in a process of identifying standards for the provision of adolescent health services, and recommendations for future actions. Policy-makers and senior officials of the Ministry of Health, Staff training as well as ser vice providers and Prior to commencement of the review, adolescents, attended the workshop. a series of training activities were conducted with the local team in Limitations of the methodology Ulaanbaatar in order to build their capacity for conducting the review. The process of sample selection was not Training sessions were conducted on the based on a randomly selected, or necessarily fully representative sample of following topics: services and respondents. Since the • Adolescent health and primary purpose of the review was to provide information about service development; provision as a basis for identifying • Adolescent-friendly health actions to strengthen health services for adolescents, an action-research approach services; was adopted. Despite the limited • Research design and number of survey sites, the sample methodology; provided a fairly representative profile of services, as the general health system • Inter view/focus group structure is the same in almost all aimags discussion techniques; and districts. While caution should be exercised in generalizing the findings to other regions of Mongolia, there was a 77
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high level of agreement and consistency of findings across all the different categories of respondent and review location. The findings are also in line with the results of previous surveys that have investigated adolescent health services.68 69
degree, by the lack of available data on adolescent morbidity and mortality, as well as service utilization data from hospital, primary care and school health services. Although such data are routinely collected, they are usually not age-specific, and cannot be readily separated for the adolescent age group.
Data collection was also limited, to some
2. Findings of the survey
2.1 Voices of adolescents Adolescents’ health problems Adolescents in both Ulaanbaatar and aimags reported that their main health problems were: kidney diseases; headaches; influenza; tonsillitis; allergies; accidents and injuries; and hepatitis. Acne was a major concern for rural adolescents between 15 and 19 years of age, as well as other developmental problems of puberty. Rural girls and boys 10-14 years of age did not know about major health problems, showing that they have insufficient information about these issues due to misinformation and myths about health. Problems identified by respondents in 78
rural areas were difficulties in relationships between boys and girls, unwanted pregnancies and STIs. Most of them had experienced stress and a few had attempted suicide, mainly due to parental abuse. Other reported health problems included injuries, mostly resulting from sporting or traffic accidents, and smoking. Attitude towards using health care services For the majority of respondents, the mother was the first person to be asked for help and advice with health problems. All respondents from aimags and Ulaanbaatar City reported that they did not seek medical assistance immediately. They preferred self-treatment first. It seems that many adolescents only seek medical care when complications arise. Most of the respondents said that they
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would not inform their parents about STIs and unwanted pregnancies. Rather, they would consult with their friends and then see a gynaecologist or go to a private clinic for treatment or abortion. The majority of younger adolescents (10-14 year-olds) from aimags and Ulaanbaatar City said that they would inform their parents if there was a problem and would attend the doctor with their parents. In contrast, 15-19 year-olds reported that they would not inform their parents because of fear of criticism. Respondents generally prefer to see a provider who is familiar to them. Urban adolescents generally prefer to visit private health providers. They also reported that, although inpatient treatment services were satisfactory, the conditions were uncomfortable and the food quality was poor.
communicate with them well. Some respondents mentioned that they had never seen a school doctor or even had never received health care services. “Health professionals and representatives from children’s organizations and the Center against Violence visited our school. Students asked a lot of questions. Although I wanted to visit the Center against Violence for counselling, I was embarrassed and could not visit it because it was located among apartment buildings.” (Chingeltei District, 18 year-old girl from low-income family, individual interview). Access to health care services and difficulties faced
According to the review participants, there are many barriers to accessing health services for adolescents, including, Adolescents consider that only sick among others, financial constraints, long persons visit health providers for waiting hours and confidentiality issues. treatment purposes, and not for preventive consultations or advice. In Service fees: general, they view ‘health services’ as being hospitals only. The main obstacles Although the health insurance scheme to seeking medical assistance were given covers all children under 16 and as lack of information on the location secondary and higher school students, and types of service provided, fear of out-of-school or unemployed injections, fear of being criticized by the adolescents between the ages of 17 and doctor, and embarrassment. They stated 19 remain uninsured. The financial that health care providers did not constraints to accessing health services 79
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are especially pronounced for adolescents without health insurance. In addition, although health services for adolescents are free, they have to pay for testing. The respondents noted that it was difficult for them to pay for testing as the cost for one test was, on average, 1000-3000 tugriks. Another concern expressed by the respondents was that rural residents could not get medical care in the capital city without a special form number 36 (referral form). Access to health services is restricted for students and other people from rural areas living in the capital city without official registration. This is especially true for students who live with their extended families, as they do not register officially because rent and utility charges increase with the number of occupants in a dwelling. The situation is compounded by the fact that adolescents have little idea about the types of paid services and service fees.
0.5-2 hours for services. ‘Health care provider’s ignorance’ was reported as the most negative aspect adolescents face at hospitals. Soum (village) respondednts answered that visits to soum hospitals took only 10 minutes. In some cases at the bag level health services were not accessible due to long distances.
Obtaining return visits: Some adolescents mentioned that they very often visited health facilities to attend health services, although respondents said that health service providers did not pay attention to them when they visited on their own. Health professionals also did not warn them about influenza and colds and implied that adolescents should visit school doctors to get illnesses diagnosed.
Point of service environment:
Respondents from rural and urban areas suggested that hospitals should have special cabinets appropriate for their age. Waiting hours: Some of the rural participants noted that hygienic conditions at the hospitals did The majority of participants reported not satisfy their requirements, and that that, in order to get health services in wards were small and overcrowded. public hospitals, they needed to go there Urban respondents felt that they were early in the morning, because by the time able to get medical care as they lived in their classes were over hospitals were the city. Some mentioned insufficient closed. According to their experiences, availability of syringes and glasses for they had had to wait for an average of testing. 80
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Adolescents expressed their interest in getting psychological counselling and Rural girls who were interviewed infor mation on puberty, cosmetic complained that medical check-ups at treatment, sexuality, human relations and schools were organized without ensuring prevention of STIs and other infectious the students’ confidentiality. However, diseases. girls who visited the Adolescent Reproductive Health Cabinets of aimag For aimag respondents, the main sources hospitals were satisfied with the available of health information were parents, grandparents and siblings. However, it services. should be noted that the overwhelming Soum respondents found it impossible to majority of young people were reluctant ensure confidentiality, as there is only one to talk about sexuality or reproductive hospital per soum , where everybody health issues with parents. Rural respondents were interested in getting knows each other. information from newspapers; however, On average, urban respondents’ not much information was available, satisfaction with the confidentiality of except for the “Love” newspapers. health services was higher than their rural Availability of IEC materials was severely limited for soum adolescents. counterparts. Information sources: The major sources of health information for adolescents in Ulaanbaatar were: • friends; • parents; • TV, FM radio stations; • magazines, newspapers; and • information leaflets and other distributed materials. In general, adolescents were satisfied with the hygiene, drug supply and diagnostic equipment of health facilities. Adolescents who had been hospitalized expressed satisfaction with the care they 81 Both urban and rural respondents reported that health lessons in schools were irregular, limited in time, and that teachers were often unable to answer their questions. Topics on reproductive health and sexuality were often omitted. Positive aspects of health care services
Confidentiality:
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had received. They said that doctors had treated them well, had examined them regularly, and had given them injections and medicines on time. They were happy about using disposable syringes in hospitals. Most respondents considered that medical institutions and doctors were a reliable source of medical assistance when they needed it. Negative aspects of health care services
• Long waiting hours. • Patients are often asked to provide drugs for their treatment because of an insufficient drug supply. • Insufficient supply of drugs and injectibles. • Lack of sheets and blankets in hospitals.
City respondents identified a number of • Overcrowded wards. deficiencies within health care services. They felt that doctors were ignorant 2.2 Voices of parents and key sometimes, and that services were not informants provided promptly. Adults, especially the ones familiar with the providers, were Adolescent health problems usually given priority over adolescents. According to parents, the main health Many respondents did not feel confident problems faced by adolescents include: about the skills of family doctors, or their ability to diagnose and provide adequate • dental problems; health information relevant to the needs of particular groups of adolescents. • helminthiasis; Aimag adolescents identified the following shortcomings of health services: • Doctors often require the clients to visit health facilities frequently, without considering the long distance between the health facility and home. 82 • anaemia; • cardiovascular diseases; • renal problems; and • diseases of the respiratory system.
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Parents were also concerned about the increase in injury-related disabilities and allergic conditions. According to key informants, mental health problems, including suicide, are on the rise among adolescents. There is a common belief that in recent years renal problems have been increasing due to the wearing of poor quality shoes and clothes.
opinions. According to them, very often adolescents do not like to discuss their health issues, especially such sensitive issues as sexual health. In general, girls are more cooperative with their mothers, while boys prefer not to discuss health issues with their parents at all.
Key informants highlighted the lack of attention on the parents’ part, especially “We have heard that police inspectors fathers’ side. In terms of reproductive have information that some teenagers health issues, teachers and parents lack smell glue as a form of substance abuse... the knowledge and skills to communicate “ (Arkhangai aimag, key informants, with adolescents on such sensitive issues. focus group discussion) The key informants felt, therefore, that it was necessary to help parents to A few key informants pointed out that understand the complexity of the existence of commercial sex workers adolescents’ health and change their among adolescents was alarming. attitudes. Attitudes towards using health Access to health services and services difficulties faced Parents said they usually tried to treat their children at home first, and sought professional health care only if the condition did not improve. Some parents prefer traditional herbal medicine to modern drugs. In cases where children are infected with sexually transmitted diseases, parents said they usually tried to hide the fact and treat the disease secretly. It was noted that adolescent health services, especially reproductive health services are mainly for girls; there are very few services available for boys. There is an over-reliance on treatment and limited provision of prevention services and IEC activities.
”The scent of drugs and noises of medical equipment frighten adolescents. Therefore, medical personnel should pay It is common for parents to consider more attention to the provision of a young people to be ignorant of adults’ supportive environment and warm 83
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atmosphere” (key informants, focus same room simultaneously. group discussion, Arkhangai aimag) Another example of poor ser vice School doctors are overloaded with organization at several review sites was counselling, teaching health lessons, that STI cabinets were located separately attending to sick students and from other health services. Thus, monitoring school hygiene. Therefore, someone going there was likely to be they are often unable to provide noticed and suspected of having an comprehensive health services for STI.Parents said that they considered that they had a right to know everything adolescents. about the health of their children. Some key infor mants noted that, although adolescents’ reproductive Information source health cabinets, paediatric hospitals for children and hotline services provide One of the effective ways of providing counselling, they lack the capacity for accurate and comprehensive health counselling on mental health and information to schoolchildren is via health classes. Unfortunately, classes are substance abuse. often ineffective because the instructors have not been specifically trained to teach Different sub-groups: the course. Parents were concerned about adolescents with limited access to health The key informants pointed out that IEC services, such as school drop-outs, materials were limited in scope. Only the unemployed youth and the disabled. The newspaper “Love” provided information key informants also indicated that many on reproductive health issues. There were adolescents from low-income families very few IEC materials on other healthhad little access to health care services. related issues. Privacy and confidentiality: Parents reported that it was often impossible to receive confidential services as many doctors and nurses had to work in one room. Consequently, several patients were examined in the 84 Parents and key informants felt that adolescents should be provided with health information appropriate to their age and needs. Health education and information for adolescents should be provided by educational organizations in a systematic manner, starting early in childhood.
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Positive aspects of health services
2.3 Voices of service providers
The hotline service is one of the most Adolescent health problems helpful and needed services designed for adolescents to ensure privacy and According to health providers at the confidentiality. MCRC (state level), the following are the major health problems among Some of the key informants considered adolescents: the availability and coverage of current health services for girls to be satisfactory. • unwanted pregnancies; They highly appreciated the implementation of the National • dental problems; Reproductive Health Programme, and the UNFPA-funded publication of • tonsillitis; “Love” newspaper, training manuals and IEC materials. • diseases of the digestive system, particularly hepatitis; Negative aspects of health services • post-traumatic headaches; There are still insufficient health services for disadvantaged adolescents. It is • facial nerve disorders; common for adolescents to be unaware of available services and their location. • renal diseases; Adolescents seem to be reluctant to utilize health ser vices because of ignorance and poor communication on the side of the providers. Some parents complained of a multilayered referral system, especially in cases of teenage pregnancy. • menstrual disorders; • genital diseases and STIs; and • suicide attempts and sedative drug abuse.
According to district-level health The lack of follow-up treatment for providers, the following are the major detected cases makes well organized health problems among adolescents: preventive examinations both ineffective and inefficient. • hepatitis; 85
Sexual and Reproductive Health of Adolescents and Youths in Mongolia
• acute infectious diseases such as measles, rubella and influenza; • acute respiratory infections; • injuries, accidents and poisoning; • diseases of the digestive system and diarrhoea; and • menstrual disorders. Adolescents mostly attend health services when they are sick; however, for mental health issues they usually do not seek care.
• substance abuse. Health service provider’s attitude and skills All service providers of the MCHRC and district hospitals who attended the interviews stated that they provided adequate curative and counselling services on reproductive health and sexual health issues, while some mentioned that mental health services were inadequate. Aimag service providers thought that they had a good knowledge of tuberculosis, brucellosis and anthrax. They assessed themselves and their capacity as “not too bad and not too good”.
Health problems identified by aimag- and soum -level service providers were Most participants at each level said that different: they had received no training on adolescent health issues and had • renal diseases; insufficient and inadequate IEC materials and books, and some of them considered • tuberculosis; that they had been given no opportunity to improve their skills and capacities. • rheumatism; • dental problems;
Some district-level service providers admitted that they did not fully • acute appendicitis; comprehend the services they were supposed to be providing to adolescents. • brucellosis; Service providers were certain of the need to change school principals’ • external genital organ attitudes towards school doctors, and the inflammation in teenage girls; for m and methods of medical and examinations at schools. 86
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“Most school principals have an understanding of the school doctor as a person in charge of restroom cleanliness and school hygiene…” ( Chingeletei district, individual interview, school doctor) Service providers requested training on the following topics:
MCHRC service providers did not mention the training sessions they had attended, or negative and positive aspects of service provision. Health service provision
The MCHRC provides health services for adolescents at the national level. However, the participants from the • ear, nose and throat diseases and centre did not know the exact number other specialized medical of adolescents to whom services were provided. courses;
• methodology of health course Most respondents admitted that they only provided curative services due to a instruction; lack of time, tight schedules and a lack of counselling skills, particularly mental • communication skills; and health counselling. Most ser vice • psychological counselling skills. providers responded that they collaborated with other government Many service providers at aimag and organizations and NGOs such as the district levels attended the following police, the Adolescent Future Centre and the Centre against Violence. training sessions: • 3-day training programme on health education; • 5-day training on adolescent reproductive health; • training adolescent reproductive health doctors; • 3-day training on substance abuse and health education. The main services provided by soum, aimag and district health service providers include: • screening and provision of first aid; • drug prescription; • referral to other or next level health care facilities; 87
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• curative services; • vaccinations; • community-based promotion; and • emergency care. health
rooms. • Adolescent cabinets have neither timetables, nor any information about the services provided. • In general, health services are not adolescent-friendly.
According to the service providers, the Access to health services and average waiting time for an emergency difficulties faced call varies from 30 minutes to two hours. Service fees: Many district health service providers stated that they collaborated with school The majority of national-level service doctors and family doctors. Some school providers offer screening services and doctors offer treatment services for examinations free of charge, excluding dental health problems. abortion services. The observation of adolescents cabinets demonstrated that: • • “In cases of suicide attempt, adolescents are required to pay 45000 tugriks (equal to around US$40) for the services. Adolescent cabinets do not have Usually such cases are rare. In my their addresses posted. practice, I have met only two girls and a boy who attempted suicide…” The available equipment is (Àrkhangai aimag, focus group inadequate: for example, discussion) Khuvsgul aimag adolescent cabinet only has two desks, a TV, Service provision and information: a telephone, a clock on the wall and a screen. Many aimag and district service providers believe that adolescents do not attend Client registry and counselling adolescent cabinets for health services because they know little about the reports are not confidential. services available. The situation is There is an absence of waiting compounded by the lack of counselling
• • 88
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skills on the side of service providers. The majority of doctors admitted that health service provision for adolescents was still insufficient, in spite of the establishment of a special cabinet for boys.
• Tobacco-Free Initiative • Drug Free Initiative • Positive Communication Skills • Respect for the Elderly
Service environment confidentiality:
and • Hepatitis Prevention • Individual Hygiene • Oral Health • Menstruation • Mental Health
According to service providers, financial constraint is the major barrier to building friendly health services for adolescents. There is a lack of IEC materials and other logistics at each level, which undermines the quality of services provided.
• Information for Boys Service providers identified the following equipment and supplies as required for effective ser vice provision for Service confidentiality cannot usually be ensured. Several doctors have to work adolescents: together in one cabinet. At the soum level, it seems to be impossible to ensure Equipment: patients’ confidentiality. • Spirometer ”In winter, the patients are examined at • Paediatric sphygmomanometer home behind the bed curtain…” (Arkhangai aimag, Khashaat soum, bagh doctor, individual interview) • Thermometer • Overhead projector • TV and VCR IEC materials: 89
Different sub-groups: Aimag and district-level health providers admit that they fail to reach street
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children, herdsmen in remote areas, soldiers, the unemployed and school dropouts over the age of 16, because they usually have no health insurance. Increased population migration is further compounding the problem of health service provision. Positive aspects of service provision
• availability of IEC materials on reproductive health and STI; • trained peer educators; • NGOs and government organization collaboration on adolescent health issues.
Negative aspects of health service Service providers identified the following provision positive aspects of service provision: Most service providers identified the • free health ser vice for following barriers to effective provision adolescents under the age of 16; of health services for adolescents: • the National Programme on Adolescent Health; • equity in provision; health service • poor hygiene in the service environment; • lack of preventive examination follow-up; • providers’ lack of counselling skills; • insufficient on-the-job training; • unclear job descriptions for service providers;
• adolescent cabinets; • hotline services and counselling by the Adolescent Future Centre • the school health curriculum;
• positive and supportive provider attitude toward building • work overload and duplication. adolescent-friendly health services; 2.4 Voices of managers and
policy-makers
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Health facilities in Arkhangai Aimag
only screening. • Hotline counselling services – run by the Adolescent Future Centre. • Family group practices – although FGPs offer services for adolescents, very few utilize them, mainly due to the lack of privacy.
Health service provision The following health services are offered to adolescents:
• General services – inpatient and outpatient health services are generally available to adolescents. There are separate inpatient units set aside for adolescent boys and girls who require hospitalization. Positive aspects of service provision:
• A range of services is available • Specific services – there is a to adolescents. screening programme for oral health. However, the equipment for treating dental problems is • There are good linkages and poor, and there is often no integration between services. effective follow-up after the screening. Gynaecological Difficulties with service provision: screening is also offered as a part of the reproductive health • There is often a lack of followprogramme. A number of other up after health screening. programmes have components that cater for the needs of • Most services lack appropriate adolescents, such as the privacy and confidentiality for immunization and IDD adolescents. programmes. • Services lack appropriate medical • School doctors – mainly conduct equipment and resource health screening and link with materials. adolescent cabinet doctors and FGP. • Service providers have little or no training in adolescent health, • Adolescent cabinet – a recent and are only able to deal with a initiative, which currently offers limited range of medical
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concerns. There is a growing number of psychosocial problems that providers are unable to deal with.
Many providers are not aware of the needs of adolescents or the AFHS concept. They are often insensitive to adolescents’ need for privacy and confidentiality.
• There is no clear job description for the adolescent cabinet Adolescents doctor. Major health problems: • The quality of health education in schools is poor. • dental health; • There is only limited promotion of services to adolescents, and so many adolescents are unaware of the services available to them. Service providers • respiratory problems; • kidney problems; • sexual health – unwanted/ unplanned pregnancies and abortions; • mental health; and Some service providers have received basic training in certain aspects of adolescent health, but the majority lack knowledge and skills in the key areas of adolescent health and development. Providers are not trained in either counselling skills or in dealing with complex psychosocial issues, such as mental health, family relationship problems, drug abuse and other social problems. Providers also lack skills in delivering health education to adolescents. • social problems – school dropouts; social disadvantage; unemployment.
Knowledge/Skills:
Different sub-groups: The following groups are seen as having particular health needs and not being well served by the health system: • school dropouts; • youth living in remote areas; and
Provider’s attitude: 92 • disabled adolescents.
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Overall context: The community in general lacks awareness of the health needs of adolescents and is not very supportive of services for them. There is a lack of available funding for adolescent health services and programmes, as well as accurate and reliable data on adolescent health problems and the reasons for which they seek services. Health facilities in Chingeltei District
Positive aspects of service provision: • A range of specialist and general services are available to adolescents. • Actions have been taken to increase the accessibility of services, with activities to attract adolescents. • Health screening is conducted at a number of different sites. • There are a number of organizations involved in health service provision for adolescents – both governmental and nongovernmental.
Health service provision
A range of services are provided to adolescents through general inpatient hospitals and outpatient services at the polyclinics. These include: dental health; reproductive health; emergency and Difficulties with service provision: ENT services. Health screening and treatment are provided at the polyclinics. • Adolescent cabinets are not functioning according to their School doctors conduct health screening designated roles. The cabinet and provide some health education. The doctors are unclear about their City Health Department coordinates roles, often have many other with school doctors in providing tasks, and lack appropriate screening and education. The District training and skills. Therefore, government is in the process of they are limited to providing establishing cabinets to provide health screening and coordination with information at schools. school doctors. Adolescent cabinets offer mainly health screening and education services. • There is a lack of privacy and confidentiality for adolescents in these services. 93
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• Health facilities lack appropriate consulting rooms, have insufficient equipment and resources, and have no clear clinical practice guidelines or job aids for service providers. • The provision of health education at schools is poor, and teachers lack appropriate training and skills. • There is little or no emphasis on health education or prevention of health problems. In general, the services are strong on screening, but weak on services. Service providers • Service providers in general lack appropriate knowledge and skills in adolescent health.
• Poor physical development • Dental health • Accidents and injuries • Respiratory problems • Sexual health • Mental health • Social problems – school dropouts; street and unemployed youth
Different sub-groups: The following groups were seen as having particular health needs and not being well served by the health system: • Out-of-school adolescents
• Boys/young men • Ser vice providers have not received adequate training in Overall context: adolescent health. There is insufficient coordination • There are few allied health staff between different sectors involved in involved in service provision to providing services to adolescents and a adolescents. Providers are almost lack of awareness and support in the exclusively doctors. community regarding their health needs, as well as a lack of accurate and reliable Adolescents data on adolescent health problems. 94
Major health problems:
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3. Conclusions A range of health facilities provide services to adolescents at all levels of the health system - from soum to district level, and from general to adolescent-specific services. However, findings from the review show that, overall, the current health service provision for adolescents is inadequate for meeting their complex health needs in terms of disease prevention, health promotion and curative services. Many barriers exist to adolescents’ access to appropriate services and the quality of service provision is low in many areas of the health system in terms of the identified criteria for adolescent-friendly health service provision. The quality of service provision is constrained by the absence of adolescent-friendly service approaches, a lack of coordination between the different delivery systems providing services to adolescents, a lack of suitable resource materials and particularly by a lack of relevant skills and training among service providers. Nevertheless, there is a strong consensus at all levels of the health system about the importance of investment in adolescent health. Clear commitment to improving ser vice provision to adolescents exists at both central and provincial levels of the health system. The review highlighted a number of opportunities for improving service provision to adolescents, both through strengthening the existing service delivery points and developing adolescent-specific models of service provision. The following conclusions can be drawn about specific aspects of current service provision to adolescents. AFHS criteria Findings from the review show that, in regard to the identified criteria for adolescent-friendly health services, many aspects of service provision to adolescents fall below the recommended standards. There are currently no clear standards or guidelines on service provision, quality of care, service providers or facility requirements for adolescent health services. The review identified a number of key problems and constraints, which adversely affect service provision to adolescents, and act as barriers to adolescents’ access to and use of services. 95
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Organizational framework for provided in these cabinets. Yet the need adolescent health services for such services to be provided to adolescents in an accessible, communityThere is a lack of coordination between based setting was consistently identified different levels of the health system, both by focus group respondents, including in the provision of services to parents, adolescents and key informants. adolescents, and in the planning of The adolescent cabinets have the services and programmes. The position potential to effectively fulfill this role. of adolescent health services within the However, the terms of reference for the overall organizational structure of the adolescent cabinets, and their role within Ministry of Health is unclear. This is the overall primary health care system, particularly evident in relation to the needs to be more clearly defined. structure and functions of the adolescent cabinets. Currently, these services fall There is, therefore, a need to develop a under the responsibility of the clearly defined overall strategy for Department of Public Health. As a determining priorities and guiding the result, the role of the cabinets is limited development of ser vices and mainly to public health activities such as programmes that will provide a health screening, although in reality, continuum of inter ventions from cabinet doctors generally reported that preventive to curative ser vices to their activities are limited to coordination adolescents. with school doctors and other administrative tasks. Other services, such Health services/facilities as general hospital and specialized ser vices, fall either under the Many services are not easily accessible responsibility of the Department of to adolescents because of waiting times, Medical Services or, in the case of family cost, or lack of provider skills and group practices, under the Health Sector adequate consultation time. Adolescents Development Programme. are generally given a low priority within the health system, and young people Therefore, the function of adolescent interviewed expressed dissatisfaction cabinets is not well defined and cabinet with the services that they had received. doctors are generally unclear about their Many experienced difficulty with the roles and responsibilities. Consequently, attitude, approach and communication primary health care services, such as of service providers towards them. In medical or counselling services, are not addition, the cost of services is not 96
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identified well for different sub-groups among adolescents. Adolescents who are uninsured, such as those over 16 who are working or studying and living in another family’s home, cannot afford to pay for the health services.
prevention/health promotion programmes targeting major adolescent health problems.
Linkages and referral pathways between different services are not clearly defined, contributing to the lack of coordination The addresses of health facilities are not and continuity of treatment. There is also clear and adolescents do not know when, a lack of adequate follow-up treatment where and how to apply to attend health after health screening (especially in service providers. schools). The physical environment and operating procedures of most facilities and services are not ‘adolescent-friendly’. Facilities, especially those in rural and remote areas, generally lack the necessary equipment, supplies and resources to provide services to adolescents. There is a limited range of services for adolescents. Generally, they focus on curative services and do not cater well for adolescent-specific health problems - especially psychosocial problems. Adolescents can access services for some problems more readily than for others, for example chronic illness. While reproductive health services are becoming more readily available, for some problems very little information or help exists. This is especially true for emerging problems such as mental health, and alcohol and drug abuse. There is very little counselling or health education, and there are few coordinated Out-of-school youth; street youth; the disabled; boys/young men; and youth living in remote and rural regions are particularly vulnerable and at risk, or have special needs. Yet, they are currently not well served by available services. While adolescents are target groups for family group practices and soum hospitals, these facilities do not provide any adolescent-specific services. Providers lack the knowledge and skills in dealing with adolescents and have received little or no training in adolescent health. The physical environments of the facilities are generally not “adolescent-friendly” (for both adolescents and service providers), and the privacy and confidentiality of adolescents are not ensured. There is little or no education for adolescents on how to stay healthy or to prevent health problems. While health education classes have been introduced 97
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in schools, ser vice providers and adolescents both complained about the quality of the health education curriculum. Teachers appear not to have been adequately trained, there are insufficient teaching and resource materials, and there is no meaningful monitoring of the quality and outcomes of these sessions. There needs to be greater collaboration between the Ministry of Education and the Ministry of Health over the role of the school doctor and the teaching of the Health Education curriculum. Adolescent cabinets
system. Most providers reported that they had received little or no training in adolescent health. Some had participated in short courses on adolescent reproductive health. Others had received some basic input on adolescent health during their undergraduate education, or as part of their training in paediatrics. Almost universally they reported that they lacked knowledge in adolescent health and development, as well as the skills to effectively work with adolescents. The physical environments of these facilities are generally not “adolescentfriendly”: they are usually located in cramped surroundings that do not encourage privacy and confidentiality, lack appropriate resources to provide adequate services and education, and are poorly promoted to adolescents, and so adolescents are generally unaware of their existence.
The structure and activities of the adolescent cabinets vary from one location to another. However, currently they provide no actual treatment services, such as medical care or counselling. Although terms of reference have been developed for the cabinets, the cabinet doctors interviewed seemed uncertain about their roles and what services they Family group practices should be offering. The family group practices (FGP) are a They had not been provided with a clear relatively new service that will eventually description of their duties, nor had they be established in all provinces. These been given appropriate training in services have a mandate to provide fulfilling their roles. Moreover, cabinet primary care services to all age groups. doctors are called upon to perform a Data provided by the Health Sector number of different roles, including Development Program (HSDP) show, administrative duties, and in some cases, however, that relatively few adolescents providing services in the general hospital are attending these services. Providers 98
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reported that they lacked knowledge and skills in dealing with adolescents. There are also difficulties regarding lack of privacy and adequate time for adolescent consultations. Although there is a small component on adolescent health in their current training programme, it is relatively superficial. The HSDP team was very receptive to the inclusion in the training programme of a more comprehensive component on adolescent health and development.
themselves do not see a school doctor as someone that they can go to with their health problems, reflecting the emphasis of the school doctor’s role on public health. Some of the school doctors interviewed complained that they had too many broad responsibilities in the school, including the monitoring of general hygiene. NGOs Two nongovernmental organizations that provide useful models of service provision to adolescents were reviewed. Marie Stopes International (MSI) provides a range of sexual and reproductive health services. Although not adolescent-specific, the MSI Ulaanbaatar clinic sees up to 200 adolescent clients a month. A feature of the MSI model is the emphasis on privacy and confidentiality, and quality of care through a clearly defined set of standards and procedures for service provision. The Adolescent Future Centre provides medical and counselling services, although again in somewhat cramped surroundings not conducive to privacy. An Adolescent Future Centre ‘Hotline’ service is also provided with the active participation of young people, and delivers counselling, diagnostic and treatment services.
Soum hospitals Soum hospitals are the focal point for service provision in rural and remote areas. Although general services are available to adolescents, there is very little offered in the way of services specific to the needs of adolescents. The environments again have very few ‘adolescent-friendly’ characteristics. There is a lack of privacy and confidentiality, and service providers have had no specific training in adolescent health. School doctors/School health programme School doctors mainly conduct healthscreening activities in schools. Providers reported that there is a lack of adequate follow-up treatment and continuity of care following screening. Adolescents
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Most service providers have a very positive and supportive attitude towards There are no clear guidelines for the establishing adolescent-friendly health selection of service providers chosen to services, with possible solutions and work with adolescents. Providers are recommendations. usually selected on the basis of their specialization as paediatricians or Adolescents gynaecologists. Throughout all levels of the health system, providers have a low Adolescents generally are not aware of level of skills and lack training in available services. They experience many adolescent health and development, barriers to accessing health services. It approaches to treating young people and is their belief that many service providers appropriate communication and have negative, judgmental attitudes and counselling skills. There has been little poor communication skills, and do not or no training provided, even to those understand their needs. They also fear specializing in working with adolescents, that their privacy and confidentiality will in the key attitudes and knowledge not be protected. Adolescents generally required for working with young people. have a low level of knowledge about their own health needs and problems. They There are no practice guidelines or job often prefer to self-treat health problems aids to guide providers in the treatment and may only go to health services as a of adolescent health problems, with the last resort. exception of some reproductive health clinical guidelines produced by UNFPA However, there was consensus among (though these are not adolescent- the adolescents in the focus group specific). Service providers generally feel discussions that, if appropriate services that they have insufficient time available were made more accessible, provided in for adequate consultations with adolescent-friendly environments, and adolescents. There is also a lack of staffed with providers with appropriate suitable IEC materials that are attitudes and skills, they would utilize adolescent-specific in content and style those services. and cover a range of health issues (those that are available mainly focus on According to FGDs, there appears to be reproductive health). Health service a growing incidence of health problems provision is limited to medical related to lifestyle, risky behaviour and examinations to detect diseases and not adverse social circumstances. These to treating them. include tobacco, alcohol and other drug 100
Service providers
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use; oral health problems; kidney diseases; colds; influeza; violence and stress; unwanted pregnancies; respiratory infections; mental health problems; accidents and injuries; liver and bladder diseases; hepatitis; and sexual health problems. However, no accurate data are available. Dental problems are more common at soum level than aimag or city level. Adolescents consider drug abuse as a serious health threat in Ulaanbaatar City. In many other countries, problems of this nature have been shown to be major contributors to the overall burden of disease both in adolescence itself, and also persisting into adulthood. Overall context The current Health Insurance Law guarantees free health care up to the age of 16 (or 18 if attending secondary school). Adolescents over 16, who are not living with their family (because of migration, family breakdown, or who have moved to the city to study) often experience difficulty in registering for the local administration insurance and, therefore, often do not have access to health care. Several laws and policies prohibit the consumption of alcohol and tobacco by adolescents. However, there is inadequate sales law enforcement.
Consequently, the review found that these products were freely available to adolescents, and were often sold on the campuses and dormitories of colleges and universities. Many of the major health problems identified in the review - dental health; mental health; alcohol consumption; accidents/injuries; sexually transmitted diseases - are preventable. Tobacco and drug use is an issue of concern. Yet there appears to be no coordinated or systematic approach to prevention of specific adolescent health problems through the development of preventive and health promotion programmes. The parental attitude to health service provision is that they prefer to treat their children at home first and only consult doctors if major problems arise. There is a great need to conduct education and IEC activities with parents because of their lack of knowledge and their attitude towards adolescent health issues and counselling on such issues as reproductive health and STI. There is also a belief among parents that family members should know everything about the adolescent. There is a lack of collaboration between different sectors involved in the provision of health and related services to adolescents, for example between the health and education sectors. 101
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Data collection and surveillance systems are inadequate for gathering age-specific data on health problems and service utilization, limiting capacity to effectively monitor the emergence of adolescent health problems and to evaluate services and programmes.
Adolescents generally appear to lack accurate information about health and ways of preventing health problems. They do have some access to IEC materials on reproductive health and STI, but these are not available to everybody. IEC materials regarding other major health issues are not available at all.
4. Recommendations There should be an agreement within the Ministry of Health about the structure and functions of adolescent-specific services, and the scope of service provision to adolescents at all levels of the health system. The key departments in the Ministry of Health responsible for adolescent health services should identify what package of services are to be provided to adolescents at different levels and what service providers are required - particularly at adolescent cabinets, soum hospitals and FGPs. Actions should then be taken to strengthen service provision in line with identified standards and criteria of adolescent-friendly health service provision. The development of adolescent health services and programmes should be based on a coherent overall strategy for the promotion and protection of adolescent health. In line with the WHO/UNFPA/UNICEF Joint 102 Framework for Programming in Adolescent Health, this strategy should be based on an understanding of adolescent health and development, and the need for a comprehensive, biopsychosocial approach to adolescent health. The strategy should aim to promote the healthy development of adolescents, as well as to prevent and respond to health problems. A continuum of interventions should be developed and implemented, from the provision of health promotion and preventive programmes through to curative services. In the development and strengthening of adolescent health services and programmes, the special needs of vulnerable and at-risk groups of young people (such as out-of-school youth; street youth; the disabled; boys/young men; and youth living in remote, rural regions) should be taken into account,
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and appropriate actions taken to improve their access to relevant services.
confidentiality of adolescent clients; creating an adolescent-friendly environment; furnishing providers with Terms of reference for adolescent suitable and sufficient resources and cabinets should be revised to include equipment to effectively provide services counselling, screening, risk assessment to adolescents; and providing effective and health education. Initially, this could promotion of services to adolescents. be done in the adolescent cabinets in the three pilot areas (Arkhangai and Following on from the activities of the Khuvsgul aimags and Chingeltei District national workshop conducted on of Ulaanbaatar). These cabinets could 21-22 November 2005, a small working be developed as innovative models of party should be convened by the Ministry adolescent health service provision. The of Health, in collaboration with NCHD, cabinets would also serve as a point of UNFPA and MCRC, to further develop referral for adolescents in need of more and define standards and criteria for specialized services. The role of these adolescent-friendly health services, as cabinets vis-à-vis other services needs to well as identifying guidelines for the be clearly identified, with clearly defined structure and provision of adolescent linkages and referral pathways. For this health services. Initially a small set of to happen, the Departments of Public standards should be developed to ensure Health and the Medical Services needs quality improvement in terms of to clearly define (1) the role of the adolescent-friendly health ser vice cabinets; (2) the package of services to provision. Technical support can be be provided; and (3) the linkages and provided by WHO and the State referral pathways. In order to create an Inspectorate for Health (the national adolescent-friendly atmosphere and to body responsible for monitoring promote adolescents’ access and implementation of standards). participation, it is recommended that a A framework for the formulation of range of social and educational activities standards and criteria in adolescentbe offered at the adolescent cabinets friendly health services was developed (especially at the aimag level). during the review and can serve as a model for the working group. Actions should be taken to upgrade adolescent cabinets, FGPs and soum Once these standards are approved by hospital facilities, in line with agreed the Ministry of Health, they should be standards for ensuring the privacy and selectively applied to different services 103
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(adolescent cabinets, soum hospitals, FGPs) according to the relative circumstances and activities at each level. The working party should, however, identify some standards that would apply at all levels of service provision. These would include privacy and confidentiality; attitudes and skills of service providers; and some characteristics of an ‘adolescent-friendly’ environment. Greater attention should be paid to promoting health services to adolescents. Adolescents themselves could be actively involved in the promotion of services in their local area. Opportunities and structures should be created for more effective adolescent participation in the development and provision of health services - for example through the development of adolescent advisory groups, involving adolescents in the design of IEC materials, such as posters and media promotion services, and recruiting adolescents as peer educators. Adolescent cabinets should have a sign posted outside the facility advertising the range of services available, hours of operation, etc. There should be greater emphasis placed on the development and implementation of preventive and health promotion programmes targeting specific adolescent health problems. These 104
programmes should be based on recognized models of prevention in adolescent health (such as the WHO/ UNFPA/UNICEF Framework), and aimed at reducing health-risk behaviour among adolescents and promoting protective types of behaviour and safer environments. Data from school doctors, adolescent cabinets and FGPs could be used to identify the key health problems to be targeted. A range of adolescent-friendly IEC materials should be developed. Priorities for the development of IEC materials should be identified as a component of key prevention and health promotion campaigns. As a matter of priority, training and a comprehensive integrated training curriculum should be provided to service providers dealing with adolescents at all levels of the health system. Initially, training should be directed towards providers in those services that have a critical role as the first point of contact for adolescents in the primary health care system - namely, adolescent cabinets, soum hospitals and FGPs. Training for these providers should be comprehensive, covering key knowledge, attitudes and skills in areas such as: (1) adolescent health and development; (2) adolescent-friendly health service provision; (3) psychosocial risk
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assessment; (4) privacy and confidentiality; and (5) communication and counselling skills. Providers also require training in dealing with specific psychosocial issues in adolescent health - such as mental health, and drug and alcohol abuse.
system for follow-up treatment.
The Health Insurance Law should be reviewed with a view to extending the age for provision of free services to 19 years. Policies relating to the consumption of alcohol and tobacco should be reviewed to provide stronger The role of allied health care workers, restrictions regarding the sale and such as public health nurses and social availability of these substances to workers, should be broadened to allow adolescents. them to play a greater role in service provision to adolescents, particularly in the adolescent cabinets, and also in the implementation of health promotion programmes. They should be provided with appropriate training in adolescent health at both undergraduate and postgraduate levels. Consideration should be given to incorporating training components on adolescent health and development into the undergraduate medical curriculum, and into the registration, accreditation and continuing education requirements for doctors. This could be undertaken in collaboration with the Medical University and NCHD. The Ministry of Health should meet with the Ministry of Education in order to clarify the role of school doctors in relation to other adolescent health services, and to establish protocols for more effective linkages with the health 105
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Annex 1. Complete List of Methods Used for Collecting Data from Different Sources
REVIEW DATA COLLECTION METHODS Data source 1. Service providers Method -individual inter view schedule measuring ser vice provider characteristics – current practice aspects of service quality - staff capacity -areas for improvement/change - focus group discussions -individual interview schedule measuring health service characteristics (infrastructure; admin. procedures; policies; access issues; staff capacity/ training, etc); areas for improvement/ change -observation checklist of facility characteristics 3. Policy -makers 4. Adolescents - individual interview schedule -focus group discussions / individual interviews with sample of adolescents perceptions of services/service providers - difficulties in access/use of services areas for improvement /change -focus group discussions: parents perceptions of services, difficulties in access, areas for improvement
2. Service / Health system managers
5. Parents
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6. Key Informants
-focus group discussions: key informant’s perceptions of services, difficulties in access, areas for improvement - Desk review -Identification and analysis of relevant Government and service policy documents, review of relevant reports / surveys -Information audit -collation of available health status data and service utilization, data inventory of available services in review locations
7. Reports/Policy documents/Surveys
8. Service/Hospital records
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Annex 2. Responsibilities of the adolescent cabinet doctor Adolescents’ cabinet doctors have the following responsibilities: • To be a team member of the public health centre; • To prevent diseases and strengthen the health status of pre-school, schoolchildren and adolescents under the age of 20 in the catchment area; • To establish a team involving methodologist doctors, family doctors, fitness instructors, nutrition specialists and hygiene doctors and to integrate and coordinate their activities on adolescent health and development; • To conduct community-based training on health and healthy lifestyles; • To organize yearly screening and medical examinations and conduct follow-up treatment in order to decrease common diseases among adolescents; to evaluate the health status of adolescents and report the results of these activities to collaborating agencies; 108 • To coordinate and monitor the Health-Promoting Schools movement; • To conduct surveillance of 10 leading causes of morbidity among adolescents and develop a plan for their management; • To provide technical support to school doctors and regularly monitor their activities; • To collect data related to adolescent health, assess causes of common health problems among adolescents and conduct activities to reduce risk factors for these health problems; • To coordinate the collaboration with international and community organizations and involve relevant agencies in health prevention and promotion activities; • To report on annual activities, including reports of collaborating schools and kindergartens.
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Annex 3. Selected AFHS Criteria For The Review 1. Health service/facility characteristics (a) Availability/access • A comprehensive range of services is available at different levels – health promotion, preventive and curative. • Availability of both general and adolescent-specific services in a variety of settings - inpatient, outpatient, community. • Services are available for specific adolescent health problems (e.g. chronic illness, reproductive health, mental health, dental health, substance abuse). • Services are recognizable, and have locations and opening hours convenient to adolescents. • The needs of different target groups are catered for (age/ gender/marginalized groups). • Linkages / referral networks are established with other relevant services. • Services are promoted to adolescents. (b) Operating procedures • Confidentiality and privacy are protected - private space for service provision. • Short waiting times for service. • Flexible service delivery drop-in clients welcomed; outreach services provided. • “A d o l e s c e n t - f r i e n d l y ” environment and reception area. • Organizational policies support adolescents’ access to services/treatments relevant to age / gender / marital status. • “User-friendly” administrative procedures promoting ease of access - appointment system, appropriate monitoring, data 109 • Services and treatments are affordable for adolescents.
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collection and evaluation systems. • Clear/consistent protocols, guidelines and standards exist for guiding staff in provision of services to adolescents and dealing with sensitive issues (e.g. confidentiality; reproductive health services).
skills, ability to conduct healthrisk assessment. • Basic knowledge of key health issues - consequences of substance use, transmission and prevention of STIs / HIV. • Adequate consultation time is allowed to cater for young peoples’ needs.
• Patient records are kept confidential. 3. Adolescent psychosocial characteristics • Adolescent-friendly IEC materials are available. • Adolescents are aware of services and informed about • The service encourages youth how to use them. participation. • Adolescents receive information 2. Service provider characteristics about major adolescent health problems, are aware of their • Staff adopt a non-judgmental health needs and when to seek attitude. services. •Staff respect adolescents’ confidentiality, privacy and rights. • Staff are trained in key competencies in adolescent health - understanding of adolescent developmental issues, sensitivity to the needs of young people, developmentally appropriate communication 110 • Adolescents perceive that services respect privacy and confidentiality. • Adolescents perceive that they are welcome at the service (regardless of age; gender; marital status; etc). • Adolescents perceive that services are youth-friendly, easy
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to access, welcoming and appropriate to their needs. • Adolescents perceive that service providers are trusted, competent, sensitive and respectful of the needs of adolescents. 4. Overall context • Health policies/legislation support adolescents” access to and rights regarding use of health services. • Policies do not restrict access based on age/sex/marital status. • Adolescents have access to health insurance. • The community is aware of and supports the provision of health services for adolescents. • Effective intersectoral collaboration exists between different government (and nongovernment) sectors in implementing a range of promotive, preventive and curative services to adolescents. • Systematic data collection and surveillance systems exist at all
levels of the health system in order to gather age-specific data on health problems and service utilization; and to facilitate effective monitoring and evaluation of services and programmes.
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Annex 4. List of Review Team Members 1. Mr. Peter Chown - WHO Consultant 2. Dr. Dulamsuren S., Team Coordinator, Director of NCHD 3. Dr. Ayush, Deputy Director of Adolescent Future Centre 4. Dr. Erdenezaya, Adolescent Cabinet Doctor, Chingeltei District Health Centre 5. Dr. Bolormaa, Medical Doctor, Maternal and Child Research Centre 6. Dr. Atarmaa, Master student of National Medical University of Mongolia 7. Ms. Oyungerel N., Officer, Health Management Department, NCHD 8. Ms. Enkhtuya S., Officer, Health Management Department, NCHD 9. Ms. Shirnen L., Officer, Health Management Department, NCHD 10. Ms. Nanasalmaa B., Officer, Health Management Department, NCHD 11. Mr. Chuluunzagd B., Officer, Health Management Department, NCHD 12. Br. Batnasan Ch., Officer, Health Promotion Department, NCHD 13. Dr. Munkh-Od A., Officer, Health Statistics Department, NCHD
Mrs. B. Oyun, WHO ADH Project Manager supervised the review process
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Annex 5. Survey Instruments Interview Schedule Service Providers Name of service: Location:
Type / Description of service (hospital; community health; school clinic; etc): Role/Position of respondent 1. Provision of Services to Adolescents a. How many adolescent clients would you (or the service) see on average each week? b. What are the main problems that adolescents present to your service with? c. What type of services does this facility provide to adolescents (screening; medical; counselling; outreach, RH etc)? d. (List different services/programmes - e.g. medical; counselling; health education; outreach; RH services; etc) e. Are there any services that you are unable to provide to adolescents that you think you should be providing (e.g. sexual or reproductive health services; drug & alcohol treatment; etc)? Yes No
If Yes, please specify? f. What are the main barriers/problems that service providers face in providing 113
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services to adolescents? (e.g. policy restrictions; lack of resources; lack of training etc) NOTE: Ask them to list the five main problems/barriers 2. Access/Acceptability of Services a. Have you taken any steps to make adolescents feel comfortable using the services and to create an “adolescent-friendly” environment? Yes No
If Yes, please describe (e.g. separate waiting room; reading materials; specific youth activities; etc) b. Do you work in collaboration with any other organizations in providing services in the community? (e.g. outreach services, health promotion activities) Yes No
c. Are there any groups of adolescents for which you feel the service does not cater well? (street youth; out of school youth; adolescent boys; etc) Yes No
d. How do you promote your services to adolescents (e.g. marketing; signage; posters)? 3. Attitude/Comfort a. Generally, how comfortable would you say you feel in providing services to adolescents? Low 114 1 2 3 High 4
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b. What do you think is good about the services provided by you to adolescents? Why? 4. Privacy/Confidentiality a. When consulting with an adolescent patient, what steps do staff members take to ensure client privacy/confidentiality? 5. Staff capacity a. How confident/component do you feel staff members are in providing services to adolescent clients? Low 1 2 3 High 4
b. Have staff members received any training in adolescent health? If yes, please describe any training received (length; frequency; level): c. In which topics/skills do you think that staff members need training in order to provide effective services to adolescents? d.Are there any practice guidelines/medical literature available to guide staff in providing treatment of adolescent health problems? Yes No
If yes, please describe: e. Do staff members have sufficient resources/equipment to effectively provide services to adolescents? (e.g. clinical supplies; condoms; IEC materials, etc) Yes No 115
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If, no what resources are needed? 6. Areas for improvement a. List five things that you think should be done to improve the quality of service provision to adolescents? Service Managers Name of service: Location:
Type / Description of service (hospital; community health; school clinic; etc): Role/Position of Respondent: 1. Provision of Services to Adolescents a. How many adolescent clients would you (or the service) see on average each week? b. What are the main problems that adolescents present to your service with? c. What type of services does this facility provide to adolescents (screening; medical; counselling; outreach, RH etc)? d. (List different services/programmes - e.g. medical; counselling; health education; outreach; RH services; etc) e. Are there any services that you are unable to provide to adolescents that you think you should be providing (e.g. sexual or reproductive health services; drug & alcohol treatment; etc)? Yes No
If Yes, please specify? 116
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f. What are the main barriers/problems that service providers face in providing services to adolescents? (e.g. policy restrictions; lack of resources; lack of training etc) NOTE: Ask them to list the five main problems/barriers 2. Access/Acceptability of Services a. Have you taken any steps to make adolescents feel comfortable using the services and to create an “adolescent-friendly” environment? b. Is extra time allocated to adolescents clients if necessary? c. Is it possible for adolescents to drop in and receive services without an appointment? d. How long on average do adolescents have to wait before seeing a service provider? e. Does your service charge any fees for services to adolescents? If yes, which services? f. Are any services/treatments refused to adolescents because of age, sex, marital status or other factors? If yes, which services? g. Do adolescents require parental consent for any services? If yes, which services? h. Do you work in collaboration with any other organizations in providing services in the community (e.g. outreach services; health promotion activities)? If yes, please specify: i. Are there any groups of adolescents for which you feel the service does not cater well? street youth; out of school youth; adolescent boys; etc) Yes No 117
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j. How do you promote your services to adolescents (e.g. marketing; signage; posters)? k. Does the service have any IEC materials specifically for adolescents? If yes, give examples: l. What sort of IEC materials on adolescent health do you think you need? 3. Attitude/Comfort a. Generally, how comfortable would you say that you feel in providing services to adolescents? Low 1 2 3 High 4
b. How comfortable do you/staff feel providing services or information to adolescents in the following areas: Low Sexual health Alcohol and drug abuse Tobacco use Mental health Other (specify) Comments: c. What do you think is good about the services provided by you to adolescents? Why? 118 1 1 1 1 1 2 2 2 2 2 3 3 3 3 3 4 4 4 4 4 High N/A N/A N/A N/A N/A
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4. Privacy/Confidentiality a. How important do you think it is to maintain the confidentiality/privacy of adolescent clients? Low Importance 1 2 3 High Importance 4
b.When consulting with an adolescent patient, what steps do staff take to ensure client privacy/confidentiality? 5. Staff capacity a. How confident/component do you feel staff members are in providing services to adolescent clients? Low 1 2 3 High 4
b.Have staff members received any training in any of the following topics
Adolescent health and development Communicating with adolescents Health risk assessment with adolescents Counseling skills Adolescent reproductive health Drug/alcohol/tobacco use problems
Yes Yes Yes Yes Yes Yes
No No No No No No 119
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Health education with adolescents Gender issues Other (please specify)
Yes Yes
No No
Please describe any training received (length; frequency; level) c. In which topics/skills do you think that staff members need training in order to provide effective services to adolescents? d.Are there any practice guidelines/medical literature available to guide staff in providing treatment of adolescents health problems? Yes No
If yes, please describe: e. Do you have sufficient resources/equipment to effectively provide services to adolescents? (e.g. clinical supplies; condoms; IEC materials, etc) Yes No
If, no what resources do you need? 7. Areas for improvement a. List five things that you think should be done to improve the quality of service provision to adolescents? Adolescents Focus group discussion 1. Health Issues 120
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a. What are the main health problems/concerns that you or your friends experience? (PROMPT: physical health problems; accidents/injuries; drug or alcohol use; sexual health; nutrition; hygiene; etc.) Explore contributing factors - e.g. lack of shelter; lack of food; lack of knowledge/ information; lack of awareness of services; etc. 2. Access to Services a. Where would you or your friend go if you /they had one of these health problems? NOTE: for 3-4 of the key health problems that group identified, explore what they think adolescents would do/ where they would go for help:
Problem Type of services Sexual or RH problems Girls doctor e.g. Explore: • Why would you go to this place/person?
Place where it available Aimag hospital
• Explore for specific problems-e. g. sexual health; dental health; injuries etc. • If a young man wants to get some condoms for his use where could he get some? • What would people like you do if they got an STD? • What would a girl/young woman do if she thought that she was pregnant? b. At what point do you think that you would seek help for a health problem?(e.g. when the pain is unbearable) c. What are some of the difficulties/barriers in using the available health services? (e.g. location of services; opening hours; concerns about 121
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confidentiality; getting appointments; attitudes of service providers; etc) d. What would make you feel more comfortable in using these services? e. Are there any problems or concerns that you feel you could not ask for help with? (e.g. sexual health; drug and alcohol use) • Explore reasons why not. 3. Service Provision a. What was your or your friends’ experience of using any of these health services? Positive opinions/experience Negative opinions/experience
Probe for: • What was good about the services/treatment you received? • How were you/they treated by staff ? • What was the atmosphere of the service like? (e.g. did you feel comfortable there?) • Did you feel that your privacy/confidentiality was protected? • Did the service meet your needs? 1. Information a. How did you hear about the health services that are available? (e.g. through friends; media; posters; etc) b. From whom and where would you like to receive information about health? 122
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(e.g. health professionals; parents; peers) c. On what topics would you like to receive health information? 2. Areas for Improvement a. What other health services do you think it would be good to provide for young people in this area? b. What could be done to improve the quality of services provided to young people? Parents and Key Informants 1. What, in your opinion, are the main health problems that adolescents in your community face today? NOTE: They may identify some social problems as well as health problems. If they do, try to guide them in focusing on the health problems, but do not prevent them from identifying the social problems as well. 2. What do adolescents in your community do when they have on of these health problems? NOTE: For 3-4 of the key health problems that the group identifies, explore what they think adolescents would do/ where they would go for help:
Problem Type of services Sexual or RH problems Girls doctor e.g.
Place where it available Aimag hospital
3. What do you and parents do when your adolescent children developed one of these problems ? • What services do you go to?
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NOTE: Probe for actions that they themselves take and the help they get from relatives/friends and from providers of health and social services Probe: Present specific situations • If a young man wants to get some condoms for his use where could he get some? • What would people like you do if they got an STD? • What would a girl/young woman do if she thought that she was pregnant? 4. We would like to find out about your opinions and experiences about the services that you have mentioned above and how well they provide for adolescents NOTE: If they or their adolescents have used any of these services ask them to describe their experiences (or the experiences of their adolescents) in using those services. In exploring their opinions or experiences about a service, ask them to identify both positive and negative attributes and experiences Probe for: • What was good about using the services? (service provision; approach of staff; access; etc) • What difficulties did they experience in using the services? (service location; booking appointment; approach of staff; provided service quality)
Positive opinions/experience
Negative opinions/experience
5. Are there any services that, in your opinion, should not be provided to adolescents? Probe regarding sensitive services (e.g. sexual and reproductive health; drug and alcohol services; mental health services) 124
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NOTE: For each service that they say should not be provided to adolescents, probe for the underlying reasons. For example: • What is your opinion about the school health services? • What is you opinion about reproductive health services for adolescents? 6. In your opinion, are there any health services which are not currently available to adolescents that should be provided? (including sensitive services such as sexual health; drugs and alcohol; mental health; etc) 7. What, in your opinion, are the three most important things that must be done to improve the provision of health services to adolescents? NOTE: Also explore what sort of assistance parents need to more effectively help their adolescents (e.g. IEC materials on adolescent health) 8. Do you have any other suggestions for improving the health of adolescents in your community? 9. Are there any issues that you would like to raise?
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References 1. Byambaa E. Communication and advocacy strategies for adolescent reproductive and sexual health: Case survey Mongolia. Bangkok, Thailand, 1999. 2. Children’s Rights Centre. Survey report on the situation of children in the Child Care Centre. Ulaanbaatar, 1999. 3. Gantuya S, Otgonbayar R. Survey report on the health situation of children in the Child Protection Centre. Ulaanbaatar. 4. Gundegmaa J. (2002). Protecting adolescent health. Society and physician. Ulaanbaatar, 2002. (In Mongolian). 5. Malchinkhuu D, Radnaakhand N. Survey report on morbidity of adolescents. Ulaanbaatar, 1995. 6. Maternal and Child Research Centre. Project report on maternal and child health. Ulaanbaatar, 1999. (In Mongolian) 7. Maternal and Child Research Centre. Health of school children: Project report. Ulaanbaatar, 2000. (In Mongolian). 8. Maternal and Child Research Centre. Project report on clinical aspects of infant mortality, children’s common diseases and emergencies. Ulaanbaatar, 2001. (In Mongolian). 9. Mitsuaki T et al. and others. Smoking among high school students in Ulaanbaatar. Ulaanbaatar, 2000. 10. Mitsuaki T et al. Smoking in Mongolia: prevalence, knowledge and attitudes: Results of an urban survey. Ulaanbaatar, 2000. 11. Ministry of Education, Culture and Science. Education for all-Assessment-2000 in Mongolia. National Report. Ulaanbaatar, 2001. 12. Ministry of Education, Culture and Science. Foundation of the education sector in Mongolia and its development in 80 years. Ulaanbaatar, 2001. (In Mongolian) 13. Ministry of Health. Public health policy documents (resolutions, orders and programmes) Ulaanbaatar, 2002. 14. Ministry of Health and the Asian development Bank. Legal documents of family group practitioners. Ulaanbaatar, 2001. (In Mongolian). 15. Ministry of Health, the Maternal and Child Research Centre and the United Nations Children’s Fund. Maternal mortality in Mongolia 1996-1998. Ulaanbaatar, 2001. 16. Ministry of Health and National Centre for Health Development. Health indicators 1999. Ulaanbaatar, 2000. 17. Ministry of Health and National Centre for Health Development. Health indicators 2000. Ulaanbaatar, 2001. 18. Ministry of Health, Health Management, Information and Education Centre and the United Nations Population Fund. Adolescent reproductive health survey. Ulaanbaatar, 1996. 19. Ministry of Health and the United Nations Population Fund. Mongolia-reproductive health, gender and rights. Ulaanbaatar, 2000. 20. Ministry of Health and the United Nations Population Fund. Needs assessment Survey on reproductive health. Ulaanbaatar, 2000. 21. Ministry of Health and the Public Health Institute. Public health in the new millennium. Ulaanbaatar, 2001. 22. Ministry of Health and Social Welfare and the Health Management, Information and Education Centre. Health indicators 1997. Ulaanbaatar, 1998. 23. Ministry of Health and Social Welfare and the Health Management, Information and Education Centre. Health Indicators 1998. Ulaanbaatar, 1999. 24. Ministry of Health and Social Welfare and the United Nations Children’s Fund. Survey report on children in difficult circumstances. Ulaanbaatar, 1998. 25. Ministry of Health and Social Welfare and WHO. Health sector review. Ulaanbaatar, 1999. 26. Médecins sans Frontières. Survey on the KAP on STD/HIV/AIDS for young persons 15-25 years old in Mongolia. 1999. 27. National Committee for Children. National report on implementation of the Convention on the Rights of the Child. Ulaanbaatar, 2001.
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28. National Committee for Children and the United Nations Children’s Fund. State children-1998. Ulaanbaatar, 1999. 29. National Centre for Health Development and the Mongolian Foundation of Open Society. Report of the quantitative and qualitative survey on the KAP on STD/HIV/AIDS for young persons 15-25 years old in Mongolia. Ulaanbaatar, 2000. 30. National Centre for Health Development and the United Nations Population Fund. Unwanted pregnancies and abortions in Mongolia. Ulaanbaatar, 2001. 31. National Centre for Health Development and WHO. Adolescent Health Service Survey report. Ulaanbaatar, 2002. 32. Nutrition Research Centre and UNICEF. First National Nutrition Survey. Ulaanbaatar, 1997. 33. Nutrition Research Centre and UNICEF. Second National Nutrition Survey. Ulaanbaatar, 2000. 34. National Statistical Office. Population and household census-2000. Ulaanbaatar, 2000. 35. National Statistical Office. Mongolian statistical yearbook-2000. Ulaanbaatar, 2001. 36. National Statistical Office. Health behaviour of adolescents. Ulaanbaatar, 2002. 37. National Statistical Office. Situational analysis of the rural sector. Ulaanbaatar, 2002. 38. National Statistical Office and the United Nations Development Programme. Living standards measurement survey. Ulaanbaatar, 1998. 39. National Statistical Office and the United Nations Population Fund. Reproductive health survey. Ulaanbaatar, 1998. 40. Otgonbayar P. Protecting adolescents’ health from smoking. Project proposal. Unpublished document, 2002. 41. Rice M. Advocacy and sex education. Regional meeting on youth and reproductive health. Copenhagen. 1997. 42. Save The Children Fund. Girl children as sex workers: Situation and trends in Mongolia. Survey Results. Ulaanbaatar, 1998. 43. Susan Eltayeb. A comparison study of the KAPs between trained and untrained teachers in reproductive health and sexuality education in Mongolia.. Heidelberg University, Germany, 2001. 9Dissertation for MSc in CHHM.0 44. Government of Mongolia. National Programme of Action for the Development of Children in the 1990s. Ulaanbaatar, 1993. 45. Government of Mongolia. Population Policy of Mongolia. Ulaanbaatar, 1996. 46. Government of Mongolia. National Programme on Population Health Education. Ulaanbaatar, 1998. 47. United Nations. Plan of Action of the Cairo Conference on Population and Development. Ulaanbaatar, 1999. 48. United Nations. New generation: Children’s National Assembly report. Ulaanbaatar, 2001. 49. United Nations country team and the Scout Association. Mongolian adolescents needs assessment survey. Ulaanbaatar, 2000. 50. United Nations Development Programme. Human development report 1996 –Mongolia. Ulaanbaatar, 1997. 51. United Nations Development Programme. Human development report 2000 - Mongolia. Ulaanbaatar, 2001. 52. United Nations Population Fund (2000) Mid-term review-Country Brief-A basis for discussion and decisionmaking. Ulaanbaatar 53. United Nations Population Fund. Fact sheets on the Reproductive Health Survey 1998. Ulaanbaatar, 2001. 54. United Nations Children’s Fund. Situation of children in difficult conditions. Ulaanbaatar, 1998. 55. United Nations Children’s Fund. Children and women in Mongolia. Situation analysis report-2000. Ulaanbaatar, 2000. 56. United Nations Children’s Fund and Mongolian National Board for Children. State of children-1998. Ulaanbaatar, 1999.
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57. Wei W. Adolescent reproductive health: Evaluation of school-based sexuality education in Mongolia. Heidelberg University, Germany, 2001. 58. World Health Organization. Guidelines on health education training for secondary schools. Ulaanbaatar, 1998. 59. World Health Organization, Regional Office for the Western Pacific. New horizons in health. Manila, 1995. 60. World Health Organization, Regional Office for the Western Pacific. Policies on adolescent health and development: a guide for policy-makers. Manila, 2002. 61. World Health Organization, Western Pacific Regional Office. Value adolescents, invest in the future. Manila, 2002.
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Endnotes National Statistical Office. Population and household census-2000. Ulaanbaatar, 2000 Ministry of Health and Social Welfare and the Health Management, Information and Education Centre. Health Indicators 1998. Ulaanbaatar, 1999. 3 Ministry of Health and Social Welfare, 1999. 4 Ibid. 5 United Nations Development Programme. Human development report 2000 - Mongolia. Ulaanbaatar, 2001. 6 Ministry of Health, the Maternal and Child Research Centre and the United Nations Children’s Fund. Maternal mortality in Mongolia 1996-1998. Ulaanbaatar, 2001. 7 Ministry of Health and National Centre for Health Development. Health indicators 1999. Ulaanbaatar, 2000. 8 Ministry of Health and National Centre for Health Development. Health indicators 2000. Ulaanbaatar, 2001. 9 United Nations Development Programme. Human development report 1996 –Mongolia. Ulaanbaatar, 1997. 10 Op. cit. Ref. 7. 11 Ministryof Health and Social Welfare and WHO. Health sector review. Ulaanbaatar, 1999. 12 Op cit. Ref. 9. 13 Malchinkhuu D, Radnaakhand N. Survey report on morbidity of adolescents. Ulaanbaatar, 1995. 14 Maternal and Child Research Centre. Project report on maternal and child health. Ulaanbaatar, 1999. (In Mongolian.) 15 Nutrition Research Centre and UNICEF. Second National Nutrition Survey. Ulaanbaatar, 2000. 16 United Nations country team and the Scouting Association. Mongolian adolescents needs assessment survey. Ulaanbaatar, 2000. 17 Op cit. Ref. 15. 18 Ministry of Health and Social Welfare, Ministry of Education. Student and Adolescent Health Programme. 1997. 19 Op cit. Ref 15. 20 National Centre for Health Development and the Mongolian Foundation of Open Society. Report of the quantitative and qualitative survey on the KAP on STD/HIV/AIDS for young persons 15-25 years old in Mongolia. Ulaanbaatar, 2000 21 United Nations Popoulation Fund, National Statistical Office. Reproductive Health Survey Report. 1998. 22 United Nations Population Fund. Fact sheets on the Reproductive Health Survey 1998. Ulaanbaatar, 2001 23 Ibid. 24 National Centre for Health Development and the United Nations Population Fund. Unwanted pregnancies and abortions in Mongolia. Ulaanbaatar, 2001. 25 Op cit.Ref 19. 26 Ministry of Health and the Public Health Institute. Public health in the new millennium. Ulaanbaatar, 2001. 27 Op. cit. Ref, 20. 28 National Statistical Office. Health behaviour of adolescents. Ulaanbaatar, 2002. 29 Ibid. 30 Op cit. Ref. 14. 31 Ministry of Health and Social Welfare, Health Management, Information and Education Centre and WHO. Health conscious behaviour: Habits and attitudes in adolescents. 1997. 32 Mitsuaki T et al. Smoking in Mongolia: prevalence, knowledge and attitudes: Results of an urban survey. Ulaanbaatar, 2000. 33 United Nations Development Proigramme. Assessment on Alcoholism in Mongolia. 1998. 34 Op cit. Ref. 29. 35 Op cit. Ref. 26. 36 Op cit. Ref. 28. 1 2
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Maternal and Child Research Centre. Project report on clinical aspects of infant mortality, children’s common diseases and emergencies. Ulaanbaatar, 2001. (In Mongolian). 38 National Committee for Children. National report on implementation of the Convention on the Rights of the Child. Ulaanbaatar, 2001. 39 Ministry of Health and Social Welfare and the United Nations Children’s Fund. Survey report on children in difficult circumstances. Ulaanbaatar, 1998. 40 National Centre for Health Development and WHO. Adolescent Health Service Survey report. Ulaanbaatar, 2002. 41 Op cit. Ref. 28. 42 World Health Organization and Health Management, Information and Education Centre. Guidelines on health education training for secondary schools. Ulaanbaatar, 1998. 43 National Statistical Office. Mongolian statistical yearbook-2000. Ulaanbaatar, 2001. 44 National Statistical Office and the United Nations Development Programme. Living standards measurement survey. Ulaanbaatar, 1998. 45 Ministry of Health. Working group presentation on the hygiene and sanitation situation in schools. 2002. 46 Op cit. Ref. 16. 47 United Nations Children’s Fund. Children and women in Mongolia. Situation analysis report-2000. Ulaanbaatar, 2000. 48 Save The Children Fund. Girl children as sex workers: Situation and trends in Mongolia. Survey Results. Ulaanbaatar, 1998. 49 Op cit. Ref 47. 50 Op cit. Ref 48. 51 Op cit. Ref. 28. 52 National Committee for Children and the United Nations Children’s Fund. State children-1998. Ulaanbaatar, 1999. 53 Op cit. Ref 16. 54 Children’s Rights Centre. Survey report on the situation of children in the Child Care Centre. Ulaanbaatar, 1999. 55 Gantuya S, Otgonbayar R. Survey report on the health situation of children in the Child Protection Centre. Ulaanbaatar. 56 Op cit. Ref 38. 57 Op cit. Ref. 16. 58 Convention on the Rights of the Child.United Nations, 1989. 59 New horizons in health. Manila, WHO Regional Office for the Western Pacific, 1995. 60 Cairo Declaration on Population and Development. United Nations, 1999. 61 Ministry of Health, HMIEC and UNFPA. Adolescent Reproductive Health Survey. 1996 62 NSO and UNFPA . Reproductive Health Survey. 1998. 63 Wei Wang. Adolescent reproductive health: Evaluation of school-based sexuality education in Mongolia. A Dissertation for MSc in CHHM. 2001 64 Eltayeb S. A comparative study of the KAP between trained and untrained teachers in Reproductive Health and Sexuality education in Mongolia. A Dissertation for MSc in CHHM. 2001. 65 Op cit. Ref. 62. 66 Op cit. Ref. 26. 67 Rapid Assessment Tools 68 Adolescent Needs Assessment Survey, MOH and UN agencies in Mongolia, Ulaanbaatar, 2000. 69 Knowledge, Attitude and Practice on STD/HIV/AIDS for 15-25 Year-Old Young Persons in Mongolia (Quantitative and Qualitative Research), HMIEC, MSF, MFOS, Ulaanbaatar, 2000. 37
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