The principal reasons for the low use of contraceptive methods among adolescents are:

• Lack of access to information about sexual and reproductive health – There is no integrated sex education in schools; the media transmit ambivalent messages; and parents lack the necessary information and experience difficulties in discussing sex with their children.
• Lack of access to sexual and reproductive health services – Existing centres lack confidentiality, privacy and quality of service, all considered essential characteristics by adolescents. Centres with specialized services for young people are rare and/or relatively expensive, so poor adolescents cannot access them.
• Low quality of care – Many doctors lack the knowledge and skills to provide adequate sexual and reproductive health services consultations to adolescents and treat them in a paternalistic way.

The adolescent voucher programme

Inspired by the success of a voucher programme for sex workers in Managua in improving access to treatment and reducing the incidence of STIs, ICAS piloted a voucher programme for poor adolescents in Managua. Aiming at the reduction of the incidence of unwanted pregnancies and HIV/STIs among poor adolescents in Managua, the specific objectives were defined as: 1) to facilitate access to and improve the quality of sexual and reproductive health services; 2) to increase adolescents' use of  services; and 3) to increase their knowledge and use of contraceptives.

A Memorandum of Understanding was signed with the Ministry of Health and the scheme was first piloted in Managua from 2000-2002, with DFID support. In 2002, with funding from the Dutch Government, the programme was extended to cities in the districts of Rivas and Chinandega and recently, to Matagalpa and Leon, where it will operate until 2007. Under the programme, vouchers are distributed to poor adolescents, aged 12 to 20 years, at markets, outside schools and door-to-door in disadvantaged neighbourhoods. Distribution is done by ICAS adolescent fieldworkers, NGOs, clinics (for example, for friends of pregnant girls or partners of STI patients), and adolescent clubs associated with clinics.

The vouchers are not person-bound and are regularly transferred to others in greater need. They are valid for three months and entitle the bearer to a free consultation and follow-up visit at any of the four public, eight private, or thirteen NGO clinics contracted. The  service package consists of counselling, family planning, pregnancy testing, antenatal care and syndromic STI treatment. All clients receive a booklet on adolescent health; two condoms with supportive information; as well as access to laboratory tests (for pregnant girls), drug treatment for STIs and contraceptives, as required. The selection of clinics by ICAS is based on suitability and proximity to the areas where vouchers are distributed. Doctors complete standard medical forms during each consultation. Participating clinics receive reimbursement based on the number of completed forms with voucher attached, according to agreed fees, between 2.5 and 5 U$ for the first consultation.

Capacity building for staff of participating clinics includes a short introduction to the programme, followed by training sessions on counselling, adolescence and sexuality, contraceptives, syndromic STI treatment and sexual abuse. Monitoring and evaluation of the programme takes place through different strategies, including information on distribution and use of the vouchers; medical forms; interviews with doctors and simulated patients before, during and after the programme; and focus group discussions with adolescents.

Results so far

The reception of the programme by parents and teenagers has been very positive. Nearly all adolescents accept a voucher when offered, and during distribution in neighbourhoods parents often request additional vouchers for other teenage children. The programme demonstrates a high level of unmet need for sexual and reproductive health services among poor adolescents. The most important reasons for girls to consult the services in 2003 were contraceptives, STI treatment, general information/counselling and antenatal control (in order of importance); for boys the main reasons were contraceptives, general information/counselling and STIs. To date, over 11,000 consultations have been provided. In 2003/2004, 23% of the 22,786 female and 15% of the 17,314 male adolescents who received a voucher used it. These are relatively high percentages, considering the fact that the vouchers are distributed without asking adolescents about their sexual and reproductive health needs. Many adolescents – 63% of the girls who received a voucher in the pilot – are not yet sexually active, and thus have limited needs for related services. Among sexually active adolescents, experience so far shows that many use their vouchers: during the pilot; half of the sexually active girls who had received a voucher used it. Boys normally do not use these services, because they have less sexual and reproductive health needs and they usually go to a pharmacy for STI treatment (where they receive neither counselling nor partner treatment). Vouchers succeeded in mobilizing young men towards the clinics: for each 100 male voucher receivers, fifteen vouchers were used and of these two consulted the doctor for an STI. Although reliable prevalence data on STIs in this age group is missing, it is not likely to be much higher than 2%. Summarizing, the programme is a promising strategy to improve adolescents' access to, and use of sexual and reproductive health services, as was confirmed by a recent evaluation.¹

The programme also has a positive impact on quality of care. It succeeded in strengthening and updating the technical knowledge of many participating doctors on subjects such as contraceptives and syndromic STI treatment. However, it is more difficult to change attitudes, social skills and the existing curative focus. The high turnover of doctors in all types of clinics has been a limitation.

The voucher programme is a strategy that works through organizations that are already in contact with the target group and uses existing infrastructure and staff. All health-care providers approached were very interested to participate. In most districts, except in Managua, public health services were integrated successfully into the programme, and scaling up to other geographic areas proved to be relatively easy.

Lessons learned and challenges for the future

The voucher programme has shown that poor adolescents have large unmet needs for sexual and reproductive health services, which can be met with a relatively simple intervention that removes barriers to confidential care. However, a number of important challenges remain:

• A voucher programme will never be able to achieve nationwide coverage for sexual and reproductive health services for 25% of a population. The only sustainable way to organize such essential care requires that public, private and NGO services see it as their task to help adolescents – whether they are married or not – with confidential health care. This is presently not the case. The sustainability sought by the programme is that young people familiarize themselves with the use of sexual and reproductive health services; that clinics learn to provide adequate services in a confidential way; that clinics become interested in attracting this new group of clients; and that the young boys and girls reached by the voucher programme become the agents for change in the way teenagers and society handle teenage sexuality.
• While quality control is important, training and feedback for medical doctors and clinics have proven insufficient to increase the quality to the level required. In order to improve the ability of doctors and other medical staff to provide adolescent-friendly sexual and reproductive health services, it is necessary to change their attitudes and curative focus, by adapting medical training at universities.
• The huge available information gap that still exists among young people cannot be met by medical doctors during one consultation: safer sexual practices among young people require increased access to sexual and reproductive health information. However, this is difficult in a context where government and some donors fail to accept adolescent sexuality, and reject open discussion on sexuality and effective sex education in schools.
• It is a particular challenge to provide continued support to adolescents under 15 years – of whom 10% of girls is already pregnant or a mother, and who have the highest unmet needs – when a number of important donors prefer to exclude them from voucher programmes.