Bojan Jovanovski.1
1Health Education and Research Association (HERA), the former Yugoslav Republic of Macedonia.
Executive summary
The idea of creating specific youth centres for sexual and reproductive health reflects the intention of the government and the nongovernmental organization (NGO) Health Education and Research Association (HERA) to integrate health and social services within primary health care and reach out to the most vulnerable young people, including sex workers, men having sex with men (MSM), street and institutionalized children and young Roma.
Integration had to ensure operational and financial sustainability from the state health system beyond donor support, while the NGO’s involvement was crucial in ensuring young people’s participation in all stages of youth clinic development, accelerating access to services of those who are most vulnerable and marginalized and building the capacity of state service providers on the crucial aspect of young people’s sexuality and reproductive health.
The “I want to know” youth centres are special because they provide a wide range of free and anonymous sexual and reproductive health services and counselling that are segregated from other health services at the clinics, enabling young people to feel welcome and safe. Young peer educators are involved inside and outside the clinics, organizing promotional and entertainment events and being involved in evaluation of services to ensure young people are equal partners in service delivery and the promotion of sexual and reproductive health.
Even today, however, the “I want to know” youth clinics are not fully covered within the government health programme and budget. There appears to be a lack of political will to effectively implement adopted policies that acknowledge sexual and reproductive health issues among young people. Ongoing reforms and privatization of primary health care services are not seen to be in favour of introducing and/or integrating specific youth clinics in primary health care settings. New approaches are needed at central and local government levels to better address the sexual and reproductive health needs of young people and to ensure that the new reforms do not negatively influence accessibility to services through decreases in financial support and quality of care.
Socioeconomic background of young people in the former Yugoslav Republic of Macedonia
The former Yugoslav Republic of Macedonia has gone through demographic transition in recent decades in terms of increased ageing of the population and an increase in the rate of older people in the total
population. The country’s population is still considerably younger than that of countries in western Europe with a median age of 35.3 years, according to the 2002 census, but the number of older people is on the rise. Average ages in the countries of the European Union (EU) and central and eastern Europe are also increasing and the proportion of older people in the former Yugoslav Republic of Macedonia is significantly lower than this average.
Numbers and proportions of adolescents in the population are shown in Table 1.
Key socioeconomic trends and indicators concerning children and adolescents include the following.
The national unemployment rate is very high (33.8% in 2008), with extremely high youth
•
unemployment (56.4% among 15−24-year-olds) (1).
There is a high and increasing concentration of poverty among households with children (49.3% in
•
2002 to 66.6 % in 2005) (2).
The rate of children in institutional care is increasing: 164.4 per 100 000 population aged 0−17 years
•
in 2002 to 182 per 100 000 in 2005 (2).
The majority of children (92%) live in traditional families with both parents, with an average of 3−4
•
members in families originating in the former Yugoslav Republic of Macedonia and 5−6 in families of Albanian or Roma ethnic origin (2).
Data on young people’s health and health-related behaviours
In general, basic data about adolescent mortality and morbidity in the former Yugoslav Republic of Macedonia have poor reliability and accuracy. Specific data for the age groups 10−14 and 15−19, data on social determinants of health such as place of residence, economic status and education level, and data on certain morbidity statistics are either not available or are not presented as disaggregated data in official health statistical reports. In addition, data are only available from state-owned health institutions, with those from the private health sector lacking. Currently, there is no national system for systematic data collection on healthy lifestyles among adolescents, meaning the data that are available arise from random health surveys. It is essential that this situation is resolved.
Available data on young people’s health from the former Yugoslav Republic of Macedonia can be grouped under the following headings.
Mortality
The mortality rate is the key indicator of the health and safety of the population. In 2005, the mortality rate among young people aged 15−24 years was 5.4 deaths per 10 000 among males and 2.8 among females. The mortality rate among boys is double that of girls in the same age group.
Violent deaths, which include accidents, suicides and homicides, are the predominant causes of death in this age group. From a total of 587 registered cases of violent death in 2005, 23 in the age group 0−14 years and 28 among 15−19-year-olds were due to accidents. According to the State Statistical Office, there were 16 suicides committed by young people between 15 and 24 years in 2005, which is the lowest standardized suicide mortality rate in Europe (4.34 per 100 000). The number of registered homicides among young people of 15−19 years is increasing, from 8 registered in 1995 to 13 in 2005.
Table 1. Numbers and proportions of adolescents in the total population
Some statistics on mortality rates among young people aged 15−24 years are shown in Table 2.
Morbidity
In the health care institutions that provide primary health care for school-aged children and youth, the largest proportion of registered diseases is acute respiratory diseases. Increases in morbidity from mental disorders, malignant disease, infectious diseases and injuries were found between 1999 and 2005. Alongside increased levels of physical abuse of adolescents and violence within the family, in schools and on the streets is now more frequently seen, although there are no data to support these observations.
Some statistics on morbidity rates among young people aged 15−19 years are shown in Table 3.
Accurate determination of the external cause of violent death is of essential importance in estimating risk factors to support measures to prevent violence and violent death. Adolescents comprise one third of self-injured hospitalized patients. Females at the age of 15–19 years are most likely to self-injure, while males of the same age group have the highest rate of hospital morbidity through intentionally caused injury by another individual.
Around 2% of children under 5-years-old in the former Yugoslav Republic of Macedonia are moderately underweight, and less than 0.5% are classified as severely underweight. Nine per cent of children have stunted growth or are too short for their age and 2% are too thin for their height (2).
Because of the dangers of increasing obesity in the future and the raised concerns about this public health problem throughout the EU, it is essential to collect appropriate data on the height and weight of adolescents and young people in the former Yugoslav Republic of Macedonia and to take appropriate health promotion Table 2. Mortality rate per 10 000 young people aged 15−24 years by gender and
cause of death, 1997−2005
Table 3. Most prevalent causes of morbidity per 10 000 young people aged 15−19 years registered by health care services, 1999−2005
steps concerning their eating habits now, so as to avoid the consequences of obesity in the population as a whole.
Young people and their sexual and reproductive health
Data on sexual and reproductive health, like other data relevant to adolescents and young people, are not routinely collected as part of health statistics in the former Yugoslav Republic of Macedonia and are not sufficiently addressed in the collection of data on mortality and morbidity. A number of quantitative and qualitative behavioural studies relating to sexual and reproductive health have, however, been conducted in the country, and they indicate the following.
Knowledge, sexual norms and sexual behaviour
Young people (aged 15−24 years) have high levels of awareness and knowledge of HIV/AIDS and sexually transmitted infections (STIs). The level of HIV/AIDS knowledge among young people (42%) has remained practically unchanged since 2005 (when it was 40%), but knowledge among injecting drug users, sex workers and MSM has improved (3).
The majority of young people are sexually active, mostly with a regular partner. There has been a slight decrease in the percentage of young people (aged 15−24) who started sexual activity before the age of 15.
Just over 14% of males said they had first sexual intercourse under the age of 15, with the equivalent for females being 4.4%. This means around 24 000 males and 7 000 females under the age of 15 are sexually active – a worrying statistic. Fifty per cent of adolescents males, compared to 25% of adolescent females, had their first sexual experience by the age of 17 years (3).
Most young men report having at least one non-regular partner in the last 12 months. Only 39% of males reported that they used a condom during their last sexual intercourse, with around 59% of them citing reduced sensitivity as the main reason for not using a condom (3).
Small numbers of young people engage in particularly high-risk sexual behaviour. These include the 12%
of young men and 2% of young women who are involved in commercial sex and the 2.6% of young men having sex with other men, with almost half not using a condom at last sex (3).
Around 50% of high-school students lack information about contraceptives and have insufficient knowledge about contraceptive use. Less than 60 % of students believed contraceptive pills were efficacious and
only one third agreed with the principle of dual protection. The prevalence of modern contraceptive use (excluding condoms) is extremely low, with only 1.6 % of young girls reporting using pills (4).
Fifty-six per cent of young girls have one or more friends or close relatives who have had abortions, but only 29% are familiar with the places where the abortion could be performed (4).
Teenage pregnancy is part of the reproductive behaviour of adolescents in the former Yugoslav Republic of Macedonia. In 2005, 7.8% of newborns were born to juvenile mothers (under the age of 19). The specific fertility rate in that year was 21.7 live births per 1000 women under 19 years (5). Even though there is a downward trend in the specific fertility rate in the age group 15−19 years (it was 45.6 per 1000 live births in 1994), the country still has a significantly higher rate than is found in EU countries (6).
The abortion rate among adolescents is an important indicator of the sexual and reproductive health of this population group, and the lack of this indicator renders reproductive health statistics incomplete. Official data on the national abortion rate are unreliable as they have mainly been taken from the state-owned health care institutions and are not disaggregated by age groups or other health determinants. In addition, due to privacy and confidentiality issues, large numbers of young girls decide to have their abortions in private clinics, meaning they remain unreported.
The incidence of STIs among adolescents and young people, as reported in data from the state-owned health care reporting system, does not give an accurate estimate of the extent of the problem. According to some sources, the former Yugoslav Republic of Macedonia is experiencing an increasing trend in STI incidence among youth, particularly in relation to Chlamydia, trichomonas and the human papillomavirus (HPV). Out of 111 registered HIV-positive cases, 19% are aged 20−29 years.
Sexual and reproductive health services for young people and adolescents and the policy environment
Sexual and reproductive health services available to young people
There are no specialized age- or gender-appropriate services at primary health care level focusing on the sexual and reproductive health of adolescents. Girls of over 14 years have the right to choose a gynaecologist in primary health care who provides health care services to all women in the reproductive period; there are no special services for adolescents. No services for sexual and reproductive health are provided for adolescent boys at primary health care level.
Preventive health care is provided in the form of systematic examinations, immunization, health education and counselling for children in and out of schools settings. These are provided by the so-called “preventive health teams” working within health care centres at municipal level. However, less attention is paid to sexual and reproductive health education and counselling due to school doctors lacking the skills, time and space necessary to address these issues properly. There is no specified number of classes related to the health and development of adolescents in the undergraduate medical curriculum and postgraduate specialization in school medicine has recently been terminated.
Youth-friendly service approaches do not form part of existing national adolescent and youth health programmes. Health services for adolescents and young people, including sexual and reproductive health services, are fragmented, specialized, use biomedical approaches in health service delivery and lack sound referral mechanisms between health, education and social services. The utilization rate of existing reproductive health services is very low: according to a United Nations Children’s Fund (UNICEF) report published in 2006, only 16.6% of female adolescents aged 13−19 years have visited a gynaecologist and almost half do so only once in their lives (7). This very low attendance rate leads to the conclusion that these services are neither attractive to, nor acceptable to, young clients.
Male adolescents in the same UNICEF study considered existing reproductive health services as not
appropriate to their needs. Only 16.2% of male respondents aged 13−19 years could indicate which medical specialist was responsible for STI treatment. Just over 41% of male and 36.1% of female adolescents (aged 13−19 years) felt comfortable when visiting health facilities and more than half considered their health care workers to lack motivation in their daily work (7).
Most health care providers lack training in youth-friendly approaches, particularly in relation to practising counselling and communication skills, acknowledging the rights of all adolescents to service delivery and understanding adolescent and youth participation in the design, delivery and monitoring of youth-friendly services. This is explained by the existing policy and legislative environment regarding young people’s health and development in the former Yugoslav Republic of Macedonia, which is inconsistent and fragmented and does not recognize young people as a specific social category. National regulations spanning the social, health and education sectors are not integrated into a cross-sectoral youth policy and are not based on the principles of empowering young people to actively influence decision-making processes on issues that are relevant to their health and well-being.
In 2004, the International Planned Parenthood Federation (IPPF) knowledge, attitudes and practice (KAP) survey concluded that most of the problems are related to the demand of adolescents for sexual and reproductive health services than to actual provision of services. No adolescent or youth-only sessions are offered by sexual and reproductive health services or public health institutions in the former Yugoslav
Republic of Macedonia. However, the Ministry of Health, in partnership with relevant international organizations (IPPF, UNICEF, UNFPA and Partnership for Health) and the NGO HERA, has since 2005 been promoting the concept of youth-friendly health services as part of primary health care. As a result, two youth-friendly sexual and reproductive health centres, called “I want to know”, now operate in the capital city of Skopje.
These serve as “best practice” models for integrated health and social services within public health
institutions countrywide, primarily focusing on promotion and provision of free and anonymized sexual and reproductive health services for mainstream and the most vulnerable young people, with an emphasis on Roma youth, street and institutionalized children, sex workers and young MSM.
NGOs, supported by the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria (GFATM) project, are mainly involved in providing youth peer-education opportunities, outreach HIV-prevention services and testing for most-at-risk youth groups, including MSM, sex workers and injecting drug users. Existing harm-reduction programmes are being effectively implemented by local community-based NGOs. The GFATM project has increased the role and capacities of a large number of local and community-based NGOs in the last five years, especially those dealing with vulnerable young people, and has fostered collaboration between state health institutions and local NGOs, particularly in the field of HIV testing. There are still, however, no funds available to support NGOs’ activities within existing state health preventive programmes for young people and vulnerable groups; this presents a potential threat to the continued sustainability of numerous NGOs beyond the project life.
Specialist doctors in school medicine received UNICEF-supported training on new approaches to adolescent health and development in 2006/2007.
Health institutions involved in providing health care services for adolescents and youth, regardless of the level of health care provided, do not have specified quality standards and protocols for working with adolescents and young people on issues such as confidentiality, privacy, access to information and working hours adjusted to their needs.
Policy environment and regulatory framework
The government adopted the national strategy for child and adolescent health and development in February 2009. This positively addresses the sexual and reproductive health of young people and the need for youth-friendly services. The national HIV/AIDS strategy 2007–2011 and the national youth strategy also focus on preventive programmes and activities targeting young people, with an emphasis on the most-at-risks groups.
Most strategies detail action plans that accurately address the needs of young people in relation to HIV and sexual and reproductive health. But while the documents are in place, there is lack of government commitment to effective implementation and provision of adequate resources. Most strategies also lack monitoring and evaluation plans.
Ongoing reforms in primary health care and the privatization of gynaecological services have led to increases in costs for users of sexual and reproductive health services and the withdrawal of gynaecology services from the poorest areas in the country on economic grounds. For instance, there is no gynaecologist in the biggest Roma community in the former Yugoslav Republic of Macedonia, the municipality of Suto Orizari (30 000 inhabitants); Roma women have to travel around 5 km to the nearest gynaecological
“cabinet”; although this is not a great distance, the cost of getting there and accessing the services impinges on the family budget, which acts as a disincentive to use the services.
The Law on Health Care and the Law on Health Insurance regulate public health issues. These state that the children of each insured person will be medically insured until 18 years of age. After this, they will remain insured (to their 26th birthday) only if they are enrolled in the formal education system. The former Yugoslav Republic of Macedonia has a high coverage of children and young people enrolled in the education system,
so most of the young population is medically insured through their parents’ participation in mandatory health insurance.
No specific health legislation is in place, however, for adolescents and young people on issues such as access to contraception. The basic health insurance package does not contain specific clauses related to adolescents and young people; particular measures on age or vulnerability have to be specified in the policy to cover
No specific health legislation is in place, however, for adolescents and young people on issues such as access to contraception. The basic health insurance package does not contain specific clauses related to adolescents and young people; particular measures on age or vulnerability have to be specified in the policy to cover