Evaluating the implementation fidelity of national standards for adolescent- and youth-friendly sexual and reproductive health services in Tanzania: a descriptive cross-sectional survey

Abstract

Background

Adolescents and youth require age-appropriate, comprehensive sexuality education and health services to support healthy growth and development. This study evaluated the coverage and fidelity of implementation of the National Standards for Adolescent- and youth-friendly Sexual and Reproductive Health (SRH) Services across types of health facilities in Tanzania.

Methods

A descriptive cross-sectional study was conducted from November,1st − 30th, 2022, in eleven purposely selected health facilities across three Tanzanian regions: Dar es Salaam, Dodoma, and Kigoma. Facilities were stratified by ownership (government versus faith-based) and type (Dispensary, Health Center, Hospital). Data were collected using an observation checklist adapted from the Tanzanian Ministry of Health and analyzed with an International Business Machine (IBM^®) Statistical Package for Social Sciences (SPSS™) version 26, and the findings are presented in frequencies (n) and percentages (%).

Results

Of the 11 health facilities assessed, 9(82%) were government-owned and 2(18%) fatith-based; 3(27%) were Dispensaries, 55% (n = 6) Health Centers and 18% (n = 2) Hospitals. Findings revealed that all facilities (100%) offered adolescent- and youth-friendly SRH services. However, the average implementation fidelity of the National Standards of SRH services was 65%, of which none achieved full compliance with the National Standards. Health centers, including Tandale health center (73%), Kigogo health center (71%), Ujiji health center (67%), Baptist Council Designated Hospital, and Magomeni (60%) health center had the highest coverage and fidelity implementation of the adolescent-and youth-friendly SRH national standards, while Murufiti dispensary was the lowest (43%). Nevertheless, government-owned facilities achieved the highest coverage and fidelity in implementing adolescent- and youth-friendly SRH services compared to faith-based facilities.

Conclusion

The study revealed suboptimal coverage and incomplete implementation fidelity of National Standards for adolescent- and youth-friendly SRH services in Tanzanian health facilities. Enhancing infrastructures, strengthening healthcare worker capacity, and improving access to SRH education and associated services are critical to advancing the quality and reach of these services across the country.

Introduction

The global demographic landscape continues to shift toward a higher proportion of adolescents and youth, particularly within the African continent [1]. Current estimates indicate that out of approximately 7.2 billion worldwide, over 42% (more than 3 billion) are under the age of 25 years, with adolescents aged between 10 and 19 years comprising 18% (1.2 billion) of this population [1]. Notably, 88% of adolescents and youth globally reside in developing nations, with Sub-Saharan Africa (SSA) accounting for 18% of this demographic [2]. The adolescent population in SSA is projected to reach approximately 1.3 billion between 2010 and 2030. For instance, in Tanzania, adolescents constituted approximately 23% of the national population in 2022, with youth accounting for 20%, and young people nearly 32% [3]. Given this demographic dominance, any developmental or health-related agenda in Tanzania is intrinsically driven by this age group [4].

Adolescence and youth is a period marked by a rapid physical, cognitive, and psychosocial growth and developmental changes, which significantly influences an individual’s perception, decision-making process, and interactions with the world around them [5, 6]. Despite the perception of adolescence as a relatively healthy life stage, this period is frequently associated with elevated risks of morbidity and mortality due to injury, illness, and other health-related challenges [7]. Many of these issues are preventable or treatable but remain widespread, adversely affecting adolescents’ and youth potential to thrive [8]. To support healthy development, adolescents and youth require access to comprehensive, age-appropriate information, context-specific and culturally sensitive services including SRH education, opportunities for acquiring vital life skills, and access to high-quality health services that are acceptable, equitable, appropriate, and effective within a safe and supportive environment to foster resilience [6, 9]. Equally crucial is meaningful adolescent and youth participation in the design, implementation, and evaluation of health interventions, an approach that is believed to ensure responsiveness to their specific needs and rights [10].

Youth-Friendly Services (YFS) or Adolescent and Youth-Friendly Health Services (AYFHS) are specialized models designed to address the barriers encountered by adolescents and youth in accessing high-quality sexual and reproductive health (SRH) services [11]. In Tanzania, however, considerable gaps remain of which, many adolescents and youth lack access to accurate context-specific SRH information, education, and services including contraceptives which contributes to increased risk of early and unintended pregnancies and childbirth, unsafe abortions, Human Immunodeficiency Virus (HIV) and Sexually Transmitted Infections (STIs), malnutrition, anemia, substance abuse, mental health issues, and violence including Violence Against Children (VAC) and Gender-Based Violence (GBV) [12]. Additionally, social determinants such as gender inequality, harmful norms and practices (e.g., child marriage, female genital mutilation), school dropouts, and violence disproportionately affect adolescents and youth, perpetuating disparities [13].

Recognizing these barriers, the Tanzanian government has initiated policies and standards to improve adolescent and youth health service delivery [14, 15]. Notably, the National Standards and Implementation Guide for Quality Health Care Services for adolescents and youth has been established to facilitate the provision of adolescent-and youth-friendly SRH services [16]. To facilitate the making of existing health services youth-friendly, the Government of Tanzania has developed the National Standards and Implementation Guide for Quality Health Care Services for Adolescents [17, 18]. The 2007 National Health Policy specifically aims to reduce morbidity and mortality among vulnerable groups, including adolescents and youth, by improving healthcare quality [4]. The Health Sector Strategic Plan (HSSP) V (HSSP 2021/2022–2025/2026) emphasizes a survival, thriving, and transformative health strategy [19].

Similarly, the One Plan III (2021/2022–2025/2026) prioritizes a people-centered approach, aiming to expand access to adolescent and youth-friendly SRH services, promote retention in schools, and enhance infrastructure and service quality. This plan underscores the need for health workforce reorientation towards compassionate, rights-based care and aligns with commitments made through the National Adolescent Reproductive Health and Development Strategy (2019–2023) and other strategic documents including National Accelerated Action and Investment Agenda for Adolescent Health and Welbeing (NAIA-AHW) (2021/2022–2024/2025) and the National School Health Strategic Plan (2018–2023) [20]. NAIA-AHW (2021/2022–2024/2025) builds on the National Adolescent Reproductive Health and Development Strategy (2019–2023) and focuses on accelerating the improvement of adolescent health and wellbeing to support the growth and development of health [21].

Empowering adolescents and youth through education and health promotes positive knowledge, attitude, and life skills necessary to navigate SRH challenges [22]. The current strategic framework is built around six pillars: preventing HIV; preventing teenage pregnancies; preventing sexual, physical, and emotional violence; improving nutrition; keeping boys and girls in school; and developing skills for meaningful economic opportunities [8, 23, 24]. Nevertheless, questions persist regarding the sustainable implementation of the SHR National Standards and accessibility of adolescent and youth-friendly SRH services across different seasons and regions, as well as the extent to which service delivery approaches are truly adolescent- and youth-friendly. This study aimed to evaluate the coverage and implementation fidelity of the National Standards for adolescents and youth-friendly SRH services at health services delivery points in Dar es Salaam, Dodoma, and Kigoma regions. By evaluating these dimensions, this study seeks to inform the status quo and strategies for enhancing the quality, reach, and sustainability of adolescent- and youth-friendly SRH interventions in Tanzania.

Methods and materials

Study area and design

This study was conducted in three regions of Tanzania, specifically the Dar es Salaam, Dodoma, and Kigoma regions, based on their official designation by the Tanzanian Ministry of Health as providers of Adolescent- and youth-friendly SRH services [15]. A descriptive cross-sectional design with a quantitative research approach was employed, as recommended by similar previous studies [25–27]. Data were collected from selected health service delivery points between November 1st to 30th, 2022.

Sampling procedures

As shown in Table 1, a total of 11 health facilities were purposively selected based on their official designation by the Tanzanian Ministry of Health as providers of Adolescent- and youth-friendly SRH services in the country. Selection was guided by the alignment with national policy priorities using a criterion-based sampling strategy, ensuring the inclusion of facilities is aligned with their established capacity to deliver targeted services to adolescents and youth across ownership categories [28, 29]. Additional considerations included geographic distribution, facility level (e.g., Dispensary, Health Center, and Hospital), and service utilization volume, to enhance the relevance and generalizability of findings across diverse healthcare settings. Specifically, eight (8) public and three (3) private facilities met the inclusion criteria, and therefore were recruited and included in the study. Three (3) health facilities were sampled from Dar es Salaam, three (3) from Dodoma, and five (5) facilities from the Kigoma region.

Table 1.

Distribution of regions alongside health facilities and ownership sampled in this study (n = 11)

Region	Local government authority	Owner	Health facilities
Dar es Salaam	Kinondoni Municipal Council	Government	Kigogo Health Centre
Dar es Salaam	Kinondoni Municipal Council	Government	Magomeni Health Centre
Dar es Salaam	Kinondoni Municipal Council	Government	Tandale Health Centre
Dodoma	Dodoma City Council	Government	Kikuyu dispensary
Dodoma	Dodoma City Council	Government	Makole Health Centre
Dodoma	Dodoma City Council	FBO	St Gemma DD Hospital
Kigoma	Kasulu Town Council	Government	Murufiti dispensary
Kigoma	Kigoma Municipal Council	FBO	Baptist CD Hospital
Kigoma	Kigoma Municipal Council	Government	Gungu Health Centre
Kigoma	Kigoma Municipal Council	Government	Kigoma dispensary
Kigoma	Kigoma Municipal Council	Government	Ujiji Health Centre

Data collection procedures

A triangulation approach was employed, combining document review and direct non-participant observations. Data collection tools were adopted from the Ministry of Health’s national assessment tools for adolescent- and youth-friendly SRH services.

Document review

Key national, regional, and global policy documents and program materials related to adolescent- and youth-friendly SRH service provision, particularly from the program “Improving Access to Sustainable Quality of Integrated Sexual and Reproductive Health Services to Women and Girls,” were reviewed. These documents were accessed via official Ministry of Health sources and databases. Before data collection, the research team engaged with Ministry officials to ensure contextual alignment and scope clarity of the information to be collected. A document review was conducted to support the design and contextual interpretation of the quantitative analysis, which included the reviewed documents, including SRH national policies, SRH strategic plans, SRH implementation guidelines, and training manual related to adolescent- and youth-friendly SRH services obtained from the Tanzanian Ministry of Health and participating facilities. These materials were examined to identify relevant service delivery standards, criteria, and eligibility criteria for facility selection, as well as indicators aligned with national frameworks, which informed the customization and harmonization of data collection tools. The document review was descriptive and intended to complement quantitative data.

Observation

Assessment through structured non-participant observations was conducted at selected facilities to assess the availability and accessibility of adolescent- and youth-friendly SRH services conducted in two settings, including client-provider and a facility transect walk to verify infrastructure, supplies, and equipment. The observation tool was an adapted version of the World Health Organization (WHO) Service Availability and Readiness Assessment (SARA) tool, which provided a standardized checklist for evaluating key indicators, including human and non-human characteristics of the facilities [18, 30]. Observations were supplemented with field notes to record extra contextual details that could affect SRH service delivery. To ensure data readability, observations were conducted by trained research assistants working in pairs, and inter-rater agreement was assessed regularly through joint reviews and debriefing sessions. Discrepancies were resolved through consensus, and retraining was conducted as needed to maintain consistency across observation sites. Consent was obtained from both the adolescent client and the healthcare provider before the observation. Facility managers also granted permission for inventory inspections.

Data collection tools and variable measurements

The data collection instruments were adopted from the Ministry of Health tools [15, 18, 28, 29], which are based on global standards for evaluating the availability and accessibility of adolescent-and youth-friendly SRH services [18, 30]. The tools collected information from infrastructures and various stakeholders (facility managers, providers, support staff, adolescent clients) and incorporated findings from both document review and direct observations. Each health facility’s compliance with the eight national quality SRH standards was assessed using a structured point-based scoring system. A score of 1 was assigned to indicators showing that SRH-friendly services were available and accessible, while a score of 0 indicated non-availability or inaccessibility. In certain cases, weighted scores were applied to reflect the relative importance of particular observations. Final scores per standard were expressed as percentages of the maximum possible score, averaged across data sources.

Data quality assurance

In accordance with recommended best practices by other scholars [31, 32], several measures were employed to ensure data quality. All data collectors underwent comprehensive training on the study objectives, tools, data collection methods, data collection tools and research ethical procedures. Triangulation of data sources enhanced the credibility and validity of the findings. Furthermore, daily review and validation of the collected data ensured consistency and helped identify and correct anomalies in real time. Preliminary findings were shared with the Ministry of Health and key adolescent- and youth-friendly SRH services stakeholders during a validation workshop, where their feedback enhanced the reliability and accuracy of the final dataset by identifying factual and interpretive errors and filling data gaps.

Data management and analysis

Data were entered, managed, and analyzed using the International Business Machine (IBM^®) Statistical Package for Social Sciences (SPSS™) version 26, a tool widely recognized and used in [33, 34]. Data analysis was guided by both the study objectives and the scoring framework outlined in the Global Standards for Quality-Health-Care Services for Adolescents Volume 4 [18]. Descriptive statistics (frequencies, mean, and percentages) were used to analyze and summarize data. Thematic content analysis was conducted to analyze information from the document review, focusing on predefined themes such as service delivery standards and criteria that helped to contextualize findings from the primary data source and identify alignment or gaps between policy directives and service delivery practices. Moreover, insights from the document review were triangulated with primary data to enhance the depth and credibility of the study findings.

Findings

This section provides detailed descriptions of the findings across 11 health facilities in three regions of Tanzania (Dar es Salaam, Dodoma, and Kigoma) between 13th and 30th November 2022, focusing on the coverage and fidelity of implementation of Adolescent- and Youth-Friendly SRH services.

Adolescent and youth friendly services delivery points

Findings in Table 2 indicate that the facilities sampled included three dispensaries (27%) from Dodoma City Council (DCC), Kasuku Town Council (KTC), and Kigoma Municipal Council (KMC). Moreover, 55%(n = 6) of the facilities were health centers, three from Kinondoni Municipal Council, one from Dodoma City Council, and two from Kigoma Municipal Council. The study also sampled 18% (n = 2) hospitals, one from Dodoma City Council and another from Kigoma Municipal Council. A majority (82%) were government-owned, while the remaining 18% (n = 2) were managed by Faith-Based Organizations (FBOs).

Table 2.

Adolescent and youth friendly services delivery points (n = 11)

Region	Local Government Authorities	Dispensary n = 3 (27%)	Health Center n = 6 (55%)	Hospital n = 2 (18%)
Dar es Salaam	Kinondoni MC	0	Kigogo HC	0
			Magomeni HC
			Tandale HC
Dodoma	Dodoma CC	Kikuyu Disp.	Makole HC	St Gemma DDH
Kigoma	Kasulu TC	Murufiti Disp.	0	0
	Kigoma MC	Kigoma Disp.	Gungu HC	Baptist CDH
			Ujiji HC

Adolescent- and youth-friendly srh services coverage and implementation fidelity at health facilities

The findings of the study in Fig. 1 indicate that Adolescents and Youth-Friendly Sexual and Reproductive Health Services were available to all sampled delivery points (100%) in accordance with national standards by the adolescent- and youth-friendly sexual and reproductive health services guidelines in Tanzania [15, 28]. Although all facilities reported delivering adolescent- and youth-friendly SRH services, none achieved full adherence to the SRH national standards set for adolescent- and youth-friendly SRH service delivery. The average implementation fidelity of the National Standards of SRH services was 60%, which health centers achieved better than other types of health facilities. Tandale health center (73%), Kigogo health center (71%), Ujiji health center (67%), Baptist council designated hospital, and Magomeni (60%) health center had the highest coverage and fidelity implementation of the adolescent-and youth-friendly SRH national standards, while Murufiti dispensary was the lowest (43%).

Fig. 1.

Adolescent- and Youth-Friendliness of the SRH Services coverage and implementation fidelity at Health Facilities (n = 11)

Nevertheless, government-owned facilities had the highest achievement in the coverage and fidelity implementation of adolescent- and youth-friendly SRH service delivery compared to faith-based facilities. Differences in the coverage and fidelity implementation of adolescent- and youth-friendly SRH services may probably be attributed to the fact that government facilities, particularly health centers, have standardized SRH protocols, comprehensive training programs, trained staff, community and stakeholder involvement and engagement, better availability and accessibility to supplies and services, which can enhance fidelity to the standards. This indicates a significant gap between policy commitments and actual service provision practices on the ground.

Proportional distribution of the SRH National standards coverage and fidelity implementation at health facilities

This section presents the findings that demonstrate the extent to which facilities adhered to the national standards for adolescent- and youth-friendly SRH services, with a focus on the proportional distribution of coverage and fidelity implementation. It further disaggregates performance by specific criteria under each standard, providing a detailed assessment of how comprehensively and consistently the standards are applied. The findings highlight strengths and gaps in service delivery, offering critical insights for improving quality and equity in SRH care for adolescents and youths across Tanzania. The criteria were studied as commonly practiced in the Tanzanian context to find out whether the SRH services were available, and delivered equitably, acceptably, accessibly, and effectively.

Under standard I: Adolescent health literacy, the assessment revealed that while efforts had been made to promote awareness, none of the facilities reached 100% of the coverage and fidelity implementation. Findings in Fig. 2 indicate that Tandale Health Center achieved the highest proportion at 77%, while Murufiti dispensary achieved the lowest at 54%. Particulalry weak performance was observed in the availability of adolescent-specific information, education and communication materials in waiting areas (Criterion 2 of the national standards (35%), adolescents’ basic health knowledge (Criterion 8 of the SRH national standards) (47%), and the existence of outreach programs led by trained personnel (Criterion 4 of the SRH national standards) (59%). These findings suggest that many adolescents and youth accessing these facilities may lack the information and literacy required to make informed decisions about their health, thereby limiting their ability to effectively navigate available services. The staff at these 11 health service delivery points do not have adequate health literacy to enable them to gain access to, understand, and effectively use it in ways that promote and maintain their good health.

Fig. 2.

Proportional distributions of the implementation of standard I on adolescent health literacy about adolescent- and youth-friendly SRH services (n = 11)

Standard II: Parent and community support for adolescents assessed the extent to which parents, guardians, and community members were engaged in supporting adolescents’ and youths’ health needs. As shown in Fig. 3, achievements of the coverage and fidelity implementation of standard II ranged from 47% (Murufiti Dispensary) to 78% (Kikuyu Dispensary), with notable deficiencies in systematic engagement with parents, teachers, and religious leaders. Only 37% of facilities had healthcare providers who regularly informed parents and teachers during school meetings about adolescent services (criterion number 15 of the SRH national standards). Just over half (55%) of the assessed facilities had plans for community outreach activities and/or involvement of outreach workers in activities to increase caregivers’ support for adolescents’ use of services, while 59% (Criterion 12 of the SRH national standards). Nevertheless, 59% of the facilities maintained partnerships with local agencies to enhance community support. These findings imply that health services are still largely facility-centered and fail to leverage community-based support systems crucial for adolescents and access and uptake of SRH services (criterion 11).

Fig. 3.

Proportional distributions of the implementation of standard II on Parent and community support for adolescents in receiving adolescent- and youth-friendly SRH services (n = 11)

In relation to standard III: Appropriate package of services, significant implementation gaps were evident. While all facilities indicated in Fig. 4 demonstrated offering some form of adolescent and youth SRH services, the comprehensiveness of those services varied widely. Tandale health center led with a 69% score, while murufiti dispensary lagged at just 27%. Critical deficits were observed in referral systems (Criterion 22 of the SRH national standards), only 4% of facilities effectively referred adolescents and youth to appropriate levels of care, and the delivery of services beyond facility-based care, such as community outreach and follow-ups. Only 51% offered a complete package of SRH services that fulfil the needs of all adolescents and youth in the facility or through referral linkages and community outreache (Criterion 23 of the SRH national standards). Just 56% had established referral procedures based on the existing policies to services within and outside the health sector, including provisions of transition care for adolescents and youth with chronic health conditions (Criterion 20 of the SRH national standards). These findings underscore the urgent need for standardization of SRH service packages and reinforcement of referral pathways to ensure continuity of care for adolescents and youths.

Fig. 4.

Proportional distributions of the implementation of standard III on the appropriate adolescent- and youth-friendly SRH package for adolescents and youth (n = 11)

Standard IV: Provider competencies evaluated the preparedness and capacity of healthcare providers to offer adolescent- and youth-friendly SRH services. Findings in Fig. 5 indicate that none of the facilities achieved full compliance, with scores ranging from 44% (Murufiti dispensary) to 75% (Ujiji Health Center). Deficiencies were especially pronounced in continuing professional education for providers that includes an adolescent and youth healthcare component (Criterion 30 of the SRH national standards) (18%), the public display of adolescents’ rights and providers obligations in health facilities (Criterion 27 of the SRH national standards) (41%), and supportive supervision mechanisms in place to improve healthcare providers’ performance (Criterion 29 of the SRH national standards) (44%). These gaps reveal systemic weaknesses in maintaining provider competency and accountability, which are essential for respectful, confidential, and non-judgemental care. Notably, data elements used to evaluate whether adolescents and youth received effective services (Criterion 33 of the SRH national standards) were absent from the tools, highlighting a methodological limitation that also needs to be addressed.

Fig. 5.

Proportional distributions of the implementation of standard IV on provider competences in delivering adolescent- and youth-friendly SRH services (n = 11)

The assessment of standard V: Facility characteristics highlighted concerns regarding the physical and operational environments of the health facilities. Findings in Fig. 6 show that none fully met national standards for adolescent- and youth-friendly settings. Kigogo and Tandale health centers had the highest coverage and fidelity implementation of the standard (67%), while Kikuyu Dispensary achieved the lowest (46%). Core issues included lack of essential technology, equipment, and supplies needed to ensure effective service provision to adolescents and youth (Criterion 48 of the SRH national standards, only 5% availability across facilities), insufficient privacyand confidentaliaty during consultations and provision of healthcare at all times (Criterion 47 of the SRH national standards) (48%), and poorly maintained or unwelcoming facility environment (Criterion 46 of the SRH national standards) (50%). More than half (54%) of the facilities specifically Kigogo health center, Kikuyu dispensary, Magomeni health center, Murufiti dispensary, St. Gemma designated district hospital, and Ujiji health center, lacked adequate resources to deliver adolescent- and youth-friendly SRH services effectively. These gaps reduce adolescents’ willingness to seek care and compromise service delivery outcomes.

Fig. 6.

Proportional distributions of the implementation of standard V on facility characteristics in delivering adolescent- and youth-friendly SRH services (n = 11)

Standard VI: Equity and non-discrimination assessed whether adolescents and youth from diverse backgrounds could access services equitably. Again, findings in Fig. 7 demonstrate that none of the facilities scored a full 100%, with Kigogo health center achieving the highest score (94%) and Kikuyu Dispensary the lowest (25%). Several facilities lacked policy commitments to non-discrimination that are displayed prominently and take remedial actions when necessary (Criterion 52 of the SRH national standards) (35%) or formal policies and procedures ensuring universal access to SRH services regardless of age, marital status, education, ethnicity, sexual orientation or socioeconomic status (Criterion 49 of the SRH national standards) (41%). Criterion 50 of the SRH national standards for the presence and implementation of policies and procedures for services that are free at the point of use, or affordable, accounted for 52% of the facilities.

Fig. 7.

Proportional distributions of the implementation of standard VI on equity and non-discrimination of adolescents and youth in friendly SRH services (n = 11)

Nevertheless, two criteria under standard VI of the SRH national standards were not scored during this assessment because the data elements to measure their achievements are not currently accommodated by the assessment and monitoring tools. These criteria are namely criterion 54: “Health-care providers and support staff demonstrate the same friendly, non-judgemental, and respectful attitude to all adolescents, regardless of age, sex, marital status, sexual orientation, cultural background, ethnic origin, disability, or any other reason”; and criterion 58: “Vulnerable group(s) of adolescents are involved in the planning, monitoring, and evaluation of health services, as well as in certain aspects of health-service provision. Moreover, at three health services delivery points (Kikuyu Dispensary, Murufiti Dispensary, and Ujiji HC); the Health-service providers did not know who the vulnerable group(s) of adolescents in their community are”. The assessment also noted that, at four health services delivery points(Kikuyu Dispensary, Makole HC, Murufiti Dispensary, and Ujiji HC); the health services delivery point does not involve vulnerable group(s) of adolescents in the planning, monitoring, and evaluation of health services, as well as in certain aspects of health-service provision.

Standard VII: Data and quality improvement evaluated whether facilities used disaggregated service data to confirm continuous improvement efforts. The results in Fig. 8 showed a clear gap in using data as a tool for quality enhancement. Kigogo health center scored the highest with 87%, while Murufiti dispensary and St. Gemma designated district hospital had the lowest scores at 49% for coverage and fidelity of SRH national implementation standards. Only 12% of facilities had reward and recognition systems for high-performing staff (Criterion 63 of the SRH national standards), while just 41% had self-monitoring mechanisms in place for the quality of adolescent- and youth SRH services (Criterion 61 of the SRH national standards). Only three(48%) facilities (Baptist, council-designated hospital, Kigogo health center, and Makole health center) had systems for recognizing and rewarding provider excellence. In contrast, St. Gemma designated district hospital had no supportive supervision framework linked to monitoring outcomes, and both Kigogo and Tandale health centers lacked systems for recognizing outstanding staff performance. These findings hinder motivation, accountability, and sustained SRH service improvement.

Fig. 8.

Proportional distributions of the implementation of standard VII on data and quality improvement of adolescent- and youth-friendly SRH services (n = 11)

Lastly, Standard VIII: Adolescent participation emerged as the most underimplemented area, with no facility scoring 100% and a range from 29% at St. Gemma designated district hospital to 70% at Tandale health center, as shown in Fig. 9. Only three (7%) facilities (Gungu health center, Tandale health center, and Ujiji health center) had policies supporting adolescent and youth participation in SRH service design, implementation, monitoring, and evaluation (Criterion 72 of the SRH national standards). Adolescents and youth were not involved in planning or service delivery at five facilities (8%) (Baptist council designated hospital, Kigoma dispensary, Kikuyu dispensary, St. Gemma designated district hospital, and Ujiji health center) (Criterion 78 of the SRH national standards). Moreover, health providers and significant others are adequately prepared to support adolescents and youth engagement (Criterion 74 of the SRH national standards) in only three facilities (27%). These findings reveal that adolescents and youth are largely (36%) treated as passive recipients rather than active participants in shaping SRH services that affect their lives (Criterion 80 of the SRH national standards).

Fig. 9.

Proportional distributions of the implementation of standard VIII on adolescents and youth participation in SRH services (n = 11)

Discussion

This study evaluated the coverage and implementation fidelity of the National standards for adolescent- and youth-friendly SRH services across selected Health services delivery points in Dar es Salaam, Dodoma, and Kigoma regions. The findings indicate that while all assessed facilities offer adolescent- and youth-friendly SRH Services, their coverage and implementation fidelity were average, as none of the health services delivery points achieved full (100%) implementation of the National Standards. Nevertheless, government-owned and health centers such as Tandale, Kigogo health center, Ujiji health center, Baptist council designated hospital, and Magomeni health center exhibited comparatively higher implementation fidelity to the standards than faith-based owned and other types of health facilities, suggesting potential best practices or favourable enabling environment in these settings.

The government of Tanzania, particularly the Ministry of Health, expects that adherence to the developed National standards for the provision of quality SRH services to adolescents and youth would enhance the quality, coverage, and full uptake of the services. However, findings of this study underscore critical gaps in implementation, with particular deficits noted in several criteria across the eight national standards. Specifically, five standards included criteria with particularly low proportional performance below 25% that significantly contributed to the overall underperformance. These include: Standard III: criterion 22 (service providers refer adolescents to the appropriate service and level of care according to local policies and procedures, and follow the policies for transition care) and Standard IV: criterion 30 (a system of continuous professional education that includes an adolescent health-care component in place to ensure lifelong learning).

Others included standard V: criterion 48 (the facility has the equipment, medicines, supplies, and technology needed to ensure effective service provision to adolescents); standard VII: criterion 63 (mechanisms are in place for reward and recognition of highly performing healthcare providers and support staff) and standard VIII: criterion 72 (there is a policy in place to engage adolescents in service planning, monitoring, and evaluation). Nevertheless, standard VIII: criterion 78 (Adolescents are involved in planning, monitoring, and evaluation of health services). These findings reflect substantial system-level gaps in training, resources, policy reinforcement, and participatory service design factors critical to adolescent and youth-responsive healthcare [18]. Adolescent- and youth-friendly SRH services may not be as widely available or as reliable as they could be because government facilities, especially health centers, have standardized SRH protocols, comprehensive training programs, trained staff, community and stakeholder involvement and engagement, and better access to supplies and services. These factors can help ensure that the standards are followed.

These findings are consistent with prior research, including a case study conducted by Mwanangombe et al., [35] in Zambia found that the availability and accessibility of SRH services significantly influence adolescents and youth’s utilization rate. Their work reinforces the notion that strict adherence to national guidelines and standards can improve service uptake by addressing the unmet needs for information, education, and care among adolescents and youth. Similarly, a qualitative study conducted by Mgopa et al. [36] on the perceptions of sexual and reproductive health provision in Tanzania highlighted barriers to SRH access rooted in policy implementation challenges. They emphasized that inadequate training of healthcare providers on national guidelines and standards contributes to poor service delivery, echoing the current study’s findings. Addressing these gaps may be essential in ensuring equitable adolescent- and youth-friendly SRH service provision across healthcare delivery points.

A study by Getachew et al., [11] in South-Western Ethiopia on young people’s friendly SRH services knowledge, attitude, and practices found that adolescents’ low knowledge, negative attitudes, and limited service-seeking behavior were significantly associated with both individual factors and health system challenges. Notably, their results suggest that poor utilization of SRH services is not solely a function of demand-side factors but is equally influenced by health service availability and quality, further supporting the findings from this study. Additional observational and interventional works from Tanzania by Millanzi et al., [8, 22, 37–41] underscore similar challenges. Their research reveals that adolescents often encounter early sexual initiation, unintended pregnancies, and sexually transmitted infections not only due to moral feelings but also due to systemic shortcomings in delivering timely, age-appropriate SRH education and services. These findings advocate for stronger implementation of national SRH standards, delivered by competent and well-trained providers in adolescent- and youth-friendly settings.

Ndayishimiye et al., [42] in a descriptive cross-sectional study on the availability, accessibility, and quality of adolescent and youth-friendly SRH services in the health facilities available in Rwanda, found that while SRH services were technically available in most facilities, their accessibility for adolescents and youth remained limited. They concluded that involving adolescents and youth in service design and ensuring fidelity to national guidelines and standards is critical for improving service utilization, which is highly consistent with the current study’s conclusion. Collectively, these studies highlight a common theme that adolescents and youth have the right to access comprehensive, age-appropriate, and friendly SRH information and services. The low implementation fidelity found in this study not only limits the realization of this right but also undermines national and international efforts to reduce adolescents’ and youth’s SRH-related vulnerabilities.

The alignment of this study’s findings and those from similar regional and international studies may be attributed to comparable sociocultural contexts, health system structures, and methodological approaches. Nonetheless, the current gaps identified suggest an urgent need for policy action, resource allocation, and strengthened accountability mechanisms to enhance adherence to the national adolescent- and youth-friendly SRH guidelines and standards.

Conclusion

This study reveals that while all facilities in Dar es Salaam, Dodoma, and Kigoma regions provide adolescent- and youth-friendly SRH services, none fully implement the national standards for such services. The overall coverage and implementation fidelity in healthcare facilities were low, highlighting significant systemic and operational gaps, which pose a major barrier to the delivery of high-quality, equitable, and responsive SRH services for adolescents and youth. Addressing them requires a multifaceted approach that includes strengthened policy enforcement, investment in provider training, availability of friendly infrastructure and resources, and active involvement of young people in service design, implementation, monitoring, and evaluation.

Improving implementation fidelity to the national guidelines and standards is critical for enhancing service uptake, meeting the SRH needs of adolescents and youth, and achieving national and global targets for adolescents and youth health and wellbeing. This study contributes important evidence to inform health systems strengthening efforts and underscores the urgency of aligning health services delivery with policy commitments to adolescent and youth health in Tanzania.

Limitations of the study

This study addressed a sensitive subject, the availability and accessibility of adolescent- and youth-friendly SRH services across Tanzanian health facilities through direct observations and document review. Given the nature of the study context and data collection procedures, there was a possibility that the sample size alongside inclusion criteria of the documents and facilities was small for the generalizability and transferability of the findings. Although efforts were made to minimize these effects, such biases may still have influenced the findings and should be considered when interpreting the results. Furthermore, while the study followed a structured descriptive cross-sectional design, the documentation of the specific methods and materials used may benefit from clearer alignment between methodological procedures and the results presented. Enhancing transparency in the methodological reporting would support reproducibility and strengthen the credibility of follow-up research in this area and therefore, interpretation of the findings in this case should be based on the methods, and materials used to conduct this study.

Abbreviations

AYFHS

Adolescent and Youth-Friendly Health Services

CC

City Council

CDH

Council Designated Hospital

DDH

Designated District Hospital

SRHR

Sexual and Reproductive Health Rights

HIV

Human Immunodeficiency Virus

HC

Health Center

HSSP

Health Sector Strategic Plan

LGA

Local Government Authority

MC

Municipal Council

NAIA-AHW

National Accelerated Action And Investment Agenda For Adolescent Health And Wellbeing

RRH

Regional Referral Hospital

SPSS

Statistical Package for Social Sciences

SRH

Sexual and Reproductive Health

SRHS

Sexual and Reproductive Health Services

TC

Town Council

VAWC

Violence Against Women and Children

YFS

Youth-Friendly services

Authors’ contributions

G.K.: Conceptualization, methods and materials, conduct of the study, data curation, and analysis. M.N.M.: Conceptualization, methods and materials, conduct of the study, data curation, and analysis. W.C.M.: Conceptualization, methods and materials, data curation, and analysis, writing and editing the original draft of the work. The author has read and approved the manuscript.

Funding

This work has not been externally awarded and the authors have not received any financial grant from the government or other organizations. The work was privately sponsored.

Data availability

The data sets generated during and/or analyzed during this study are available from the corresponding author on reasonable request via wcleo87@gmail.com or walter.millanzi@udom.ac.tz.

Declarations

Ethics approval and consent to participate

All facilities and participants who were covered by the Youth Friendly Services Assessment were informed about the content and the purpose of the assessment before the commencement of the assessment. Written informed consent was also requested before the commencement of an observation schedule. In this regard, all key informants willingly agreed to participate in the Youth Friendly Services Assessment.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.