The voucher program succeeded in increasing access to SRHC for poor and underserved girls. The needs of adolescents were met with a relatively simple intervention through existing health facilities. Many adolescents appeared willing to protect themselves against the risks of sexual intercourse. This suggest that access to SRHC can play an important role in changing youth behavior and increase the use of contraceptives and condoms.

Background: Little is known about how sexual and reproductive (SRH) health can be made accessible and appropriate to adolescents. This study evaluates the impact and sustainability of a competitive voucher program on the quality of SRH care for poor and underserved female adolescents and the usefulness of the simulated patient (SP) method for such evaluation.

This article describes and analyzes the impact of the introduction of a cost recovery system in 11 health centres of Tillabéri district, Niger, West Africa, between August 1997 and August 1999. The study is based on data collected by the health workers, observations of district activities and policy meetings and literature from similar programmes in the region. The central question addressed by this article is why a well-formulated programme, which was implemented accordingly, failed to succeed. The system described fits within the national health policy framework in Niger, which opted to introduce fixed attendance fees in health centres. The system was introduced as a part of a comprehensive package to improve the accessibility, quality and organization of the districts' health care. Discussed are the problems encountered in the functioning of the system, such as the unpredictability of the cost recovery rate, the drop in patients' attendance and the undermining effect of serious and regular shortages of essential generic drugs at the wholesale dealer. Further discussed are the supervision and control of the financial and drug administration and the participation of the population, which are identified as key areas of interest for sustainability of any cost recovery system.

Summarybackground To meet the needs of female adolescents from low-income urban areas for sexual and reproductive health (SRH) care, vouchers providing free-of-charge access to SRH care at 19 primary care clinics were distributed in Managua, Nicaragua. These vouchers substantially increased the use of services, demonstrating that many adolescents are willing to use such services, if readily accessible. The voucher redemption made it possible to identify the nature of existing, but largely unmet, needs for SRH care.method The medical files from 3301 consultations with female adolescents were analysed using descriptive statistical methods and multiple logistic regression.results Female adolescents presented SRH problems that merited medical attention. The mean number of problems presented was 1.5 per consultation: 34% of the vouchers were used for contraceptives, 31% for complaints related to sexually transmitted infection (STI) or reproductive tract infection (RTI), 28% for advice/counselling, 28% for antenatal check-up and 18% for pregnancy testing. A new category of health care users emerged: sexually active girls who were neither pregnant nor mothers and who sought contraceptives or STI/RTI treatment. Contraceptive use doubled among the sexually active non-pregnant voucher redeemers. Consultation with a female doctor younger than 36 years was associated with a higher chance of having contraceptives prescribed.conclusion Accessible and appropriate SRH care has the potential to make an important contribution to the increased contraceptive use, decreased risk of unwanted teenage pregnancies and decreased prevalence of STIs/RTIs among underserved adolescents. Once adolescents access the services, providers have a crucial role in ensuring current and continuing needs are met.keywords adolescents, Nicaragua, sexual and reproductive health care, unmet needs, voucher programme, access to care