Good Practices and Experiences Linking Comprehensive Sexuality Education and Youth Health Services in Mozambique - Zambezia Region
An overview of experiences and good practices from Zambezia in Mozambique
Background and flagship project description
The central and northern provinces in Mozambique are among those with the poorest health outcomes in the entire country. The percentage of People Living with HIV (YPLHIV) in Zambezia is higher than the country’s average of 12.5% of all PLHIV between 15 and 49 years. Nationally, new HIV infections have decreased by 24% and AIDS-related deaths by 46% since 2010. However, the lack of quality monitoring data limits coordination efforts and the success of large interventions in many sectors in Mozambique.
Activities targeting Mozambican youth are coordinated under the umbrella of the programme GeraçãoBIZ, which takes a multisectoral approach: the Ministries of Education, Health and Youth form a committee at both national and provincial level. Leadership of the committee should be rotated between the ministries, but has been with the Youth and Sports Commission of the Youth Ministry for several years now. A number of activities and programmes are being implemented on sexual reproductive health (SRH) in the school environment. In 2017, for instance, the ESA Regional Programme, in close cooperation with United Nations (UN) partners, supported the Ministry of Education in the rollout of comprehensive sexuality education (CSE) online teacher training in the Nampula and Zambezia provinces. Yet, due to a weak monitoring and reporting system, only little has been documented at national level on the strengths and weaknesses of other approaches.
It is against this background that in December 2017, on request of MINEDH and other stakeholders of the PGB, Health Focus was contracted by the ESA Regional Programme to support the implementation of an assessment on links between schools and health facilities in providing CSE and adolescent and youth-friendly health services (AYFHS). In close consultation with the PGB committee, it was decided to map and identify good practices in Zambezia Province. The products of the field mission – reports, a brochure containing a collection of case studies, and documentation of selected good practices – were developed with significant input from key stakeholders.
GIZ ESA RP supported an in-depth review of good practices linking comprehensive sexuality education in the school environment with youth friendly health service provision in one province in Mozambique.
Mozambique looks back at more than 15 years of experience in designing and rolling out multi-sector youth sexual and reproductive health programmes. The country is now integrating the ESA targets into its new youth health strategy and bringing new partners on board to ensure coverage of the five ESA targets by 2020.
Review objectives and brief methodology
The good practice review had two main objectives: Identifying and documenting good practices linking comprehensive sexuality education in the school environment with youth friendly health service provision
- to inform Mozambique´s new Youth Health Strategy; and
- to contribute to regional learning on approaches CSE and AYFS linkages that work well.
The coordination group of Mozambique´s youth health programme, the Programa Geração BIZ (PGB), served as entry point and sounding board to the team undertaking this review. The group´s inputs informed the methodology and ensured the involvement of key stakeholders. They validated results, supported the documentation, and will ensure the findings are used to inform the formulation of the new youth health strategy. The figure below presents an overview of the major steps that were undertaken.
Results and key findings
Five projects with a larger outreach were identified as good practices. The two biggest ones, ‘raparigaBIZ’ and ‘DREAMS’ contribute to a link between the three sectors of youth, health and education. Under the Health Ministry, youth-specific health units (SAAJ) are integrated into existing health facilities. In schools, so-called ‘health corners’ are established, where a specially trained nurse provides SRH counselling to the school students. Volunteer mentors proactively get in contact with youth, present awareness-raising sessions in schools and community gatherings, and refer youth to the school health corners or to the SAAJ. In addition to providing SRH education, all projects have a strong focus on gender equality, early motherhood and early marriages, as well as the prevention of gender-based violence (GBV).
Adolescent and youth-friendly health services are strengthened through increased demand, which is a result of the activities undertaken by the school health corners and the mentor volunteers. The mentor volunteers serve as a bridge between health services (including health corners) and youth, who are often reluctant to approach respected persons (such as a school nurse) for advice. The mentors also link communities and schools, for example when they help young mothers to return to school after having dropped out during pregnancy. Countrywide, increasing numbers of volunteers are active (7 506 in 2017). They played an important role in reaching over 700 000 youth in communities, and the fact that over one million youth attended AYFHS in health facilities in 2017. During the field mission it was repeatedly stated that the number of early pregnancies and related school dropouts decreased significantly.
Other donor-funded initiatives include an anonymous SMS counselling service, which aims to provide education on reproductive health and to sensitise youth on HIV prevention. The association AMODEFA runs the only civil society-implemented youth health facility, while it also works with youth volunteers who promote family planning and the use of AYFHS more broadly.
Intervention mapping was carried out jointly with the provincial coordination structure of the PGB in Quelimane, the capital of Zambezia Province. A total of 103 ASRH interventions are listed in the province´s database of the Provincial Secretariat for the Fight against AIDS (CPCS). The interventions were clustered according to the approach taken (health service based, school based, community based, mass media, advocacy; see figure right).
Five projects with wider reach and impact were identified as good practices and analysed in detail:
- Digital monitoring
- Civil Society Advice & Counselling (AMODEFA)
- Mobile Health Clinics (AMODEFA)
The findings are presented in chapter 2 of this document.
The two largest projects, “raparigaBIZ” (busy girls) and “DREAMS” link the youth, health, and education sectors. Under the Ministry of Health, youth specific health units (SAAJ) are integrated in existing health facilities. In schools, so-called “health corners” are established, where a specially trained nurse provides SRH counselling to students. As part of the raparigaBIZ and DREAMS projects, volunteer youth mentors pro-actively approach students providing peer-education, organising awareness raising sessions at schools and during community gatherings, and refer youth to school health corners or to the SAAJ. The projects have – in addition to SRH – a strong focus on gender equality, early motherhood and early marriages, as well as gender-based violence (GBV) prevention. The innovation lies in the mentoring approach, representing a shift from PGB’s traditional peer-to-peer approach to a longer-term relationship between mentors and youth. The mentor volunteers serve as a bridge between health services (including school health corners) and youth, who are often reluctant to approach respected persons (such as a school nurse) for advice. The mentors also link communities and schools, for example when they help young mothers to return to school after having dropped out during pregnancy.
The association AMODEFA also works with youth volunteers, who promote family planning and the use of AYFS more broadly. It also runs the only civil society implemented youth health facility and runs mobile health clinics to conduct outreach activities.
The professionalism and commitment of youth volunteers and of education and health sector professionals observed was impressive. Referrals from the school health corners, teachers and youth mentors in schools and the community contribute significantly to increased use of services. The linkage of youth relevant sectors promotes youth’s understanding of family planning, and strengthens their ability to take control over their own lives, especially in the case of young women. Most interventions implemented in Zambezia Province focus on girls and young women. However, this bears the risk that boys and young men feel left out, and an imbalance develops that undermines the ability of girls/young women to utilise new skills in intimate relationships.
The review revealed a lack of coherent data on outputs, and the impact of interventions at district, provincial and national level. Although the monitoring system is actually quite simple and easy to understand, there is lots of room for data loss and duplication. It was revealed that in Zambezia Province, 19 district coordinators and 12 nurses coordinate health events and exchange monitoring data via a mobile messenger application (WhatsApp), compensating for the limited exchange of paper-based documents. Although the use of WhatsApp may be questionable for privacy reasons, this clearly shows the willingness to use digital tools for coordination and monitoring. Building on this momentum could lead to improved data quality and reporting, not only in Zambezia, but also in other provinces.
Lessons learnt and recommedations
(1) Well-functioning multisectoral programmes increase service use by adolescents and youth more than programmes that target changes in one sector only. Although statistical data that would illustrate the impact of the above interventions in Zambezia province are missing, it can be concluded that linking CSE and SRH in the school environment has an important impact on youth health. Key findings include:
- School health services are located where adolescents are, and help to overcome barriers such as transportation, inconvenient opening hours, long waiting times, and fear of „being seen by community members when seeking services and being talked about.”
- School health services create demand for further professional health services that are provided at youth friendly health clinics (SAAJ).
- School health services establish relationships between health care personnel and teachers, leveraging advice and exchange of information, thus supporting CSE.
- Mentoring by trained volunteers, as opposed to peer-education interventions, establishes a strong relationship between students/adolescents and their mentors, thus leveraging pointed and longer-term support in critical life situations.
- Interventions in Zambezia do not sufficiently address sexual and reproductive health needs of boys and young men or of out of school youth.
- It is recommended to integrate and scale up the model combining youth health corners at schools, volunteer youth mentors and youth friendly service provision in the National PGB Plan currently under development.
- It is further recommended to define objectives addressing the sexual and reproductive health needs of boys and young men in the National PGB Plan currently under development.
- It is recommended to establish multi-professional support groups where teachers and health care providers can exchange and learn from each other on how to address and tackle challenges with regards to their role as educators and supporters of adolescents in critical life situations.
(2) The lack of consolidated data on progress and achievements of AYSRH interventions presents a key challenge to the government of Mozambique, with regards to strategic planning and reporting (among others on the ESA targets) at national, provincial and district levels.
- Within the context of PGB strategy development, it is strongly recommended to develop a PGB indicator framework that speaks to PGB targets, the PENIV targets, as well as to the ESA targets. The indicator framework should be as simple as possible and build on existing information systems in order to reduce the burden of data collection and reporting at provincial and district levels. The introduction of easy to use electronic tools and messenger services would support the reporting function and strengthen the timeliness, completeness and validity of data.
||GeraçãoBIZ (PGB) Steering Committee at national and provincial level, in particular representatives from the Ministries of Youth, Education and Health|
||Youth, PGB committee members, public servants at provincial and district level|
||Mozambique, in particular the Zambezia Province|
||November 2017 to August 2018 (Field research phase: March and April 2018)|
||Mapping projects and approaches regarding youth’s access to sexual and reproductive health knowledge and services|
||Five good practices were identified and documented by the assessment. The PGB Committee will use the findings and recommendations of the assessment to inform the development of its new strategy|