Programa Geração Biz, Mozambique: how did this adolescent health initiative grow from a pilot to a national programme, and what did it achieve?

Overview of PGB

PGB adopted a three-pronged approach to reaching young people with sexual and reproductive health interventions in health clinics, schools, and the community. The clinical aspect of the programme involved integrating ASRH services into existing public-sector health facilities. Aspects of adolescent-friendly health service provision included competent and empathic staff, expanded and/or dedicated clinic hours for adolescents, offering services in a dedicated room/space within the health facility, provision of appealing health promotion information including through peer educators in waiting areas, and reduction of cost barriers [1]. The school-based aspect of the programme was implemented by peer educators (or activistas as they were called under the programme) and selected teachers who were trained to provide SRH education in secondary schools. Peer educators underwent 80 hours of training that prepared them to discuss early pregnancy, sexually transmitted infections (STIs) and other SRH topics with fellow students [5]. In addition to providing health education, peer educators also provided referrals to nearby adolescent friendly health clinics where students could access services [1]. Finally, out-of-school youth were trained as community-based peer educators who were responsible for reaching their out-of-school peers and others not reached through school-based programmatic activities. These community-based peer educators facilitated conversations about SRH and provided referrals to adolescent friendly health services (AFHS) [1].

Clarity

The intervention package was clearly defined with distinct activities and implementers. Clinical activities, including the establishment of AFHS in existing clinics, were implemented by the Ministry of Health. School-based activities were implemented by the Ministry of Education and consisted of intra and extra-curricula peer education. The Ministry of Youth and Sports spearheaded community-based activities to reach out-of-school youth. Robust referral linkages were established between these three types of activities ensuring referrals from school-based and community-based interventions to local facility-based AFHS.

Relevant

From its inception PGB was well placed for successful scale-up because programmatic activities composed an innovation that was relevant to its target population, a key characteristic identified in the WHO-ExpandNet framework [10]. A national assessment conducted by the Intersectoral Committee for the Development of Youth and Adolescents prior to the inception of PGB [1] as well as studies done at the time demonstrated the SRH needs of adolescents in Mozambique. Adolescents and those who had been pregnant as adolescents were found to be over-represented among women seeking care for complications of illegal abortion [17, 18]. Furthermore, studies conducted during this period describe high levels of pregnancy complications among adolescents including but not limited to low birth weight [19], malaria-related maternal mortality [20, 21], and maternal mortality due to eclampsia [20]. Finally, Granja and colleagues (2001) reported an adolescent maternal mortality ratio of 387 per 100,000 births compared to 294 per 100,000 births among non-adolescents [20]. These studies were sufficient to provide evidence that adolescents in Mozambique were in need of SRH interventions based on their levels of sexual activity and sexual risk behaviours, as well as their differential reproductive health outcomes compared to adult women. From its inception, PGB directly addressed many of these identified SRH needs through school, clinic, and community-based programme activities [1].

Credible

Furthermore, the credibility of PGB was raised through both international support and local ownership. Following the ICPD in 1994 the Intersectoral Committee for the Development of Youth and Adolescents was established in Mozambique, which led to the development of the National Plan for the Development of Adolescents and Youth, out of which came PGB [5]. PGB, therefore, came from the global agenda to advance SRH rights as established by the ICPD, and subsequently implemented by ministries of the government of Mozambique [1].

Compatible with local norms

Certain aspects of the Programme, such as open discussion of sexuality and SRH, particularly among unmarried youth, were not compatible with local norms. Qualitative research conducted with adolescent girls and parents in Mozambique found that there was frustration among both young people and parents about the quality of parent–child communication around sexuality and sexual risk [15]. Despite this incompatibility, the urgency of the HIV epidemic, as perceived by both the international community and within Mozambique, led to the prioritization of a risk-reduction programme despite these sensitivities.

Easy to install

The complexity of the multisectoral package led to some difficulties in implementing some components. Attempts were made to understand and correct implementation challenges as they arose. For example, during the course of implementation and scale-up, Pathfinder International identified challenges in recruiting and retaining female peer educators for the school-based and community-based components of PGB. In order to address this issue, the organization revised the protocol for peer-educator training and assessed the effect of the new protocol on improving retention of female peer educators [3].

Lessons learned

Our analysis of the characteristics of the innovation using the WHO-ExpandNet framework highlights a number of facilitators and barriers to PGB success. Contextually, PGB addressed salient ASRH needs at a time when there was political will to act on this issue due to momentum from the ICPD as well as mounting concern about the HIV epidemic. The clarity of PGB activities as well as assignment of responsibilities to the appropriate ministries facilitated implementation and encouraged local ownership within the ministries. On the other hand, the multisectoral design of the intervention introduced difficulties in coordinating and implementing the various components of PGB.

Credibility

At the national level the three government ministries had the credibility and authority to lead this initiative. Over the course of programme implementation, PGB activities were integrated with other existing government initiatives, lending further credibility to these efforts. For example, the Ministry of Health trained a significant cadre of nurses to provide AFHS as a part of the School and Adolescent Health Programme. These providers were eventually integrated into PGB. This training conducted through the School and Adolescent Health Programme introduced the idea of AFHS to local communities lending credibility to PGB [5].

Capacity

Strong mechanisms were put into place to ensure adequate capacity building to establish the necessary expertise at each level of implementation. The three implementing Ministries had prior experience in programming in each of their three respective sectors. In order to strengthen their capacity for adolescent-focused SRH programme planning and implementation, they received technical support from Pathfinder International [4]. The technical advisors situated in each Ministry at the national level in turn supervised provincial technical advisers. Quarterly technical meetings at both the provincial and district levels ensured information sharing and knowledge and skills transfer among managers and direct implementers. At the district level these meetings included service providers as well as peer-educators, who were adolescents themselves [4]. As the Programme developed and scaled-up, the role of the external technical advisors was gradually scaled back, starting at the national level and progressing to the provincial level as local ownership and capacity grew to meet the needs of the Programme [5]. One of the early evaluations of PGB noted that the intersectoral approach was working well, particularly at the national and provincial levels. The evaluators noted that decision making and responsibilities for implementation were shared, such as strategic selection of sites for scaling up and delegation of sector-specific activities to the relevant ministries [7]. However, the evaluators also noted that this approach was more problematic at the district level due to sparse staffing and inadequate resources; for example, in some districts Programme activities were implemented in only two of the three sectors, reducing the overall fidelity to the planned activities [7].

Commitment

While UNFPA and Pathfinder International drove the planning and implementation of PGB, the Government of Mozambique showed growing commitment to the Programme at the national level. Published in 2010, the government’s five-year plan indicated that PGB was the model for addressing ASRH needs and preventing new HIV infections in adolescents [22]. The Ministry of Education, for example, provided financial support for PGB and has incorporated SRH health content into the national curriculum [5]. In the Ministry of Youth and Sports as well as the Ministry of Health, components of PGB were integrated with and supported by other policies and programmes supported by these ministries [5]. In addition, activities relating to PGB were incorporated into national, provincial and district work plans and budgets. Attempts to establish local commitment to the initiative included community sensitization involving parents, community members, and local leaders [4]. An early evaluation notes that PGB activities such as efforts to include parents in education sessions could benefit from increased coordination and systematization [7]. While in some areas Programme activities met with some initial resistance, the rapid scale-up was achieved in part through the great demand for services in areas where it had not yet been implemented [5]. In general, urban communities were more accepting of Programme activities than rural communities [5].

Lessons learned

One of the strengths of the multisectoral design of PGB was that each of the three ministries was responsible for Programme activities for which it was advantageously positioned to implement. Technical assistance from resource organizations provided capacity building support to the ministries in places where they were not yet equipped to implement new PGB activities. These strategies led to institutionalization of various aspects of PGB within each ministry both in terms of financial commitments from the Mozambican government and through policy action.

National

Several policies at the national level fostered a supportive environment for the inception and scale-up of PGB. The ICPD set the global agenda for addressing ASRH and led to the development of several supportive national initiatives including the Government of Mozambique’s National Youth Policy in 1996, and the establishment of the Intersectoral Committee for the Development of Youth and Adolescents in 1997 leading to the development of an Integrated Programme and Plan of Action to Support the Development of Adolescents and Youth [1]. Out of this plan came a needs assessment of SRH services for adolescents in Mozambique, leading to discussions on the need for intersectoral collaboration to address young people’s SRH [4]. Furthermore, programmes specifically addressing HIV and AIDS, including those set forth in the National Strategic Plan on HIV/AIDS, blazed the way in so far as they initiated dialogue among policy makers and implementers about SRH programming [1].

Sub-national

PGB activities were to be implemented through cooperation with local leaders and youth associations. AMODEFA, Mozambique’s International Planned Parenthood Federation member association, was to implement school and community-based activities in Maputo with collaboration with local youth associations. These youth associations were well established in Maputo prior to PGB and were well positioned to take up this role [5]. Outside of Maputo, however, youth associations were new and not well established at the time of Programme expansion, so strengthening of these groups became part of the Programme’s agenda [5]. Initial steps in scale-up included sensitization activities at the district and provincial levels to garner support for school, community, and facility-based services from local leaders and community members in order to facilitate Programme implementation [4].

Lessons learned

The success of PGB was partially due to the momentum from the ICPD and the ensuing national commitment to ASRH. Further success in scaling up was ensured by engaging local institutions and identifying and addressing local contextual factors to enable Programme implementation.

Horizontal scaling-up

PGB was initially piloted in Maputo and Zambezia followed by staged horizontal expansion starting in 2000 when the Programme was expanded within these districts to additional provinces [1]. By 2007 PGB had initiated activities in every province in Mozambique and by 2010 activities were implemented in 83% of districts [5]. The horizontal scaling-up process was facilitated by a series of deliberate steps to ensure success and most efficient use of resources. Needs assessments were conducted to identify target provinces for expansion followed by inter-sectoral consultation to identify appropriate scopes of work within the identified provinces [4]. Throughout this process community sensitization activities were conducted with local leaders, community members, and other key stakeholders in order to garner community support and pave the way for smooth Programme roll-out [4]. Support mechanisms in each of the three sectors at the sub-national level were then established and linked vertically with national-level support as well as with other provinces with established PGB activities [4].

Vertical scaling-up

Components of PGB have been integrated into national policies, work plans and budgets showing strong vertical integration. With regard to clinical services, the Ministry of Health took advantage of the momentum provided by PGB activities relating to AFHS to improve pre-existing activities within the School and Adolescent Health Programme including through the training of 2,451 nurses in the provision of youth friendly health services [5]. The Ministry of Education now includes PGB content in the national curriculum, trains teachers to support peer educators, and has integrated PGB activities into its budget [5]. The Ministry of Youth and Sports has also made efforts to integrate PGB strategies into recent policies affecting adolescent health and in some provinces supports PGB coordinators [5].

Dissemination and advocacy

Advocacy for PGB was conducted by Pathfinder International and UNFPA in collaboration with the Ministry of Health, Ministry of Education, and Ministry of Youth and Sports. UNFPA and Pathfinder International provided technical assistance for advocacy in order to support the institutionalization of policies supportive of ASRH [8]. Additionally these two organizations provided support to a youth advocacy group consisting of PGB peer educators from youth associations [8]. Furthermore, these agencies collaborated on a study tour for donors to see the results of PGB, resulting in support from NORAD and SIDA [4]. Certain aspects of the Programme were presented in various forums outside of Mozambique for the purpose of sharing best practices [23, 24].

Deciding on the managerial and organizational processes of scaling-up

The scaling-up process for PGB relied on substantial efforts at all levels of implementation. At the national level, programme managers worked with donors to identify targets for expansion where existing physical and human resources, such as health clinics and active youth organizations, could be most efficiently harnessed [5]. Expansion to new provinces required the establishment of new provincial-level management structures, which received support vertically from the national-level management as well as horizontally from other established provincial programmes (Figure 3) [4]. At the national level, the central management committee for PGB was responsible for bringing together representatives from the three involved Ministries in order to share information and coordinate Programme planning. This structure was mirrored at the provincial level, where information was shared vertically with national-level structures as well as horizontally amongst sectors within the provincial management committee [4]. Community sensitization activities were conducted at both the province and district levels to garner support for Programme implementation [4]. Coordinators in the three sectors at the district and provincial level worked together to ensure smooth roll out of Programme activities [4]. During the course of scale-up, increased demands on provincial-level staff for activities including supervision of youth associations and peer educators, required increased staffing [5]. Gradual integration of costs and staff into the respective government sectors of Programme activities was coupled with staged reduction in technical assistance from Pathfinder International at both provincial and national levels [5]. This strategy was not without difficulties given the diversity of the settings to which PGB was scaled. In some provinces and districts the scale-up process was relatively smooth, while other struggled with issues largely related to human resources. Some provinces noted difficulties related to strained communications between sectors as well as difficulties in filling vacant technical assistance positions [7]. However, on the whole this scaled-up strategy increased the sustainability of the initiative by reducing the role of support coming from outside the government despite individual difficulties in some provinces.

Costs

Overall, the PGB budget appears to have been substantial. The mid-project evaluation found that the cost per young person reached by PGB had stabilized to $4.40 in 2006 [8]. Total project expenditures from 2002 through 2006 were $18.9 million while expenditures in 2005 through 2009 were $27.2 million, an increase in line with the substantial scale-up that had occurred during the decade [9]. Funding for PGB activities came from a variety of international funding bodies as well as from the government of Mozambique. UNFPA and Pathfinder International took the lead in organizing donor support for the scale up [4]. Primary external donors included DANIDA, NORAD, SIDA, and Trocaire [5]. External funds were disbursed by UNFPA to the provinces for implementation of Programme activities [4]. Some funding came from within the Government of Mozambique, from a number of Ministries [4, 6]. Other funders have provided support to pieces of the initiative specific to the interest areas of the funding organizations. For example, the World Bank’s Treatment Acceleration Project provided $1.25 million over four years starting in 2004 to integrate HIV testing and care into AFHS in Maputo and Gaza Province. Through this Project more than 600 new Adolescent HIV cases were identified and adherence support efforts resulted in high retention in antiretroviral therapy [25]. USAID’s Interagency Gender Working Group, UNFPA, and the Flanders Government provided support for improving recruitment and retention of female peer educators [4, 26]. The Flanders Government also funded an initiative to integrate a response to gender-based violence into existing PGB structures [4].

Monitoring and evaluation

A strong emphasis was placed on monitoring and evaluation (M&E) throughout the planning and implementation of PGB. The initial Programme objectives included a mandate to build the capacity of user organizations to monitor and evaluate implementation of the Programme [1]. Monitoring of Programme activities occurred in each of the sectors of implementation. For example, within the education sector, peer-educator recruitment, training, and activities were tracked [1]. One of the early external evaluations indicated that while this was generally an acceptable system, pieces of it were perceived by some stakeholders as overly complicated and some others had not received necessary training for completing monitoring forms [7]. Linkages between the sectors of implementation were also monitored by recording referrals from community-based activities to facility-based services [1]. Throughout Programme implementation the monitoring and evaluation system evolved. A large amount of data was lost in 2006, after which the Management Information System was redesigned [8]. The later 2007 external evaluation indicated that the M&E system was performing well in collecting Programme implementation data, but could improve in documenting capacity building, advocacy, and similar activities [8]. Furthermore, this evaluation noted that M&E efforts had focused on clinic-based service delivery, while other aspects, including peer education, advocacy, and capacity building, were not as closely monitored [8]. The final 2011 external evaluation noted weakness within the M&E systems in many of the provinces, largely due to rapid turnover of project staff, which contributed to late or absent Programme reports [9].

In addition to these internal mechanisms for M&E, three external evaluations were carried out over the course of the scale-up of PGB to assess the Programme’s implementation, reach, and effect on multiple sexual and reproductive health outcomes. An evaluation in 2004 included a review of Programme documentation as well as interviews with individuals at all levels of Programme implementation [7]. In 2007 an external evaluation was conducted with the support of NORAD. This evaluation consisted of key informant interviews and a review of Programme documentation [8]. A third evaluation was conducted in 2011, which involved document review as well as both qualitative and quantitative data collection from Programme beneficiaries [9].

Lessons learned

Successful scaling-up requires adequate resources to support making strategic decisions for where to expand, conduct community mobilization, and train and support new Programme staff at multiple levels within each ministry. While emphasis was placed on M&E, the Programme could have benefitted from an evaluation strategy from the outset that examined changes in health behaviours and clinical outcomes as the Programme expanded to new areas.

Adolescent sexual and reproductive health during PGB piloting and scale-up (1999–2007)

During the years of PGB scale-up poor SRH outcomes, such as high rates of early pregnancy and incident STIs, and low use of SRH services remained salient. Analyses of the country’s 2003 Demographic and Health Survey data indicated that 10% of girls gave birth by the age of 15 years [27]. Secondary analysis of surveillance data showed that from 2000 to 2004 the HIV prevalence in Mozambique among young women ages 15 to 24 was gradually increasing [28]. Nationally representative data collected in 2001 indicated that among sexually experienced youth aged 15 to 24 about 20% had a history of STI symptoms while less than 4% had ever used HIV counseling or testing services [29]. In qualitative research conducted in 2002, adolescents in Maputo indicated a scarcity of information on SRH provided in school and expressed a desire for more comprehensive instruction on these matters [30].

Furthermore, additional research highlighted the ongoing behavioral trends in sexual activity and condom use that are intermediate to SRH outcomes. Secondary analysis of Demographic and Health Survey data revealed that early sexual debut increased from 1997 to 2003 among adolescent boys [28]. A 2007 survey of in-school youth found that 27% of male students and 22% of female students aged 16 had ever experience forced or coerced sex [31]. And condom use at last sex among sexually active young people ranged from 20-30% in surveys conducted in 2001 and 2003 [28, 32].

In addition to the general research on ASRH, several studies specifically acknowledged PGB activities, though none provide extensive evaluation. Melo and colleagues surveyed young women attending a PGB clinic in 2002 with encouraging results [33]. About three quarters of those who had casual sexual partners reported condom use at last sex [33]. STI rates were similar to or lower than those reported in other studies conducted in Mozambique [33]. Furthermore, these young women had relatively high-levels of correct knowledge about STI prevention and somewhat lower levels of STIs when compared to other studies conducted in Mozambique [33]. While this study provides several interesting insights into the users of the clinics supported by PGB, it is not possible to determine if the positive indicators, such as high condom use and low STI prevalence, were due to intervention activities or due to self-selection of service users. Groes-Green conducted ethnographic fieldwork among youth in Maputo and published several papers that comment on the peer education and school-based components of PGB [34, 35]. He observed gender equitable discussions of sex and sexuality among male and female students and teachers [35].

Additional insights into possible PGB impact can be gleaned from quantitative surveys that were conducted in 2003 and 2005 in several provinces as part of PGB evaluation activities and reported in the grey literature [4]. Notably, the proportion of respondents who used contraception at first sexual intercourse increased from 36% in 2003 to 60% in 2005. Condom use within committed relationships increased from 70% to 83% and the percent who had taken an HIV test increased from 11% to 38% from 2003 to 2005 [4].

Adolescent sexual and reproductive health after PGB scale-up (2008–2013)

A Programme evaluation conducted in 2011 included an additional quantitative survey of PGB’s target population and examined knowledge, attitudes, and behaviours by exposure to PGB activities [9]. The proportion of respondents who used contraception was somewhat higher among those who had been exposed to PGB (57%) compared to the overall study population (53%); knowledge of modern contraceptive methods was higher among those exposed to the PGB as well, possibly indicating a positive intervention effect. PGB exposure also appeared to increase use of healthcare services, as adolescent girls in the survey were more likely to access AFHS if they had been exposed to PGB activities [9]. Respondents exposed to PGB also had somewhat more positive attitudes toward condom use. For example, they were more likely to agree that using condoms with a new sexual partner is a good practice [9].

Data from Demographic and Health Surveys show some indications of overall reductions in adolescent fertility. From 1997 to 2003 fertility among urban adolescents aged 15–19 decreased from 175 to 143 births per thousand adolescents [36, 37]. The fertility rate in rural areas decreased somewhat later, possibly corresponding to later scale-up of PGB activities. In 2003 the rural fertility rate among adolescents aged 15–19 was 207 while in 2011 it had dropped to 183 births per thousand adolescents [36, 38].

Independent research conducted in Mozambique after the completion of PGB scale-up indicates that there is much work to be done. Condom use among sexually active adolescents ranges from low to moderate [39]. Modeling estimates indicate no statistically significant change in the HIV prevalence among women ages 15–24 at antenatal care [40]. A study conducted in Beira from 2009 to 2012 found that among older high-risk adolescent girls (those with multiple partners in the previous month) HIV prevalence was almost 20% [41]. Clearly the programmatic activities of PGB remain relevant and on-going efforts are needed to sustain and adapt interventions to the evolving environments and needs of adolescents.