Background
Methods
Contextual background
Analysis of the implementation process
Semi-structured interviews with key informants
Structured interviews with FSW-points of contact
Group discussions with peer outreach workers
Mixed analysis
Implementation outcome and themes | |||||
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Research component | Number in interview | Fidelity | Theoretical feasibility | Acceptability | Potential sustainability/ scalability |
Analysis of the implementation process | – | Extent to which planned activities were conducted | – | – | – |
Key informant interviews | 14 | – | Barriers to implementation | Coherence with national guidelines Endorsement by policy makers and health managers | Potential to maintain, institutionalise and expand on a national scale |
FSW-point of contact interviews | 4 | Extent to which the activities were practical to implement | – | Agreeability of the intervention to the providers | Potential to maintain the intervention |
Peer educator group discussions | 16 | – | – |
Results
Fidelity and theoretical feasibility
Planned activities | Progress by the end of the project | |
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Targeted peer outreach and community mobilisation
| Expand No. of FSW peer educators (PE) from 15 to 30 | Partially done. The PE cadre was expanded to 18. |
Orient PEs through a comprehensive training program that comprises the essential information on all SRH components, techniques on how to provide peer education services, and how to use monitoring tools | Mostly done. Two trainings were conducted, one on human rights and empowerment, and one on refreshment of peer education and mobilisation strategies. In addition, 10 new peer educators were trained. | |
PEs will be paid a stipend of 1500 MZN (USD35) per month working daily from 4 pm to 10 pm operating from the Night Clinic | Done | |
PEs will: • provide essential IEC on all key SRH aspects • distribute free male and female condoms and lubricants • provide information and sensitisation on a correct use of SRH services • implement a system of referral slips • track FSWs who dropped out of certain services, such as HIV care • provide IEC on substance/alcohol abuse and mental health services | Mostly done. Tracking of HIV care defaulters not done. | |
PEs will mobilize the community at large to sensitise them about the needs of sex workers to reduce stigma and discrimination | Mostly Done. ICRH-Mozambique conducted sensitisation activities, with involvement of peer educators. | |
ICRH-Mozambique will facilitate the creation of a local sex worker association and build capacity among FSWs through workshops and other means | Mostly done. An informal association was created. Capacity was built through exchange visits in India, Malawi and elsewhere in Mozambique. | |
Support groups and safe spaces will be encouraged by the project to provide an opportunity and platform for sex workers to discuss and share experiences | Mostly done. The Night Clinic functions as a sort of safe place, a Vulnerable Women’s Support Group was created. | |
Targeted clinical services
| The package of services at the Night Clinic will be expanded to include: • IEC on all sexual and reproductive health topics • Provision of male and female condoms and lubricants • Syphilis screening • HIV Testing & Counselling • Free contraception, including long-lasting methods, such as implants, and emergency contraception • Care for incomplete abortions, and support to women with unwanted pregnancies • Sexual and gender-based violence (SGBV) counselling • initiate HIV care, including antiretroviral therapy | Partially done. Female condoms and lubricants were added to the package, emergency contraception is offered, implants are offered but with frequent stock-outs, care for incomplete abortions and the initiation of HIV care were not done, and the SGBV services were only provided for part of the intervention period. |
Memoranda of Understanding will be developed with the district health departments that will describe the responsibilities of each | Done | |
In addition to the current Night Clinic in Moatize, a second Night Clinic will be constructed within the City of Tete, offering the same services | Not done. Was replaced by organising mobile clinical outreach. | |
FSWs will be invited for routine clinic visits for regular HIV and syphilis testing, genital exams and counselling around e condom use and risk reduction | Done, but limited effectiveness because very few FSWs returned for their follow-up visits. | |
HIV+ FSWs will be linked to ART adherence support groups | Not done | |
Improve access to the general health services
| Workshops with health facility managers and key SRH providers of 4 selected public health facilities | Done. But late in the project. |
Appointment of FSW points of contact at 4 selected public health facilities | Done. But late in the project. | |
Assess whether data on the number of FSW attending the services can be collected in a confidential manner | Done. But late in the project. | |
The project will evaluate with the provincial and district health departments if FSWs can be targeted through existing organised outreach activities, such as HIV testing & counselling | Partially done. No FSW-targeted outreach was done by the government, but outreach was done by NGO instead. | |
The project will coordinate with the provincial and district health departments and MSF how ART adherence support groups can be further expanded. The support groups will be linked to the Night Clinic and the community mobilisation activities | Not done | |
Linkages and referral systems
| Identifying 2 focal persons at each of the 4 health facilities who will be the point of contact | Done. But late in the project. |
Regular meetings between members of the FSW community, the focal persons and health managers of the 4 selected public health facilities, the Night Clinic staff and ICRH-Mozambique | Partially done. There were 7 meetings between all points of contact, the ICRH-Mozambique staff and the peer educators, but no health facility specific meetings between the points of contact and FSW representatives | |
Referral and counter-referral systems between the Night Clinics, the 4 health centres and the provincial hospital | Done | |
Referral and counter-referral systems between the PEs and the health services | Done | |
Tracking of defaulters by PEs | Not done | |
Monitoring systems
| The monitoring tools for peer outreach will be adapted and expanded | Done. But late in the project. |
The daily registers will be replaced by an electronic FSW individual monitoring system | Done. But late in the project. | |
A system will be developed to monitor attendance by FSWs at the 4 public health facilities | Done. But late in the project. |
The four health facility points of contact said that the intervention to make the facilities more FSW-friendly had been practicable to implement and that there had been no resistance from the SRH providers. The only reported problem was that FSWs continued not to disclose their occupation when visiting the facility. The peer outreach workers agreed that the peer outreach activities had been practicable, although they faced challenges, such as stigmatisation by the general community, difficulties in reaching certain FSW-subpopulations and the FSWs’ high mobility.‘The experience shows that (the activities) are feasible as long as you have the resources. I mean human resources as well as material resources. It is feasible, yes, but you need the resources: human, financial and material’ (Local-level health manager)
Acceptability
Nevertheless, three key informants, all from international agencies, questioned if all governmental policy makers were genuinely committed to the development of programmes for key populations, such as sex workers and men who have sex with men, and attributed the delays in the operationalisation of the national guidelines to persisting resistance.‘It is necessary, essential to have this type of services, particularly in areas with the greatest need.’ (National-level stakeholder)
Most intervention components were judged appropriate by informants. All, including the health facility points of contact, were in favour of making the public health services more FSW-friendly and highly appreciated the trainings held and the introduction of points of contact. It was said to be in full agreement with the guidelines that the Ministry of Health (MoH) was developing at the time to make selected health facilities more key population-friendly [35].‘For example, we are still awaiting the national guidelines for this population, that until now haven’t been signed yet, and this shows us once more a certain reluctance by the government authorities to accept an investment and a special attention for this population…’ (Local-level stakeholder)
Also, peer outreach and community mobilisation were considered appropriate and aligned with national health policies. There was no national strategy yet on these components, but the National AIDS Council had started to develop guidelines on peer outreach.‘We have to have (FSW-)friendly services so that those people come to the health facility and feel comfortable with the offered services, and so that the health care provider as well is at ease in working with those people without stigma, without discrimination’ (National-level policy maker)
Resistance was lower among representatives of donor and non-governmental agencies of whom three had doubts about the effectiveness of an approach focusing on public health services only. The omission of targeted outreach services in the government guidelines was considered a weakness.‘The only aspect that falls out, that is not in accordance with our guidelines, is the establishment of night clinics. It wouldn’t be sustainable for the system to have some services that operate at night clinics. And also, in terms of stigmatisation, it is clear that all that is vertical...[meaning at parallel clinics] considering our context it is preferable to follow the path of integration’ (National-level policy maker)
Also at the local level, the three district and provincial health managers, and the community representatives were all in favour of maintaining the Night Clinic and the targeted outreach services.‘FSWs, it makes a lot of sense to have clinics (such) as these, specifically for this type of groups. These women have a complicated time schedule, some work at night and during daytime they rest and perform other tasks, which makes it difficult for them to go to a health centre… The big problem really is how can these services be adopted by the government.’ (National-level non-governmental stakeholder)
Our integrated conclusion is that there was a broad consensus on the need to ensure adequate access to SRH services for a key population such as FSWs, but that there was less agreement on how this should be achieved. In particular the approach of having FSW-targeted clinical services is no longer endorsed by the national government.‘To have the Night Clinic helps in the sense of having a point of care, very near to the place where high-risk people concentrate, who might be in need of these services and can have them nearby… So, I think it is positive… I think it is a good strategy and it should be given continuity.’ (Local-level health manager)
Potential sustainability and scalability
Three informants, all from international agencies, also doubted if there was sufficient institutional capacity within the public health services to maintain the activities to make public health facilities more FSW-friendly without external support.‘The question of sustainability (of the peer outreach component)... if we look at the financial side, it is difficult to say ‘yes’, because who will sustain it? We know that the responsible institution, which would be the National AIDS Council, is a coordinating organ. It is not an implementing agency. So, who will implement?... They need materials, who will buy these materials?’ (National-level non-governmental stakeholder)
Because of the lack of national government endorsement, all informants agreed that the concept of the Night Clinic could not be replicated elsewhere in the country. Regarding other components that were in line with the government policies, respondents said that they should be scaled up nationwide. In particular, the peer outreach model applied by the project and the concept of FSW points of contact, were mentioned by respectively six and five informants, from both the government and international agencies.‘In the Geração Biz project [a project of adolescent-friendly services] there was technical assistance in each province, in all provincial health departments, that implemented the programme. But when the technical assistance was removed, the programme died. There was no plan to transform this technical assistance in something…’ (National-level non-governmental stakeholder)