Mainstreaming Youth-Friendly Sexual and Reproductive Health Services in the Public Sector in Mozambique and Tanzania

"Emerging global guidance suggests that, to reach youth in a sustainable and scalable way, youth-friendly services must be mainstreamed in the community and health systems. However, there is little evidence from project implementation about how to integrate youth-friendly services on a large scale.”

This technical brief explores how youth-friendly services (YFS) were mainstreamed within public sector facilities and communities supported by a Pathfinder International cross-country project - MAIS Qualidade, Acesso, Saúde in Mozambique, and Chaguo la Maisha in Tanzania – which sought to improve access to and quality of youth-friendly sexual and reproductive health (SRH) services for Mozambican and Tanzanian adolescents and youth. Pathfinder used a people-centred approach that focuses on a continuum of interventions in the community and the facility to deliver mainstreamed YFS in a sustainable and scalable manner. The brief provides an overview of the context of the project, its strategy and implementation, facility-based and community-based interventions, the tools and approaches used to ensure that the YFS met quality standards, and adaptations made during implementation. The brief also offers recommendations for future YFS programming.

As explained in the brief, the importance of YFS has been recognised for awhile, and in most cases includes the following components: training for providers on YFS provision and competencies for delivering adolescent health services; improvements in facilities to increase access to and quality of services for adolescents and youth; and community-based activities to foster an enabling environment and to create demand for adolescent and youth sexual and reproductive health (AYSRH) services. Traditionally, these services have been provided in separate spaces which, although effective in attracting and providing quality services to youth, are often difficult to sustain. In response, the World Health Organization (WHO), the United States Agency for International Development (USAID), and SRH implementing organisations including Pathfinder International have argued for the importance of considering mainstreamed YFS. "Mainstreamed or integrated YFS require that all health providers and support staff in health facilities offer quality services to adolescents and youth as part of routine service delivery. In a mainstreamed model, any provider - whether offering HIV treatment and care, contraceptive services, maternity services, or primary care services - provides non-judgmental care to all adolescent and youth clients, while ensuring privacy, and confidentiality. Conceptually, mainstreamed YFS are attractive because they are scalable and sustainable. In practice, however, there is little information available about how to systematically implement mainstreamed YFS."

The brief describes how the MAIS and Chaguo la Maisha projects mainstreamed YFS through facility- and community-based interventions, as well as those linking the facility and community, and how each intervention component aligned with WHO and Pathfinder's YFS quality standards. The project was implemented in 37 public health facilities in Mozambique and 68 public health facilities in Tanzania. The project selected urban and peri-urban sites characterised by a large concentration of youth, economically poor, and underserved people, as well as poor SRH outcomes. According to the brief, in each country, the project supports 100% of the urban public health facilities in project-supported districts.

The training, mentorship, and tools used to ensure that service delivery met quality standards are explained. A tablet-based tool was used to support mentorship of facility-based staff, and a mobile-based job aid was designed to assist community health workers (CHWs) with offering contraceptive counseling, making and confirming referrals, and sending reminders for scheduled follow-up visits. Adaptations made during project implementation included a school-based demand generation component in which CHWs and peer educators worked with existing extracurricular clubs to provide SRH information to students in small group settings using activity cards adapted from the USAID-funded Gender Roles, Equality, and Transformations (GREAT) project.

The projects made efforts to incorporate youth perspectives directly by engaging youth to participate through co-management communities comprised of volunteer community members, facility staff members, and government health office representatives. The project also developed a digital version of the Citizen Report Card survey tool that was integrated into the tablet-based CHW job aid.

The report provides age-disaggregated data and graphics describing:

• number of new contraceptive users
• contraceptive method mix
• number and percentage of clients receiving method of choice
• non-judgmental service provision
• client satisfaction with services

It also discusses: data regarding the percentage of youth aged 10-24 years who were offered the full method mix; satisfaction with facility-based services among clients in that same age group; and data on a shift in method mix towards long-acting reversible contraceptives (LARC) uptake in both countries.

Regarding recommendations, the brief states that since the project's digital health tools elicited almost identical rates of participation from youth and adults, future efforts could consider digital methods to ensure youth participation in implementation. It suggests improvements to elicit more nuanced feedback from youth and to reach youth who aren't visited by CHWs. It indicates that building a health system that is fully responsive to the needs of adolescents and youth requires:

• further advocacy with governments to support youth participation in design and monitoring of YFS
• age-disaggregated data collection to further advance system-level interventions, thus maximising sustainability, scalability, and reach.

The brief also suggests that making the conceptual leap of shifting away from the model that provides separate spaces for YFRHS towards fully integrating YFS into every component of a project from its inception can lead to increased uptake of SRH services and LARCs by adolescents and youth.