Programa Geração Biz, Mozambique: How Did this Adolescent Health Initiative Flow from a Pilot to a National Programme, and What Did It Achieve?

"[T]he government's five-year plan indicated that PGB was the model for addressing ASRH needs and preventing new HIV infections in adolescents."

This is one finding from a paper describing the inception and nationwide scale-up of Programa Geração Biz (PGB), a multicomponent initiative aimed at improving the sexual and reproductive health of adolescents in Mozambique. The researchers also analyse what helped and hindered the scale-up effort and set out the results achieved at the levels of the programme, health behaviours, and health outcomes. The objective of this analysis is to inform policymakers, programme managers, and international organisations operating in Africa and elsewhere about how the scale-up of this initiative was realised

Many details about this programme's communication activities and strategies are available through the Related Links, below, but, in short, PGB was inspired by Mozambique's delegation that attended the 1994 International Conference on Population and Development (ICPD). PGB adopted a 3-pronged approach to reaching young people with sexual and reproductive health (SRH) interventions in health clinics, schools, and the community. The clinical aspect of the programme involved integrating adolescent sexual and reproductive health (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, services offered 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. The school-based aspect of the programme was implemented by peer educators ("activistas") 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, including HIV/AIDS prevention, with fellow students. In addition to providing health education, peer educators provided referrals to nearby adolescent friendly health clinics. Finally, out-of-school youth were trained as community-based peer educators who were responsible for reaching their out-of-school peers. These community-based peer educators facilitated conversations about SRH and provided referrals to adolescent friendly health services.

To assess the efforts that have been made to scale up PGB, the researchers gathered reports about PGB from United Nations (UN) agencies and Pathfinder International that describe the conception, inception, phased implementation, and monitoring and evaluation of the initiative. In addition, they carried out a systematic review of the literature on ASRH in Mozambique for information on the context in which these activities took place. Of the 39 full text articles selected from an initial search that resulted in 630 unique citations, 22 were deemed to be relevant and are included in this paper. These papers describe the state of ASRH in Mozambique prior to the inception of PGB (n=5), during PGB scale-up (n=6) and after scale-up (n=3). In addition, several papers report on other ASRH interventions implemented in Mozambique (n=5) or on PGB itself (n=3).

To analyse how the scale-up was planned and managed, as well as what factors helped or hindered this, the researchers used the World Health Organization (WHO)-Expandnet framework developed by WHO's Department of Reproductive Health and Research (RHR). "Effectiveness of a scaling-up strategy depends on the characteristics of the innovation to be scaled up, as well as the characteristics of the resource team and the user organization, each of which is influenced by the environment in which they operate. Successful management of the scaling-up process requires attention to four strategic choice areas - dissemination and advocacy, organizational processes, resource mobilization, and monitoring and evaluation. We examine each of these areas in turn with reference to PGB."

One selected finding: "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."

Overall, however, PGB has achieved what many other adolescent sexual and reproductive health (ASRH) programmes in Africa have not i.e. large scale and sustained scale up of a complementary set of interventions.

The following are seen to have contributed to this:

Government leadership and support:

• There was support for the initiative from the highest level of the government. The availability of an enabling policy and a dedicated unit in the Ministry of Health meant that the initiative had the legitimacy to move ahead and had the leadership it needed. 

Design:

• The initiative started with a good understanding of the epidemiologic situation and was well informed by a situation assessment which demonstrated the need for multisectoral action. 

• The objectives of the initiative were carefully thought through and set out clearly.

• The responsibilities of each sector were laid out clearly and clear coordinating mechanisms were set up at the national, provincial and district levels. 

• The brand was developed with thought and consultation.

Pilot tests:

• Pilot projects were designed and implemented. There was substantial mentoring and coaching in the pilot phase. The pilot phase was externally evaluated and findings as well as lessons learned informed the planning of the subsequent phase.

Scale up and Continuity:

• The initiative was designed from the outset for scaling up. A scale up model was carefully chosen. The rapid scale up effort resulted in challenges such as having inadequate number of master trainers to roll-out training in an expeditious manner and with quality over a short timeframe. This was later resolved by training additional trainers and certifying them to ensure they could deliver quality training. In addition, new players were brought in and their capacity was developed to support expanded coverage of the program. 

• The initiative was designed for sustainability by being grounded within existing government structures (e.g. clinics and schools) and by institutionalizing activities such as training, e.g. adding adolescent sexual and reproductive health content into existing training programmes, and including adolescent-specific indicators into the existing Health Management Information System.

Implementation:

• Support was provided both on managerial and on technical issues. A great deal of effort was made to delineate and support processes. Capacity building was a major area of focus.

• There was considerable flexibility. The objectives of the initiative evolved with time as lessons were learned. The scope of the initiative was broadened in response to the needs and opportunities, and in response to evaluation findings. The key players involved in the initiative from the different sectors, and the coordination mechanism also evolved over time. The roles and functions of different sectors were clarified based on the experience gained.

• Adequate funds were generated to translate words to actions and concerted efforts were made to bring new donors on board.

The challenge for Geracao Biz is to continue and build on its good work of providing adolescents with information, education and health services, and in addition to find ways of addressing the powerful social, economic and cultural factors that drive which decisions adolescents make, and which of their decisions they act upon. 

In terms of areas of weakness, the evaluation found that young women continue to initiate sexual activity early, that intergenerational sex occurred at higher levels among girls who had dropped out of school and that there are big gaps between knowledge that condoms can protect one from HIV and their consistent use. They rightly note that while PGB appears to have successfully provided SRH information and services to many adolescents in Mozambique, it did not sufficiently address  social, economic and cultural factors that contribute to girls’ vulnerability. This area of weakness must be addressed more effectively in the future.