Feasibility, acceptability and potential sustainability of a ‘diagonal’ approach to health services for female sex workers in Mozambique

Feasibility, acceptability and potential sustainability of a ‘diagonal’ approach to health... Background: Female sex workers (FSWs) in many settings have restricted access to sexual and reproductive health (SRH) services. We therefore conducted an implementation study to test a ‘diagonal’ intervention which combined strengthening of FSW-targeted services (vertical) with making public health facilities more FSW-friendly (horizontal). We piloted it over 18 months and then assessed its performance. Methods: Applying a convergent parallel mixed-methods design, we triangulated the results of the analysis of process indicators, semi-structured interviews with policy makers and health managers, structured interviews with health care providers and group discussions with peer outreach workers. We then formulated integrated conclusions on the interventions’ feasibility, acceptability by providers, managers and policy makers, and potential sustainability. Results: The intervention, as designed, was considered theoretically feasible by all informants, but in practice the expansion of some of the targeted services was hampered by insufficient financial resources, institutional capacity and buy-in from local government and private partners, and could not be fully actualised. In terms of acceptability, there was broad consensus on the need to ensure FSWs have access to SRH services, but not on how this might be achieved. Targeted clinical services were no longer endorsed by national government, which now prefers a strategy of making public services more friendly for key populations. Stakeholders judged that the piloted model was not fully sustainable, nor replicable elsewhere in the country, given its dependency on short-term project-based funding, lack of government endorsement for targeted clinical services, and viewing the provision of community activities as a responsibility of civil society. Conclusions: In the current Mozambican context, a ‘diagonal’ approach to ensure adequate access to sexual and reproductive health care for female sex workers is not fully feasible, acceptable or sustainable, because of insufficient resources and lack of endorsement by national policy makers for the targeted, vertical component. Keywords: Sexual and reproductive health, Female sex workers, Service delivery, Implementation research, Mixed methods, Mozambique * Correspondence: yves.lafort@ugent.be International Centre for Reproductive Health, Ghent University, Ghent, Belgium Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Lafort et al. BMC Health Services Research (2018) 18:752 Page 2 of 11 Background equipment, and second-line general health services might In many settings, female sex workers (FSWs) are amongst therefore be better suited. They also might not reach the most vulnerable groups for adverse sexual and repro- FSWs who only occasionally engage in commercial sex or ductive health outcomes. They are 10 times more likely who do not consider themselves as sex workers and there- than other women to acquire HIV [1], and in countries fore avoid targeted services [12, 22]. General health ser- with medium and high background HIV epidemics the vices might be a better option for these women. Finally, overall prevalence was estimated to be 30.7% in 2012 [2]. general health services have a more extended network of Other sexually transmitted infections (STI), including clinics and a better potential to achieve full geographical HPV [3, 4], unintended pregnancies [5–7] and sexual vio- coverage. A combination of both targeted and general lence [8] are also very common among FSWs. At the same health services might thus be necessary. The ‘Diagonal In- time, their access to prevention and care services is terventions to Fast-Forward Reproductive Health’ (DIF- severely restricted. They are often migrants, working in FER) project tested this approach in four cities where sex unfamiliar environments [9]. At public health services work is common: Mysore in India, Durban in South Af- they are confronted with stigmatising attitudes by pro- rica, Mombasa in Kenya and Tete in Mozambique [23]. viders and other users [10, 11]. They therefore often avoid This paper presents findings from the Mozambique site. these services, or hide their profession when they do, Results of the other sites are available in the DIFFER final resulting in care not being tailored to their needs [12]. In evaluation report [24]. addition, the morning opening hours of clinics are not For the overall design of the project, we applied a compatible with their nightly work [13]. For these reasons, methodological framework for health systems research several initiatives have developed services specifically tar- developed by Grodos and Mercenier [25]. In this frame- geted to sex workers, either through mobile outreach or work, an intervention is designed based on the concep- parallel stand-alone clinics [14–16]. These initiatives, tual model, pre-existing knowledge, and a thorough however, generally achieve a low coverage and offer a lim- policy and situational analysis. The intervention is then ited scope of services [17]. piloted and its action process and action results are eval- Our hypothesis for this study was that, to ensure a com- uated. For the evaluation, we used an implementation prehensive package of SRH services for FSWs, a ‘diagonal’ research approach, based on the Consolidated Frame- approach is needed, combining FSW-targeted services work For Implementation Research [26]. We measured (vertical) with improved access to general health services implementation outcomes following the WHO frame- (horizontal) (Fig. 1). Targeted interventions have demon- work for implementation research [27]. We assessed sev- strated to be effective in increasing uptake of basic SRH eral provider-related outcomes: (1) two aspects of commodities and services, such as peer education, con- feasibility, the degree to which the intervention was im- doms, lubricants, simple contraceptive methods, for ex- plemented as it had been designed (fidelity) and the ex- ample oral contraception, STI care and HIV testing, and tent to which it theoretically could be carried out in a in mobilising and empowering the FSW community [15, Mozambican setting (theoretical feasibility), (2) the per- 18–21]. They, however, rarely include services such as ception among providers, managers and policy-makers HIV care, more advanced contraception methods, for ex- that the intervention is agreeable (acceptability), and (3) ample tubal ligation, cervical cancer screening and treat- the potential to maintain, institutionalise and expand the ment, or termination of pregnancy (TOP) [17, 18]. These intervention (potential sustainability/scalability). In a services require highly skilled staff or specialised separate analysis we assessed the intervention’s accept- ability and effectiveness from the perspective of the beneficiaries. The results of these beneficiary-related outcomes have been published in a separate paper [28]. Methods Contextual background The DIFFER project site in Mozambique was situated in an urban area comprising the adjoining cities of Tete and Moatize. Sex work is common due to the presence of a large mining industry and major transport routes intersecting the area. About two thirds of the FSWs are of foreign, mostly Zimbabwean, origin [29]. The baseline policy and situational analysis showed an HIV preva- Fig. 1 A ‘diagonal’ approach to enhance access to health services lence of 62%, high rates of genital complaints, unin- for high-risk women tended pregnancies and sexual violence, and low level of Lafort et al. BMC Health Services Research (2018) 18:752 Page 3 of 11 community empowerment [30]. The public health sector meetings held. At the end of the intervention, the re- was the main provider of SRH care for FSWs, but the corded information was cross-checked and tabulated services had not been adapted to the needs of that popu- with the activities that had been planned, to assess what lation [31]. FSW-targeted services were available at a activities had not been executed as planned and why. stand-alone drop-in clinic (the ‘Night Clinic’) that of- fered peer outreach and some SRH services (informa- Semi-structured interviews with key informants tion, condoms, STI treatment, family planning and HIV The eligibility criterion for participation in the key in- testing). It was jointly operated by an NGO and the Dis- formant interviews was to have an important role in trict Health Department. It was located in Moatize and defining or influencing SRH policies for key popula- did not sufficiently reach FSWs residing in Tete City, sit- tions at national level, or to play an important role in uated 20 km from the clinic. the management of SRH programmes at provincial or Following the situational analysis, a context-specific, district level. We developed a semi-structured guide intervention was designed, applying our diagonal ap- in English and Portuguese. We explored theoretical proach, as described in detail elsewhere [32] and sum- feasibility by inquiring about legal or formal barriers marised in Table 2. In brief, the vertical component to the intervention’s implementation; acceptability by entailed expanding the targeted services to cover the en- assessing coherence with national guidelines and tire area and offer a more complete package of SRH ser- personal endorsement of the intervention by the in- vices. A mining company was to construct a second formant; and potential sustainability/scalability by stand-alone clinic in Tete City, through a public-private asking the respondent’s view on maintaining, institu- partnership; additional services were to be offered at the tionalising and expanding the intervention on a na- clinics; and the peer outreach was to be strengthened tional scale. and expanded by recruiting and training additional peer We interviewed 14 key informants. Six were policy outreach workers, both of Mozambican and Zimbab- makers or decision takers at national level: two govern- wean origin. Mobilisation of the FSW community com- ment employees and four representatives of international prised capacity building and empowerment through the development agencies or NGOs. At local level, we inter- establishment of a FSW community-based organisation viewed two provincial-level and two district-level and exchange visits with FSW-organisations elsewhere. government officials, two community representatives, and In the horizontal component, public health services were two representatives of a non-governmental agency. The to be made more FSW-friendly by sensitizing and train- interviews were audio-recorded, transcribed and thematic- ing the SRH care providers and appointing one of them ally analysed using N-Vivo 11 by two independent re- as FSW-point of contact at four health centres located searchers. Data were first deductively and selectively near FSW hotspots. These points of contact served as coded according pre-defined themes [34]: outcomes (feasi- the contact person for FSW-related issues and regularly bility, acceptability, sustainability, scalability), how the out- met with FSW representatives. Linkages between the come was evaluated overall (positive or negative), and targeted and general SRH services were to be strength- intervention components (peer outreach, community mo- ened by establishing referral systems between the Night bilisation, targeted clinical services, public health services, Clinics, the peer outreach, and the public health ser- linkages). The codes were then analysed through vices, and by having regular joint meetings. cross-tabulation in matrices. We identified differences in The intervention was gradually implemented from views by type of informant (local vs. central; government mid-2014 onwards. At the end of 2015, the intervention vs. international organisation). was evaluated. We applied a convergent parallel mixed-methods design [33], combining the analysis of Structured interviews with FSW-points of contact the implementation process with semi-structured inter- Using a structured questionnaire, we interviewed each of views with key informants, structured interviews with the four FSW-points of contact at the public health facil- the health facility points of contact and group discus- ities. The questionnaire enquired whether the activities sions with peer outreach workers. to make the services more FSW-friendly carried out at their facility had been practical to implement (fidelity), Analysis of the implementation process were agreeable to the providers (acceptability), and their To assess fidelity, we developed a structured digital perception on maintaining the intervention (potential register (MS Excel 2016), divided by type of activity, in sustainability/scalability). The results were transcribed in which the details of all activities conducted during im- a spreadsheet (MS Excel 2016) and qualitatively ana- plementation were periodically recorded. These included lysed, applying an axial matrix with the three implemen- the new services and systems introduced, people tation outcomes on the Y-axis and the evaluation of the recruited, trainings conducted, supplies procured and outcome (positive or negative) on the X-axis. Lafort et al. BMC Health Services Research (2018) 18:752 Page 4 of 11 Group discussions with peer outreach workers partners were not fulfilled. For the construction of the We held two group discussions, one with nine Mozam- second night clinic, the project opted for a private-public bican, and one with seven Zimbabwean peer outreach partnership, but in practice this did not work as both workers, using a semi-structured guide in either Portu- the private mining company and the local government guese or English. The guide explored if the peer educa- were unable to provide adequate support. tion activities had been practical to implement and the The consulted policy makers and health managers peer educators’ perceptions on the adequacy and judged the designed intervention to be theoretically relevance of the conducted activities. The discussions feasible, and saw no legal or other impediments. How- were audio-recorded, transcribed, deductively and select- ever, this was conditional on the necessary resources ively coded and thematically analysed using N-Vivo 11 being available. by two independent researchers. The codes were cross- tabulated in matrices by outcome (feasibility, acceptabil- ‘The experience shows that (the activities) are feasible ity) and how it was evaluated (positive, negative). as long as you have the resources. I mean human resources as well as material resources. It is feasible, Mixed analysis yes, but you need the resources: human, financial and The results of all methods were tabulated, applying a material’ (Local-level health manager) joint display strategy [33], with in the X-axis the imple- mentation outcomes and in the Y-axis the research com- The four health facility points of contact said that the ponents (Table 1). We then formulated integrated intervention to make the facilities more FSW-friendly conclusions, drawing on all sources. had been practicable to implement and that there had been no resistance from the SRH providers. The only re- Results ported problem was that FSWs continued not to disclose Fidelity and theoretical feasibility their occupation when visiting the facility. The peer out- Table 2 presents the comparison of the planned with the reach workers agreed that the peer outreach activities implemented activities. Although the intervention had had been practicable, although they faced challenges, been designed to be practicable with a limited budget, such as stigmatisation by the general community, diffi- adapted to a low-resource setting, in practice it was not. culties in reaching certain FSW-subpopulations and the Many of the planned intervention components could FSWs’ high mobility. not be fully implemented. The most important challenge Triangulating the results of the four data sources, to fidelity was the non-establishment of a second tar- we conclude that it was not possible to implement geted clinic in Tete City, which was replaced by mobile the intervention as designed, but that it is theoretic- clinical outreach, and the expansion of the range of ser- ally feasible to implement it in a Mozambican con- vices offered at the Night Clinic and of the peer outreach text, if sufficient financial resources are available, activities. The major factor was that the financial re- institutional capacity is created and all stakeholders sources and institutional capacity needed to establish fulfil their commitments. and operate such an intervention were underestimated. In particular, the expansion of the FSW-targeted services Acceptability required much more resources than were available. An- All informants felt that it is very appropriate to have in- other factor was that some commitments made by terventions to improve FSWs’ access to services. It was Table 1 Mixed-methods analysis matrix: Analysed themes by implementation outcome and research component Implementation outcome and themes Research component Number in Fidelity Theoretical feasibility Acceptability Potential sustainability/ interview scalability Analysis of the – Extent to which planned–– – implementation process activities were conducted Key informant 14 – Barriers to Coherence with national Potential to maintain, interviews implementation guidelines institutionalise and Endorsement by policy expand on a national makers and health managers scale FSW-point of 4 Extent to which the – Agreeability of the intervention Potential to maintain contact interviews activities were practical to the providers the intervention to implement Peer educator group 16 –– discussions Lafort et al. BMC Health Services Research (2018) 18:752 Page 5 of 11 � � � � � � � � � � � � � � Table 2 Comparison of the planned and implemented activities (fidelity) Planned activities Progress by the end of the project Targeted peer outreach and Expand No. of FSW peer educators (PE) from 15 to 30 Partially done. The PE cadre was expanded to 18. community mobilisation Orient PEs through a comprehensive training program that comprises the essential Mostly done. Two trainings were conducted, one on human information on all SRH components, techniques on how to provide peer education rights and empowerment, and one on refreshment of peer services, and how to use monitoring tools 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 Done 4 pm to 10 pm operating from the Night Clinic PEs will: Mostly done. Tracking of HIV care defaulters not done. 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 PEs will mobilize the community at large to sensitise them about the needs of sex Mostly Done. ICRH-Mozambique conducted sensitisation workers to reduce stigma and discrimination activities, with involvement of peer educators. ICRH-Mozambique will facilitate the creation of a local sex worker association and Mostly done. An informal association was created. Capacity build capacity among FSWs through workshops and other means 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 Mostly done. The Night Clinic functions as a sort of safe place, opportunity and platform for sex workers to discuss and share experiences a Vulnerable Women’s Support Group was created. Targeted clinical services The package of services at the Night Clinic will be expanded to include: Partially done. Female condoms and lubricants were added to IEC on all sexual and reproductive health topics the package, emergency contraception is offered, implants are Provision of male and female condoms and lubricants offered but with frequent stock-outs, care for incomplete Syphilis screening abortions and the initiation of HIV care were not done, and the HIV Testing & Counselling SGBV services were only provided for part of the intervention Free contraception, including long-lasting methods, such as implants, and period. 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 Memoranda of Understanding will be developed with the district health departments Done that will describe the responsibilities of each In addition to the current Night Clinic in Moatize, a second Night Clinic will be Not done. Was replaced by organising mobile clinical outreach. constructed within the City of Tete, offering the same services FSWs will be invited for routine clinic visits for regular HIV and syphilis testing, Done, but limited effectiveness because very few FSWs returned genital exams and counselling around e condom use and risk reduction for their follow-up visits. HIV+ FSWs will be linked to ART adherence support groups Not done Improve access to the general Workshops with health facility managers and key SRH providers of 4 selected public Done. But late in the project. health services health facilities 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 Done. But late in the project. in a confidential manner Lafort et al. BMC Health Services Research (2018) 18:752 Page 6 of 11 Table 2 Comparison of the planned and implemented activities (fidelity) (Continued) Planned activities Progress by the end of the project The project will evaluate with the provincial and district health departments if FSWs Partially done. No FSW-targeted outreach was done by the can be targeted through existing organised outreach activities, such as HIV testing & government, but outreach was done by NGO instead. counselling The project will coordinate with the provincial and district health departments and Not done 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 Linkages and referral Identifying 2 focal persons at each of the 4 health facilities who will be the point of Done. But late in the project. systems contact Regular meetings between members of the FSW community, the focal persons and Partially done. There were 7 meetings between all points of health managers of the 4 selected public health facilities, the Night Clinic staff and contact, the ICRH-Mozambique staff and the peer educators, ICRH-Mozambique 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 Done and the provincial hospital 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. Lafort et al. BMC Health Services Research (2018) 18:752 Page 7 of 11 said to respond to a real need and to be consistent with against targeted services were mostly the perceived low sus- both the country’s constitution and national health tainability and cost-effectiveness, the potential stigmatisa- policies. tion of service users, and the principle that the public health system should provide services to all. ‘It is necessary, essential to have this type of services, particularly in areas with the greatest need.’ ‘The only aspect that falls out, that is not in (National-level stakeholder) accordance with our guidelines, is the establishment of night clinics. It wouldn’t be sustainable for the system Nevertheless, three key informants, all from inter- to have some services that operate at night clinics. national agencies, questioned if all governmental policy And also, in terms of stigmatisation, it is clear that all makers were genuinely committed to the development that is vertical...[meaning at parallel clinics] of programmes for key populations, such as sex workers considering our context it is preferable to follow the and men who have sex with men, and attributed the de- path of integration’ (National-level policy maker) lays in the operationalisation of the national guidelines to persisting resistance. Resistance was lower among representatives of donor and non-governmental agencies of whom three had ‘For example, we are still awaiting the national doubts about the effectiveness of an approach focusing guidelines for this population, that until now haven’t on public health services only. The omission of targeted been signed yet, and this shows us once more a certain outreach services in the government guidelines was con- reluctance by the government authorities to accept an sidered a weakness. investment and a special attention for this population…’ (Local-level stakeholder) ‘FSWs, it makes a lot of sense to have clinics (such) as these, specifically for this type of groups. These women Most intervention components were judged appropriate have a complicated time schedule, some work at night by informants. All, including the health facility points of and during daytime they rest and perform other tasks, contact, were in favour of making the public health ser- which makes it difficult for them to go to a health vices more FSW-friendly and highly appreciated the centre… The big problem really is how can these services trainings held and the introduction of points of contact. be adopted by the government.’ (National-level non- It was said to be in full agreement with the guidelines governmental stakeholder) that the Ministry of Health (MoH) was developing at the time to make selected health facilities more key Also at the local level, the three district and provincial population-friendly [35]. health managers, and the community representatives were all in favour of maintaining the Night Clinic and ‘We have to have (FSW-)friendly services so that those the targeted outreach services. people come to the health facility and feel comfortable with the offered services, and so that the health care ‘To have the Night Clinic helps in the sense of having provider as well is at ease in working with those people a point of care, very near to the place where high-risk without stigma, without discrimination’ (National- people concentrate, who might be in need of these ser- level policy maker) vices and can have them nearby… So, I think it is posi- tive… I think it is a good strategy and it should be Also, peer outreach and community mobilisation were given continuity.’ (Local-level health manager) considered appropriate and aligned with national health policies. There was no national strategy yet on these Our integrated conclusion is that there was a broad con- components, but the National AIDS Council had started sensus on the need to ensure adequate access to SRH to develop guidelines on peer outreach. services for a key population such as FSWs, but that The only contested intervention component was the there was less agreement on how this should be clinical services, targeted at a specific population. Because achieved. In particular the approach of having FSW- the MoH was in the process of adopting a strategy to im- targeted clinical services is no longer endorsed by the prove access to selected public health facilities, three re- national government. spondents from the central level, two from the government and one from an international agency, no longer saw a need Potential sustainability and scalability to maintain targeted clinical services. Existing targeted All interviewees considered the piloted diagonal model clinics were expected to be temporary until full expansion as a whole not sustainable, due to its dependence on of FSW-friendly services was achieved. The arguments international funding. In particular, respondents believed Lafort et al. BMC Health Services Research (2018) 18:752 Page 8 of 11 that the government would never absorb the targeted Discussion clinical services into its services. Eleven of the 14 We designed, piloted and tested an intervention to en- respondents also held that the peer outreach component hance access to SRH commodities and services by FSWs was not sustainable: the MoH did not see it as one of its using an implementation research design. This paper responsibilities to implement or coordinate peer presents the providers’ perspectives on how practicable outreach activities. The National AIDS Council has the it had been to implement the activities that were identi- responsibility to coordinate community-level HIV inter- fied as necessary during the situational analysis (fidelity) ventions, but not to implement or provide significant and if there were structural barriers to implementation, funding. The expectation was that NGOs would conduct or if the intervention could theoretically be carried out this type of activities with external funding, and they in a Mozambican setting (theoretical feasibility). We remained therefore highly donor-dependant. further evaluated acceptability by assessing if the inter- vention was in accordance with national guidelines and ‘The question of sustainability (of the peer outreach endorsed by policy makers, health managers and component)... if we look at the financial side, it is providers; and if it could be sustained and scaled up over difficult to say ‘yes’, because who will sustain it? We a longer period of time (potential sustainability/ know that the responsible institution, which would scalability). be the National AIDS Council, is a coordinating Our findings suggest that the intervention may not to organ. It is not an implementing agency. So, who will be entirely feasible nor sustainable or scalable in the implement?... They need materials, who will buy these Mozambican context. In particular the vertical, targeted materials?’ (National-level non-governmental component was challenged by a lack of resources and stakeholder) political endorsement. Models of providing targeted services to FSWs, similar to the one planned in our Three informants, all from international agencies, also project, have proven to be feasible and sustainable doubted if there was sufficient institutional capacity elsewhere [36, 37]. This indicates that if there is a will to within the public health services to maintain the activ- mobilise the required long-term resources such ities to make public health facilities more FSW-friendly interventions are possible, and that the main barrier in without external support. Mozambique is the strategic choice made by the government. During the baseline situational analysis, ‘In the Geração Biz project [a project of adolescent- national-level government officials had already expressed friendly services] there was technical assistance in each a preference to make public health services accessible to province, in all provincial health departments, that all over parallel targeted services [31]. During the course implemented the programme. But when the technical of the intervention, the opposition of national level pol- assistance was removed, the programme died. There icy makers to targeted clinical services grew firmer, in was no plan to transform this technical assistance in particular towards parallel clinics. Targeted outreach something…’ (National-level non-governmental offering peer education, condom distribution and HIV stakeholder) testing by NGOs is endorsed by the government, but not directly supported. This stance was not evidence- Because of the lack of national government endorse- based, but rather motivated by the argument that it is ment, all informants agreed that the concept of the the government’s duty to provide health services to Night Clinic could not be replicated elsewhere in the all and the perceived higher cost-effectiveness of inte- country. Regarding other components that were in line grated services. Resistance towards a parallel clinic for with the government policies, respondents said that they key populations was markedly lower among govern- should be scaled up nationwide. In particular, the peer ment health managers at peripheral level. In contrast outreach model applied by the project and the concept with the political perspectives of national leaders, they of FSW points of contact, were mentioned by respect- took a more practical viewpoint, having experienced ively six and five informants, from both the government the advantages of having such clinic. Endorsement and international agencies. was also higher among representatives of international The integrated conclusion on potential sustainability is agencies. Their main concern was to ensure adequate that the piloted model is not fully sustainable, nor replic- access to services, and not necessarily through the able, because of lack of government endorsement for public health system. targeted clinical services, viewing the provision of com- To date, there is no clear evidence that making general munity activities as merely a responsibility of civil soci- health services FSW-friendly effectively results in ety, and insufficient long-term financial commitments increased uptake, and that they are a valid alternative to and institutional capacity. targeted services [15]. This is supported by the Lafort et al. BMC Health Services Research (2018) 18:752 Page 9 of 11 effectiveness analysis of our intervention that demon- Conclusions strated an increased uptake of services, but that this was A ‘diagonal’ intervention to enhance uptake of SRH ser- almost entirely due to the expansion of the targeted ser- vices by FSWs in Mozambique is currently not fully feas- vices [28]. In particular the FSW-targeted mobile clinical ible, sustainable nor replicable, because of insufficient outreach had raised access to care. Despite having made political will and resources for the targeted components. the public services more FSW-friendly, their utilisation Policy makers need to be aware that until the approach of had not (yet) increased. making general health services more FSW-friendly has The perceived high cost of targeted clinical services proven to be effective, targeted clinical services need to be is at odds with a previous assessment of the Night maintained. A strong targeted peer outreach and commu- Clinic that showed that the costs were relatively low nity mobilisation component will continue to be necessary in comparison to the number of visits [29]. Targeted in order to educate, sensitise and empower FSWs, and interventions have shown to be cost-effective long-term funding needs to be secured. elsewhere [38]. Clearly, more evidence is needed on Abbreviations the effectiveness of making public health facilities AIDS: Acquired immune-deficiency syndrome; ART: Antiretroviral therapy; FSW-friendly. While rolling out the recently devel- DIFFER: Diagonal interventions to fast-forward expanded reproductive health; oped strategy of key population-friendly public health FSW: Female sex worker; HIV: Human immunodeficiency virus; HPV: Human papilloma virus; ICRH: International centre for reproductive health; IEC: Information, facilities, the Mozambican government should care- education and communication; MoH: Ministry of health; MSF: Médecins sans fully monitor and assess its effect. The concept of frontières; MZN: Mozambican metical; NGO: Non-Governmental Organisation; FSW-points of contact could be integrated into that PE: Peer educator; SGBV: Sexual and gender-based violence; SRH: Sexual and reproductive health; STI: Sexually transmitted infections strategy. Meanwhile, the parallel, targeted services should be maintained wherever possible, and even Acknowledgements further developed. Resources need to be provided by The authors acknowledge all people who kindly gave their consent to the international community, and institutional cap- participate in the key informant interviews, health care provider interviews and peer educator group discussions, as well as the staff of ICRH-Mozambique, in acity for quality service delivery further developed. particular Osvaldo Jocitala, the Tete Provincial Department of Health who facili- For this to be feasible, key population-targeted clinical tated the study, and the DIFFER Community and Policy Advisory Boards in services, either through outreach or at parallel clinics, Mozambique. have to be accepted or tolerated by the government. Funding A cost-effectiveness analysis of the targeted compo- The research leading to these results has received funding from the International nent of our intervention could provide additional ar- Department Flanders (DIV) under agreement A11/TT/0382 and the European guments to substantiate this approach. Union Seventh Framework Programme under grant agreement number Health- F3–2011-282542. The funding agencies had no role in the design of the study, Feasibility and sustainability were not only question- the collection, analysis, and interpretation of data, and in writing the manuscript. able for the targeted clinical services, but also for some other components. Even though all respondents consid- Availability of data and materials ered peer outreach to be a useful and necessary activity, The datasets during and/or analysed during the current study available from the corresponding author on reasonable request. the government had no intentions to provide funds for this. It fell to civil society organisations to take the initia- Authors’ contributions tive, establish, operate and manage this type of activity, YL was the coordinator of the DIFFER project and the principal investigator with external funding. This typically leads to small-scale, of the final assessments in Mozambique. He developed the study protocol and the data collection tools. He analysed all the collected information and temporary projects that may never have the desired had the lead in the writing of the survey report and of the article. MSIM long-term impact. Peer outreach programmes have been participated in the analysis of the key informant interviews and peer demonstrated elsewhere to achieve high coverage and be educator group discussions, and contributed to the writing of the survey report and the article. FL was the field coordinator of the final assessments sustainable, if a comprehensive and budgeted strategy is in Mozambique, and contributed to the development of the study protocol available [39, 40], and such a strategy is currently lacking and data collection tools, and to the writing of the survey report and the in Mozambique. article. SG was the director of ICRH-Mozambique and as such, provided in- puts to the study protocol and data collection tools, and the writing of the Even the sustainability of the strategy to create key survey report and the article. MC is the PhD co-promotor of the first author. population-friendly health facilities was not guaran- He was involved in the initial stages of the DIFFER project, contributed to its teed. It did not have a budgeted implementation overall design and to the writing of the article. WD is the PhD promotor of the first author, provided feedback on the study design and the writing of plan and its operationalisation appeared highly the article. All authors have approved the final manuscript. dependent on initiatives by non-governmental and international actors. As was mentioned by some in- Ethics approval and consent to participate formants, previous experiences with youth-friendly The study protocol was approved by the National Committee of Bioethics for Health in Mozambique (Ref: 67/CNBS/2015). All participating key services in the country demonstrated that having a informants, health managers, and service providers were thoroughly strategy is not sufficient to guarantee long-term sus- explained the study procedures and risks, received an explanatory sheet, tainability [41]. were invited to participate and, if consenting, signed the consent sheet. Lafort et al. BMC Health Services Research (2018) 18:752 Page 10 of 11 Consent for publication female sex workers in resource poor setting: a systematic review. Tropical Not applicable. Med Int Health. 2008;13(5):659–79. 17. Dhana A, Luchters S, Moore L, Lafort Y, Roy A, Scorgie F, et al. Systematic Competing interests review of facility-based sexual and reproductive health services for female The authors declare that they have no competing interests. sex workers in Africa. Glob Health. 2014;10. 18. Chersich MF, Luchters S, Ntaganira I, Gerbase A, Lo YR, Scorgie F, et al. Priority interventions to reduce HIV transmission in sex work settings in sub- Publisher’sNote Saharan Africa and delivery of these services. J Int AIDS Soc. 2013;16. Springer Nature remains neutral with regard to jurisdictional claims in 19. Okafor UO, Crutzen R, Aduak Y, Adebajo S, Van den Borne HW. 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Baral S, Beyrer C, Muessig K, Poteat T, Wirtz AL, Decker MR, et al. Burden of DIFFER consortium; 2017 [cited 2017]. Available from: http://differproject.eu/ HIV among female sex workers in low-income and middle-income Project_Documents. countries: a systematic review and meta-analysis. Lancet Infect Dis. 2012; 25. Grodos D, Mercenier P. Health systems research: a clearer methodology for 12(7):538–49. more effective action. Antwerpen: ITGPress; 2000. 107 p. 3. Cwikel JG, Lazer T, Press F, Lazer S. Sexually transmissible infections among 26. Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. female sex workers: an international review with an emphasis on hard-to- Fostering implementation of health services research findings into practice: access populations. Sex Health. 2008;5(1):9–16. a consolidated framework for advancing implementation science. 4. Pruss-Ustun A, Wolf J, Driscoll T, Degenhardt L, Neira M, Calleja JMG. 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The importance of sex- worker interventions: the case of Avahan in India. Sex Transm Infect. 2010; 86:I6–7. 41. Governo e parceiros reativam "Geração Biz". Noticias Online. 8 May 2015. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png BMC Health Services Research Springer Journals

Feasibility, acceptability and potential sustainability of a ‘diagonal’ approach to health services for female sex workers in Mozambique

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Medicine & Public Health; Public Health; Health Administration; Health Informatics; Nursing Research
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Abstract

Background: Female sex workers (FSWs) in many settings have restricted access to sexual and reproductive health (SRH) services. We therefore conducted an implementation study to test a ‘diagonal’ intervention which combined strengthening of FSW-targeted services (vertical) with making public health facilities more FSW-friendly (horizontal). We piloted it over 18 months and then assessed its performance. Methods: Applying a convergent parallel mixed-methods design, we triangulated the results of the analysis of process indicators, semi-structured interviews with policy makers and health managers, structured interviews with health care providers and group discussions with peer outreach workers. We then formulated integrated conclusions on the interventions’ feasibility, acceptability by providers, managers and policy makers, and potential sustainability. Results: The intervention, as designed, was considered theoretically feasible by all informants, but in practice the expansion of some of the targeted services was hampered by insufficient financial resources, institutional capacity and buy-in from local government and private partners, and could not be fully actualised. In terms of acceptability, there was broad consensus on the need to ensure FSWs have access to SRH services, but not on how this might be achieved. Targeted clinical services were no longer endorsed by national government, which now prefers a strategy of making public services more friendly for key populations. Stakeholders judged that the piloted model was not fully sustainable, nor replicable elsewhere in the country, given its dependency on short-term project-based funding, lack of government endorsement for targeted clinical services, and viewing the provision of community activities as a responsibility of civil society. Conclusions: In the current Mozambican context, a ‘diagonal’ approach to ensure adequate access to sexual and reproductive health care for female sex workers is not fully feasible, acceptable or sustainable, because of insufficient resources and lack of endorsement by national policy makers for the targeted, vertical component. Keywords: Sexual and reproductive health, Female sex workers, Service delivery, Implementation research, Mixed methods, Mozambique * Correspondence: yves.lafort@ugent.be International Centre for Reproductive Health, Ghent University, Ghent, Belgium Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Lafort et al. BMC Health Services Research (2018) 18:752 Page 2 of 11 Background equipment, and second-line general health services might In many settings, female sex workers (FSWs) are amongst therefore be better suited. They also might not reach the most vulnerable groups for adverse sexual and repro- FSWs who only occasionally engage in commercial sex or ductive health outcomes. They are 10 times more likely who do not consider themselves as sex workers and there- than other women to acquire HIV [1], and in countries fore avoid targeted services [12, 22]. General health ser- with medium and high background HIV epidemics the vices might be a better option for these women. Finally, overall prevalence was estimated to be 30.7% in 2012 [2]. general health services have a more extended network of Other sexually transmitted infections (STI), including clinics and a better potential to achieve full geographical HPV [3, 4], unintended pregnancies [5–7] and sexual vio- coverage. A combination of both targeted and general lence [8] are also very common among FSWs. At the same health services might thus be necessary. The ‘Diagonal In- time, their access to prevention and care services is terventions to Fast-Forward Reproductive Health’ (DIF- severely restricted. They are often migrants, working in FER) project tested this approach in four cities where sex unfamiliar environments [9]. At public health services work is common: Mysore in India, Durban in South Af- they are confronted with stigmatising attitudes by pro- rica, Mombasa in Kenya and Tete in Mozambique [23]. viders and other users [10, 11]. They therefore often avoid This paper presents findings from the Mozambique site. these services, or hide their profession when they do, Results of the other sites are available in the DIFFER final resulting in care not being tailored to their needs [12]. In evaluation report [24]. addition, the morning opening hours of clinics are not For the overall design of the project, we applied a compatible with their nightly work [13]. For these reasons, methodological framework for health systems research several initiatives have developed services specifically tar- developed by Grodos and Mercenier [25]. In this frame- geted to sex workers, either through mobile outreach or work, an intervention is designed based on the concep- parallel stand-alone clinics [14–16]. These initiatives, tual model, pre-existing knowledge, and a thorough however, generally achieve a low coverage and offer a lim- policy and situational analysis. The intervention is then ited scope of services [17]. piloted and its action process and action results are eval- Our hypothesis for this study was that, to ensure a com- uated. For the evaluation, we used an implementation prehensive package of SRH services for FSWs, a ‘diagonal’ research approach, based on the Consolidated Frame- approach is needed, combining FSW-targeted services work For Implementation Research [26]. We measured (vertical) with improved access to general health services implementation outcomes following the WHO frame- (horizontal) (Fig. 1). Targeted interventions have demon- work for implementation research [27]. We assessed sev- strated to be effective in increasing uptake of basic SRH eral provider-related outcomes: (1) two aspects of commodities and services, such as peer education, con- feasibility, the degree to which the intervention was im- doms, lubricants, simple contraceptive methods, for ex- plemented as it had been designed (fidelity) and the ex- ample oral contraception, STI care and HIV testing, and tent to which it theoretically could be carried out in a in mobilising and empowering the FSW community [15, Mozambican setting (theoretical feasibility), (2) the per- 18–21]. They, however, rarely include services such as ception among providers, managers and policy-makers HIV care, more advanced contraception methods, for ex- that the intervention is agreeable (acceptability), and (3) ample tubal ligation, cervical cancer screening and treat- the potential to maintain, institutionalise and expand the ment, or termination of pregnancy (TOP) [17, 18]. These intervention (potential sustainability/scalability). In a services require highly skilled staff or specialised separate analysis we assessed the intervention’s accept- ability and effectiveness from the perspective of the beneficiaries. The results of these beneficiary-related outcomes have been published in a separate paper [28]. Methods Contextual background The DIFFER project site in Mozambique was situated in an urban area comprising the adjoining cities of Tete and Moatize. Sex work is common due to the presence of a large mining industry and major transport routes intersecting the area. About two thirds of the FSWs are of foreign, mostly Zimbabwean, origin [29]. The baseline policy and situational analysis showed an HIV preva- Fig. 1 A ‘diagonal’ approach to enhance access to health services lence of 62%, high rates of genital complaints, unin- for high-risk women tended pregnancies and sexual violence, and low level of Lafort et al. BMC Health Services Research (2018) 18:752 Page 3 of 11 community empowerment [30]. The public health sector meetings held. At the end of the intervention, the re- was the main provider of SRH care for FSWs, but the corded information was cross-checked and tabulated services had not been adapted to the needs of that popu- with the activities that had been planned, to assess what lation [31]. FSW-targeted services were available at a activities had not been executed as planned and why. stand-alone drop-in clinic (the ‘Night Clinic’) that of- fered peer outreach and some SRH services (informa- Semi-structured interviews with key informants tion, condoms, STI treatment, family planning and HIV The eligibility criterion for participation in the key in- testing). It was jointly operated by an NGO and the Dis- formant interviews was to have an important role in trict Health Department. It was located in Moatize and defining or influencing SRH policies for key popula- did not sufficiently reach FSWs residing in Tete City, sit- tions at national level, or to play an important role in uated 20 km from the clinic. the management of SRH programmes at provincial or Following the situational analysis, a context-specific, district level. We developed a semi-structured guide intervention was designed, applying our diagonal ap- in English and Portuguese. We explored theoretical proach, as described in detail elsewhere [32] and sum- feasibility by inquiring about legal or formal barriers marised in Table 2. In brief, the vertical component to the intervention’s implementation; acceptability by entailed expanding the targeted services to cover the en- assessing coherence with national guidelines and tire area and offer a more complete package of SRH ser- personal endorsement of the intervention by the in- vices. A mining company was to construct a second formant; and potential sustainability/scalability by stand-alone clinic in Tete City, through a public-private asking the respondent’s view on maintaining, institu- partnership; additional services were to be offered at the tionalising and expanding the intervention on a na- clinics; and the peer outreach was to be strengthened tional scale. and expanded by recruiting and training additional peer We interviewed 14 key informants. Six were policy outreach workers, both of Mozambican and Zimbab- makers or decision takers at national level: two govern- wean origin. Mobilisation of the FSW community com- ment employees and four representatives of international prised capacity building and empowerment through the development agencies or NGOs. At local level, we inter- establishment of a FSW community-based organisation viewed two provincial-level and two district-level and exchange visits with FSW-organisations elsewhere. government officials, two community representatives, and In the horizontal component, public health services were two representatives of a non-governmental agency. The to be made more FSW-friendly by sensitizing and train- interviews were audio-recorded, transcribed and thematic- ing the SRH care providers and appointing one of them ally analysed using N-Vivo 11 by two independent re- as FSW-point of contact at four health centres located searchers. Data were first deductively and selectively near FSW hotspots. These points of contact served as coded according pre-defined themes [34]: outcomes (feasi- the contact person for FSW-related issues and regularly bility, acceptability, sustainability, scalability), how the out- met with FSW representatives. Linkages between the come was evaluated overall (positive or negative), and targeted and general SRH services were to be strength- intervention components (peer outreach, community mo- ened by establishing referral systems between the Night bilisation, targeted clinical services, public health services, Clinics, the peer outreach, and the public health ser- linkages). The codes were then analysed through vices, and by having regular joint meetings. cross-tabulation in matrices. We identified differences in The intervention was gradually implemented from views by type of informant (local vs. central; government mid-2014 onwards. At the end of 2015, the intervention vs. international organisation). was evaluated. We applied a convergent parallel mixed-methods design [33], combining the analysis of Structured interviews with FSW-points of contact the implementation process with semi-structured inter- Using a structured questionnaire, we interviewed each of views with key informants, structured interviews with the four FSW-points of contact at the public health facil- the health facility points of contact and group discus- ities. The questionnaire enquired whether the activities sions with peer outreach workers. to make the services more FSW-friendly carried out at their facility had been practical to implement (fidelity), Analysis of the implementation process were agreeable to the providers (acceptability), and their To assess fidelity, we developed a structured digital perception on maintaining the intervention (potential register (MS Excel 2016), divided by type of activity, in sustainability/scalability). The results were transcribed in which the details of all activities conducted during im- a spreadsheet (MS Excel 2016) and qualitatively ana- plementation were periodically recorded. These included lysed, applying an axial matrix with the three implemen- the new services and systems introduced, people tation outcomes on the Y-axis and the evaluation of the recruited, trainings conducted, supplies procured and outcome (positive or negative) on the X-axis. Lafort et al. BMC Health Services Research (2018) 18:752 Page 4 of 11 Group discussions with peer outreach workers partners were not fulfilled. For the construction of the We held two group discussions, one with nine Mozam- second night clinic, the project opted for a private-public bican, and one with seven Zimbabwean peer outreach partnership, but in practice this did not work as both workers, using a semi-structured guide in either Portu- the private mining company and the local government guese or English. The guide explored if the peer educa- were unable to provide adequate support. tion activities had been practical to implement and the The consulted policy makers and health managers peer educators’ perceptions on the adequacy and judged the designed intervention to be theoretically relevance of the conducted activities. The discussions feasible, and saw no legal or other impediments. How- were audio-recorded, transcribed, deductively and select- ever, this was conditional on the necessary resources ively coded and thematically analysed using N-Vivo 11 being available. by two independent researchers. The codes were cross- tabulated in matrices by outcome (feasibility, acceptabil- ‘The experience shows that (the activities) are feasible ity) and how it was evaluated (positive, negative). as long as you have the resources. I mean human resources as well as material resources. It is feasible, Mixed analysis yes, but you need the resources: human, financial and The results of all methods were tabulated, applying a material’ (Local-level health manager) joint display strategy [33], with in the X-axis the imple- mentation outcomes and in the Y-axis the research com- The four health facility points of contact said that the ponents (Table 1). We then formulated integrated intervention to make the facilities more FSW-friendly conclusions, drawing on all sources. had been practicable to implement and that there had been no resistance from the SRH providers. The only re- Results ported problem was that FSWs continued not to disclose Fidelity and theoretical feasibility their occupation when visiting the facility. The peer out- Table 2 presents the comparison of the planned with the reach workers agreed that the peer outreach activities implemented activities. Although the intervention had had been practicable, although they faced challenges, been designed to be practicable with a limited budget, such as stigmatisation by the general community, diffi- adapted to a low-resource setting, in practice it was not. culties in reaching certain FSW-subpopulations and the Many of the planned intervention components could FSWs’ high mobility. not be fully implemented. The most important challenge Triangulating the results of the four data sources, to fidelity was the non-establishment of a second tar- we conclude that it was not possible to implement geted clinic in Tete City, which was replaced by mobile the intervention as designed, but that it is theoretic- clinical outreach, and the expansion of the range of ser- ally feasible to implement it in a Mozambican con- vices offered at the Night Clinic and of the peer outreach text, if sufficient financial resources are available, activities. The major factor was that the financial re- institutional capacity is created and all stakeholders sources and institutional capacity needed to establish fulfil their commitments. and operate such an intervention were underestimated. In particular, the expansion of the FSW-targeted services Acceptability required much more resources than were available. An- All informants felt that it is very appropriate to have in- other factor was that some commitments made by terventions to improve FSWs’ access to services. It was Table 1 Mixed-methods analysis matrix: Analysed themes by implementation outcome and research component Implementation outcome and themes Research component Number in Fidelity Theoretical feasibility Acceptability Potential sustainability/ interview scalability Analysis of the – Extent to which planned–– – implementation process activities were conducted Key informant 14 – Barriers to Coherence with national Potential to maintain, interviews implementation guidelines institutionalise and Endorsement by policy expand on a national makers and health managers scale FSW-point of 4 Extent to which the – Agreeability of the intervention Potential to maintain contact interviews activities were practical to the providers the intervention to implement Peer educator group 16 –– discussions Lafort et al. BMC Health Services Research (2018) 18:752 Page 5 of 11 � � � � � � � � � � � � � � Table 2 Comparison of the planned and implemented activities (fidelity) Planned activities Progress by the end of the project Targeted peer outreach and Expand No. of FSW peer educators (PE) from 15 to 30 Partially done. The PE cadre was expanded to 18. community mobilisation Orient PEs through a comprehensive training program that comprises the essential Mostly done. Two trainings were conducted, one on human information on all SRH components, techniques on how to provide peer education rights and empowerment, and one on refreshment of peer services, and how to use monitoring tools 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 Done 4 pm to 10 pm operating from the Night Clinic PEs will: Mostly done. Tracking of HIV care defaulters not done. 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 PEs will mobilize the community at large to sensitise them about the needs of sex Mostly Done. ICRH-Mozambique conducted sensitisation workers to reduce stigma and discrimination activities, with involvement of peer educators. ICRH-Mozambique will facilitate the creation of a local sex worker association and Mostly done. An informal association was created. Capacity build capacity among FSWs through workshops and other means 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 Mostly done. The Night Clinic functions as a sort of safe place, opportunity and platform for sex workers to discuss and share experiences a Vulnerable Women’s Support Group was created. Targeted clinical services The package of services at the Night Clinic will be expanded to include: Partially done. Female condoms and lubricants were added to IEC on all sexual and reproductive health topics the package, emergency contraception is offered, implants are Provision of male and female condoms and lubricants offered but with frequent stock-outs, care for incomplete Syphilis screening abortions and the initiation of HIV care were not done, and the HIV Testing & Counselling SGBV services were only provided for part of the intervention Free contraception, including long-lasting methods, such as implants, and period. 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 Memoranda of Understanding will be developed with the district health departments Done that will describe the responsibilities of each In addition to the current Night Clinic in Moatize, a second Night Clinic will be Not done. Was replaced by organising mobile clinical outreach. constructed within the City of Tete, offering the same services FSWs will be invited for routine clinic visits for regular HIV and syphilis testing, Done, but limited effectiveness because very few FSWs returned genital exams and counselling around e condom use and risk reduction for their follow-up visits. HIV+ FSWs will be linked to ART adherence support groups Not done Improve access to the general Workshops with health facility managers and key SRH providers of 4 selected public Done. But late in the project. health services health facilities 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 Done. But late in the project. in a confidential manner Lafort et al. BMC Health Services Research (2018) 18:752 Page 6 of 11 Table 2 Comparison of the planned and implemented activities (fidelity) (Continued) Planned activities Progress by the end of the project The project will evaluate with the provincial and district health departments if FSWs Partially done. No FSW-targeted outreach was done by the can be targeted through existing organised outreach activities, such as HIV testing & government, but outreach was done by NGO instead. counselling The project will coordinate with the provincial and district health departments and Not done 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 Linkages and referral Identifying 2 focal persons at each of the 4 health facilities who will be the point of Done. But late in the project. systems contact Regular meetings between members of the FSW community, the focal persons and Partially done. There were 7 meetings between all points of health managers of the 4 selected public health facilities, the Night Clinic staff and contact, the ICRH-Mozambique staff and the peer educators, ICRH-Mozambique 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 Done and the provincial hospital 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. Lafort et al. BMC Health Services Research (2018) 18:752 Page 7 of 11 said to respond to a real need and to be consistent with against targeted services were mostly the perceived low sus- both the country’s constitution and national health tainability and cost-effectiveness, the potential stigmatisa- policies. tion of service users, and the principle that the public health system should provide services to all. ‘It is necessary, essential to have this type of services, particularly in areas with the greatest need.’ ‘The only aspect that falls out, that is not in (National-level stakeholder) accordance with our guidelines, is the establishment of night clinics. It wouldn’t be sustainable for the system Nevertheless, three key informants, all from inter- to have some services that operate at night clinics. national agencies, questioned if all governmental policy And also, in terms of stigmatisation, it is clear that all makers were genuinely committed to the development that is vertical...[meaning at parallel clinics] of programmes for key populations, such as sex workers considering our context it is preferable to follow the and men who have sex with men, and attributed the de- path of integration’ (National-level policy maker) lays in the operationalisation of the national guidelines to persisting resistance. Resistance was lower among representatives of donor and non-governmental agencies of whom three had ‘For example, we are still awaiting the national doubts about the effectiveness of an approach focusing guidelines for this population, that until now haven’t on public health services only. The omission of targeted been signed yet, and this shows us once more a certain outreach services in the government guidelines was con- reluctance by the government authorities to accept an sidered a weakness. investment and a special attention for this population…’ (Local-level stakeholder) ‘FSWs, it makes a lot of sense to have clinics (such) as these, specifically for this type of groups. These women Most intervention components were judged appropriate have a complicated time schedule, some work at night by informants. All, including the health facility points of and during daytime they rest and perform other tasks, contact, were in favour of making the public health ser- which makes it difficult for them to go to a health vices more FSW-friendly and highly appreciated the centre… The big problem really is how can these services trainings held and the introduction of points of contact. be adopted by the government.’ (National-level non- It was said to be in full agreement with the guidelines governmental stakeholder) that the Ministry of Health (MoH) was developing at the time to make selected health facilities more key Also at the local level, the three district and provincial population-friendly [35]. health managers, and the community representatives were all in favour of maintaining the Night Clinic and ‘We have to have (FSW-)friendly services so that those the targeted outreach services. people come to the health facility and feel comfortable with the offered services, and so that the health care ‘To have the Night Clinic helps in the sense of having provider as well is at ease in working with those people a point of care, very near to the place where high-risk without stigma, without discrimination’ (National- people concentrate, who might be in need of these ser- level policy maker) vices and can have them nearby… So, I think it is posi- tive… I think it is a good strategy and it should be Also, peer outreach and community mobilisation were given continuity.’ (Local-level health manager) considered appropriate and aligned with national health policies. There was no national strategy yet on these Our integrated conclusion is that there was a broad con- components, but the National AIDS Council had started sensus on the need to ensure adequate access to SRH to develop guidelines on peer outreach. services for a key population such as FSWs, but that The only contested intervention component was the there was less agreement on how this should be clinical services, targeted at a specific population. Because achieved. In particular the approach of having FSW- the MoH was in the process of adopting a strategy to im- targeted clinical services is no longer endorsed by the prove access to selected public health facilities, three re- national government. spondents from the central level, two from the government and one from an international agency, no longer saw a need Potential sustainability and scalability to maintain targeted clinical services. Existing targeted All interviewees considered the piloted diagonal model clinics were expected to be temporary until full expansion as a whole not sustainable, due to its dependence on of FSW-friendly services was achieved. The arguments international funding. In particular, respondents believed Lafort et al. BMC Health Services Research (2018) 18:752 Page 8 of 11 that the government would never absorb the targeted Discussion clinical services into its services. Eleven of the 14 We designed, piloted and tested an intervention to en- respondents also held that the peer outreach component hance access to SRH commodities and services by FSWs was not sustainable: the MoH did not see it as one of its using an implementation research design. This paper responsibilities to implement or coordinate peer presents the providers’ perspectives on how practicable outreach activities. The National AIDS Council has the it had been to implement the activities that were identi- responsibility to coordinate community-level HIV inter- fied as necessary during the situational analysis (fidelity) ventions, but not to implement or provide significant and if there were structural barriers to implementation, funding. The expectation was that NGOs would conduct or if the intervention could theoretically be carried out this type of activities with external funding, and they in a Mozambican setting (theoretical feasibility). We remained therefore highly donor-dependant. further evaluated acceptability by assessing if the inter- vention was in accordance with national guidelines and ‘The question of sustainability (of the peer outreach endorsed by policy makers, health managers and component)... if we look at the financial side, it is providers; and if it could be sustained and scaled up over difficult to say ‘yes’, because who will sustain it? We a longer period of time (potential sustainability/ know that the responsible institution, which would scalability). be the National AIDS Council, is a coordinating Our findings suggest that the intervention may not to organ. It is not an implementing agency. So, who will be entirely feasible nor sustainable or scalable in the implement?... They need materials, who will buy these Mozambican context. In particular the vertical, targeted materials?’ (National-level non-governmental component was challenged by a lack of resources and stakeholder) political endorsement. Models of providing targeted services to FSWs, similar to the one planned in our Three informants, all from international agencies, also project, have proven to be feasible and sustainable doubted if there was sufficient institutional capacity elsewhere [36, 37]. This indicates that if there is a will to within the public health services to maintain the activ- mobilise the required long-term resources such ities to make public health facilities more FSW-friendly interventions are possible, and that the main barrier in without external support. Mozambique is the strategic choice made by the government. During the baseline situational analysis, ‘In the Geração Biz project [a project of adolescent- national-level government officials had already expressed friendly services] there was technical assistance in each a preference to make public health services accessible to province, in all provincial health departments, that all over parallel targeted services [31]. During the course implemented the programme. But when the technical of the intervention, the opposition of national level pol- assistance was removed, the programme died. There icy makers to targeted clinical services grew firmer, in was no plan to transform this technical assistance in particular towards parallel clinics. Targeted outreach something…’ (National-level non-governmental offering peer education, condom distribution and HIV stakeholder) testing by NGOs is endorsed by the government, but not directly supported. This stance was not evidence- Because of the lack of national government endorse- based, but rather motivated by the argument that it is ment, all informants agreed that the concept of the the government’s duty to provide health services to Night Clinic could not be replicated elsewhere in the all and the perceived higher cost-effectiveness of inte- country. Regarding other components that were in line grated services. Resistance towards a parallel clinic for with the government policies, respondents said that they key populations was markedly lower among govern- should be scaled up nationwide. In particular, the peer ment health managers at peripheral level. In contrast outreach model applied by the project and the concept with the political perspectives of national leaders, they of FSW points of contact, were mentioned by respect- took a more practical viewpoint, having experienced ively six and five informants, from both the government the advantages of having such clinic. Endorsement and international agencies. was also higher among representatives of international The integrated conclusion on potential sustainability is agencies. Their main concern was to ensure adequate that the piloted model is not fully sustainable, nor replic- access to services, and not necessarily through the able, because of lack of government endorsement for public health system. targeted clinical services, viewing the provision of com- To date, there is no clear evidence that making general munity activities as merely a responsibility of civil soci- health services FSW-friendly effectively results in ety, and insufficient long-term financial commitments increased uptake, and that they are a valid alternative to and institutional capacity. targeted services [15]. This is supported by the Lafort et al. BMC Health Services Research (2018) 18:752 Page 9 of 11 effectiveness analysis of our intervention that demon- Conclusions strated an increased uptake of services, but that this was A ‘diagonal’ intervention to enhance uptake of SRH ser- almost entirely due to the expansion of the targeted ser- vices by FSWs in Mozambique is currently not fully feas- vices [28]. In particular the FSW-targeted mobile clinical ible, sustainable nor replicable, because of insufficient outreach had raised access to care. Despite having made political will and resources for the targeted components. the public services more FSW-friendly, their utilisation Policy makers need to be aware that until the approach of had not (yet) increased. making general health services more FSW-friendly has The perceived high cost of targeted clinical services proven to be effective, targeted clinical services need to be is at odds with a previous assessment of the Night maintained. A strong targeted peer outreach and commu- Clinic that showed that the costs were relatively low nity mobilisation component will continue to be necessary in comparison to the number of visits [29]. Targeted in order to educate, sensitise and empower FSWs, and interventions have shown to be cost-effective long-term funding needs to be secured. elsewhere [38]. Clearly, more evidence is needed on Abbreviations the effectiveness of making public health facilities AIDS: Acquired immune-deficiency syndrome; ART: Antiretroviral therapy; FSW-friendly. While rolling out the recently devel- DIFFER: Diagonal interventions to fast-forward expanded reproductive health; oped strategy of key population-friendly public health FSW: Female sex worker; HIV: Human immunodeficiency virus; HPV: Human papilloma virus; ICRH: International centre for reproductive health; IEC: Information, facilities, the Mozambican government should care- education and communication; MoH: Ministry of health; MSF: Médecins sans fully monitor and assess its effect. The concept of frontières; MZN: Mozambican metical; NGO: Non-Governmental Organisation; FSW-points of contact could be integrated into that PE: Peer educator; SGBV: Sexual and gender-based violence; SRH: Sexual and reproductive health; STI: Sexually transmitted infections strategy. Meanwhile, the parallel, targeted services should be maintained wherever possible, and even Acknowledgements further developed. Resources need to be provided by The authors acknowledge all people who kindly gave their consent to the international community, and institutional cap- participate in the key informant interviews, health care provider interviews and peer educator group discussions, as well as the staff of ICRH-Mozambique, in acity for quality service delivery further developed. particular Osvaldo Jocitala, the Tete Provincial Department of Health who facili- For this to be feasible, key population-targeted clinical tated the study, and the DIFFER Community and Policy Advisory Boards in services, either through outreach or at parallel clinics, Mozambique. have to be accepted or tolerated by the government. Funding A cost-effectiveness analysis of the targeted compo- The research leading to these results has received funding from the International nent of our intervention could provide additional ar- Department Flanders (DIV) under agreement A11/TT/0382 and the European guments to substantiate this approach. Union Seventh Framework Programme under grant agreement number Health- F3–2011-282542. The funding agencies had no role in the design of the study, Feasibility and sustainability were not only question- the collection, analysis, and interpretation of data, and in writing the manuscript. able for the targeted clinical services, but also for some other components. Even though all respondents consid- Availability of data and materials ered peer outreach to be a useful and necessary activity, The datasets during and/or analysed during the current study available from the corresponding author on reasonable request. the government had no intentions to provide funds for this. It fell to civil society organisations to take the initia- Authors’ contributions tive, establish, operate and manage this type of activity, YL was the coordinator of the DIFFER project and the principal investigator with external funding. This typically leads to small-scale, of the final assessments in Mozambique. He developed the study protocol and the data collection tools. He analysed all the collected information and temporary projects that may never have the desired had the lead in the writing of the survey report and of the article. MSIM long-term impact. Peer outreach programmes have been participated in the analysis of the key informant interviews and peer demonstrated elsewhere to achieve high coverage and be educator group discussions, and contributed to the writing of the survey report and the article. FL was the field coordinator of the final assessments sustainable, if a comprehensive and budgeted strategy is in Mozambique, and contributed to the development of the study protocol available [39, 40], and such a strategy is currently lacking and data collection tools, and to the writing of the survey report and the in Mozambique. article. SG was the director of ICRH-Mozambique and as such, provided in- puts to the study protocol and data collection tools, and the writing of the Even the sustainability of the strategy to create key survey report and the article. MC is the PhD co-promotor of the first author. population-friendly health facilities was not guaran- He was involved in the initial stages of the DIFFER project, contributed to its teed. It did not have a budgeted implementation overall design and to the writing of the article. WD is the PhD promotor of the first author, provided feedback on the study design and the writing of plan and its operationalisation appeared highly the article. All authors have approved the final manuscript. dependent on initiatives by non-governmental and international actors. As was mentioned by some in- Ethics approval and consent to participate formants, previous experiences with youth-friendly The study protocol was approved by the National Committee of Bioethics for Health in Mozambique (Ref: 67/CNBS/2015). All participating key services in the country demonstrated that having a informants, health managers, and service providers were thoroughly strategy is not sufficient to guarantee long-term sus- explained the study procedures and risks, received an explanatory sheet, tainability [41]. were invited to participate and, if consenting, signed the consent sheet. Lafort et al. 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