Rita Badiani - Geraçao Biz, Pathfinder International, Mozambique
September 2007
Rita Badiani has 20 years of professional experience in global health program management and has worked primarily in the fields of reproductive health, HIV/AIDS and population studies. She currently serves as Director of Operations for Pathfinder’s COMPASS Project in Nigeria, and is responsible for overall management of the project. Previously she has worked on Youth Reproductive Health/HIV/AIDS, and has provided ongoing technical assistance for youth programs in Angola, Ghana, Nigeria, Ethiopia, and Mozambique. Ms. Badiani is responsible for designing and implementing the national Adolescent Sexual and Reproductive Health/HIV/AIDS program in Mozambique entitled “Geraçao Biz,” which was featured as the “Best Practice Model” in the World Bank Resource Book. The HIV/SRH Integration site interviewed Ms. Badiani about her experience with providing integrated services in Mozambique.
Can you tell me about the Geraçao Biz program that integrated HIV and Sexual and Reproductive Health?
This program was an attempt to respond to the needs of adolescents and youth in Mozambique. It began in 1999 and was influenced by the results of the International Conference on Population and Development (ICPD) in 1994. The ICPD marked a turning point in relation to adolescent reproductive health. At the IPCD conference the adolescents began to be seen as a group with specific needs that differ from adults and children and required specific interventions to address those needs. In trying to respond to those needs UNFPA, in close cooperation with the government, began this multisectoral program. Pathfinder was providing technical assistance and I was hired as Chief Technical Advisor (CTA) to provide the needed technical assistance.
What was the problem you were responding to when you developed the program?
Mozambique had a very large young population. What adolescents were dealing with in Mozambique, like many other countries, was early pregnancy, non-use of contraceptives in the first sexual intercourse, vulnerability of HIV infection, and getting pregnant and having to drop out of school. In addition to those issues, adolescents experienced a lack of power to negotiate use of condoms, and gender bias in communication among boys and girls. In general, those were the issues we were trying to address with this program.
We developed a program that would try to respond to those needs in an integrated manner. It was integrated from several perspectives. It was integrated in the context of sexual and reproductive health and HIV, but was also integrated multisectorally. Interventions comprised mainly three components: Youth-friendly clinical services, under the responsibility of the Ministry of Health; in school intervention to educate boys and girls on sexuality and RH issues as well as HIV, coordinated by the Ministry of Education, and community outreach targeting out of school youth coordinated by the Ministry of Youth and Sports. When we talk about integration, this program was multidimensional. It went beyond integration within the clinical component.
What was the length of the program?
The program is still going on. In 1999, we began in two provinces. Gradually the program was expanded. Phase 1 was from 1999 to 2000: what we call the pilot phase which began in two provinces. Then we expanded and entered phase 2, which was from 2000 to 2005. In phase 2 we added four new provinces, for a total of 6 provinces. That was the time that I left the program, as the CTA. When we began phase 3, we expanded to the remainder of the country throughout the provinces. Today we have a national program, which is implemented gradually. Every year we add one or two provinces. The program currently covers all 11 provinces in Mozambique.
Throughout the program, if you came across youth that needed Sexually Transmitted Infection treatment or services, were they referred to local clinics?
At the clinic level, we established youth-friendly services. There are adolescent-only clinics where adolescents would come, and they would be attended by a provider trained in the youth-friendly approach. The provider was also trained to provide integrated services. So if the adolescents' needs were in the area of contraception, they would receive those services in this integrated clinic. If they were in need of treatment for an STI, they would also be treated over there. If they were in need of counseling for HIV prevention or pregnancy prevention or for any other issue related to reproductive health, they would be receiving all of these services at the same facility. Of course we had a referral system for more complicated cases, but in all of our training, from the beginning, it was integrated training. STIs, contraception, gender awareness, postabortion care, all of those subjects were part of the training. The training comprised theory and practice.
If you came across youth when you were doing the education component in the schools, would you refer them to the youth-friendly clinics?
The program was integrated in the fact that one component reinforced the other. We provided education in the school as well as in the community through the strategy of peer educators. Peer educators were both student peer educators and out of school peer educators and were linked to services. The intervention was developed and designed to be implemented in a selected geographic area where there was a school and a health facility nearby that would serve as a reference to the school. We would also work with a youth association in the given community to ensure that peer educators would be referring young people that were not in school to these services.
Something else that was very unique for Mozambique was that we established what we call the school corners in each school. These corners (small room allocated to the peer educators) were managed by peer educators who were trained to provide counseling, information, and distribute condoms in the schools where this was allowed. The peer educators from the school corners would make referrals to the health facilities for condoms in most of the schools where we couldn't provide condoms. Additionally, the service providers would come to the schools and support the peer educator activities and ensure that students know that if they visit the health facility, the exchange with the service provider would be confidential. We also developed this cooperation between peer educators and service providers which further enhanced the capability of the young people to really look for services.
Was it up to each school to decide whether they wanted to give condoms or not?
There was no policy as to whether or not schools should be allowed to distribute condom for high school students; however, some directors would have a more liberal position and would allow the peer educators to make condoms available through the school corners.
Who was involved in deciding how to start the program? Was there local input from anyone in the community?
There was the government -- and when I talk about the government it is three levels: central level, provincial level, and district level. The implementation of this program took place at the district level so those three sectors were involved with different roles. We also had UNFPA as the donor agency and Pathfinder as the technical assistance provider, and we had local NGOs and some youth groups/associations involved with implementing the project. Those associations were not youth NGOs, although in the course of the project some became youth NGOs. From day one, the youth were participating in the program. Even for the development of the project proposal, some of the NGOs brought youth who contributed.
Once the project was approved by the government and UNFPA, a multisectoral team comprising representatives of all sectors, NGOs, and Pathfinder International went to the provinces and conducted an initial assessment to determine priority districts and targets, how many providers were needed, how many centers should be established, and where to begin. There was a need to determine how many youth-friendly service centers to be established, how many schools could be included, how many communities should be involved, how many providers needed to be trained, how many peer educators needed to be trained, and what monitoring and capacity building systems needed to be in place. How many technical advisors should we have? Was there a need to have technical advisors in each sector? What monitoring systems would be developed? How about capacity building strategies? How would it be implemented? It was a very participatory process. Of course, it was a program implemented with the government; the public sector was always involved. Health centers, public schools, and even the out of school activities were coordinated by the each respective ministry and on a rotative basis one of the ministries would be selected to do the overall coordination. This program has always been seen as a government program, but with the input of the youth and largely implemented by the young people.
Have you gotten any feedback from the clients about how they feel about the program?
Oh, they love the program. The program is really a great success in the country, and I think this program helped to set the benchmark of what really is involved in being a peer educator. I haven't been there in the past year, but I know that an external evaluation was just conducted and the evaluators were really impressed with the fact that this program is contributing to building capacity among the young people. The young people are very critical regarding what a youth program should look like, how it should work, and the role of the youth in a program. I can also say that the program provided excellent training for the youth. We have provided training on sexuality, reproductive health, and gender, as well as human rights. We used this approach, and this really helped increase the young people’s level of awareness about being the protagonist of a program that works for their benefit.
You mentioned the evaluation process. Was there was a formal evaluation of the activity?
We have conducted two external evaluations since 1999. The midterm evaluation indicated that while some actions could be taken to further strengthen the out of school component, the program was on the right track for substantial accomplishments and important lessons learned about the benefits and challenges of integrated programs. This recent evaluation is the second one. I think the preliminary report will be released very soon.
Can you talk a little more about the training you do with the peer educators? I know you mentioned it, but can you talk about how it is set up?
The training lasted two weeks. It comprised theory and practice in a way that allowed peer educators to learn a concept and immediately apply the concept. This program has developed a good set of tools and systems, and that is why we are expanding year by year. The parents of the peer educators were invited to come for the training. They participated in the first day of the training where we explained to them what it takes to be a peer educator and the role of a peer educator.
Parents were invited as a strategy to support increased participation of female peer educators. There was a larger group of males than females participating as peer educators, and we had to have parents understand the program and allow their female children to participate. Their parents would come on the first day and for the closing ceremony. They would receive a certificate as a parent of a peer educator of the Geraçao Biz program. Later on we expanded the program to train some parents to help especially with the out of school program. They helped parents understand the needs for their children to protect themselves from HIV and unwanted pregnancy.
Coming back to the training of peer educators, the training is 14 days, combining theory and practice. The content includes adolescent development, feelings and body changes, dating, gender, contraception, STI and HIV as well as communication and negotiation skills. The profile of the epidemic in Mozambique is such that the young people are the ones that are hit the hardest. The number of young people who are being infected is so huge that we are not meeting their needs if only talking about HIV prevention. In 2004 the program included access to HIV treatment in two of the youth-friendly services sites. The training content was further expanded to include the content of youth living with HIV/AIDS.
Was there separate training for the youth-friendly providers?
The training was separate. It also lasted around two weeks. We included theory and practice. The training varied depending upon the type of providers we worked with. Some providers did not have STI training before, so they would be referred to a large health facility or hospital in order for them to get the appropriate practical training on STIs. The provider training consisted of the youth-friendly approach and informed providers why adolescents need a specific orientation, the challenges and issues of working with adolescents, and how to address them. The training also focused on counseling skills; for example, what is youth counseling, what does it take, how to be a good counselor, how to counsel on contraceptive options, what are the best methods available for young people, and what does it take to provide them. In each training, also it was included the monitoring system to be used so the providers could be reporting the services statistics accordingly.
Did the team come across any problems or obstacles when they set up the program in 1999?
Yes. It was a new program. First of all, not everybody understood the concept of a multisectoral program. We are more exposed to vertical programs, so it took some time to develop an understanding of what it takes to develop a multisectoral program and the advantages of multisectoral programming. Rather than taking from each other, multisectoral programs maximize synergies and reinforce each other’s activities. Today they really value it and respect each sector. For the establishment of the clinical component, we had some obstacles with nurses who were not youth-oriented and even after training continued to be an obstacle. We had to kindly ask the government to refer such nurses to other services and get more youth-oriented nurses, and we were able to do that. The participation of girls as peer educators and the permission of parents for their daughters to be peer educators were also an obstacle. The problem of no payment of peer educators is a constant challenge. Many of the peer educators see this as an opportunity to have a job, and see this as a job that should be paid.
I know you mentioned there was counseling at the youth-friendly centers, but was HIV testing also offered?
Yes, we have two levels of intervention. In 2002 we began to include Voluntary Counseling and Testing (VCT). In 2004 we began a pilot of providing antiretroviral (ARV) treatment in youth-friendly clinics. Today I think we have about 100 youth-friendly centers, and we offer VCT in 40 percent of these clinics. The tests are integrated, done by the same nurse who is counseling on contraceptive options. Currently two youth-friendly centers are providing ARV treatment.
Do you have any final words you'd like to add about Geraçao Biz?
I think one important point refers to the establishment of systems in place to manage integrated programs. We have established coordination mechanisms at the three levels: central, provincial, and district levels where on a rotative basis one of the sectors would be responsible to coordinate multisectoral activities. Technical assistance and capacity building were provided on site to all three ministries on a continuous basis; a training-of the trainers (TOT) program was implemented early to ensure that we had provincial trainers. TOT content also included integrated approaches. Integrated monitoring and supervision systems to enhance coordination and to facilitate maximization of human and financial resources were also there from the beginning. This is a very lively youth-oriented program that I feel very proud to be part of it.
For more information about Geraçao Biz in Mozambique, see http://www.pathfind.org/site/PageServer?pagename=Programs_Mozambique_Projects_GeracaoBiz.
Contact Information:
Rita Badiani
COMPASS Central Office, Abuja
Director of Operations
No. 35 Sowemimo Street, Asokoro, Abuja
Mobile: 234 80 55030063
Office: 234 9 672 0021-2, 314 5400, 314 5206-8, 314 7378
Email: RBadiani@pathfind.org