Untitled - Pathfinder International

Transcription

UNFP
A
UNFPA
and
Pathfinder Mozambique
P ROVIDING REPRODUCTIVE
H EALTH A N D STI/HIV
I NFORMATION A N D SERVICES
T O THIS GENERATION
Insights from the Geração Biz Experience
Gwyn Hainsw
orth
Hainsworth
October 2002
C ONTENTS
Pr
eface ............................................................................................................. 1
Preface
Intr
oduction and Backg
Introduction
Backgrround ............................................................................. 2
Overview of Geração Biz .................................................................................... 9
Multi-sectoral Coordination .............................................................................. 13
Pr
omoting Ownership ....................................................................................... 15
Promoting
Clinic-Based Services for Adolescents ................................................................ 19
School-Based Interv
entions ...............................................................................
32
Interventions
...............................................................................32
Outr
each for Out-of-School YYouth
outh .................................................................... 42
Outreach
Per
ception of Stakeholders ............................................................................... 53
erception
Expansion Pr
ocess ........................................................................................... 55
Process
Conclusions .................................................................................................... 57
Refer
ences ..................................................................................................... 58
References
ACKNOWLEDGMENTS
This document is based on the collective experience of all those who have been involved in the
Geração Biz project. It was written in the hope that by documenting the evolution of a multi-sectoral
ASRH project like Geração Biz, others in the field of adolescent reproductive health could benefit
from the lessons learned, challenges faced, and best practices.
Many thanks go to Dr. Georges Georgi, Rita Badiani, Odete Cossa, Ivone Zilhão, Cecilia Bilale,
Baissamo Juaia, Fernando Sumbane, Luc Van Der Veren, Julio Pacca, Dr. Lilia Jamisse, Della
Correia, Humberta Pindula, Jorge Matine, Ruth Cangela, Jose Maluleca, Alexandre Muianga,
Sebastaõ Cuinica, Helder Andrade,Constantino Oliveira Lopes Amalique, Magida Omar
Nurmahomed, Maiance Juma Seide, Noemia Manuel de Costa do Rosario, Aida Suale de Almeida
Vareia, Luis Alberto Macave, Primildo Lino Monjane, Joana Chingor, Graca Manuel, Maria Azevedo,
Ina Monteiro Nunes, Ajamia Ibrahimo, Deolinda Aurora, Racquel Jose-Daniel, Albino Adamugy
Valia, and Arao Alberto Cumbane for contributing their knowledge and insight so that others may
apply their experience in the formulation of sustainable and effective ASRH programs. Most
importantly, acknowledgment should go to all the young people who shared their stories and
allowed their photographs to be taken. Their participation created a fuller and more well-rounded
document.
Special thanks to Sarah Sheldon who coordinated the initial stages of gathering information; Linda
Casey for all her assistance throughout this long process; Sheila Webb for her review and edit; Judy
Senderowitz for her advice and counsel; and Yasmeen Khan for her assistance with layout.
P REFACE
Increasingly, governments and donors are recognizing that adolescents have different sexual and
reproductive health needs than the adult population. Traditionally, reproductive health programs
have targeted married adult clients. Young people, due to their age and marital status, have had little
access to the information and services necessary for positive and healthy development. Adults often
do not engage young people in frank and open discussions about sex, HIV, and protective behaviors
for fear that they will encourage young people to engage in sexual activity.
While adolescence is often a time of sexual exploration, young people may inaccurately perceive
themselves to not be at risk and therefore do not engage in protective behaviors. Ignorance of their
bodies, sexuality, and sexual and reproductive health contributes to their vulnerability. Their lack of
power due to age and socio-economic status impacts their ability to negotiate protective practices.
In addition, young people are easily influenced by peer pressure and social norms, which may
increase their risk for unwanted pregnancy, STIs, and HIV/AIDS.
In Mozambique, youth are confronted with a myriad of reproductive health problems, including
early sexual debut, high rates of unwanted pregnancy and unsafe abortion, increasing rates of STIs
including HIV, and gender-based violence. Sexual debut begins on average at 15 years of age and
40% of female adolescents under the age of 19 are already mothers. Mozambique’s alarming rate of
maternal mortality –1,500/100,000 live births–can be attributed in part to early childbearing and
unsafe abortion. In addition, more than one quarter of reported STIs occur in youth and HIV
prevalence has risen to 13%.
Following the 1994 International Conference on Population and Development, the Government of
Mozambique recognized that investing in youth was an investment in the future of the country.
Several initiatives were started to address the needs of youth, including the National Youth Policy.
This policy sought to increase youth involvement in the policy arena and contained special
provisions for the promotion of integrated, high-quality sexual and reproductive health services and
information. Following this, an inter-ministerial committee developed an Integrated Plan of Action
to Support the Development of Adolescents and Youth. An outcome of this Plan of Action was the
launching of a multi-sectoral adolescent sexual and reproductive health project called Geração Biz
in 1999. The project began in Maputo City and Zambezia Province. Based on the project’s success,
the government decided to expand the project on a national scale.
This report was written in the hope that by documenting the initial stages of the Geração Biz
project, others in the field of adolescent reproductive health could learn from this experience . As
the project is ongoing, numerous activites and changes have occurred since this document was
written. This document includes key strategies and interventions, challenges, lessons learned, and
recommendations. Information in this document is presented under the project’s key strategies:

Multi-sectoral coordination
Increased government ownership of the project
Clinic-based adolescent sexual and reproductive health services
School-based interventions that promote behavior change for in-school youth
Outreach efforts that promote behavior change for out-of-school youth
Insights from Geração Biz
1
I NTRODUCTION AND BACKGROUND
W
hile Mozambique has made significant economic strides in the last few years, it still
remains one of the world’s poorest countries. Plagued by civil war for 16 years until
1994, Mozambique was left with a weak infrastructure and a decimated economy. During
this time, little allocation of public funds for health and education resulted in high levels of
malnutrition; lack of access to quality health services; low levels of education and literacy,
especially for girls; and high unemployment rates. During the war, almost half (700 out of 1,600) of
all health facilities were destroyed leaving the public health system in shambles.1
After years of constant decline, Mozambique experienced strong economic growth, around 7% per
annum, during the late 1990s. However, floods in early 2000 devastated large parts of the country
unraveling much of the progress that the Mozambican economy had made in the last few years. As a
result, slightly more than 69% of the
population live below the poverty line (US$
Table 1: Major Socioeconomic and Health
0.40 per day) with the rural areas being the
Indicators for Mozambique3
2
most heavily impacted (71.3%).
GNP Per Capita (1998)
$210.00
Population
19,105,00
Urban Population
28%
Population Ages 10-24
6,200,000
Density (pop/sq mile)
62
Growth Rate
2.19%
Life Expectancy—Male
40.0
Life Expectancy—Female
39.0
Infant Mortality/1,000 live births
33.90
Child Mortality
214
Maternal Mortality/100,000 Live Births
1,500
Male Literacy
53%
Female Literacy
23%
Secondary School Enrollment of Females
5%
Mean Age of marriage
17
The Impact of HIV
Currently Married Females Ages 15-19
45
The spread of HIV/AIDS in Mozambique
was affected by several factors. The civil
war kept Mozambique isolated from
neighboring countries where HIV
transmission was escalating, thereby
delaying the onset of the epidemic. During
the civil war, three million people were
displaced from their homes, many of whom
became international refugees in countries
TFR
5.6
CPR
6%
Females Giving Birth by Age 20
65%
Births Attended by Trained Personnel,
Single Females Ages 15-19
47%
Despite some economic setbacks, the
health sector in Mozambique has been
making progress. The National Health Plan
focuses on improving coverage, availability,
distribution, and quality of health services.
While the efforts to improve access to
quality health care are commendable, it is
important to note that a large percentage of
the population is currently not being served
by the public health system. An estimated
60% of the population still do not have
access to health services and young people
are at a further disadvantage as stigma and
negative provider attitudes often serve as
additional barriers to service provision.4
2
Contraceptive Use Among Single
Females Ages 15-19 (Modern Method)
Contraceptive Use Among Married
Females Ages 15-19 (Modern Method)
5%
19%
that reported
very high levels
of HIV. Drought
in 1984 and
1991-92
increased
internal
migration to
urban areas
and transport
corridors. At
the end of the
civil war,
Mozambique
opened its
borders with
neighboring
countries,
which helped fuel economic growth in the country but also significantly contributed to the spread of
HIV with the return and relocation of refugees and internally displaced people (IDP). High STI
prevalence in Mozambique intensified the spread of HIV. Furthermore, the civil war reversed postindependence improvements in basic services and health, rendering Mozambique ill-prepared to
confront a burgeoning HIV/AIDS epidemic.
Increases in rural-urban migration and commercial sex work as well as the social disruption
encountered from the civil war have contributed to a rise in HIV. By 2001, Mozambique had an
estimated HIV infection rate of 13% for those between the ages of 15-49.5 The high incidence of HIV/
AIDS in Tanzania, Malawi, Zambia, South Africa, and Zimbabwe is also impacting HIV
transmission in Mozambique as the number of Mozambicans moving in and out of these countries
for work has dramatically increased; this is especially evident in corridor areas. Compounding this
issue is the increase in young people relocating to transport corridors, many of whom are trading
sex as a way of supporting
themselves.
According to conservative
estimates, in 1998-99
approximately 30,000 families
were affected by HIV/AIDS,
resulting in changes in resource
and income distribution,
consumption patterns, decreased
saving, family breakdown, and
disruption of family and
community structures.6 Moreover,
the burden of AIDS falls
3
disproportionately on the shoulders of women (wives, mothers, daughters, and grandmothers) who
are already overburdened by domestic chores, childcare, and subsistence activities. Young
daughters often become heads of the household, which not only compromises their own lives, in
terms of inadequate schooling, loss of income potential, and reduced choices for the future, but
also the lives of their younger siblings who are often ill-cared for, resulting in malnutrition, illness,
and lack of education.
Adolescents and Youth
Projections based on the 1997 census estimate that there are six million young adults between the
ages of 10-24 in Mozambique, which constitutes 34% of the total population. Although there is
general enthusiasm and ambition among young people, high unemployment, lack of education, and
weak leadership has led to an overall feeling of unmet expectations. While a significant number of
young people have never attended school (47% of all females and 26% of all males), even fewer
have completed any level of education (30.5% of men and 14% of women).7 Fifty-six percent of the
adult population in Mozambique is illiterate impacting future employment as well as access to
appropriate health information.8
While there are considerable variations between ethnic groups as well as between urban and rural
populations, most young women and girls in Mozambique still do not enjoy equitable status.
Gender differences are readily apparent with regard to female enrollment and dropout rates: girls
represent only 41% of all primary students and 35% of all secondary students. In rural areas, girls
fare even worse, with only 0.1% completing a secondary education due to early marriage, poverty,
and domestic demands.9 Only 23% of females are literate, compared with 53% of males, and only 5%
of females are enrolled in secondary school.10 Rural girls usually drop out of school before age 12 in
order to help at home, if they even have the luxury of attending school in the first place.11 Genderbased violence is a significant problem within all
sectors of society. Traditional customs practiced
in some areas also negatively impact young
women’s RH status. Painful practices are often
compulsory, such as vaginal tattoos, stretching of
the vaginal lips, and using vaginal drying agents.
Girls are often taught to give but not to enjoy
sexual pleasure while women are often not
allowed to use contraception without their
husbands’ permission.12
The disintegration of families and associated
values, coupled with a recent breakdown in
traditional customs and the increasing influence
of modern culture, have led to an absence of a
formal mechanism for communicating expected
adolescent behavior. Traditionally, family
members other than parents were responsible for
transmitting information related to reproduction
and sexuality to adolescents. An appropriate and
4
coherent system has yet to be created to fill this
void. This vacuum increases the vulnerability of
young girls, putting them at risk for physical and
psychological exploitation, which often results in
early pregnancy, teenage marriage, and trading
sex for money or favors. Young men who lack
education and skills often have less employment
and economic opportunities, which can put them
at increased risk for drug and alcohol abuse or
involvement in criminal activity.
A study conducted by ICS in Zambezia province
identified a series of issues that needed immediate attention, such as early sexual debut, adolescent
pregnancy, high-risk behavior that can lead to STDs and HIV/AIDS, a general lack of knowledge
about reproductive health (RH), and limited access to SRH education and services.13
Early Sexual Deb
ut According to the 1997 DHS report, 80% of women aged 15-19 years are
Debut
sexually active. The mean age of first sexual intercourse was 15.09 years for those aged 15-19 with
males registering a slightly lower age of first sex than females.14 In some areas of Mozambique,
girls are encouraged to engage in early sexual activity directly after initiation rites.15 This early
initiation of sexual activity combined with a delay in the age of marriage has resulted in an increased
period of risk for unwanted pregnancy and STI/HIV.
Adolescent Pregnancy Although 44% of married adolescents know of at least one modern method
of contraception, less than 1% are actually using a modern method.16, 17 Single adolescents hardly
fare any better, with only 5% using a modern method.18 Given such a low CPR, it is not surprising
that the 1997 DHS showed that 40% of women ages 15-19 had entered motherhood and 25% were
pregnant. The survey also showed that 60% of 19-year-old women were already mothers and 8%
were pregnant. Of those admitted to the Central Hospital for complications of abortion, 44% were
women under the age of 20 while septic abortion is the second highest cause of death in those under
20. Mozambique has an alarming rate of maternal mortality of 1,500/100,000 live births and much
of this can be attributed to early childbearing with inadequate birth spacing and limited access to
prenatal care and safe delivery.
High Risk Behavior and STD/HIV/AIDS While KAP studies demonstrate a high knowledge of
means to prevent HIV transmission, this knowledge has not been translated into behavior change.
Knowledge of two ways to prevent sexual transmission of HIV was 68.6% for those aged 15-19, while
more than 90% of in-school youth living in Maputo knew of condoms and a source of condoms.19, 20
However, the DHS showed that for those aged 15-19 years, only 10% of boys and 2% of girls used a
condom during their last sexual relation.21 While those in school demonstrated a higher rate of
condom use (31% of young women and 37% of young men in Maputo and 27% of young women and
24% of young men in Zambezia who are sexually active reported having used a condom during the
last six months), a large discrepancy still remains between knowledge and practice.22 In addition, in
the last five years, substance abuse among youth has become a serious problem in Mozambique,
especially in large towns and urban areas. Young people are also engaging in other risky behaviors,
5
such as having multiple sex partners: 33% of 15–19-year-olds and 29% of 20–24-year-olds have had
at least one non-regular partner in the last 12 months.23
More than one quarter of reported cases of STIs occurs in teenagers, demonstrating the need for
stronger efforts to be made to increase early STI treatment, partner referral, and consistent condom
use for dual protection. The link between STIs and HIV infection is well known, so it is not
surprising that young people make up 42.8% of all new cases of HIV.24 Young women’s low social
and economic status, combined with a greater biological susceptibility to HIV, put them at
increased risk of infection. Poor economic conditions, which make it difficult for young women to
access health and social services, compound this vulnerability. Young women’s disadvantage vis-avis HIV is evident in much higher prevalence rates for females aged 15-19 (16%) than their male
counterparts (9%).25
Lack of Knowledge about Reproductive Health In the KAP study conducted in schools in Maputo,
only 30% of girls and 18% of boys were able to correctly identify the fertile time during a woman’s
menstrual cycle and the majority of those students who answered correctly were above the age of
18.26 While knowledge of the condom and pill to prevent pregnancy was quite high among students
(70.% of girls and 57% of boys identified the pill as a method of
contraception, and 86% of girls and 90% of boys identified the condom),
knowledge of other methods was quite low. Younger adolescents, those
aged 13-15, were less knowledgeable about all methods of contraception.
In addition, while over half of all students could identify at least two
symptoms of STDs, less than 40% of younger students could identify two
symptoms of STDs, and only 19% identified urethral discharge as a sign of
STD. While this trend is more or less universal to adolescents, it does
bring attention to the need for targeting RH education to younger
adolescents so that they are well informed before they begin sexual
relations. It is worth noting that this KAP study only included urban, inschool youth and that the majority of young people are out of school and
live in rural areas; therefore, the above statistics do not reflect the true
extent of young people’s ignorance regarding reproductive health.
Limited Access to SRH Information and Services Young people’s access to information and
counseling facilities is practically nonexistent, and the majority of youth depend on informal
mechanisms such as the radio or peers for information about STDs and HIV/AIDS.27 KAP studies in
both Maputo and Zambezia showed that in-school youth have a fairly high knowledge of
contraception and the prevention of STD/HIV transmission; however, the majority of youth are not in
school making it harder to reach them with traditional forms of sexuality education. Adults often
protest the implementation of sexuality education due to fear that the provision of SRH information
will encourage promiscuity.28
While the MOH supports the integration of youth-friendly services (YFS) into existing clinics, some
providers still maintain negative attitudes towards providing RH services to youth. Low salaries and
high client loads contribute to a lack of morale as YFS are often seen as an additional responsibility
without an increase in compensation. YFS are often offered at specific times, usually a few afternoon
6
hours a week. While these times may not be ideal for adolescents, given that older adolescents
usually attend the afternoon shift at school, hours that are more suitable to adolescent schedules,
such as mornings, are often high-traffic periods for prenatal and primary health services. The
challenge is how to offer integrated YFS that truly meet the needs of adolescents given the fact that
the health clinics are already overburdened.
Young people who suspect they may be HIV positive are often not referred for testing due to the
lack of service delivery points (SDPs) that offer voluntary counseling and testing (VCT). While
VCT remains almost nonexistent in Mozambique, strides are being made under the auspices of the
National AIDS program and other local NGOs to increase access to VCT. In Maputo, both Alto
Mae Health Clinic and the Adolescent Clinic at Central Hospital now offer VCT although there is
still a great need to expand VCT services into the provinces.
National Youth Programs and Initiatives
Historically in Mozambique, the positive development of youth and adolescents, particularly with
regard to reproductive health, was largely ignored. Overall, young people have had few
mechanisms through which they can voice their needs and be involved in policy decisions that
affect them. However, in the last few years as a result of recent international
conferences (ICPD and Beijing), adolescent sexual and reproductive health
has garnered much attention, particularly in relation to HIV/AIDS. This
positive momentum has led to an increasingly supportive policy
environment with regard to adolescent and youth issues.
National YYouth
outh PPolicy
olicy In 1996, the Government of Mozambique
demonstrated its commitment to address the needs of young people by
ratifying a National Youth Policy that aims to increase youth involvement in
policies and decisions that affect them. The policy focuses on the healthy
development of young people by promoting and implementing programs
that increase access to information and integrated, high-quality sexual and
reproductive health services.
National Strategic Plan on HIV/AIDS (NASP) The National Strategic Plan to Combat HIV/
AIDS, approved in June 2000, includes components on youth-to-youth education, STD diagnosis
and treatment, VCT, and treatment of opportunistic infections. NASP places a special focus on
young people and other vulnerable groups such as people living with HIV/AIDS (PLWHA),
orphans, and those living in commercial corridors. Sectoral and Provincial Operational Plans for
HIV/AIDS have been developed and are now ready for implementation. In June 2000, the National
AIDS Council (NAC) was created to ensure coordination and monitoring of all HIV/AIDS
activities as well as to advocate and solicit resources for future HIV/AIDS initiatives.
Ministry of Health (MOH) Recognizing that young people have special needs when it comes to
health services, the MOH created a School and Adolescent Health Section (SEA) within the
Community Health Department. SEA is responsible for extending and improving adolescent sexual
and reproductive health (ASRH) services both in government clinics as well as public schools. To
7
improve the ability of nurses to respond to the needs of adolescents, ASRH topics were integrated
into the basic training curricula. The MOH has also recently begun the development of an
information, education, and counseling (IEC) campaign that promotes community participation in
healthy lifestyles at the individual, family, and community levels and helps increase demand for
health services.29 In addition, a National Adolescent Reproductive Health Policy was developed
that promotes the physical, mental, and social well-being of adolescents through the development
of ASRH programs.
Ministry of YYouth
outh and Sports (MO
YS) In 1992, the Ministry of Youth and Sports was created,
(MOYS)
publicly recognizing young people as an important constituent. In November 2000, the MOYS
approved two documents: 1) an outreach strategy for providing out-of-school youth with SRH
information, and 2) the AIDS Operational Plan (POSIDA) to reach out-of-school youth with a
minimum package of essential activities for HIV/AIDS prevention and impact reduction.
Ministry of Education (MOE) The MOE approved its Sectoral Strategic Plan to improve access to
education, especially in rural areas, and to expand technical/vocational education. In addition, the
MOE has also begun to operationalize its Sectoral Plan Against AIDS. Capitalizing on the major
curriculum reform that is underway, the MOE is integrating SRH issues into the national basic
education curricula and teachers’ training. To complement this new curricula, the Institute of
National Educational Development in collaboration with the MOE is providing support for the
implementation of a package of SRH intra- and extracurricular activities within primary, secondary,
and technical schools and student hostels.
Intersectoral Committee for the Dev
elopment of YYouth
outh and Adolescents (CIAD
AJ)
Development
(CIADAJ)
In 1997, a multi-sectoral committee, CIADAJ, was established that involved the ministries of health,
education, youth, women’s affairs, labor, and environmental action, as well as NGOs and religious
organizations. CIADAJ formulated the Integrated Program and Plan of Action to Support the
Development of Adolescents and Youth in 1997, which included the following key areas: policies
and legislation related to adolescents and youth; family life education (FLE); and community life
education. CIADAJ’s mandate was to promote and coordinate the implementation of this Plan of
Action; however, CIADAJ is no longer operating in this capacity.
8
O VERVIEW
OF
GERAÇÃO BI Z
O
ne major line of action in CIADAJ’s Integrated Plan was to increase access to ASRH
information and services. The first step taken in this arena was to conduct a national needs
assessment of ASRH. Findings from
this assessment demonstrated that
adolescents could not be treated as a
Guiding Framework
homogenous group. Therefore, it was
determined that the most effective response
The right of adolescents to a
to the diverse needs of young people was a
positive and healthy sexual and
multi-sectoral approach that included
reproductive life.
numerous interventions and activities
simultaneously conducted by several
Respect for cultural diversity.
government institutions in close
collaboration with existing national NGOs
Commitment to gender equality.
and community-based associations. During
follow-up meetings, the future
Recognition of all youth as
responsibilities of each sector were clearly
citizens.
delineated: the health sector would
implement youth-friendly services, education
would oversee school-based activities, while
the Ministry of Youth and Sports would implement interventions geared towards out-of-school youth.
Through CIADAJ’s efforts and under the direction of the MOYS, the Reproductive Health for
Adolescents and Youth Program in Maputo City and Zambezia Province began in 1999. The
program aimed to address the sexual and reproductive health
needs of in- and out-of-school youth. Capitalizing on the efficacy
of social marketing techniques to reach young people,
adolescents were asked to develop a name with which other young
people would identify. The program was then given the brand
name “Geração Biz” or “Busy Generation.” The brand name is
equated with quality ASRH services and the logo is used at all
service delivery points (SDPs) as well as in the promotion of any
program activities. Geração Biz was designed to include three
main program components: clinical and counseling services,
school-based interventions, and outreach.
Guiding Principles
Geração Biz employed the following general approaches in an effort to foster increased access to
appropriate ASRH information and quality reproductive health services:
1.
Build upon the achievements of previous efforts to promote and implement policies and
programs for adolescents and youth.
9
2. Adopt a comprehensive multi-sectoral
approach, which incorporates appropriate
sociocultural awareness, to promote changes
in behavior related to gender, ASRH, and
family life.
3. Articulate, complement, and maximize the
efforts of other programs supported by
UNFPA and other donors in the areas of
education and health, whenever possible
using combined resources and professionals
to maximize the impact of interventions and
capacity building.
4.
Draw on the spirit and voluntary nature of local associations, community leaders, local
churches, youth organizations, and sports associations to develop community activists to
provide information and counseling to in- and out-of-school youth. 30
Program Objectives
Geração Biz seeks to improve ASRH, increase gender awareness, reduce the incidence of
unplanned pregnancies, and decrease young people’s vulnerability to STIs, HIV, and unsafe abortion
through the following initiatives and supportive strategies:

Establish a network of quality ASRH services and counseling within the public health system
and at alternative sites.

Develop a school-based program for in-school youth that provides appropriate SRH
information and counseling and is linked to youth-friendly, gender-sensitive health services.

Develop an outreach component for out-of-school youth that provides appropriate SRH
information and counseling and is linked to youth-friendly, gender-sensitive health services.

Empower in- and out-of-school youth with life skills information that is related to the
development of their sexual and reproductive health and oriented to behavior change.
Supportive Strategies
10

Create a supportive, cohesive social environment for behavioral development and change
among in- and out-of-school youth and their social networks.

Strengthen the capacities of institutional partners (government, NGOs and other facilitators/
service providers) to plan, implement, monitor, and evaluate multi-sectoral ASRH
interventions.
Implementing Partners
In the beginning, the project was executed
through the National Directorate for Youth
(DNAJ) of the Ministry of Youth and
Sports (MOYS) in conjunction with
UNFPA and Pathfinder International.
DNAJ was the main executing agency with
Pathfinder assuming responsibility for the
provision of long-term technical
assistance as well as the execution of
interventions that are being implemented
by national NGOs. Recently there was a
shift in execution responsibilities: the
project is now executed by the three
implementing partners (MOH, MOE, and
MOYS) and their respective provincial
directorates with technical assistance from
UNFPA and Pathfinder.
Due to its multi-sectoral approach,
Geração Biz involves several public
sector institutions as well as two national
NGOs—AMODEFA and ARO Juvenil.
Further compounding the complexity of
this project is the implementation of
activities at various levels—central,
provincial, district, and city. At the central
level, Geração Biz is implemented by SEA
of the MOH, INDE of the MOE, and DNAJ
of the MOYS. At the provincial level, the
Provincial Directorate of Education
(DPE), the Provincial Directorate of
Health (DPS), the Provincial Directorate
of Youth and Sports (DPJD), AMODEFA,
ARO Juvenil, and youth associations are
responsible for project interventions. In
Maputo City, activities are implemented by
the City Directorate of Education (DEC),
the City Directorate of Health (DSCM),
AMODEFA, and several youth
associations. Through technical
assistance, Geração Biz has begun to
decentralize program management to the
provincial government and local NGOs.
Implementing Partners
DNAJ
DNAJ-National Directorate of Youth operates
under the MOYS and is responsible for the
outreach component in Maputo and executing
Geração Biz at the central level.
INDE
INDE-National Institute of Educational
Development of the MOE is responsible for
school-based interventions at the central level.
SEA
SEA-School and Adolescent Health Section of
the MOH is responsible for clinic-based
interventions at the central level.
AMODEF
A -Mozambican Association for Family
AMODEFA
Development is responsible for in-school peer
activists (Maputo) and community-based peer
activists (Zambezia).
AR
O JUVENIL
ARO
JUVENIL-responsible for communitybased peer activists and outreach activities in
Zambezia.
DPJD
DPJD-Provincial Directorate of Youth and
Sports is responsible for execution of Geração
Biz and implementation of the outreach
component at the provincial level.
DPE
DPE-Provincial Directorate of Education is
responsible for school-based interventions at the
provincial level.
DPS
DPS-Provincial Directorate of Health is
responsible for the clinic-based component at
the provincial level.
DEC
DEC-City Directorate of Education is
responsible for school-based interventions
within Maputo schools.
DSCM
DSCM-City Directorate of Health is responsible
for clinic-based interventions within Maputo.
YOUTH ASSOCIA
TIONS
ASSOCIATIONS
TIONS-responsible for
outreach to out-of-school youth.
11
Figure1: Execution Modality
Decentralized Execution
Central
Level
Technical
Assistance
Provincial
Level
12
Ministry of
Ed
Ministry of
Youth
UNFPA
Director
of Ed
Ministry of
Health
National
NGOs
Pathfinder
International
Director
of Youth
Director
of Health
M ULTI- SECTORAL COORDINATION
W
hile it is challenging to involve such a wide variety of stakeholders, a multi-sectoral
partnership was developed to increase synergistic activities. This approach was built on
the premise that more is accomplished from collaborated efforts than from isolated
sectoral activities. Since Geração Biz grew out of CIADAJ’s Intersectoral Plan of Action, it was
envisioned that CIADAJ would assume responsibility for coordinating this multi-sectoral
intervention. CIADAJ was under the auspices of DNAJ and therefore had direct ties to the main
executing agency, thus facilitating communication between the MOYS (DNAJ) and other
implementing institutions such as the Ministry of Health. Monthly meetings with representatives from
each implementing institution were to be held and a memorandum of understanding was signed with
each institution that clearly defined their role in the implementation process of Geração Biz.
While, theoretically, CIADAJ seemed to be the appropriate mechanism for the program’s multisectoral coordination, in reality the coordination proved to be difficult. Lack of clarity regarding
CIADAJ’s role and mandate resulted in CIADAJ assuming responsibility for the implementation,
rather than the coordination, of program activities.31 The constant change in representation to
CIADAJ also contributed to the malfunction of this inter-ministerial body. Each ministry and NGO
was responsible for selecting a staff member to represent their institution in CIADAJ. However, given
the constant turnover in staff that the ministries experience, membership in CIADAJ was continually
changing. CIADAJ’s progress was significantly hindered due to the lack of consistent members. The
need for permanent staff who worked on the program to be involved in CIADAJ became increasingly
evident. CIADAJ”s meetings became more infrequent and its viability as a monitoring and
coordinating body diminished.
In the absence of an effective coordinating body, DNAJ assumed much of the interim responsibility
for coordinating the activities of each sector. Recognizing that coordination of such an extensive
multi-sectoral project could not be done by one agency alone, a new multi-sectoral coodinating
body was formed. Learning from the CIADAJ experience, it was decided that responsibility for this
coordinating body would be shared equally among the three ministries. The coordinator of this new
body would be elected from one of the ministries on a rotating basis. Each sector has two
representatives on this coordinating body who are directly involved with the project. It was decided
that quarterly meetings would be held where joint planning and monitoring of activities would occur.
These meetings would also serve as a forum to exchange information and discuss planned activities.
Multi-sectoral coordination has been easier to implement at the provincial level due to several
factors. First, the provincial level is more decentralized and therefore it is easier for the three
provincial directorates to meet and interact. Second, coordination at the provincial level is less
complex than at the central level where the ministries must coordinate activities on a national scale.
Third, the mandate of the provincial directorates is more focused and limited in scope than that of
the ministries and national directorates.
13
Lessons Learned

Bringing together such a large range of stakeholders is important and creative but demands
clarity in the definition of roles and responsibilities as well as a strong ability to coordinate
the many stakeholders involved. Geração Biz sought to involve a variety of stakeholders from
both government and the private sector. While this approach was very ambitious, it became
evident that to successfully involve numerous stakeholders with varying abilities, roles and
responsibilities must be clearly stated from the outset and a mechanism to ensure multisectoral coordination must be in place.

Participation of the MOH, MOE, and MOYS is required to ensure cohesive and effective
coordination of program activities at the central level. Initially, project implementation at the
central level involved INDE, the MOH, and MOYS. INDE was a natural choice with regard to
school-based interventions because of its involvement with the POP/FLE program that was
being piloted in Zambezia. However, after the scope of the Geração Biz project expanded
and INDE’s work with POP/FLE ended, a gap in the central coordination of educational
activities became evident. The absence of the Ministry of Education (MOE) in this multisectoral coordination hindered the successful establishment of linkages between POP/FLE
activities, clinical services, and the network of peer activists. To rectify this earlier omission,
Geração Biz has now solicited the active involvement of the MOE to strengthen the
coordination of school-based activities in relation to the other project components.
Coordination of this multi-sectoral project must be shared equally among the three ministries.
At the outset of the project, CIADAJ, which was under the auspices of DNAJ, was responsible
for coodinating the implementation of the project’s mutlisectoral activities. It was found that to
increase ownership and accountability as well as facilitate coordination, all three ministries and
their respective directorates must equally share the responsibility of coordination. A new
coordinating body has been formed which elects a chair from the three ministries on a rotating
basis. Each sector has equal representation within this new body.
All partners must have a common vision of the mission of the project and its intended results.32
Although each implementing partner is responsible for different project components, the overall
mission of the project and its expected outcomes must be shared among all the partners. The
coordination of workplans and allocation of resources must all support the same overall goals
and objectives. A shared common vision should be established before the implementation of
project activities.
Differences among agencies’ workstyles, approaches, and mandates must be respected and
valued. Each ministry and its provincial and city counterparts is unique in the way that it
operates and is responsible for different aspects of the project. Collaboration among such
different agencies demands flexibility from all the partners. The strengths that each partner
brings must be valued and conformity to one workstyle or approach cannot be imposed on the
other member agencies.
14
P ROMOTING OWNERSHIP
R
ecognizing that all too often adolescent
reproductive health projects are rarely
sustained beyond the initial project phase,
UNFPA sought to promote ownership of Geração Biz by
the partnering institutions with the hope that the project
would eventually become a sustainable program.
Ownership is a process that encompasses commitment,
inclusion in all stages of the program, and capacity
building so that institutions are fully able to manage the
program on their own. One of the goals articulated in the
design of Geração Biz was to strengthen both the
technical and institutional capacity of public sector and
NGO partners so that they are able to plan, implement,
coordinate, and monitor multi-sectoral ASRH programs.
Technical capacity building is done through training in ASRH as well as in other areas, such as
management and computer skills. Short-term consultancies and long-term technical assistance
complement on-going training activities.
Long-term technical assistance is provided to the Central level of the GOM as well as Maputo City
by the project’s Chief Technical Advisor and two Technical Advisors (one who specializes in clinical
services and the other who specializes in school-based interventions). In Zambezia province, longterm technical assistance is provided by the Zambezia Technical Advisor, who oversees the
outreach and clinical components, and the DPE Project Technical Advisor who oversees the schoolbased component. To ensure coordination of activities at the Central level with those occurring at
the provincial level, the Chief Technical Advisor provides technical assistance and supervision to
the Zambezia Technical Advisor.
Given the extensive training needs of the program, a team of 11 core trainers was trained in ASRH
and a comprehensive training manual was developed. The team included representatives from the
three sectors (health, education, and youth) in Maputo and Zambezia as well as AMODEFA and
ARO Juvenil.
In order to implement project activities in Maputo City, the three executing partners, DNAJ, UNFPA,
and Pathfinder, collaborated with the Ministry of Health and National Directorate of Education
(INDE) at the central level, DEC and DSCM at the city level, and AMODEFA. The implementing
agencies were visited by the Chief Technical Advisor and the Director of DNAJ to review program
activities and objectives. A coordinator was appointed to represent each agency. In order to ensure
coordination of individual workplans, a seminar was held with all the implementing agencies, at
which time one master workplan was developed. The respective Technical Advisors conducted
working sessions with each agency to provide technical assistance during the design and planning of
activities. In cases where there were activities that one or more agency was responsible for
implementing, joint working sessions were arranged. Monthly meetings were then conducted to
ensure effective collaboration throughout the process and to maximize resources.
15
In contrast to the situation in Maputo City, Geração Biz worked with the provincial level of
government in Zambezia. Mirroring the executing framework at the central level, the Provincial
Directorate of Youth and Sports (DPJS) was responsible for overall coordination of activities in
collaboration with UNFPA and Pathfinder International, while the Provincial Directorate of
Education and the Provincial Directorate of Health oversaw implementation of school-based and
clinic-based activities. NGOs, such as AMODEFA and ARO Juvenil, spearheaded community-based
outreach activities. While in Maputo City, the initial emphasis was placed on the implementation of
activities, in Zambezia, beginning efforts were
channeled into promoting multi-sectoral
coordination and capacity building of public and
“My main role, as I see it, is to
private sector partners. The approach taken in
educate young people. Health
Zambezia has resulted in a stronger sense of
ownership and has facilitated coordination
is important to all people;
amongst partnering institutions. Based on this
therefore it is
success, a strategy for promoting ownership has
been developed for expansion to other provinces.
important for me to be
involved in this project .“
While commitment and active involvement of
government and NGO partners are requirements
-School Director, Quelimane,
for true ownership, involvement alone will not
guarantee that ownership takes place. Essential to
Zambezia
creating true ownership is the development of skills
so that implementing partners are able to carry this
program forward on their own. Effective capacity
building goes beyond training and also includes technical assistance that supports the ministries
and organizations as they lead the process of planning, implementing, and evaluating activities. In
order for implementing partners to successfully conduct program activities, it is crucial that they
possess institutional and technical capacity before they are charged with implementing activities.
However, sometimes capacity building takes several years, making it difficult to achieve program
results that donors and others expect. Often in projects of this type, there is a compromise between
building long-term sustainability and the immediate achievement of results. The Technical Advisors
of Geração Biz have wrestled with the understandable struggle between developing the capacity of
the implementing ministries and NGOs so they can lead the process of program implementation and
ensuring that the expected results of the program are achieved within the current funding period.
Insight has been gained as the program has progressed. While time-consuming, initial phases of the
program must be devoted to establishing effective multi-sectoral coordination as well as developing
the planning and implementation skills of implementing partners. In the long run, implementing
partners, rather than the Technical Advisors, will be responsible for conducting activities, and the
Technical Advisors will focus most of their attention on supporting the institutions as they take the
leading role in implementation. This lesson will be applied as Geração Biz expands to other
provinces in Mozambique. It will be critical that any additional funding for expansion takes into
consideration the large commitment of time and financial and human resources needed for
promoting ownership and develops realistic outputs that reflect both ASRH activities as well as the
capacity building process.
16
During the expansion process, an assessment of the capabilities of implementing partners including
youth associations must be one of the first steps undertaken. This assessment will allow technical
assistance and capacity building to be directed towards the most critical needs. In this project,
concern was expressed that often the public sector and the NGOs have different needs in terms of
capacity building.33 The ministries often do not have enough skilled personnel to implement the
program activities. Their staff requires training and other assistance to develop skills needed for
ASRH interventions. While some NGOs have staff that is able to implement ASRH projects,
sometimes they do not have sufficient capacity in financial and program management or evaluation.
These needs are emblematic of the nature of NGOs. Often NGOs are given funding to implement a
project that lasts a few years. While they gain skills in implementation, they are often not required to
undertake extensive program and financial management that includes reporting mechanisms. By
focusing on short-term projects versus programs, they often are not expected to effectively evaluate
their initiatives. The Technical Advisors need to be cognizant of these essential differences in order
to effectively develop institutional and technical capacity.
Lessons Learned

Expansion to other provinces should begin with the promotion of multi-sectoral coordination
and capacity building to facilitate ownership of project activities by public and private sector
partners. While there needs to be a balance between the process of developing ownership
and capacity and the implementation of activities, a foundation of strong multi-sectoral
coordination and partner involvement must precipitate project activities to ensure
sustainability. Given that the process of developing ownership can be time consuming and
demand large amounts of assistance from the TAs, workplans should allot adequate time for
coordination and capacity building activities with implementing partners.

New ASRH programs require a strong commitment of support in order to become
institutionalized. Political commitment and support for Geração Biz has not only facilitated
ownership of the project by different sectors within the government but it has also allowed the
project to be scaled up in other provinces.

Young people must be engaged in finding solutions to their own problems. Youth must be
involved as active participants in planning, implementing, and evaluating ASRH activities.
True youth involvement is necessary for the success of the program and to create ownership of
the program by the youth.
Recommendations

As the project expands to other provinces, a crucial first step will be to conduct an
assessment of the implementing partners’ capabilities. The assessment should examine the
ability of both the public sector and NGOs to plan, implement, and evaluate ASRH activities,
as well as assess their capability to manage their human and financial resources. The outcome
of the assessment should be used to determine the types of technical assistance and capacity
building that are needed.
17
Strategy for Promoting Ownership at the Provincial Level
1) Obtain commitment on the part of the DPJD, DPS, DPE, and NGOs/Youth Associations
working in ASRH.
2) Conduct a planning workshop with representation from the DPJD, DPS, and DPE.
Conclude the workshop by drafting an operational plan.
3) Arrange study tours to Zambezia Province or Maputo, where Geração Biz has been
implemented. These tours will allow for lessons learned and best practices to be shared.
4) Finalize the operational plan.
5) Assure an execution role for each directorate (health, education, and youth), including
their own workplan and budget.
6) Develop a multi-sectoral team with a management council at the provincial level, to
coordinate and monitor activities. Team members should be individuals who will actually
be involved with implementing program activities. Identify who will serve, on a rotating
basis, as coordinator of the management council. Determine who will be responsible for
implementing and coordinating program activities in each sector (4-8 people per sector)
and within partnering public and private institutions.
7) With the team, develop an action plan to meet the program objectives that includes a
proposed budget and monitoring and evaluation system.
8) Submit the plan to the provincial directors of health, education, and youth. After
approval, the plan will be given to DPS, DPE, and DPJD staff.
9) Develop a quarterly workplan with a timetble that is agreeable to all three directorates.
10) Facilitate a meeting with all the project stakeholders (politicians, district directors,
deputies, youth associations, and school directors) to ensure commitment.
11) Select a training team from the youth, education, and health sectors in each province.
Conduct a training of trainers (TOT) on ASRH, communication, and counseling led by
staff from the Central level. Participants of the TOT will then become trainers for other
trainings associated with the project.
12) Facilitate monthly team follow-up meetings in order to monitor and coordinate on-going
activities. This meeting will also act as a forum to solve problems or issues that have
arisen in the course of implementation.
18
C LINIC- BASED SERVICES
FOR
ADOLESCENTS
U
nlike many adolescent reproductive health
projects, Geração Biz has embraced two
models to increase access to quality SRH
services: adolescent-only clinics and integrating
youth-friendly services into existing public sector
clinics. The employment of both models provides a
unique opportunity to compare the advantages and
disadvantages of each, and provides insight into the
most appropriate application of each model.
In Maputo, it was envisioned that access to quality
and integrated ASRH services would be increased through the establishment of specialized
adolescent SRH clinics within Maputo Central Hospital and AMODEFA, while in Zambezia
Province, an Adolescent Center affiliated with AMODEFA would be established in Quelimane City.
Multi-disciplinary teams at the clinics/centers would provide high-quality preventive, clinical, and
counseling services. To complement
these adolescent-only clinics/centers, a
ASRH Clinical and Counseling Services
network of youth-friendly services would
be available at existing MOH clinics
both in Maputo and Zambezia Province.
Established specialized adolescent clinics and
youth centers

Established a network of youth-friendly
services offered at existing health clinics
Steps Taken:

Conducted needs assessment

Rehabilitated and equipped clinics so they are
youth-friendly and offer privacy

Developed ASRH training curriculum

Trained service providers

Recruited specialized personnel

Developed IEC materials for use in
clinics

Pursued the development of MIS

Monitored activities and progress

Conducted periodic technical meetings for
service providers to exchange information
Adolescent Clinic at Central
Hospital
In November 1999, the Adolescent
Clinic attached to Central Hospital in
Maputo became the first service delivery
point to offer SRH services exclusively
to young people between the ages of 1024 years. The Clinic not only attracts
young people from Maputo, but also
serves youth from the outlying areas and
other nearby provinces such as Gaza
and Sofala. A full range of SRH
services, including counseling,
contraception, emergency
contraception, STD prevention and
treatment, prenatal care, and postpartum/post-abortion counseling, are
provided. Hours of operation are
Monday through Friday, 7:30 a.m.3 p.m.
19
The Clinic has an added advantage of
being attached to Central Hospital,
which allows clients access to a higher
level of care, such as laboratory tests in
cases where syndromic management
has failed to adequately treat a STD,
post-abortion care, and delivery
services. The clinic has established
links with the Centro de Reabilitação
Psicológica Infantil e Juvenil (CRPIJ), a
center that offers counseling and other
support services. Psychologists from
CRPIJ work in the clinic on a rotating
basis four hours per week providing
counseling and referrals in cases of substance abuse, sexual abuse, and other complex issues.
Recognizing that for young people cost is often a barrier to obtaining services, the Clinic provides
all services and methods of contraception free of charge and a nominal fee is charged for
medication used in the treatment of STDs. While HIV is a serious concern, especially for young
people in Mozambique, VCT services are grossly insufficient to meet the demand for confidential
testing. Currently, to increase the number of service delivery points that offer VCT to young
people, the Adolescent Clinic began offering VCT in November 2001.
The Clinic is currently staffed by a director, three nurses, and a receptionist, and physicians from
the OB/GYN department of Central Hospital rotate daily to ensure the availability of one physician
during hours of operation. Two of the three nurses have been trained in both counseling and ASRH
services. The third nurse and the doctors from the OB/GYN department were trained in January
2001 in counseling and will be trained in ASRH services in the near future. While the nurses
reported that their ASRH skills were sufficient to deal with client needs, they did express the desire
to improve their skills in other areas, such as gender-based violence and substance abuse. To fill
this gap, psychologists from CRPIJ have been asked to conduct information sessions on these topics
as well as develop providers’ counseling skills in these areas.
“Educating youth is the biggest challenge. Even though we
counsel on practicing safer sex, we may see a client repeatedly for the
same thing. It is hard to get adolescents to accurately assess their risk
and use condoms.”
-Service Provider, Adolescent Clinic at Central Hospital
20
In addition to the clinic staff, peer activists from
nearby schools also provide information on
various SRH topics in the waiting area; activists
often conduct information sessions or group
discussions with clients as they wait for services.
The intention is to raise awareness on SRH topics,
like safer sex, HIV, and unwanted pregnancy. A
recent evaluation found that the use of peer
activists in the waiting areas was a good way of
welcoming clients to the clinic services and
disseminating SRH information to new and
returning clients.34 Because the activists are the
same age as the clients, it is helpful in establishing
trust and increasing the perception of a youthfriendly atmosphere.
“It is wonderful to have an
adolescent-only clinic. In the
beginning,
I
had
a
bad
experience with other clinics.
Clients who were interviewed reported friendly
The nurses in other clinics
encounters with providers and acknowledged the
importance of a clinic that only served
were judgmental and often
adolescents. One client, who had also attended
shouted at young people. When
MOH clinics with youth-friendly services, reported
that she preferred the adolescent-only clinic to
I heard about the Adolescent
clinics with integrated services. She reported that
Clinic, I came to see if the
adolescent-only clinics give young people the
special attention they need. Adolescent-only
services would be better. The
clinics are often more appealing to young people
nurses here respect me
because they send a clear message that young
people are important and they can be specifically
and speak nicely to me.
tailored to young people’s needs in terms of
services, hours, and atmosphere. Exclusively
Now I only come to the
serving young people allows providers to become
Adolescent Clinic because of the
highly skilled in ASRH and often leads to the
provision of higher quality services than can be
quality of the services.”
obtained in a clinic where serving adolescents is
-Adolescent Client,
just one of a myriad of providers’ responsibilities.
However, while the premise of an adolescent-only
Adolescent Clinic at Central
clinic is attractive to both young people and those
Hospital
working in ASRH, it is usually feasible only in
large cities that have a substantial adolescent
population that justifies the expenditure of large
amounts of financial and human resources. In addition, serving only young people also has its
challenges, as providers and staff at the Adolescent Clinic report.
21
Adolescent Clinic-Mozarte Center
The Mozarte Center offers training for artisans in various handicrafts, such as batik, carpentry,
ceramics, papermaking, weaving, and print
and design. The facility is attractive with
well-kept grounds, plenty of studio/
workshop space, and a small shop that
sells goods made at the center. Most of the
students undergoing training are between
the ages of 20-24, making this an ideal
venue for reaching young people with SRH
services. A small one-room clinic was
established within the center where youthfriendly services are offered four days a
week from 2:00 p.m. - 5:30 p.m. and on
Saturdays from 10:00 a.m.- 12:00 p.m.
The Mozarte Center is unique in the fact
that clinical services are being housed in the same building as vocational training. Given the high
unemployment of young people in Mozambique, offering quality SRH counseling and services in
conjunction with the opportunity to develop income-generating skills provides an additional
incentive for young people to come to the center because it addresses two of their critical needs.
The center clinic is staffed by a devoted and
enthusiastic nurse who provides pills and
condoms, STD prevention and treatment, and
counseling. While the clinic is only one room, the
space has been used to its maximum potential
with a variety of visual aids on the walls, a
screened-off area for conducting exams, and a
small workspace where files and contraceptive
supplies and drugs are kept. To ensure privacy,
only one client is allowed in the clinic at a time
and the door to the clinic is closed to provide
auditory privacy as well. Additional clients wait
outside in the enclosed courtyard.
While the center is able to reach a targeted
niche–young artisans who are undergoing
training–it has yet to capitalize on its potential to
attract young people for SRH services beyond this
initial target group. More publicity as well as
events to draw youth from the surrounding
community to the Mozarte Center might be
strategies to increase the number of clients
accessing services.
22
“Another challenge is that
parents often come to the
clinic very angry wanting to
know about their child and why
s/he came to the clinic. ...We
never tell parents because we
respect the confidentiality of
the adolescent client, so we
must instead facilitate
communication between the
parents and their child.”
- Service Provider, Adolescent
Clinic at Central Hospital
AMODEFA’s Youth Center and
Adolescent Clinic
AMODEFA has recently completed an
Adolescent and Youth Center in Maputo that
is proving to be highly attractive to young
people. It offers an internet café, video room,
and meeting room. An on-site nurse provides
counseling and condoms while those needing
SRH services are referred next door to the
AMODEFA clinic, which offers youth-friendly
services in addition to serving adult clients.
Referrals from the youth center to the clinic
are monitored so that the impact of this
linkage can be assessed.
As previously mentioned, AMODEFA planned to pilot the concept of a male-oriented adolescent
clinic in Zambezia. However, after significant delays due to problems procuring equipment and
materials, AMODEFA was unsuccessful in establishing a male-oriented adolescent clinic.35
YFS at Existing Clinics
Historically, clinical services within MOH facilities were designed for adults and served very few
adolescents. In October 1999, to increase demand for services and meet the needs of young people,
a network of youth-friendly services was developed in Maputo City. Based on clinic assessments
conducted by joint missions from the MOH and UNFPA, six out of the 19 Maputo Health Centers
(Maxaquene, Jose Macamo, 1° de Junho,
Romao, Xipamanine, and Alto Mae) were
selected for the integration of youth-friendly
“I came [today] for contraception.
services. Zambezia province followed suit
in March 2000, establishing youth-friendly
The services here are good. The
services in four clinics within Quelimane
nurses seem friendly. I had gone
City (24 de Julho, 17 de Setembro, 4 de
Dezembro, and Coalane). Small-scale
to the Adolescent Clinic at Central
rehabilitation of the health centers and the
Hospital before because I had a
provision of clinical equipment and
STD... I came here instead of the
supplies were required before services
could be offered. In seven other districts
Clinic at Central Hospital because I
within Zambezia, a process for
live on the outskirts of the city
implementing youth-friendly services has
and this clinic was closer.”
begun that involves identifying which health
facilities will offer ASRH services, training
-Client at 1° de Junho
service providers, and undertaking any
necessary rehabilitation and procurement
of equipment.
23
Special hours for adolescents are offered in the youth-friendly clinics. In Maputo, the Alto Mae clinic
serves young people between 7:30 a.m. - 12:30 p.m. on Mondays and Wednesdays and between 2:00
p.m. - 3:50 p.m. on Tuesdays, Thursdays, and Fridays. The other five clinics in Maputo provide
services to adolescents from 2:00 p.m. - 5:00 p.m. twice a week with 1 de Junho offering services
during these hours 3 times a week. In Zambezia, the four youth-friendly clinics are open twice a week
in the afternoon from 2:00 p.m. - 5:00 p.m. As with the Adolescent Clinic at Central Hospital,
awareness activities on various SRH topics are conducted by peer activists in the waiting areas.
In 1999, 1,173 clients attended clinics for counseling and services in Maputo City; 90% of those
served were females and 10% were males. In 2000, after the establishment of the network of youthfriendly clinics, the number of clients served jumped to 11,726 with an almost two-fold increase in the
percentage of young men served (19%). Condom distribution also rose significantly from 2,472 in
1999 to 91,550 in 2000. 36 Table 2 shows the number of clients served in Maputo City from January to
December 2001 by sex.
Table 2: Client V
isits to Clinics in Maputo fr
om January-December 2001
Visits
from
Fa c i l i t y
Central Clinic
1° de Junho
Fe m a l e
Male
Total
% of Male
C l i e n t Vi s i t s C l i e n t Vi s i t s C l i e n t Vi s i t s C l i e n t Vi s i t s
Condoms
D i s t r i bu t e d
6,644
1,034
919
127
7,563
1,161
12%
10%
73,208
8,478
Maxaquene
1,017
20
20
1,037
2%
2%
8,853
Xipamanine
Jose Macamo
945
594
344
162
1,289
756
27%
21%
11,114
9,545
Romão
1862
366
2,228
16%
8,551
Mozarte
1,360
536
1,896
28%
11,558
Alto Maé
TOTAL
2,010
15,466
869
3,343
2,879
18,809
30%
18%
15,587
146,894
Table 2 demonstrates that the Clinic at Central Hospital is the most heavily accessed clinic
compared to MOH clinics that have integrated youth-friendly services; the Clinic at Central Hospital
accounts for 40% of the total clients. Alto Mae is the second most accessed clinic which may be due
to the fact that they are the only other clinic that offers VCT services.37 Maxaquene and Jose Macamo
clinics will need to be examined to determine if issues of quality are contributing to low utilization of
services or if other factors play a role.
While service statistics for young people in Zambezia were not available for 1999, anecdotal
evidence suggests very few adolescent clients were served by MOH facilities. After the introduction
of youth-friendly services, the number of youth accessing services in 2000 rose to 11,669. Table 3
illustrates the number of clients served in 2001 by sex. Unlike Maputo, a substantial number of young
clients were males (39%) although the reasons for this are not totally clear.38
24
Table 3: Client V
isits to Clinics in Zambezia fr
om January-December 2001
Visits
from
Fe m a l e
Male
Total
% of Male
Condoms
C l i e n t Vi s i t s C l i e n t Vi s i t s C l i e n t Vi s i t s C l i e n t Vi s i t s D i s t r i bu t e d
Fa c i l i t y
24 de Julho
2,335*
1,185*
3,520*
34
34
185,821*
1 7 d e S e t e m b ro
4 d e D e z e m b ro
2,164
2,419
825
1,732
2,989
4,151
28
28
42
42
12,933
20,509
Coalane
TOTAL
3006
9,924
2,605
6,347
5,611
16,271
46
46
39
39
11,398
230,661
* Service statistics were not available for October 2001; therefore, the total numbers are higher than those shown
in the table above.
As noted in Table 3, attendance at Coalane Health Clinic represented a significant proportion of the
total attendance in Zambezia. Condom distribution also rose from 26,800 in 1999 to 158,000 in
2000 to 230,661 in 2001.39 While ASRH services were not yet established in 1999, condoms were
distributed in Zambezia through outreach activities. Clinics in Zambezia have been much more
successful in attracting young men (39%) compared with clinics in Maputo (18%). This may be in
part due to mobilization efforts in Zambezia to increase male utilization of clinical services,
especially for STD prevention and treatment.
However, both Tables 2 and 3 show a higher use of services by young women than men. Several
factors are responsible for this gender difference. First, pregnancy prevention has traditionally been
a female responsibility and large numbers of young women come to the clinics for prenatal and
contraceptive services. In addition, services are provided by female nurses. Finally, anecdotal
evidence suggests that discussing problems with others is easier for girls than boys.40 These findings
highlight the need to supply boys with condoms, information, and referrals for STD treatment
through other mechanisms.
Table 4: Number of Adolescents Serv
ed Since 1999 in Maputo City and Zambezia Pr
ovince
Served
Province
20,000
15,000
Maputo
10,000
Zambezia
5,000
0
1999
2000
2001
25
As noted in Table 4, the number of adolescent clients served, as the Geração Biz program
continues, provides evidence that the provision of quality youth-friendly services can result in an
increased use of ASRH services. By training service providers and creating youth-friendly
environments, Geração Biz has been able to meet the large demand for services by young people.
oup in 2001
Table 5: Clients Serv
ed By Ag
Served
Agee Gr
Group
12000
10000
8000
10-14
6000
15-19
4000
20-24
2000
0
Maputo
Zam bezia
Table 5 provides a client breakdown by age in Maputo and Zambezia. Given that many young
people below the age of 14 are not sexually active, it is not surprising that most clients seeking SRH
services are above the age of 15. Only 11.5% of all clients in Zambezia and 2% in Maputo were aged
10-14 years. Although it is important that younger adolescents have access to services should they
need them, most adolescents between the ages of 10-14 need access to appropriate SRH
information. This type of information is provided through other channels within Geração Biz, such
as peer educators, counseling corners, and
schools.
“Many youth do not have good
The majority of young people served by
youth-friendly services in Maputo are those
communication at home and they
aged 15-19 years (54%). Nurses reported
come to the clinic with many
that students are the majority requesting
services.41 This indicates the challenge of
different needs and problems, many
reaching out-of-school youth with clinical
outside the area of RH.”
services but is also a testament to the
linkages between in-school activities and
-Service Provider, Adolescent Clinic
clinical services. Zambezia had a slightly
at Central Hospital
higher usage of services by those aged 2024 (46%) as compared with those between
the ages of 15-19 (42.5%), although there
was no apparent reason for this difference.
Perhaps this is due to the fact that linkages with the out-of-school component (including youth who
have finished school) were established earlier and more effectively than the linkages with the inschool component.
26
Table 6: Reason for Clinic V
isit in Maputo in 2001
Visit
Fa c i l i t y
Counseling
Contraception
STD
P re n a t a l
Other
Central Clínic
1 de Junho
Maxaquene
Xipamanine
José Macamo
Romão
Mozarte
Alto Maé
7,443
1,010
999
964
756
2,145
1,336
2,797
7,024
1,103
779
672
363
1,155
498
207
1,263
156
221
342
276
307
315
1,959
171
59
59
4
214
83
83
326
56
56
70
70
776
33
33
79
79
81
81
362
47
47
185
787
TOTAL
17,441
11,801
4,839
878
2,350
P l e a s e n o t e : S o m e c l i e n t s a c c e s s e d m o re t h a n o n e s e r v i c e i n a g i ve n v i s i t .
As noted in Table 6, counseling is the most utilized service in all clinics (67.6%). There is some
variation between clinics with regard to STD prevention and treatment and contraceptive services.
Some clinics, such as the one at Central Hospital, report contraceptive services as the second most
utilized service while others report STD prevention and treatment. While not reflected specifically
in the service delivery statistics, providers reported that clients often came to the clinic with
questions regarding physical development. “Other” services include PAC services, sexual abuse,
substance abuse, and other concerns.
An adolescent client’s story reflects both the success and
challenge of providing young people with SRH services
Maria (not her real name) is a 17-year-old unmarried woman who recently became a mother.
While she knew about contraception, her lack of knowledge of where and how to obtain services
prevented her from protecting herself from unwanted pregnancy. She heard about the Adolescent
Clinic at Central Hospital when she was three months pregnant and came for prenatal care. Her
excellent rapport with the nurses helped ease her anxiety during delivery. She was counseled
about post-partum contraception and has planned to come to the clinic to obtain a method.
However,she reported not being aware of how to protect herself from HIV. While the nurses do
include HIV prevention in their counseling sessions, young people often need multiple
interventions to reinforce behavior change prevention messages. Young people are often faced
with many issues and concerns, such as Maria who was faced with pregnancy and malaria when
she came for her first visit, which hinder their ability to receive multiple simultaneous messages
and practice appropriate changes in behavior.
27
In Zambezia, the number-one reason for client visits was contraception followed by counseling.
The reason for this difference may be due in part to the way that contraceptive services are
reported. In Maputo, the monthly reports disaggregate the reason for a client visit including
contraception. However, this number usually does not include those who receive condoms unless
they specifically request condoms as their contraceptive method. In other words, a young man who
comes in for condoms but does not specify if it is for pregnancy or STI protection may not be
captured in the data on contraception. Although the Zambezia monthly reports also include a
disaggregation by reason for the visit, the information on contraception was not accurately
captured. Therefore, the data displayed in Table 7 is the total of all clients who received a
method, including condoms regardless of the reason why since condoms offer dual protection
from both pregnancy and STIs.
Table 7: Reason for Clinic V
isit in Zambezia in 2001
Visit
Fa c i l i t y
24 de Julho
1 7 d e S e t e m b ro
4 d e D e z e m b ro
Coalane
Total
Counseling
Contraception
STD
P re n a t a l
Other
9,725
2,727
2,063
1,873
16,388
17,250
1,109*
3,327
1,479
23,165
3,155
1,529
2,400
2,287
9,371
2,893
677
254
1,044
4,868
1,948
280
161
143
2,532
P l e a s e n o t e : S o m e c l i e n t s a c c e s s e d m o re t h a n o n e s e r v i c e d u r i n g t h e i r v i s i t . S t a t i s t i c s o n c o n t r a c e p t i o n
a re t h e t o t a l o f a l l c l i e n t s re c e i v i n g a m e t h o d i n c l u d i n g c o n d o m s e ve n i f t h e c o n d o m s we re g i ve n o u t f o r
t h e p u r p o s e o f S T I p re ve n t i o n .
* No data on any method in November and no data on number of clients receiving condoms in December.
28
ASRH Training of Providers
In Maputo, 16 MCH nurses were trained in youthfriendly services, while 31 physicians and 32
nurses received training in counseling and 3
health professionals attended an international
course in counseling techniques. In Zambezia,
15 service providers from Quelimane City and 14
providers from seven districts (Gurue, Milange,
Alto Molucue, Mocuba, Maganja da Costa,
Morumbala, and Mopeia) were trained in ASRH
services and counseling.42 The training in youthfriendly services lasted 15 days and covered topics such as stages of adolescence, communication
with adolescents, prevention and treatment of STD, HIV/AIDS, and gender. Providers reported
during interviews that additional topics such as drugs and violence would also be useful to include in
future trainings.43 At the end of the training, a practicum allowed providers to practice their newly
acquired skills.
In addition to training, monthly supervisory meetings are held between service providers and the
MOH supervisory team. At these
meetings, monthly service statistics are
reviewed, any difficulties encountered
Community Awareness of YFS
are discussed, and additional
information on various SRH topics is
“One mother came into the clinic with her 15-yearprovided as a way of improving quality.
old daughter. She told me privately that she was
In Maputo, two psychologists from the
concerned because her daughter was coming in
Central Hospital attend the monthly
late and saying that she had been at her uncle’s.
supervisory meeting to provide support
The mother suspected she had a boyfriend so she
and technical assistance on counseling.
Random supervisory visits are also made
brought the girl in for counseling. The girl admitted
to the clinics by the DPS or DCS
to me that she had a boyfriend and was sexually
supervisor where direct observation of
active but that the mother didn’t know. I gave her
providers’ skills is possible.
an exam and provided her with pills and condoms.
I felt bad because I couldn’t tell the mother anything
ASRH has also been incorporated into
the pre-service training curriculum at
because I need to protect the girl’s confidentiality.
Maputo Nursing Institute as a sustainable
However, now the girl keeps coming back for pills
approach to producing skilled providers
and condoms so I feel very satisfied. Also the fact
who can offer youth-friendly services.
that the mother came in with the daughter shows
The introduction of ASRH topics has
the community is aware of the youth-friendly
been well-received by nursing students
services we provide.”
and based on the success of this pilot
model, ASRH will be introduced into
-Nurse at Xipamanine Clinic, Maputo
other nursing institutions within
Mozambique. In Tete Province, plans are
29
under way to construct an adolescent corner in the training center. This corner will serve as a
resource for nursing students interested in better serving youth.
Lessons Learned

To ensure quality of care, all providers, doctors, and nurses should receive training in YFS
before providing ASRH services. The development of an effective training plan can help
ensure that providers are trained in a timely manner and before the onset of the ASRH service
delivery. If a clinic is advertised as youth-friendly before providers are trained, clients may not
return for services if they are met by a provider who is not yet sensitized to their needs.

In order to maintain high-quality youth-friendly services, it is important that an effective
supervision system is in place to support providers in this new endeavor. Although training
providers is essential in the implementation of youth-friendly services, training by itself is not
sufficient to maintain the introduction of special services for young people. Supervisors also
need to be trained on how to supervise the provision of youth-friendly services. Supervisors
can help identify areas where providers need extra training or support in order to effectively
serve youth. Young people often need longer client-provider interaction than adult clients due
to their limited knowledge of SRH issues and to their shyness when discussing sensitive
topics. Supervisors need to support providers so that they are able to handle this increased
demand on their time.

Youth-friendly services can be offered at a variety of sites, including adolescent-only clinics,
MOH clinics, and youth centers. Under the Geração Biz, youth-friendly services have been
offered in a variety of settings. Although young people report that they like the concept of an
“adolescent-only clinic.” service statistics show that youth are also willing to come to public
sector clinics when quality ASRH services are integrated into the existing services.

It is important that youth-friendly ASRH services are also geared toward the needs of young
men. To counteract the perception that reproductive health services are mostly for young
women, clinics must make concerted efforts to offer services that are appealing to young men,
such as STI prevention and treatment, counseling on sexuality, and the provision of condoms.
Utilization of services by young men can be increased by hiring a male provider, publicizing
services that are most in demand by young men, and establishing links between male peer
educators in both the schools and the community.

ASRH services must be provided in a comprehensive and integrated manner. Young people
often come to a clinic with more than one SRH need; it is therefore important that providers
are able to meet a range of needs during one visit.
Challenges

30
Due to prenatal services and other primary health services being provided during the morning
hours, MOH clinics are only able to offer youth-friendly services during the afternoons which
is when older youth, the ones most likely to seek services, usually attend school. While this
conflict has been recognized by program staff, finding alternative times to offer services to
young people is constrained by the fact that these are public MOH facilities with limited
numbers of staff.

It can be difficult to maintain provider motivation without extra incentives. While they are
committed to serving young people, the integration of youth-friendly services is sometimes
viewed as an increase in responsibility without an increase in compensation, thus contributing
to a low morale. Currently under Geração Biz, small incentives, such as the opportunity to
participate in trainings and the establishment of monthly meetings to review providers’ work
and to receive technical updates, have been used to help maintain provider motivation.44

On-going capacity building of service providers, such as refresher courses or workshops, are
needed as the program continues.

Traditionally, male utilization of clinical services is low,

Occasional shortage of condoms does occur in some of the health centers. This appears to
be a bigger problem in Zambezia than Maputo.

Young people do not always return for follow-up after STD treatment and there is some
difficulty in partner notification and treatment for STDs. This issue is beginning to be
addressed through outreach activities.

Now that youth-friendly services have been established, improving the quality of ASRH
services is the challenge that will need to be addressed in the future.
Recommendations

To evaluate the quality of existing youth-friendly services, a mystery client study that uses
trained young people to pose as clients and seek services could provide an objective
assessment of services offered.

Job aids, such as counseling cue cards and competency-based checklists, can be used to help
reinforce knowledge and skills that providers obtained through training.

Ensure that young men are reached with condoms and SRH information (including where to go
for STD treatment) through other channels, such as kiosks, sporting events, workplaces, and
other non-clinical settings.
31
S CHOOL- BASED INTERVENTIONS
Peer Education
Y
oung people predominantly turn to their peers for SRH information, as demonstrated in
the results of the 1999 Maputo and Zambezia KAP studies. Fifty-eight percent of girls and
seventy percent of boys reported going
to friends for SRH information. While both
sexes list friends as their primary source of
information, young men tend to rely on the
media for much of their information (23%) and
girls tend to approach family members (23%) or
health workers (16%).45 It is not surprising that
males do not go to health workers for
information since RH clinical services
traditionally served females.
In order to reach large numbers of young
people with SRH information and services, it
was decided that Geração Biz should capitalize
on existing patterns of information-seeking
behavior, in this case, fellow peers. As Judith
Senderowitz notes, there is a growing body of
evidence that demonstrates the efficacy of using
peer educators/activists to reach young people
with SRH information and contraceptives (either
through direct distribution or referral).46 However, to ensure that the information given would be
accurate and useful, a formal peer-education program was established that included training and
supervision.
“At first your legitimacy as a peer educator
is questioned because the students see you
as the same age as them and they wonder
what you could possibly know that they don’t
know already. But after meeting with them
and answering their questions, they begin
to respect you and now students wait for
me after class to speak with them.”
-Peer Activist, Maputo
32
The peer activist program was
established in target schools in
Maputo City and Zambezia
Province. Peer activists are
responsible for providing SRH
information, counseling, and
referral for SRH services, as well
as for distributing condoms.
Topics covered include sexuality,
unwanted pregnancy, abortion,
HIV/AIDS, and STDs. Information
is disseminated through a variety
of channels, including one-on-one
counseling, drama, film, group
debates, discussions, and music.
In addition to the peer activists, teachers
are also selected to serve as teacher
activists with their primary role being the
facilitation of peer activist activities and the
provision of accurate SRH information in
and out of the classroom. Once a week for
one hour, a different ASRH topic is
covered in each classroom. These sessions
are either led by the peer or teacher
activist. The subject of the session rotates
between classrooms so that all students are
exposed to the same content.
In Maputo City, DEC works in collaboration
with AMODEFA to coordinate the peer/
teacher activist program. While AMODEFA
assumes the majority of the day-to-day
activities, including supervision of the peer
activists, DEC monitors all on-going
activities and participates in peer training.
Currently, out of 13 secondary schools
within Maputo City limits, Geração Biz has
peer activists in 10 schools. Recognizing
the need to expand the peer activist
program in the peri-urban areas, Geração
Biz has begun to implement activities in
four schools in the outlying areas.
School-Based Interventions
Established networks of peer and teacher
activists to disseminate ASRH information
and encourage behavior change.
Established adolescent counseling corners in
target schools.
Linked peer activists with nearby clinics.
Worked with INDE to transversally integrate
ASRH information into the basic national
curriculum and to implement a package of
ASRH intra- and extra-curricular activities in
primary, secondary, and technical schools.
Steps Taken:
Worked with NGOs and DPE to develop
a system for selection and monitoring of peer
and teacher activists
Conducted sensitization sessions with
stakeholders, including parents
Trained peer and teacher activists
Developed ASRH training curriculum for
peer activists
Sensitization sessions with school
Recruited a nurse to staff the adolescent
directors, teachers, parents, and students
corners on a rotating basis
are held in each of the targeted schools.
During the sensitization sessions, the peer
Developed IEC materials for use in
schools
activist program is explained and any
questions regarding the program are
Hired a Technical Advisor to work with INDE
answered. After the sensitization session,
on extracurricular ASRH activities
teacher activists are chosen based on selfselection. The same process is used with
students. Each school has between 10 and
20 peer activists. If too many students
volunteer to become peer activists, teachers are consulted for the final selection.
AMODEFA with DEC conducts a five-day training for students selected as peer activists (see Table
8 for the number of activists trained as of 2001). On the final day of the training, a plan is developed
for peer education activities, including which ASRH topics will be covered within the school. Each
school selects one male and one female peer activist to act as representatives for the school.
33
AMODEFA holds weekly
meetings with these
representatives to discuss the
outcomes of activities and any
questions or problems that
arise. These meetings are also
used to plan new activities.
Occasionally, psychologists are
invited to these monthly
meetings to discuss complex
issues, provide advice on
effective counseling techniques,
as well as provide support to the
peers themselves.
In addition to the peer activists who work with AMODEFA, Nucleo de Mavalane also has peer
activists working in four schools within Maputo City (Noroeste, Eduardo Mondlane, Forca do Povo,
Table 8: Number of Activists T
rained and YYouth
outh Reached in Maputo in 2001
Trained
School
F e ma l e
Ma l e
P eer
P eer
Ac t i v i s t s Ac t i v i s t s
F e ma l e
Teacher
Ac t i v i s t s
Ma l e
Total
Teacher Activists
Ac t i v i s t s
10 de Novembre (EP2)
9
7
1
4
21
2,134
Maxaquene (EP2 &
Esc. Sec.)
5
19
5
6
35
3,802
Francisco Manyanga
(Esc. Sec.)
18
30
0
0
48
3,652
Eduardo Mondlane
9
8
0
1
18
920
Comercial
13
14
3
3
33
6,680
Lhanguene (Esc. Sec.)
20
12
6
6
44
5,506
Moamba (Esc. Sec.)
12
10
1
10
33
712
Comunitaria 3 de Fev.
9
11
n
n
20
1,080
Santo Antonio da Mal.
9
9
n
n
18
260
1a Unidade 8
13
7
n
n
20
z
Sec. da Inhaca
9
14
n
n
23
z
1 26
1 41
16
16
30
30
280
24, 746
Total
n No d a t a w a s a v a i l a b l e
z Ac t i v i t i e s d i d n o t b e g i n u n t i l 2 0 0 2
34
# of Youth
Re a c h e d
and Escola Mavalane). Nucleo de Mavalane initially addressed issues of substance abuse and HIV,
and provided counseling services within secondary schools. Under Geração Biz, existing peer
activists were used to reach young people with ASRH messages. Unlike AMODEFA, these activists
conduct activities both in schools and in the community. Theater has been their medium of choice
for delivering messages on safe sex, substance abuse, HIV/AIDS, and other SRH topics.
In contrast to the school-based peer education program in Maputo, the DPE is primarily
responsible for this intervention in Zambezia Province. A work team was formed within the DPE to
oversee and implement all school-based interventions within the province. This team consists of a
coordinator, an assistant coordinator, administrative assistant, and provincial and district
supervisors. The coordinator is the Provincial Director of Education and the assistant coordinator
is the Department Chief of Pedagogy. Technical assistance is provided to this team through the DPE
Project Director who is employed under Geração Biz. A full-time Technical Advisor is housed in
the DPE and works on a daily basis building the capacity of the work team.
Currently, school-based interventions are being implemented in 64 schools throughout the province
in the districts of Quelimane, Alto Molocue, Gurue, Milange, Morrumbala, Mopeia, and Maganza
de Costa. In each school, an AIDS/ASRH group was established that consisted of four to five
teachers who are involved in ASRH activities conducted at the school. To increase stakeholder
commitment and ensure a commmon understanding of the school-based component, a one-day
sensitization session was held with teacher activists, school directors, and pedagogical directors.
The teacher activists participated fully in the training of peer activists from their school. Table 9
shows the number of trained peers (192) and teachers (153) in 2001. At last count, the number of
peers trained had risen to a total of 364, although the ratio of female to male activists was only 42%
(150 females and 214 males). By the end of 2001, a total of 18,000 young people were reached with
ASRH information through debates, drama, and cultural events.
Table 9: Number of Activists T
rained and YYouth
outh Reached in Zambezia for 2001
Trained
Di s t r i c t
F e ma l e
P eer
Ac t i v i s t s
Ma l e
P eer
Ac t i v i s t s
F e ma l e
Teacher
Ac t i v i s t s
Ma l e
Teacher
Ac t i v i s t s
Total
Ac t i v i s t s
# of Youth
Re a c h e d
Quelimane
25
24
22
23
94
Z
Alto Molocue
13
12
3
18
46
Z
Maganja da Costa
12
13
5
13
43
Z
Milange
15
10
2
17
44
Z
Gurue
12
13
6
14
45
Z
Morrumbala
9
15
6
14
44
Z
Mopeia
7
12
3
7
29
Z
Total
93
93
99
99
47
47
1 06
345
1 8, 000
z Da t a w a s n o t b r o k e n d o w n b y d i s t r i c t
35
While monetary compensation is not
provided to the peer activists, small
incentives are given, such as notebooks,
pens, a small transportation stipend, as
well as T-shirts, bags, and caps bearing
the Geração Biz logo. In Zambezia,
peers are also periodically selected to
attend conferences as a way to build
their leadership skills.
The success of the peer education
program has varied between schools. In
Maputo, students in the peri-urban
schools tend to be shyer than those in
the inner city, therefore requiring more
facilitation by the teacher activists. Schools that have the solid support and commitment of the
school director have also been more successful than those where support is negligible. In
Zambezia, the Eduardo Mondlane school is an example where the school director promoted and
supported the peer/teacher activist program. To help create support from parents and to ease their
fears regarding the provision of SRH information and condoms to their children, the director
facilitated the involvement of parents in the program by holding parent meetings and appointing
parent representatives for each class.
One challenge that peer activists in Maputo and Zambezia have expressed is the need for more
written and audio-visual IEC materials as well as the need for on-going training on various SRH
topics.47 Peer educators also admitted that some topics, such as reproductive health, abortion,
contraception, and STDs, were easier to discuss than issues such as love, homosexuality, and
substance abuse.48, 49 In addition, transportation to different events and the lack of a physical
meeting space was problematic for those in the rural areas.50 Technical advisors in Maputo and
Zambezia are devising strategies to help combat some of these problems.
Another difficulty is the retention of peer activists. In Maputo, out of 267 youth who were trained as
peer activists, only 195 were still active by the end of the year. Even more challenging is maintaining
an equal number of female peer activists given that girls’ school enrollment is already very low and
that there is a much higher attrition rate among girls. The provision of scholarships to female peer
activists to cover their school fees is being considered as both a recruitment incentive as well as a
way to maintain female school enrollment.
Adolescent Counseling Corners
To complement the peer education component, seven schools in Maputo and eight schools in
Zambezia have established adolescent corners. These corners are unique to Geração Biz and serve
as physical locations where students can access IEC materials, counseling, and advice. In many of
the schools, these corners are actually separate rooms within the confines of the school building.
36
Adolescent Corners
Adolescent counseling corners are a unique
feature of the Geração Biz project. Peer
educators provide couneling and information,
referrals for services, and condoms. Linkages
between the adolescent counseling corners and
the clinics have been strengthened by having a
nurse work in the counseling corners on a
rotational basis.
In 2001, a total of 5,762 young women and
2,087 young men were reached through the
adolescent corners with ASRH information and
counseling as well as porovided with referrals
and condoms when needed.50
The corners are staffed by peer activists
and a nurse who works on a rotating
basis. While both the peer activists and
nurse provide information, counseling,
and condoms, the nurse is able to
provide a higher level of counseling as
well as give referrals for contraception,
STD treatment, pregnancy tests, and
other issues. In Maputo, the nurse visits
each adolescent corner twice a month.
The other two weeks of the month, she
conducts needs assessments, provides
supervision, and works with the
providers in the health clinics associated
with Geração Biz. The nurse provides a
critical link between the school-based
interventions and the clinic-based
interventions, which helps to harmonize
the activities that are being done in each
of these sectors.
It should be noted that while condoms are distributed through the peer activists, condom
distribution is still an informal process due to its controversial nature. Currently, students can obtain
condoms by asking a peer or the nurse in the adolescent corner. While peers admitted that they
were initially embarrassed to distribute condoms, they now feel comfortable providing this service.52
However, peers still encounter some difficulty dispensing condoms to the younger age group (10-13
years). Some peers reported that problems can occur in the homes if a very young person admits
that s/he was given a condom in school because the parents will infer that the peer educator was
granting permission for that young person to have sex.53
One issue identified by peer activists in both Maputo and Zambezia was the shortage of condoms.54
Part of the shortage is due to the informal
nature of the distribution. Without a
formalized mechanism, peers are relying on
AMODEFA or the DPS for their condom
supplies. There is no formal system in
place for replacing condom supplies, so
often the peer activists do not request more
condoms until their supply is completely
depleted. In many countries, condom
distribution to adolescents in school has
been a difficult initiative to establish, so it
is not surprising that Geração Biz is
struggling with this issue.
37
Links with Youth-Friendly Clinics
The role of the peer educator is multi-faceted. In addition to conducting ASRH activities within the
classrooms and staffing the adolescent counseling corners, they also work on a rotating basis in
nearby youth-friendly clinics. Discussions and educational sessions are planned and conducted
while clients are in the waiting rooms. The employment of peer activists in the clinics serves two
purposes: it makes use of the time that clients spend waiting for services and educates the peer
about the clinic and what services are provided. By acquainting the peers with the clinic, clinic staff,
and services offered, they become more comfortable referring other students to those clinics for
needed services.
A mid-term evaluation of Geração Biz notes that in
Maputo most of the clients accessing clinical services
are students. It was concluded that this clearly
demonstrates the strong impact of the linkage
between school-based interventions and the youthfriendly clinics. However, it also demonstrates the
delay in the outreach activities for out-of-school youth
in Maputo and the weak link between community
activists and youth-friendly services.55
POP/FLE Curriculum
In 1986, the MOE, through its National Institute for Education Development (INDE), with assistance
from UNFPA, initiated a project that sought to integrate population and family life education into
the EP2 (6th and 7th grade) curriculum. The project implemented by INDE was piloted in seven rural
and urban schools in three districts of Zambezia. Under the POP/FLE curriculum, topics, such as
gender, family life, primary health care, STD/HIV prevention, and substance abuse, were discussed.
Teachers from the selected schools were trained on the use of materials produced under the
project. In order to assess the implementation of the POP/FLE curriculum, follow-up sessions were
conducted until 1998 with all of the teachers involved in the project.
After an assessment of the initial pilot POP/FLE project, the need for a broader approach to
introduce ASRH knowledge and life skills was identified. The original POP/FLE curriculum
constituted a strong basis for the integration of similar topics in INDE’s Basic Education Curriculum
Transformation Project. Unlike the POP/FLE curriculum, which was a stand-alone course, the Basic
Education Curriculum Transformation Project integrates elements of ASRH, with a strong emphasis
on sexual health and HIV/AIDS, into existing subjects contained in the national curriculum. Science
courses will absorb the majority of the newly developed ASRH material, with other subjects such as
social sciences adopting ASRH topics as appropriate.
This integration process was incorporated into a larger initiative undertaken by the MINED/INDE to
reformulate the primary education curricula and educative materials. Educative materials, including
textbooks, are being designed to capture the same subject matter that was transversally integrated
within the new curricula. To ensure that the materials have successfully incorporated and
38
complemented the ASRH elements, the materials will be tested before they are approved for
general dissemination to the schools for classroom use.
In 2000, the MINED prepared its Sectoral Operational Plan for Combating HIV/AIDS. A review of
the current ASRH project was recommended, principally to address HIV/AIDS issues among
adolescents and youth, through an intra-curricular, as well as an extracurricular, approach. INDE,
with technical support from Pathfinder, has developed a strategic plan that contains the following
objectives: the incorporation of SRH content, family life, and HIV/AIDS prevention in the official
curriculum and local education of the country, and the implementation of extracurricular activities
to prevent STD/HIV.
Extracurricular materials that emphasize life skills and behavior change will be designed for use in
schools. Under the current education policy, each school must devote 80% of their teaching to
subjects included under the national curriculum while the remaining 20% may be devoted to topics
that the school and the community deem relevant. It is envisioned that the extracurricular materials
will be used by teachers during times that they are teaching topics not included under the national
curriculum (i.e., during the 20% of discretionary teaching).
Strategy For Effective Recruitment and Retention of Peer Activists
To maximize commitment from school personnel and communities to a school-based
peer activist program, Geração Biz has improved their recruitment and retention strategy
so that the education sector and parents are involved from the outset.
The revised strategy is as follows:

Sensitization session with school directors
Sensitization session with teachers
Solicit volunteers for teacher activists
Sensitization session with parents/guardians
Sensitization session with students
Solicit volunteers for peer activists
Discuss with teachers the names of the volunteers
Select peer activists in collaboration with school director based on teacher
recommendations
Selection criteria include ensuring a 50:50 ratio of girls to boys and that the students
are not in their last year of school
Conduct a training of peer and teacher activists
Develop workplans and monitoring forms for the implementation of activities
Establish adolescent counseling corners
Conduct quarterly technical meetings to update peer activists on issues
Weekly meetings with supervisor (i.e., AMODEFA, Aro Juvenil)
39
Lessons Learned

Coordinating and implementing activities through the DPE appears to be a more sustainable
approach than using an NGO such as AMODEFA to fulfill this function. Although working
through the public sector can sometimes be more challenging than working through an NGO,
the benefit is that the government will always exist and therefore its programs tend to be more
sustainable over time.

Strong linkages between the networks of peer activists and youth-friendly clinics are necessary
to support peer education activities and to strengthen the referral system to clinics.

Students perceive adolescent corners as their “own space” and are therefore more willing to
access information and services here than at clinics. Many youth are visiting the adolescent
corners for counseling or to see the nurse for services. Because young people percieve these
corners as their space, they are less concerned about privacy. Often they come in groups for
counseling or services and are not concerned with confidentiality, the way they are when they
visit a clinic.

Condoms must be available from the onset of activities and there must be a continuous supply
throughout the life of the project. If young people are to rely on peer activists to obtain
condoms then peer activists must have an adequate supply of condoms. If there are condom
shortages then the legitimacy of the peer activists is undermined.

The role of the teacher activists must be reinforced by the integration of ASRH activities into
their normal responsibilities.

A positive difference has been noted in the commitment and motivation of teacher activists
where there is a committed school director.57
Challenges
40

Given that Mozambique has multiple shifts at the EP2 and secondary levels (morning,
afternoon, and evening), an approach must be developed that will allow both day and evening
students to be reached with peer education activities.

The active participation and retention of female peer educators needs to be addressed. One
strategy being pursued in Zambezia is to identify and recruit pairs of young women who are
already participating in other types of activities, like drama clubs or sports clubs.

While capacity building of AMODEFA staff has occurred, it is not clear if it is sufficient for
AMODEFA to fulfill its tasks especially, as the number of program activities increase.56

Peer educators expressed the desire for more training and professional development. While
well-trained peers are essential, the amount of training provided must be balanced with their
role as peer educators. For difficult and complex matters, peers should be trained to provide
a referral to a trained counselor or service provider rather than try to address all issues that a
young person may have.

Teachers are overworked and are not compensated for their roles as teacher activists;
therefore it has been difficult to retain motivated and capable teacher activists.

The major reason for dropout of peer activists is due to the lack of incentives. While
monetary compensation may not be a sustainable option, other incentives should be explored.

One challenge of the integrated curriculum approach is that the number of teachers who need
to be trained in teaching ASRH increases exponentially when compared to teaching POP/FLE
as a stand-alone course. To address this challenge, the pre-service teaching curriculum is
also being modified so that all new teachers will be trained in teaching the new “integrated
curriculum.” Over a three-year period, current public school teachers will be retrained so that
they develop competency in ASRH education. To accommodate such large numbers of
teachers, 35,000 in total, distance learning will also be examined as a way of conducting
ASRH teacher training.
Recommendations

Explore the possibility of using peer activists during the evening shift so that all students
benefit from this activity regardless of which shift they attend.

Provide scholarships for school fees to female peer activists as a way of reducing school
dropout among girls and of recruiting young women to become peers.

Over-recruit young women to act as peer activists to allow for higher attrition of female
activists.

Provide additional mentoring or other supportive activities to increase self-esteem and
assertiveness of female activists. Possibly explore leadership-development activities.

Ensure that clinic-based duties are part of the school-based peer activists’ mandate in order
to maximize linkages.

Explore other possible forms of compensation for teacher activists, such as promotions,
additional vacation days, opportunities for professional development, or a system of
recognition.
41
O UTREACH
FOR
OU T- O F- SCHOOL YO U T H
I
n Mozambique, more than 70% of all youth are out of
school by the age of 13 and it is this very population that
has limited RH knowledge, is the most difficult to reach,
and is often the one most at risk.58 It is hard to provide
information and services to those out of school because they
are often poor and highly mobile. A level of skepticism or
distrust often exists that prevents youth from seeking services,
and low literacy levels limit the effectiveness of traditional
IEC materials.
Youth who are not in school are usually more influenced by
religious and cultural constraints in discussing ASRH issues,
such as the use of condoms, reproduction, and contraception.
Parents, especially in rural areas, often oppose RH education
fearing that it will promote promiscuity. Some churches and
religious leaders have also voiced their opposition to RH
education, especially if condoms are being promoted or
distributed. Past initiatives to increase reproductive health
knowledge have been linked to schools thus limiting access
for those out of school. As part of Geração Biz’s
comprehensive strategy to target all young people, both those
in school as well as out of school, an outreach component was developed that relies on networks of
community-based peer activists and is linked to a network of youth-friendly services.
Competence in SRH
A young person is “SRH competent”
when s/he:
Accurately assesses his/her personal
assets and the impact of early and
unwanted pregnancy, STDs, HIV/
AIDS on those assets.
Assesses the factors that put him/
her at risk for these problems as
well as protective factors.
Acquires and uses the knowledge
and skills to reduce his/her risks
and strengthen his/her protective
factors.
42
While the primary focus of the outreach component is
out-of-school youth, parents, community and religious
leaders, and faith-based organizations are encouraged
to be active partners in addressing sources of risk as
well as fostering a protective and supportive
environment for young people. The aim of the
outreach component is to develop young people’s
ability to form gender-equitable relations; make
decisions that will result in a positive and healthy
reproductive and sexual life; negotiate condom use
and other healthy practices; resist social and/or sexual
pressures; and act as leaders in their community.
Interventions included under this component are
designed to increase young people’s sexual and
reproductive health competence.
In 2000, the MOYS, with technical assistance from
Pathfinder and UNFPA, developed an Outreach
Strategy for Vulnerable, Hard-to-Reach Youth in
Mozambique. The strategy outlined the types of outreach interventions and identified different
opportunities for reaching out-of-school youth. The following strategic objectives were identified:
1) To link out-of-school youth to youthfriendly, gender-sensitive health and
social services, particularly for
counseling, contraception, prevention
and treatment of STDs, prevention of
HIV/AIDS, and livelihood
improvement.
Outreach for Out-of-School
Youth
Established network of community activists
Built community youth centers
Established linkages between community
2) To empower out-of-school youth with
life-saving information and skills
related to the development and
protection of their sexual and
reproductive health.
3) To strengthen the capacities of
government, NGOs, and other
facilitators and service providers to
implement decentralized, youthcentered programs to reach hard-toreach populations.59
The main outreach activities include:

Reorientation of existing schoolbased, community-based, and mass
media programs to target out-ofschool youth and incorporate SRH
information and interventions.
Outreach to out-of-school youth in
places where they congregate, such
as areas where youth engage in
livelihood or recreational activities,
churches, youth associations and
clubs.
activists, community youth centers, and
youth-friendly clinics
Launched media and IEC campaign
Steps Taken
District planning for the outreach component
with assistance from the provincial level
Established partnerships with youth
associations
Conducted sensitization sessions with
community leaders
Conducted community mapping in selected
areas
Recruited and trained community peer
activists
Recruited and trained parent activists
Trained journalists, DJs, and other media
professionals
Established youth centers
Developed referral system for clinical
services and VCT
Developed IEC materials
Creation of attractive places/
Conducted outreach activities, such as drama,
opportunities to reach out-of-school
dance performances, concerts, and festivals
youth, such as health/social services
that are friendly to out-of-school
youth, activities that develop
livelihood skills or provide access to credit, sports and recreational activities/centers.
43

Reconstruction of traditional mechanisms of SRH education, including initiation rites and
traditional healers.

Support for innovative approaches developed through local initiatives.60
Mapping and Coordination
Recognizing that out-of-school youth are a diverse group of
young people who gather in a variety of places and possess
different levels of SRH knowledge, conducting a survey of
their knowledge and behavior was an essential first step. To
encourage youth involvement, the participatory approach of
community mapping was selected because it allows young
people to be involved in the process of identifying SRH
problems, gaps in knowledge, as well as possible outreach
interventions. Mapping was conducted in five districts and
Quelimane City in Zambezia Province. In Maputo, mapping
was conducted in four high-risk areas as the first step in
implementing outreach activities. Moamba and Ressano
Garcia are located in the transport corridor to South Africa.
Magude, a large boardinghouse, provides shelter to youth
who work in South Africa, and Xinavane is home to a sugar
plantation that employs large numbers of young people. In
each location, DNAJ or the DPJD identified a youth
association to conduct the mapping activity and participate
in the planning of activities. The advantage of using these
associations is that membership is made up of local young
people and therefore they are recognized and trusted within
the community.
A professor from the University of Eduardo Mondlane who specialized in survey techniques was
hired to work with these associations to devise a
standard list of questions on SRH knowledge and
behavior. In addition, the types of locations to be
included in a physical map of the community
were agreed upon. These locations represented
positive (schools, churches) and negative (bars,
clubs) environments for young people. Two
members of each youth association were trained
in community participation and mapping
techniques, thus building their capacity to
conduct future needs assessments. The members
of the youth associations then recruited 15 more
people from the community to assist with the
mapping exercise.
44
Youth association members and their assistants went out into the community and involved other
young people in the process of drawing a physical map of their community as well as identifying
attitudes, knowledge, and practice with regards to sex, contraception, unwanted pregnancy, STDs,
and HIV/AIDS. The results were summarized and shared during a workshop with all of the youth
associations and DNAJ/DPJD. Association members were thus able to share their experiences as
well as learn from their colleagues. The results were then summarized and presented to the
community, including the young people who had helped in the mapping activity. By involving the
community throughout the entire assessment process, the community was sensitized to the
importance of ASRH issues and mobilized to find its own solutions to these problems. DNAJ/DPJD
worked with district-level leaders to design outreach interventions based on the identified needs of
the community.
Community Mapping
As a way of identifying needs and opportunities for reaching young people, especially those
out of school, youth associations, under the direction of DNAJ or the DPJD, conducted
community mapping activities in target areas. Community mapping is a process that includes:
Creating a physical map of the community that marks the location of neighborhoods,
schools, health centers, vocational/training centers, counseling centers, clubs, discos,
gardens, parks, churches, NGOs, youth associations, and cultural groups (theater,
cinema, dance, music). Information on activities, capacities, access, areas of influence,
and beneficiaries of each institution was also collected.
Documenting socio-cultural practices including what young people do and where they
go, recreational activities in which they engage, meeting places, topics of conversation
between female friends, male friends, friends of the opposite sex, boyfriend/girlfriend,
and married couples. When young people have free time, what day of the week, and what
time of the year, were considered as factors when documenting socio-cultural practices.
Surveying what, where, when, and with whom young people discuss sex, pregnancy,
STDs, and HIV/AIDS, including if they discuss these topics with their parents and if so,
why or under what circumstances. Information was also extracted to determine if the
answers to these questions changed depending on if the young person was speaking to
friends of the same sex, friends of the opposite sex, a boyfriend/girlfriend, or their
spouse (if they were married).
Identifying where, when, who, and how young people choose their partners.
Noting what methods of protection young people know about and use with regard to
pregnancy, STDs, and HIV/AIDS.
Identifying where they currently obtain condoms and other venues that they would like to
be able to obtain condoms. (This question was asked in Zambezia only.)
45
The youth associations reported that many of the youth involved in the mapping exercise expressed
surprise that someone was interested in what they thought about ASRH issues and that it was the
first time that anyone had involved them in this way.61 The youth associations reported that the
mapping activity was an excellent learning opportunity, drawing attention to myths and practices that
they were unaware of prior to surveying their peers. However, they also reported the difficulties in
implementing a participatory approach such as community mapping.
“Many youth were very shy, especially women when discussing issues like abortion and sexuality.
There is a cultural taboo on discussing sex and sexuality.”-Representatives from CEJOC and
ADEJOR
“Sometimes it was very hard to enlist youth in the mapping activity because they were afraid that
their responses would not be kept confidential. We explained that the mapping activity was to help
us design interventions to help them. Some of the youth accepted this and agreed to participate but
others did not.”-Representatives from ADEJOR and Massangulo
Despite some difficulties, the youth associations were able to survey a very diverse group of young
people through the community mapping activity.
“We involved many kinds of youth in the mapping activity, such as youth who were at sporting clubs,
those that were working in the informal economy (working on the roadside), those who hang around
in discos and bars as well as those young people who belong to small business cooperatives.”Representative from CEJOC
“In Magude we also worked with youth who sell on the streets, those that frequent bars, and those
who exchange sex for money or other favors. We interviewed adolescent women who had dropped
out of school due to pregnancy.”-Representative from ADEJOR
46
Community Activists and Outreach Activities
In Maputo Province, DNAJ has carefully followed the Outreach Implementation Strategy. Given that
the strategy was not developed until 2000, implementation of outreach activities has been delayed.
DNAJ is working with select
districts to design key
interventions based on the
results of the community
assessment. Examples of
these interventions include
training of 100 sports team
leaders in HIV/ASRH
content, the development of
seven radio programs on
sexuality, pregnancy, and
contraception, and a launch
of the film Yellow Card which
800 youth attended. In
addition, the youth
association, Nucleo de Mavalane, performs skits on ASRH and substance abuse both in the
community and the clinics.
In contrast to Maputo, outreach activities have progressed steadily in Zambezia. A work team
comprised of members of the DPJD, Aro Juvenil, and AMODEFA, together with the heads of small
youth organizations, is leading the process of implementing the outreach component. The Zambezia
Technical Advisor provides technical assistance to develop the capacity of the team so that they can
continue outreach activities after the project has ended. To mobilize the community around ASRH
issues, the Zambezia Technical Advisor involved local elders, chiefs, and religious leaders.
Sensitization sessions on ASRH were held for 332 local leaders in Mopeia, Morrumbala, Gurue,
Alto Molocue, Maganja da Costa, and Milange.62 Before the onset of program activities, consensus
was reached with these influential community
members.
The DPJD collaborated with two NGOs,
AMODEFA and ARO Juvenil, to reach out-ofschool youth with community youth activists.
As of 2001, 411 community activists (237
males and 174 females) had been trained in
Zambezia. These activists conduct similar
activities as the peer activists operating within
the schools: they conduct educational
activities, provide referrals to health centers,
and distribute condoms. AMODEFA has male
and female community activists in the
districts of Quelimane, Gurue, and Alto
Molocue. Like AMODEFA, ARO Juvenil has
“My family supports me as a
peer activist because they see
that I am working to combat
HIV/AIDS. They even come to
me with their own reproductive
health questions.”
-Community Peer Activist,
Mocuba, Zambezia
47
members of both sexes who are located in Alto Molocue,
Gurue, and Morrumbala. Aro Juvenil also works with a variety
of local youth associations, such as Comunidade Madalena
and NDJC, to conduct community outreach activities. Some
associations, such as Comunidade Madalena, are affiliated
with the Catholic Church and their membership includes
parents and young people. While this helps create a supportive
community environment by having parents involved, working
with faith organizations can also prove challenging when it
comes to condom promotion and distribution. However, peer activists from Comunidade Madalena
reported that they provided referrals to the local health clinic for young people who wished to
obtain condoms; this way, they were not discouraging condom use but also were not violating
religious bans on condoms.63
Other youth associations, such as NDJC, use theater as a medium for disseminating HIV prevention
and SRH messages. Theater allows the messages to be delivered in Portuguese or local languages
depending on the audience. Due to the popularity of drama in rural communities, many of these
skits have a high turnout with audience members ranging in age from young children to elderly
grandparents. After the skits are performed, discussion groups are held so that messages are
internalized and understood. Skits that were observed by both an outside evaluation team as well as
by Pathfinder staff were of extremely high quality; however, other methods, such as participatory
theater, may be explored to increase the reception of messages included in the skit.64, 65
In addition to community peer activists, parents were also trained as activists. In 2001, 80 parents
were trained as parent peer educators. Their primary responsibilities are to target other parents in
the community and educate them about
ASRH and HIV/AIDS. Involving parents as
activists has helped create a supportive
“We have a saying , ‘when things
environment for the provision of SRH services
are not in order, you start at
and information and has also helped facilitate
home’. I learned the skills and the
parent-child communication on sensitive
topics, such as sexuality and HIV prevention.
need to talk about sexuality issues
Recognizing the influence that performers
and radio personalities have on young
people, 28 musicians, actors, dancers, and
DJs from four districts were trained in ASRH
and advocacy skills.66 In addition,
sensitization sessions on ASRH, including
HIV/AIDS, have also been held with sports
associations and clubs.
48
during the Geração Biz training,
and so I started with my sister. I
put the topics on the table and the
people around it began to talk. We
haven’t stopped yet.”
-Parent Activist
By the end of 2001, 314 discussions, 201 theater performances, and 48
video sessions had been conducted. Youth festivals have also been used to
reach youth in Quelimane, Mocuba, Milange, Gurue, Morrumbala, and
Maganja da Costsa; an estimated 17,150 young people attended. As of
December 2001, a total of 39,972 young people had been reached through
these different channels since the project began.67,68
To mirror the setup of adolescent counseling corners for in-school youth,
seven community counseling centers were built in Zambezia to provide
information, counseling, referrals, and condoms. These community centers are run by the local
youth associations and staffed with ten to fifteen community peer activists from Geração Biz. They
are open Monday through Saturday. Linkages with nearby youth-friendly clinics have been
established as a way of increasing demand for services.
BCC Material
In order to reach both those in school and out of school, a variety of colorful and attractive BCC
materials were produced under Geração Biz. While these materials were produced first in Maputo,
they were then adapted and produced for Zambezia Province. The materials covered a variety of
ASRH topics, such as unwanted pregnancy, STDs, HIV prevention, and healthy sexual relationships.
The materials also included a list of youth-friendly clinics and their hours of operation. To introduce
the BCC materials and train providers, teachers, and peer activists on their appropriate use,
workshops were held with 36 participants from Maputo, Zambezia, and Gaza Provinces.
The following BCC strategy was developed under Geração Biz:
1) Develop and produce posters, pamphlets, stickers, and other written materials that have
consistent themes on healthy relationships, condom use, and where to go for services.
2) Work with local radio stations and DJs to include more
programming on ASRH topics and to encourage DJs to
incorporate ASRH messages during their programs.
3) Work through different channels, such as theater, music,
and sports to disseminate ASRH and HIV/AIDS
prevention messages.
One of the goals of Geração Biz in Zambezia
province has been to increase media coverage
of ASRH events. Besides educating the
community on youth and SRH issues, the media
can also give recognition to those young
people who are trying to make a difference with regard
to their peers’ health and well-being. Recently, the
49
Geração Biz has begun working with one of the oldest district-based community radio stations,
Licungo Community Radio, to disseminate ASRH information three times a week. Licungo is on the
air 12 hours every day in three languages— Portuguese, Makua, and Lomue. Issues discussed on the
radio station vary on a weekly basis.
The model of using community radio to reach young
people with ASRH messages is now being
replicated in Gurue, Mocuba, Morrumbala, and
Alto Molocue. In Mocuba, community activists have
joined various groups who have air time on the
local radio station. By participating in these groups,
they are able to influence the messages that are
delivered during the groups’ radio programming. A
training for media personnel on ASRH topics has
also been conducted with the intention of developing key point people who can effectively report on
ASRH issues. While progress is being made, the DPJD expressed the desire to expand their work
with the media by using lessons learned from similar projects in other countries.69
Lessons Learned
50

Working through local youth associations is a more effective way to reach out-of-school
youth. Out-of-school youth are a very diverse and heterogenous group and therefore require
multiple local interventions to target them with ASRH information and behavior change
messages. One of the benefits of working through local youth associations is that it allows for
a variety of approaches, and trust has already been established with hard-to-reach groups,
like orphans, street children, and youth who engage in sex work.

The role that youth organizations can play in outreach activities needs to be carefully
examined with realistic expectations of their contribution to reaching out-of-school youth.
Youth organizations are generally small and underdeveloped. They will always need financial
support, commodities, training, and supervision in order to successfully carry out outreach
activities on a large scale.

There needs to be a clear strategy to empower parents and communities to understand and
respond to the needs of adolescents. Parents and the community can play a significant role in
the healthy development of adolescents. However, many parents and community members are
not sensitized to the importance of ASRH and do not possess the skills to support young
people in their quest for information and services. The training of parents as community
activists has proven to be a successful strategy to increase support for ASRH activities and to
facilitate communication between them and their children.

Peer activists must be within close proximity in order for young people to access their
services. Whether peer activists work in schools or the community, it has been found that
young people will not go far outside their normal path to access services or information from
peer activists. It is therefore critical that a network of peer educators is created with
representation from different schools and
communities to ensure wide geographical
coverage.

Recruiting youth who are already
members of a theater group, dance
company, or sports team as peer activists
is an effective way to expand the reach of
peer education activities. In Zambezia,
young people who already had a vehicle
for dissemination of ASRH messages,
such as through drama, dance, or sports,
were able to reach a larger number of
young people in the community. In
addition, these peer activists were also
responsible for training other group or
team members in the dissemination of ASRH information and behavior change messages,
thereby creating a cascade effect.
Challenges

The outreach strategy of the MOYS may be over ambitious given the weak capacity of NGOs
and youth associations. The strategy may need to be revised to better reflect outcomes that
can be realistically achieved.

Many youth associations hold meetings and events in an informal manner making it difficult to
adequately monitor them and provide feedback.70

Many of the youth associations involved in community mapping had predominantly male
memberships, which sometimes hindered the successful involvement of young women in the
mapping exercise.

Multi-lingualism and multi-ethnic groups pose a real challenge for community-based outreach
approaches.

It is a challenge to target hard-to-reach youth, especially in the rural areas.

Many out-of-school youth experience multiple levels of vulnerability, illiteracy, poverty,
migration to transport corridors, broken families, violence, and substance abuse.

Girls are harder to reach than boys because there are greater demands on their time and they
are often expected to stay close to home.

The infrastructure of DNAJ, DPJD, and the youth associations needs to be strengthened so
that they are able to successfully implement the outreach component. Unlike the health and
education sectors, there are no existing operations or structures that can be accessed in order
51
to introduce and monitor outreach activities.73 For instance, peer educators require training,
retraining, technical assistance, monitoring, and mentoring, and currently there is no effective
oversight structure to accomplish this.

In Zambezia, space for outreach activities is very limited and many places do not have
electricity, making activities that involve music or A/V equipment difficult.71, 72

There is no harmonization of the different ASRH messages that are promoted by other
organizations, therefore leading to duplication and contradiction.
Recommendations
52

Increase linkages between the clinics and community peer activists.

Conduct a thorough needs assessment of youth associations to determine in what areas
capacity building is needed.

Strengthen the network of youth associations in order to increase sustainability of outreach
interventions.

Strengthen linkages between the outreach component and the health sector and PSI to
improve condom supplies.
P ERCEPTION
O F STAKEHOLDERS
G
eraçaõ Biz is a very ambitious program that involves a variety of public and private sector
stakeholders. Overall, stakeholders who were interviewed expressed a strong sense of
ownership for the program and satisfaction with program activities.74 The importance of
contributing to the healthy development
of youth was acknowledged by all
sectors and an enthusiasm for working
with young people was noted. Although
the program’s achievements are many,
and considerable progress has been
made in meeting the required outputs, a
number of challenges were also
identified. While there is a general
recognition of the benefits to working in
partnership, effective communication
and planning among the implementing
agencies has proven to be difficult at
times. In addition, the de facto
dissolution of CIADAJ has created a
vacuum with regard to an effective
coordinating body. It should be noted that coordination at the provincial level has proceeded more
smoothly than at the central level, in part, because it is easier to work at a decentralized level.
The MOYS, as the main executing agency, has also struggled to balance its program responsibilities
with its current abilities. Recently created, the Ministry of Youth and Sports is still building its
institutional and technical capacity. As the program continues and the MOYS gains more experience
in implementing ASRH initiatives, it will be better prepared for its leadership role.
According to one MOYS official, the Ministry must make the transition from a project mentality to a
program mentality. 75 External funding and the initiation of Geração Biz in only two locations created
the perception that is was a “project.” However, the recent expansion of Geração Biz to other
provinces and the integration of ASRH
activities into the national system demonstrates
the Ministry’s efforts to move to a program
“[We] must make a transition
approach.
from a project mentality to a
program mentality.”
Compared with clinical services and schoolbased interventions, the outreach component
faces more limitations. Youth associations and
NGOs do not have a strong tradition in
Mozambique. Years of civil unrest contributed to an unstable environment that did not foster the
establishment of organizations devoted to youth. While in recent years there has been an increase in
the number of youth associations and NGOs, many of them do not have the capacity to effectively
plan and implement activities. Many associations have trouble attracting youth due to lack of
53
equipment (VCR/TV or musical instruments/equipment), electricity, and meeting space. Monitoring
activities of these associations also can be difficult because they often hold events on an informal
and irregular basis. 76 Yet, to reach out-of-school youth at the community level, youth associations
must be involved as implementing partners.
Staff within the MOYS have stated a need to augment advocacy efforts with respect to youth and
youth issues. Better media coverage of ASRH events and issues is one approach that is being
pursued. In Zambezia, the DPJD is working with the local radio station on ASRH programming. A
training on ASRH for journalists and media personnel has led to an increased understanding of
ASRH issues and the role that the media can play in raising awareness of these issues.
At the provincial level, it was reported by various stakeholders that coordination and ownership are
less of a problem.77 This is partly due to an initial emphasis on planning and coordination among the
implementing partners. Monthly meetings with all three provincial directorates (youth, education,
and health) have led to greater coordination of efforts and better working relations. Geração Biz is
also seen as the impetus for desired change within provincial directorates such as the DPS.
Stakeholder’s Share Their Views on Geração Biz
“The DPS was already looking at integrating YFS into existing services before the initiation of
the project. The project helped us to accomplish this goal. The project was instrumental in
helping us implement a sytematic approach to integration.”-Magida Omar Nurmahomed,
DPS Zambezia.
“This project is important because youth are coming together to deal with the problem of
ASRH. Before there was a top-down approach (an expert would talk to youth about ASRH)
but now we are implementing a participatory approach. This new approach is very
important. Youth are taking responsibility for their own futures. This creates ownership of the
problem and a solution by the youth.”-Helder Andrade, DPJD, Zambezia
“Youth are important, so for that reason, the project is important. The youth of Mozambique
are a lost generation. They have no direction and are waiting for the government to guide
them. The project is good in the sense that it is an attempt to mobilize young people.”
-Albino Adamugy Valia, DNAJ
“The multi-sectoral approach is new in Mozambique. Because of this, the skills of the
personnel are not up to par for the coordination aspect of this multi-sectoral approach. The
capacity in the MOH needs to be developed. Ownership is not the issue, capacity is.”
-Lilia Jamisse, SEA of the MOH
54
E XPANSION PROCESS
Gaza Province
B
ased on the success of the program in Maputo and Zambezia, the MOYS sought to expand
Geração Biz to other provinces. In 2000, the program was expanded to six districts within
the province of Gaza. Using the experience of Maputo and Zambezia as a model, the Gaza
program was designed with the same three components: clinical services, school-based
interventions, and outreach. As in Zambezia, the provincial directorates of health, education, and
youth act as the implementing partners. A Technical Advisor was hired to facilitate coordination
among the implementing partners, as well as to build the technical and institutional capacity of
these agencies.
The application of lessons learned and best practices from Maputo and Zambezia has led to an
accelerated progression of program activities in Gaza. The employment of the new strategy for
promoting ownership has not only strengthened commitment from the provincial-level government,
but the strong emphasis on community mobilization and involvement has also translated into a
cohesive and supportive environment for program activities (see Promoting Ownership, p. 15).
In the summer of 2000, health care providers, teachers, and peer educators completed a set of
comprehensive trainings on ASRH issues and ten health facilities were identified for the integration
of youth-friendly services. To increase community awareness of ASRH issues and create a
supportive environment for the provision of SRH services and information to youth, 197 community
leaders participated in a two-day sensitization
workshop. After that, 13 nurses and three
physicians were trained in ASRH services and
counseling and two of the ten clinics began
offering youth-freindly services.
In addition to youth-friendly services, schoolbased interventions were initiated in five
schools in Xai Xai City and four schools in
Chokwe City in August 2001. Seventy-eight
students and 19 teachers from the nine schools
were trained as peer and teacher activists while
75 community activists were trained to
implement the outreach component. The
breadth and reach of the Gaza program
conitnues to expand rapidly with the
implementation of all three components.
Linkages between clinical ASRH services,
schools, and communities have been
developed through referrals, education and
information, and the presence of peer activists
at the youth-friendly clinics.
55
Maputo Province
During the first few years of
implementation, program activities in
Maputo Province focused primarily on
Maputo City and peri-urban areas. With
all three components well established
within the capital, the provincial
directors of health, education, and youth
and sports have worked to harmonize a
strategy for expansion throughout the
province. A multi-sectoral meeting was
held on the expansion with participation
from provincial and district directors,
community leaders, and local youth associations. In addition, a training seminar on HIV/AIDS,
project management, and outreach techniques, such as music and theater, was conducted for local
youth associations and District Directors of Youth and Sports.
Second Expansion Phase
Encouraged by the success of Geração Biz in selected areas, the MOYS, MOH, and MOE are
committed to implementing the program on a national scale. The provinces of Tete and Cabo
Delgado have been selected for the second phase of expansion. In addition to the strategies
employed in Maputo and Zambezia, attention will be focused on geographic areas and districts
affected by commercial corridors, a mentoring and support program targeted at keeping girls in
school will be established, and micro-enterprise initiatives for youth will be supported.
The health, education, and youth sectors of the provincial government, in collaboration with NGOs,
will be responsible for program implementation. However, in this new phase, the National AIDS
Council at the central level and the Provincial AIDS Coordination Unit at the provincial level will
facilitate and promote the coordination and harmonization of the implementing agencies’ efforts.
Pathfinder and UNFPA will continue their mandate to provide technical assistance to all the
implementing partners, and Technical Advisors for each province and sector will be hired to assist
the implementing agencies.
It is expected that a decentralized and multi-sectoral approach will facilitate a higher level of
coordination and will further capitalize on all stakeholders’ efforts to provide young people with
culturally sensitive SRH information and services. Roles and responsibilities of the central,
provincial, and district levels will be clearly defined in the initial stage of the program expansion.
The central-level Ministries of Health, Education, and Youth and Sports, as well as national NGOs
and the National Youth Council, will develop ASRH policies, strategies, guidelines, and procedures
in accordance with their HIV operational plans. They will also plan and monitor any central level
programs and provide support to their provincial directorates for the planning and implementation
of national policies and guidelines. The provincial directorates will, in turn, be responsible for
implementing ASRH activities at the provincial level. All activities will be designed in accordance
with the provincial HIV operational plan.
56
C ONCLUSIONS
S
ince the inception of Geração Biz, UNFPA and Pathfinder have sought ways to maximize
the program’s impact on young people’s sexual and reproductive health. By incorporating a
multi-sectoral design that calls for close coordination between the three components
(clinical services, school-based, and outreach), ASRH messages are reinforced and linkages
between services and information are strengthened.
Recognizing the need to develop programs that are sustainable versus short-lived projects, the
Government of Mozambique was selected as the key implementing partner. Although working in
partnership with government can be more demanding than working with NGOs or the private sector,
Geração Biz has demonstrated that with perservance, capacity building, and commitment, it is
possible to implement sound ASRH programs through the public sector. Initally, when Geração Biz
began, it was executed through the Ministry of Youth and Sports. However, in an effort to find the
best execution modality, agreements have been signed with each of the three sectors and each
sector is now responsible for its own financial management and program activities. Based on the
experience that multi-sectoral efforts are easier to implement at the provinical level, program
management has been decentralized to the provincial and district level. Both of these descisions
will hopefully lead to a more effective and efficient implementation process.
Somewhat unique to Geração Biz has been the incorporation of periodic reflection to assess
progress and the flexibility to make alterations in the program design based on lessons learned.
This process of documenting and building on previous project experience has allowed Geração Biz
to flourish. Although Geração Biz started out as a project in two provinces, it has now been scaled
up to six provinces and promises to become a truly national program as long as it maintains the
strong support of the Government that it has enjoyed thus far.
This document highlights the need for more well-designed ASRH projects, like Geração Biz, which
consider issues of sustainability, scale, and impact. A key lesson from the Geração Biz experience
is that ASRH issues
involve the entire
community; therefore,
mobilization of all sectors
is necessary to truly
impact change. Young
people should not be
viewed as just the
beneficiaries of ASRH
projects and programs;
they must also be equally
involved as partners in the
design and
implementation of
activities.
57
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59
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60