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

Abstract

BackgroundFemale sex workers (FSWs) in many settings have restricted access to sexual and reproductive health (SRH) services. We therefore conducted an implementation study to test a ‘diagonal’ intervention which combined strengthening of FSW-targeted services (vertical) with making public health facilities more FSW-friendly (horizontal). We piloted it over 18 months and then assessed its performance.MethodsApplying a convergent parallel mixed-methods design, we triangulated the results of the analysis of process indicators, semi-structured interviews with policy makers and health managers, structured interviews with health care providers and group discussions with peer outreach workers. We then formulated integrated conclusions on the interventions’ feasibility, acceptability by providers, managers and policy makers, and potential sustainability.ResultsThe intervention, as designed, was considered theoretically feasible by all informants, but in practice the expansion of some of the targeted services was hampered by insufficient financial resources, institutional capacity and buy-in from local government and private partners, and could not be fully actualised. In terms of acceptability, there was broad consensus on the need to ensure FSWs have access to SRH services, but not on how this might be achieved. Targeted clinical services were no longer endorsed by national government, which now prefers a strategy of making public services more friendly for key populations. Stakeholders judged that the piloted model was not fully sustainable, nor replicable elsewhere in the country, given its dependency on short-term project-based funding, lack of government endorsement for targeted clinical services, and viewing the provision of community activities as a responsibility of civil society.ConclusionsIn the current Mozambican context, a ‘diagonal’ approach to ensure adequate access to sexual and reproductive health care for female sex workers is not fully feasible, acceptable or sustainable, because of insufficient resources and lack of endorsement by national policy makers for the targeted, vertical component.

Women Who Sell Sex in Eastern and Southern Africa: A Scoping Review of Non-Barrier Contraception, Pregnancy and Abortion

“…Fourteen of the studies were conducted in Kenya [ 10 – 23 ], eight in South Africa [ 13 , 14 , 24 – 29 ], eight in Uganda [ 30 – 37 ], six in Mozambique [ 13 , 14 , 38 – 40 ], five in Tanzania [ 41 – 45 ], three in Eswatini [ 46 – 48 ] and in Malawi [ 49 – 51 ], two in Ethiopia [ 52 , 53 ], in Zambia [ 54 , 55 ], and in Zimbabwe [ 56 , 57 ] and one each in Democratic Republic of Congo [ 58 ], Lesotho [ 59 ], Rwanda [ 60 ], and online (Australia, Brazil, El Salvador, France, Kenya, Malawi, Russia, South Korea, Spain, Tanzania, the United States of America, and Zimbabwe) [ 56 ]. Thus, knowledge production concerning WSS in relation to non-barrier contraception, pregnancy and abortion is dominated by studies conducted in Kenya.…”

“…In a different paper, Lafort et al [ 40 ] reflect on the feasibility of up-scaling the DIFFER programme. Interviews with key informants—policymakers, government employees, international development or NGO workers and community representatives – revealed that expansion of targeted services were hampered by financial constraints, institutional capacity and lack of buy-in.…”

How to control the sexually transmitted diseases in Benjina?: qualitative studies on the practice of prostitution

“…Intervention programs and policies must adopt the local context in setting priorities if they want an effective and sustainable program. 33,30,34,35…”

Fast-track interventions for HIV and AIDS epidemic control among key populations: A rapid review

“…Most articles included in this review were primary studies ( n = 17), while others involved the review of existing literature and policies ( n = 1) and routinely collected data ( n = 1). Of the 19 articles included, 12 employed quantitative methods ( n = 12), 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 5 used qualitative approaches ( n = 5) 24 , 25 , 26 , 27 , 28 ; only one study ( n = 1) 29 employed mixed methods approaches while yet another study comprised a review of literature and policy documents collectively ( n = 1). 30 Most studies ( n = 6) were conducted in the United States of America, 12 , 13 , 17 , 22 , 26 , 28 while others were conducted in China ( n = 5), 14 , 15 , 16 , 21 , 23 Kenya ( n = 2), 18 , 24 South Africa ( n = 1), 20 Mozambique ( n = 1), 29 Nigeria ( n = 1), 25 Botswana ( n = 1) 27 and New Guinea ( n = 1).…”

“…Of the 19 articles included, 12 employed quantitative methods ( n = 12), 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 5 used qualitative approaches ( n = 5) 24 , 25 , 26 , 27 , 28 ; only one study ( n = 1) 29 employed mixed methods approaches while yet another study comprised a review of literature and policy documents collectively ( n = 1). 30 Most studies ( n = 6) were conducted in the United States of America, 12 , 13 , 17 , 22 , 26 , 28 while others were conducted in China ( n = 5), 14 , 15 , 16 , 21 , 23 Kenya ( n = 2), 18 , 24 South Africa ( n = 1), 20 Mozambique ( n = 1), 29 Nigeria ( n = 1), 25 Botswana ( n = 1) 27 and New Guinea ( n = 1). 19 The remaining studies were unaccounted for in terms of country and region, as these were document reviews conducted on regional policies and research.…”