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.
Highlights
Female sex workers (FSWs) in many settings have restricted access to sexual and reproductive health (SRH) services
The public health sector was the main provider of SRH care for FSWs, but the services had not been adapted to the needs of that population [31]
The most important challenge to fidelity was the non-establishment of a second targeted clinic in Tete City, which was replaced by mobile clinical outreach, and the expansion of the range of services offered at the Night Clinic and of the peer outreach activities
Summary
Female sex workers (FSWs) in many settings have restricted access to sexual and reproductive health (SRH) services. We 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 assessed its performance. The morning opening hours of clinics are not compatible with their nightly work [13] For these reasons, several initiatives have developed services targeted to sex workers, either through mobile outreach or parallel stand-alone clinics [14,15,16]. These initiatives, generally achieve a low coverage and offer a limited scope of services [17]
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