The synergistic relationship of institutionalization and expansion: Lessons from scale-up of youth-friendly services in five countries Gwyn Hainsworth, Deputy Director of Technical Services, Pathfinder International/E2A
BACKGROUND • Large adolescent and youth population with disproportionate burden of poor SRH outcomes • Youth-friendly services (YFS) that are equitable, accessible, acceptable, appropriate, and effective can address access barriers • Many countries have YFS on a limited scale • How to scale up YFS to achieve adequate coverage?
METHODOLOGY: THE EXPANDNET FRAMEWORK Environment The elements of The innovation : Youth-friendly SRH scaling up services User organization: Scaling-up Ministry of Health and NGOs/FBOs Strategy Resource team : Pathfinder, UNFPA and partners, including experts from user orgs Strategic choice Type of scaling up : Expansion and institutionalization areas Dissemination and Organizational Costs/resource Monitoring and advocacy process mobilization evaluation
INNOVATION: YOUTH-FRIENDLY SERVICES Characteristics of the innovation – Package of SRH services offered by trained providers at public-sector facilities and (depending on country) through private facilities, workplace programs, and CBD. – Emphasis on privacy, confidentiality, respectful treatment, free or subsidized services – Accompanied by demand generation and enabling environment activities – Emphasized youth participation and leadership in program design and implementation
SCALE UP APPROACH Institutionalization (Vertical scale up) BOTH institutionalization and expansion were pursued contributing to the sustainable scale-up of YFS Expansion (Horizontal scale up)
INSTITUTIONALIZATION Mozambique Ethiopia Tanzania Vietnam Ghana • • • • • Policies & guidelines supporting YFS • • • • • National YFS curricula & training network • Incorporation of YFS in national preservice training • • • • • National YFS tools • YFS integrated in NGO/FBO service delivery system • • • HMIS age disaggregation • • • • YFS in national/regional/district budgets & workplans
EXPANSION Mozambique (Geração Biz) Phase 1 Phase 2 Phase 3 Phase 4 1999-2000 2000-2005 2005-2008 2008-2012 Consensus building; pilot Expansion to 83 Expansion to 244 System strengthening & introduced to 12 sites in 2 sites in 8 YFS sites in 11 capacity building; provinces provinces provinces (nat’l transition to government scale) Ethiopia (RH/FP Project and Integrated Family Health Program ) Phase 1 Phase 2 Phase 3 Phase 4 2005-2007 2008-2009 2010-2011 2012-2014 Consensus building; study Expansion to 64 Expansion to 115 Expansion to 163 YFS sites tour to Mozambique; pilot YFS sites in 4 YFS sites in 4 in 6 regions; transition to in 20 YFS sites in 4 regions regions regions government
Vietnam (Reproductive Health Projects) Phase 1 Phase 2 Phase 3 2004-2006 2007-2008 2009-2011 Consensus building; study Expansion to 19 YFS sites in 7 Expansion to 28 YFS sites in 17 tour to Thailand; pilot of 5 YFS provinces provinces sites in 3 provinces Ghana (African Youth Alliance) Phase 1 Phase 2 Phase 3 2000-2001 2002 2003-2004 Consensus building YFS introduced in 19 Expansion to 65 YFS sites in 5 sites in 3 regions regions Tanzania (African Youth Alliance) Phase 1 Phase 2 Phase 3 2001 2002 2003-2004 Consensus building 11 YFS sites introduced in 4 Expansion to 58 YFS sites in 8 regions regions
SYNERGIES BETWEEN VERTICAL AND HORIZONTAL SCALE Supportive policy environment (under • institutionalization) provided needed mandate for expansion of YFS YFS expansion led to greater service use and • generated momentum—holding gov’ts accountable for fully operationalizing adolescent health policies Timing was key! • First expansion occurred soon after creation of • supportive policy environment Investment in development and dissemination of tools • and technical resources (e.g., network of YFS trainers) allowed for efficient scale-up, achievement of economies of scale and sustainability As YFS was expanded, needed system changes or tool • development identified to ensure fidelity to the innovation during scale up
PURSUING VERTICAL AND HORIZONTAL SCALE SIMULTANEOUSLY INCREASES SUSTAINABILITY Factors influencing sustainability: • – Degree of expansion (horizontal scale): National or close to national scale can help mitigate staff turnover and create high visibility of YFS making it harder to dismantle – Extent of institutionalization (establishment of systems to support YFS delivery, incorporation of YFS into relevant budget lines, and integration of YFS within preservice education) Capacity building of MOH and NGO staff critical for supporting expansion • and institutionalization of YFS and incorporation of YFS within national, regional and district budgets and workplans Internal funding for YFS and less reliance on external funding is a crucial • factor to long term sustainability
CONSIDERATIONS WHEN SCALING-UP A YOUTH- FOCUSED INTERVENTION Young people’s lack of political voice requires greater advocacy to ensure • expansion and institutionalization of youth-focused interventions Partner with health systems strengthening efforts to ensure age- • disaggregated HMIS and that youth-focused interventions are included in national supervision and quality improvement systems Adult bias requires additional efforts to shift attitudes and commitment to • addressing young people’s health needs Lack of donor commitment may require innovative funding strategies and • capacity building from of gov’t counterparts to include youth-focused interventions within budgets and workplans from the onset
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