GOOD PRACTICES SRH APPROACHES FOR YOUTHS - ESA INITIATIVE GERAÇÃOBIZ - CORESULT

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GOOD PRACTICES SRH APPROACHES FOR YOUTHS - ESA INITIATIVE GERAÇÃOBIZ - CORESULT
Republic of Mozambique

ESA Initiative
GeraçãoBIZ

                                    Good Practices
                                    SRH approaches for youths
GOOD PRACTICES SRH APPROACHES FOR YOUTHS - ESA INITIATIVE GERAÇÃOBIZ - CORESULT
Intro
                                                                                                           Young women defend
                                                                                                                  their dreams.

The busy generation takes over

M     arisa wants to become a teacher. Joana wants to             Marisa, Joana, Ábida and Xiluva are doing things diffe-
                                                                  rently. These four young women, like many others, are ta-
study in South Africa, Capetown would be her preferred
city, Ábida would like to work in a bank, and Xiluva wants        king control of their lives. They volunteer in youth groups
to run a volunteer organisation.* These young women are           comprising young women and men. These groups aim to
between 16 and 18 years old and live in Mocuba, a small           spread the word on adolescent’s sexual self-determina-
town 150 kilometres north of Zambezia’s capital Queli-            tion – and they are the target group of adolescent and
mane in central Mozambique. They are four of Mozam-               youth friendly health services and comprehensive sexual
bique’s 2.9 million young women aged 14 to 24.                    and reproductive education.
Statistically, at least one of them has already experienced
gender-based violence, and two of them could already be
mother of one or two children. To realise their dreams
would be much more difficult then.

But the barriers already start before pregnancy: Most
young women have no experienced older friend with
whom they can talk about sexuality and reproductive
health. In many (rural) communities, aunts or mothers will
most likely tell them to have babies early. Boys’ views are
shaped by their fathers and uncles. It can be difficult to
find information, with health facilities usually being the only
source. But many young people won’t visit a health facility
to seek information: They are afraid that family members
or neighbours might see them and ask: What’s wrong with
you, are you ill? Therefore, many adolescents become
young adults believing that having lots of children as early
as possible is important for social standing and women's
identity. For many adolescent girls, early pregnancy leads
to school drop-out. Even those wanting to return to school
after having given birth often face obstacles.

                                                                  * Not real name; persons shown in the picture do not correspond
                                                                  to the people referred to in the text due to privacy reasons.
GOOD PRACTICES SRH APPROACHES FOR YOUTHS - ESA INITIATIVE GERAÇÃOBIZ - CORESULT
Index

        About ESA, the mission, and this brochure                                          4

                      ︎
                    ▶︎ Access to reproductive health
                          and what it means to Mozambican youth                            4

    ▼ Mozambique                                                                           7

    ▼ GeraçãoBIZ                                                                           8

                          PGB: About the Programme GeraçãoBIZ                              8

    ▼ Good Practice                                                                       10

               PGB Monitoring                                                             10

                          From paper to digital — the challenge                           10
                          The true reports come by WhatsApp       Testimony: Clotilde     11

               School Approach                                                            12
                    ►“Cantinho”: the little health corner                                 12
                    ►For healthier youth: cooperation of schools,
                                                                  Testimony: Carlos
                     nurses and community                                                 13

                    ►Cantinhos’ empty fridges                                             14
                    ►“Most of the visitors are boys”              Testimony: Marie Rosa   15
                                                                             & Olinda
                    ►Girls for Girls                                                      16
                    ►Leading the girl volunteers                  Testimony: Lídia        17

                    ►Young mothers back at school                                         18
                    ►Favours for good marks                       Testimony: Josina       19

               Clinical Approach                                                          20
                    ►SAAJ — the safe health alternative                                   20
                    ►SAAJ in action                               Testimony: Digna        21
                    ►Schools revitalise Youth Health Facilities   Testimony: Feliciana    22
                    ►Community outreach: “First, we talk
                                                                  Testimony: Digna
                     to the people”                                                       23
GOOD PRACTICES SRH APPROACHES FOR YOUTHS - ESA INITIATIVE GERAÇÃOBIZ - CORESULT
About ESA, the mission, and this brochure

Access to reproductive health
and what it means to Mozambican youth

         T  his brochure aims to present a picture of the
current situation regarding the sexual and reproductive
health (SRH) of youth in Mozambique, using the example
of Zambezia Province. It describes approaches to providing
better access to preventive health care and other services
for youth in the school environment and in communities.
These include measures rolled-out regionally, as well as lo-
cally-developed solutions that are considered good prac-             vinces to strengthen the linkages between the provision of
tices in addressing challenges on the ground. It also                sexuality education and youth-friendly health services, the
examines gender equality issues, which are important for             national level has only little information about these. It is
understanding and responding to the needs of youth.                  against this background that the PGB stakeholders at na-
                                                                     tional level have requested the GIZ ESA Regional Pro-
                                                                     gramme to support the assessment of approaches on linking
The brochure is one of the products of a consultancy and             CSE and Youth-Friendly Health Services (YFHS) in Zambe-
field mission in the Mozambican province Zambezia during             zia Province.
the first half of 2018. The consultancy was undertaken in the
context of the German Development Cooperation’s (GIZ)
ESA Regional Programme to support the implementation of
the Eastern and Southern African (ESA) Commitment.

The Programa GeraçãoBIZ is Mozambique’s large um-
brella programme, led by the Government, under which                    About the Eastern and Southern Africa (ESA)
most of the youth-health related activities are implemented.            Initiative
Both ESA and PGB objectives aim to strengthen youths’ ac-
cess to health information and services. Through this, they             The Eastern and Southern Africa Commitment Process
                                                                        has its origins in late 2013. It is a self-commitment of
contribute to reducing the number of early pregnancies and
                                                                        20 governments in Eastern and Southern Africa to
early marriages, as well as the incidence of HIV and gen-               scale-up initiatives on sexual and reproductive health,
der-based violence. Whereas the PGB focuses particularly                education and services for youth. The process was ini-
on peer-to-peer approaches, the ESA Commitment also                     tiated by UNAIDS, and is supported by UNESCO,
considers the scaling-up of comprehensive sexuality edu-                UNFPA, Germany’s Ministry for Economic Cooperation
                                                                        and Development (BMZ) as well as other development
cation (CSE) in schools, including the integration of CSE into
                                                                        partners. Twenty Ministers of Health and Education
the curricula and teacher training.                                     have committed to achieving set targets by 2020. Im-
                                                                        plementation is tracked through a regional accountabi-
                                                                        lity framework. Since April 2015, BMZ has
The GIZ ESA Regional Programme has supported Mo-                        commissioned GIZ with the ESA Regional Programme
zambique’s Ministry of Education in the roll-out of CSE                 to support the implementation of the ESA commitment
teacher training in both Nampula and Zambezia provinces                 in four cluster countries - Mozambique, Zambia, Nami-
in close cooperation with UNESCO and UNFPA. Although                    bia and South Africa.
quite a number of activities are happening in these pro-

                                                                 4
GOOD PRACTICES SRH APPROACHES FOR YOUTHS - ESA INITIATIVE GERAÇÃOBIZ - CORESULT
The objective of this consultancy mission was hence to
                                                                    Mozambique
support Mozambique’s ESA commitment and the PGB im-
plementation process by mapping projects and approaches
regarding youth’s access to sexual and reproductive health
knowledge and services. The outputs are reports explaining
the mission’s detailed findings; the reporting mechanism of
the state driven youth initiative Programa GeraçãoBIZ
(PGB), and the involved public services and departments of
health, education and youth; as well as identified good prac-
tices.

This consultancy was implemented by Health Focus, com-
missioned by the GIZ ESA Regional Programme. The mis-
                                                                                                                     Zambezia
sion’s consultants were accompanied by a representative of
                                                                                                            Quelimane
MISAU and of MINEDH. They cooperated closely with the
provincial and district administration in Zambezia’s capital
Quelimane, as well as surrounding districts. Some of the
local officials also accompanied the field visits. Interviews
were held with staff of health centres, schools and local
community-based organisations (CBO); with community
members as well as with youth volunteer groups. The first
step involved mapping projects and their targets using a
web-based survey tool. From this overview, some projects
were identified as potentially good practices, which were
then more closely documented. An important challenge of
                                                                                                                               Credit: wikiMedia

this mission was that comprehensive quantitative data and
result based outcomes were rarely available.                                        Maputo

   MINEDH:Ministério da Educação e Desenvolvi
             mento Humano / Ministry of Education                    Zambezia is a province in Mozambique’s central region
             and Human Development                                   with over five million inhabitants in an area of the size of
   MISAU: Ministério da Saúde / Ministry of Health                   Iceland; its capital is Quelimane. In 1999 it was the first
                                                                     province, along with Maputo City, where PGB was im-
   MJD:      Ministério da Juventude e Desporto /                    plemented. The national partners decided that the field
             Ministry of Youth and Sports                            mission should be conducted in Zambezia Province,
   MGCAS: Ministério do Género, Criança, e Acção                     since many activities are currently implemented in that
          Social / Ministry of Gender, Children and                  province. The fact that PGB started in 1999 in Zambezia
          Social Affairs                                             and Maputo City may have also influenced the decision.

                                                                5
GOOD PRACTICES SRH APPROACHES FOR YOUTHS - ESA INITIATIVE GERAÇÃOBIZ - CORESULT
The products of the field mission – the reports, this bro-                                             that the examples selected were indeed good practices, and
chure, and documentation of selected good practices – were                                             discussed how these could be improved upon and/or repli-
developed with significant input from key stakeholders, na-                                            cated in other areas. In June, PGB committee members at
mely representatives from the Ministry of Youth and Sport                                              national level participated in a workshop, where the draft
(MJD), Ministry of Education and Human Development (MI-                                                brochure and good practices documentation were presented
NEDH), and Ministry of Health (MISAU); PGB’s new part-                                                 and discussed. Participants provided concrete suggestions
ners, Ministry of Gender, Children and Social Action                                                   for improving the documents, with a particular focus on ma-
(MGCAS) and Ministry of Justice; as well as important in-                                              king them useful and appropriate for national stakeholders.
ternational and national partners such as UNFPA,                                                       Currently, the PGB stakeholders plan to develop a new stra-
UNESCO, UNAIDS and the youth network Coalizão. The                                                     tegy for their coordination of youth (including health-related)
findings of, and key recommendations emerging from the                                                 objectives. The outcomes of this mission deliver important
field mission, were first presented at a workshop for key sta-                                         inputs to this process. This presents a great opportunity to
keholders at the provincial level, as well as PGB committee                                            align the PGB priorities to the targets of the ESA commit-
members, in Beira in May 2018. Stakeholders confirmed                                                  ment.

                      Map of countries included in the ESA Commitment
                      Process

                                                                                                           All interviewees consented to the publication of their
                                                                                                           pictures and statements. However, in order to protect
                                                                                                           the privacy, names of youths have been changed and
                                                                                                           photographs are not of the youths mentioned in the ar-
 Credit: youngpeopletoday.net

                                                                                                           ticle on the same page.

                                                                                                           This brochure could only be developed due to the
                                                                                                           openness and professionalism of all involved stakehol-
                                                                                                           ders. Therefore, the consultants want to express their
                                                                                                           gratitude to these partners.
                                Note: Map is indicative and does not reflect official boundaries

                                                                                                   6
GOOD PRACTICES SRH APPROACHES FOR YOUTHS - ESA INITIATIVE GERAÇÃOBIZ - CORESULT
Mozambique

                                                       M    ozambique is one of the poorest countries of the world with an extremely young population (ave-
                                                 rage age: 17.2 years). Almost half of the population is under 15 years old. This equates to about 13 million
                                                 people, many of whom will become adolescents in the near future. A fifth of the population are already ado-
                                                 lescents (in Mozambique up to 24 years old). Half of the adolescent girls have their first child before the
Credit: GDJ — Pixabay

                                                 age of 18, more than 20 per cent before 16. Access to education and to health services has improved si-
                                                 gnificantly in the past years. Nevertheless, knowledge regarding sexual and reproductive health is limited
                                                 among large parts of the population. The initiative Programa GeraçãoBIZ is the most important access
                                                 point to youth – and in some cases indirectly to their parents – to facilitate behaviour change that enables
                                                 adolescents to lead healthy and autonomous lives.

                        Mozambique Demographic                                Baseline Data
                        Profile 2018                                          Prevalence in per cent

                                     65+ - 3%
                                                                                Target

                                                                                                    Woman married
                                                                                 ESA

                                                                                                                                                           48%
                                                                                  5

                                   55-64 - 3%                                                 before the age of 18 ***
                                                                                Target

                                                                                                     Prevalence of
                                                                                 ESA

                                                                                                                                                    37%
                                                                                  4

                                                                                             genderbased violence *
                                    age 25-54
                                       27%                                                             Pregnancies
                                                                                                                                                             56%
                                                                                                among 18 year olds *

                                                                                                       Pregnancies
                                                                                                                                                     39%
                                                                                                among 17 year olds *
                                                                                Target
                                                                                 ESA

                                                                                  3

                                                                                                       Pregnancies
                                                                                                                                              22%
                                    age 15-24                                                   among 16 year olds *
                                       22%
                                                                                                       Pregnancies
                                                                                                                                    10.5%
                                                                                                among 15 year olds *

                                                                                                     HIV prevalence
                                                                                                                              2.8%
                                                                                                  among young men

                                                                                                    HIV prevalence
                                                                                                                               4.6%
                                                                                               among young women

                                     age 0-14                                                    HIV prevalence rate
                                                                                Target

                                       45%                                                         among men aged                  10.2%
                                                                                 ESA

                                                                                  1

                                                                                                            15 to 49
                                                                                                 HIV prevalence rate
                                                                                                among women aged                      14.2%
                                                                                                            15 to 49
                                                                                                 HIV prevalence rate
                                                                                                  among adult aged                   12.3%
                                                                                                          15 to 49 **
                                         Age

                                                                              * INE 2013; data 2011 (Instituto Nacional de Estatistica, MZ)
                                                                              ** HIV prevalences: UNAIDS 2016
                        Source: IndexMundi.com                                *** UNICEF 2015

                                                                                       7
GOOD PRACTICES SRH APPROACHES FOR YOUTHS - ESA INITIATIVE GERAÇÃOBIZ - CORESULT
GeraçãoBIZ

PGB: About the Programme GeraçãoBIZ

         M    ozambique's youth are                                socio-cultural, physical/sports and economic activities as a
always busy, or ‘bizy’ as many young                               mechanism to improve … life quality and well-being”. Some
people like to write. That’s why it is the                         of PGB’s objectives are also related to the National HIV
BIZgeneration – GeraçãoBIZ: Always                                 Council’s strategic objectives for 2015 to 2019 (PEN IV).
seeking challenges and trying to do
things differently. This at least was the
assumption when the initiative Pro-                                After some years of limited activity, PGB has been under-
grama GeraçãoBIZ (PGB) was laun-                                   going a process of revival since 2016. Zambezia is again
ched in 1999, first in Mozambique’s central province               one of the priority provinces. The largest current PGB initia-
Zambezia, and the nation’s capital Maputo, then all over the       tives are financed and implemented by UNICEF, UNFPA and
country.                                                           PEPFAR. It is steered by a committee comprising the Minis-
                                                                   try for Youth and Sports (MJD), the Ministry of Education
                                                                   (MINEDH), and the Ministry of Health (MISAU) with the par-
PGB is Mozambique’s most important initiative that targets         ticipation of the ministries of gender and of justice, and im-
youth. It covers social and educational activities. The main       plemented by local and international organisations,
objective is based on the 2nd priority of Mozambique’s Five-       predominantly through large networks of youth volunteers.
Year-Plan, namely: to “promote the participation of youth in

  Coherence between GeraçãoBIZ and the ESA Initiative
 ESA
  ESAtargets
      targets                                                       PGB targets

     TARGET 1: Consolidate recent and hard-won gains                 Main Objective: Improve adolescent sexual and re-
     in the reduction of HIV prevalence, and push towards            productive health (ASRH) and reduce the incidence
     eliminating all new HIV infections among adolescents            of HIV and AIDS… and STIs.
     and young people aged 10-24.                                    PEN IV: Reduce … HIV infection by 30% until 2019.

                                                                     Reduce the vulnerability of adolescents and youth by
                                                                     promotion of access to information about SRH, STI,
     TARGET 2: Increase to 95% the number of adoles-                 HIV/AIDS.
     cents and young people aged 10-24 who demonstrate               PEN IV: Increase the comprehensive knowledge of
     comprehensive HIV prevention knowledge levels.                  youth 15 to 24 years old in regard to HIV by 60% until
                                                                     2019.

     TARGET 3: Reduce early and unintended pregnan-                  Specific Obj.: Reduce the incidence of early pre-
     cies among young people by 75%.                                 gnancy; Reduce the incidence of unsafe abortions.

     TARGET 4: Eliminate gender-based violence.                      Foster life skills and the promotion of quality clinical
                                                                     (medical) services, in regard to human rights and gen-
                                                                     der (equality).
     TARGET 5: Eliminate child-marriage.

                                                               8
GOOD PRACTICES SRH APPROACHES FOR YOUTHS - ESA INITIATIVE GERAÇÃOBIZ - CORESULT
ESA and PGB objectives
                                                                                                         aim to strengthen youths’
                                                                                                       access to SRH information.

Mozambique’s Ministry of Health (MISAU)
has inaugurated youth-oriented spaces in a
large number of health centres (Serviço de
Amigos dos Adolescentes e Jovens, SAAJ).
Other donor funded initiatives include an
anonymous SMS counselling service, which
aims to provide education on reproductive
health and to sensitise youth on HIV preven-
tion. It also promotes the use of family plan-
ning services and motivates its users to seek
health advice at a SAAJ. The cascading
mentoring system among girls and young
women, used by the projects “DREAMS”
and “raparigaBIZ” has similar objectives:
specially trained nurses counsel the pupils
on SRH and refer them to newly (re-)establi-
shed youth friendly health services (SAAJ).
Mentors – youth volunteers – pro-actively hold presentations
about SRH topics for school students and community youth
and, where required, refer them to the school nurses or
SAAJ. The mentors also link communities and schools, for
example when they help young mothers to return to school
after having dropped out during pregnancy. The innovation
in this approach is that this represents a shift from PGB’s
traditional peer-to-peer approach to a mentor-based ap-
proach. Many more activities are implemented by local and
national NGOs, such as AMODEFA, which is the only civil
society organisation providing youth counselling and a youth
health facility, thereby supporting the public service with the
provision of better access to SRH services.
                                                                      ●   A “SAAJ” is an area of a health facility especially
                                                                          for youth to facilitate their access to SRH services.
.
                                                                      ●   A “Cantinho” is a dedicated space in schools,
                                                                          where a nurse provides counselling in SRH, and
                                                                          ensures the linkage to the nearest SAAJ.
    The ESA Commitment targets complement the
    PGB’s targets. The main focus of PGB measures are                 ●   “DREAMS” and “raparigaBIZ” are two of the lar-
    on peer-to-peer approaches for in and out-of-school                   gest current programs targeting youth health.
    youth. The institutionalisation of CSE in schools is                  DREAMS targets youth irrespective of gender,
    not addressed by the PGB. The ESA Commitment                          while RaparigaBIZ focusses on girls and young
    targets consider both the development of a CSE cur-                   women. Both contribute significantly to lower rates
    riculum framework as well as capacity building of                     of early pregnancy, marriage, and school drop out
    teachers in CSE.                                                      of young mothers.

                                                                  9
GOOD PRACTICES SRH APPROACHES FOR YOUTHS - ESA INITIATIVE GERAÇÃOBIZ - CORESULT
Good Practice
             PGB Monitoring

From paper to digital — the challenge

         M    onitoring is complex. The simplest tasks are              level, with representatives of the three main stakeholder mi-
those most prone to error: volunteers fill out short forms sta-         nistries of health, education and youth, accompanied by the
ting whom they visit when and why. Their supervisor reviews             ministries of justice and gender. There are also similar mul-
and aggregates the information. Everything is written by                tisectoral committees at province level. Their members’
hand. That is the case with most of the volunteer programs,             tasks are to coordinate implementing organisations; to liaise
including “raparigaBIZ”, which provides young female men-               with NGOs and other sectors; and understand the needs
tors for adolescent girls. “Since I started coordinating the ra-        and demands on the ground. Therefore, theoretically, data
parigaBIZ mentors, I never had a reporting form,” says a                from the health, education and youth ministries feeds into
youth volunteer coordinator. She developed one herself, and             the PGB reports. But at the community level, reporting from
now aggregates the information on her computer and                      sectors is combined. Data on numbers of youth trained at
passes this on to her organisation’s supervisor. So far, she            an individual school in health, may therefore be fed into to
never received any feedback on the data. “I have no idea                all three sectors at the provincial and national level, and, as
what they do with it,” she says.                                        a result, be over-reported in national reports.

Nurses in youth health centres also fill in forms that are              Furthermore, PGB at national level collects youth-relevant
crammed with columns. They record patients, number of                   data from several ministries, but may also receive data from
youth counselled, as well as results of health tests. Some-             the PGB province committee, as well as from implementa-
times they get confused and fill the monthly totals in each             tion partners. Their data may or may not have already been
of the four week-columns, quadrupling the number of pa-                 integrated at province level. As a result, it is difficult to inter-
tients. Simple offices, overflowing folders and shelves, and            pret aggregated data.
humid air pose difficulties for storing
these paper-based forms. District health
officers are meant to collect the forms.                                                      The revitalisation of PGB led to an effort
That’s why for many administration per-                                                       to strengthen data collection and mana-
sonnel, monitoring is considered equal                                                        gement, especially in Zambezia. The
to field visits. Sometimes, nobody                                                            PGB provincial coordinators were ex-
comes to collect the forms. In other                                                          pected to implement a mapping process
cases, the forms are only collected by                                                        by June 2017. However, only eight of
the international organisation who finan-                                                     Mozambique’s eleven provinces contri-
ced the equipment.                                                                            buted data; Zambezia had not finalised
                                                                                              its mapping by May 2018. In addition,
                                                                                              many of the coordination meetings at
The forms that reach the district or pro-                                                     provincial and district level were not
vince office have to be digitised into                                                        held in 2017.
Excel sheets. Thousands of handwritten
numbers combined with time pressure
can lead to simple errors, for example
mixing-up the use of decimal and thou-
sands separators.

PGB follows a multisectoral approach: it                                                            At ground level, monitoring is
is steered by a committee at national                                                               paper based.

                                                                   10
Clotilde receives reports
                                                                                                                              via WhatsApp.

                                          Testimony
              Clotilde

The true reports
 come by WhatsApp

          Clotilde plays with her mo-
                                              The group exists since March 2016;         planning. Sexually transmitted di-
                                              currently there are 19 district coordi-    seases will be another important
bile phone. In front of her, on her           nators, 12 nurses and five province        topic during discussions and
desk, are a laptop and an old compu-          staff in the group. Three district coor-   speeches.
ter. Mostly she uses the laptop, but          dinators are not in the group because
some data are still stored on the old         they do not have mobile phones that        Four participants will be awarded a
computer. Eleven other desks with             support WhatsApp.                          prize for asking questions. Who asks
computers, and another with a ty-                                                        the most, or most pertinent, ques-
pewriter, stand in the large room on          Some group members send pictures           tions will receive a t-shirt for example.
the third floor of a Portuguese colo-         from health days in remote commu-          The aim is to motivate youth to speak
nial building. The room’s floor looks         nities or schools. Others use the          out, to ask questions, and to share
like a spider web made of power               group to prepare a health market with      knowledge. Where youth are reluc-
cords. Four colleagues sit in the             different prevention activities, pre-      tant to ask when something is not un-
room, their backs to the big windows.         sentations and testing opportunities.      derstood, such approach is of high
The provincial health administration          “The true reports are here”, she           value.
has its offices in this building.             says. Clear messages, short sen-
                                              tences, facts, pictures and observa-       Clotilde has been working for one
Clotilde checks her WhatsApp mes-             tions. Formal reports need much            year at the provincial health adminis-
sages: “Here I get the news from              more time.                                 tration coordinating PGB activities.
my colleagues in the schools and                                                         She is directly subordinate to the di-
health centre,” she says. As the per-         “Right now, we are preparing a             rector to strengthen health at
son responsible for school health,            school show”, says Clotilde. “The          schools. Before that, she worked as
she is part of a WhatsApp group               health director had the idea last          a nurse and studied psychology, and
comprising officers and focal points          year. Two months later, the first          was a youth health counsellor. So-
from education, youth and sports,             school show was held. That was             metimes she misses working directly
and health in the various administra-         not planned nor budgeted. Even             with youth and patients.
tions. One member asks for some               so, we managed to get the money            Again she checks her messages: a
statistical data. Clotilde answers that       together from our budget, and by           nurse from a youth health centre 150
the district officer for youth and edu-       involving some NGOs.” Four more            kilometres away just sent a photo-
cation has this. The inquirer now             school shows are planned for 2018 in       graph of the weekly monitoring
knows to whom to write the letter re-         and around Quelimane, Zambezia’s           sheet, packed with columns showing
questing information. “This is much           provincial capital. They anticipate        numbers of youth advised, tested,
faster, than the usual way: asking            about 200 participants for each            and adhering to treatment plans. Clo-
here and there, writing letters to            event, mostly school students. Volun-      tilde will have to transfer the numbers
several institutions one after ano-           teers will be there to provide counsel-    to the Excel sheet on one of her com-
ther”, Clotilde states.                       ling to participants regarding family      puters.

                                                                11
Good Practice
             School Approach

                                                                                                       Volunteer mentors pro-actively talk
                                                                                                         to school students and motivate
                                                                                                               them to seek advice in the
                                                                                                                  school’s health corner.

“Cantinho”: the little health corner

         177    is the number of cantinhos in Mozambique.
Many secondary schools have a “little corner”, where school
students can receive counselling, family planning advice,
and condoms. Here they can talk about gender roles as well
as sexual harassment or early pregnancies. In Zambezia
province, nurses specifically trained to counsel youth work
here every day.

All the rooms look very much the same, usually equipped                cess to the students than the nurse. They make contact with
with a small black sofa, a few white metal chairs, and an              the students during the school assembly before the school
empty refrigerator. The equipment is donor financed, the               shift starts or during school breaks. The pupils share their
nurses’ salaries too.* The schools provide a room and                  personal cases with the mentors, who try to convince them
contribute with electricity supply. As yet no concept has              to seek counselling at the cantinho. Some students may
been developed to facilitate the integration of nurses into            also be advised to visit the psychologist, who attends about
the public health sector to ensure sustainability.                     once a week.

A similar approach was previously implemented until                    The use of volunteer-“mentoras” to refer students to the can-
2011/2012: Students ran small school clubs, where other                tinho’s nurse is a good practice, as it helps overcome the
students could seek advice regarding sexual and reproduc-              reluctance of many adolescents to ask the nurse for advice
tive health. Nowadays, cooperation exists between the can-             because of their respect for her. This is despite the fact that
tinhos and the nearest health facility or youth friendly health        many of the nurses are only five to ten years older than the
service (SAAJ). If a school’s nurse thinks that a student              students.
should do a health test, she advises them accordingly. It
may take one meeting or several, until a student is ready to
take a HIV test. Then she refers the student to the health
facility. A voucher system is used for monitoring: the health
facility staff signs one copy for return to the school nurse
and keeps another. This enables the nurse to count and fol-
low-up how many referred students really went to the health
facility.

The school nurse cooperates with volunteer mentors, the                * The installation of “cantinhos” with nurses in schools and mento-
                                                                       ras, is part of PEPFAR’s regional project “DREAMS”; in Mozam-
school director, and a psychologist. Volunteers are about              bique with 13 local partners at least until 2019
the age of the elder students and therefore have easier ac-            (www.pepfar.gov/documents/organization/249176.pdf).

                                                                  12
Carlos from the education district administration
                                                                                         visits a school’s health corner, which is managed
                                                                                                               by the health administration.

                                           Testimony
               Carlos

For healthier youth:
cooperation of schools,
nurses and community

          “C    antinhos are a big             phies of women who fight against          neficiaries receive a backpack, pens,
challenge”, says Helder. “There is             gender inequality and violence. The       and notebooks. This is supposed to
simply not enough space”. The                  nurses could also support the             motivate the parents to send their
personnel of the provincial education          schools’ focal points and social assis-   children back to school.
administration are responsible for             tants, who are there to support the
health at schools, including HIV pre-          teachers in terms of HIV prevention       The distribution of the school mate-
vention (Saúde Escolar), as well as            and mitigation. Healthier teachers –      rials, as well as coordination tasks
for the coordination with the district         that would probably also reduce the       with local organisations and cantin-
administration and the provincial              number and length of absences.            hos, is recorded in reports compiled
PGB committee. “Without the sup-                                                         by Helder and Carlos. The report
port of individual organisations,              The idea to integrate HIV or health       contains everything that has to do
we would hardly be able to imple-              subjects in the school curricula has      with youth or education, and is inten-
ment the Program GeraçãoBIZ,”                  been discussed for a number of            ded to be transferred to the provincial
adds Carlos, responsible at district           years already. However, a final deci-     administration. Additionally, Helder
level for education, youth and sports.         sion has yet to be reached. There is      meets with his counterparts in the pu-
There are volunteers to coordinate,            a Pacote Básico, the basic package:       blic health sector – sometimes infor-
decisions to make regarding the lo-            a book, some brochures, and maybe         mally, sometimes in official meetings.
cation of new cantinhos, and schools           some flyers informing about HIV pre-      Topics are the management of the
to advise on how to cooperate with             vention and mitigation. Most schools      volunteers, who may be exempt from
the cantinhos’ nurses.                         are said to have received the basic       school or university fees, or enjoy
                                               package, some of them may use the         priority in selection processes for pu-
But the administration staff are al-           material. This year, Carlos had just      blic service vacancies.
ready thinking ahead. Wouldn’t it be           23 sets to distribute for one hundred
great, if the nurses in the schools            schools that requested one.               “We report what we consider rele-
also provided advice to the teachers?                                                    vant to the Program GeraçãoBIZ
The aim would be for teachers to feel          Carlos also participates in the distri-   committee,” confirm Carlos and Hel-
more confident to integrate health is-         bution of school material to poor pu-     der. The activities are discussed du-
sues into the lessons: multiplying             pils. Most of them already dropped        ring trimestral meetings of the
condoms in math; discussing the be-            out of school in order to help at         provincial GeraçãoBIZ committee
ginning of HIV in history lessons. In          home. The beneficiaries are chosen        and may find their way to the national
language lessons there may be                  by local community leaders. During        level via reporting of the ministries’,
space for stories about famous peo-            the half-day event, which includes        GeraçãoBIZ, and the partner organi-
ple living with HIV, and for the biogra-       speeches and TV interviews, the be-       sations.

                                                                 13
Good Practice
             School Approach

                                                                       Nurses are specially trained
                                                                       to counsel youth.

Cantinhos’ empty fridges

M   ost cantinhos are equipped with a refrigerator. The little
cube with a glass door usually stands on one of the metal
chairs in the room where nurses provide advice to students
on sexual and reproductive health. The refrigerator is always
empty.

It was intended to be filled with several health and HIV tests.              leader, would be the ideal institution to convince the parents
However, schools are prohibited from providing HIV tests.                    of the importance of this measure, once the health ministry
The public administration is concerned about the reaction                    approves health tests being conducted in schools.
from parents. Would they protest? Would they tell their chil-
dren not to go to school anymore? Therefore, the schools’
nurses refer students to health facilities if they believe a                 The discussion regarding the availability of HIV testing in
health test is appropriate. After leaving the cantinho, some                 schools, performed by the specifically trained nurses, be-
of the students may choose not to                                                                came more important again during the
take the test. They may have deve-                                                               field mission for the ESA initiative in
loped confidence and trust in the                                                                Mozambique. Some individuals in the
school nurse, but she would not be                                                               education and health ministries are in
there when they receive their result                                                             favour of allowing HIV testing in
in a health centre or SAAJ.                                                                      schools. However, official approval is
                                                                                                 still needed from the ministries.

In the first quarter of 2018, the pu-
blic discussion was relaunched:
some administrators in the educa-
tion ministry are now in favour of
permitting HIV testing in schools.
This will likely require a consulta-
tion process with parents to obtain
their consent. Probably the school
councils, composed of teachers                                                                           Youth health facilities are equipped
and parents and sometimes a local                                                                        with new furniture.

                                                                  14
When boys ask for condoms, the
                                                                                                    cantinho nurse starts talking to
                                                                Testimony                          them about family planning and

              Maria Rosa                             Olinda                                                          responsibility.

“Most of the visitors
   are boys”

         M    aria Rosa’s work day
starts about seven o’clock in the mor-
ning. At this time, the young nurse      the uterus, or that the
opens the door to her cantinho. Only     free public condoms
a few months ago, this small room        are of bad quality.
was a storage room. Now, a plaque        The topics are similar with female pu-    to zero”, says the female director of
outside the room states “Cantinho” –     pils.                                     the school. In 2016, before there was
the school’s health corner. “Some-                                                 a cantinho, more than twenty young
times more than hundred students         “It is harder to make girls visit the     women aged between 14 and 18 had
come through each day”, she says.        cantinho”, observed Olinda. They          left school before their final exam.
“It wouldn’t be so many, if there        are afraid of being laughed at by their   Most of them have since returned
weren’t the mentoras”, Maria Rosa        classmates, “and they are asha-           after being visited by a mentora.
adds. 3,552 students are registered      med to talk to a respected person,
at this school in the suburbs of Zam-    such as a nurse.” This is despite the     If Maria Rosa considers it necessary,
bezia’s capital Quelimane. “Mento-       fact that Maria Rosa is only a few        she refers students to the nearest
ras” are female youths who actively      years older than the senior students.     SAAJ, or arranges a meeting with the
seek contact with the students, to                                                 psychologist. “It would be impor-
motivate them to visit the cantinhos.    Four mentoras volunteer at this           tant for us to be able to do HIV
Olinda is one of them: “Just a few       school. They are trained peer-educa-      tests at the school”, she says, and
years ago, I was also a student          tors. During the morning gathering, or    the school director agrees. She also
here.”                                   when teachers are absent or late,         would like to cooperate more with the
                                         they explain different aspects of         school’s HIV Focal Person to find a
“Most of our visitors are boys”,         sexual and reproductive health, gen-      way to integrate health and HIV
observed Maria Rosa, they ask for        der-based violence, or family plan-       knowledge in school lessons. But her
condoms. In March 2018 alone she         ning to the classes. “There is            time is limited. Since the volunteers
distributed 4,000 male and 50 female     always someone approaching us             motivate the students to use the can-
condoms. But before she gives them       after the presentation”, says             tinho, there are only very few mo-
some, she starts a discussion. She       Olinda. That’s how they can initiate      ments when the cantiho is empty.
tries to get them talking about sexua-   regular contact with the students.
lity, family planning, STIs, HIV and     They can follow up their concerns         Maria Rosa is employed by an inter-
other related topics. She asks them      and refer them to the cantinho. Ge-       national organisation. Her contract is
to show, using a wooden penis            neral issues are also discussed with      limited to approximately two years.
model, that they know how to use a       the school directorate. “Since ha-        Her training and the training of the
condom correctly. Lots of myths also     ving a cantinho, the number of            volunteers is implemented by an or-
have to be debunked, such as the         school drop-outs due to unwanted          ganisation from the USA.
beliefs that contraception will burn     pregnancy has decreased almost

                                                           15
Good Practice
            School Approach

                                               Program raparigaBIZ:
                                              girls learn and discuss
                                               about family planning
                                              and their rights in safe
                                                              spaces.

Girls for Girls

T  he raparigaBIZ approach seeks to create safe spaces for
female adolescents. Boys and men are excluded in order
that the young women feel free to talk about their doubts
and wishes, their fears and hopes. These opportunities for
exchange help them to understand that they are not alone
with their questions. They seek answers and advise each
other with the help of trained female volunteer mentors.
They discuss their parents’ and aunties’ perceptions of fe-
mininity, expectations of boyfriends and male family mem-
bers, and take more control over their lives. They feel safer                 The strength of the approach is also its weakness: The ra-
as a community. Many of these young women learn to                            parigaBIZ approach targets girls and young women. It is not
speak out, to articulate what they expect and what they                       for boys or young men. Although girls and young women are
want. They learn what sexual harassment is, and that they                     learning that early pregnancy and dependency on men limit
can denounce it. They learn to ask questions confidently,                     their personal freedom, the effectiveness of this program
with their head raised and their                                                                       may be limited as long as men
eyes directed to the teacher or                                                                        consider that these women are
other respected-person in front of                                                                     breaking long-standing “traditions”.
them.

RaparigaBIZ is financed by the                                                                         There are some other gender-
Swedish government and is im-                                                                          mixed volunteer networks focus-
plemented by several local and                                                                         sing on youth health. These can be
national NGOs under the um-                                                                            seen as a first step in the right di-
brella of the youth organisations                                                                      rection.
network Coalizão, for example in
Zambezia province. Its aim is the
“full realisation of sexual and re-
productive rights of girls and                                                                         During this field mission, the issue
young women through empower-                                                                           was raised and some PGB stake-
ment for informed choices and                                                                          holders are now aware that there
provision of access to SRH ser-                                                                        is a need for a boys program – let’s
vices”. In Zambezia, the project                                                                       call it rapazBIZ – to strengthen
has reached about 4,900 girls                                                                          equal opportunity.
aged between 10 and 24 years
old since its beginning in 2016.
Girls aged between 10 and 14
years old are its largest cohort.

                                                                         16
Lídia coordinates young
                                                                                                                            girl volunteers.

                                           Testimony
               Lídia

Leading the girl volunteers
          L    ídia coordinates 300 girl       Each      mentor
volunteers. 135 of them are active             meets every Sa-
mentors, the others are waiting for            turday and Sunday with their group         water, or at least receive some-
their initial training. The 19-year-old        of up to thirty girls and young women.     thing to eat, instead of just atten-
is in the 11th class. She supports the         They are between 11 and 19 years           ding our meetings.” But slowly, also
selection and training of the volun-           old, mostly around 16. They talk           the parents are seeing the advan-
teers from several schools around              about what they learned about them-        tages of the meetings.
Mocuba, a small city in Mozam-                 selves, as well as family incidents: for
bique’s central region.                        example about the uncle who always         “I don’t even want to tell what I did
                                               gives compliments to his niece;            on the weekends in the past”, says
Until two years ago, she was a volun-          about their boyfriends expecting           one of Lídia’s mentors. Night-life, al-
teer in Hulene, a township close to            them to get pregnant; or the com-          cohol and young men promising ex-
the airport in Mozambique’s capital            ments of teachers, who expect              pensive presents were their escapes
Maputo. In 2016 she moved to her               sexual favours in return for good          from everyday life – bringing some
brother’s apartment in Mocuba. A few           grades. They learn to speak-out and        hope for a better future, or at least
months later, a flyer circulated calling       how to solve difficult situations. The     some pleasure. Today they know
for participants in the raparigaBIZ            mentors also visit families and try to     more clearly what they want – and
movement. She applied, like hun-               convince parents of the advantages         fight for their dreams against old-
dreds of other youth. She was selec-           of young women finishing school and        fashioned rules and perceptions.
ted and soon became a coordinator.             further education, as well as avoiding     Lídia is their role model, self-confi-
                                               early marriage and pregnancies.            dent, taking care of herself without
Every month she meets her girl vo-             Those needing more help, are refer-        being in conflict with her family, going
lunteers to train and advise them on           red to the nearest youth health facility   to school, and leading so many vo-
becoming a mentor for other girls.             (SAAJ).                                    lunteers.
She imparts her knowledge of ado-
lescent reproductive health, youth             “When we invite girls to our advo-
rights, contraception and family plan-         cacy sessions, parents often ask:
ning. The girl mentors take that               ‘What will she bring back for
knowledge to their communities.                us?’”, says Lídia. “They believe it
They motivate girls to join in and dis-        would be better for the girls to
cuss.                                          help in the household, to fetch

                                                                 17
Good Practice
            School Approach

                                                                                                     Volunteers support young mothers,
                                                                                                                  and convince them to
                                                                                                                       return to school.

Young mothers back at school

“W     e have brought eight girls back to school this                   approach”, where training sessions are used to sensitise
                                                                        participants on healthy and good social behaviour.
year”, says Célia happily. These young women aged bet-
ween 15 and 17 were pregnant – “some from teachers,
some from their community”. They had left school when
they found out that they were pregnant.                                 Regularly, the volunteers visit neighbouring communities.
                                                                        They perform improvised plays and hold small discussions.
                                                                        Through such gatherings they get into contact with other
Célia is one of the more than twenty school girls and boys              youth and identify those who may have personal difficulties
who joined the Namagoa Secondary School Youth Club. A                   and/or have left school too early. The volunteers will then
third of them have already received some training and are               visit them and offer basic counselling, sometimes together
passing their newly gained knowledge on to their peers: fa-             with the parents. Through their activities in the communities,
mily planning is the most talked about subject, but also ha-            they are also able to build trust with young women who had
rassment and abuse, health prevention, as well as “rights               dropped out of school in the previous year and encourage
and duties of children”. Some of the school club members                them to return. The husband of one young mother was
visit school during the morning, others in the afternoon, be-           strictly against the idea that she could return to school. He
cause in Mozambique school is organised in shifts. “That’s              believed she would be better off to take care of the house-
how we reach pupils in both groups.”                                    hold. In the end, the 17-year-old left him.

The club is supported by a local NGO named RESA. The                    “Unfortunately, there is no youth health centre around
local community leader is also involved in the project. The             here”, laments Célia. And the nearest normal health centre
school club members can count on his support when they                  is still far away. “We would like to distribute condoms,
implement their activities in the communities. This is be-              but there are never enough,” Célia continues. The geo-
cause he is also the president of the school council and pre-           graphical isolation makes it difficult to refer youth to health
sident of the co-management committee of the local health               services or to get there regularly to obtain condoms. Howe-
facility. The coordinator of the club is the sports teacher, who        ver, the school club volunteers continue advocacy in the
is also the school’s HIV Focal Person. The young male tea-              communities, seeking to bring young mothers back to
cher started a football club with the volunteers. He applies            school.
elements similar to the “youth development through sports

                                                                   18
Teachers may be reprimanded
                                                                                                                       for sexual abuse.

                                           Testimony
               Josina

Favours for good marks
          J osina* cries. She was
late for the Portuguese language
test. The teacher still let her partici-
pate, but gave her a bad grade. Du-
ring a moment when he was alone
with her he said: “How can I sup-              For the harassed girls, the mentor        would be “culturally inappropriate”.
port your promotion to the next                volunteers and cantinho nurses are        However, they let the story circulate.
[school] year, if you don’t want to            extremely important. They may not         Without any direct talk between the
be with me?”** Ashamed, Josina                 be able to take action against the tea-   students and the director, the director
tells her closest friends about the            chers, but at least they advise the       summons Josina’s teacher and ad-
threat. One of them is a volunteer             girls on how to tackle the situation      monishes him. A few days later, the
mentor. She advises her to not follow          and how to reject such men. The girls     school council convened a meeting
the teacher’s demand.                          learn that no man, teacher or not, has    to discuss the matter and publicly re-
                                               any right to claim favours. This          primand the teacher. Josina receives
Many teachers are young, about                 contrasts with the beliefs of many pa-    a better test result and will be promo-
twenty years old, when they start              rents and students, who still consider    ted to the next year. But she will still
their career. In remote areas, they            such behaviour as inevitable, some-       have to continue lessons with that
are the most respected person with a           thing that can’t easily be changed. A     teacher…
regular salary. At the same time, they         majority of men as well as women
are a stranger, since they are often           also believe that short skirts are an
transferred from other provinces.              invitation for sexual advances.
Despite the law and the teacher’s
union code of conduct prohibiting              There is only one female teacher at
sexual relations between teacher and           Josina’s school, the other twenty are
student, teachers demand favours               men. The female teacher is known as
from female students again and                 rigorous and distanced, usually lea-
again. Consequences are rare.                  ving the school quickly after her les-
There may be some small note in the            sons. Today she is not at school.
personnel record, or a teacher might
get transferred to another school.             The school director sits under a tree
Some administration staff say they             beside his office together with some
prefer to educate the teacher, instead         teachers. None of the girls nor the       * not real name
of demotivating them through punish-           volunteer mentor dare to mention the      ** in Mozambican Portuguese:
ment.                                          incident. They consider that doing so     “…namorar comigo”

                                                                19
Good Practice
            Clinical Approach

                                                                                                      Girls accompanied by a mentor-
                                                                                                        volunteer have priority access
                                                                                                              to youth health facilities.

SAAJ — the safe health alternative

444       is the number of SAAJ in Mozambique. In Zambe-
zia province, about 55 SAAJ offer their services for youth
aged up to about 24 years. SAAJ stands for Youth Friendly
Health Services, which are specialised units in health faci-
lities. SAAJ offer health services ranging from counselling
to health tests. In case of positive results, the patient com-
mences treatment immediately – irrespective of whether it
is a sexually transmitted disease, malaria, or diabetes. The
basic concept is to offer services for youth in a separate
space, usually in the backyard of a health facility. This ap-
proach reduces waiting times for the target group, and uti-
lises specially trained staff. It also reduces fear of being
seen by other, often older, relatives or neighbours. There-
fore, the inauguration or rehabilitation of a SAAJ itself, can
be considered a good practice, as this facilitates the use of           These partners generally rehabilitate and equip SAAJ
medical services by youth.                                              rooms, with PEPFAR funds. The Mozambican Association
                                                                        for Family Development (AMODEFA) is the only organisa-
                                                                        tion that provides a privately run specific SAAJ in Zambezia
There are two types of SAAJ: specific and alternative. While            province.
the specific SAAJ is an independent physical ward in a
health facility, the alternative SAAJ may refer to just a room,
or the availability of specifically trained staff during opening        The SAAJ provide youth with improved access to adoles-
hours within the health facility building. Currently, there are         cent-oriented health information and care, especially in re-
some alternative SAAJ being upgraded and equipped to be-                gard to sexual and reproductive health. There are many
come specific SAAJ.                                                     examples that demonstrate that the existence of the cantin-
                                                                        hos (school health corners) strengthen the demand for and
                                                                        existence of SAAJ.
This clinical approach is implemented by the health sector
with the support of four partners: Friends in Global Health
(FGH); International Center for AIDS Care and Treatment
Program (ICAP); and Family Health International (FHI 360).

                                                                   20
Nurse Digna explains
                                                                                                                         monitoring forms.

                                           Testimony
               Digna

SAAJ in action
          D   igna smiles when she             only 24 years old,” she
talks. Her questions are focused and           won’t question them, Digna
direct. When she listens, she holds            confides with a twinkle in
the gaze of the person speaking. Be-           her eye. “Young women are much             have to wait. An old poster warning
fore answering a question, she re-             more likely than men to come to            against tuberculosis is peeling off the
peats it to make sure she understood           the SAAJ”, Digna continues. Most of        main door.
correctly. She has been working as a           them heard about family planning
nurse, mostly with youth, for around           and come wanting to know more              SAAJ-visitors who only ask for coun-
thirty years. About three years ago            about it, and what contraception op-       selling are not even counted. Digna
Digna became responsible for two               tions there are. Among the young           records only the patients who ask for
youth health facilities, called SAAJ, in       women seeking advice are those             contraception, who receive tests, or
a small district almost 150 kilometres         who work during the weekends               who are ill. In case of positive results,
north of Quelimane. More than one              around the small bars, right in front of   the patient commences treatment im-
hundred 12 to 24 year olds pass by             the health centre. They come be-           mediately irrespective of whether it is
here every day. “Actually, we                  cause of STIs and ask for condoms          a sexually transmitted disease, ma-
should open the SAAJ every day                 – “If they actually use the                laria or blood pressure. Drugs and
until 7 pm, not just until 3 pm,” she          condoms, I don’t know”, says               test kits are always available. There
says. “That’s too early for many               Digna.                                     are only shortages of Salferoso, used
school students.” But the public                                                          to treat anaemia, from time to time.
system cannot pay for the extra                Her small SAAJ consists of a desk,         Digna records the patients in a list,
hours, nor can the U.S. American               on it a stack of papers and some           disaggregated by gender and age.
university, which contributed equip-           condom bulk-packs, there are four          These lists are the SAAJ’s reports,
ment to the youth health facility.             simple chairs, a small empty refrige-      collected in large folders. Up until one
                                               rator for medicines, a locker, and two     year ago, the only person who ever
The youth come individually or in              rubbish bins. No computer, no tablet.      came to collect the lists, was so-
groups of five to ten. “Last Monday,           The white-washed walls show traces         meone from the international organi-
a group of 15 girls came here,”                of people who have leaned on it. The       sation that funded the SAAJ
Digna reports. “They wanted to                 door of the three by seven-meter           equipment. What they do with the
know what sexually transmitted                 room leads directly outside to the hot     monitoring papers – nobody in the
diseases are.” Teachers frequently             sun. This is where the young women         administration knows. Nowadays,
send students to the SAAJ to                   wait. Those wanting to go to the main      since Clotilde has been working in
research various health topics.                clinic need to go around the building      the provincial health administration,
                                               and through a narrow corridor, with        Digna uses WhatsApp to send pho-
The SAAJ is limited to youth up to the         similar basic treatment rooms on           tographs of the monitoring lists. The
age of 24 years to keep waiting times          both sides. On every door hangs an         provincial health administration then
short. Although “some come here                A4-sized printed document announ-          has to transfer the data into Excel
with three babies and say they are             cing that coughing patients do not         sheets.

                                                                 21
Good Practice
        Clinical Approach
                                                                                                     Some SAAJ only provide limited
                                                                                                     space for nurses, administration
                                                                                                                   and examination.

                                           Testimony
                 Feliciana

   Schools revitalise
   Youth Health Facilities

                                               mentors

             “O
                                               come from a
                   ur SAAJ was revita-         school, ac-
   lised because of the cantinhos”,            companying
   says Feliciana. “It practically did         a        girl”,
   not exist anymore.” Since nurses            usually urgent cases. The SAAJ          friends, who do not consider it ne-
   started working in schools counsel-         and the cantinhos have agreed that      cessary for young, healthy people to
   ling the students and referring them        priority will be given to mentor-ac-    attend health facilities. They may
   for services, many more youth have          companied young women. Every            trigger rumours about their “bad
   been taking advantage of the youth          month Feliciana meets with nurses       health state” which may then lead to
   friendly health service in Coalane’s        who work in school cantinhos. They      discrimination.
   health centre.                              exchange observations and discuss
                                                                                       Sometimes young women them-
                                               important issues, such as how they
   Feliciana worked for several years                                                  selves do not know what exactly to
                                               can convince the young girls to
   in the main patient reception. Youth                                                expect from their visit to the SAAJ.
                                               avoid early pregnancies.
   had to wait there as long as any-                                                   “Often we have to convince the
   body else. From 2016 more and                                                       mothers how important it is that
                                               Most visitors are young women,
   more adolescents started to come,                                                   their daughters come to the
                                               many of them seeking information
   sent from the cantinhos in the near-                                                SAAJ and receive advice regar-
                                               about menstruation, family planning
   by schools. That’s how she was                                                      ding reproductive health”, says
                                               advice and methods. Others are
   able to convince the directors – and                                                Miranda, Feliciana’s colleague. It is
                                               pregnant, and many of them come
   those higher up– to provide a dedi-                                                 important to delay the age at which
                                               with their babies. “15 minutes are
   cated space for a specific SAAJ.                                                    girls have their first sexual relations-
                                               not enough for most of the
                                                                                       hip in order to avoid early pregnan-
                                               cases”, states Feliciana.
   “Most people come in the mor-                                                       cies.
   ning”, says Feliciana and points to         Young men come usually around
   the terrace in front of the SAAJ’s          midday or in the early afternoon.       During the afternoon the visitor
   entry. There is space for about fifty       They mostly come for HIV tests.         numbers reduce. Feliciana uses the
   visitors to wait. Others have sought        This gives hope for a behaviour         time to prepare reports. Her col-
   a shady place under the trees bet-          shift: traditionally men avoid HIV      leagues count the vouchers, often
   ween the one-storey-buildings. Be-          tests, while women are tested as        called referral slips: adolescents
   hind the door of the SAAJ stands an         part of pre-natal care. This often      who were referred from schools
   old table, covered with registration        causes conflicts at home when a         usually bring a kind of referral vou-
   forms. Blood samples are taken              pregnant woman receives a positive      cher. The SAAJ nurses sign a copy,
   here before meeting the doctor in           test result, but the man continues to   which the student should return to
   the room behind. The room of less           consider himself HIV negative.          the school’s nurse. Another is used
   than twenty square meters contains                                                  by the SAAJ for record keeping. Fe-
   a folding privacy screen, a kind of a       Many of young women feel asha-          liciana completes the list, which she
   stretcher, another large table, a few       med to be seen in a health centre.      will bring to the district health admi-
   chairs, and a tiny wooden bench.            They worry that aunts, other family     nistration. In her case, that’s not far.
   Two nurses work here with the doc-          members, or neighbours may see          If the photocopy machine works,
   tor; one to two patients may be             them. They are afraid of uncomfor-      Feliciana will also keep a copy for
   handled at a time. “Sometimes               table questioning by relatives or       the hospital’s reporting.

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