| 4. In which ways is the initiative creative and innovative?
As mentioned earlier, four strategies have been implemented in this project. More details of how they were implemented are as follow:
Empowerment of female adolescents. Female youths were trained to obtain knowledge, skills and attitudes on key subjects such as an understanding about sexuality, HIV and STIs, negotiating skills and leadership skills so that they can become a leader to be able to provide further assistance to their friends or other girls. They could assist in providing referral services and bringing friends into health services. In this process, health staff and trainers did coach and provide close supervision.
Development of female youth friendly health service. With this strategy, health service providers were trained in terms of attitudes and understanding female youths and their nature. They were equipped with knowledge and counseling skills in various subjects including reproductive health, STI testing and treatment and others to build up their confidence to provide confidential, comfortably and comprehensive “one stop service” for female youths.
Specific services for female youths include, for example, vaginal examination, ante-natal care and counseling on reproductive health. The project developed “friendly service” guidelines and standard operating procedure to all practitioners who move forward “friendly service” program implementation.
Development of networks of providers on female youth friendly services. BATS facilitated the development of networks and services using female youths friendly approach. Fund has been provided to provincial health offices for coordination works between government agencies, civil society and private sectors so that they participate in the development and in the provision of services. These include local administrative organizations, drug stores, schools and female youth leaders. The provincial health offices organized consultation meetings to make them understanding about problems and ways to support female youth and to get them involved in planning and implementing project activities.
The project also aimed to develop capacity of female youth leaders in various subjects with intention to support them to establish groups and networks, and finally a council of female adolescents in school or community. Along the process, coaching and assistance from advisory teams were made to all levels: from the province to school. By this means, it has created more opportunities for female adolescents to have representation, express their needs and concerns, in various meetings to improve the system and services.
Development of assistance and follow-up system for female youths in schools. The development of female youth friendly services and the development of the assistance system to all levels including at the schools were being developed together at the same time.
In practice, public health offices invited headmasters of schools, mayors or president of local administrative organizations, community leaders, entertainment owners, and girl leaders to participate in consultative meetings to increase their awareness and to develop an action plan altogether. Guidelines on provision of care and assistance to the female youths who faced with the problems, including those infected by STIs or got unplanned pregnancies are developed. Measures to assist them such as to provide basic counseling and to provide further assistance and follow up were introduced.
By involving all stakeholders, participating agencies knew how to provide care and assistance in an effective manner. In schools, there was a system which helped screen, assist and follow up for those who were at risk of HIV and STIs. In communities, there were drop-in centers where female youths could visit without fear and received services. When they were in the center, they learned about diseases and preventive tools, such as condoms, and related services. The center will assist them for referral to appropriate service, if needed.
| 5. Who implemented the initiative and what is the size of the population affected by this initiative?
BATS as the project manager has played a role to coordinate the implementation and takes the overall responsibility of the management. In addition, it has developed manual, guidelines, communication materials, monitoring and evaluation, and reporting.
Organizations which have jointly worked on female youth friendly services include personnel from government, private sector and civil society. There are 3 main groups of organizations involving in this project.
(A) Technical support organization:
1) BATS also served on the supervision, capacity development and networking of service providers.
2) DOH, Department of Mental Health, Universities and Path2Health provided supports for comprehensive sexual education and development of One stop Crisis Center (OSCC).
(B) Field Operational Organizations: including
1) Office of Disease Control, Provincial Health Offices, and District Health Offices, all of them function as a coordinating mechanism in the field to ensure that friendly health services were in place, continuing provision of technical supports and field level monitoring.
2) Regional hospitals, general hospitals and community hospitals acted as friendly service providers to ensure proactive provision of service to meet the needs of female youths.
3) CSOs in the field to provide prevention services such as provision of education; dissemination of materials, condoms and lubricants; and referral services to appropriate care.
4) Schools, colleges and universities to give counseling, condoms, contraceptives and referral to more appropriate services, if needed.
5) Female youth leaders in communities and schools, village health volunteers, drugstores, and beauty salon shops provided condoms, lubricants, contraceptives, and advice of referral.
(C) Monitoring and evaluation organizations:
1) The Global Fund’s Office of Principal Recipient monitored and evaluated programme performance under the GF grants.
2) The National AIDS Management Center (NAMC) conducted monitoring and evaluation based on the current National AIDS Prevention and Alleviation strategies.
| 6. How was the strategy implemented and what resources were mobilized?
Resources which were used under this project were divided into 2 types: Domestic funding and External funding.
For domestic funding, both financial and human resources were supported by the following agencies.
1) Department of Disease Control by BATS used the resources to develop manual, guidelines, communication materials, monitoring and evaluation, reporting, purchasing condoms and lubricants.
2) DOH used their resources for the development of standard operating procedure (SOP) for youth friendly service model.
3) Department of Mental Health used their resources to develop OSCC (one stop crisis center) guideline and support for “To Be Number One Project”.
4) Local government organizations used their resources for training on sexual and AIDs education, issues related to drugs, empowerment of female adolescents in communities and provision of subsistence fees for PLHAs and disadvantaged persons.
5) Ministry of Education used their resources for the development of health and sexual education and leadership building for teachers.
6) Civil society organizations in the field used their resources for activities to educate female adolescents and develop capacity as well as to assist them in referring to appropriate services.
Domestic funds were mobilized by several organizations since problems encountered by female youths are co-responsible by all of them. Integration of work and is a more efficient way to tackle the problems effectively.
For external funding, most came from the Global Fund to fight AIDS, TB and Malaria (GF-ATM). BATS managed this fund to develop capacity of the personnel, development of referral system, and field monitoring. There were also developments of guideline for referral, producing of printed media materials, awareness raising campaign and promotion of services access, and purchasing of condoms.
In terms of staffing, both domestic and external funds were utilized, with a majority from domestic funding source. Staff was responsible for certain aspects of works. First group was in project management including planning, field monitoring based on project indicators, validation of data as well as analysis and synthesis of project results.
Other group was responsible for finance, financial management and budgeting, including disbursement of budgets, book keeping, audit, reporting from the provinces where the projects were implemented. In this group, there was staff looking after procurement, inventory of articles and audit of project articles.
For the personnel in the field, staff in provincial health office functioned as a local project coordinator. The personnel involved in youth friendly services included physicians, nurses, counsellors, social workers, psychologists who provided specific services including counseling and laboratory tests. Personnel involved in friendly services provision in communities were nurses at sub-district hospitals, teachers, in-school and in-community youth leaders, health volunteers, staff of local government organizations and female youth leaders. For the personnel in charge of technical aspects in the field, they were members of AIDS provincial committee, Officers from Ministry of Education and Ministry of Social Development and Human Security.
| 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
The most successful output of this project was increased capacity, leadership and partnership ensuring provision, and increased access of friendly services among female youths.
Based on the pilot project implemented in 2010 in Suphanburi province, the development of capacity for partners had resulted in a strong network, staff had better attitudes and understanding on female adolescents’ problems. Staff was equipped with skillful counseling and coaching, working as an inter-disciplinary team with proactive personality, referring more cases for appropriate service. Additional committed participants from local government organizations were identified.
Within schools and communities, following aspects were observed: ability of female adolescents to manage and to avoid risky situation, leadership and skill in organization management, clear role of peer in helping friends and other female adolescents, development of school system to provide assistance, more teaching and learning about sexual education and disseminating communication materials and tools. With strengthened partnerships, female adolescents had developed their own capacity, improved attitudes, and been more encouraged to seek assistance in terms of counseling and treatment when needed. Groups and networks of female adolescents were formed in schools and communities and they provided further assistance to other female adolescents.
The results from the project implemented in Suphanburi Province indicated satisfactory outcome. STIs among female school students had trendily decreased from 20 cases in 2009 to only 2 cases in 2011. Giving births by female adolescents declined from 307 in 2012 to 246 cases in 2014 (see more details in response of Q10). From evaluating the satisfaction of the female adolescents, 80% of respondents were satisfied with the services provided by hospitals and more than 85% of the female school students were satisfied with the activities that had been developed in their schools.
After expansion of the project to overall 5 districts in 5 provinces, there were 8,461; 8,432; and 9,227 female youths receiving services from the hospitals providing youth friendly service, as part of the network, during 2011-13 respectively. Before this project, number of cases getting this kind of services was low. Of these, number of teenage pregnancies was level off at around 800 cases a year during the intervention periods. Annual HIV infection rate observed among clients were around 0.4-0.42 % and number of STIs found were 7-8 cases each year.
Based on these data, it is very clear that the project has created a more accessibility to essential service by female youths.
| 8. What were the most successful outputs and why was the initiative effective?
The project designed a built-in monitoring and evaluation (M&E) component as part of the project implementation. They were as follows.
At the field level, data was collected and recorded by various implementing agencies. Participating hospitals, as focal point, gathered data and reported to provincial health offices. For field evaluation purpose, several activities have been done including: box to receive appeals/complaints, questionnaires surveys to assess services satisfaction, and meetings between NGOs, community networks and youths in the field to assess feedback.
At the provincial level, provincial health offices were in-charge for reporting from the field. Various methods were used in M&E at this level, including: using of Provincial Coordinating Mechanism, a forum among participating agencies in the GF supported projects, to follow up on progress and challenges; supervision and monitoring at the hospitals, schools, NGOs and community networks; and analysis of data collected from the field through indicators and resources utilization. Data was then compiled and submitted to BATS, every trimester through online system at the address: http://data-system.aidsthai.org/.
For project M&E, BATS developed and maintained online reporting system. Verification of data in each indicator, as well as resources used, was performed, and if errors were found, provincial public health offices would be notified to check the data. After data was clear, reports would be sent to the Global Fund’s Principal Recipient Office (PR Office). In order to support the M&E works at the provincial and field level, BATS coordinated with the provincial coordinator to ensure M&E implementation were done within the same direction. Field visits to selected provinces were conducted to monitor activities data, finance and filing of documents. In the field visit activities, group discussions with field staff and partners were performed. Meetings to discuss lessons learnt to ensure achievement against project objectives were organized at the end of each fiscal year.
M&E for donors was done by the PR Office. Quarterly monitoring of the progress on implemented activities was developed and reported to GF. Quarterly meetings were conducted to follow up on progress, identify problems and obstacles so that solutions were planned to solve the problems.
The overall M&E at the country level is taken care by the National AIDS Management Center (NAMC). Project manager compiled data output and reported to NAMC and both organizations jointly analyzed the results and identified key success factors which would be used as input for national strategy development addressing female youths.
| 9. What were the main obstacles encountered and how were they overcome?
Based on the performance of this project, main obstacles include:
1. Stigma and discrimination is still prevalent. Social values on sex and gender result in negative judgment blaming on female youths who engaged in sex and encountered with sexual related problems. Interventions to support female youths were often perceived as a pointer to promiscuous. BATS and partners had conducted several campaigns to disseminate knowledge on gender, HIV/STIs, and condom use. Messages also promoted responsibilities of male and female in sexual behavior, and awareness among female youths on self-protection. Together with the other services provided, female youths who once faced with the problems were able to live normally and return to schools.
2. At the beginning of the project, condom use was not well accepted and accessed by female adolescents, resulting in increasing risk of increased HIV and STI, and pregnancy. In order to solve this problem, the project set up condom distribution points. Female youths were trained to gain more knowledge and skills from drop-in centers and through leading teachers and female youth leaders.
3. Limited access to health services is another main observed obstacle. In fact, the project aimed to promote access by developing friendly health services targeting female youth. In the development, 5 steps were taken:
(1) assessing needs of female youths by the health volunteers, community leaders and civil society organizations,
(2) developing referral systems including the referral models, channels of the refers, list of names and contact information of sending and receiving coordinators, and referral notification,
(3) developing of counseling and referral services through a “call center”.
(4) developing of on-line communication for services, through the hospital’s face-book on friendly services and LINE, and
(5) providing comprehensive friendly services on reproductive health, HIV/STIs, and linkage to one stop crisis center and hospital’s system for youths.