Empowering female youths on sexual health and HIV/STIs prevention through collaborative friendly ser
Bureau of AIDS TB and STIs

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
During the past decades, more young Thai women engaged in risky casual sex in school aged. Compounding with HIV and sexually-transmitted-diseases (STIs), new infections have increased. Bureau of Epidemiology (BOE) reported that STIs rate increased from 41.5 per 100,000 population in 2005 to 76.5 in 2009. Of these, 50% were female youths. More importantly, condom used by female adolescents declined from 66% in 2006 to 48% in 2008. Another consequence was increasing rates of unwanted teenage pregnancies and abortions. Department of Health (DOH) reported 133,176 pregnant adolescents aged <20 years in 2012, resulting in delivery rate of 53.8 per 1,000 women aged 15-19 years old. This rate was almost double comparing to 31.1 in 2000. Though there is no statistics on pregnant adolescents who underwent abortion, but based on scientific estimations, the figure was closed to delivery number. In addition, there had been mortality reports among pregnant adolescents from abortion. In Thai context, men’s role is pre-dominant, as a saying “male is the elephant’s front leg whereas female is the back leg”. This is particular true in sexual life. In general, men determined their sexual relations, and condom used is male’s choices. Female adolescents are lacking of bargaining power, thus, are at risk of infections or becoming pregnant. Moreover, socialization of female youths is subject to certain conservative values towards abstinence. If female youths contracted HIV/STIs or got pregnancy, they were stigmatized as bad girls. Frequently, parents and teachers reject female adolescents’ sexuality and pregnancy problems. Hence, they seek help from peers or sources which often induce improper solutions such as buying medicine from drug store, or taking illegal abortions leading to risk of physical harm or death. Schools’ administrators and teachers frequently see sex education and support for HIV/STI prevention and birth control in schools as promotion of promiscuous for students. System looking after female adolescents with sexually related problems is weak. Those with problems are often asked to resign to save school’s image. Health service system has not addressed this problem properly and there is no specific service for prevention and mitigation. In general, health care workers do not have positive attitudes, services are not friendly, and no respond to serve the needs. In brief, there is no access for comprehensive services and no reach out to these female adolescents. The situation pushed them into more vulnerable status and it seems there was no suitable way to support them to get out of the problem. According to the situation mentioned above, Thai female youths are in need to be empowered to protect their own health and dignity, especially to safeguard themselves from unsafe sex and unwanted pregnancies. To fill this gap, in 2010, Bureau of AIDS, TB and STIs (BATS) and partners initiated a project to empowe female youths on sexual health and HIV/STIs prevention through networks of friendly health services in Songpeenong District, Supanburi Province. In 2012, project was expanded to 4 more districts, each from a province namely Chiang Mai, Nakornsawan, Nongkhai and Chonburi.

B. Strategic Approach

 2. What was the solution?
BATS, Department of Disease Control (DDC), mandated with a key mission to prevent HIV and STIs, and to develop supporting system for all population groups has seen through the said problems affecting girls in terms of sexuality, stigmatization, poor bargaining power and decision, developed an initiative on female youth friendly services to reduce stigma and increase opportunities for them to develop capacity so that they are able to make self-decisions on HIV and STI prevention and reduce unwanted pregnancies. Since the beginning, a survey on female youths’ problems together with an analysis of strength, weakness and developmental opportunities was conducted. The development was done with participation of and brainstorming from all concerned partners, including those organizations that had experienced working with female youth and have brought the problems and needs into account. Finally a Female Youth Friendly Service Project has been established and four strategies has been developed. They are as follows: Empowerment of female youths. This strategy targets to empower female youths so that they feel of their self-value, honor and human dignity and that they can reduce their self-stigma. When they are empowered, female youths will be enabled to control themselves and being able to avoid risky sexual behavior. Development of a female youth friendly health service. Health services will have to be improved to directly meet needs of female youths and to solve their problems. This can be done by developing capacity of the health service providers in terms of attitudes and understanding about female youths and their nature with an aimed to develop female youth friendly health service in health care setting. Development of networks of providers on female youth friendly services. Networks participating agencies in the development of female youth friendly approach services is essential to ensure that services are comprehensive and really meet the needs of female youths. Development of assistance and follow-up on female youths in schools. In this strategy, all partners participated in the project received training and participated in series of consultative meetings, so that assistance and follow up on the activities performed for female youths can be implemented. Based on the implementations of these strategies by all partners in the network, female youth friendly services have been developed and implemented in five provinces in this project. Strategies used in this project are inter-related and they are deployed to the partners in the local area for actual implementation. This is the key to the success of this project.

 3. How did the initiative solve the problem and improve people’s lives?
Before this project was implemented; social support, educational and health service system were passive in awaiting clients coming in for services. The system ignored the needs of female youths who are encountered with sexually related problems and most of them are defensive for change. These are barriers for female youths to access to services as they are discouraged and full of fears about stigma and discrimination. This project created a new concept to the development of comprehensive friendly services for female youth. Starting from desensitizing attitudes of service providers to reduce prejudices against female youths, reduce steps and increase fast tracks so that female youths receive services conveniently. There are linkages of service from communities to service providers through linking networks such as schools, drugstores, drop-in centers and leaders of female youth. In the community, Teen Centers have been developed to relay services information to communities by diversified means such as public relations material so that female youths are able to access to data in need. These data include list of responsible persons, time period of service provision, telephone numbers, LINE, Facebook, and IEC materials on HIV/STIs, healthy sexuality, reproductive health and contraceptive method to prevent pregnancy.

C. Execution and Implementation

 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.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
Prior to the implementation of the project, female youths did not learn sexual education comprehensively. Teachers were not open minded and did not teach sexuality and hospitals did not integrate services for female adolescents. From project’s outcome, female adolescents were empowered on sexual health and HIV/STIs prevention through collaborative friendly service networks. Female adolescents were more confidence and had capacity enough to behave self-prevention from HIV/STIs. They were able to access to condoms, had negotiating skills to refuse or to say “No” to unsafe sex. They are courageous to receive counseling and services that are specifically arranged for female adolescents. Female adolescents received knowledge and information from their peer leaders and networks which conducted outreach works and reached them. They received counseling on reproductive health services. At the hospitals, there were services organized specially for female youth in a friendly oriented. This has resulting in more female youths coming to the services and leading to an opportunity to finding more HIV/STIs, thus receiving further necessary treatment and care in a promptly manner, and based on the service provided by the friendly service network, their rights and dignity had been protected. A good example from one hospital in Nongkhai Province was that a 17 year old girl got pregnant after having sexual relations with a 13 years old boy. But the parents on the boy’s side did not accept and legally accused the girl. The network of female youth friendly services came to assist in negotiating and eventually the pregnant girl was given permission to take leave to give birth and was able to return to the school afterward. The parents of the boy agreed to withdraw the case and take care of the baby. This is considered a successful case due to the development of female youth friendly service approach to reduce stigma and discrimination among female adolescents, families and communities, reduce opportunistic infections from abortions and unwanted pregnancies, and eventually reduce HIV and STI infections and deaths related to AIDS. Another example from Suphanburi Province demonstrated a strong positive role of peer leaders in school. In each class there was a trained youth leader who was responsible for taking care and providing counseling to her school friends. Their friends were then encouraged to seek counseling on problems such as in case of having had unsafe sex as they would ask for contraceptive drugs or condom. Building female youth leaders started at “Boh Suphanburi School” which is the district school and then expanded to 3 and 5 more schools respectively. At present, this leadership building initiative has covered all districts. Based on the Suphanburi’s Provincial Health Office, it is found that the sexually transmitted infections among female school students has trendily decreased from 20 cases in 2009 to 2 cases in 2011. Birth cases in female adolescents have decreased from 307 in 2012 to 246 in 2014. In addition, local government organizations have played more important roles in promoting participation of female adolescents in creativity and implementation of activities in communities. This has brought about teamwork between school, sub-district administrative organization, sub-district health promotion hospital and community hospital. Data from the surveillance program of the BOE elaborated that, of the 5 provinces participated in this project, trend of condom used among sexually active grade 11 female students has steadily increased from 49.2 % in 2010 to 54.1 % in 2011. Rate of pregnancy among young women aged 15-19 years old was dropped in all 5 provinces during 2011-2012 as shown in the Table-1.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
BATS which is a central and national organization functioning as the National Program Manager of HIV/AIDS Program, has foreseen the negative impact from the sexually related problems among youths on the development of the country. BATS has therefore initiated and developed the project on female adolescent friendly service system, starting in the areas where there were problems among female youths whose behavior were at risk. At the beginning phase, in 2010, there was only one province (Suphanburi) piloting in the project. Two years after the project started, or in 2012, 4 more provinces participating in the next piloting phase. They were Nongkhai, Chiang Mai, Nakornsawan, and Chonburi. Based on the positive outcomes of the piloting sites, BATS and other partners scaled up the project to 14 provinces in 2013, and 43 provinces in 2014. The results from the project have been used to formulate policy of the Ministry of Public Health (MOPH). Currently, MOPH’s policy has addressed specific population and youth has been pointed as one of the priority group for the health system to work for. Specifically, several strategic statements targeting the female adolescents are cited, for example, prevention of STIs among female youths, and reduction of teenage pregnancy. In order to pursue the project in a more effective ways, of works among Departments within MOPH, including DDC, Department of Health and Department of Mental Health have been integrated and common guidelines has been developed. In implementing the project in the field, provincial health offices and health offices at the district and sub-district levels, as well as the hospitals deployed the policy and implemented the services according the national guidelines. In terms of funding to support the continue scaling up of the project, BATS together with NAMC and other civil society organizations has proposed to establish the National AIDS Fund to support the works on HIV prevention. Recently, the National AIDS Committee, the top-most body in issuing policy on AIDS for the Government endorses the proposal, hence, the HIV Fund will going to be established, with subject to the priority of budget allocation. The strategic focus on empowering female youths on sexual health and HIV/STIs prevention through collaborative service networks will be a critical component of services to be supported by the Fund. Furthermore, as female youth issue is also a concern of most community in the country, it is therefore a critical role of the Local Administrative Organization to hand in and provide financial support for the service to be delivered by the agencies in the community and in the schools. With the ownership of the community and people, and financial support from the Central Government and the Local Administrative Organization, the works performed by the networks in the field on empowering female youths will be obviously sustainable. The knowhow developed by the project will be eventually scaled up to other targeted provinces all around the country.

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
The important lessons learnt from this project included the lessons from developing service system for female adolescents to access to knowledge and information to prevent themselves from HIV/STIs, and from being pregnant when they are not ready. They also received the opportunity to get access to necessary services on a voluntary basis. There are several key success factors, including: - Understanding female adolescents’ way of thinking and point of view while adjusting service providers’ way of thinking and point of view toward the female adolescents’ need. This was very essential in the development and implementation to empower female youths as they are subjected to the needs and expectation of the female adolescents. Critical points in the development of services matched with the needs of female youths are, for example, providing diversified channels for access to knowledge and information; providing fast track channel of services in hospitals, which include the least and most convenient steps for the services; and building confidence for female adolescents that information regarding their visits would be kept confidential. - At the same time, it is important to also focus on the service providers. Attitudes of service providers and full understanding on the limitations and hardship of the female adolescents who are needed of the services are critical to the successful of the service delivery. Organized by the project activities, there were sessions to help the providers to adjust their attitude so that they would be ready to provide their services and duties by reducing prejudices toward female youth clients. It is noteworthy to mention that sometime it is not always easy to modify the attitude of health care workers since attitude is somehow accumulated from culture and tradition for a long time, and to adjust the attitude, time is needed. - Adjusting a service model from a passive way in a hospital approach to be more active and become outreach by female youth clients. In this project, drugstores, civil society organizations, school teachers and female youth leaders in communities participated as key agencies to carry out the service in the community. This project’s model and its service delivery in the community, has been successfully able to provide information and other services and engage female youths who have problems of having unsafe sexual relations so that they volunteer to receive counseling and share with their friends about the services, as well as link to referral services from communities to a regular service system of hospitals in a systematical way. This has brought about community ownership and commitment to prevent and mitigate the problems of female youths in the community. - Counseling, moral support, promoting female adolescents’ rights, as well as access to knowledge and essential preventive interventions and equipments have empowered female youths to be able to stand on to protect themselves from HIV/STI infections, being pregnant, and the courage to refuse unsafe sex.

Contact Information

Institution Name:   Bureau of AIDS TB and STIs
Institution Type:   Government Agency  
Contact Person:   Sumet Ongwandee
Title:   Director of BATS  
Telephone/ Fax:   66 2 5903201
Institution's / Project's Website:  
E-mail:   yupinchin@gmail.com  
Address:   88/21 Tiwanon Rd., Maung district.,
Postal Code:   11000
City:   Nonthaburi
State/Province:   Nonthaburi

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