Peter Fajans

Helping Public Sector Health Systems Innovate: The Strategic Approach to Strengthening Reproductive Health Policies and Programs

Public sector health systems that provide services to poor and marginalized populations in developing countries face great challenges. Change associated with health sector reform and structural adjustment often leaves these already-strained institutions with fewer resources and insufficient capacity to relieve health burdens. The Strategic Approach to Strengthening Reproductive Health Policies and Programs is a methodological innovation developed by the World Health Organization and its partners to help countries identify and prioritize their reproductive health service needs, test appropriate interventions, and scale up successful innovations to a subnational or national level. The participatory, interdisciplinary, and country-owned process can set in motion much-needed change. We describe key features of this approach, provide illustrations from country experiences, and use insights from the diffusion of innovation literature to explain the approachs dissemination and sustainability.

AIDS knowledge, risk behaviors, and factors related to condom use among male commercial sex workers and male tourist clients in Bali, Indonesia.

ObjectivesTo describe the AIDS/sexually transmitted diseases (STD) knowledge and risk behaviors, and to determine factors related to condom use among male commercial sex workers (CSW) and male tourist clients in Bali, Indonesia. DesignIndividual survey interviews were conducted with a sample of 80 male CSW and 100 tourist clients in the Kuta area of Bali. MethodsSurvey interviews included detailed questions on AIDS/STD knowledge, sexual behavior, and psychosocial measures related to risk taking. ResultsMost of the male CSW had heard about AIDS and other STD, although some misconceptions about transmission and risks of different sexual practices remained. Both oral and anal intercourse with tourists were common and condom use was far from consistent. Factors related to condom use for anal intercourse with tourist clients were condom beliefs, self efficacy, susceptibility to STD infection, and STD knowledge. Tourist clients were mainly from Australia and Europe and many had paid for sex in other parts of Indonesia as well as in high prevalence countries. Knowledge of AIDS/STD was very good among the tourists and previous experience with STD was common. Factors related to condom use with male CSW were condom beliefs and self efficacy. ConclusionThere is a very active and mobile group of male CSW and tourist clients present in Bali. Interventions with these men are needed due to the low level of knowledge about AIDS among CSW, their experience with STD and STD symptoms, and their level of risky sexual behavior.

AIDS and STDs: risk behaviour patterns among female sex workers in Bali, Indonesia.

This study investigated AIDS and STD knowledge, risk behaviour patterns and condom use among three distinct groups of female commercial sex workers (CSWs) in Bali, Indonesia. Individual in-depth interviews were conducted with 71 female CSWs. These CSW groups differ in the prices they charge, their places and modes of employment, educational backgrounds, levels of AIDS and STD knowledge, number of clients served and levels of condom use. Knowledge of the routes of transmission and appropriate prevention practices is low among all groups, and despite significant differences in their number of clients and their condom use, all groups report high levels of STD symptoms. Although HIV seroprevalence rates are currently low in Indonesia, high risk sexual behaviour patterns place all three groups of CSWs and their clients at great risk of infection. Interventions targeted to specific groups of CSWs and clients should be undertaken as soon as possible, including educational activities utilizing peer educators, condom promotion and distribution, together with improved STD diagnosis and treatment for CSWs and their clients.

AIDS knowledge, risk behaviors, and condom use among four groups of female sex workers in Bali, Indonesia.

The objectives of this study were to discover the AIDS knowledge, risk behaviors, and condom use of four groups of female professional sex workers (n = 614). Personal interviews were conducted with women working in low-price brothels, mid-price and high-price houses, and tourist areas. Only 51% of women in the low-price brothels had heard of AIDs, although most of the women in the other groups had heard of it. Knowledge of transmission and symptoms was weak in all groups, and most women were unaware of asymptomatic transmission. Most women felt safe from HIV due to ineffective strategies such as taking medications or client selection practices. Condom use with clients varied widely by group. Women in the low-price brothels reported the lowest levels of use (19% of encounters in the previous week), with women from the mid- and high-price groups reporting higher levels (68% mid-price; 71% high-price). Women working in the tourist areas reported the highest levels of use (90%). Interventions for each group need to reflect these differences in knowledge as well as the contexts of their work; important contextual factors to consider include the level of AIDS and STD knowledge in their environment, the characteristics of the clients served, and the degree of supervision that they receive.

STD knowledge and behaviours among clients of female sex workers in Bali, Indonesia

This study investigated knowledge, beliefs, and practices related to STDs and AIDS among clients of low price sex workers in Bali, Indonesia. These men are at high risk of STD and HIV transmission. They have poor knowledge of the basic concepts of STD and HIV transmission and prevention, and they practice a variety of ineffective prevention strategies including partner selection and the prophylactic use of antibiotics. They report a mean of 1.9 paid sexual partners in the previous week and very low frequencies of condom use. Over 25% had experienced an STD symptom in the previous 6 months, with self treatment with antibiotics reported by a third. Recent experience of an STD was related to the number of sex worker partners in the previous month and to ever having used a condom with a sex worker. The implications of the study findings for the development of comprehensive STD control programs including educational campaigns, condom promotion, and the strengthening of STD case management by health care providers are discussed.

Beginning with sustainable scale up in mind: initial results from a population, health and environment project in East Africa

Abstract Small-scale pilot projects have demonstrated that integrated population, health and environment approaches can address the needs and rights of vulnerable communities. However, these and other types of health and development projects have rarely gone on to influence larger policy and programme development. ExpandNet, a network of health professionals working on scaling up, argues this is because projects are often not designed with future sustainability and scaling up in mind. Developing and implementing sustainable interventions that can be applied on a larger scale requires a different mindset and new approaches to small-scale/pilot testing. This paper shows how this new approach is being applied and the initial lessons from its use in the Health of People and Environment in the Lake Victoria Basin Project currently underway in Uganda and Kenya. Specific lessons that are emerging are: 1) ongoing, meaningful stakeholder engagement has significantly shaped the design and implementation, 2) multi-sectoral projects are complex and striving for simplicity in the interventins is challenging, and 3) projects that address a sharply felt need experience substantial pressure for scale up, even before their effectiveness is established. Implicit in this paper is the recommendation that other projects would also benefit from applying a scale-up perspective from the outset. Résumé Des projets pilotes à petite échelle ont démontré que des approches qui intègrent les questions de population, de santé et d’environnement peuvent répondre aux besoins et aux droits des communautés vulnérables. Pourtant, ces projets et d’autres types de projets de santé et développement ont rarement influencé l’élaboration de politiques et programmes plus larges. ExpandNet, un réseau de professionnels de santé qui s’emploient à étendre les projets, avance que c’est parce que les projets sont rarement conçus en gardant à l’esprit la viabilité et l’expansion futures. Pour préparer et réaliser des interventions durables pouvant être appliquées à une plus grande échelle, il faut une mentalité différente et de nouvelles approches des tests pilotes/à petit échelle. Cet article montre comment cette nouvelle approche est appliquée et les leçons initiales de son utilisation dans le projet sur la santé de la population et l’environnement dans le bassin du lac Victoria actuellement mené en Ouganda et au Kenya. Les leçons spécifiques qui émergent sont les suivantes : 1) l’engagement concret et suivi des acteurs a sensiblement façonné la conception et l’application, 2) les projets multisectoriels sont complexes et la recherche de simplicité dans les interventions est difficile, et 3) les projets qui répondent à un besoin profondément ressenti subissent des pressions les poussant à s’étendre, avant même que leur efficacité soit avérée. La recommandation selon laquelle d’autres projets bénéficieraient aussi de l’application d’emblée d’une perspective de mise à l’échelle est implicite dans l’article. Resumen Proyectos piloto en pequeña escala han demostrado que mediante enfoques integrados de población, salud y medio ambiente se puede atender las necesidades y los derechos de las comunidades vulnerables. Sin embargo, estos y otros tipos de proyectos de salud y desarrollo rara vez influyen en la formulación de políticas y programas más amplios. ExpandNet, una red de profesionales de salud que trabajan en ampliación, argumenta que esto se debe a que los proyectos generalmente no son diseñados con futura sostenibilidad y ampliación en mente. La creación y ejecución de intervenciones sostenibles, que puedan aplicarse en mayor escala, requiere una mentalidad diferente y nuevos enfoques con relación a pruebas piloto en pequeña escala. En este artículo se muestra la aplicación de este nuevo enfoque y las lecciones iniciales de su uso en el Proyecto Salud de las Personas y el Medio Ambiente en la Cuenca del Lago Victoria, actualmente en curso en Uganda y Kenia. Las lecciones específicas que están surgiendo son: 1) la participación significativa y continua de partes interesadas ha influido considerablemente en el diseño y la ejecución; 2) los proyectos multisectoriales son complejos y es un reto lograr simplicidad en las intervenciones; y 3) los proyectos que abordan una necesidad muy sentida experimentan considerable presión para ampliación, aun antes de establecida su eficacia. Este artículo presenta la recomendación implícita de que otros proyectos también se beneficiarían de aplicar una perspectiva de ampliación desde el principio.

From Project to Program: Tupange’s Experience with Scaling Up Family Planning Interventions in Urban Kenya

Abstract This paper describes how the Urban Reproductive Health Initiative in Kenya, the Tupange Project (2010-2015), successfully applied the ExpandNet approach to sustainably scale up family planning interventions, first in Machakos and Kakamega, and subsequently also in its three core cities, Nairobi, Kisumu and Mombasa. This new focus meant shifting from a “project” to a “program” approach, which required paying attention to government leadership and ownership, limiting external inputs, institutionalizing interventions in existing structures and emphasizing sustainability. The paper also highlights the project’s efforts to prepare for the future scale up of Tupange’s interventions in other counties to support continuing and improved access to family planning services in the new context of devolution (decentralization) in Kenya. Résumé Cet article décrit comment le projet Tupange (2010-2015), une initiative de santé génésique en milieu urbain au Kenya, a appliqué avec succès la méthode ExpandNet pour étendre durablement les interventions de planification familiale, tout d’abord à Machakos et Kakamega, puis dans les trois villes principales, Nairobi, Kisumu et Mombasa. Cette nouvelle orientation a exigé de passer d’une approche de « projet » à une approche de « programme », ce qui nécessitait d’accorder une attention au leadership et l’appropriation du Gouvernement, de limiter les contributions externes, d’institutionnaliser les interventions dans les structures existantes et de mettre l’accent sur la viabilité. L’article décrit également les activités pour préparer l’expansion future des interventions du projet Tupange dans d’autres pays en vue de soutenir et d’élargir durablement l’accès aux services de planification familiale dans le nouveau contexte de la décentralisation. Resumen Este artículo describe cómo la Iniciativa de Salud Reproductiva Urbana en Kenia, el Proyecto Tupange (2010-2015), aplicó exitosamente la estrategia ExpandNet para ampliar de manera sostenible las intervenciones de planificación familiar, primero en Machakos y Kakamega, y posteriormente en las tres principales ciudades: Nairobi, Kisumu y Mombasa. Este nuevo enfoque se centró en el “programa” en vez del “proyecto”, lo cual requirió prestar atención al liderazgo y apropiación del gobierno, limitando aportes externos, institucionalizando intervenciones en estructuras existentes y haciendo hincapié en la sostenibilidad. Además, el artículo destaca los esfuerzos del proyecto por prepararse para la futura ampliación de las intervenciones de Tupange en otros países, con el fin de apoyar el acceso continuo y mejorado a los servicios de planificación familiar en el nuevo contexto de devolución (descentralización) en Kenia.

Contraceptive introduction and the management of choice: the role of Cyclofem in Indonesia

This paper presents a programmatic perspective on the relationship between the introduction of new contraceptive technology and expanding contraceptive options, using the example of Cyclofem in Indonesia. Past approaches to contraceptive introduction have considered only the characteristics of the new method in the decision-making process. In assessing whether the introduction of a new method actually expands contraceptive choice for women and whether the program has the managerial capabilities to assure quality of care in this process, the authors argue that consideration must be given to all methods within a delivery system and how new technology relates to the management of contraceptive choice. Using this perspective, the authors suggest that choice would not necessarily be expanded with scaled-up service delivery of a new once-a month injectable in the Indonesian public sector context.