Out-of-Facility Service Delivery

© 2000 Sara A. Holtz, Courtesy of Photoshare

Youth-friendly health services can be provided in a health facility (such as a health center, clinic or hospital), or in an “out-of-facility” setting. Young, poor or hard-to-reach people have many challenges reaching a traditional facility. An out-of-facility setting or approach may serve them better. These may include:

  1. Mobile outreach services
  2. Community-based services
  3. Drug shops and pharmacies
  4. Sexual and reproductive health (SRH) services in non-health settings (such as workplaces)
  5. School-based health clinics
  6. Social marketing

Out-of-facility approaches can be especially important for reaching young people in urban areas. Young people may be apprehensive of traditional facility-based health services for many reasons (for example, lack of trust, feeling judged or unwelcome, the cost of travel or isolation). Some groups of urban young people – like young people who use drugs, street-connected young people or those residing in slum areas – are even more likely to feel unwelcome at traditional facilities (Godia et al., 2014). Providing out-of-facility services can be a means to reaching them (Denno et al., 2012).

What Are the Benefits?

  • Reaches more marginalized, vulnerable groups of young people: Despite efforts to make facility-based services youth-friendly, many young people still do not access traditional facilities. Urban young people from marginalized populations are most likely to be affected by HIV, STIs and lack of access to contraception – but less likely to visit static health facilities. Out-of-facility services can help them get access to sexual and reproductive health (SRH) information and services.
  • Addresses issues like long waiting times, lack of privacy and limited awareness of service availability: Research reveals that even for less-marginalized groups, health service facilities are difficult to access (Godia et al., 2014). Long waiting times, lack of privacy and lack of awareness of service availability (especially among recent migrants) prevent many young people from seeking health services. Providing out-of-facility services can address these barriers (Denno et al., 2012). Innovative models such as vouchers and social franchises increase adolescents’ knowledge of and access to reproductive health services (Glinski et al., 2014). Vouchers have shown success in increasing privacy and confidentiality of services.
  • Increases access to a range of contraceptive methods: Out-of-facility service delivery channels, including mobile services and social marketing, can broaden the method mix available to young people. Social marketing programs complement the public health system by tapping into private providers and pharmacies. Since these sources provide more anonymity, underserved young people tend to prefer them for accessing contraception. Social marketing also helps increase awareness of the range of contraceptives available. (Refer to this Family Planning High Impact Practices brief to understand how to engage in social marketing.)

How to Implement?

Understand the context and realities of the population group to be reached

Health services can be delivered through schools, workplaces, households, streets or markets, and drug shops and pharmacies. There is varying evidence on the effectiveness of all of these mechanisms when it comes to health service uptake. For example, some data show that a youth-specific community-based condom and contraception distribution strategy is more effective than school-based services. Pharmacies have also been seen as effective in increasing uptake of contraceptive services among young people (Denno et al., 2015). Marie Stopes International has experience from Bangladesh, Nepal, and Zambia where appropriate services, activities, and community engagement improved uptake. It is important to adopt a service delivery mechanism that is best suited to your context.

Evidence to Action (E2A) has a useful decision-making tool to guide program designers in choosing youth-friendly service delivery model(s). The tool covers country context, target population, desired behavioral and health outcomes, SRH services to be offered and needs and objectives for scalability and sustainability.

Example: Population Services International in Africa

PSI has done a review of its programs providing sexual and reproductive health and rights (SRHR) products and services through different models in several countries: ‘From innovation to scale: Advancing the sexual and reproductive health and rights of young people. A review of PSI programming approaches and experiences

  • In Swaziland, mobile clinics in 20 districts provide integrated family planning and HIV services. The mobile clinics focus on reaching adolescent girls and young women aged 15 to 24, although clients of all ages are welcome. PSI developed this approach through research and collaboration with girls and young women.
  • In the Democratic Republic of the Congo and Mozambique, PSI trained pharmacy staff in how to provide youth-friendly services. This training helps pharmacy staff welcome young people and provide products such as condoms, oral contraceptives and emergency contraception without discrimination.
  • In Liberia and Zimbabwe, PSI trained hair salon workers to speak with their clients about SRHR, sell products like female condoms, and make referrals for methods and services.
Identify community members, private-sector providers and/or informal services

Conduct a landscaping exercise: What kinds of services are already available to young people in your program context? Which services do they access? Certain groups of young people – such as those living in slums, street connected, or engaging in transactional sex or drug use – may trust some community members more than others. For example, many adolescents in Central America prefer getting contraceptives from pharmacies (Gottschalk et al., 2015). In addition, girls and young women, both married and unmarried, may not be allowed to interact with outsiders. Knowing who the trusted community members are, and where youth already go for services, would enable your program to tap into existing, credible resources for increasing contraceptive uptake or other SRH services.

 

Example: Training Pharmacists in Nigeria

The second phase of the Nigerian Urban Reproductive Health Initiative (NURHI) has successfully engaged non-clinical providers to promote contraceptive services. In collaboration with local governments, NURHI identifies non-clinical providers who have a high volume of work. In Nigeria, this has shown to be clinical pharmacists, patent medical vendors, and traditional birth attendants. After deciding on key target groups, NURHI holds a two-day, interactive training, which covers information about non-clinical family planning methods, interpersonal communication skills and counseling, and referral for contraceptive services. After the training, the non-clinical providers are equipped to provide contraceptive information and counseling in their communities. NURHI follows up with the participants on a quarterly basis to check in with them, revise the training materials, and address any challenges. NURHI has found that traditional birth attendants have been particularly successful at referring clients for contraceptive services, given the high volume of antenatal, delivery and postnatal services that they provide. Their continuity of engagement with young women in their communities allows them to give a young woman information about contraception over the course of a pregnancy and link them to the appropriate services after delivery.
Establish partnerships with the government or private sector

Based on which model of service delivery you choose, you will need to establish partnerships to reach young people, and to train service delivery staff on providing youth-friendly services that respond to and fulfill young people’s sexual and reproductive rights; service delivery staff should also be trained on interpersonal communication.

Example: In Their Hands (ITH) Project in Kenya

In April 2017, In Their Hands (ITH) Project began with a vision to ensure that girls ages 15-19 years in Kenya would be able to choose when they wanted to get pregnant and not have to resort to an unsafe abortion. The key outcome of the project is to enable these girls to have access to and use sexual and reproductive health products and services. ITH is seeking to drive this through providing awareness through various media and mobilization teams which strengthens the girl’s perception of her sexual and reproductive health rights and increases her ability to choose a contraceptive method of her choice from various service points, such as clinics or pharmacy outlets within her location. ITH is currently being implemented by three Consortium partners:

  • Well Told Story who is driving demand generation through Shujaaz comic and FM radio;
  • Triggerise, the t-safe platform provider which enrolls girls via their mobile phones making her eligible to access free SRH services at the select outlets; and
  • Marie Stopes Kenya, the key service provider using its network of clinics and pharmacy outlets.

By enrolling on the t-safe platform and accessing SRH services, the girl earns TIKO points for health and beauty products. This campaign is complemented by another campaign targeted at the girl’s support system.

What Is the Evidence?

  • Successful approaches to out-of-facility service delivery include mail-based STI screening, condom distribution through street outreach in higher-income countries and promoting pharmacy-based over-the-counter access to emergency contraception (Denno et al., 2012).
  • Mobile services in urban areas can reach a range of young people at carefully chosen locations, such as a marketplace or mall, school or workplace, or neighborhood corner or youth club. MSI has several examples of reaching young married girls (in community settings), boys and young men (in marketplaces, youth clubs and sports groups), in-school young people (in schools or universities), and young migrant women (in factories).
  • School-based health centers in New York City have successfully provided long-acting reversible contraceptives (LARC) for adolescents. Since the service delivery point was in their school, students trusted the providers more. They could wait in a private office instead of a public waiting area, ensuring confidentiality and reducing anxiety. They could also bring a friend with them for support(Sangraula et al., 2016).

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    Kate Walsh
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    Connect, learn and share what you know about this approach.

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    Peter Kagwe
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    From our experience with the G-Amini project in kenya, this has proved to be one of the best models for service provision to the young people

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Helpful Tips

Youth Participation

  • Work with the young people you want to reach, to map their current service access and identify their trusted community members.
  • Engage young people in implementing out-of-facility service delivery and linking their peers with the services.

Data Management

  • Ensure that out-of-facility service provision has monitoring and evaluation mechanisms and are provided with supportive supervision.
  • Harmonize data collection from out-of-facility service provision with facility-based service data, and use both to inform further strategy for service uptake.

Multisectoral Collaboration

  • Partner with innovative and non-traditional entities that urban young people will be more likely to access.

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Challenges

  • Reaching special groups (like married girls and first time parents) with services may take additional effort, as they often have more barriers to overcome. One key barrier is cost – the cost involved in going to a place that delivers services, taking time off from housekeeping or employment and paying for contraceptives. Removing user fees, or providing vouchers or cash transfers where possible, could increase young women’s access to services. Another barrier is isolation. Home visits by community health workers to provide contraceptive services and information about the importance of delaying first birth and spacing is a promising approach.
  • An out-of-facility approach cannot provide comprehensive services without strong referral links to facility-based services. Some services (like IUD insertion, sterilization and post-abortion care) need to be provided in a static facility; and this may be mandated by law. Ensuring that out-of-facility staff are prepared to refer patients to a traditional facility is crucial for fully meeting the SRH needs of urban youth.

References

See a listing of all AYSRH references.