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Feasibility, acceptability and potential sustainability of a 'diagonal' approach to health services for female sex workers in Mozambique

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Abstract
Background: Female sex workers (FSWs) in many settings have restricted access to sexual and reproductive health (SRH) services. We therefore conducted an implementation study to test a 'diagonal' intervention which combined strengthening of FSW-targeted services (vertical) with making public health facilities more FSW-friendly (horizontal). We piloted it over 18 months and then assessed its performance. Methods: Applying a convergent parallel mixed-methods design, we triangulated the results of the analysis of process indicators, semi-structured interviews with policy makers and health managers, structured interviews with health care providers and group discussions with peer outreach workers. We then formulated integrated conclusions on the interventions' feasibility, acceptability by providers, managers and policy makers, and potential sustainability. Results: The intervention, as designed, was considered theoretically feasible by all informants, but in practice the expansion of some of the targeted services was hampered by insufficient financial resources, institutional capacity and buy-in from local government and private partners, and could not be fully actualised. In terms of acceptability, there was broad consensus on the need to ensure FSWs have access to SRH services, but not on how this might be achieved. Targeted clinical services were no longer endorsed by national government, which now prefers a strategy of making public services more friendly for key populations. Stakeholders judged that the piloted model was not fully sustainable, nor replicable elsewhere in the country, given its dependency on short-term project-based funding, lack of government endorsement for targeted clinical services, and viewing the provision of community activities as a responsibility of civil society. Conclusions: In the current Mozambican context, a 'diagonal' approach to ensure adequate access to sexual and reproductive health care for female sex workers is not fully feasible, acceptable or sustainable, because of insufficient resources and lack of endorsement by national policy makers for the targeted, vertical component.
Keywords
Sexual and reproductive health, Female sex workers, Service delivery, Implementation research, Mixed methods, Mozambique, SEXUALLY-TRANSMITTED INFECTIONS, SEEKING BEHAVIOR, HIV PREVENTION, INTERVENTIONS, BURDEN, INDIA, CARE, COUNTRIES, AFRICA, AVAHAN

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MLA
Lafort, Yves, Malica Sofia Ismael de Melo, Faustino Lessitala, et al. “Feasibility, Acceptability and Potential Sustainability of a ‘Diagonal’ Approach to Health Services for Female Sex Workers in Mozambique.” BMC HEALTH SERVICES RESEARCH 18 (2018): n. pag. Print.
APA
Lafort, Y., de Melo, M. S. I., Lessitala, F., Griffin, S., Chersich, M., & Delva, W. (2018). Feasibility, acceptability and potential sustainability of a “diagonal” approach to health services for female sex workers in Mozambique. BMC HEALTH SERVICES RESEARCH, 18.
Chicago author-date
Lafort, Yves, Malica Sofia Ismael de Melo, Faustino Lessitala, Sally Griffin, Matthew Chersich, and Wim Delva. 2018. “Feasibility, Acceptability and Potential Sustainability of a ‘Diagonal’ Approach to Health Services for Female Sex Workers in Mozambique.” Bmc Health Services Research 18.
Chicago author-date (all authors)
Lafort, Yves, Malica Sofia Ismael de Melo, Faustino Lessitala, Sally Griffin, Matthew Chersich, and Wim Delva. 2018. “Feasibility, Acceptability and Potential Sustainability of a ‘Diagonal’ Approach to Health Services for Female Sex Workers in Mozambique.” Bmc Health Services Research 18.
Vancouver
1.
Lafort Y, de Melo MSI, Lessitala F, Griffin S, Chersich M, Delva W. Feasibility, acceptability and potential sustainability of a “diagonal” approach to health services for female sex workers in Mozambique. BMC HEALTH SERVICES RESEARCH. 2018;18.
IEEE
[1]
Y. Lafort, M. S. I. de Melo, F. Lessitala, S. Griffin, M. Chersich, and W. Delva, “Feasibility, acceptability and potential sustainability of a ‘diagonal’ approach to health services for female sex workers in Mozambique,” BMC HEALTH SERVICES RESEARCH, vol. 18, 2018.
@article{8579839,
  abstract     = {Background: Female sex workers (FSWs) in many settings have restricted access to sexual and reproductive health (SRH) services. We therefore conducted an implementation study to test a 'diagonal' intervention which combined strengthening of FSW-targeted services (vertical) with making public health facilities more FSW-friendly (horizontal). We piloted it over 18 months and then assessed its performance. 
Methods: Applying a convergent parallel mixed-methods design, we triangulated the results of the analysis of process indicators, semi-structured interviews with policy makers and health managers, structured interviews with health care providers and group discussions with peer outreach workers. We then formulated integrated conclusions on the interventions' feasibility, acceptability by providers, managers and policy makers, and potential sustainability. 
Results: The intervention, as designed, was considered theoretically feasible by all informants, but in practice the expansion of some of the targeted services was hampered by insufficient financial resources, institutional capacity and buy-in from local government and private partners, and could not be fully actualised. In terms of acceptability, there was broad consensus on the need to ensure FSWs have access to SRH services, but not on how this might be achieved. Targeted clinical services were no longer endorsed by national government, which now prefers a strategy of making public services more friendly for key populations. Stakeholders judged that the piloted model was not fully sustainable, nor replicable elsewhere in the country, given its dependency on short-term project-based funding, lack of government endorsement for targeted clinical services, and viewing the provision of community activities as a responsibility of civil society. 
Conclusions: In the current Mozambican context, a 'diagonal' approach to ensure adequate access to sexual and reproductive health care for female sex workers is not fully feasible, acceptable or sustainable, because of insufficient resources and lack of endorsement by national policy makers for the targeted, vertical component.},
  articleno    = {752},
  author       = {Lafort, Yves and de Melo, Malica Sofia Ismael and Lessitala, Faustino and Griffin, Sally and Chersich, Matthew and Delva, Wim},
  issn         = {1472-6963},
  journal      = {BMC HEALTH SERVICES RESEARCH},
  keywords     = {Sexual and reproductive health,Female sex workers,Service delivery,Implementation research,Mixed methods,Mozambique,SEXUALLY-TRANSMITTED INFECTIONS,SEEKING BEHAVIOR,HIV PREVENTION,INTERVENTIONS,BURDEN,INDIA,CARE,COUNTRIES,AFRICA,AVAHAN},
  language     = {eng},
  pages        = {11},
  title        = {Feasibility, acceptability and potential sustainability of a 'diagonal' approach to health services for female sex workers in Mozambique},
  url          = {http://dx.doi.org/10.1186/s12913-018-3555-2},
  volume       = {18},
  year         = {2018},
}

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