Speaker
Description
Background
Sexual and reproductive health (SRH) among adolescents and young people in Sub-Saharan Africa is characterized by multifaceted inequities, including poor service coverage, fragmented health systems, and restrictive socio-cultural norms. High burdens of unintended pregnancy, unsafe abortion, and sexually transmitted infections persist in this demographic, yet SRH interventions often remain inadequately tailored to their unique developmental, psychosocial, and structural needs. Community health worker (CHW) integration, specifically through Village Health Teams (VHTs) has gained recognition as a decentralized strategy for enhancing SRH equity in resource-constrained settings. The ANSWER Programme, financed by the Dutch government and implemented in collaboration with UNFPA, aimed to strengthen youth-responsive SRH systems through VHT capacity-building, targeted outreach, and improved service linkages. The endline evaluation assessed the programme’s effectiveness in catalyzing SRH service uptake and enhancing the quality of care.
Methods
A mixed-methods endline evaluation was conducted, triangulating data from quantitative baseline and endline surveys, facility assessments, and service utilization metrics with qualitative insights from interviews and focus group discussions involving VHTs, district health officials, health facility in-charges, and adolescent service users. Primary indicators included: (1) health worker competence in adolescent-friendly service provision (measured via standardized knowledge and performance assessments); (2) facility service readiness (availability of commodities, infrastructure, and trained staff); and (3) youth satisfaction (evaluated using a validated client perception instrument). Complementary qualitative data were collected via semi-structured interviews and focus group discussions with VHTs, adolescent service users, district health authorities, and facility in-charges, enabling contextual interpretation of implementation dynamics and perceived outcomes. A total of 722 VHTs were trained in pregnancy mapping, contraceptive service provision, and referral protocols.
Results
The programme exceeded service coverage targets, reaching 121,622 individuals in 2021 (217%) and 263,212 in 2022 (470%), including 86,238 and 192,053 adolescents and young people, respectively. The voucher-based referral mechanism issued 162,092 vouchers, with a 50% redemption rate for maternal and family planning services. VHT-led pregnancy mapping was associated with a significant increase in first-trimester antenatal care (ANC) attendance (from 16% to 30%), suggesting improved early health-seeking behaviour. Facility-level assessments revealed substantial improvements in adolescent SRH readiness: 78.4% of facilities met adolescent-friendly standards at endline (up from 32.6%). Health worker competence in youth-centred counselling and information provision rose from 18.9% to 76.2%. Notably, young people reported satisfaction with provider respect and professionalism increased from 63.5% to 87.2%, reflecting improvements in interpersonal dimensions of care. Qualitative data, triangulated from in-depth interviews and FGDs, corroborated quantitative findings. Adolescents reported increased SRH literacy and greater autonomy in health-seeking behaviour.
Conclusion
The evaluation provides compelling evidence that strategic engagement of CHWs through structured training and community-based outreach can significantly advance adolescent and youth SRH outcomes in fragile health systems. The ANSWER Programme catalyzed improvements across critical dimensions of access, quality, and user experience. Nonetheless, concerns regarding programme sustainability persist, particularly related to VHT workload saturation, entrenched gender and cultural norms, and limited absorptive capacity of the formal health system. Findings inform scalable policy reforms to institutionalize youth-responsive primary care, highlighting the role of pre-service training, research, and clinical care in advancing SRHR in low-resource settings.
