Empoderar a los jóvenes para que tomen decisiones saludables en materia de salud sexual y reproductiva: lecciones de los héroes de la acción transformadora de género en Uganda

Project Intro: Ensuring equity in access to sexual and reproductive health (SRH), strengthening new and existing partnerships, and fostering resilience and innovation in health systems is vital for expanding comprehensive SRH access and addressing diverse population needs. To support SRH projects in achieving these goals, the Conocimiento ÉXITO project, in collaboration with the Red OMS/IBP, is featuring a series of three program implementation stories that showcase implementers who have successfully navigated these complexities to deliver impactful outcomes. This feature story on the Heroes for Gender Transformative Action Program (Heroes4GTA) is one of the three implementation stories selected for the 2024 series, with the other two accessible through the link provided here.

Program Background

Almost half of Uganda’s population (44%) is under 15 years of age and one in four girls aged 15–19 has begun childbearing. los Heroes for Gender Transformative Action Programme (Heroes4GTA) is a six-year (2020–2026) integrated sexual and reproductive health and rights (SRHR) program in Uganda implemented by Amref Health Africa Uganda, Cordaid, y MIFUMI and funded by the Kingdom of the Netherlands.

The program uses a socioecological model to implement interventions across four levels:

• Individual: The project works with young people (aged 9–24) and adults of reproductive age (15–49).
• Interpersonal: The project engages couples, parents, teachers, religious leaders, health workers, and other community leaders.
• Comunidad: The project engages various youth-led, women-led, and disability-led community-based organizations.
• Institutional: The project works within the justice system to support action against sexual and gender-based violence (SGBV).

Heroes4GTA has four main objectives:

1. Empower young people and women to make healthy choices regarding their SRHR
2. Increase uptake and quality of SRHR-SGBV services among hard-to-reach groups
3. Increase awareness and activism by influential community members (referred to as “gatekeepers”) to reject social norms and practices that perpetuate gender inequality and SGBV
4. Improve the quality of SGBV response systems to effectively address SRHR violations and enhance access to justice

The program supports 65 health facilities and 54 communities within nine high-burden districts in Uganda, comprising Kalangala, Burgiri, Mayuge, Iganga, Namayingo, Mbale, Budaka, Bukwo, and Kween.

The nine districts were selected based on an initial baseline assessment conducted by the Ministry of Health and District leadership. Districts were selected based on their attitudes towards gender and SGBV, school attendance rates, and the number of skilled birth attendants. Many of the districts were also hard-to-reach geographically, such as districts like Kalangala—a remote community made up of over 40 populated islands scattered across Lake Victoria, the world’s largest tropical lake.

Get to Know the Heroes4GTA Program Model

In order to empower young people and women to make healthy choices regarding their SRHR, Heroes4GTA uses five different age-appropriate curriculums, both in and out of schools, that is implemented through a combination of community facilitators, teachers, youth peers, and village health teams (VHTs).

• Journeys Plus: In-school youth aged 10–14
• Program Y: Youth aged 15–24
• Family Health: Men and women of reproductive age (15–49 years)
• Men Engage: Men and boys
• Sinovuyo (a Xhosa name of South African origin, meaning “we have joy”): Parents, caregivers, and teens

The Heroes4GTA program is brought to life by over 900 community health workers (CHWs), all of whom were trained by the Heroes4GTA project to implement curriculum-based programs. These CHWs receive regular supervision from community-based organizations (CBOs) and are supported by youth and community engagement officers. Reflecting on her role, Dolly Ajok, a project manager and youth officer for the program, shared, “I’m very excited to be a part of this program and that youth positions like mine exist, because there is a common youth slogan: ‘nothing for us without us.’ But sometimes youth programs are put in place and you don’t actually find youth working in these programs. It’s great to see that in this program, there is transformation going on for my fellow youth in the community.” With over 21 CBOs supporting the project, these organizations are selected by community stakeholders through the use of the Organizational Capacity Assessment tool. The program is intentional about including at least one woman-led and one youth-led organization in each district, with three CBOs also focused on disability inclusion. Across the project, the CBOs play a crucial role in leading reporting and community engagement activities, including facilitating referrals to health facilities.

For the in-school Journey Plus program, youth called Y-Heroes, deliver SRHR knowledge to their peers with the support of teachers. The project creates safe spaces and reporting mechanisms ultimately meant to support youth to conclude their education. Y-Heroes are often youth from higher risk categories, including those living with HIV or those who have experienced SGBV themselves, and support others through a peer-to-peer model. The project implements a “whole school approach” including partnering with parent-teacher associations and district health and welfare committees and facilitating teacher training integration of SRH/ SGBV, Water, Sanitation, and Hygiene (WASH), and menstrual hygiene management, among other topics. During the curriculum, participants are introduced to different tools (translated into local languages), including the use of tablets to support referrals to care and SGBV reporting.

The program also includes an e-voucher system, distributed by Y-Heroes and VHTs, to SGBV survivors to facilitate their access to medical services, ability to report incidents, and link to other SGBV actors. The e-voucher is provided through a digital platform on the Sauti Plus app. The e-vouchers can be redeemed at designated service providers for various SGBV services, such as medical care, counseling, and legal aid. The process is designed to be confidential and user-friendly, ensuring that girls can access services without stigma.

To increase uptake and quality of SRHR/SGBV services among hard-to-reach groups, Heroes4GTA implements a health systems strengthening approach whereby local health systems are strengthened to deliver quality, integrated SRHR, SGBV, family planning, postabortion care, basic emergency obstetric care, and comprehensive emergency obstetric care services. Heroes4GTA conducts facility readiness assessments, trains health staff, VHTs, and youth peers to provide services, generates demand through awareness and referrals, and supports various health committees across supported health facilities.

Explore some of the key program strategies employed to strengthen SRHR/SGBV services:

The program also implements social and behavior change activities to support gatekeepers, such as religious leaders and cultural institutions, within communities to reject social norms and practices that perpetuate gender inequality and SGBV. This includes conducting awareness sessions, hosting community dialogues, and hosting radio talk shows and campaigns against SGBV, teenage pregnancy, and child marriage. In addition, Heroes4GTA supports various districts to develop ordinances against harmful practices that perpetuate SGBV, including child protection against SGBV.

Finally, the project works within the formal justice system to strengthen the quality of SGBV response systems, increase reporting and follow-through of SGBV cases, and enhance access to justice. For example, the project formed nine advice centers, run by SGBV champions that provide mediation, psychosocial support, counseling, and referral services for SGBV cases. SGBV survivors are organized into Survivor Support Groups to facilitate and strengthen social networks for psychological support as well as economic empowerment for resilience and sustainability.

Program Impact

In 2021, the program led a robust baseline survey among the nine implementation districts and three control districts. The study included over 7,000 individuals and was a cross-sectional, mixed-method design leveraging both quantitative and qualitative data collection techniques. Heroes4GTA measures the quantity and quality of services received at health facilities including the number of facilities offering adolescent-friendly services, contraceptive use and availability, and family planning/immunization integration readiness, among other indicators. To assess progress at midline, Heroes4GTA conducted a primarily qualitative cross-sectional midterm evaluation among 96 key informants, including 33 focus group discussions—reaching over 400 community members in their assessment. Community data is collected through the program register and entered into the Amref electronic system. For health facility data, the program contributes to strengthening the single data source system using the Ministry of Health HMIS tools and reporting using DHIS2, supporting routine facility, district-level quarterly performance review meetings and routine data quality assessments.

Comparing the findings from the baseline in 2020 to the most recent impact data in 2023, the project has contributed to the following achievements:

• Reached over 745,280 young girls, boys, and women with comprehensive sexuality, SRHR, SGBV, and life skills training across nine districts.
• Contributed to a reduction in teenage pregnancy/adolescent birth rate, from 25% to 23%.
• Contributed to a decrease in facility maternal mortality ratio (deaths per 100,000), from 59 to 38.
• Increased couple years of protection (CYP), from 45,770 to 94,762.
• Increased the number of unintended pregnancies averted, from 13,182 to 27,291.
• Increased the number of births attended by skilled health personnel in Heroes Health facilities, from 56% to 70%. (Source: MOH-DHIS2, July 2024).
• Over 4,950 survivors (girls and women) were provided with access to justice through the program. Of these, 142 cases have been taken to court and 56% of them concluded through the court system. (Source: Programme Data accessed July 2024).

Showcasing the impact of the project, Emmanuel Mugalanzi, Local Capacity Development Advisor for Uganda Health Activity (UHA) noted “We have seen progressive action in the reduction of GBV cases and an increase in the reporting of cases that arises from the sensitizations using the men-alone sessions.”

An endline study is planned for 2026, commissioned by the Netherlands Embassy in Uganda, and will include both a quantitative and qualitative assessment of the changes in the program districts in comparison with the control districts. The assessment will also explore changes at the endline compared with the baseline on different parameters, including comprehensive SRHR knowledge among the target population, SRHR indicators and service systems, gender equity attitudes, and SGBV practices and response mechanisms. In addition, the assessment will explore the relevance and sustainability of the program interventions.

Addressing Common Barriers: Challenges and Effective Solutions

Lecciones aprendidas

Conclusión

In summary, “Our success was not accidental,” said Dolly Ajok, Project Manager and Youth Representative, explaining that the program’s achievements were rooted in four overarching strategies:

1. A youth-centered approach
2. Significant investment in conocimiento administrativo
3. Using sustainable incentives to ensure young people are deeply invested in their own programming
4. A strong emphasis on data-driven action

Dolly emphasized that these four elements made the program highly responsive and adaptive and that identifying effective, intrinsic motivators was crucial for ensuring youth ownership of the program. “For me, these are the key things and you’ll crack the nut.”