An evaluation of pay for performance incentives for community health workers
Background
Designing effective incentive systems for community health workers (CHWs) represents a
longstanding policy issue with substantial impact on the success and sustainability of CHW programs.
Using pay-for-performance (P4P) incentives for CHWs represents a novel approach worthy of testing
and evaluation. This report evaluates the use of P4P incentives for CHWs in Kisoro, Uganda.
Methods
Surveys were conducted of CHWs (n=30) and programme supervisors (n=7) to assess system
acceptability and feasibility. Interviews were conducted with all 8 programme supervisors and with 6
purposively selected CHWs to gain further depth on issues raised in the surveys. Programme budget
records were used to assess the costs of the programme. Detailed payment records were used to
examine overall programme outputs (i.e., patients identified, sanitation facilities built, community
talks delivered, follow-up visits to families with high-risk issues, etc.), the impact of CHW and village
characteristics on success under the P4P system, and changes in payments over time.
Results
In surveys and interviews, supervisors expressed high satisfaction with the pay-for-performance
system. CHWs perceived the system as generally fair, but complained that they were underpaid for
their work. The annual total programme cost was $18,000 for 34 CHWs (including training,
supervision, administration and stipends); $516 per CHW, and $1.12 per individual served by the
program. CHWs covering more households tended to earn more. There was no evidence that male
gender, greater education, or closer proximity to the hospital were associated with higher earnings.
Payment amounts declined over the course of the year; however, payment amounts were
essentially equal in the rainy and dry seasons.
Conclusion
Pay-for-performance incentives require close supervision of CHWs and detailed record-keeping. In
settings where this is possible, performance-based incentives can aid in the development of highfunctioning, data-driven CHW programs.
Around the Fire: Local Perspectives of an Improved Cookstove in Mwaya Beach, Malawi
Throughout the developing world over 2 billion people rely on biomass fuel sources, such as wood,
for use in traditional cooking practice (Fullerton, 2009:1). In recent years the problems associated
with traditional cooking practice have become the focus of developmental and environmental
policies and research. This focus centres on the environmental impact of woodfuel consumption and
health issues associated with smoke inhalation and burning. One response to these problems has
been the
implementation of preventative measures, such as the creation of improved cookstoves, which aim
to reduce wood consumption and indoor air pollution caused by smoke emissions. Various types of
improved stoves have been created, ranging from basic stoves made from locally available materials
to more sophisticated products made using metal and harnessing solar energies (Adkins, Tyler,
Wang, Siriri and Modi, 2010:172). These improved stoves have been disseminated in a range of
settings including South America, India and Africa and this distribution has been backed by both
governments and non government organisations (NGOs).While much of the research concerning
these improved cook stoves reflect the current concerns about health issues and contributions to
deforestation, it focuses less on the opinions of the recipients of these new cooking technologies.
This research attempts to highlight such opinions and investigates local perspectives concerning the
‘RippleRocket’, an improved cook stove, made from clay sand and brick, being distributed by an NGO
in Nkhata Bay District, Malawi. These local perspectives centre on the problems and benefits
associated with the RippleRocket and the traditional three stone fire, and highlight how well the
improved stove is being integrated into cooking practice
A serological and social mixing study of typhoid in Fiji to inform modelling and control Typhoid fever is an acute, life‐threatening, bacterial disease, transmitted from the faeces or urine of patients and carriers, often on food or in water. Confirmed case numbers in Fiji have been rising since 2005, almost exclusively affecting the indigenous iTaukei community, both as sporadic cases and in outbreaks, with young adults, particularly men, most at risk. With the support of the Chadwick Trust, I was able to do a large‐scale serological field study – measuring immune antibodies in blood serum samples – to investigate typhoid exposure in different population groups, and look at risk factors for having antibodies against typhoid. While the fieldwork is complete, the laboratory tests and epidemiological analysis are ongoing. Regardless of the answer we find – how common high or low antibodies are; whether children or adults are more affected – the research will aid understanding of typhoid transmission, and help prioritise interventions. The Fijian government needs good information to make decisions on the best ways to prevent typhoid. The study will directly inform control measures in Fiji, such as vaccination programmes and sanitation improvements. Data will be developed into a transmission model to assess the potential impact of different strategies. It has been a hugely beneficial experience personally. The fieldwork has given me invaluable experience of managing a team and budget to deliver a complex public health project in a sometimes challenging working environment. I will be better equipped as a public health consultant to investigate disease outbreaks and implement evidence‐informed measures to control threats to the health of the public. Assessing Household Health Risks in Delhi
With low quality informal houses accounting for around half of the stock, summer temperatures above
40ºC, income limited ownership of air conditioning, and annual average outdoor PM2.5 levels of
3
177µg/m recorded, Delhi is facing a multi-dimensional problem to provide adequate indoor
environments. This project proposes to address the extent of the indoor health risks from temperature
extremes and pollutants on household occupants across Delhi, via a combination of measurement
campaigns and modelling studies using validated building simulation models. The Chadwick Trust
Travelling Fellowship is helping to support the measurement campaigns that will help validate models
as well as provide evidence of indoor environmental conditions in Delhi.
An initial pilot study was carried out in a low-income settlement in the outskirts of Delhi during
December 2013, where temperature and relative humidity was monitored in 14 homes. Alongside the
monitoring campaign, housing surveys identified building characteristics, number of electrical
appliances and cooking fuel type. Two focus groups with residents from the monitored houses helped
identify perceived indoor environment quality and comfort issues within homes. Brief analysis
suggests that there is a variation of up to 2°C in mean indoor temperatures between homes during
December, however more in-depth analysis in required. Focus group findings suggest that residents
sometimes feel claustrophobic in their homes due to the limited size, but they failed to link housing
characteristics with health and rarely felt cold indoors, as they had sufficient blankets for warmth. This
data once fully analysed will help focus further research, validate models and inform intervention
studies. A follow up trip will help expand understanding of building performance and variability across
Delhi, as well as capture indoor temperatures during a period of extreme summer heat.
Diverse Use Of Bednets; An Investigation Of Outcomes And Determinants
The aim of the research is to gain a better understanding of how bednets are used within the
community of Mbita-Rusinga in Western Kenya. The six week investigation used questionnaires, indepth interviews, focus groups, key informant interviews and observation to identify; who uses
bednets, uses for bednets other than for malaria prevention, and bednet disposal methods. The
community was found to have high bednet coverage; however the efficiency of bednets is
questioned based on the potentially detrimental effects of the bednet washing process. Many wider
uses for bednets were identified; some are deemed economically important such as the use to dry
fish or protect trees. The reported use of bednets as fishing nets has a negative impact on the Lake
Victoria fishery. Once the community has no more uses for their bednets, the nets are burnt. This
may have human health implications however these are deemed less important than ensuring
continued distribution of bednets. The short period of data collection, the apparent research fatigue
of the community and the limitations of the methods used mean that many of the conclusions
drawn from the study require further investigation.
Design and user management characteristics of latrines associated with fly and larval densities in
the Kilombero district of Tanzania
Background
Latrines provide a favorable environment for certain flies to breed and or feed. These flies can carry
excreted pathogens to human food and fomites. There is very little known on why some latrines
attract large numbers of flies while other latrines nearly fly-free. This project seeks to describe which
characteristics of latrines are associated with high fly densities to inform evidence-based latrine
design to ultimately lessen this mode of diarrhoea transmission.
Methods
This study was a cross-sectional survey nested within the longitudinal pit latrine study currently
taking place in the Kilombero valley. Forty-two latrines were studied in the villages of Sululu, Signali
and the town of Ifakara. The longitudinal study gathered the data on the design and user
management features of latrines using questionnaires. Adult flies were collected using 24-hour exit
traps that were placed over the latrine drop-hole. Larvae samples were collected by dipping a ladle
into the pit contents; only 24 latrines were suitable for larva dipping.
Results
A total of 3,539 flies were caught, ranging from 0 to 951 per trap. Four traps caught zero flies. The
mean number of flies per trap was 84 (95% CI: 32-139). The dominating families in traps were
Psychodidae and Calliphoridae, making up 99% of the total catch. The presence of a roof was found
to have the strongest association with mean total fly numbers. Latrines with roofs had an average of
41 flies (95% CI: 12-70) compared to an average of 242 flies (95% CI: 23-461) in latrines without
roofs. There is strong evidence that the difference in mean fly numbers was not due to chance
(p=0.0008).
Conclusions
This study suggests that the mean number of flies emerging from latrines may be associated with
the presence or absence of a roof. Whether this is due to the amount of light entering the latrine,
the temperature or the ease of access for the flies in unknown. This knowledge provides a
foundation for future studies on the characteristics of latrines associated with high and low fly
densities. Building a roof should be explored as a simple, low-cost modification for fly control.
Evaluating the impact of development projects on food security in Central America
In my field study, I intended to survey three different development projects – one aimed at
increasing local food availability through improving agricultural techniques, one focused at
increasing food access through community business training (and hence increased income), and
finally one aimed at improving food utilization through the provision of access to cleaner drinking
water. Due to financial and time constraints I managed to evaluate only the latter two projects in the
field research that I carried out last year, which means that in order to complete the evaluation I will
have to make another trip to the region this year. Both projects examined were being carried out in
the Achuapa region of Nicaragua, by two different NGOs. The first, ‘food-access’, project provided its
recipients, primarily women, with artisanal training and subsequently helped them market the
finished products. The second project involved construction of water wells in local communities
along with pipes that brought drinking water to every participating household (previously, most
people obtained drinking water from a river nearby).
In the first project, I managed to gather survey data on 213 individuals (111 treated and 102
controls), while in the second one on 244 individuals (130 treated and 114 controls). The surveys
focused primarily on gathering key demographic statistics (age, gender, education…) and then
information regarding food security (food security index based on questions about the frequency
and depth of hunger, the quantity and quality of food consumed, and the frequency of illness in the
family). I analyzed the impact of each project on the recipients’ food security through Propensity
Score Matching, which compares the means of the outcome variables of the treated and the control
group after controlling for the demographic variables.
In neither project did I find the treated group to have a significantly higher food-security index.
Nevertheless, in the first project (the food-access one), the treated group did appear to suffer
significantly less frequently from lack of food, while in the second project, the treated group
appeared to be significantly less ill than the control group. Both of these variables are indicative of
greater food security; albeit the first one might be more directly so than the second one.
Interestingly, in the second project the treated group was found to also consume significantly more
fruit than the control group, which might be an indicator of greater food security or better health as
well.
The results so far indicate that the link between food security and aid in food access projects might
be more direct than in food utilization projects; however, food-utilization projects might be more
cost-effective and/or more sustainable in the long-term than the food-access ones. However, since I
have yet to examine the last type of project – the food-availability one – I cannot draw any final
conclusions thus far.
Investigating the density, distribution, and characteristics of Anopheles and Aedes breeding sites
in Palawan Province, the Philippines.
Purpose
This project aimed to describe and analyse the potential breeding sites present in areas of differing
land-use and land-cover in Palawan Province, the Republic of the Philippines. Information on the
abundance of water-bodies, their physical attributes, and the distribution of mosquito larva between
them, is relevant to current entomological research.
Methods
Four transects, following the paths of streams, and covering a range of land-cover and situation
types were selected. All water bodies encountered were physically assessed on a number of
characteristics; habitat type, depth, permanence, water-movement, degree of canopy cover,
elevation, and situation-type. Water-bodies were explored for mosquito larva which were collected,
returned to an insectary, and reared to adults. Adult mosquitoes were identified, as were
anopheline larva.
Results
An. balabacensis larvae were collected, confirming the presence of the vector’s breeding sites in the
area. The high number of Ae. albopictus and the absence of Ae. aegypti in the area is in accord with
reports of their respective breeding site preferences. A great variety of water-bodies, with differing
characteristics, were discovered and analysed. The proportion of water-bodies positive for mosquito
larva was seen to differ between water-body characteristics. Other than the habitat-type of waterbodies and the presence of Anopheles larva, none of the variables were shown to be associated with
the presence or absence of Anopheles or Aedes larva.
Implications
Palawan Province has the highest number of malaria cases of all 80 provinces in the Republic of the
Philippines. Novel Plasmodium knowlesi infections, and a geographical overlap between malaria and
dengue cases further complicate the public health challenges posed. The results of this study provide
both a deeper understanding of the entomology of vectors in the area, as well as helping to link the
life cycle of these vectors to the transmission of human malaria and dengue.
Malaria in Myanmar: Understanding the epidemiology of malaria in Eastern Bago Region. Aims To understand who gets malaria in Eastern Bago region, Myanmar (Burma), and why. This region is a transport hub at the centre of Myanmar and therefore of strategic importance in the control of malaria. The study also has international significance because Myanmar, for geographical and population‐movement reasons, is important in the spread of drug resistant malaria across Asia. Our primary objective is to map the epidemiology of malaria in Eastern Bago region in Myanmar. This will include quantifying the burden of malaria in permanent residents; identifying factors associated with infection including migrant worker status; and identifying the different species of plasmodium affecting participants. Methods A cross‐sectional survey of the resident population was carried out. Participants were visited by a UK researcher, a Burmese doctor and a local healthcare worker. A short questionnaire was administered to collect demographic information (gender, age, ethnicity, occupation, income, first language etc); travel information; malaria awareness; malaria prevention methods; and self‐reported malaria incidence in the last three months. All participants aged over 1 year had a capillary blood sample taken (blood spot taken by pin prick) for thin and thick film malaria microscopy and laboratory analysis in the UK. Their tympanic temperature was also measured. A rapid diagnostic test was performed on all participants with temperature of over 37.5C. Results 1700 participants were randomly selected to take part in the study. None were diagnosed with active malaria (fever plus positive RDT or positive microscopy). Analysis is ongoing of prevalence of asymptomatic parasitaemia (including microscope or PCR positivity), but initial results indicate this will be considerably higher than the prevalence of active malaria. Serological analysis will give an indication of the average age at which local residents first contracted malaria. This will lead to inferences of the transmission intensity – very low levels of endemic transmission are expected. Analysis of the information from questionnaires will give an indication of risk factors for asymptomatic parasitaemia, self‐reported malaria, or seropositivity (indicating past infection). This information will be used to test the hypotheses that working in nearby forests or migrating for employment reasons are risk factors for malaria. These data will be useful for the Myanmar Ministry of Health in targeting malaria prevention and treatment services to appropriate populations, whether these are local residents or migrant populations. Piloting a sanitation related risk assessment methodology using innovative data collection and processing techniques in Maputo, Mozambique Public health issues due to a lack of proper sanitation are a serious concern throughout the developing world, where incidence of faecal‐oral transmitted disease is significantly higher than in the developed world. Every 20 seconds a child dies as a result of poor sanitation (UN Water, 2013). One of the principal reasons cited for sanitation health risk is the mismanagement and lack of understanding of municipal sanitation infrastructure (WHO, 2007). This study aimed to demonstrate the effectiveness of innovative data collection and processing methods in order to survey the condition of critical sanitation infrastructure elements and estimate the risk to human health arising from sanitation system malfunctions in a given urban area. The goal was to demonstrate the validity of a rapid and practical methodology suitable for use in a development context which would enable decision makers to understand the scale of the problem and maximize cost‐effectiveness of infrastructure interventions. This report documents the piloting of a proposed methodology in Maputo, Mozambique. It combines participatory research methods, sanitary surveying and risk assessment techniques. The results of this research project are two‐fold: 
The results of the methodology application describe the sanitation problems that Maputo is facing and were analysed to explore different infrastructure intervention options. 
The practical application of this experimental methodology provided insight into the validity of the techniques used. The challenges and benefits of using this innovative approach were discussed and options for further refinement and validation of the methodology were given consideration. The application of the methodology revealed that the sanitation system that presents the greatest risk to human health in Maputo is the sewer system. The low hanging fruit in terms of infrastructure interventions to reduce risk to human health is refurbishment of the waste stabilisation ponds which are severely mis‐managed and in disrepair. In the context of methodology development, integrating participatory research, sanitary surveying and risk assessment techniques proved suitable for data collection in the development context. Steps to ensure their efficacy in this type of application were uncovered as were many possible sources of error. Due to a lack of information in the literature the accuracy of the methodology could not be definitively confirmed. Necessary steps for refining the methodology and confirming its validity were identified. Rational planning of Village Health Worker placement to improve cost-effective access to
community-based health services in Myanmar: a Health Policy Report
The project involved looking at the spatial distribution of volunteer health workers, who in
Myanmar, as in many countries in the world, provide a vital (and in some cases the only easily
accessible) form of basic health care to communities that are too remote, rural, or simply too poor
to gain access to anything else. Initial hopes about the potential of volunteers in the 1970s-1980s
had died down when results from large scale volunteer programmes fell short of high expectations.
The last few years, particularly with the considerable efforts to try and achieve the Millennium
Development Goals, have seen a reawakening in interest.
Merlin in Myanmar works through a network of well over a thousand of these volunteers. The
primary focus in on maternal and child health issues. The volunteers provide, for example, first line
treatment for simple infections, antenatal care, newborn care and a route for referral to other
services.
As Merlin and others know only too well, however, “volunteer” does not mean “free” – the ongoing
costs of training and support, particularly where turnover is high, can make these programmes
unsustainable for the Ministry of Health in the long term. Merlin wanted to investigate whether an
adequate level of access to the basic services volunteers provide could be achieved with less
volunteers. Mapping, using geographical information systems, had suggested substantial overlap
between the “catchment” areas of volunteers in the particular area they were interested in, Laputta
township in the Ayeryarwady Delta. My role was to try and find out about the more human side of
things – to people who use volunteers, how important is the distance they have to travel to reach
them, and what were the other factors affecting access to volunteers? From the volunteers’ side,
how receptive might they be if they were asked to cover a larger number of villages or “clients”?
Broadly speaking I found that the things that govern whether people use volunteers are much the
same as those that affect access to health services in other settings – the distance to them, their
affordability, whether or not the providers are trusted, and so on. Asking volunteers to cover wider
areas may work well – depending on the volunteer’s energy and reputation – or less well, according
for example to what substitute services may be available and the willingness of villages to work
together. Merlin are now going to undertake cost effectiveness studies to understand the potential
savings that might be released by spreading volunteers out differently, and in parallel work together
with partners on improving the effectiveness of the volunteers they have and also at other ways to
support the health system.
Watering with waste – a “farm-to-fork” evaluation of produce hygiene status in Accra, Ghana .
The use of untreated wastewater (a combination of sewage, run-off and rainwater) to irrigate plants
is a common practice in farming, and one which has many potential benefits – wastewater is cheap
and easy to source, and contains many nutrients which are beneficial to plant growth. However,
there are concerns about risks to human health from microbes that may be spread in this way,
including food poisoning, polio and hepatitis. This research project aimed to identify the effect of
wastewater use on the quantity of the bacteria E coli at various points along the pathway from
production to consumption.
The study was carried out in Accra, capital of Ghana. A total of 450 samples from 3 farms, 3
markets, and 50 prepared food sellers - 80 lettuce, 80 soil and 80 irrigation water samples from farm
sites, 80 produce and 80 cabbage from 3 market sites, and 50 prepared salad samples were
collected. Additional information was also collected from each site to aid in the interpretation of
results. E coli from each sample were then grown and the quantity calculated.
E coli levels measured from farm samples were higher on both plants and in soil when more
contaminated irrigation water has been used. However, E coli levels were significantly higher at the
market than those found at the farm. This suggests that irrigation water is unlikely to be the single
most important factor in determining produce hygiene status, and aspects of market handling (such
as spraying display produce with water) may play an important role. The data here do not suggest
reasons for this, and further work to understand the cause will be important in appropriately
targeting risk reduction strategies. Salad samples from street food vendors were found to be
significantly more contaminated than those from hotels. Where vendors reported using salt water
and vinegar in the preparation of the salad, contamination was less than where water alone was
used. This may warrant further investigation as a low-cost means of reducing risk to the consumer.
Women’s Empowerment and Children’s Nutritional Status in Timor‐Leste Nature of the problem addressed (background) Children’s nutritional statuses in Timor‐Leste worsened among all three anthropometric indicators between 2003 and 2009 [1] [2]. Timor‐Leste currently has the second highest stunting prevalence (58%) and the highest moderate underweight prevalence (47%) among children under five in the world. Resent research links improving women’s empowerment with improved children’s nutritional statuses, but results have not been replicated across countries [3] [4] [5] [6]. The aim of this research is to determine the context‐specific meaning of women’s empowerment in Timor‐Leste. Methodology This study collected semi‐structured individual interviews from August 5 – 9, 2013 in the Ainaro and Manufahi Districts of Timor‐Leste. Researchers purposively sampled participants based on the following criteria: women aged 18 – 49 with at least one child under the age of five. Researchers interviewed a total of 33 women. Individual participants were sampled across various geographical locations in the Ainaro and Manufahi Districts of Timor‐Leste and occupations in order to increase the sample variation [3]. Six local women were trained as interviewers and collected the data in collaboration with a local NGO, Mercy Corps. Directly after interviewing each participant, the interviewers expanded their interview notes by writing detailed accounts of the interview and their observations. The data was analysed by the primary researcher (Jill Scantlan) and an outside researcher from the University of Cornell (Angela Previdelli) using thematic analysis. Findings 
Women expressed empowerment/disempowerment in three different areas of their lives: within the household (domestic); market (income‐generating activities); and community. 
Women consistently stated that they make joint decisions with their husbands on all household and community activities. However, participation in joint decisions was not equal between women and their husbands. Some women considered “asking permission” or “being informed by their husband” as being involved in the decision. 
Respondents faced several barriers to participating in the community and in income‐generating activities. These included: lacking time; not finishing their education due to lack of income and/or early marriage; the need to prioritize household activities/child care and having young children or too many children. 
Respondents described several ways in which men had more power than women, particularly in their ability to: participate in community activities; secure government jobs or have more job options; and participate in cultural ceremonies. 
Respondents expressed several health beliefs. Positive health beliefs included the role of good nutrition in growth, development and survival. Respondents also had unconventional health beliefs around malaria, diarrhoea, and anaemia. References Black, R. E., C. G. Victora, S. P. Walker, Z. Bhutta, P. Christian, M. De Onis, M. Ezzati, et al. (2013). Maternal and child undernutrition and overweight in low‐income and middle‐income countries. Lancet, 382(9890): p. 427–51. Grantham‐mcgregor, S., Y. B. Cheung, S. Cueto, P. Glewwe, L. Richter, & B. Strupp (2007). Developmental potential in the first 5 years for children in developing countries. Lancet, 369: p. 60–70. Patton, M. (1990). Qualitative evaluation and research methods. Qualitative evaluation and research methods. Beverly Hills, CA: Sage. pp. 169–186 Rico, E., B. Fenn, T. Abramsky, & C. Watts (2011). Associations between maternal experiences of intimate partner violence and child nutrition and mortality: findings from Demographic and Health Surveys in Egypt, Honduras, Kenya, Malawi and Rwanda. Journal of Epidemiology and Community Health, 65(4): p.360–367 Bhagowalia, P. & A. R. Quisumbing (2012). What dimensions of women’s empowerment matter most for child nutrition? Evidence using nationally representative data from Bangladesh. Washington D.C. Retrieved from http://www.ifpri.org/publication/what‐dimensions‐women‐s‐empowerment‐matter‐
most‐child‐nutrition Ruel, M. T., & H. Alderman (2013). Nutrition‐sensitive interventions and programmes: how can they help to accelerate progress in improving maternal and child nutrition? Lancet, 382(9891): p. 536–551. Youth Friendly Services: Are They Meeting the Health Needs of Adolescents in South Africa?
Purpose
In the context of South Africa’s national youth-friendly services (YFS) program this project aimed to:
investigate the extent to which publically funded health facilities in a rural area are implementing
health services for young people, document perceived barriers to the delivery of quality, confidential
services to young people in this area and investigate young people’s experiences of using
reproductive health services in an urban area.
Methods
Semi-structured interviews were conducted with eight professionally trained nurses at each of the
eight publically funded health facilities in rural Agincourt, Mpumalanga Province. Fifteen publically
funded health facilities in urban Soweto, Gauteng Province were randomly sampled and each
received four visits from simulated patients requesting advice on condoms or contraceptive
methods. A structured questionnaire with closed and open-ended questions was administered to
simulated patients after each visit. Informed consent was obtained from all facilities and
participants.
Results
All facilities in rural Agincourt provided health services to young people and half had peer educators
linked to YFS (groundBREAKERS). Only two had ever implemented YFS and only one continued to.
Nurses perceived lack of staff and training on providing services for young people as barriers to YFS
implementation and general provision of quality health services for young people. Reported lack of
space may affect service delivery for all age groups but particularly young people who may perceive
a greater need for privacy. Although results from Soweto are not yet available, basic information
from all clinics showed a greater percentage of publically funded facilities had peer educators in
Agincourt than Soweto (50% and 19% respectively). Both areas have been involved in the program
since the early stages so it is interesting that peer-education is being implemented in a higher
proportion of facilities in the rural area.
Conclusions
In rural Agincourt, human resource and infrastructural issues were perceived barriers to
implementation of YFS, and general provision of quality health services for young people.
Infrastructure problems will affect all service delivery (although may be more important to young
people), but specialised training should affect delivery specifically for young people. More staff and
training are required to allow facilities to implement YFS. Desire to implement YFS among all
facilities in Agincourt is promising for future program rollout. As one of the few countrywide,
government-run youth-friendly services programs in a low or middle-income country, evidence on
YFS’s implementation are of interest to program managers and policy makers in other Southern
African settings.