We present findings from the interviews and focus group discussions; several themes and subthemes were identified with related quotes from stakeholders to help illustrate the emerging themes. Responses from the focus group discussions with the adolescent in Zambia were employed to provide greater context and, validate the results were incorporated within the thematic areas, where relevant. Major themes from the study included priority shifts: how the emergency response limited access to SRH for AYP shortages of human resources, supply chain disruptions, compromised quality of service provision, and limited AYP’s access to SRH information. Suggestions for interventions to improve SRH services and lessons learned include; disaster preparedness strategy, increased funding for ASRHR, use of community health workers and community-based ASRHR strategies, and use of technology and social media platforms such as mhealth.
Priority Shifts: how the emergency response limited access to SRH for AYP
At the height of the pandemic, several stakeholders in Zambia, Malawi, and Zimbabwe reported that government and/or funding agencies had shifted both their focus and resources almost entirely to the primary health sector as a response to COVID-19. This shift in focus and resources had a ripple effect that permeated throughout the service delivery of ASRHR and other adjacent programming (outreach, education, and peer support) thus negatively impacting other routine services such as resource-related challenges which meant that medical staff was shifted to COVID-19-related services; loss of donor funding; reductions in pre-and post-natal care; post-abortion care; and other sexual and reproductive health services (for which resource allocation was already scarce). It was also reported that the provision of SRH services and outreach activities for AYP were commonly suspended or cancelled since, at the time, health facilities were overwhelmed with the COVID-19 pandemic response. Therefore, outreach activities that were heavily reliant on face-to-face interactions or public gatherings were either suspended or cancelled due to mandatory COVID-19-related restrictions. One key informant in Malawi described how the introduction of COVID-19 restrictions challenged how ASRHR activities were delivered.
COVID-19 caught the country by surprise. As a country, we did not have time to adjust. Restrictions made it even hard to adjust. The bigger challenge is that most of our activities are information-sharing activities that require gatherings. (Government Ministries, Departments, and National Councils Stakeholder, Malawi)
In Zimbabwe, the priority that was given to COVID-19 was due to resource challenges. Stakeholders reported that funds and capacity were diverted to COVID-19 response and to support the local healthcare system which had a depleting effect on SRH services. It was shared that most resources were shifted to the COVID-19 response including human resources.
And another issue that we also faced was prioritization, which was given to attending to COVID cases. This meant that the other services also suffered in the sense that they were not, especially when you look at the routine, reproductive, and health services. They suffered in the sense that people prioritized attending to cases of COVID-19. (Government Ministries, Departments, and National Councils Stakeholder, Zimbabwe)
In addition to facility reallocation, some respondents also described how their project ended up asking for a reallocation of resources to accommodate a COVID-19 response. Additionally, in Malawi, Zambia, and Zimbabwe frontline healthcare workers or medical staff who were typically responsible for providing SRH services to young people were reassigned to other pandemic-related duties. Furthermore, spaces dedicated to providing SRH services to adolescents such as youth-friendly spaces were turned into COVID-19 testing points or waiting areas due to the limited space at the health facilities. A managerial adolescent focal-point person in Zambia explained,
It was a little bit tricky because there are facilities, I will give an example of [redacted]. One of the facilities with a very active adolescent-friendly space had to give away the tent that they use for adolescent-friendly services to the COVID-19 case because there was nowhere else to put a patient if they tested positive. They would put that client in that tent for adolescent-friendly services. So, it was discouraging that even the peer educators had to temporarily be on hold, they were not coming to the facility to come and offer the services to their fellow peers. (District adolescent focal point person-Female, Zambia)
The case in Zimbabwe was similar, key informants discussed a lack of availability of SRH services for AYP. One stakeholder mentioned that at that time, organizations that supplemented government efforts to provide SRHR services to young people were closed indefinitely. The mere closure and the uncertainty that prevailed during the closure restricted access to services as there was no sure sign that service providers would resume. They shared:
It was really difficult because some of our clinics there were closed due to the unavailability of personal protective equipment [PPE], especially in rural areas. So, it was really difficult for young people to access services and I think due to the prioritization of COVID-19 patients, other issues that would come with that would come with his young people to their facilities were now not considered is important. So sometimes you will be back home, simply because you don't have the signs and symptoms of COVID. They were only concentrating on, COVID-19 so it was a big challenge for us in terms of access to services. (Local NGOs stakeholder, Zimbabwe)
Furthermore, stakeholders in Zimbabwe highlighted the critical role those local businesses play in ASRHR by supplying young people with condoms. During the pandemic, many local businesses temporally closed or reduced their operating hours to reduce the spread of COVID-19. One participant described,
It wasn't just schools that were closed. Even some shops, you find that they close earlier, and some wouldn't even open at times. So then with access to SRHR services like condoms and things like that, you'd find that you wouldn't have them readily available as you would have before COVID, before lockdown and everything. So that was one of the factors that I'm increased the teenage pregnancies and stuff. (Adolescent, 18–24, Zimbabwe)
Human resource challenges
Interview participants also reported that throughout the pandemic, there were shortages of already insufficient human resources, as the healthcare workforce was also infected with COVID-19. While it was reported that few human resources died from COVID-19, others were placed in isolation centres which left a gap in service delivery. Notably, it was reported that these staff shortages in Zambia affected access to abortion, family planning/contraceptive, and HIV testing services. A nursing officer shared,
There was something which could have made our teenagers not access some services because we had a high number of illnesses amongst the staff. The staff were getting sick because of COVID-19. So that could have affected the provision of some services to adolescents such as safe abortion. In some facilities which offer (abortion services), you would find that there is only one person who is trained in providing those things, and if that person is sick then it will affect the accessibility of that service. (District nursing officer-Female, Zambia)
A similar situation was also reported in Malawi, where one key informant explained that medical staff in their organization also contracted COVID-19 which increased the workload on the remaining staff as one respondent shared,
Some medical staff also contracted COVID-19 thereby increasing the workload for the remaining staff. At a certain time, two clinics were closed because more than half of the medical staff at the clinic tested positive for COVID-19.
(Clinic (Private / NGOs) stakeholder, Malawi)
In Zimbabwe, a key informant mentioned that there was a noted brain and skills drain from Zimbabwe to other countries experiencing health workforce shortages, such as the UK, in consideration of the financial benefit of serving in the UK, compared to Zimbabwe. Thus, the lack of competitive remuneration for health workers contributed to the human resource shortages that were widely reported in the region.
Zimbabwe lost a lot of health workers, with some facilities losing their entire workforce; healthcare workers would rather go to the UK for caring as it made them a living against the rather poor remuneration offered to our national health workers. (Local NGO stakeholder, Zimbabwe)
Shortages of commodities/supplies
Disrupted supply chains led to shortages in commodities. Along with the COVID-19 pandemic brought about several supply chain disruptions that lead to shortages of important SRH-related commodities and supplies which were still felt at the time of data collection. One stakeholder in Malawi explained that the supply chain for the commodities was disrupted and mainly only COVID-19-related commodities were given priority. One stakeholder in Malawi described the scarcity of SRH commodities when they shared,
There were drastic periodic stock-outs of family planning commodities. These family planning commodities are procured centrally. It seems the priority for the government shifted from the procurement of family planning commodities to the procurement of COVID-19 response commodities. As an organization, we also started having problems with accessing condoms. It was believed that the companies that are major manufacturers of condoms went into mass manufacturing of gloves hence reducing manufacturing of condoms (Clinic (Private / NGOs) stakeholder, Malawi)
Both adolescents and stakeholders in Zambia indicated that there was a lack of supplies, including SRH commodities during the pandemic. In some cases, procurement of important commodities such as HIV testing kits and reagents was not done on time, leaving some health facilities with no commodities. A young person said,
It was very difficult to get tested or go to the health facility and get tested because of COVID-19. So, you would find that you go, they would want to test you quite all right, but they don't have the instruments (supplies). (FGD, adolescent girls-14-18, Zambia)
Adolescents and youth also reported the lack of essential medicines that addressed their health needs. For example, adolescents and youth not receiving treatment for STIs, information, or their requested supplies such as condoms. This shortage was overshadowed by the availability of COVID-19 supplies.
You would find that most medicine and the available vaccines were those for COVID-19. There was nothing to give for those with STIs or disinfectants so that you don't get sick. (FGD, adolescent boys-14-18, Zambia)
Compromised service delivery
The disruptions in service provision and commodity shortages also meant service quality was also compromised. While it was policy to provide HIV counselling alongside testing services, some young people who had access to testing services were not provided with counselling. In Zimbabwe, it was mentioned that young people were viewed as a special group that needed counselling, and thus, the pandemic robbed them of this service, leaving them vulnerable to negative coping strategies after testing positive for HIV. The informant said:
We have other ASRHR challenges that you want to discuss with these people, especially relationships about disclosure, etcetera. So, it was now that difficult for them to be equipped with the knowledge and skills, given confidence to cope with their HIV status. So, it really affected [us] a lot. (Local NGO stakeholder, Zimbabwe)
Limited AYP’s access to SRH information
Disruptions in learning programs limited access to points where adolescents could access information. Although education and health policies mandate the provision of comprehensive sexuality education (CSE) to young people, it was revealed that during school closures and the implementation of distance learning, CSE was often dropped from the school curricula. It was reported that pre-pandemic, teachers provided information to adolescents weekly, to help them make informed decisions regarding their sexuality. However, the school closures led to adolescents and youth spending more time at home and without access to SRH information within the school setting. An ASRH program implementer said,
We have been supporting the Tikambe (let's talk) clubs but generally, they are called the "Anti-AIDS club" or the "AIDs Action Clubs. These are clubs where young people go to access information and share conversations or discussions, the challenges that they have, the peer-to-peer conversations that they have, or discussions on the challenges that they have regarding sexual reproductive or comprehensive sexual education. With the suspension of schools, there was no point where these adolescents could go and just ask for further information or if they wanted to ask for services or they wanted to seek clarity, or have a conversation. (ASRH program implementer-Male, Zambia)
Furthermore, it was reported that access to health services for young people was severely impacted and either interrupted or discontinued throughout the peak of the pandemic. In Zimbabwe misinformation was a challenge, where young people turned to social media for SRH information which could have been misleading in most cases. This meant that there was a platform to ask questions or obtain further clarity on information received in the community.
So, the knowledge gap was created with COVID-19 through school closure. It really caused a lot of challenges among young people. Because even if you want to, you are told something in the community, there was no room for clarification. Sometimes you just use, those spaces that they have at school for comprehensive sexuality education, they no longer have access to that. (Local NGO stakeholder, Zimbabwe)
Suggestions for interventions to improve SRH services and lessons learned
Throughout interviews, several organizational stakeholders offered recommendations, and suggestions on how to maintain and modify SRH services during the pandemic to ensure that SRH information and services are accessible to adolescents, these recommendations are discussed below;
Disaster preparedness strategy
It was also suggested by stakeholders in Malawi, Zambia, and Zimbabwe that on the organizational level, time and effort should be devoted to developing or updating a disaster preparedness strategy to ensure that future pandemics or other types of crises do not repeat the same types of debilitating effects. Stakeholders offered a range of suggestions for future disasters or crises such as establishing solid HIV self-testing protocols and stockpiling tests,
So, I think what's, what's important for now is to come up with a disaster preparedness strategy for us is in Zimbabwe. So that even if we encounter another pandemic apart from COVID-19, will be ready to face it because just like what I have said when COVID-19 came, every organization it’s closed in Zimbabwe. All operations they stopped because people didn't know what to do next. So, this is really needed for us to make sure that. Even if we come to a pandemic, I will make sure that young people, they continue to have access to the services. (Local NGO stakeholder, Zimbabwe)
Furthermore, given that the COVID-19 pandemic tended to amplify some weaknesses in the policy frameworks that influence ASRHR, some stakeholders discussed how improvements to specific policies are critical.
Our public Health Act says, says that one was legal capacity [and] should be able to access services, but in Zimbabwe legal capacity means that you're 18 years old. So, it is our recommendation that the Public Health Act be reviewed to allow for those who are below 18 to be able to access services. So, this means that reviewing the age of consent to accessing services to ensure that adolescents who are in need of those services are prioritized and given their services. [This] will reduce, the high [levels of] teenage pregnancies, STI infections and new HIV infections that we continue to witness amongst the 10 to 24 years. (Local NGO stakeholder, Zimbabwe)
Moreover, the same stakeholder in Zimbabwe, also raised that more work could be done to lift how all aspects of ASRHR should be prioritized as an essential service and specific safeguards need to be implemented to ensure that SRH services can be accessed. For example, restrictions on movement limited AYP access to SRH services during the pandemic.
It is important for the government to prioritize sexual reproductive health and rights as an essential service during pandemic, and that security forces need to be sensitized around sexual reproductive health and rights services. Because if you would go and tell a police officer that you had sex and want to go and buy contraceptive pills, you know, they would consider [this as] a minor issue, but the magnitude of that, you know, remains a big issue. So, it is important that the government should continue to prioritize sexual reproductive health and rights services. As a priority or essential service during pandemics and ensure that security services are sensitized around issues of SRHR. (Local NGO stakeholder, Zimbabwe)
Increased funding for ASRHR
Stakeholders in Malawi, Zambia, and Zimbabwe also touched on the need to reorient resources, funding, and capacity to support further advancements of ASRHR in each context to progress towards universal accessibility. One stakeholder in Zimbabwe explained,
So, I think, the long-term effect is that even up to now, the resources [had] already [been] shifted away. So, it really affecting in terms of access of contraceptives for free or other services that are being given for free, they are now limited due to that fact. So, it's really a challenge [for] young people when [they] want services and we don't find them. So, the issue of resources being shifted, that's the greatest problem. (Local NGO stakeholder, Zimbabwe)
It was also emphasized and discussed by stakeholders, that given the current context, further investments should be put toward supporting SRH service providers and resources/commodities. Since often resources such as HIV test kits or contraceptives can be scarce at many facilities.
Use of community health workers and community-based ASRHR strategies
In all three countries, it was highlighted the important role that communities play in terms of advancing ASRHR. For example, in Zimbabwe, it was communicated that on the community level, throughout the pandemic, community members stepped up to keep programs running despite the challenges. Therefore, it was suggested that community systems for health promotion were strengthened so that communities are better prepared for future emergencies.
I know of the stop the bus campaign. Were uh, those mobile clinics were taken to adolescent localities. And they will be offered the services I think that was one of the interventions, which really helped young people to access services. But however, now the challenge is if the mobile clinic, comes to your community, but it means that if in your parents would also want to, to access the service at the same facility. So sometimes it was a, a, hindrance to us young people to access because you cannot stand in the same queue with your parents to access contraceptives. But it was really beneficial for other young people, those mobile clinics and all those campaigns that were being done at during this period. (Local NGO stakeholder, Zimbabwe)
It was also emphasized that given the current context of COVID-19, it is especially important to acknowledge the important roles that community members have in terms of providing SRHR information and care. In Zimbabwe, it was conveyed that this should also include the authentic engagement of young women and adolescent girls positioning them as local experts and community insiders. It is suggested that young women and adolescent girls should be invited to actively contribute to program development and adaptation through the sharing of expertise, community wisdom, and insights to identify and distil community-identified priorities and needs.
When we when we get into emergency situations, it can be very hard especially for our population to access services. But these community carers do have a very important role to play in terms of the provision of primary care to our communities, so I would want to recommend that we invest more and also rope in our adolescent girls and young women. They are not only recipients of services, but their active participation in terms of even evaluating the quality of services that are being provided to them [and] also contributing to giving recommendations in terms of how best we can improve in terms of service provision. … So, there is also a need for us to really invest in the meaningful involvement and meaningful participation of, of adolescent girls and young women in, in programming for themselves. one of the lessons that we learned is when emergency it is mostly the most vulnerable that are affected the most. So, we really need to, to invest more on empowering our, our adolescent girls and young women to be able to, to be financially independent. (Government Ministries, Departments, and National Councils Stakeholder, Zimbabwe)
Service implementers lamented the need for guidelines to ensure the presence and sustained operation of spaces where adolescents can access information and services from community health workers, or through outreach services by health care providers, as they did during the pandemic. A nursing counsellor said,
During the pandemic, we have a team whom we call community health workers in the community. Those are the people that will go door to door, they are the people that will even educate on family planning, those with pregnancies, they will encourage them to go to the clinic, we have such people who are doing that, they were doing that in the community itself. So, we never had a lot of problems for those coming from the community because we have people who are doing that for us. (Nursing Counsellor-Female, Zambia)
While another stakeholder in Malawi shared how they successfully trained young volunteers to deliver door-to-door services. Furthermore, stakeholders reported using community-based distributors of SRH services to increase access to ART services and contraceptives. A managerial healthcare provider said,
It’s good that in some communities there are some community-based distributors who are able to distribute certain family planning commodities to adolescents around and they are able to access them. So, I think that would be one good solution to provide these services, we could use community-based volunteers so that we minimize moving around or chances of transmitting that disease around. (District adolescent focal point person-Female, Zambia)
Use of technology and social media platforms such as WhatsApp (mhealth)
Throughout the interviews and FGDs, stakeholders acknowledged that the adoption of virtual platforms and technology was ‘eye-opening’ for their respective organizations. In many ways, at the organisational level, the utilization of technology (especially digital communication technology) improved and advanced communication flows allowing for a positive evolution during the COVID period. This also provided a unique opportunity for organizations to reflect upon and reimagine how these tools can be utilized to improve organizational operations and potential service delivery. One of the strategies that organizations working with adolescents employed was to intensify social media engagement such as utilizing the use of platforms such as WhatsApp groups. Through these WhatsApp groups, they engaged experts who shared more information on particular topics. Adolescents were able to make clarifications when they needed more accurate information.
One of the strategies that we had employed in order to ensure that there is some continuity in accessing information…We intensified the creation of WhatsApp groups in each community. Where adolescents are from, the youth-friendly spaces where they joined, it became more like an online space via WhatsApp. Where the similar days that they would meet at the facility, and they would then discuss issues to do with sexual reproductive health via those WhatsApp groups. So ideally the WhatsApp groups became the access points for adolescents to have conversations as well as signposting (Local NGO stakeholder, Zambia)
Stakeholders in Zimbabwe also suggested similar strategies in terms of utilizing virtual and social media platforms to disseminate information to AYP on SRHR. For example, one organization described the use of WhatsApp, Facebook, and YouTube as tools that could be used to support information dissemination activities to facilitate more active engagement from populations of AYP.
There are examples of the young people who at some stage at university were part of the peer educators, who were running physical dialogues on a weekly basis where they discussed the different issues affecting them…Students simply just moved on, and moved these to the WhatsApp group, and that allowed us to then support them in terms of [continuing] with the discussions. In the same vein, we also went ahead and changed our support and ensured our online presence. We started generating a lot of content which we put up on our YouTube. We also started generating a lot of content, which we put on our Facebook pages and even on Twitter to allow the young people to continue to access the information that they required. (Local NGO stakeholder, Zimbabwe)
In addition to the increased use of virtual platforms, other stakeholders in Malawi and Zambia also described how during the pandemic, the radio was important for disseminating information about SRH. The beneficial use of radio is a useful tool that can transcend the urban and rural divide and thus reach both rural and remote populations and often more vulnerable populations.
So, we have adapted our learning materials. We have actually put them on virtual platforms, so that if you [are] ever in an emergency, at least we can sustain the momentum in terms of sharing of information via virtual means. (Government Ministries, Departments, and National Councils Stakeholder, Zimbabwe)