Triggerise launched a pilot in Malawi – Lilongwe centred on sexual reproductive health (SRH) with a focus on contraception, targeting girls aged 15-19. This pilot came after the success of a similar (but bigger) program previously launched in Kenya, called In Their Hands (ITH) project.
This pilot is showing promising results as within two/two and a half months at least and 1,152 young people have been reached and sensitised on family planning; Triggerise is excited! Let’s take a closer look!
What are the pilot goals and who is it targeting?
- Goal: to increase adolescent uptake of sexual and reproductive health (SRH) services, with a focus on contraception;
- Target: girls (aged 15-19) who live in Lilongwe and would otherwise not be able to afford access to professional SRH services and quality products.
How does it work?
- The project works with the participation of young mobilisers/Tiko Pros (entrepreneurs who help girls enrol in the program) from local communities, who try to engage this age group, ensuring that they have all the information they need about SRH and know where to access free services;
- The project uses mobile phones to enrol 15-19-year-old girls onto the Triggerise platform, ensuring that data is available in real-time.
The pilot period was established to run from December 2018 – March 2019. Should the pilot be successful, the project will be scaled up to other regions in Malawi and extended to reach those girls who do not have access to a mobile phone through the use of membership cards and will introduce high-tech solutions through Facebook and a mobile app.
Some numbers we are aiming to get
- Get 30 active Tiko Pros (providers of services and products) by the end of the pilot; currently, there are already 25;
- Reach 2,000 young people (by March 7th – 1,020 young people had been made aware of contraceptive methods;
- Up to the beginning of March 2019, 833 people were sent to the clinics (where they can get injectable and oral contraceptives, implants or IUDs)
So why Malawi?
Malawi was chosen as the country for the implementation of this project after Kenya because it presented a vast number of opportunities for Triggerise to work with other organisations like PSI Malawi Engender Health & Girl Effect, etc., and possible avenues for learning. Additionally, it was discovered through our preliminary research that adolescents could benefit from the project given that the teenage pregnancy rate between 2016 & 2017 stood at 29%.
The operations in Malawi are small but its implementation relied on learnings that came from operations in several and more established countries: Kenya, India (model markets), Democratic Republic of the Congo (DRC) and Burundi. The experience from some Kenyan service providers (such as Marie Stopes, PSI, IPPF, etc.) was very helpful.
For this project, we decided to get a specific partner – Tingathe Malawai – a non-profit organisation which works with young people and is focused on marketing, entrepreneurship and SRH. This decision was key to get a cohort of Tiko Pros.
A Malawian surprise
Malawi proved to be a project for surprises and firsts.
This is the first agnostic platform for Triggerise – which means that we went in without any service of demand partners. This allowed Triggerise to truly have a platform that benefits the girl, measuring attribution from demand generation to SRH services uptake without constraints of working with specific partners (as it can lead to a conflict of interest).
There are some barriers amongst this age group (15-19) to access family planning services because these services are expensive and sometimes the girls can’t get access to them at private facilities, where they actually offer good quality services. Additionally, some young people are not aware of the availability of these services.
Also, because the Malawian society is still conservative, it was not expected that the pilot would be as successful as it turned out to be.
However, the team has observed that these girls, who are at the prime of adolescence, are very keen and very open to learning about their sexuality and family planning. This allowed the program to be more easily accepted.
“A very unique thing we saw in Malawi is the way the community has accepted this project. Because we see a lot of young people visiting the clinics and a lot of young people taking contraceptive methods (medium and long term). This is something that doesn’t always happen in other countries where we work: for instance, in Cameroon and DRC was a little bit difficult for people to allow mobilisers to create awareness amongst adolescents in the community about taking contraceptive methods. In Malawi, people were actually much more open to getting to know more about contraception”, the expert said. For the team, this was a surprise. “It was a good surprise as it eliminated some barriers we were expecting”, Maria described.
The power of feedback
Also having a team on the ground is helpful: during the pilot, the team realised that the most preferred contraceptive method is oral contraceptives (the girls are still very scared of injecting or getting implants because they are visible).
This learning and also feedback from the girls was what helped the team to give them what they wanted in a more personalised way.
For instance, the girls have access to retailers, who are normally grocery stores, where they can get products. “Some feedback we got from the girls is that they also want to get access to other services like dressmakers and tailors”, Maria observed. This kind of feedback is what allows the Rafikis (the platform users) to get more personalised offers.
Should the pilot be successful, the project will be scaled up to other regions in Malawi and extended to reach those girls who do not have access to a mobile phone through the use of membership cards and will introduce high-tech solutions through Facebook and a mobile app.
So the team is now looking for additional donors so that this project can go on for many years. Why? Because Malawi is a promising market for Triggerise. “We have promising funding coming in April. We think that the girls really appreciate what we are trying to do. The numbers have been increasing steadily. This project has been received better than in any country that I know because in three months, in a very small pilot area, we have been able to reach 1020 girls (just talking about family planning). And about 850 have been to the health facilities for different family planning services”, Maria concluded.
1 – Triggerise has projects in India, Kenya, Ethiopia, etc., and now has just landed in Malawi. Why did we choose this country?
The reason why we decided to work in Malawi is just because Triggerise considers Malawi to be an interesting country. The Malawi project is funded by CIFF, which is one of our biggest donors and currently also funds our project in Kenya. Initially, CIFF wanted us to test the project with Sayana® Press (a hormonal birth control option for women) in Tanzania (it would be Malawi or Tanzania). But because of certain restrictions that came from the Tanzanian Government, we decided to go with Malawi. This was one of the major reasons why we moved to Malawi. There were a lot of opportunities that presented themselves in Malawi, like Engender Health, PSI Malawi and also Girl Effect. The projects that could potentially come up from these organisations were one of the reasons why we choose Malawi.
2 – What are the project’s goals and what does it consist of? What are the plans for this country regarding project implementation, activities, funding, etc.?
This project is about family planning, centred on adolescent girls aged 15-19. Because we saw that the rate of teenage pregnancy in Malawi was quite high (in 2017-2018 it was about 43%). One of the reasons why young people don’t access family planning services or take contraceptives is because they are too expensive, and sometimes they can’t get access to this at private facilities, where they actually offer good quality services.
The project is implemented mostly in Lilongwe, the capital. We are currently working with three different clinic chains: Marie Stopes clinics, CHAM (Christian Health Association of Malawi) clinics and Family Planning Association of Malawi (FPAM). In total, we work with six healthcare facilities in Malawi. But we are doing all the implementation project in Malawi by ourselves. We are in charge of the Tikosystem and we make our own decisions.
The funding came mainly from CIFF. The pilot was launched in December 2018 and it showed we could create a Tikosystem which would create an impact in Malawi. We are hoping that after the pilot, we will get additional funding from CIFF or from other donors. So we are trying to get the highest possible activity on the Tikosystem. About our activities, we have recruited Tiko Pros by ourselves. We currently have 25 active Tiko Pros and they are working around the clinics. Our goal is to get 30 active Tiko Pros by the end of the pilot (March 2018). We plan to reach 2000 young people (in the whole pilot); we have now 1020. So far we have sent 643 young people to the clinics, where they can get injectable and oral contraceptives, implants or IUD. The most prefered method is the oral contraceptive because they are still very scared of injecting or getting implants because they are visible.
3 – Success usually involves a lot of people. Can you please tell me more about the team that will make this happen and its partners?
As Triggerise, we have two consultants in Malawi on the ground. We are yet registered in Malawi, that’s why they are consultants but after we register they will become employees. We have also Marie Stopes, CHAM and FPAM. The train of clinics on how to offer high-quality family planning and maternal health services. We chose them because of their reputation. For instance, we chose Marie Stopes because we already worked with them on the Kenya project and they’re known for the excellence in family planning and safe abortion. The decision to work with CHAM and FPAM was also all about the quality of their services. We didn’t want to go and hire individual clinics by ourselves because we wanted to work with clinics who had their services already verified by other entities such as the Government.
Nathalie-Ann Donjon and Maria Ndzelen oversee the project, support the field team, providing direction on what needs to happen and advice based on our learnings from other countries. Richard, Benoit and Daun also get involved, also looking for additional funding for different projects in Malawi.
4 – How does the experience from other projects in other countries help?
Malawi is a country where we control the activities and is still a seed market. The operations are small. Most of the learnings that helped me with the Malawi project implementation came from other projects like Cameroon, Democratic Republic of Congo and Burundi. We also took lessons from the Kenya and India project, which is our model markets. It’s very important to always use the learnings from other countries. Every country is very unique because there’s always something different when you start the operations. When we put everything in place, we put everything in the same way in all the markets. But as soon as we start, we realise that there are specific features in that country. So we have to adjust to that specific country, every time. They are never too different from each other, but there are always some differences.
When we started the Malawi project, in December 2018, we had Tiko Pros and we didn’t give them any formal identification, for when they go into the field. So they simply go into the field, and so they go to the remotest communities to speak to the users (Rafiki). But what happens, when they go into these communities, is that no one knows them. They can’t identify themselves. They are not well received in those communities. In Kenya also happened a situation similar to this one, when the project started. So we realised we needed to create an identification so that they can use every time they to the communities and are able to introduce themselves. When we created this identification, we had to make it very clear that we work with certain organisations that were already popular in Malawi, like CHAM and FPAM. So when people see this on the badge, and the Tiko Pros introduces themselves as someone who is helping young people to receive free services at these organisations, they are more easily accepted within the community. When we started using those badges we saw an increase in the activity because the Tiko Pros would talk to more people in the community. This one was of the main things we learned from Malawi and also Kenya.
5 – Is there anything special about Malawi that can help the team achieve success?
One of the main differences between Kenya and Malawi is that, in terms of exposure and how open the society is, Kenya has a more open and exposed society than Malawi. Malawi is still a very closed country. People have not been exposed to a lot of things yet, like other countries in Africa. A lot of young people don’t even talk about their sexuality. One of the unique things about Malawi is that each group aged 15-19, are at the prime of adolescence, and they are very keen and very open to learning about their sexuality and family planning. Because most of them are already very sexually active. So a very unique thing we saw in Malawi is the way the community has accepted this project. Because we see a lot of young people visiting the clinics and a lot of young people uptaking contraceptive methods (short, medium and long term). This is something that in other countries where we work, like Cameroon, DRC and maybe Kenya, was a little bit difficult. For people to allow mobilisers to create awareness in the community about taking contraceptive methods. In Malawi, society is much more open to knowing more about contraception. For Maria, this was a surprise. With the way, the project picked up. It was also an eye-opener to the partners in Malawi. But it was a good surprise as it eliminated some barriers we were expecting.
5 – Reports say that policymakers and program implementers should consider the diverse preferences among youth and parents and continue seeking their input when designing policies and programs. Youth clubs and school-based services were among the most common suggestions. How will the Triggerise project work and will it have this into account?
What we are doing in Malawi right now is still a pilot. When we went in there we did our research, we worked with in the partners to find out what exactly the leads are and we included, as much as possible, the youth associations and organisations. This is something we always do in all the countries we work with. We engage the community and the parents every time we do work around family planning and young people. And is Malawi, this is definitely something we will consider because we will engage the youth associations, the mobilisers. This helps not only to make the project more easily acceptable and also because this allows us to get more insights about the problems that we are trying to solve.
Feedback was what helped us realise that oral contraceptives are the most prefered method. We gave access to all of our different contraceptives and some of our clinics (if not all) ran out of oral contraceptives. The feedback we got was that the girls wanted oral contraceptives available. And so we informed our partners about this, so that they could contact the suppliers in order to always have oral contraceptives available at the clinics.
In terms of the offer, we give the girls access to Tiko retailers, who are normally grocery shops, where they can get products. Some feedback we got from this is that they also want to get access to other services like dressmakers.
Pilot launched in December 2018 and the donors has funded until the end of March 2019. We are looking for additional donors. We are hoping that this is a project that can go on for many, many years.
5 – What’s next?
This a very promising market. We are now looking for additional funding. We are trying to keep the team working at least until May. We have promising funding coming in April. We think that the girls really appreciate what we are trying to do. The numbers have been increasing steadily. The way this project has been received in better than in any country that I know because in three months, in a very small pilot area, we have been able to reach 1020 girls (just talking about family planning). And about 650 have been to the health facilities for different family planning services.
Some SRH Malawian numbers
Two-thirds of Malawi’s populations are under 24 years old. However, most of these people are not well informed about SRH. And this brings serious complications.
By the time they are 18, most Malawian girls already have three children (Malawi has one of the highest fertility rates in the region). This high rate of teenage pregnancy leads to school dropout (also due to early marriage) and also puts the girls at risk from HIV and other sexually transmitted infections (STI).
According to a Reproductive Health report, published in 2018, Malawi has shown progress regarding modern contraceptive prevalence since 2000. But the scenario among young people, aged 15-24 years, has not improved as much.
There are still a lot of teenage pregnancies and there is little family planning progress among young people.
Barriers to family planning access among young people
- Stigma – Adolescents are not able or are hesitant to seek information about SRH issues. This leads to a lack of knowledge about SRH and family planning.
- Contraception misconceptions – Sterility, illness, cancer, affecting men’s libido and oral contraceptives are the main misconceptions; there were fewer misconceptions about condoms.
- Costs – Most of young Malawians said they prefer government providers over NGO providers because they are supposed to be free. Some people also mentioned transport costs and long distances as a barrier to getting family planning services, while others prefer to go services further way in order to get more privacy.
- Country culture – People in Malawi value big families and usually every Malawian woman has, on average, five children. As the country is very male-dominated, most of the women feel they have almost no right to make decisions about family planning.
- Condoms, birth control pills, Depo-Provera, IUCD, Norplant and sterilisation are the most common contraceptives
- 44% of married women over the age of 20 use modern contraceptives
- 50% unmarried and sexually active women use modern contraceptives
- 26% married adolescent girls use modern contraceptives
- 30% of women aged 15-19 are already mothers or pregnant with their first child
Some general HIV Malawian numbers
The Malawian adolescents have to deal with unrecommended cultural habits such as the lack of awareness and lack of information about access to family planning education. This leads, among others, to unwanted pregnancies, unsafe abortions, early childbearing and a high HIV rate. But let’s take a look at some numbers (data from UNAIDS Data 2018):
- 1 million people with HIV
- 9.6% adult HIV prevalence (ages 15-49, one of the highest prevalences in the world)
- 17,000 AIDS-related deaths
- 71% adults on antiretroviral treatment
- 63% children on antiretroviral treatment
Malawi has one of the highest HIV prevalences in the world, however, the country has made very significative progress in controlling the HIV epidemic in the last years. There is a very high risk among young people due to early sexual activity and marriage (50% new HIV infections affect people aged 15 to 17. This high rate is also reflected in the country’s low life expectancy (57 years for men and 60 for women).
One of the greatest barriers to progress is a stigma (especially among men who have sex with men and sex workers).
According to a national assessment of the impact of HIV on the population, carried out by the Malawian Ministry of Health in 2015/2016, the HIV prevalence among women aged 15-64 was 12.8% (compared with 8.2% among men). The disparity is particularly prominent among 25-29-year-olds.