We have been involved in sexual and reproductive health educational activities for the past two decades.  But this is the most successful project so far.
                                                                                                                                                   Mr Daya Abeywickrema
                                                                                                                                               Executive Director of FPASL

How It All Started

FPASL had observed that the number of young people seeking services at the clinic was rapidly increasing. A majority of these young visitors had, if any, very little knowledge about sexuality and reproductive health. Findings of a survey undertaken in 1986 corroborated these observations.  “Concerns  related to youth reproductive health are serious and call for an urgent response. Since most youth are in schools, we decided to bring information on reproductive health to them in the schools. Thus the beginning of the Reproductive and Sexual Health Education project” says Dr Sriani Basnayake, the founder of the project.

This project, started in 1992, is the first effort in bringing  reproductive and sexual health education to the schools in a  systematic manner. A trained teacher, assisted by a project  officer, is assigned to a participating district where she conducts, on average, 20 classes a month. Participating in the project are school children in grades 10-13, those in the age group 14-18.

Cultural sensitivity prevailing in Sri Lanka only allows for a programme which is exclusively an educational activity. As such, no service component was included. Because the RSHE project was the first attempt at providing education to youth in a systematic manner, the FPASL decided that it would be best to try the project on a pilot scale in four districts in 1992 before it was expanded to another four the following year.

The Classroom Lectures

Every lecture is arranged with the consent of the class teacher. The three-hour lecture usually takes place  between 10.30 a.m. and 1.30 p.m. and is attended by about 60-80 female and male students. The school principal  determines which students should attend the lecture.

The session begins with the project officer explaining to the students the aims of the programme and the FPASL. Then the project teacher carries out a pre-test. She then talks about physical development and about the human reproductive system. She talks about the misunderstandings and myths. Lectures are delivered with the aid of an overhead projector, flash cards, and flipcharts.

Two films are then shown, one on HIV/AIDS and the other on human birth. After each film the project teacher offers more explanation. Students are then given the opportunity to ask questions. For those who are shy, they write their questions on paper. The project teacher ends the session with a post-test.

Started as a programme outside school hours, the lectures have now become an activity during school hours. To avoid suspicions that the FPASL may use the programme as a means to promote family planning, teachers and principals are invited to observe the lectures. This effort enhances the teachers’ involvement in the programme and creates good rapport between the trainers and the school authority.

IEC Materials

The materials used in the programme were designed by the project teachers. After pre-testing the materials, they were further improved before standard overhead transparencies and flipcharts were finalized. During the pilot project, the project teachers were requested to write down students’ questions. As a result, a booklet giving the correct answers to 100 most commonly asked questions was produced. This booklet is distributed free to students attending the programme. In addition, a book called “Facts of Life” written by Dr Sriani Basnayake is sold at R10 (US$0.25) per copy. The choice of films shown was made by the teachers in consultation with the FPASL.

Staff Training

Training of Teachers

The programme implementers are selected female teachers, several of whom are retired, who have teaching experience in science subjects. They attend a six-week training programme prior to project implementation. The table below summarizes the training programme:

The training programme was designed to ensure that the project teachers are well equipped to conduct the classes. Findings of research on reproductive health, FPASL clinical work, and Dr Basnayake’s experience in working with youth, formed the basis for the training curriculum. On the completion of the training, the project teachers were posted to each of the participating districts. Each teacher was provided with a TV, video deck, overhead projector screen and IEC materials which they had developed. Since the first initial training, two refresher training courses were carried out.

Project Officer

Assisting the project teachers are project officers who are mostly retired teachers, principals, and public health inspectors. They were trained together with the teachers in the six-week training programme. Their responsibilities are multiple:

• arrangements with schools for the organization of in-school programmes
• draw up a fortnightly programme in consultation with the FPASL head office
• check facilities in schools, organize logistics and transport equipment
• give introduction to the lectures and closing remarks
• assist the teacher with the audio-visual equipment
• be available during the programme in case of problems
• keep records on the numbers of programmes organized and youth reached

Generating Commitments and Linkages

During a visit to Sri Lanka, Dr Halfdan Mahler, Secretary General of IPPF, took the opportunity to discuss the needs of the RSHE project with the Minister of Education. This meeting was the impetus for the Ministry of Education to approve the project.

As a follow-up to the approval, a series of seminars on the importance of conducting reproductive and sexual education to school children, for Directors of Education, and school principals were carried out by the FPA. A few meetings were also held with groups of teachers to ascertain their views on the programme in order to avoid their objections. The seminars and meetings significantly changed the attitudes of the participants in recognizing the reproductive and sexual needs of youth/adolescents which paved the way for the FPA to win support of the school authorities.

Apart from the linkages with the ministry and selected youth organizations, no other NGOs or agencies were involved in the implementation of the project. The FPASL was careful not to create too much publicity and attention to the efforts lest creating public opposition. Had the FPA tried to involve too many people, there could have been some opposition from the public thus creating reluctance in the Ministry of Education and among the principals to openly support the project. Negative parental reactions and public opinion would have created a politically difficult environment for the programme and would have made the project impossible.
Project Management

Organization Structure

The project is managed centrally from Colombo under the joint supervision of the medical and training directors. A field supervisor is responsible for the day to day running of the project which includes liaising with field staff, providing supervision, and other assistance required by field staff. While project officers at the field level set up all organizational arrangements for the programme, lectures are carried out by the project teachers.

To facilitate project management, all personnel involved meet once a month in Colombo, thus providing an opportunity to discuss issues and to find solutions to problems. In the first instance, solutions are to be provided by the field staff. When they are unable to do so, decisions are made jointly by all involved. Through these meetings, support from senior management to field staff is strengthened and a good teamwork spirit is created.

Monitoring and Evaluation

Close attention is paid to the monitoring and evaluation of the project as well as to its cost-effectiveness. In addition to pre and post-course evaluation questionnaires completed by students in a random sample of schools, evaluation and feedback comments are also solicited from school principals, teachers, students and the project staff. Moreover, the Evaluation Division of the FPASL takes a particular interest in the project and conducts periodic monitoring visits.

Project records are well prepared. Each month, statistics are prepared and presented to the Executive Committee of the FPA. The statistics are presented by district and include: (1) number of programmes organized; (2) number of participants; and (3) the cost per programme and per participant. Pre-and post-test evaluation results are collated and discussed at the monthly project meetings.

Promotional Efforts

The influence of Dr Halfdan Mahler on the Minister of Education gave a big boost to the project. After gaining approval from the Minister, most of the promotional work was carried out by Mr Abeywickrema and Dr Basnayake. Project officers also play an important role in promoting the programme. They visited schools, discussed how the project would be carried out, and showed the principals that it would not disturb the school working day in any way.

Financial Support

The in-school project is solely sponsored by the FPA as part of the International Planned Parenthood Fund (IPPF) funded programme. The section on cost analysis provides the budget details. On the other hand, activities with out-of-school youth are partly funded by the participating youth organizations.
 

Building a Human Resource Base

Both the Directors of Education and the school principals who had attended orientation sessions conducted by the FPA are positive about these sessions and the need for RSHE in schools. In some cases, school principals had gained the support of parents for the programme through the parent-teacher association. One director of education had organized a two-day training  programme by the FPA for seventy teachers in his district.

Encouraged by the response and suggestions from the directors of  education, FPASL is now building a resource base of teachers as part of the RSHE project. It is felt that each school should have at least one teacher trained to provide information and counselling to students after the initial classes have been held. Therefore, a programme consisting of a three-day training was initiated for teachers. The selection of volunteers is made jointly by the Director of Education and the principals of the respective schools. The response has been encouraging. Four hundred teachers have been trained so far. Many of them have requested refresher training and were even willing to pay for it.

Achievements

The biggest success of this initiative was getting the approval of the Ministry of Education to bring reproductive and sexual health education to schools. This was followed by the participation of Directors of Education, principals and teachers through seminars, thus creating commitment from all levels in the ministry to support the project.

Beginning as a pilot trial in four districts, the project has now been expanded to eight districts. In total, 191,267 students were reached by the end of 1994 as indicated in the table below.

 Cost  Analysis

The project cost includes initial costs, recurrent costs arising out of capital equipment depreciation and staff, and support costs of the Family Planning  Association of Sri Lanka. The details are as follows:

Initial costs

Item	Cost (Rs)
Survey	Rs40,000
Meetings and conferences	Rs50,000
Developing IEC materials	Rs80,000
Producing IEC materials	Rs800,000

 Recurrent Costs

Item	Cost(Rs)
Motorbike	70,000
TV monitor, VCR and overhead	40,000
Microphone, loudspeaker and screen	50,000
Total	160,000

Approximately 130 programmes are carried out by each team.  Each programme reaches an average of 75 students.  Therefore, about 9,750  students are reached per year.  Assuming a life of four years, per student cost will be:

 160,000/(4 years x 9,750) = Rs4.10
 

Staff Costs

Item	Cost (Rs)
One project officer	72,000
One teacher	80,000
Total	152,000

  The cost per student is: (152,000/9,750) = Rs15.59

Per Programme Cost

Item	Cost (Rs)
Transport	592
Labour	25
Total	617

The cost per student is: (617/75) = Rs8.23
Cost Per Student

Item	Cost (Rs)
Programme cost	8.23
Staff cost	15.59
Recurrent cost of capital equipment	4.08
Cost of booklet	4.00
Total (direct cost)	31.90   (or US$0.64)

Support Cost of FPASL

Assuming 30 per cent of the direct cost as support and management costs of the project, per student cost is US$0.20.

Cost Per Capita

The total cost per student is: US$0.64 + 0.20 = US$0.84.

Birth rate is around 20 per 1,000, therefore, each year 20 students need to be educated per 1,000 population. If cost per student is US$0.84, the national cost would be:

(population 17.5 million x birth rate 20/100 x US$0.84 per student) =
US$294,000 per year.

Therefore, the total cost per capita is:

(US$294,000 / 17.5 million) = US$0.0168

Cost Comparison

How does this compare with the cost of family planning (FP) programme? Unfortunately we do not have estimates for the cost of the family planning  programme in Sri Lanka.  However, if FP cost is US$0.60 per capita, then the cost per capita (US$0.0168) of RSHE is 2.8 per cent of the FP cost. On the other hand, if FP cost is as low as US$0.25 per capita then the cost of RSHE per capita is 6.74 per cent of the FP cost.

Managerial Requirements

Matching Strategy to Environment

The environment in Sri Lanka is culturally sensitive; sex is a topic not to be discussed with youth.  In light of this sensitivity, the project concentrates exclusively on educational activities. Similarly, the curriculum focused on biological and health aspects of sex and reproduction. As such, the curriculum does not address other aspects of this issue.

Sri Lanka’s good infrastructure facilitated the strategy of using teams to visit the schools while high literacy rates allowed the use of IEC materials  containing substantial amount of details.  Box 1 summarizes the compatibility between strategy and environment.
 

Environmental features Large number of youths in school  Sociall conservative culture  Well connected roads  High literacy

Strategy Focus on inschool programes  Orchestrate careful entry strategy  Lectures limited to biological facts  Use teams to visit schools  Provide written educational IEC materals

Attention to Implementation Details

The project has a clearly defined organizational structure as well as staff responsibilities. At the head office, a field supervisor is in charge of the project. At the district level there is a team of a project officer and a teacher, each with clearly defined activities. The monthly meetings are used to resolve problems, monitor performance, and sustain team work. The importance given to team work may have contributed significantly to the successful implementation of the project.

Issues in Upscaling

With commitment from the Ministry of Education, the project can be replicated in the remaining fifteen districts. The following issues need to be addressed if this project is to be upscaled:

Recruitment and Training of Staff

Recruitment of teachers and project officer, with the assistance of the education authorities, should not be a problem. In terms of training, the FPA may wish to investigate the possibility of incorporating themes on psychological and social aspects of youth sexual and reproductive health behaviour. It has been discussed in the narrative report that introduction of such themes to youth may be counter-productive to the project because cultural sensitivities only allow for education on anatomy and physiology. Although these themes may not be presented to the youth, it is beneficial for project teachers to be aware of the issues and how to address them, even if they cannot be introduced at the present time.

Institutionalization

Should the project be institutionalized, it needs to be decided whether the current strategy should be applied or school teachers should be trained to provide the information as part of school activities. These two alternatives have advantages and disadvantages. Having a special team allows a higher level of competence and experience in terms of service delivery. Moreover, students’ enthusiasm is enhanced when outsiders conduct the lecture and they feel more free to ask questions to outsiders than to their teachers. The team also permits more intensive use of audio-visual materials which many schools are not able to provide. On the other hand, this strategy fails to provide follow-up information and/or counselling on a regular basis. Furthermore, teams incur costs -- transportation and salary, etc.

If teachers are trained to carry out the programme, students can approach their teachers for follow-up on a regular basis. However, this strategy runs the risks of (1)  inadequately trained teachers, (2)  insufficient contents, and (3) lack of enthusiasm in the activities. Should this happen, it can be rectified by strengthening teacher’s training programme and modifying lecture presentation.

The project needs to find an effective strategy for institutionalization. A possible route to finding the answer is to conduct an operations research study whereby the two alternatives discussed above are pilot tested.

Project Implementation and Funding

In institutionalizing and upscaling the project, who should bear the costs? Two scenarios emerge in response to the question. One, the continuation of the FPA’s funding may not, in the long run, be an advantage if the project fails to be institutionalized. Two, if the Ministry of Education incorporates the project into its funding cycle, the likelihood of institutionalizing reproductive and sexual health education in schools is much greater.  However, efforts will be required to ensure that programmes are of requisite quality.

Impact

While the project has improved students’ knowledge, it cannot be assumed to indicate change in attitudes and behaviour. If this project is upscaled, an evaluation methodology that assesses behavioural change must be put in place.