International Women’s Day Includes Health and Empowerment

March 8 is International Women’s Day, celebrating the accomplishments of women in all aspects of society, including their rights for access to health services that meet their needs.

Meeting client needs was an aspect of the topic investigated in a recent study in two districts of Botswana. The study looked at referrals among health programs aimed specifically at young women. The study was conducted in May 2019 to determine if the programs were meeting the needs of young women and if programs were referring clients to all services that might be appropriate. Of special concern for these programs is keeping young women HIV-free or treating them if they have acquired the virus. This need is crucial because young women in Botswana acquire HIV at almost three times the rate of young men,[1] contributing to the fact that Botswana’s HIV prevalence is among the highest in the world (estimated at 18.5% overall).

Societal factors, such as poverty, gender inequality, gender-based violence (GBV), transactional sex as a livelihood, and a lack of education are among the reasons that young women are more at risk of acquiring HIV than are young men.

The evaluation was conducted by Data for Impact (D4I), which is funded by the United States Agency for International Development (USAID). It looked at the DREAMS program (Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe), which is funded by USAID and the United States President’s Emergency Plan for AIDS Relief (PEPFAR). DREAMS is aimed at adolescent girls and young women (AGYW) from age 10 years to 24 years and includes care for survivors of GBV, socioeconomic interventions, HIV testing and treatment, pre-exposure prophylaxis (PrEP) for HIV, condom distribution, and other family planning services.

D4I’s evaluation was a mixed-methods study to learn about the referral networks among DREAMS-related facilities. Referrals are necessary for the full functioning of DREAMS because the program crosses many sectors.

The study used (1) organizational network analysis (called ONA) of facilities providing DREAMS services to find out how program implementers collaborated in referring AGYW to various forms of care or social support; (2) conducted focus group discussions to explore knowledge and preferences of AGYW about HIV testing, condoms, family planning, PrEP, and post-GBV care; and (3) during focus groups conducted participatory mapping of the places where AGYW believed services were available and their opinions of the quality of those services. Results showed:

  • A limited number of referrals occur between “Safe Spaces” (a program component that supports social-asset building and HIV and GBV prevention for at-risk youth) and facilities that offer youth-friendly services (YFS).
  • YFS are not using most of their known network and have few shared connections that would help them link AGYW to other services.
  • YFS have some service gaps in contraceptive services and in nonclinical services for GBV survivors.
  • In focus groups, AGYW reported that few YFS or DREAMS facilities were the ones they would choose for accessing the services DREAMS is meant to provide.
  • Gaps were found in providing PrEP at YFS and AGYW reported uncertainty about where to obtain PrEP.
  • AGYW reported mixed experiences with post-GBV service sites and providers. 

Results from this study will be used by PEPFAR Botswana to improve and strengthen the referral network for health facilities and other organizations that support AGYW and to align services with AGYW preferences for accessing care.


[1] Among 15- to 19-year-olds, male prevalence is 3.6 percent, compared to 6.2 percent for females. Among young adults ages 20–24 years, HIV prevalence is 5.0 percent for males and 14.6 percent for females (Statistics Botswana, 2013)

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