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Objectives \ud Young people in Tanzania are known to access reproductive health services from a range of close-to-community providers outside formal health settings such as drug stores, village AIDS committees, traditional healers and traditional birth attendants (TBAs). However, questions remain about the quality of services such agents provide. This study investigated their capacity to provide adolescent reproductive health (ARH) services and explored their readiness and ability to integrate with the mainstream health sector through community referral interventions.\ud \ud Methods \ud Thirty-five focus group discussions exploring close-to-community provider experiences and attitudes to ARH service provision were carried out in two districts in Northern Tanzania. Discussions were conducted in Kiswahili, digitally recorded, verbatim-transcribed, translated and back-translated from Swahili to English. A thematic analysis was conducted using NVivo 9.\ud \ud Results \ud The major close-to-community cadres providing reproductive health services were drug stores, traditional healers, TBAs and village health workers. They reported being the first port of call for adolescents seeking reproductive health services, but their knowledge of ARH needs was poor. They had negative attitudes to, and lacked the necessary resources for, the provision of such services for adolescents. Some were particularly unwilling to provide condom services and were prejudiced against adolescents using them. There was poor integration between the close-to-community providers and the formal health sector, further limiting their ability to provide adequate services.\ud \ud Conclusions \ud Although close-to-community providers are considered a key resource in the community, most have limited capacity to provide ARH services. Without capacity-building investments such as training and cooperation with the mainstream health sector, their contribution to positive reproductive health outcomes is limited, or could indeed lead to adverse outcomes.

This thesis documents the development and evaluation of an mHealth intervention for sexual and reproductive health (SRH) referral from drugstores to health facilities in Mwanza Tanzania. SRH is an important factor for human development. Over the last 2 decades, provision and accessibility to SRH services has benefited from international and national health promotion interventions. In developing countries, use of close to community providers (CTC providers), such as village health workers, has been a key component of health promotion. This has been especially true in Tanzania where up to 70% of formal primary health care facilities lack health staff. CTC providers have been promoted through international initiatives such as the World Health Organization’s (WHO) task-shifting initiative. WHO’s recognition of CTC providers ranges from cadres at the grassroots level such as village health workers and drugstores to formal auxiliary providers based in health facilities, such as medical aides and nurses. In Tanzania, drugstores provide a range of SRH services ranging from simple advice on how to use a condom to complex prescriptions of antibiotics for STI treatment. Evidence has shown that drugstores – though more likely to have health-related training than any other informal CTC providers – lack skills necessary for provision of SRH services. This may contribute to poor SRH outcomes, such as increase in prevalence of sexually transmitted infections (STIs)/human immunodeficiency virus (HIV) and antibiotic resistance. Accessing SRH services at the formal health facility level is key to improving these outcomes. To create SRH service linkages and integration between drugstores and health facilities in Mwanza, Tanzania, an intervention that pioneered an mHealth SRH referral from drugstores to health facilities was designed and implemented for 18 months from September 2012 to February 2014. Referral between these two SRH providers using mHealth tools had not been attempted before. The intervention provided an electronic platform accessible to 52 drugstores and 18 health facilities in two districts of Mwanza region. Through a toll-free number and password, drugstores referred patients with SRH conditions to health facilities using the text-messaging feature on their mobile phones. From the platform’s in-built data collection tool, SRH uptake data demonstrated that 38% of patients referred from drugstores accessed HIV, STIs, family planning and maternal health services at the health facility level. A follow-up randomised household survey found that 72% of the participants would accept such type of referral in future, and among those who had ever visited drugstores for SRH services, 15% had heard about the intervention. At the end of the intervention, drugstores and health facilities confirmed that it was beneficial to their SRH service provision and that they would like to continue implementing it. In conclusion, this text messaging intervention pioneered community referral from drugstores to health facilities for SRH treatment by using mobile phones which appeared to be acceptable and effective in Mwanza Tanzania. With the growing use of mobile phones in Africa and the need to provide SRH services beyond the Millennium Development Goals (MDGs) era, mobile phone-based community referral through CTC providers, such as drugstores, could make an important contribution to achieving Universal Health Coverage targets.