The hypothesis was that a ‘diagonal’ strategy incorporating both ‘horizontal’ strengthening of sexual and reproductive health (SRH) services, and more ‘vertical’ targeted approaches will improve SRH services and outcomes overall. We focussed special attention on the needs of FSW, who constitute an extremely marginalised, stigmatised and vulnerable population with a high burden of HIV and other SRH problems, yet who are often missed by mainstream health services. Services were strengthened through integration of a combination of interventions implemented in public facilities and in specialised targeted clinics.

The study was designed as a set of case studies, with the ‘case’ being a well-defined geographical area where sex work is common. The project applied a methodological framework for health systems research as presented in the figure below. In a first phase each site conducted a detailed situation and policy analysis that informed the development of site and context-specific packages of interventions to strengthen SRH service delivery in the secopnd phase.  These packages were implemented for at least 18 months.  At the end, the feasibility, adequacy, effectiveness, cost, sustainability and equity of each intervention package was studied, combining qualitative and quantitative research methods. Individual and cross-country analysis was conducted. We compared process and outcome indicators at each study site pre- and post-intervention, and made comparisons across study sites.