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This report covers the FHI AIDS Control and Prevention (AIDSCAP) Project (1991-1997). Volume 1 covers regional program overviews, technical strategies, and program support strategies.
Volume 1 |
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| Year 1 | Year 2 | Year 3 | Year 4 | Year 5 |
| HQ | . | . | . | . |
| Asia RO in Bangkok | Africa RO moves to Nairobi | . | . | . |
| Africa RO in HQ | . | . | . | . |
| LAC RO in HQ | . | . | . | . |
| Kenya, Brazil, Thailand, South Africa, Haiti, the Dominican Republic, Tanzania, Cameroon | Jamaica, Nigeria, Rwanda, Ethiopia Malawi, Senegal, Nepal, India Lesotho, the Philippines | Honduras, Zimbabwe | Indonesia | Mozambique |
Program Design and Management Systems
AIDSCAP/FHI designed comprehensive, multiyear programs in 20 countries around the world. The project used a three-step strategy for program design that incorporated participation by all individuals involved in HIV/AIDS prevention, such as village-based clients, local and national stakeholders, globally recognized leaders, and technical experts.
Step 1. As its foundation the project developed a set of technical strategies incorporating the global lessons and best practices of the time. Technical working groups composed of participants from around the world were convened to guide the design of each technical strategy.
Step 2. At country level, programs were designed using a collaborative, participatory process that identified critical gaps in effective national programs and applied best practices to address country-specific needs. AIDSCAP/FHI used a participatory process to conduct its initial needs assessment in HIV/AIDS prevention, which involved gathering tactical information from and by host country stakeholders and developing a strategic plan for country support.
Step 3. The strategic plan was expanded into a comprehensive implementation plan that specified objectives and anticipated results, incountry implementing partners, technical support needs, a time frame, a budget, and an evaluation plan.
AIDSCAP/FHI followed these steps in designing diverse programs, such as a primarily grassroots nongovernmental organization (NGO) program to address prevention, care, and orphan support in Tanzania; a program that supported and was housed in Jamaica's national AIDS control program; a program in South Africa to address the international isolation and lack of program exposure the country's community-based organizations had experienced; and global HIV/AIDS prevention programming. Most of these programs had annual budgets ranging from $1 to 3 million.
AIDSCAP/FHI also designed smaller programs, with budgets ranging from $50,000 to $1 million, and provided technical assistance in more than 25 other countries. These programs and activities, which provided targeted expertise to national efforts, included strengthening sexually transmitted infection (STI) services in Morocco, conducting a program needs assessment in Papua New Guinea, and evaluating a USAID bilateral STI/HIV/AIDS prevention program in Uganda.
During the project, AIDSCAP/FHI worked with more than 500 local agencies, from small, community-based groups to larger NGOs to local, regional and national government agencies. These groups implemented nearly 800 subprojects, from $500 rapid-response community awareness initiatives to $400,000 multiyear efforts, to effect behavior change among target audiences in communities.
| Type of Agency | Total Number of Projects Implemented |
| Nongovernmental organization | 306 |
| Ministry of Health | 57 |
| Private voluntary organization | 121 |
| For-profit firm | 15 |
| Other government agency | 3 |
| Other | 18 |
As Table 26 shows, the vast majority of AIDSCAP/FHI subprojects involved the promotion of behavior change. Most of these subprojects also included direct condom distribution or were linked to national condom social marketing (CSM) efforts, and either provided or more often had linkages to STI services.
| Technical Strategy | Sole Focus of Subproject | Number of Subprojects |
| Behavior Change Communication | ||
| Counseling and testing | 3 | 39 |
| Integrated family planning programs | 1 | 2 |
| Mass media | 12 | 70 |
| Materials development | 35 | 167 |
| Outreach | 6 | 98 |
| Peer education | 3 | 166 |
| Theater/drama | 7 | 67 |
| Training | 10 | 77 |
| Sexually Transmitted Infections | ||
| Referrals to STI treatment | 0 | 85 |
| Research | 35 | 18 |
| STI clinic upgrading | 2 | 29 |
| STI management | 7 | 75 |
| Condom Distribution and Logistics | ||
| Condom distribution, free | 0 | 131 |
| Condom sales, non-CSM | 0 | 30 |
| Condom social marketing | 13 | 72 |
| CSM links | 1 | 54 |
| Condom logistics | 1 | 26 |
| Policy | 24 | 23 |
| Behavioral Research | 12 | 7 |
| Evaluation | 16 | 4 |
| Behavioral surveillance | 8 | 5 |
| Women's Initiative | 11 | 6 |
| Program Design and Management | 8 | 7 |
In addition to special programs to increase participation of community-based groups in HIV/AIDS prevention, AIDSCAP/FHI launched the following program initiatives to address distinct programming needs:
- a competitive grants program that fostered partnerships between U.S.-based private voluntary organizations and developing country NGOs for large ($400,000), multiyear program awards;
- a "domestic areas of affinity" program, which brought together NGOs in the Dominican Republic and Haiti with U.S. AIDS service organizations reaching Dominican and Haitian populations in the United States to encourage sharing lessons and foster collaborative ties;
- the Rwandan refugee program, which demonstrated the importance and feasibility of introducing HIV prevention services into refugee camps and has been used by such groups as the United Nations High Commission on Refugees as a model of such programming; and
- AIDS care and management grants, which pilot tested community-based models for care and prevention programming in resource-poor settings.
Managing the country program was the primary responsibility of the country office's resident advisor and his or her staff. Country offices were responsible for effecting the implementation plan, including negotiating and monitoring subagreements with implementing agencies, coordinating technical support, and tracking progress in implementing the overall country plan.
AIDSCAP/FHI used many mechanisms to monitor subproject results and country program implementation. First, it developed an evaluation plan for each country program at the time of implementation planning. Second, in partnership with implementing agencies, AIDSCAP/FHI identified process and outcome indicators for each subproject and mechanisms for periodically tracking both types of indicators over the life of the project. Finally, AIDSCAP coordinated ongoing oversight and feedback from country, regional, and headquarters levels, including a joint incountry program management review midway through each country program.
The program management review involved representative senior managers from all levels of AIDSCAP in collaboration with USAID central and Mission-level staff and incountry implementing agencies. Their job was to review the implementation plan for continued relevance, examine the level of human and financial resources available to the program, identify problems, and propose necessary modifications and solutions. Program reviews resulted in practical, critical changes, including increasing the emphasis on STI activities in Senegal, broadening the Jamaica program to include western parishes, and reconfiguring or augmenting country staff in many countries. In short, AIDSCAP/FHI's design processfrom initial strategic planning to subproject design and program updatingwas an ongoing, iterative effort.
Subproject Design Process
Designing subprojects was also an ongoing activity. Although AIDSCAP was a 6-year project, some country programs existed over a much shorter time frame, and subprojects within those country programs had even less time for design and implementation. For example, in Tanzania AIDSCAP/FHI began managing program activities in Tanzania that were continuing from the previous AIDSCOM and AIDSTECH projects. However, the country program was completely reconfigured in AIDSCAP's third year with the launch of the USAID mission's newly designed Tanzania AIDS Project.
Program efforts in Indonesia and Honduras were not initiated until the fourth year four of the AIDSCAP Project. To allow these late-starting programs maximum implementation time, AIDSCAP/FHI tested three mechanisms for "jump starting" the subproject design process. The processes included individual community-based IA strategic planning, joint training of all IAs in effective prevention and care program design, and joint training in proposal development. On the basis of the intensive technical support provided to IAs during the process, AIDSCAP/FHI was able to abbreviate its subproject's technical and financial review process and accelerate its initial disbursement of funding to the IAs. Using these mechanisms AIDSCAP/FHI launched between 10 to 15 subprojects in each country within 3 months.
The advantages of this participatory process included rapid start-up of country programs, team building of all partners in the implementation of the country programs, strong formal and informal linkages between subprojects and AIDSCAP IA partners, and opportunities for joint planning of follow-on technical training and materials development. The process, however, greatly intensified the demand for country office technical support and monitoring.
Capacity Building
A major focus of AIDSCAP/FHI's efforts was building the capacity of partner organizations from developing countries to effectively develop, implement, manage, and evaluate HIV/AIDS prevention programming. Capacity building efforts addressed four major areas: technical skills building, management skills building, organizational systems development, and networking. AIDSCAP/FHI developed tools for assessing the capacity of IAs, including a process enabling IA staff to assess their own organization's strengths and weaknesses, for evaluating the results of capacity building efforts, and for conducting strategic planning. During the life of the AIDCAP Project, 186,967 individuals were trained.
AIDSCAP/FHI not only developed the capacity of the organizations with which it collaborated, but also created strong, effective prevention management teams in its country offices. Acknowledging the value of these critical resources to incountry programming, AIDSCAP/FHI launched its NGO Partnership Initiative in 1996. Under this initiative, the project assisted several of its country offices to register as new, independent NGOs and provided training in business planning, strategic planning, grants management, and financial management. Seven countriesBrazil, Cameroon, the Dominican Republic, Ethiopia, Haiti, Honduras, and Zimbabwebecame independent organizations continuing to provide needed services and support in their countries.
Special Issues
AIDSCAP/FHI faced many unique management challenges during its life, most notably the conversion from a cooperative agreement with USAID to a contract in the second year of the project and the impact of USAID's major reengineering of philosophy and procedures in the fourth year.
The decision by USAID to convert the AIDSCAP Project from a cooperative agreement to a contract created a significantly different relationship between AIDSCAP/FHI and its USAID counterparts. The change inserted an "arms-length" distancing between former collegial partners, narrowing the scope of dialogue permitted by USAID Missions with AIDSCAP/FHI, particularly open consultation about potential program design questions and financial parameters. It also diminished the flexibility that the Missions and AIDSCAP country offices enjoyed to easily and quickly adapt a country's program design in response to lessons learned, emerging opportunities, and the evolution of the epidemic. The conversion caused significant project delays in many because Missions were precluded from joining or augmenting funding to AIDSCAP programs during the extensive conversion process. (For example, Senegal's program start-up was delayed for more than 1 year, and the conversion contributed to Malawi's decision to withdraw from AIDSCAP.) Finally, the conversion required FHI to significantly revise management systems and develop a number of ones and, in some instances, required rescinding policies that encouraged decentralization.
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Building local capacity involves more than training NGOs in material development and budget development and management. Critical to organizational sustainability is the capacity of institutions to create linkages with local resources to improve impact. Two such models include the NGO and government clusters in Tanzania and the focus site intervention teams (FSITs) in Ethiopia. In the Ethiopia model, AIDSCAP/FHI encouraged the formation of an FSIT in each of its four major urban program sites. FSIT members included the Ethiopian NGOs funded by AIDSCAP/FHI; the local Ministry of Health units, including the STI clinics upgraded through the program; and the CSM manager for the area. Under the USAID/Ethiopia-funded program, each organization managed its own project and resources, but as community members of FSIT, these groups met regularly to coordinate activities, informally share resources, and lend their support to each other's programs. In Tanzania, a country with hundreds of local NGOs, the cluster concept provided a mechanism for encouraging formal partnerships among community-based institutions. Under this strategy, NGOs working in HIV prevention and AIDS care in a region were encouraged to develop a joint project that would build on the unique strengths and interests of each organization. A lead or "anchor" organization was elected to coordinate the monthly representational steering committee meetings, disburse project funding according to the joint work plan, and meet donor reporting requirements. Over time, the clusters broadened and formalized their relationships with local government agencies. To date, nine clusters comprising nearly 200 NGOs have been formed in Tanzania under the USAID-funded Tanzania AIDS Project. The clusters and the FSITs have resulted in less competition, stronger collaboration, and a more sustainable community response. |
Lessons Learned and Recommendations
AIDSCAP/FHI lessons in program management address four major areas: planning and monitoring, forging partnerships, mobilizing communities, and sustainability.
Planning and Monitoring
- A systematic, participatory planning process articulates a clear vision for a program and provides a framework for implementing programs and assessing their progress. This process needs to be as wide-reaching as possible, involving stakeholders, clients, and other influential people and, most important, the target audience.
- Joint planning by all organizations that will be involved in implementing a country program results in more effective individual projects and encourages valuable collaboration and synergy.
- Effective project monitoring requires intensive on-site support and can be facilitated with easy-to-understand tools that help programs track critical benchmarks and progress toward identified targets.
- Mechanisms for reviewing and revising project objectives, strategies, and activities are essential to ensure that HIV/AIDS interventions remain responsive to the evolving epidemiology of the epidemic and the changing needs of target audiences.
- Ensuring regular input from clients in project design, implementation, and evaluation is essential for effective programming.
Forging Partnerships
- Formal collaborative relationships among all the organizations working on HIV/AIDS prevention in a region can strengthen prevention efforts, create opportunities to share resources, and reduce unnecessary duplication of effort.
- Linkages between international and U.S. domestic HIV/AIDS organizations can be mutually beneficial, particularly when the organizations work with similar populations. Lack of financial support, however, can jeopardize the sustainability of such partnerships.
Mobilizing Communities
- Working with existing organizationseven with groups that have little or no health experienceis generally more effective and sustainable than setting up new ones. Their established constituency bases, service delivery mechanisms, and organizational structures increase the likelihood of their sustainability.
- Even small, community-based groups with little or no previous HIV/AIDS experience can be mobilized to support HIV/AIDS in their communities if funding and reporting mechanisms are kept simple.
- Sustainability
- Capacity building and achieving program results should not be seen as conflicting or competing program objectives. Without appropriate attention to capacity building, sustainable results cannot be achieved.
- Sustainability requires effective partnerships between the public and private sectors. Donors should encourage collaboration among all community resourcesNGOs, private sector companies, and governmentsto capitalize on the comparative advantages and responsibilities of each sector.
