|
Programs |
||||||||||||||||||||||
|
|
||||||||||||||||||||||
|
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 |
|||||||||||||||||||||||
|
In Kenya, policy development included assessments and socioeconomic impact analysis. An important, well-publicized event occurred with the publication of the AIDSCAP/FHI/USAID book, AIDS in Kenya: Socioeconomic Impacts and Policy Implications. The book was published in mid-1996 and was officially launched in October 1996. Kenya's vice president was the keynote speaker at the launch, which also featured the U.S. ambassador, the country representative of the World Health Organization, and the director of medical services at the Kenyan Ministry of Health as supporting speakers. The book featured 10 articles by Kenyan and North American specialists, including two senior editors who were AIDSCAP/FHI staff members. The launch was extensively publicized in both print and electronic media. In addition, the book and various findings were mentioned in articles and editorials in the English-language press. For example, an article in the Kenya Times (October 26, 1996) said: "Although Kenya is in many ways ahead of other countries in understanding the epidemic, the country, however, lacked a cohesive program document before the launching of the book. It is hoped that new policies coupled with recommendations from the book will be pursued in order to prevent the further spread of HIV and to mitigate its impact." An original printing of 2,000 copies of the book was quickly distributed throughout Kenya and other countries. A subsequent printing of 5,000 copies permitted wider distribution, including hundreds of copies to such organizations as the National AIDS and STI Control Programme, the United Nations Population Fund, and the Kenya AIDS NGOs Consortium. AIDS in Kenya was the first book-length study in Africa to address the multiple implications of the HIV/AIDS epidemic. Chapter topics included the impact of the epidemic on households, on orphans, on the formal business sector, and on the national economy. A series of case studies focusing on women drew particularly strong attention during the national launch ceremony and in follow-up media coverage. The major finding of the assessment was that although multiple issues surrounding HIV/AIDS concerned many people in Kenya, there had been minimal national leadership and little public debate or involvement in addressing the epidemic. |
| Categories of Countries | Country Examples | Examples of Existing Policies | Approaches to Stimulate Further Policy Action |
| Countries with low-scale epidemics and little policy awareness or action | Indonesia, Egypt | NACP created, but lacks resources and adequate staff | Surveillance for accurate data and modeling, study tours, policy assessments |
| Countries with major epidemics, an outline of a policy plan or strategy but only a limited response by policymakers in one or more sectors | India, Malawi, Burma, Nigeria, Zimbabwe | National plan or strategy exists or drafted, but funding primarily from several donors | Socioeconomic impact studies; studies of youth sexual behavior; examples of other countries; increased media coverage; engaging one or more of the nongovernmental sectors (religion, NGOs, businesses) |
| Countries with major epidemics, informed policymakers, but without significant policy responses in all sectors | Kenya, South Africa, Tanzania, the Dominican Republic, Jamaica | National strategy or policy exists, some specific laws enacted or considered, all sectors involved | Development of local policy and advocacy capacity; extensive and accurate media coverage; legal and legislative provisions for specific issues, especially for vulnerable populations |
| Countries with major epidemics and significant policy responses | Thailand, Uganda | National strategy implemented, national funding and other resources committed, specific prevention policies enforced | Maintaining BSS, ensuring ongoing implementation of policies and development of new policies, especially for mitigating impact in special needs populations |
Policy Identification
Identifying both policy issues and appropriate policies is a standard process, but discussing the issues and adopting the policies usually require significant time, sustained analytical input, and focused advocacy, as demonstrated in the adoption of STI syndromic management in Cameroon, Tanzania, Brazil, and Haiti. This adoption of a new approach to STI management by national medical communities was a policy decision and, in many countries, was preceded by validation of the approach and adoption of appropriate guidelines for practitioners.
The policy process can also contribute to building a constituency for development of a longer-term policy, as demonstrated in a project conducted by the Kenya AIDS NGOs Consortium. The project staff solicited policy issues from district and provincial implementing agencies, refined the issues into policy recommendations, and presented the recommendations to the appropriate national authorities.
AIDSCAP/FHI aided the program by including advocacy as a technique to highlight issues and motivate decision makers. In Brazil, advocacy by activists resulted in federal elimination of taxes on condoms, making them more affordable for everyone. In the Dominican Republic, an advocacy strategy to influence the outcomes of national legislation included a timely presentation to high-level policymakers of modeling projections of HIV/AIDS impacts.
Social and Economic Policy Development
The absence of mitigation policies to protect socioeconomic groups from losing their savings by caring for family members with AIDS has become evident as more people move from HIV into full-blown AIDS. Discrimination and stigmatization remain real factors in many communities, perpetuating vulnerability, social instability, and divisiveness. In many cases, policy rhetoric among governmental and religious leaders has not been translated into effective mechanisms that will address discrimination, both formal (e.g., blood tests for insurance coverage) and informal (e.g., some pastors refusing marriage services without HIV tests).
AIDSCAP/FHI was recognized as the lead organization for expanding the scope of economic impact analyses and integrating economic analyses into policy development. Socioeconomic impact assessments were conducted in eight countries with technical assistance from AIDSCAP/FHI, raising awareness of the economic implications of the epidemic. In the Dominican Republic and Honduras, for example, the analyses were presented to senior policymakers and were followed up by local specialists, resulting in legal reform and increased resource allocation for STI/HIV/AIDS prevention.
Policymaker Education
Numerous policymakers in government, religious, and business communities have been poorly informed about HIV/AIDS and its many implications for national welfare and economic development. There are two sides to this finding. First, incomplete data and analyses about the epidemic precluded policymaker education. Second, many policymakers have resisted understanding the epidemic, its transmission patterns, and its long-term impact on local and national institutions. Denial is the catchall term used to describe these reactions, although the term obscures as much as it illuminates. Effective policy development attempts to understand and address the rationale for denial.
Policymakers often are prepared to act on suggested recommendations for STI/HIV/AIDS prevention when presented with clear and precise information. For example, South Africa's minister of health adopted as national policy a comprehensive NGO-prepared draft of a national response to HIV/AIDS. Policymakers are less likely to act on vague, unsubstantiated recommendations (e.g., "youth should be educated"). Specificity and reference points to familiar data or related issues can facilitate policymaker actions.
Training provided by AIDSCAP/FHI in socioeconomic impact assessments in El Salvador, Guatemala, Honduras, and Nicaragua was directed toward technical and policy specialists, who then were able to influence policymakers. In Senegal, Islamic and Catholic representatives recommended that assistants and spokespersons for religious leaders be engaged in initial dialogue to help guide policy responses.
AIDSCAP/FHI demonstrated the effectiveness of using several policy tools to inform policymakers. Early in the project, epidemiological modeling was seen as most effective in sensitizing policymakers. Midway through the project, socioeconomic impact assessments -- building upon epidemiologic modeling and economic impact projections -- were found to be a more comprehensive and forceful tool. In turn, socioeconomic impact assessments have evolved to include information on sectorial, household, gender, and national economic impacts.
Policymakers in the private and religious sectors, too, must be sensitized and informed to ensure their involvement in prevention efforts. Surveys of business leaders in several African countries found they were aware of and concerned about the impact of AIDS on business operations but lacked guidance on adopting appropriate policies and prevention programs. Christian policymakers in Kenya collaborated to adopt a public statement endorsing the creation of STI/HIV/AIDS prevention policies within their respective denominations.
Policy Interventions
AIDSCAP/FHI recognized and supported international guidelines on STI/HIV/AIDS prevention but did not directly intervene in the policy process within countries. Rather, through policy assessments, training, and technical assistance, AIDSCAP/FHI supported the efforts of governmental and nongovernmental organizations to inform and influence policy development in government, NGOs, or business and religious organizations. AIDSCAP/FHI also facilitated research, dialogue, and consensus building, which provided information about international and national experiences on specific policies and policy approaches.
Study tours sensitized and informed policymakers. For example, visits to Thailand by Indonesian policymakers helped inform the preparation of Indonesia's national strategy. Even though study tours and other educational efforts targeted policymakers directly, AIDSCAP/FHI emphasized the training of policy "influencers" -- the technical and policy specialists inside and outside the government who inform and advise policymakers. Through this training, many people who had believed that policy was not their responsibility realized that they had important roles to play in policy development.
Policy Collaboration
Local organizations need to identify their policy needs and guide the process of policy development. However, most NGOs and business, worker, religious, and community organizations consider "policy" to be a governmental or political function, not their responsibility. AIDSCAP supported the efforts to train these nontraditional groups in policy skills so that they could have a stake in policy outcomes and a role in the policy development process.
Some large businesses showed concern about the impact of HIV/AIDS on productivity and profitability. However, only a few companies initiated prevention programs or adopted prevention policies. Workers' associations also have been slow in making HIV/AIDS a workplace issue, although exceptions exist. Cost-effectiveness data were particularly useful in convincing business owners and managers to support workplace STI/HIV/AIDS prevention policies and programs. AIDSCAP/FHI's Private Sector AIDS Policy package, which has been used in more than 10 countries, includes spreadsheets and examples to help managers calculate the potential financial impact of HIV/AIDS on their workplaces and the cost of a workplace prevention program. The project worked with hundreds of companies in 27 countries to establish STI/HIV/AIDS prevention interventions for employees and to encourage the adoption of supportive workplace policies.
Collaboration has been a concern of many national AIDS control programs, donors, and NGOs. However, mechanisms to foster collaboration and coordination often are weak, as are mechanisms for interministerial collaboration. Collaboration often arises unexpectedly. A series of study tours by Indonesian policy and technical specialists to review Thailand's response to HIV/AIDS resulted in most of the participants subsequently forming an informal group that helped guide Indonesia's response during the formative months.
AIDSCAP/FHI, together with USAID in Washington, initiated an informal network of economists and other specialists concerned about the economic impact of HIV/AIDS. The AIDS and Economics Network held eight meetings in the AIDSCAP/FHI headquarters, attended by 25 to 50 people representing USAID, the World Bank, the United Nations Development Programme, the Joint United Nations Programme on HIV/AIDS, and several other federal offices and NGOs. A variety of topics were presented and discussed, ranging from the impact of HIV/AIDS on households and tourism to the economics of commercial sex.
|
AIDSCAP/FHI conducted studies of 17 African, formal sector businesses to learn about private-sector responses to HIV/AIDS. The findings from this business case study illustrate the key role of this sector. Most of the managers of the 17 companies reported that after prevention programs had been introduced, they experienced significantly fewer cases of STIs and absenteeism. Many managers commented that the prevention programs helped create a more tolerant and accepting attitude among workers toward HIV-positive employees, resulting in positive effects on morale and productivity. The managers of the companies recognized the value of the prevention programs. AIDSCAP/FHI's analysis of the financial impact of HIV/AIDS and the cost of prevention for several of the companies confirmed that program costs tend to be about half of losses from AIDS. Other studies also have demonstrated that prevention is cheaper than the losses incurred by businesses as a result of disruptions in production and the increased health and benefit costs associated with HIV/AIDS. |
Lessons Learned and Recommendations
- Policy assessments provide a baseline and a context for designing and implementing prevention interventions, preparing case studies, and consolidating incountry thinking and actions on policy issues.
- Policy assessments also may offer recommendations, which must be presented with substantiated information and within the policymaking context of the country and institution concerned.
- Both general and sector-specific policy assessments can offer valid insights and important information for subsequent policy development and advocacy work.
- Given the diverse pattern of the epidemic throughout the world, no predetermined policies can accommodate all countries. AIDSCAP/FHI developed a matrix (as shown in Table X) that reflects this diversity as a guide for policy activists to identify stages of policy responses and tools to facilitate the response.
- Public health responses to HIV/AIDS, no matter how logical and timely, may not be readily adopted by government, political, religious, and business policymakers. It may take 1 to 5 years for policymakers to adopt an initial public health recommendation.
- Unless a compelling economic or political argument exists, efforts to gain public policy guidance on promotion and distribution of condoms, especially to youth, should be avoided or given a low profile. Reactions may make such efforts counterproductive. Social marketing techniques have been effective in stimulating demand and sustaining supply.
- Although social and economic factors contributing to HIV vulnerability and transmission are easy to describe in general terms, little data exist to fully make the case. For example, while poverty is often cited as a risk factor (e.g., women engaging in survival sex and lack of access to information and health care systems), confirming evidence is only anecdotal and may become a point of diversionary argument by policymakers.
- Public-sector resource allocations for STI/HIV/AIDS prevention -- either in-kind allocations or allocations obtained through traditional mechanisms, such as delivery of health care services -- have been low, except in Thailand and Uganda. Resource allocations have been hindered by the lack of political acknowledgment of HIV/AIDS and the lack of political commitment to prevention programs. Also, competing demands for limited national resources and weak HIV/AIDS bureaucracies have curtailed adequate resources for prevention programs. Several countries, however, have received loans from the World Bank to finance these programs.
- Few mitigation policies have been enacted by national governments. De facto national policies on access to health or medical care have permitted people living with HIV and demonstrating symptoms of AIDS to use no-cost or low-cost public health facilities. Religious-based medical and development organizations have provided treatment and some support for community-based mitigation efforts. A growing number of middle-income countries are subsidizing the purchase of antiretroviral drugs for individuals who are infected with HIV, although unanswered policy questions remain about availability of and accessibility to antiretroviral drugs and related medical care.
- AIDSCAP's experience across regions affirms that policy development is rarely a quick or direct process. It involves engaging political processes that may be vague, time consuming, and even threatening. The processes require negotiation and compromise and may result in outcomes that are unexpected or different than originally envisioned.
- With limited policy capacity, a focus on policy development within government institutions is understandable. However, where governmental and nongovernmental sectors have policy or advocacy capacity, or both, religious and private sector organizations need to be incorporated into discussions and into the formulation of appropriate policy responses to the epidemic.
- Policymakers in any sector are often sensitized by graphic representations of data illustrating the likely impact of the epidemic. They may even ask how the projected impact can be prevented. That sensitization, however, usually will not translate into policy initiatives unless:
- presentations of the projected impact of HIV/AIDS are accompanied by specific suggestions and recommendations for policymaker discussion and action;
- recommendations are specific, clear, and practical and can be substantiated with convincing data, including (where possible) indications of the costs associated with recommended actions; and
- a single presentation (such as the AIDS Impact Model for policymakers) is followed up with additional information, reminders of the proposed actions, and advocacy;
- The value brought by an external agency, such as AIDSCAP/FHI, to national or sectoral policy development is primarily comparative perspectives -- what has or has not worked in other countries and in other situations. Even technical expertise is most valuable when offered with comparative examples.
- Policymakers, policy influencers, and technical specialists prefer data and analysis compiled from their own countries or sectors, or both. Occasionally, individuals from each group have resisted conclusions drawn from "similar situations" and have demanded locally relevant data.
- Collaboration is an inexpensive way to expand the advocacy constituency for STI/HIV/AIDS prevention and to share information and experiences. At the same time, organizational collaboration does not just happen; it must be fostered by mutual self-interest.
- HIV/AIDS networks have proliferated, some with AIDSCAP/FHI assistance and others through AIDSCAP/FHI implementing agencies. Several networks are strong and effectivesuch as the Kenya AIDS NGOs Consortium and the National AIDS Convention of Southern Africawhile others exist in name only. External efforts to stimulate network formation often failed or did not last beyond initial funding. The effective networks succeeded because they served the needs of a diverse membership, had committed and skillful leadership, and had diversified funding sources at an early stage and maintained that diversification. In addition, they provided a service for members and the government, and they engaged in both policy and advocacy activities rather than focusing exclusively on program development and outcomes.
Challenges for the Future
- To identify areas for policy development and to build constituencies for STI/HIV/AIDS prevention, policy assessments should be conducted at the start of a project. The assessment should be as multisectoral as possible. To strengthen advocacy around HIV/AIDS issues, policy assessments should be widely distributed or reported.
- Policy development for STI/HIV/AIDS prevention will yield lasting and informed policy outputs when it focuses on processes. These processes incorporate the following elements: collecting issues from diverse constituencies to test their viability and applicability to different interest groups; prioritizing issues into a short list manageable by organizations, since not all issues can be addressed at once; refining issues with supporting data into viable policy recommendations; and increasing awareness and demonstrating constituent concern by using a variety of education and advocacy techniques.
- Policy specialists should be included, even informally, in the planning or strategizing of condom social marketing campaigns and STI syndromic management adoption.
- The relationship of the HIV/AIDS vulnerability to povertyor to levels of wealthand to the causes of poverty are assumed but not sufficiently described or analyzed. Socioeconomic data on specific groups of peopleboth high and low riskare needed to clarify the relationship between HIV/AIDS vulnerability and poverty and to link HIV/AIDS with multisectoral development.
- Many policy tools are needed to increase the ability of local policy influencers to engage policymakers. Such tools include policy assessments and retrospective reviews of policy responses; socioeconomic impact studies and presentations; epidemiological modeling and presentations; prevention tools specific to particular interest groups, such as the Private Sector AIDS Policy materials designed for private-sector managers; and core groups, or teams, of technical and advocacy experts.
- At least 1 year is required to lay the groundwork for informing policymakers and motivating them to action. Thus, realistic timelines and accompanying staff and resources are needed to achieve policy successes.
- Projects like AIDSCAP/FHI must monitor policies, policymaking processes, policy gaps, and opportunities across many countries to facilitate the sharing of information and experiences. Also, AIDSCAP/FHI can encourage countries and organizations to review and adapt internationally sanctioned guidelines. It is inappropriate, however, for external organizations to direct, coerce, or pressure countries or organizations to adopt policies.
- Networks are an important element in HIV/AIDS policy development and advocacy. Effective networks can be supported and strengthened, but not created, by external organizations. Similarly, informal collaboration that serves a specific purpose or that exists for a limited time can be supported by external organizations. Where collaboration is weak, it can be fostered through meetings, study tours, workshops, and similar activities that provide a focus for common discussions and work.
- Policy technical assistance that is overly directive, uses expatriates as spokespersons to senior officials and policymakers, or lacks sensitivity to the multiple factors that influence policy development should be avoided.
