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Final Report for the
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1. Program Implementation Background USAID/Jamaica initiated the AIDS/STI Prevention and Control Project in 1988 to address the growing HIV/AIDS epidemic and the accompanying dramatic increase in other STIs, with the Academy for Educational Development (AED) and the Centers for Disease Control and Prevention (CDC) as primary providers of TA. The original project had two strategic objectives:
An amendment to the Project Paper in 1992 recast the original project, extended it for an additional four years and named FHI and CDC as primary providers of TA. The amendment added a focused strategy that concentrated on three key interventions:
Based on the Amendment to the Project Paper, AIDSCAP initiated activities by developing a preliminary 15-month implementation plan to allow for the immediate startup of project activities. An AIDSCAP/USAID team worked closely with the Ministry of Health and collaboratively developed a plan which emphasized the supportive role of AIDSCAP in implementing the National HIV/STI Control Program. This implementation plan included the following components:
In 1992 a USAID/AIDSCAP team found the project conceptually and technically sound, but insufficiently funded to assure sustainable national-level impact. USAID/Jamaica agreed to design an expanded, sustainable program with augmented resources from the LAC Bureau. The preliminary implementation plan was then superseded by the comprehensive Strategic and Implementation Plan in 1993 which covered the entire four-year funding period and integrated the LAC Bureau contribution with the existing USAID/Jamaica program and Core-funded activities. The components of the Strategic and Implementation Plan included:
The primary areas of emphasis were STIs and BCC which accounted for 80% of the overall subproject expenditures. Activities in condom distribution and promotion, behavioral research and policy development and dialogue were reduced or eliminated due to budget cuts. In 1995 a one-year extension was granted to complete project activities and to further strengthen host country institutions to directly manage and implement their HIV/AIDS prevention activities. Upon completion of the AIDSCAP extension period, USAID/Jamaica continued support for the control of HIV/AIDS through a direct bilateral project which focused on the sustainability of the National STI/HIV/AIDS Control Program with an emphasis on decentralizing efforts to the 13 parishes in the country. Project Design and Startup The preliminary Implementation Plan allowed for the immediate startup of subproject activities which were later expanded under the comprehensive Implementation Plan. An AIDSCAP team designed five subagreements under targeted interventions, hired staff to be seconded to the MOH and initiated STI training and research activities. Once the in-country team was in place additional subagreements were prepared. Two workshops on Program Design using logical frameworks were held with potential Program Managers which introduced the concept of indicators and means of verification. Based on the logical frameworks developed by local counterparts the Country Office worked with implementing agencies to complete 18 subagreements in accordance with the comprehensive Implementation Plan. USAID/Jamaica later used the evaluation plans within the subagreements as their prototype in designing and launching multiple projects. Most of the subagreements focused on direct program implementation specifying target populations and strategies; however, three subagreements provided support for the overall program, including Hope Enterprises for evaluation, Berl Francis for public relations and CATC with staff support. Hope Enterprises conducted evaluation activities for individual subagreements as well as recording progress of the overall program. This assured the quality of the data and gave implementing agencies an appreciation for evaluation information. Berl Francis effectively publicized AIDS prevention activities amongst all the subagreements creating more demand for activities as well as obtaining financial and in-kind support for the NHCP. Staff support for the Epi Unit was provided through a private management firm, Caribbean Applied Technology Association (CATC). Due to previous audit problems within the MOH it was required by USAID/Jamaica to provide funding for seconded staff through an external mechanism. AIDSCAP/Jamaica provided funding for the following professional and support staff : STI Technical Advisor, Counseling/Community Outreach Specialist, two Communication Specialists, Social Worker, Private Sector Officer, and three secretaries. The arrangement with CATC included recruiting staff, keeping track of leave, payroll, health insurance as well as managing the funds for the seven subagreements implemented by the Epi Unit. A minor problem was experienced when CATC volunteered technical input creating confusion amongst program managers which was quickly corrected by clearly specifying roles and responsibilities. Thereafter the implementation process continued smoothly. Program Evaluations The AIDSCAP/Jamaica program participated in three mid-term reviews including the AIDSCAP internal review in June 1994; the overall AIDSCAP Project mid-term Evaluation in November 1994; and the USAID/Jamaica mid-term Evaluation in November 1995.
An internal program review was conducted in June 1994 and found the program was "well-designed, well-coordinated and an integrated program". Overall, the program was found to be comprehensive and deemed to have potential for achieving a national impact. In addition, the team concluded that some aspects of the program, such as BCC and AIDS in the workplace could serve as models for other countries in the region and elsewhere. As an outcome for this assessment, successful interventions were expanded outside of Kingston, more TA was scheduled and trips were planned for local implementers to observe activities in other countries, for example, the Helpline Coordinator visited the US-based AIDS/STI hotline sponsored by CDC.
The overall mid-term Evaluation of AIDSCAP was conducted in November 1994 and included Jamaica as one of five countries for site visits. Although the Team was focusing on global findings and issues the team did comment on the excellent relations the Jamaica Country Office had with USAID/Jamaica. This relationship allowed for the quick approval of documents and for coordinated efforts in implementing activities. In addition the Team commented on the financial management system which was successfully adapted for the particular needs of the country.
USAID/Jamaica conducted a mid-term evaluation of all of their AIDS prevention activities including AIDSCAP in November 1995. Overall, the team concluded by recommending that this "good project" continue in the present form while consolidating the activities. The team made the following four specific recommendations:
The three evaluations provided useful opportunities to review strategies and progress. The findings and recommendations in the different evaluations validated that capacity building had successfully occurred and recognized the capability of the MOH to directly manage their own activities. 2. Program Management Country Office The Country Office was not established until 18 months into the project due to delays in hiring a Resident Advisor. Initially the MOH and USAID envisioned hiring a local Resident Advisor. Despite extensive efforts, the recruitment process was unsuccessful and an Acting Resident Advisor was appointed and an Accountant was hired to assist with project startup In light of the situation, an expatriate was placed in the position with the understanding that the position would eventually be turned over to a local person. Upon the arrival of the expatriate Resident Advisor, the Country Office was established within the Epi Unit of the MOH. Additional staff were hired including a Secretary, Program Assistant and Driver. Later, a Program Officer was hired. This person eventually assumed the role of Resident Advisor in late 1995 and saw the project through close-out in 1996. Funding AIDSCAP/Jamaica received funding from USAID/Jamaica, the LAC Bureau and Core funds. The comprehensive Strategic and Implementation Plan was immediately approved by USAID/Jamaica but extensive delays were incurred in securing the level of obligation from the LAC Bureau. The level of obligation changed annually which created an extended period of uncertainty resulting in the elimination of behavioral research, and policy development and a reduction in condom activities. Project Monitoring Project monitoring activities included monthly meetings with Project Managers; monthly Meetings with USAID, Monthly meetings with MOH; Quarterly Steering Committee Meetings and monthly Epi Unit Staff Meetings. Although their were numerous regular meetings they resulted in a well coordinated program allowing the different stakeholders to monitor progress. The AIDSCAP/Jamaica monthly report documented all aspects of program implementation. Monthly meetings with Program Managers were guided by reviewing progress and planned activities. Discussions covered numerous issues including program management, personnel issues, financial expenditures, as well as program activities. In addition, field trips to observe field activities were scheduled regularly allowing for opportunities to observe interactions with the target populations which assisted in determining level of effectiveness. Monthly meetings with USAID focused on the AIDSCAP/Jamaica monthly report as well as identifying future implementation issues. Due to the extraordinary number of visitors quite a bit of time was consumed in preparing itineraries. Quarterly Steering Committee Meetings brought together implementing agencies, USAID, the National Family Planning Board, Senior MOH staff and Epi Unit staff which provided for the broad coordination of resources. Epi Unit staff meetings provided detailed monthly updates of the different subagreements allowing for input from technical staff. The location of the Country Office within the Epi Unit provided for daily access to NHCP staff. Program Managers outside of the MOH were located nearby in the Kingston area hence monitoring activities was logistically easy. In addition, their visits to the Country Office allowed for further coordination with the public sector. A survey of Program Managers conducted by the Country Office in early 1995 found that Program Managers were very satisfied with the level of monitoring and technical assistance that AIDSCAP provided. Technical assistance was provided primarily in BCC and STI but also included some in Condoms, Evaluation and Management. Overall program managers rated the TA as good and four rated it as excellent specifying the usefulness of the STI TA. The majority of them found that the subagreement provided clear guidelines about activities and they felt they had sufficient access to the Resident Advisor. Management Challenges For the most part managing the AIDSCAP/Jamaica program went smoothly but there were a few added challenges which involved multiple stakeholders, program planning, visitors to observe activities, and close-out.
The numerous stakeholders involved in the Jamaica program provided an added challenge for management. Stakeholders included USAID/Jamaica, USAID/Washington HIV/AIDS Division, USAID/ LAC Bureau, AIDSCAP LAC Regional Office, AIDSCAP Headquarters and the MOH. Providing feedback to each group with their special interests required extensive documentation in the monthly reports generated by the Country Office.
Prior to AIDSCAP's involvement the NHCP had years of experience and had developed its own system in terms of planning activities, managing funds and evaluation. Although AIDSCAP's contributions were welcomed, the AIDSCAP systems were not initially perceived as helpful. Only after systems proved to be effective was there a willingness to accept these changes. For example, Epi Unit Program Managers previously operated on short term plans, the introduction of a subagreement requiring them to plan up to two years of work in advance was met with resistance. However, after subagreements were approved and the implementation process initiated Program Managers began to value the clarity of expectations and budget allocations.
The AIDSCAP/Jamaica program received an extraordinary number of visitors which although often proved beneficial was also time consuming. The Country Office was frequently called upon to organize schedules and accompany visitors to sites throughout Jamaica. Visitors included USAID/Washington, US-based Private Volunteer Organizations (PVOs), Pan American Health Organization (PAHO), regional counterparts as well as the three mid-term evaluation teams.
The AIDSCAP/Jamaica program began close-out activities in early 1996. Throughout the close-out phase many uncertainties remained about future funding which hindered the effective management of a transition. 3. Capacity Building from the Management Perspective AIDSCAP's efforts enhanced the capacity of the NHCP and the private sector to implement AIDS prevention efforts.
Prior to AIDSCAP's involvement success of AIDS prevention efforts had been documented by various implementers but not shared with all interested parties. In order to demonstrate technical effectiveness, AIDSCAP supported the compilation of qualitative research findings and a synthesis of quantitative data which was disseminated widely. To follow on with this coordinated effort to view evaluation data, AIDSCAP conducted evaluation activities including process, outcome and impact measurements at individual subagreement levels and of the program as a whole through a private research firm. Combining all the evaluation activities under one subagreement allowed for consistency in the quality of the data and for an effective interpretation of the data which influenced future program implementation. The only draw back of this strategy was lack of capacity building for the individual implementing agencies as they relied on the services of another organization.
With support from AIDSCAP, the NHCP was able to leverage funds for the expansion and continuation of activities. The National AIDS Committee (NAC) successfully raised funds using minimal AIDSCAP resources for special events. For example, the ANC sponsored the movie "Philadelphia" as a special premiere which heightened awareness, generated funds and initiated a policy dialogue on the treatment of PWAs. The public relations project raised $180,000 in contributions for the NAC. In addition, numerous implementing agencies developed their own fund raising activities. For example JAS held monthly special events for income generation purposes, ACOSTRAD held a special annual function which was widely publicized. Links with international counterparts also assisted implementing agencies in the fight against AIDS. For example JAS linked up with the Gay Men's Crisis Center in New York and received donations of medical supplies. |
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