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Final Report for the
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5. Policy and Policy-related Interventions Policy Project:NGO Consortium FCO 55469
Background As the severity of the HIV/AIDS epidemic became increasingly conspicuous from epidemiological data and personal experiences, the need to establish policies and guidelines on HIV/AIDS issues became more pressing. Legal issues related to the epidemic, such as termination if an employee was found to be HIV positive, were increasingly evident. But there was little clear policy direction to assist in behavior change decisions, and no established forums for discussion and debate on the numerous issues arising from the epidemic. The Policy Project of the Kenya AIDS NGOs Consortium was designed to help fill this gap. The Kenya AIDS NGOs Consortium and its member NGOs were already actively collaborating with the National AIDS Control Programme on AIDS prevention and care at both national and district levels. The project was designed to provide the means to facilitate discussions of policy issues by NGOs, government, and religious organizations and the development of locally and nationally relevant options for adoption of prevention policies. Project activities were intended to solicit and encourage the movement of ideas, concerns, and initiatives from field-based experience to the central level. Objectives The overall purpose of the project was to involve KANCO members and their collaborators in the government and other sectors in a process that would facilitate the establishment of a conducive policy environment for effective HIV/AIDS programs to target populations in Kenya. The main objectives were to:
Activities and Accomplishments The Kenya AIDS NGOs Consortium (KANCO) utilized its unique position with NGOs, religious groups and the government to facilitate four provincial workshops, attended by 128 participants at which representatives from those groups identified issues related to HIV/AIDS that concerned their organizations and constituents. A subsequent national workshop for 57 participants prioritized the initial lists of 72 issues and developed a short list of eight priority issues. These were:
Both workshops were successful in involving all sectors at the provincial level, including Provincial Commissioners, and Provincial Medical Officers, Health Education Officers, and Nursing Officers as well as NGO representatives. A five-day Training of Trainers workshop was later held for 50 participants from leading NGOs to reinforce their understanding of the policy development process, advocacy and networking and to improve their skills in policy development and advocacy. A second TOT workshop was attended by 47 participants. It is interesting that at the start of the project, questions were asked about why NGOs should be involved in policy development since this was seen as the sole responsibility of the government. It was realized, however, that community groups had not been involved in decision-making processes in which their input would have been valuable, for example, in the development of the first two Medium Terms Plans on HIV/AIDS. This resulted in many NGOs not being aware of these documents. Participants in the workshop also agreed that policy development and advocacy is a continuous process which stakeholders need to understand. Following the selection of priority issues, the KANCO project staff collected supporting information about them, which was developed into three policy papers, Discrimination of persons infected with or affected by HIV and AIDS, Removing stigma and developing appropriate IEC strategies for STI prevention and control, and HIV/AIDS education for Kenyan youth. The papers were then submitted to appropriate policy makers. A major accomplishment of the project was providing formal input on NGO concerns both through the three policy papers and as recommendations to the Sessional Paper on HIV/AIDS, which was adopted by the Cabinet early in 1997 and published in June 1997. The success of KANCO's involvement in policy development was also evident in the increasingly influential role of the KANCO secretariat. Secretariat staff were invited by UNAIDS to sit on the review committee on Medium Term Plan 2 and the framing of MTP3, by the National AIDS Control and STI Programme (NASCOP) to review project proposals from NGOs seeking funding available from a World Bank loan for HIV/AIDS/STI, and by print and broadcast media for numerous interviews and opinions. Another accomplishment was the formation and rapid growth of district-based branches of the KANCO network. At the beginning of the project, no branches existed; by the end of the project there were over twenty branches. Overall, the capacity of Kenyan NGOs and religious groups at district, provincial and national levels to engage credibly in the policy development process and advocacy was very much strengthened. KANCO staff acquired or strengthened skills in policy analysis and writing, in developing advocacy strategies, in working with the media and with policy makers. Constraints The major external constraint was the project planners' under-estimation of the amount of time and training needed to raise the skills of district level activists to engage in policy activities. The project built-in additional training to overcome this constraint. The major internal constraint related to the rapid growth of KANCO and the increased demand for its assistance from numerous sources. KANCO staff, including those of the Policy Project, tried to respond to the heavy demand for their services which occasionally reduced the amount of time available for managing the Policy Project. This internal constraint is recognized by KANCO staff and is being addressed. Lessons Learned Major lessons learned, as drawn from discussions with Policy Project staff, the end-of-project evaluation, and observations by technical consultants, included:
Country Office Assessment There is no doubt that KANCO and this project contributed to changes in the policy climate in Kenya. That opinion is shared by other donor agencies, NGOs and within government. The approach adopted in the project assured success; it is doubtful if a more assertive or centrally-focused approach would have worked and might have even resulted in a counter-response by powerful interests in the country. Nor would a series of events (one time presentations, news conferences, etc.) have produced the same results for they would have lacked the capacity building aspects for KANCO secretariat and the network; follow-up would have been problematic. For the AIDSCAP technical advisor to the project, it was impressive to watch the internal learning of KANCO staff as they adapted a policy development approach to fit local and national needs. As the technical advisor noted on several occasions, the policy project operated by KANCO was the most comprehensive within any AIDSCAP country and it offers a model for other countries wishing to expand the policy environment for HIV/AIDS prevention and care. USAID and other international donors have recognized the effectiveness of KANCO, in policy development and as a national network. It appears that such recognition will translate into further financial support which will allow KANCO to follow-up with the policy work begun during this project. Policy analysis and development, and facilitating such a process, are not services that can command fees in Kenya. Thus, this aspect of KANCO's work will continue to require external funding. KANCO works with several international donors to assure continuity, and management is implementing a long-term plan reflecting the recent growth of the organization. Process Indicator Summary
AIM Presentations by Senior Government Officials FCO 56489
Background Although Kenya had been carrying out HIV sentinel surveillance since 1990, the results were treated as confidential and not disseminated to policy makers or the public. Many policymakers did not therefore understand the magnitude of the epidemic. As of 1995, no government policies or legislation had been developed to address the AIDS epidemic. In order to formulate policies to address the different HIV/AIDS issues, providing accurate information to policymakers was necessary. In order to facilitate this information dissemination, the Futures Group, through USAID's RAPID 4 project, developed the AIDS Impact Model (AIM) in collaboration with the National AIDS/STD Control Programme and the National Council for Population and Development. AIM is a methodology for presenting information about the AIDS epidemic, through using computer software and/or slides to project graphics and data presentations on screen. This approach enabled data on a range of topics, (including, for example, current and projected HIV prevalence, morbidity and mortality, socioeconomic impact, health service use, and how these might be affected by different intervention models) to be presented to a wide audience. In 1993, training in making AIM presentations was conducted for presenters from NASCOP and NCPD. Senior civil servants from 13 ministries were then trained in a workshop in November 1994. AIDSCAP was asked to support follow-up activities to this initial training. The trained senior civil servants were to make AIM presentations to their colleagues at their respective ministries' headquarters and later to senior provincial and district civil servants. These were expected to include the District Commissioner, the District Medical Officer of Health, the District Prisons Officer, and the District Development Officer in each of the districts covered. Approximately 20 senior provincial civil servants from each of six selected ministries were expected to attend the presentations. A total of 29 presentations was planned for 696 senior civil servants (116 from the districts and 580 from the provinces). Objective The purpose of the AIDSCAP project was to use AIM to increase the awareness and understanding of the impact of the AIDS epidemic of senior government officials, including those at district and provincial levels. Activities and Accomplishments A total of 31 presentations were made, attended by 1,450 persons. The initial presentations included most of the provincial commissioners and district commissioners, together with other influential political and religious leaders from all the provinces. Following recommendations from these leaders, the presentation audience was then expanded to include senior representatives from departments who deal with professions that may be exposed to high risk behavior. These included senior staff from the Armed Forces training colleges, military barracks, prisons, National Youth Service training camps, and major colleges. Constraints Development of the agreement was a long process and this delayed the presentations, since funds arrived when many officers had already scheduled other activities. More important, however, were issues related to the selection of officers for training as presenters. Most of the presenters who were trained in the November 1994 workshop have either retired, or been promoted to positions which will not allow them enough time to make future presentations. There is an inherent conflict in selecting officials who are senior enough to have credibility with their colleagues, yet at a stage in their careers when they can continue to use their skills on the job. Lessons Learned Lack of good understanding of the AIDS epidemic among key political, government, private sector and community leaders, contributed to inadequate support for effective AIDS control efforts. There was little good information available about the epidemiological and socio-economic impact of AIDS on national and district levels. AIDS was considered a problem that only fell within the realm of the Ministry of Health. Most policymakers were not aware of the serious impact of the epidemic and therefore were unable to articulate policy issues in their respective areas. In addition, the media tended to mix rumors and facts in their reporting. The introduction of AIM created awareness that information on HIV/AIDS impact, projections and interventions can be made available to everyone. AIM created interest in discussing causes, impacts and interventions. There are now requests for information from a cross-section of government departments and the private sector who had not previously been aware of how AIDS impacted their operations. The many questions asked during the AIM presentations also catalyzed NASCOP to find appropriate answers. These were included in a new section in the 1996 edition of AIDS in Kenya: Background, Projections, Impact, Interventions (NASCOP, 1996). AIM presentations contributed immensely to the development and finalization of the first (policy) sessional paper on HIV/AIDS in Kenya. The AIM approach worked in providing reliable official information and stimulating discussions for policy development and implementation. Its contribution to making policymakers more knowledgeable is evidenced by the many public statements on AIDS being made by leaders, increased media reports on AIDS, increased inquiries about AIDS to NASCOP, and debates and questions in the national assembly. AIM's dissemination to policymakers contributed to the active, informed participation of leaders in the consensus workshops on HIV/AIDS which were an important preliminary step to developing the Sessional Paper. Country Office Assessment The activity was both effective and cost effective, largely because of the collaboration between NASCOP and the Provincial Commissioners. The latter used their influence to ensure the attendance of influential local leaders. The provincial and district administrations also contributed to transport and meeting costs, which strengthened their commitment to a successful outcome. The AIM methodology has potential for even wider use. In the end-of-project report, the NASCOP epidemiologist recommended that an advocacy group in the Office of the President and key ministries should be formed to lobby for a brief presentation to the President, Cabinet, and the National Assembly; that presentations should be made to religious organizations; and that a simpler AIM presentation should be developed in English and Swahili to address youth in and out-of-school. In addition, though AIM can now be accessed at the Kenya AIDS NGOs Consortium, it would be useful to explore ways to make it available at colleges, schools, and institutions for professional training, including non-medical institutions. Process Indicator Summary
Rural HIV/STD Sentinel Surveillance FCO 40475, 57477, 57482
Background The three activities noted above all supported the addition of a rural surveillance component to the national Kenya HIV Sentinel Surveillance system and are therefore discussed together in the following section of the report. The first rural HIV Sentinel Surveillance was carried out in six sites in Kenya in 1994, supported by funding from AIDSCAP through the Rapid Response Fund. That study extended the existing sentinel surveillance system, which had been carried out annually at 13 urban sites, to six "rural" sites, namely Chulaimbo, Mbase, Morisot, Karurumo, Maragua, and Tiwi. In July 1995, a Letter of Agreement was signed with the National AIDS/STD Control Programme, to repeat the surveillance activity at the same six sites for the 1995 survey. The agreement covered training the sentinel surveillance officers, collecting serum samples, on-site supervision, data analysis and preparation of the sentinel surveillance report. Supplies, including HIV testing kits, needles, syringes, gloves, and specimen containers were procured by WHO/GPA Kenya. Samples were transported to the Provincial/District laboratories bi-weekly for screening. The following year, the sites were further expanded. It had been discovered in 1995 that some areas which were considered rural in 1994, had actually grown to peri-urban centers. Five additional sites were therefore selected, to represent a rural population. These were: Bamba Health Centre (Kilifi District), Kaplong Mission Hospital (Kericho), Mbita Health Centre (Suba), Njabini Health Centre (Nyandarua), and Motomo Mission Hospital (Kitui). As in the previous year, the Letter of Agreement supported training of the sentinel site officers, on-site supervision, and data analysis. Supplies were provided by the STI World Bank-funded Project. Accomplishments Surveillance activities were completed for each year, though it took longer than predicted to complete the sampling exercise in 1995, mainly owing to logistics problems caused by an irregular and inadequate supply of HIV screening kits coupled with the doctors' strike in Kenya. Though STD data was also collected in 1994 and 1995, the sample size was too small and therefore not analyzed. In 1994 and 1995, a six-day workshop was held for 30 participants, including nurses, clinical officers, medical records officers, laboratory technologists, and pathologists from the six sites. Training was given by a core staff from the Ministry of Health and the Kenya Medical Research Institute, and covered the principles of surveillance, the practice of sampling, and use of test kits. In 1996, a similar training was given to a total of 44 sentinel site officers (from the 11 sites) in data collection at the clinic level and supervision of the surveillance process. Two supervision visits during each annual rural surveillance were made to the sites by a NASCOP team. The 1995 data was incorporated into the 1996 surveillance report AIDS in Kenya: Background, Projections, Impact, Interventions (NASCOP, 1996). Publication of the 1996 data is pending. Lessons Learned Assumptions may not be correct. There is need to validate them with actual study. Prior to 1994 all the HIV/STDs sentinel surveillance sites were located in the urban centers with no rural population representation. Rural HIV prevalence was assumed to be between 1/2 and 2/3 (0.58) of the urban rate. Data collected from the rural sites (1994-1996) showed that there are rural areas in Kenya with HIV prevalence higher than some urban centers. Seroprevalence rates in ante-natal clinics attendees in rural and peri-urban sites indicate that there has been a dramatic rise in HIV prevalence in those areas. Sero-prevalence rates in ante-natal clinic attendees in rural and peri-urban sites from 1994 - 1995 show the following trends:
Some changes may be attributed to enlarged access to rural areas through new roads, new markets or new airports. Focus group discussions and discussions with opinion leaders in high prevalence areas revealed that some men believe that women in urban areas are more infected and may be seeking rural partners. Further studies are needed to understand these changes in sero-prevalence rates. Prevention efforts targeting the rural population should therefore be intensified as most prevention activities have in the past targeted urban and high-risk populations. Other population samples apart from ante-natal clinic attenders should also be identified, for example, malaria patients in rural areas, armed forces recruits, and college students. Conducting sentinel surveillance is expensive because there is need for regular training, supervision and other logistic support. Surveillance needs to be conducted at regular intervals over time to determine trends. This necessitates long term planning, budgeting, resource allocation and sustainability. Staff , who are likely to move, need training and updating and should be supervised on site. It is imperative that other donors supporting the surveillance system be well coordinated to ensure that the logistic support (syphilis, HIV kits, needles, syringes, etc.) are available before any training or supervision is conducted. AIDSCAP's contractual obligations meant that they could not procure HIV kits and other supplies. WHO, the STI project and UNAIDS therefore were requested to provide logistical support. However, it was difficult to coordinate the timing of inputs from all three donors, which led to some delays in finalizing the annual surveillance studies. Adequate supplies should be procured for the entire exercise and distributed to the sites before sampling begins. Surveillance data is a very strong tool in policy development. There is a very high demand for reliable epidemiological and other factual information. The data which was obtained through sentinel surveillance was used as a basis for developing the AIDS Impact Model slide and computer presentations for policy makers, and thus influencing policy. Recommendations
Country Office Assessment The findings of the rural surveillance confirmed that the epidemic now affects both urban and rural areas and, unexpectedly, indicated that some rural sites have a higher prevalence than urban sites. It is noteworthy that AIDSCAP was asked to fund this activity in the interim period between the closedown of WHO/GPA support and the start of funding through the World Bank loan to the GOK for the STI Project. The important data gained from the rural surveillance indicate the value of providing such interim support and therefore of reserving some unassigned funding resources in a long-term program (in addition to the Rapid Response Funds) than can be used to respond to new situations. As noted above, the data indicates the need to target future prevention interventions to the rural populations, in particular young women at risk. Process Indicator Summary: 1995 Rural HIV/STD Sentinel Surveillance
Process Indicator Summary:1996 Rural HIV/STD Sentinel Surveillance
Private Sector AIDS Policy (PSAP) Needs Assessment in Kenya FCO 25466
Background African policy makers realize that HIV/AIDS is becoming a major obstacle to social and economic development in their countries and that greater attention and resources must be devoted to the prevention of the spread of HIV/AIDS. With increasing demand on scarce public resources and recognition that the workplace provides a good environment for HIV/AIDS prevention and education activities, policy makers and prevention experts believe that the private sector must be brought into the HIV/AIDS prevention effort. It is anticipated that this increased private sector involvement in HIV/AIDS prevention will complement existing national resources while contributing towards greater integration of AIDS prevention into national development plans. USAID/Washington's Bureau for Africa, Office of Sustainable Development (AFR/SD) contracted AIDSCAP's to develop a Private Sector AIDS Policy (PSAP) tool. The aim of PSAP is to provide managers and workers' groups with information and guidelines that will help them decide to support/implement appropriate HIV/AIDS policies and prevention programs in the workplace. In order to develop the PSAP manual, a needs assessment was carried out in companies in Kenya, Senegal and Western Africa, and Botswana and Southern Africa. Health Economics and Development Research Associates (HEDRA) was contracted to carry out the study in Kenya. Objectives The specific objectives of the needs assessment were to identify:
The assessment sought information in two main areas: the attitudes and practices of employers towards HIV/AIDS prevention, which was obtained through in-depth interviews with management; and the knowledge and attitudes of workers and workers' representatives about HIV/AIDS, obtained through focus group discussions. Workers were also asked to assess the company health services. Financial information on several companies was also collected. Nineteen companies or labor organizations participated in the study. All were required to have more than 50 employees. The companies covered a range of business interests and types, as follows: industrial/manufacturing (3), garment/textiles (1), plantations and food processing (6), tourism (1), transport (2), service (2), motor vehicle import and maintenance (1), wood processing (1) and trade unions (2). Ownership of the companies varied between international ownership, joint ownership by Kenyans and non Kenyans and local ownership. All 17 companies are members of the Kenya Federation of Employers, and the participating trade unions are affiliated to the Central Organization of Trade Unions in Kenya (COTU). Findings Although workers had been exposed to massive information about HIV/AIDS, it was evident that their knowledge of the disease was full of critical gaps and wild misconceptions. Of particular concern was their view of HIV/AIDS as an old illness that has been given a new scientific name and is being used as a new method of population control. The majority of workers were afraid of the disease, both because AIDS has no cure and because of the prevailing confusion over its modes of transmission. This fear of AIDS had forced a section of the workers to change their social way of life, particularly sex-related behavior. For instance, they had reduced the number of sex partners and had accepted condom use. HIV/AIDS had become an issue among workers and between workers and management. The workers not only often talked about the disease but were also on the lookout for those with HIV/AIDS symptoms. Similarly, the disease had brought changes in the interaction between workers and management. The workers already feared being victimized because of HIV/AIDS, even in cases of incomplete diagnosis. Altogether, although there had not been significant changes in workplace operations, worker-management relations had been subjected to various adjustments depending on the extent of suspicion and mistrust at the work place. While most workers readily used the on-site clinic, they were generally reluctant to go for STD treatment because of the hostility of the health workers and workers' fear of being exposed to the rest of the labor force. The workers were aware of the various types of interventions against HIV/AIDS infection such as prevention education and the use of protective devices such as the condom. Indeed, workers appreciated the initiative of managers who had started such programs in their organizations. However, there were serious doubts about the efficiency of the condom as a protective device. Besides, advocating condom use was generally seen as encouraging sexual immorality. Management in all the participating organizations were aware of the HIV/AIDS problem. Most managers expressed concern not only over their lives and the productivity of their company but also about the danger posed by HIV/AIDS infection to their employees and the general population. Most organizations had supported at least one kind of prevention education and/or prevention device. But although the organizations had taken an interest in the prevention of HIV/AIDS infection among the workers, a lot remained to be done in terms of the participation, scope and quality of the programs. In regards to medical benefits, most organizations had dealt with affected employees through their existing medical illness provisions. Recommendations Based on the needs assessment findings, HEDRA recommended the following considerations in producing materials for worksite HIV/AIDS interventions:
Information gained from the study was used to prepare the Private Sector AIDS Policy manual, Business Managing HIV/AIDS: A Resource for Businesses in Designing HIV/AIDS Prevention Policies and Programs, which is now available from AIDSCAP. |
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