This report comprehensively summarizes the FHI/AIDSCAP program in Rwanda (1993-1997). The report includes a discussion of background and context, as well as accomplishments, constraints, implementation and management issues, outcomes, and lessons learned and recommendations for each of two components.
Table of Contents
Executive Summary
I. Country Program Description
A. Introduction
B. Country Context
C. Accomplishments and Outcomes
D. Implementation and Management Issues
II. Lessons Learned and Recommendations (See Below)
III. Refugee Intervention in Tanzania
IV. Subproject Highlights
V. Attachments
Glossary of Acronyms
II. Lessons Learned and Recommendations
The lessons learned by each individual subproject can be found in the subproject highlights section of this report. This section will repeat some of the lessons described in those sections either because of their particularly important programming implications or because of their commonality to more than one subproject. It should be noted that it was often difficult to decide into which category a lesson should be classified, because there are often implications for more than one strategy -- a lesson learned as part of a peer education project may also be applicable to condom programming, for example.
A. Overall Program
- Coordination between Implementing Agencies can save time and money, can encourage feelings of partnership and of having a common goal. The subprojects benefited greatly from each other. PSI was able to expand its reach and subsequently its condom sales at the community level by working with CARE's network of peer educators and the Gitarama Health Region's network of community health workers. In the absence of a program-wide KABP (canceled due to war), it was possible to share research information, and all of the implementing partners benefited from the research conducted by others. The research done by individual IA's was frequently mentioned in the reports of other agencies as inputs to their program and message development. The good relationship which existed between personnel at the regional health offices and CIDC staff facilitated work immensely; through the MEDIRESA's office, CIDC was able to provide IEC materials to community health workers who would then distribute materials in their constituencies after having been sensitized by CIDC.
Recommendation: Future programs should encourage continued information-sharing and teamwork from the beginning and should organize regular meetings between IA's. While it may be more difficult logistically to do this with a larger program working with more IA's, it becomes even more important to systematically encourage this "cross-fertilization" as it becomes less likely to happen spontaneously.
- Supervision is essential to program effectiveness. Whether a program has a focus on STI management, BCC/IEC, or condoms, regular supervision promotes better performance. Due to the limited resources the MOH and other implementers face, if at all possible, supervision should be done from a decentralized level. In the Rwanda case, this is the health region (or région sanitaire). Providing support at this level can also lower costs and increase coverage.
Recommendation: Future programs should budget for regular supervisory visits to subproject sites into program activities. Regular visits should be made not only by IA staff but also by FHI staff.
- Training should be done on a continuous basis. This lesson was mentioned by the PNLS, RPA, CARE, PSI and the Gitarama Health Region staff. Regular training, even if short term in duration, provides opportunities for networking, learning new skills, and it motivates people and helps reduce feelings of professional isolation.
Recommendation: Since local training is inexpensive and since it can go a long way in motivating people, future interventions should emphasize training and retraining by local trainers.
- Peer education is an approach that was found to be acceptable by the two target groups with whom it is was implemented. Both the CARE and Armed Forces projects used peer education approaches. Evaluations of both interventions found the approach to be acceptable to the target audiences and also provided a channel for condom distribution, both free and for sale. However, peer education programs tend to be labor intensive and peer educators need constant reinforcement in order to be motivated over a significant period of time.
Recommendation: In future, a greater attempt should be made to link STI management projects to networks of peer educators, even if they are not part of the same project or funded by the same source. This would encourage Peer Educators to encourage their "peers" to seek STI treatment when appropriate and could potentially decrease the number of untreated STIs.
- An important lesson learned during the CARE subproject's implementation is that voluntarism, although strong in Rwanda, is not something to be relied upon indefinitely for community-based development projects. While the level of enthusiasm and commitment was high among most of CARE's 303 volunteer Peer Educators, there were signs that some of Peer Educators would like to receive more recognition (financial or otherwise) for their contributions. CARE provided a radio to each Peer Educator as a reward for their work. This gift was extremely well received by the Peer Educators. However, it underscores the need to identify future non-financial incentives -- such as bicycles, umbrellas or rubber boots.
Recommendation: Incorporate a system of non-monetary incentives for volunteers.
- It is important to maintain high quality in all types of training, peer education and other. With more participatory IEC messages and materials focusing on attitudinal change as a precursor to changing high-risk sexual behavior, the Peer Educators will have more tools at their disposal to diversify the peer education sessions. It was observed by CARE that some Peer Educators began to show signs of boredom repeating the same educational messages in the same fashion during each peer education session. This boredom disappeared immediately when the IEC Team began showing their new video and distributing the new comic book to adolescent Peer Educators and target groups. In addition, CARE observed that the confidence of some of the Peer Educators needs to be increased to handle some of the more difficult questions about human sexuality and family planning that inevitably arise during and after the peer education sessions.
Recommendation: A great deal of attention should be paid to introducing new and innovative ideas to trainees and to refrain from repeating the same messages over and over. Peer Educators should meet regularly to discuss problems, find solutions to common problems, and learn from each other on how to address difficult questions.
- All of the NGOs receiving support from the RRF were somehow affiliated to the Catholic Church. This affiliation did not, in most cases, discourage them from including condom promotion as part of their package of interventions. Three of the four organizations specifically mentioned condoms as an important element of their prevention activities.
Recommendation: Given the importance of the Catholic Church in Rwanda (90% of the population is Catholic) and its reach through its health and other facilities, efforts should be made to create additional partnerships with the Church. It should not be automatically assumed that they object to condom programming although this may be true in some cases.
B. Condom Programming
- Low- income Rwandans are willing and, for the most part able, to pay 20 FRw. (7 US cents) for a 4-pack of condoms, but continued donor subsidization of condoms is critical and will remain so until there is significant improvement in the socioeconomic well-being of Rwandans.
Recommendation: Continue support for subsidized condoms.
- Community-based condom distribution (independent sales agents who sell within their communities, to friends and neighbors) is necessary to complement commercial sector distribution. In light of Rwanda's limited distribution network, community-based distribution is the only way to maximize reach.
Recommendation: Continue expanding a community-based network. As much as possible use the existing networks of the MOH, other ministries, and NGOs.
- Social marketing of condoms in Rwanda works well. Social marketing is an extremely effective tool in promoting behavior change and condom use, particularly in a post-disaster environment where "private" retailers must continue to sell their products to survive.
Recommendation: Every effort should be made to sustain current levels of donor subsidies until such time as the AIDS epidemic is under control or the Rwandan population has the financial resources to cover its own preventive health care needs at "for profit prices". To reduce the costs of these subsidies, condom social marketing programs should add cost-sharing or revenue-producing products to their line in order to reduce the per unit costs of the AIDS prevention component.
- While condom use is on the increase in Rwanda, regular condom use is restricted to casual partners.
Recommendation: Continue to complement brand promotion with IEC aimed to improve the image of the condom for use within stable relationships as well as to encourage consistent use in all non-regular relationships as well.
C. BCC/IEC
- Although we know that CIDC's materials were based on formative research, were pre-tested for comprehension and acceptability, were qualitatively evaluated to have achieved reach, and its messages were correctly understood and recalled by samples of the target audiences, we do not have any evidence or indication that that the materials contributed to attitude or behavior change.
Recommendation: Future projects involving IEC/BCC materials should integrate ways of measuring whether materials developed as part of an intervention in any way contributed to attitude or behavior change. While any such measurement is likely to be imperfect, it could nonetheless help project planners and implementers in assessing the impact of their programs and provide valuable information about which messages or materials need to be changed, eliminated from the program, used more widely, etc. include ways to measure, even in a rough way, whether materials contributed to attitude or behavior change. Possibilities include small surveys of patients presenting at health clinics with STIs. Questions could be asked about what motivated them to attend. Peer educators could hand out referral slips with materials, and a count of these could be made at clinics. While the methodology would have to be worked out, the attempt should be made.
- Message development has not kept up with the needs of those at risk. Materials still seem to repeat basic facts and spend too much time on the unlikely and relatively rare methods of transmission such as being infected by unclean cutting objects. This has a tendency to encourage people to avoid assessing their personal risk and becoming fatalistic as they may succumb to the human tendency of avoiding thoughts about unpleasant scenarios. It is easier to be fatalistic and to avoid taking positive action if you can assume that even if you change your behavior, you can still be infected by other means. It is important to "stay on message": unprotected sexual intercourse is the single most important mode of HIV transmission and changes in behavior are required to avoid infection.
Recommendation: Materials motivating action, personal risk assessment, and creating a sense of personal control should take priority in the future: "go to the clinic for an STI checkup", "wear a condom to protect yourself", etc. The FGDs and KABPs conducted by the IAs should be reviewed and carefully studied to develop new approaches. They contain a wealth of information, and with some creativity, could be used to develop messages that move away from the often negative and fear messages typifying programs in Rwanda and elsewhere.
- A person clearly at risk, even when mastering "the facts", remains unable to relate the risks to their own behavior. This point came out clearly in the PSI, CARE, CIDC and Armed Forces interventions. People described behaviors that clearly put them at risk of HIV/AIDS, but consistently underestimated their actual risk.
Recommendation: Personal risk assessment skills should be a priority of future BCC interventions. These risk assessment skills should be accompanied by the development of skills in how to reduce risk.
- To be effective, "peer educators" must be true peers of those they educate.. In the armed forces project, for example, educators were chosen mainly from the medical corps, making it possible for the ordinary soldier to wonder whether the information being passed on is truly coming from persons like themselves.
Recommendation: Peer educators should be selected from a variety and all levels within target groups in order to maximize the impact of true peers, and to avoid community members identifying one particular group with STI/HIV/AIDS.
- In a post-war or post-tragedy environment, it is important to use positive messages. PSI's strong sales record is believed to be partly due to the positive messages used in its campaign.
Recommendation: Use positive messages that promote empowerment and life-affirming action rather than fear-based appeals.
- There is a poor understanding by the study population of the essentials of the female and male anatomy and of human reproduction, making it difficult to understand AIDS prevention messages. If there is uncertainty regarding how a condom can prevent conception, then surely there is uncertainty regarding how a condom can prevent the transmission of an invisible virus. There is also little recognition of the difference between "normal" and "abnormal" reproductive health (i.e., the absence versus the presence of reproductive tract infections, or RTIs). Furthermore, the signs and symptoms of STIs are not widely recognized.
Recommendation: Future AIDS prevention activities particularly in rural settings of Rwanda, should broaden their focus to include a reproductive health component In future peer education and other IEC/STI interventions, basic information on reproductive health should be included.
- Radio and community meetings are potentially effective channels for the communication of messages to rural audiences, as brought to light by the CIDC study on appropriate communication channels.
Recommendation: Future projects should budget more funds for radio time and include more community-based meetings and informal chats using peers, community leaders and outreach volunteers. (Such as the community-project piloted by CIDC with elected women leaders, and the programs implemented by local NGOs throughout the Rapid Response Fund program.)
D. STI Management
- The introduction of the syndromic approach for STI management was more effective with close supervision and management. The evaluation of the STI components of three STI subprojects found much better acceptance of the syndromic approach and much higher rates of correct management at the subproject where supervision was more intense and where both monitoring and training were managed by the regional health authorities. The Gitarama subproject showed that the syndromic approach can be effectively used in Rwanda, particularly with close and intense supervision. Furthermore with proper training and continued supervision clinical staff will adopt the syndromic approach and come to believe in it.
Recommendation: STI case management should be undertaken using a decentralized approach, where close supervision and monitoring is more efficient and cost-effective. Central level involvement should be limited to policy-making, guidelines formulation, and overall program monitoring. The syndromic approach should be introduced countrywide.
- The modified method of collecting WHO indicators PI6 and PI7 is appropriate, cost-effective, and reliable. The method devised and used to evaluate the STI components of the AIDSCAP/Rwanda project has the potential for sustainability and provides the reliable information required.
Recommendation: Incorporate this evaluation technique into future programs
E. Target Groups
- Standard messages and interventions are not as effective in the unusual realities of postwar Rwanda, with a demographic balance unlike any other country, where the sex ratios are 60 to 40 in favor of women, an estimated 200,000 of them widows. This combined with poverty and a desire to have more children make women the most vulnerable group in Rwanda for STI and HIV infection.
Recommendation: Communication in this environment calls for originality, a willingness to try new approaches, and a need to be truly innovative in program and message development. Women need to be addressed with innovative messages through creative channels and empowered to effectively negotiate condom use with their partners. Health-seeking behavior should also be addressed and the desire of widows to have children should be carefully balanced with their need to protect themselves from unwanted reproductive tract diseases and infertility.
- Effective AIDS prevention interventions must target men as well as women. Although the most vulnerable target groups in Rwanda are obviously single, widowed and married women between the ages of 15 and 35 -- due in part to their lack of power in condom negotiation -- future project activities can not ignore the role that adolescent and adult males play in the spread of STIs and HIV. While project activities should continue to include single and married women, formative research should continue with adolescent and adult males to develop IEC messages targeted specifically to males.
Recommendation: Because of the influence that men and boys' behavior and attitudes have on women's vulnerability, women should continue to be targeted on a priority basis and empowered with the necessary skills to protect themselves, but at the same time, more men need to be involved in interventions and reached with specific messages to protect themselves as well as their partners.
F. Management
- Effective program implementation and management requires a solid understanding of contract terms, conditions and reporting requirements. Supplying most documents in English does not facilitate or encourage contract compliance. Rwandan implementing partners mentioned this language problem as a barrier. Without access to French language documents, French speaking staff had to work without a satisfactory reference guide.
Recommendation: Program documents such as subagreements, LOAs, and PIFs should be translated into French in order to allow them to be used as the tools they were designed to be. Funds should be provided to the Country Office to translate working documents and tools into French, and where necessary into Kinyarwanda.
