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This report comprehensively summarizes the FHI/AIDSCAP program in Tanzania (1991-1997). The report includes a background and country context for the program, as well as an overview of the Tanzania AIDS Project, and a discussion of work undertaken to mobilize communities and strengthen capacity; support interventions and create an enabling environment; and conduct research and evaluation. Lessons learned from the program are also listed.
Table of Contents II. Background and Country Context III. The Tanzania AIDS Project: An Overview V. Supporting Interventions and Creating an Enabling Environment VII. Important Lessons Learned From TAP's Experience (See Below) VIII. Subproject Highlights A. NGO Cluster Projects VII. Important Lessons Learned From TAP's Experience Six broadly stated lessons learned can be drawn from the Tanzania AIDS Project's experience to date, which roughly parallel the main program components: (1) NGO coalition and capacity building; (2) improving the policy environment; (3) behavior change communication; (4) increasing access to and use of professional STI care; (5) condom distribution and promotion; and (6) project evaluation. Lesson One: Investing in coalitions of community-based NGOs is an effective way to mobilize community resources for STI/AIDS prevention and care, and holds significant promise for realizing technically, institutionally and, to some extent, financially sustainable projects. Sustainable STI/AIDS activities need to be rooted firmly in the communities that they are intended to serve. TAP learned that, when given appropriate support, community-based NGO coalitions represent mechanisms through which such activities can take root. Appropriate support -- both in quantitative and qualitative terms -- is key. NGOs entering into coalitions come with varying levels of technical and management sophistication, different program agendas, distinct organizational styles and personalities, and uneven degrees of commitment to the coalition's stated goals. The donor (or technical assistance) agency's essential role is to assist, not direct, the coalition in funneling the organizational diversity of its membership into collaborative and complementary systems. The task demands maneuvering between continual monitoring and advising while maintaining sufficient distance for decisions and actions to emerge from and belong to the NGO clusters. Appropriate support, implies that donor agency involvement is at once intensive and at once hands-off. The TAP team conceptualizes this approach as facilitative supervision. In the place of unidirectional supervision, monitoring and evaluation from TAP over the clusters, it entails instead a consultative process that brings out the knowledge, skills, perceptions, and solutions of the NGOs themselves. Likewise, training and inter-cluster meetings are conducted in partnership, listening to and learning from each other. In this manner, confidence and capacity are built from within, and not as a result of something external to, the NGO clusters. This process is one of empowerment, and sets the stage for long-term sustainability. It is worth noting some of the characteristics that have contributed to the initial success of the NGO cluster endeavor. Most importantly, the over-arching vision of the project as community focused remained clear, consistent, and shared by core TAP staff. To reinforce this vision and the strategic approach, the same principles of consultative management used with the NGO clusters were applied to TAP staff as well. In terms of daily management, regular and frequent meetings allowed the members of the TAP team to stay appraised of the issues in the clusters as they emerge. Further, these meetings constitute a forum through which the team can collectively strategize about the approach that TAP should adopt vis-à-vis the clusters with regard to particular issues and events. In this way, different TAP staff encounters with the clusters had a unifying effect. Also, as east African nationals, TAP team members understand the socio-cultural milieu of their community-based partners. This perspective helps TAP staff communicate effectively with colleagues from partner NGOs transparently and persuasively without dominating. Lesson Two: Policy initiatives should be approached both from the most grounded level of local communities to the highest level of official national commitment. The notion that developing policy is not the sole prerogative of governments is fundamental to TAP's overall policy enhancement approach. Effective policies are considered to be manifestations of the total community's will to address issues that affect its various members' lives. Guided by this essential principle, the TAP project adopted a policy enhancement strategy that engages individuals and groups at all levels, from the community to the highest national level. The role of TAP and its implementing partners, working at these multiple and cross-cutting levels, remains primarily one of sensitization, ensuring that policy makers and community influentials are adequately educated about HIV and other STIs so that they may take informed and meaningful action. TAP's project support unit, in collaboration with the NACP, works to shape Tanzania's highest level STI/AIDS policy and to promote effective media coverage of related topics. Paralleling these national efforts, the intervention projects seek to mobilize specific social sectors and to facilitate concrete institutional and community initiatives that contribute to prevention and improved care. Whereas worksite projects enlist the support of the business community, the cluster projects tap into social and political institutions. Although the Iringa cluster stands out in this regard, all of TAP's cluster projects have, raised awareness among regional and local officials of STI/AIDS as a priority social and health issue. Cognizant of the dimensions HIV/AIDS, leaders representing all levels -- from regional commissioners, to ward development committees, to village councils -- have supported or initiated community actions that aim to reduce high risk situations or to alleviate suffering associated with AIDS. Religious groups are also important partners in TAP's cluster projects. By establishing its own coalition to promote a unified stance, the religious community in Dodoma demonstrated a commitment to effective HIV/AIDS interventions, including its position in support of condom promotion. Traditional healers and birth attendants are other key collaborators in most of the NGO clusters. In some regions -- especially in Tanga, Kilimanjaro, Arusha, and Iringa -- these community-based health providers have begun to form loose organizations to better collaborate with each other and with the biomedical community and to institute informal policies for making traditional procedures safer both for themselves and their patients (e.g., TBAs requiring expectant mothers to provide rubber gloves). Community policy initiatives emerge from concerned populations themselves and are immediately relevant to local circumstances, and acceptable to communities and their leaders. By creating a favorable overall policy environment, national-level efforts complement and reinforce local initiatives. Lesson Three: Behavior change communication initiatives that emerge from and are based in communities are culturally relevant, and have great potential for influencing individuals' decisions and behaviors. Because risk of STI/AIDS, unlike most individual health risks, implies intimate interaction between at least two individuals, changing behaviors to reduce sexual risk poses a particularly difficult challenge for health educators. Sexual networking and behavioral patterns are shaped by larger socio-cultural and economic forces. While socio-cultural norms and expectations underlie sexual debut, negotiation, and decision making, particular economic circumstances lead to differential rates of high risk behaviors in individuals and in whole communities. In seeking to modify sexual behaviors, therefore, health educators need to consider the complex context of negotiated partnerships, socio-cultural norms, and economic stressors, all of which influence sexual decision making and risk taking. The implication for behavior change communication strategies is clear: in order for BCC to be relevant, sexual behavior needs to be approached as a social phenomenon as much as it is approached as a matter of individual choice. It is in this sense, TAP learned, that community-based behavior change communication is essential. Communication themes need to reflect actual situations commonly encountered in particular populations. Behavior modeling for sexual risk reduction also needs to be community specific, offering individuals realistic and culturally appropriate behavioral alternatives. To this end, behavior change communication messages and strategies must be conceived and positioned from within target communities, rather than introduced by outside health education programs. Community drama in TAP's cluster projects was especially effective in this regard. While other educational vehicles, such as video shows, are undoubtedly useful, as outside productions, they lack local specificity, and cannot capture and convey shared community experiences in the same way that local drama can. Printed educational materials similarly, while potentially informative and educational, cannot accommodate the range of individual experiences and needs as is possible in personalized peer education and counseling. The critical point is that community-based education and behavior change communication is sensitive to the unique social grounding of individuals' sexual experiences and behaviors, and as such, represent a significant potential for influencing sexual behaviors. Peer educators, counselors, theater and cultural groups are, therefore, irreplaceable community resources for STI/AIDS interventions. Empowering communities to recognize and effectively utilize their own varied human resources should remain a priority in behavior change communication programming. Lesson Four: Increasing access to and use of high quality STI care remains a significant challenge that demands more attention from policy makers, program planners, and program implementers. While research implicating STI infection in increasing the probability of HIV transmission is conclusive, an affordable STI control strategy that is effective in all major risk groups remains elusive. In Tanzania, asymptomatic infection, (especially in women), inadequate clinical and laboratory diagnostic capacity, lack and high cost of effective drugs, and inappropriate treatment seeking, including frequent self-medication with antibiotics, all contribute to the difficulty of controlling STIs. Despite considerable overall progress, in this initial TAP phase it has become apparent that STI policy and programming to date are insufficient. To start, training in syndrome management needs to be expanded to include auxiliary health workers, namely nurses and pharmacists, who are the point of first encounter for many STI patients. The concern that such training may represent official support for indiscriminate provision of STI care needs to be balanced by consideration of the widespread practice of self-medication. Both government policy and program planners need to acknowledge and respond to this reality by improving diagnostic and treatment skills of these front line care providers or, by educating them on the need for prompt patient referral to upgraded STI facilities. At the same time, it is important to recognize that syndromic case management is not a "magic bullet." Inadequacy of syndromic screening strategies for female patients is demonstrated in TAP's study with women attending family planning clinics. A program emphasis on syndromic management, therefore, should not be promoted to the exclusion of other components of STI control including syphilis screening and treatment, partner management, and targeted services to high risk groups. And finally, programming needs to be better informed by understanding local variability in illness perceptions and treatment behaviors, both in patients and popular sector care providers. TAP's focused ethnography in Morogoro provides critical insight into the nature and complexity of STI care that occurs outside the official medical domain, and may inform the development of rapid assessment tools for use in other intervention sites. Lesson Five: The conceptual separation of condom social marketing from behavior change communication leads to undue emphasis on promoting the material product (or brand name) of condoms over the behavior of consistent condom use. Inadequate integration of condom social marketing into the overall behavior change communication strategy is a programmatic weakness of the TAP project. Although conceived as an integrated part of TAP's central support functions, PSI's condom social marketing activities have only moderately intersected TAP's other promotional and educational initiatives. The problem stems from different approaches to increase knowledge about and use of condoms. While TAP's behavior change communication unit stresses educational messages that promote alternative behavioral choices for reducing sexual risk, including condom use, the PSI strategy focuses on condom marketing plans that increase brand name visibility and condom sales. PSI in collaboration with TAP partners made enormous contributions in making condoms more widely available and easily identifiable through brand name promotion. However, in the next phase, TAP and PSI need to develop more collaborative, intersecting strategies so that brand recognition schemes can effectively complement more involved behavior change communication efforts. Condom promotion campaigns must be integrally linked to STI/AIDS and sexual risk reduction education. Associating a brand name with condoms should facilitate promotion of sustained condom use. An enduring conceptual bond must be created between condom social marketing and behavior change communication that is nurtured in a similar way that philosophical and other organizational differences were bridged among cluster members. Lesson Six: Program evaluation methods and emphases to date fail to capture the real significance of both the process and the outcomes of the Tanzania AIDS Project. In line with AIDSCAP's overall strategy for evaluating country programs, the Tanzania AIDS Project evaluation consisted primarily of: (1) compiling process indicator data, which documents accomplishment of project outputs in terms of numbers of people trained, people educated, materials distributed, and condoms sold; (2) conducting survey research to ascertain reported changes in target population members' knowledge, attitudes, beliefs, and practices related to HIV and other STIs; and (3) conducting qualitative research, including focus group discussions, a rapid ethnographic study, and capacity building assessments. Through continual interaction with NGO partners and target communities, however, TAP learned that this evaluation approach inadequately conveys the significance of the program's accomplishments. While behavioral indicator data are certainly necessary to track changes over the long term, particularly among target groups exposed to intensive interventions, the process of operationalizing highly complex conceptual variables -- such as capacity building, institutional and community empowerment, and changing social norms -- requires different methodologies and instruments, and larger budgets. Much qualitative data has been collected under TAP but not analyzed, and the lack of these potentially rich data in this report is unfortunate. Data collected but either not transcribed or transcribed but not analyzed includes the 28 focus groups conducted in 1996 to complement the 4-region KAPB study, the rapid organizational assessment of capacity building, and the Behavior Change Communication Unit's Experiences from the Field/Lessons Learned. These data at least should be available to inform design of future targeted interventions. Interpreting the process data poses similar problems. The number of supervisory and monitoring visits certainly indicate, for example, interaction between TAP and NGO partners, but in the absence of richer descriptive data and analysis on the nature, context, and content of the interaction, a meaningful evaluation of the supervisory process is impossible. Similarly, the information that x theater performances, viewed by x audience members, may in itself be impressive. But to appreciate fully the process of educating target populations through popular theater, more substantive information on the quality of the encounter between performers and audience is necessary. How performance themes relate to community experiences, how audience members are engaged in and affected by the performance, and how their reactions are used in post-performance discussion and educational sessions might be relevant information in this regard. And, as a final example, knowing whether condoms were distributed as part of a wholesale transaction with a pharmaceutical distributor, handed out free at a popular event, or solicited from community-based educators by target audience members, provides much more information about the quality of the intervention -- the process of promoting condom use -- than simply knowing the total number of condoms distributed. The essential point is that not all program implementation processes are equal or comparable. Process indicator data is only one piece of a comprehensive process evaluation. Similarly, quantitative indicator data from KABP surveys provides only one aspect of behavioral responses to the epidemic. Accurate interpretation of indicator data requires contextual description and analysis for a comprehensive evaluation of program outcomes. Many meaningful and community-specific program outcomes are not captured by standardized survey modules. Formal program evaluation needs to include an analysis of the nature, degree, and impact of improved NGO capacity to effectively manage daily financial and administrative affairs, to self-assess and to constructively critique and learn from peers, and to operationalize complex concepts into programmatic action. Institutional and community empowerment to influence local policy and social norms is difficult to assess and requires scarce resources that reduce funding available for direct interventions. Unique community initiatives and achievements -- e.g., introduction, after some resistance, of a sex education curriculum for Kilimanjaro schools; mobilization of traditional birth attendants in Dodoma who, as a group, began requiring expectant mothers to provide rubber gloves, and working with local authorities to ensure sufficient availability of gloves; community pressure in Iringa that resulted in specific regulations to discourage high risk behavior patterns -- cannot be explored in depth nor systematically addressed by standardized behavioral surveys. The challenge remains to implement cost effective methods for determining interventions' significance for and impact on individual communities. In the interest of cross-program and -country uniformity and comparability, standardized evaluation plans have tended to be delivered to AIDSCAP projects rather than developed with them so as to suit the particular informational needs of each project and country program. The primary stakeholders at the level of project implementation have, consequently, been insufficiently engaged in conceptualizing evaluation plans or even in conducting the evaluation process, which for them, was performed more as a task to meet AIDSCAP's contractual requirements than used as a tool for themselves to continually assess and improve project activities. Clearly, standardized, reliable, and quantitative behavioral data are critical for program evaluation. The TAP experience, however, underscores the need for an enriched evaluation approach in which particularity complements standardization, validity is given equal consideration to reliability, and qualitative description and interpretation are emphasized in a similar manner as quantification. |
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