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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 IV. Mobilizing Communities and Strengthening Capacity: Community- and Institution-Based Interventions (See Below) V. Supporting Interventions and Creating an Enabling Environment VII. Important Lessons Learned From TAP's Experience VIII. Subproject Highlights A. NGO Cluster Projects IV. Mobilizing Communities and Strengthening Capacity: Community- and Institution-Based Interventions A. Supporting Regional NGO Networks Rationale for NGO Coalitions: The "Cluster" Concept Support for regional NGO clusters is the programmatic centerpiece of the Tanzania AIDS Project. The objective of this critical component is to enable community-based organizations to mobilize local resources for STI/AIDS prevention and care, and gain the support and active participation of community authorities and gatekeepers in this effort. Several advantages of NGO coalition and capacity building can be highlighted. First, focusing on community-level NGO coalitions has the important advantage of rationalizing resource utilization. Collaborative programming between organizations limits redundancy and maximizes mutual exchange of experiences, skills, and resources. In 1994, TAP conducted a national organizational assessment to determine the scope and needs of NGOs interested in STI/AIDS programming. This assessment revealed that a wide variety of institutions were involved in various aspects of HIV/AIDS activities, ranging from small indigenous groups to internationally established development and health organizations. The NGOs tended to work vertically, thus duplicating each others' efforts in some areas while leaving critical program and service gaps in others. Valuable time and resources, which could have been applied to preventing HIV and helping Tanzanians cope with its consequences, were instead tied up in less constructive pursuits such as vying for funding or rivaling one another for access to target communities. The assessment revealed that fragmentation and competition prevailed over complementary planning and resource utilization. Despite the substantial talent and motivation that existed in individual NGOs, target communities did not benefit from the combined human and material resources that these organizations had to offer. Helping NGOs work together rather than at cross purposes is, therefore, the crux of TAP's cluster concept. Second, engaging a wide range and large number of local groups in partnerships produces a diversified, and integrated targeting strategy. Given that epidemics of STIs and AIDS in Tanzania are very advanced, such a strategy has the advantage of reaching multiple segments of the population. By August 1995, nine regional clusters -- in Arusha, Dar es Salaam, Dodoma, Iringa, Kilimanjaro, Morogoro, Shinyanga, Tabora, and Tanga -- with a combined participation of over 180 NGOs, began implementing TAP-supported activities. The TAP partners include groups with a variety of skills and experience including medical expertise, community and social development expertise, political and advocacy expertise. Some focus on specific target audiences, such as workers, parents, youth, churchgoers, traditional health providers, cultivators, and so on; others have a broader community focus. From a strictly targeting perspective, this kind of inclusiveness of a range of NGOs in the clusters is essential for the project to ultimately have a demonstrable impact in Tanzanian populations. This inclusiveness is important for a third, and perhaps the most significant, reason: the coalition and capacity building focus of TAP. It is through the diversity of partner NGOs that the cluster projects are able to tap into the different social spheres that together make up Tanzanian communities. Only with such broad-based, yet cohesive, community linkages can the ambitious concepts of "community mobilization" and ultimately "empowerment" be actualized. TAP's NGO cluster framework promotes local, community-based ownership of and responsibility for activities. Whereas AIDS interventions were once primarily the concerns of international health organizations and national governments, the TAP project has taken a determined step towards recasting AIDS prevention and care as the concern of affected communities. TAP is committed to the notion that sustainable programs come from within, not from outside, target populations. This necessitates intensive community involvement in programs from the start and implies a facilitative rather than a directive role for program donors. Support for NGO clusters is the programmatic manifestation of TAP's commitment to facilitating HIV/AIDS programs in Tanzania that will endure the eventual cessation of outside assistance. Cluster Formation, Organizational Structure, and Major Objectives Significant time and resources were devoted to facilitating the creation of cohesive teams of NGOs working in the nine priority regions.1 Steering committees, charged with the overall tasks of planning and monitoring the networks' activities, were established for each cluster by the participating NGOs themselves. To facilitate contractual agreement with and reporting requirements from FHI, the steering committees, in turn, selected a "coordinating" NGO, using financial and management capacity as the key selection criteria. The steering committees also designed medium-range plans in collaboration with TAP, and recruited and hired management teams. In consultation with the steering committees, these management teams -- composed of full-time project managers and support staff -- oversee daily operations of the project and implementation of planned activities. TAP provided substantial guidance and support to the clusters throughout this preliminary phase, and continues to do so as appropriate to the particular needs of each of the clusters. TAP's involvement has been facilitative and consultative, not directive. As incipient organizational units, the clusters have in this process been gradually empowered to find their own paths with regard to organizational as well as programmatic issues. Each cluster project comprises a full range of STI/AIDS interventions. During the first few years of project implementation, unique attributes, experiences, and challenges have emerged for all of them. Their programmatic emphases and expected outputs have, nevertheless, been similar during this phase, which can be summarized as follows:
The remainder of this section examines each of these major objectives separately and highlights the important achievements of and future directions for TAP's NGO cluster initiative. Strengthening Cluster Capacity Through Training, Supportive Supervision and Monitoring, and Inter-Cluster Exchange Strengthening the capacity of local partners to design, implement, and manage their own programs is the substance of TAP's NGO cluster initiative. Training in the conceptual and pragmatic dimensions of conducting community-based STI/AIDS prevention and care is, therefore, a starting point for achieving this goal. Toward this end, and to accelerate implementation of planned activities, TAP coordinated an intensive training program for key NGO personnel and selected government collaborators. A variety of management and technical areas were covered in participatory workshops, including: (1) project design, management, and accounting; (2) community-based IEC programming; (3) training and supervision of peer educators; (4) materials development; (5) home-based care and counseling; (6) STI/AIDS and gender issues; (7) income generating activities; (8) condom social marketing for community-based and peer educators; and (9) development of a manual for peer educators and counselors. Additionally, TAP supported training of health care providers from cluster areas in syndromic management of STIs (described in a later section on STI-specific programming) and sponsored attendance of selected NGO partner staff to regional STI/AIDS conferences in Africa. (Section V.A on TAP's Project Support Unit provides a brief description of each of the training areas listed above and Attachment B summarizes the number, kind, and attendance at TAP-supported trainings.) Building capacity, however, is a process in which training workshops (and "refresher" workshops) play only a part, albeit an important one. Developing and internalizing skills, and utilizing new skills in implementation of complex concepts or procedures -- all fundamental elements of capacity -- demands nurturing and continual attention. Hence, a very significant component of TAP's capacity building strategy is conducting regular and frequent participatory supervisory visits to the cluster projects. During these visits, TAP and NGO partner staff work together on all aspects of project management, implementation, monitoring, and evaluation. The spirit of these interactions is one of achieving a balance: On one hand, they are intended to provide NGOs critical guidance and to ensure that projects are technically and managerially sound and remain within the conceptual parameters of TAP's mandate, and on the other hand, TAP recommendations and guidance are carefully delivered so as to not interfere with the projects' self determination. This participatory approach to project oversight shifts the relationship of supervising donor over implementing recipient to one of full collaboration between partners who have a common vision and goal. Partnership fosters trust, and trust, in turn, fosters open dialogue and mutual critique. As a trusted partner, cluster receptivity to TAP's recommendations, training, and technical assistance is greatly enhanced. Over time, and through this continuous interplay between TAP and the clusters, NGO partners have come to better understand TAP's goals and expectations and TAP developed a keener appreciation for the diversity of existing skills and needs in the NGO clusters. Overall, the cluster projects have demonstrably improved practical skills and understanding of key issues related to STI/AIDS prevention and care. Although not readily quantifiable, the contributing role of collegial partnerships to building NGO capacity should not be underestimated. Learning by doing and learning from peers are other important aspects of NGO capacity strengthening. Regular steering committee meetings (representing the functioning arm of the cluster) and NGO member meetings (representing all participating NGOs in the cluster) are included as capacity building indicators in FHI subagreements with the clusters. While NGO member meetings allow coalition partners, as a representative body, to make decisions about cluster leadership and general strategic directions, steering committees meet to chart out specific plans of action and make decisions affecting project management and implementation. TAP stays abreast of issues and activities in the clusters in part from the minutes of these meetings. After two years into the project, organizational growth and programmatic successes of the individual cluster projects is clearly variable. Although most of the clusters have made notable achievements, some remain organizationally weak and continue to face significant challenges that obstruct effective coalition functioning. Seeing this variability as an opportunity for clusters to learn from each other, TAP coordinated inter-cluster meetings and, more recently, inter-cluster evaluation/study tours. This latter innovation has been particularly effective, and thus merits special mention here. It involves a process of bringing all project managers, steering committee chairs, and NACP coordinators from each cluster site together to collectively evaluate the activities of a selected cluster project. The selected cluster's (the evaluee's) organizational functioning, relationships with community and government collaborators, and intervention strategies and successes are examined through collective observation of cluster activities and through interviews with key regional and district authorities, persons in the targeted communities, and member NGOs in the coalition. A collective critique of the strengths, weaknesses, and needs of the cluster project follows. TAP's role remains one of facilitating the exchange. Difficult and sensitive issues are tackled in frank discussions, drawing out particular problems and experiences of each of the clusters, which are shared with the group for collective analysis and problem solving. As a final exercise, each cluster team, applying the lessons learned from collective observation and analysis, constructs a specific plan of action to improve functioning in their own regional projects. The TAP team is convinced that by helping clusters learn to effectively self-evaluate and to evaluate and learn from the work of others in a participatory and collective manner is a powerful approach to strengthening capacity. Policy Sensitization, Advocacy, and Intersectorial Collaboration Mobilizing communities to respond effectively to AIDS implies mobilizing policy influentials. To be enabling, policy leaders from all levels, and sectors, need to be actively engaged in prevention and survivor support efforts. The first step in engaging the active support of influential persons is making them aware of the issues and what is at stake for their constituencies. To this end, TAP assisted each of the clusters to sensitize local governmental authorities, religious and traditional leaders, and influential business people about the severe social, economic, and health consequences of HIV. Soliciting their leadership and material support for cluster activities was an important aspect of the sensitization workshops. A total of 668 leaders in NGO cluster sites participated in TAP's workshops. Sensitized leaders become instrumental leaders, paving the way for cluster activities, participating in media advocacy, and contributing resources (transportation, meeting space, materials, access to employees, etc.) for cluster events and training. In some clusters, sensitization as one-time workshop has been replaced with a system of continually orienting newcomers to the region. The outcome from such ongoing sensitization efforts is manifest in high moral and substantial material support for cluster interventions; the Iringa coalition project, in particular, stands out in this regard. Once sensitized and mobilized, regional and community leaders become AIDS program advocates, raising awareness vis-à-vis their peers and the general public. Special high visibility events that bring leaders together from varied social and political domains convey an especially compelling message. Participation in World AIDS Day 1996, the 13th and 14th annual International AIDS Candlelight Memorial and Mobilization, and an annual international trade fair in Dar es Salaam, have provided important advocacy opportunities for TAP's NGO cluster projects. In addition to prevention themes, these events are intended to raise awareness and increase compassion towards people living with AIDS. People infected with HIV are involved in many of the activities. To propagate messages to the broader surrounding population, special attention is also given to including local media in the events. Close collaboration between sectors and between decision makers at various levels is essential. When official policy makers, community leaders, and STI/AIDS program implementers collaborate and speak with one voice, full community involvement in and eventual ownership of the activities becomes possible. Integrated Behavior Change Interventions Channeling resources through NGO coalitions enhances the likelihood of achieving synthesis of the core technical strategies for prevention. Through collective planning and effort, program components in behavior change communication, condom distribution, and STI services upgrading converge in comprehensive interventions that offer multiple options for reducing sexual risk. TAP project support and social marketing units work to ensure that the behavior change options being promoted in NGO cluster interventions are possible, implying that: condoms are available, visible, and affordable; patients have access to expert STI care; and national-level policy is consistent with and supportive of the messages being delivered at the grass roots level. With all of these support pieces in place, the NGO clusters can focus on educating individuals, families, leaders and communities about STI/HIV risk and motivating individual behavioral and community-level change to reduce this risk. In this sense, communication and education are at the heart of the NGO clusters' community-based interventions. STI patient referral and condom promotion are intrinsic elements of the behavior change intervention strategy. Mobilizing locally available resources is a guiding principle of the clusters' behavior change communication activities, and utilization of human resources is emphasized. Interpersonal communication via peer and community-based educators, village health workers, traditional health providers, and clinic- and community-based counselors is central to all clusters. Local circumstances and resources give unique form to each cluster's interpersonal behavior change communication strategy. Where industry is prominent (agricultural estates, mining, and transportation), for example, workplace-based peer educators are important. Some clusters, have tapped into particularly strong youth organizations, while in others, traditional birth attendants and traditional healers are central to behavior change communication activities. Community-based theater and cultural groups represent other important human resources for cluster behavior change communication efforts. While cluster staff ensure that technical aspects of the messages delivered are accurate, the particular themes and content of educational performances are defined by the groups themselves and are community-specific. Wife inheritance may be perceived as a major problem in one area, while in another female prostitution and out-migration may be preoccupying themes. In community-based performances, basic STI/HIV information and education comes alive through stories and narratives that embrace the real and unique circumstances that shape community members' experiences and affect their lives. When the content of the communication is community-specific, appropriate behavior modeling becomes possible. Community-based IEC approaches, furthermore, accommodate culturally specific forms of expression. Nuance, humor, and emotion -- all critical for communicative exchange -- are expressed in vastly different ways in different languages and across cultures or even villages. Because community-based performances are generated from an insider perspective, they easily grasp the particular styles of communication that give extra meaning to mere words. Because the content and form of the communication make intrinsic sense to the audience, community-based performances prompt self-reflection and discussion. Such discussion is facilitated by health educators after each performance, thereby allowing audience members to probe for clarification or additional information pertinent to their individual circumstances. During these discussions various issues are explored in more depth and, as is appropriate, audience members are referred for individual counseling or care. Video showings and discussion groups, printed materials, and radio programs supplement and support interpersonal and community-based behavior change communication initiatives. Each cluster also established a resource center that provides counseling and referral services, distributes condoms and educational materials, and shows videos to interested persons. Materials produced centrally at TAP are also important sources of educational tools for the clusters. The project is increasingly emphasizing, however, utilization of locally produced material and mass media resources. Two clusters (Dodoma and Morogoro) already have ongoing radio programs on AIDS in their regions. As an alternative and complement to conventional posters and pamphlets, several other clusters have begun to use locally produced items (e.g., fans, baskets, plates, mats, etc.) for message dissemination. In so doing, important messages about STIs and AIDS have been tactfully introduced into the flow of daily family life. Care, Counseling and Support for Persons With AIDS, Their Families,and Orphans From a community perspective the impact of AIDS in Tanzania is tangible: health centers and hospitals are overwhelmed by AIDS patients; villages are unable to care for growing numbers of orphans; and families struggle to cope with illness of loved ones. These are the personal and community experiences of AIDS, experiences which aggregate data on HIV prevalence, cumulative deaths, and number of orphans fail to adequately reveal. As an integral part of Tanzanian communities, TAP's NGO clusters share the devastation that AIDS has perpetrated. Consequently, helping families and communities cope with AIDS is an important element of cluster projects. To mitigate deficits in basic needs caused by AIDS-related illnesses, and to empower households to care for their own ill family members, NGO clusters support activities that improve home-based care and provide basic support to families. While the clusters are at various stages of implementation of this project component, most have trained counselors and home-based care trainers, formed home-based care teams, and identified sources (external to TAP) of material assistance for persons living with AIDS and their families. Three TAP projects, which are part of the NGO have especially well developed care and counseling activities. The Tanga AIDS Working Group (TAWG), the coordinating NGO for the Tanga regional cluster, received TAP assistance for its home care and counseling program in three districts of the region. The initiative is unique in that it forges cooperation between traditional and biomedical healers and builds on the complementarily of their different practices and community contacts. Traditional remedies, which have been clinically tested for efficacy in alleviating some AIDS-related symptoms, have been integrated into home care protocols; traditional healers have also been trained as peer educators and counselors and in some clinical aspects of STIs and AIDS; and a bi-directional referral system -- e.g., biomedical to traditional for home care and traditional to biomedical in complicated cases -- has been established. In such an ambiance of cooperation and mutual respect, better overall health care for STI and AIDS patients is the important outcome. In Dar es Salaam, Walio Katika Mapambano na AIDS Tanzania (WAMATA), the coordinating NGO for the cluster, and the Pastoral Activities and Service for AIDS (PASADA), a cluster member, also have strong and well developed care, counseling and support activities. While both organizations are now integrated fully into the cluster framework, they each have received additional assistance from TAP, WAMATA to develop home-based care materials and PASADA to provide care and support to AIDS patients and their families. Altogether, through the efforts of TAWG, WAMATA, PASADA, and the NGO clusters, TAP's commitment to mitigating the impact of AIDS produced visible outcomes. "Congestion" in Tanzanian hospitals and clinics due to an over-abundance of AIDS patients has been reduced, especially in clusters that have members with strong care and support activities, and the quality of life (self-reported) for individuals and families affected by AIDS has been improved. Providing adequate support to orphans, however, has been difficult for the clusters and other care and support projects to achieve. This is not from a lack of effort, but from the complexity of the problem. Recent UNICEF projections for central and east Africa indicate that by the year 2000, 11 out of 100 children will be orphaned, largely due to premature death of their parents from AIDS. Poverty throughout Tanzania amplifies the problem. In its crisis economy, where life for the typical family is a day-to-day struggle, the traditional coping mechanism of absorbing orphaned children into the households of kin has begun to break down. Simply put, there are too many orphaned children and too few resources to adequately help them. While each TAP cluster supports orphaned children (on average 50 per cluster) in various ways -- extending essential support to care takers and orphans, such as food, clothes and school fees, providing training in income generating activities and work skills, and providing psycho-social support through counseling and peer support -- these efforts pale in comparison to the crisis. Children have many material, psychological, and social needs, and the natural role of parents in meeting these needs is not easily replaced by social and health programs, however well intended such programs may be. While admittedly insufficient compared to the problem at hand, TAP's efforts have, nevertheless, accomplished more than providing for the basic needs of some orphaned children. Through the cluster mechanism, TAP made a solid start in helping communities learn to cope with this growing social dilemma. Taking Stock of NGO Cluster Achievements and Comment on Future Directions Although there exists significant variability between the clusters in organizational stability and programmatic success, to date, the overall outcome of TAP's NGO cluster formation is promising. The TAP team, in collaboration with its many partners, believes that it has effectively laid the foundation for finding Tanzanian responses to the AIDS epidemic. Because the NGO clusters are central to TAP's overall program, before reviewing other components of the TAP project, a brief summary of the principal achievements and future directions of the cluster initiative is in order. To start, the TAP team believes that successfully forming nine regional NGO coalitions is in itself an important achievement. The process required substantial investment of TAP staff time and other resources, especially for conducting training workshops and providing continual supportive supervision and assistance. It is worth emphasizing here that, compared to a directive approach, a facilitative strategy for project supervision requires more investment of personnel and material resources. The pay off in terms of capacity building and program sustainability, however, is significant, and TAP's experience with clusters that had particularly difficult start-up phases attests to this. Iringa, for example, began with organizational conflicts that impaired the cluster's functioning. Through gradual but intensive consultative assistance from TAP, the cluster's management came to clearly identify its problems and to make decisions for redressing them. Today, Iringa is considered both by its peers and by TAP to be the strongest cluster organizationally and among the most dynamic programmatically. What is significant about the management decisions and subsequent changes made in Iringa, is that they were driven by the coalition's management body and not by TAP. The cluster, in other words, empowered itself, whereas TAP only facilitated the process. To varying degrees of success, all of the clusters have sensitized regional leaders and some district leaders, implemented projects in peer education and other forms of community-based behavior change communication, conducted counseling and care for persons with AIDS and their families, and provided some support for AIDS orphans. Most of the clusters have achieved notable successes and have initiated processes to decentralize from the regional to the district level. The Iringa cluster stands out because of its program successes, organizational strengths, and engagement of community leaders in its activities. Only one, the Dar es Salaam coalition, remains organizationally and programmatically weak, and will, therefore, be dissolved during the decentralization process to the city's three districts. All in all, the first phase of TAP's NGO cluster experience has been rewarding and programmatically effective. With continued USAID assistance, a second phase of the project will focus on creating functional clusters at the district level, a process which will primarily be managed by the regional clusters themselves. With decentralization, intervention activities will become increasingly anchored within administrative wards and ultimately within villages. It is by way of such incremental capacity building and decentralization that Tanzanian communities will gradually and finally come to "own" the interventions, with TAP assuming a more strictly technical assistance role. In the interest of long-term sustainability, TAP will also be transformed from a USAID-funded entity into a local NGO, thereby enabling it to raise funds locally and internationally, and from governmental and private sources. B. Other Community- and Workplace-Based Initiatives Every worker who dies from AIDS engenders a cascade of losses for Tanzanian society. For workers are individuals who belong not only to the workforce, and thus the economically "productive" class, but they are also members of complex social networks. The quality psycho-social exchange that occurs between people in complex social networks escape ready measurement in indicators such as "person-days" work and gross domestic product. However, the significance of such exchange and mutual support in people's lives cannot be overstated. Beyond losses to the national economy, the excessive death of people in their social prime and economically most productive years of life, leaves many gaps in Tanzanian society. Interventions targeting employed adults, consequently, have special importance in TAP. Via adult workers in the formal economy, worksite-based interventions represent another avenue by which TAP reaches Tanzanian communities. Three implementing agencies, all of which began their interventions under AIDSTECH, have collaborated with TAP on worksite and community interventions: the Organization of Tanzanian Trade Unions (OTTU), the Tanzania Council for Social Development (TACOSODE), and the African Medical and Research Foundation (AMREF). The former two are umbrella organizations, which have an extensive clientele base; both of these focus on worksite activities. AMREF's initiative evolved from a project targeting truck drivers, their assistants, and sex workers into more broad-based community interventions in "high risk transmission areas," such as truck stop towns and commercial centers located along principal transportation routes. Worksite-based activities were an important part of AMREF's high risk transmission area interventions, and eventually this component was contractually and programmatically separated out for specialized attention. Interpersonal peer education, small group sessions, and video presentation combined with discussion constitute the main communication strategies in these projects. Condom sales and distribution and STI referral are integrated fully into the educational services. The three organizations also collaborated with TAP to develop a "manager's kit," which outlines for business decision makers the key issues and considerations regarding the impact of STIs and AIDS on the health and well-being of their workforce. These kits are now used by NGO clusters to more effectively initiate worksite-based activities. In their latter stages, OTTU, TACOSODE, and AMREF projects made concerted efforts to gain material commitment from participating companies for continuation of the activities. While cost-sharing outcomes from OTTU and TACOSODE were overall unimpressive, AMREF's experience was more fruitful. To develop and improve worksite interventions in the NGO cluster projects, TAP will, therefore, retain AMREF's services to provide technical assistance in this area to the cluster projects. With regard to the OTTU and TACOSODE projects, while their regional branches have been incorporated into the NGO cluster framework, their national-level worksite activities are currently being supported by other donor agencies. Endnotes
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