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Final Report for the
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Table of Contents I. Country Program Description B. Country Program Context: A Focus on Bangkok C. Accomplishments and Constraints D. Implementation and Management Issues (See Below) II. Lessons Learned and Recommendations I. Country Program Description D. Implementation and Management Issues The AIDSCAP Thailand Program was the only AIDSCAP country program funded entirely by core budget. The five-year budget for the Program amounted to approximately 10% of the entire worldwide AIDSCAP core budget. Therefore it is not surprising that the Program received a continuous stream of visitors and evaluation teams (see Attachment B for a comprehensive list of visitors by month and year). The formal assessments began in 1991 and continued steadily until September 1996. Table 11 below presents a tabular summary of the various external and internal evaluations/audits by topic area. The reports of these assessments provide a wealth of information from generally independent and objective observers. This section draws from the reports of two of these evaluations: an AIDSCAP/USAID country program review in July 1993 and a capacity building review of the BFA Program in October 1995. Table 11: History of Internal and External Assessments of the AIDSCAP Thailand country Program
Country Program Review: July 1993 The Country Program Review was conducted as a brief, but intensive, evaluation of the method of operation, status and plans of the Country Program. The members of the review team included the senior-most staff of AIDSCAP and USAID's HIV/AIDS Division. At the time of this program review, approximately half of the $6 million earmark for Thailand had been committed through subagreements and support for the country office. The AIDSCAP/Thailand staff were becoming increasingly concerned that the BFA Program would not be able to achieve adequate coverage of intervention in order to achieve citywide impact. In view of the time remaining (three years) the most urgent questions put to the team were (a) how much of Bangkok could be covered, (b) by which subproject components, (c) at what cost per subproject. To aid the deliberation, five scenarios were presented which are crudely summarized as follows:
General agreement was reached on several points:
The initial implication of these guidelines was that all of the outreach components in the pilot area could not be retained for support by AIDSCAP in an expansion phase. Thus, some interventions had to be eliminated from AIDSCAP support. The criteria for prioritizing the outreach activities were as follows: size of target population; ease of access to target population; level of risk of the target population; and potential for sustainability. After considering these factors it was agreed to expand the coverage of the service workers outreach component and the low-income residence interventions component (and dropping large factory outreach and a planned, school-based intervention). The team instructed the AIDSCAP/Thailand office to lobby other sources of funding to support components of the BFA which AIDSCAP could not. Assessment of Capacity Building: October, 1995 At the request of the Thailand Country Program office, a multisectoral team of professionals spent two weeks examining the extent to which the BFA had built capacity to sustain the Program beyond AIDSCAP. The team consisted of highly experienced Thai professionals who had managed the national Thai AIDS program, university-based experts and a senior BCC officer from AIDSCAP/HQ. There are two components to the team report: One official report prepared by the Thai members of the team; and one report prepared by the AIDSCAP/HQ member of the team. Excerpts from both reports are presented here since they address different dimensions of program management and implementation. The BFA Program has two primary aims. It sought to: create a synergistic impact through linking the complementary strength of NGOs and the Government for greater coverage and effectiveness; and build capacity and create a sense of partnership among implementing agencies to sustain the commitment to fight AIDS together. These two aims delineate the areas which the team examined to find evidence of capacity building/enhancing. The external review team understood that the development or enhancement of new technical and managerial skills, the establishment and use of lines of communication, and respectful collaborative working relationships demonstrated aspects of capacity building in the Bangkok Fights AIDS Program. The AIDSCAP approaches aimed at reaching this goal included:
The question that this external review answered is "To what extent have these three things occurred?" How have the implementing agencies involved in the Bangkok Fights AIDS Program developed their managerial and technical capacities and capabilities to provide services and information related to AIDS? When, during the interviews, respondents were given the opportunity to reflect upon the changes in approach and capacity that had occurred during their association with AIDSCAP, they could recount numerous instances in which their actions or their thinking revealed a new understanding of HIV/AIDS and/or a clearer appreciation of the goals, constraints and methods of their BFA partners. A matrix showing PATH's technical assistance to seven implementing agencies (six NGOs and one University Institute) in the Service Workers Outreach subproject (SWOP I) gives some evidence for respondents' statements. Of particular note are the following indications of both individual skill building and improved organizational capacity: All of the implementing agencies (TRRM was not considered an implementer) took part in trainings, meetings or informal coaching dealing with technical skill building such as: training of outreach workers on interpersonal and behavior change communication strategy; training on sexuality; training on public speaking; HIV/AIDS updating sessions; and review of HIV/AIDS IEC materials. In the area of management upgrading, six of the seven agencies developed an implementation strategy and plan; five developed systems for monitoring; and five participated in a report writing workshop. Further evidence of an increased capacity to provide services and information related to AIDS comes from the subprojects undertaken with the 11 BMA/STI clinics and with the 160 private clinics. In both cases, informants told the review team that capacities to understand more about HIV/AIDS, to perform syndromic diagnosis of STIs, to develop and use STI/IEC materials, and to take social/sexual histories increased. The TMS-STD subproject for private clinics conducted 6 participatory training courses for private clinicians throughout Bangkok; while training for the syndromic approach was given for the medical doctors, pharmacists and nurses from in the BMA STD clinics. Although the team did not interview any of the outreach workers from the BMA STD clinics, it was said that these workers (nurses) had increased their empathetic understanding of the health concerns of workers in commercial sex establishments. Our respondents also felt that the equipment supplied by AIDSCAP had increased their ability to diagnose and treat patients more efficiently. Increased management skills were reported in the public sector -- DACs, the AIDS Division, and TMS-STD. AIDSCAP supported the establishment of the AIDS Division by providing funding for the hiring of staff, obtaining of equipment and the creation of an information system. AIDS Division staff report that they have become more adept at using information for diagnosing problems, planning, goal setting and determining evaluation criteria. The planning process of BAC and DACs increasingly draws upon their increased knowledge of HIV/AIDS in specific communities (e.g., from the two tools: one, for conducting a Community Diagnosis from the Community Mobilization subproject demonstrated by the Faculty of Public Health of Mahidol University and, two from the Behavioral Sentinel Survey -- BSS -- conducted by OPTA). Planning also has been affected by their more equitable relationships with NGOs working in the areas of AIDS prevention and care. NGOs are attending planning meetings and are considered a part of this planning process. Conclusion Undoubtedly skills were transferred to individuals in some implementing agencies through training. The external review team accepted meetings and trainings as proxy evidence that information and technology has been transferred. Specifically, staff capabilities in knowledge ( e.g., HIV/AIDS information and issues), skills (e.g., STI syndromic diagnosis, IEC materials development and pre-testing), intervention design (e.g., outreach worker interventions), and planning were clearly increased or enhanced. Additionally, some agencies have received ultimate recognition as qualified to work in the AIDS area by receiving outside funding (e.g., 50 million Baht funding from EC for AIHD to implement a similar project to the factory worker outreach subproject funded by AIDSCAP. AIHD readily admits that they did not have any experience and/or knowledge of HIV/AIDS related subjects before joining BFA.) In other cases, such as the Urban Development Foundation (UDF), AIDS work is being integrated into the other work of the agency. And in the public sector, several DACs, indicating both confidence and competence, have submitted their own proposals for BAC funding of AIDS activities in FY '96. It is uncertain, however, if the input into the STI clinics resulted in a sustained capacity to "provide services and information related to AIDS." While the team understands that knowledge was gained by the staff of both public and private clinics, there appeared to be insufficient staff, money (and possibly political will) to keep the BMA clinics open for extended service hours. The team was not able to ascertain to what extent various staff of the 160 private clinics were employing the knowledge and techniques learned in the workshops. How have the implementing agencies' roles and participation in advocacy for policy change improved? Through the many members of the Thai NGO Consortium on AIDS (TNCA) which was supported by AIDSCAP under the BFA, NGOs have a forum through which to advocate policy changes. At present they are particularly concerned about possible violations of the human rights of people living with HIV/AIDS. They are also actively advocating policies to ensure confidentiality, employment, and medical care. In the public sector, advocacy is also a clear goal. Both BAC and the DACs expressed the need to address HIV/AIDS as a social issue, not just a health or medical problem. Both groups are committed to working for this recognition throughout government. (It should be noted that in many cases, this awareness of the broader issues of HIV/AIDS came about as a result of the community mobilization subproject activities.) Evidence of the success in promoting this viewpoint exists in the broad membership of DACs -- i.e., members from Education, Social Welfare, Community Development and Health. Conclusion The team believes that the groundwork has been laid for further cooperation and participation in advocacy for policy change. The feeling of comradeship in BFA (rather than competition or opposition) that the team sensed from the interviews is a good omen for future coordinated policy work. The BMA officials accept the principles of the BFA even though the BFA Program is not yet fully integrated into the BMA work program. The BMA shows evidence of using data collected by AIDSCAP contractors for planning and is more inclined to include NGOs in the implementation of programs. There is clear evidence of active DAC involvement in planning, networking and fundraising. Several respondents mentioned the rapidly increasing need for improved home and community care for people affected with HIV/AIDS. It is likely that this issue will be one in which the advocacy roles of the implementing agencies will be tested. In order to get a better feel for increased participation in advocacy work, Implementing agency activities and progress should be monitored to determine if funds and activities are provided to address the issue of community-based care. How have coordination efforts and network strengthening been improved? Is there potential for sustainability beyond AIDSCAP support? Overall coordination within the BFA was ad hoc. Implementation would have been greatly enhanced through a more formalized coordination mechanism such as a "BFA Coordinating Committee" that met regularly. The plan to integrate this role into routine BMA management was not successful due to (1) limited BMA capacity at the start of AIDSCAP and an unsystematic effort by AIDSCAP to formalize the process (i.e., through a contract or MOU with the BMA). Learning among the implementing partners was also weak in some cases. For example, sharing between the BCC component and the STI strengthening teams was minimal and usually occurred at the instigation of the AIDSCAP Country Program Office. Nevertheless, evidence of coordination efforts and relationship strengthening were clearly visible in the Thai NGO Coalition on AIDS, in SWOP and in some DACs. These relationships are an important step in the process of building functional networks. AIDSCAP support to the Thai NGO Coalition on AIDS was in the form of funding for two years' salary of its one full-time staff member, office expenses, costs of training conferences and other educational seminars and the production and distribution of a newsletter. The major role of the NGO Consortium was to strengthen NGOs in terms of their understanding of HIV/AIDS and to create linkages that can be useful in advocating for both policy changes and for sources of funding. Through ACCESS, where the NGO Coalition is currently housed, AIDS education and information is readily accessible to all member NGOs. The newsletter created a channel for linkages. Coordination and relationship building (or networking) were key objectives of the SWOP implementers and their outreach workers who shared their experiences in periodic lessons-learned seminars. As one respondent from UDF explained, "The interaction of the SWOP team leaders at AIDSCAP-sponsored meetings were very useful. This gave us a chance to meet with other implementing agencies and share experiences. It was also helpful to have roundtable sessions where we could gain consensus." In other networking activities, representatives from five of these implementing agencies regularly participated in monthly meetings among NGO management and working committees. For example, in one district (Minburi), the district Director told the review team that the members of DAC feel a strong commitment to the ongoing work of DAC because they now understand their role as an active one. Consequently, he said, sustainability is not an issue. The Minburi DAC is, in fact, making action plans to extend its work to other target groups. This same DAC has the combined support of BAC, the private sector and local NGOs. Conclusion The team concluded that in the process of holding regular meetings and roundtable discussions, coordination was improved and relationships strengthened. This should continue in order to ensure that functional networks emerge from these relationships. On the question of sustainability beyond AIDSCAP, the groundwork was laid. Since many of the key players have now had significant positive interaction, there is reason to be optimistic if the implementing partners themselves will make the necessary efforts. Have efforts to build partnerships between government and NGOs resulted in anything? Are there synergistic effects from the comprehensive approach in increasing the impact of the efforts to slow down the spread of HIV? This aim of the BFA Program proved to be one of the most complex undertakings. Almost by definition, NGOs and Government organizations have an uneasy time working together. The reasons are many -- and each requires delicate handling in order to avoid a threat to potential partnerships. A few brief examples of possibly contentious areas where misunderstandings can occur: In many cases, NGOs have been established to meet a need that they perceive as not being met by the government -- and thus, they take firm and righteous ownership of it -- resisting what they perceive as government interference. Government organizations, on the other hand may resent the relative luxury that they believe NGOs enjoy because they focus on only a few issues, while government must spread its resources over many more. At the same time, Government workers, as established civil servants, may not bring the same enthusiasm, energy and dedication to a cause as do NGO workers. For these and many other reasons, the aim of BFA to put aside such differences and work together to fight AIDS is ambitious, indeed. AIDSCAP's approach depended upon a great deal of time and effort allocated to understanding and working with all parties -- the BAC, the AIDS Division of the BMA, health centers, DACs, universities and NGOs. From this base, it was hoped that AIDSCAP and the BFA Program would be in a position to "midwife" better cooperation among government agencies (BAC, AIDS Division, Health Centers, DACs); and also better attitudes and appreciation of each other by these government agencies and NGOs. Within the Bangkok Metropolitan Administration (BMA), coordination of AIDS activities rests with the AIDS Division. AIDSCAP was supportive of the AIDS Division not only in supplying equipment, but also in working closely with them to examine roles, plans, working arrangements, etc. As one of the AIDS Division respondents said, "Although AIDSCAP is a foreign agency, they worked with us as a responsible partner -- a friend." The AIDS Division has been responsible for overtures to the NGOs including convening a meeting of the 38 DACs and NGOs in order to explore how each could contribute to AIDS-related work. The AIDS Division is currently hoping to set up a special commission to facilitate coordination between and among DACs and NGOs. If this does come to pass it may represent some visible proof of the elusive "synergistic effects" that we are searching for. At the district level, the DACs are one of the main vehicles for networking and coordinating the work of NGOs within a district. Of the two DACs visited, one was very strong, the other seemingly not yet committed to its role in HIV/AIDS work in the district. If the first (Minburi) is taken as an example of what is possible with this structure, then, the team believes that with or without AIDSCAP support, meaningful partnerships between government and NGOs can emerge. As an example, in the SWOP subproject, many of the target groups are hard-to-reach young people. The NGOs who were involved with outreach work, were able to find and establish contact with the target group through the cooperation of the DAC. DACs have also been instrumental in involving worksite owners in the subproject thus allowing NGOs access to the workers. This latter case is an example of cooperation and likely synergy among a government body (DAC), the private sector (a factory) and an NGO. Conclusion The team believes that a partnership between DACs and NGOs can, with time, provide synergistic effects in increasing the impact of the efforts to slow down the spread of AIDS. However, as shown by the disparate results in the two districts visited, the DAC structure alone is not enough to ensure success. In addition, the team did not detect evidence, either in attitude or symbolic, that the BFA implementing partners shared a common Program identity. Personalities, perceptions, and other competing interests of the DAC leader and members are all likely to play more decisive roles than is the input by AIDSCAP or any other outside body. Nevertheless, the team feels that the potential good is worth pursuing. The successes that have already been achieved under the BFA Program point to the need for continued emphasis in bringing together the interests and concerns of both NGOs and government organizations in an attempt to slow down the spread of HIV. Has AIDSCAP made any contributions to the changes in capacity or networking? Virtually all respondents acknowledged AIDSCAP as being a responsible partner in the work of the implementing agency. In two different interviews, respondents remarked that AIDSCAP's example in working with them (instead of forcing decisions on them) was one of the experiences that the IA had most benefited from. Although funding and the supply of some equipment is appreciated, the AIDSCAP approach of making it possible for agencies to interact and share is seemingly the most important aspect of their association. The team found evidence of a strengthened STI referral network and increased sharing of technical training resources. Networking within and among DACs however did not appear to be strengthened by AIDSCAP. Instead, the DACs improved mostly in their use of technical information on HIV/AIDS and in their role as resource persons to the community. The DACs are also seen now as a viable implementing partner by other donors. Conclusion The team believes that AIDSCAP's example, as well as the design of the BFA Program itself, has made a significant contribution to the enhanced capacity and increased networking of the BFA partners. Recommendations for future capacity building initiatives for local agencies (from a donor perspective) The review team did not discover any AIDSCAP activity that they would discourage in a similar future program. The role of facilitator is a difficult one that must be played with delicacy and diligence. Future donors need to be aware that in order for a program of this nature to reach its aims, the implementing agencies must understand the networking/synergy concept, agree to its validity, accept it as possible, take ownership of it and operationalize it. Even with the AIDSCAP approach, which was apparently both accepted and appreciated, this process takes considerable time. |
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