Final Report for the
AIDSCAP Program in Thailand
November 1991 to September 1996

II. Lessons Learned and Recommendations

The unique features of the AIDSCAP/Thailand Country Program were the size of the target population and the attempt to establish a sustainable and coordinated set of interventions through 20 implementing partners from the NGO, university and government sectors. The lessons and recommendations that follow are intended for those who are considering applying a similar approach in the large urban setting.

Target Population

The geographic target of Bangkok was the appropriate target for AIDSCAP/Thailand, however the designers underestimated the mobility and lack of natural social networks among the 1.5 million men and women age 15 to 29. Multi-year, comprehensive prevention programs with a budget of approximately $1 million per year which rely on interpersonal communication in large urban areas should probably only attempt to cover a target population of no greater than 500,000 people.

The population target of all lower income men and women age 15 to 29 was narrow in that it excluded the also vulnerable groups of 30 to 39 and middle income populations. Various data that became available during the course of the BFA Program demonstrated these latter two sub-populations were also in need of targeted interventions. Other programs should include groups of different socioeconomic strata in their baseline assessment.

Coverage of the target population through interpersonal outreach was probably less than 10% at any one time. This is lower than diffusion theory allows for to create a ripple effect throughout a communication network. The designers of the AIDSCAP Thailand Program underestimated the number of outreach teams that would be required, the limited number of agencies with the capacity to manage street outreach, the difficulty of gaining access to small and informal worksites, and the stress of the job given worsening traffic conditions and economic pressure. Either the size of the target for outreach needs to be reduced or ways found to increase the number of outreach staff.

One "Mother" Stakeholder?

The BMA had no real structure nor the budget for a major HIV prevention initiative when AIDSCAP began in late 1991. Other organizations in Bangkok (mostly NGOs) had more experience in HIV prevention and an existing network of service outlets. However, it is hard to imagine how the BFA Program could have been implemented without the BMA as the central player. Thus, the designers could have done more at the beginning of the Program to portray the BMA at the focal point and devote more resources to strengthening the capacity of the AIDS Center and AIDS Division as the major stakeholder.

Although the BMA became the major stakeholder of the BFA Program this did not mean that they exercised total financial control. In discussions with key BMA staff, they saw it as advantageous that AIDSCAP distributed its grants directly to most of the implementing partners rather than passing funds through the BMA. Some members of the BMA felt, however, that certain components -- such as the community mobilization -- should have been awarded through the BMA in view of the heavy involvement of the DACs in that subproject. (Note: DACs are under the appointment and control of the BMA.)

Coordination Mechanisms

At the district level, the DACs were the only entities that were in the position of providing multisectoral coordination to the variety of implementing partners of the BFA. The inadequate performance of the DACs in the BFA Program still needs further study and explanation. Surely with more regular financial support from the National AIDS budget and more policy and political support from the BMA, the DACs would have been a more meaningful player. As it is though, the potential of the DACs in this Program was never fully realized.

Despite their under-performance the DACs, or at least the district administrative office of the BMA, were essential for obtaining access to many of the worksites and low-income communities that were the prime target for AIDSCAP outreach interventions. Other programs should identify these gatekeepers at the earliest part of project planning and make sure they are part of the planning and implementation.

A major oversight of the AIDSCAP Design Team was the coordination workload required by a comprehensive, interlinked prevention program. This workload was generally absorbed by the AIDSCAP country and Asia regional program staff through the first half of the program. Technically, coordination is an area of implementation and should not have been performed by the funder (i.e., AIDSCAP). Instead, a coordination subproject should have been created which placed a full-time subproject coordination unit somewhere in the BFA structure -- probably in the BMA. That unit would then be absorbed by the BMA toward the end of AIDSCAP. Although AIDSCAP did provide grants to the BMA AIDS Center, the staff of the Center were seconded from various other BMA divisions and had to spread their time over a variety of HIV/AIDS projects and activities -- of which the BFA was only one. The size and complexity of the BFA required at least one, full-time person for coordination.

In addition to the coordination role which AIDSCAP staff played, the line staff of the AIDSCAP country and regional office got far more involved in implementation than is customary for foreign assistance programs. Thus, AIDSCAP staff were members of technical working groups, convened technical meetings at the AIDSCAP office, designed BCC materials, drafted evaluation questionnaires, designed STI curricula and assisted in training activities -- all of which added value to the activities and outputs. However, this amount of involvement translated into neglect of AIDSCAP activities in other countries of Asia, an increased management burden on the Thailand country office and a perpetuation of the image of AIDSCAP as the Program "owner". The question needs to be asked: "How would AIDSCAP have managed the Thailand program if the AIDSCAP Asia Regional Office had been located in, say, Delhi?" If the amount of hands-on AIDSCAP assistant was indeed required to get the Thailand Program off the ground, then the Country Program Office should have been staffed with additional technical experts.

Creating a Program Identity

The Program-wide name and identity were created too late to take hold. Yet it is probably essential that, any comprehensive program that hopes to inter-link implementing partners from a range of agencies and sectors must have a common Program identity. A seminar was held among all implementing partners in the second year of the Program but, without a unifying Program name, logo and materials, no sense of common purpose evolved. What is more, the lack of a mass media campaign (scheduled for Year 3 of the Program) severely undermined the ability of AIDSCAP to promote a program-wide identity. More than any other input, TV and radio spots, bus-side panels and billboards would have implanted the Program concept into the minds of most of the target audience -- and given the implementing partners a more visible cause to rally round.

The public relations activities conducted in the final two years of the AIDSCAP/Thailand Program in lieu of a mass media campaign were no real substitute. The various strategies to mobilizing the existing media channels to incorporate BFA messages and themes was not as successful as planned.

Technical Components

STIs

Most persons with STIs in Bangkok seek services from pharmacies at some time during their illness. Private clinics and government centers are important sources of treatment when self-medication fails. The private and commercial STI outlets are difficult to work with because of strong competition which in turn leads to little time for training and participation in social programs such as the BFA. In addition, encouraging pharmacies and private clinics to refer difficult cases to public clinics militates against the strong profit motive of the Bangkok commercial sector. Ways are needed (such as prevention marketing) which combine AIDSCAP goals with the profit incentive of private and commercial outlets.

Even though they are a small portion of the market share of STI caseloads, the government outlets are still important as reference centers and as a source of referral for complicated cases of STI. Thus, any comprehensive program should always strengthen the public clinics while supporting private and commercial outlets.

There was considerable resistance to syndromic management of STIs by Bangkok physicians from both the government and private sector. Also, it was considered unethical to send bogus STI patients to clinics in order to assess physician practices. Other programs need to anticipate this resistance and find constructive ways of engaging the influential STI practitioners in support of program strategies. In the case of the Thailand Program, AIDSCAP established a technical working group (TWG) with AIDSCAP and local STI expert membership. Yet this was not enough to overcome resistance to some of AIDSCAP's STI strategies and policies. Thus, other mechanisms of leveraging support need to be sought as an alternative.

Evaluation

In the family of AIDSCAP country programs, the Thailand Program was the only true test of the comprehensive approach to prevention. The behavioral surveillance methodology was the appropriate tool for evaluating combined effects of linked interventions and not the sum of individual subproject evaluations. The disadvantage of a BSS methodology is that it is not possible to attribute improvements to AIDSCAP-supported subprojects directly. Inferences must be made about the plausibility of the recorded outputs from PIF reports being responsible for measured changes in risk behavior. Other comprehensive programs should use the BSS tool for overall evaluation but should strive to locate a control area to enable more conclusive evaluation judgments.

Community Mobilization

To the extent that social networks are required for the success of community mobilization Bangkok -- or other large urban centers in Asia -- are not suitable environments. The high turnover of populations, the level of crime and general mistrust prevent efforts to create, strengthen and maintain social networks. Examples of effective social networks that were mobilized for HIV prevention include West Coast gay communities in the US and intravenous drug users in Bangkok. A large portion of the members of both groups shared similar (risk behavior) lifestyles, they also shared a sense of social persecution which encourages strong bonds among members and had trusted peers from which to gain helpful information. The BFA tried to emulate these networks in the community mobilization component -- but this largely failed. Other programs should not abandon this approach because of its great potential. Instead a greater attempt should be made to identify existing, solid social networks and work through those rather than trying to create networks anew. In addition, considerable time is required for network strengthening -- more than a half day for example. With adequate resources, overnight retreats of several days were proposed as the optimal approach to network strengthening.

Overall Comprehensive Approach

Prevention marketing, as conceptualized by AIDSCAP/HQ may be the most appropriate strategy for highly mobile urban populations -- who also travel back and forth to rural areas. While interpersonal communication through outreach can provide high quality and personalized messages, it may be too costly, arduous and time consuming when trying to reach hundreds of thousands of people in a few years -- a goal which must be achieved to stem HIV spread in the large urban metropolises of Asia.