FHI - Making Prevention Work Global Lessons Learned from the AIDS Control and Prevention (AIDSCAP) Project 1991-1997 Making Prevention Work 8. Managing HIV/AIDS Programs and Building Capacity to Sustain Prevention Efforts

Table of Contents

8. Managing HIV/AIDS Programs and Building Capacity to Sustain Prevention Efforts (See Below)

9. Prevention and Care: Mutually Reinforcing Approaches

10. Crossing Borders: Reaching Mobile Populations at Risk

8. Managing HIV/AIDS Programs and Building Capacity to Sustain Prevention Efforts

Sound technical strategies and state-of-the-art technical skills are essential for HIV/AIDS prevention, but they do not guarantee the success of a prevention program. Planning, management and monitoring create the infrastructure that makes it possible to deliver effective technical services to those at risk of or affected by HIV. During the past decade, government agencies and nongovernmental organizations have strengthened their management skills and systems as well as their technical skills to meet the challenges posed by the epidemic.

NGOs have played an important role in the response to HIV/AIDS and remain one of the most effective channels for reaching and influencing target audiences. Once wary of NGO involvement in HIV/AIDS prevention, most governments now recognize the value of NGOs' contributions and accept them as partners.

Some of these NGO partners were established to respond to the epidemic, while others added HIV/AIDS prevention to their other health and development objectives. The new organizations often lack basic institutional and financial capability, and many NGOs -- new and established -- lack technical expertise in HIV/AIDS prevention. Governments, on the other hand, have longer experience in managing HIV prevention efforts, but face daunting new management challenges. Erstwhile strong, centralized programs bolstered with international technical and financial support now struggle with the complexities of decentralizing planning and management to regional and district health authorities and with the need to expand care and support services to people infected and affected by HIV/AIDS as financial resources diminish.

Strengthening the capacity of developing country NGOs and government agencies to plan, manage and evaluate HIV/AIDS programs has become an even great priority during this second decade of the epidemic with the explosive growth in the number of HIV infections in developing countries and the realization that a cure or vaccine is still a long way off. The crisis mentality of the early years, when governments, donors and NGOs moved to mount an emergency response to AIDS, has been replaced by an understanding that the epidemic is a long-term development problem requiring a long-term multisectoral response.

Managing Programs Worldwide

One of the largest donor-funded health programs ever mounted, with some 584 projects and activities in more than 40 countries and more than 500 implementing partners, the AIDSCAP Project offered a unique opportunity to develop innovative management systems for international HIV/AIDS programs and to build the capacity of local partners to sustain such programs.

From 1991 to 1997, AIDSCAP worked with local partners to design, manage and evaluate comprehensive, multiyear programs in 19 countries throughout the world. These ranged from a primarily grassroots, nongovernmental program to address prevention, care and orphan support in Tanzania (Box 8.1) to a program housed in and directly supportive of the government's national HIV/STD control program in Jamaica. AIDSCAP also provided targeted expertise to national and regional efforts in more than 20 countries. Examples include strengthening Zambia's national STD service, infusing state-of-the art HIV prevention expertise into the design and implementation of a reproductive health project in West Africa, training epidemiologists and social scientists to conduct socioeconomic impact studies in Central America, and evaluating non-AIDSCAP HIV/AIDS prevention projects in Uganda.

Two AIDSCAP grant programs offered special opportunities for strengthening community-based responses to the epidemic. A competitive grants program that paired U.S. private voluntary organizations with host-country NGOs awarded nine three-year, $400,000 grants to support innovative projects that were integrated into existing AIDSCAP programs. And by providing more than 200 "Rapid-Response Fund" grants of U.S.$900 to $5,000, AIDSCAP was able to expand the number and type of community-based organizations delivering client-centered HIV/AIDS prevention services in countries around the world (Box 8.2).

8.1. NGO "Clusters": A Coordinated Approach to HIV/AIDS Prevention and Care
One of the few lawyers in Tanzania who advises people living with HIV/AIDS and their families, Nuru Mazora meets half of her clients through referrals from local NGOs.

"Before they found out about my work, these NGOs had nowhere to refer people living with AIDS who had legal problems," she said, explaining that clients usually come to her with questions about discrimination, inheritance laws, writing wills and protections against rape and domestic violence.

The NGOs learned about the legal aid services provided by Mazora's employer, Comprehensive Community Rehabilitation in Tanzania, when they joined the Dar es Salaam HIV/AIDS "cluster." Their experience illustrates one of the advantages of the cluster strategy employed by the Tanzania AIDS Project (TAP), which brings together the NGOs working in HIV/AIDS prevention, care and support in a city or region to coordinate activities, share resources and information, and avoid duplication of effort.

The USAID-funded TAP, which was implemented by AIDSCAP from 1994 to 1997, organized these clusters in the nine regions of the country most affected by HIV/AIDS. In each region, TAP-facilitated workshops enabled representatives of participating NGOs to understand the individual and collective strengths and weaknesses of their organizations, and this understanding allowed them to rapidly design joint plans for a comprehensive, region-wide HIV/AIDS prevention, care and support program. Together they developed project goals and strategies and mapped out which target populations and technical areas each NGO would cover.

In each cluster, an "anchor" organization selected by the participating NGOs is responsible for hiring staff to manage the cluster, holding monthly meetings, dispersing funds, overseeing financial management of activities and submitting reports. TAP facilitates meetings among the clusters and provides technical assistance and training to help cluster members strengthen their technical, management, planning and evaluation skills.

Formal coordination mechanisms within the clusters include monthly meetings of a cluster steering committee of five to six NGO representatives to review the progress of their joint program and quarterly or semiannual meetings of a subcommittee consisting of two representatives from each NGO in the cluster. But informal communication among cluster members is much more frequent, as people from the different NGOs confer to plan joint events, seek advice and assistance, make referrals or just give other each some much-needed encouragement.

"I find that people who work in the same field as I do, we share our problems," Mazora said. "This is what happens in a cluster. Sometimes you're so depressed you regret you took the job, and you have somebody to boost your morale."

For Margaret Mshana, director of a grassroots women's organization called KIWAKKUKI in the town of Moshi, the greatest benefit of cluster participation is the training provided by TAP. Participation in training-of- trainers workshops TAP held for members of the Kilimanjaro cluster equipped KIWAKKUKI's volunteers to go out into the villages and train others as HIV/AIDS peer educators and community-based counselors.

Such training opportunities are rare for groups as small as hers, explained Mshana, whose organization has about 450 members but a staff of only three.

Mazora agrees that the training available to small organizations as members of a larger cluster is an important advantage. As an example she cites the training she received in counseling, which helped her cope with the hardest part of her job -- knowing what to say to a client who is distraught, angry, depressed or even suicidal.

"When I started working, I never knew anything about counseling," she said. "So I would say, 'I can provide legal service, but I cannot talk to them.' I've been able to attend some seminars on counseling and have greater skill and knowledge."

Like Mazora and Mshana, cluster participants believe that the experience has been a positive one. Although inevitable disagreements, misunderstandings and rivalries arise as cluster members struggle to cooperate, the benefits of their collaboration -- and the urgency of their shared goals -- help them overcome these difficulties. The results have been more efficient division of responsibilities, less unhealthy competition for support, strong collaborative relationships among NGOs and, ultimately, more effective HIV/AIDS prevention, care and support services.

8.2 Promoting a Rapid Community Response to HIV/AIDS
In Lagos, the largest city in Nigeria, traffic jams are an inescapable part of daily life. Many people spend as long as four hours a day traveling to and from their jobs.

But for the Nigerian NGO Health Matters Inc., a traffic jam is an opportunity, not an annoyance. Taking advantage of the large captive audience mired in Lagos traffic each day, Health Matters' mobile health educators weave their way through lines of cars and buses, stopping to talk to commuters and pedestrians about HIV/AIDS prevention and to distribute condoms and educational materials.

With U.S.$3,000 from AIDSCAP's Rapid-Response Program, a flexible funding mechanism for supporting small, innovative interventions, Health Matters was able to reach 32,000 people in just 12 weeks. The NGO's six mobile health educators also distributed 1,500 posters, 8,000 pamphlets, 7,540 bumper stickers and 21,600 condoms in the three most congested areas of Lagos.

AIDSCAP's resident advisor in Nigeria was impressed with what Health Matters had accomplished with a small amount of money and with the NGO's ability to manage the grant funds. As a result, AIDSCAP contracted with Health Matters to expand the traffic jam intervention to ten additional sites and to train 20 more mobile health educators.

Health Matters Inc. is one of 214 local organizations that benefited from the AIDSCAP Project's rapid-response grants. The grants enabled these NGOs to respond to community needs while developing their own organizational capacity to manage HIV/AIDS activities, learning from the experience before taking on larger projects.

AIDSCAP worked with its resident advisors in each country to streamline application and reporting procedures. Applicants were asked to fill out a simple form, providing brief statements on what an activity would accomplish, why it was needed, how it would be implemented and evaluated, and a short description of the applying organization. A typical application consisted of six to seven paragraphs. These applications were reviewed by the country's AIDSCAP resident advisor, who awarded grants ranging from $900 to $5,000. At the end of an activity, the grantee submitted a two- to three-page narrative report and a one-page financial report.

With these simple application and reporting procedures, the Rapid-Response Program made it possible for AIDSCAP to respond quickly to community interest in HIV/AIDS prevention without overburdening the developing infrastructures of new community-based organizations. It also gave AIDSCAP programs the flexibility to fund creative projects that were not envisioned when country strategies were designed.

Rapid-response grantees developed educational materials, organized special events, and trained outreach workers and volunteers. ARLS (the Senegalese Association Rurale de Lutte Contre le SIDA), a group of mostly women farmers, used an AIDSCAP grant to build a rural network of volunteer HIV/AIDS educators that works with marabouts (Islamic teachers) and other community institutions. In Ethiopia, the NGO Beza Lewegen trained deaf leaders and sign language professionals to educate the country's 200,000 deaf adults about prevention and developed and distributed posters and other printed materials on HIV/AIDS in sign language. And in India, the Media Foundation established a resource center that gives local NGOs access to international sources of HIV/AIDS information, helps them identify sources of technical assistance and educational materials, and provides AIDS counseling services.

AIDSCAP's Rapid-Response Program funded more than 230 such activities from 1993 to 1997. With modest amounts of money, organizations such as Health Matters, ARLS, Beza Lewegen and the Media Foundation were able to reach more than a million people worldwide with life-saving information about preventing HIV/AIDS.

Other initiatives were designed to address emerging needs and opportunities. AIDS care and management grants enabled organizations in selected countries to test interventions to link and strengthen prevention and care efforts at the community level. A "Domestic Areas of Affinity" pilot project encouraged networking and sharing of experiences between Dominican and Haitian programs and U.S.-based programs that serve similar populations. And the lessons from a demonstration project providing HIV prevention and STD services to Rwandan refugees in camps in Tanzania -- the first to test the viability of integrating such services into primary health services in a refugee setting -- have been used by the United Nations High Commission on Refugees and others to shape subsequent programs for refugees.

Systems and tools developed for managing these initiatives and the AIDSCAP Project as a whole may serve as useful models for future international HIV/AIDS programs. These include a program management manual to guide field implementation, processes for increasing local participation in project design (Box 8.3), and database management tools for indexing and tracking projects, research studies, BCC materials and program documents.

Strengthening the capacity of local organizations to design, implement, manage and evaluate HIV/AIDS programs was a key objective of the AIDSCAP Project. The vast majority of its projects and field activities were carried out by host-country NGOs, community-based organizations, government agencies and universities, with technical assistance and management support from AIDSCAP staff and consultants.

During the first half of the project, capacity building efforts emphasized project design and technical skills. Strengthening financial, management and networking skills became increasingly important during the second half of the project as AIDSCAP prepared its implementing partners to continue and sustain HIV/AIDS prevention programs. The project developed new tools for assessing, monitoring and evaluating capacity, including an instrument to help organizations identify their own strengths and weaknesses and a strategic planning manual, and trained all its resident advisors to use these tools to integrate comprehensive capacity building efforts into the programs they managed.

AIDSCAP's commitment to building local capacity was apparent in its 20 field offices, where 80 percent of country programs were directed by resident advisors from the host country or neighboring countries and almost all other field staff were host-country nationals. Their contacts and understanding of the local situation made it possible to begin programs more rapidly, resulted in stronger relationships and better communication with AIDSCAP's partners in each country, and enhanced local ownership of the programs.

Recognizing that the skills and experience of the staff of these field offices represented a valuable resource in each of the host countries, AIDSCAP launched an NGO Partnership Initiative in 1996 to help this newly developed capacity continue beyond the AIDSCAP Project. Through this initiative, AIDSCAP and FHI assisted seven of its offices in establishing indigenous NGOs and provided training in business planning, fund raising, proposal writing and financial management. These skills have enabled the new NGOs in Brazil, Cameroon, the Dominican Republic, Ethiopia, Haiti, Honduras and Zimbabwe to raise funds from a variety of sources so that they can continue to provide technical and financial support to other local organizations working to prevent the spread of HIV/AIDS.

8.3 Collaborative Design Process Creates Integrated Prevention Programs
When representatives of ten Honduran organizations met in Tegucigalpa in July 1995 to design a national HIV/AIDS prevention project, many of them had never worked together before.

"It's the first time that a project of this magnitude has been developed where the MOH (Ministry of Health) and local organizations have worked together to define strategies for intervention," explained Mar�a Luisa Gonzales of the Centro de Orientaci�n y Capacitaci�n en SIDA, a participant in the planning process.

AIDSCAP brought the ten public and private organizations together for two weeks shortly after an intensive one-week course in project planning. The goal was to use these new skills to develop a comprehensive HIV/AIDS prevention program consisting of complementary projects. And at the end of the two weeks, 10 projects had been created, the contracts between AIDSCAP and the participating organizations had been signed, and those organizations had received the initial funding for project implementation.

AIDSCAP used a similar process for its programs in Tanzania and Indonesia, holding project development workshops after initial assessments conducted with the individual organizations and training sessions in project design. This process gave participants an opportunity to receive technical assistance in project design, proposal development, financial planning and computer technology as they applied these new skills.

"Participants didn't just learn the theory of effective AIDS program design," said Gail Goodridge, AIDSCAP associate director for country programs and one of the facilitators at the Tanzania workshop. "They really had a chance to put it into immediate practice."

The workshops were also a "very effective team-building tool," Goodridge said. Designing their projects together gave participants a clear understanding of each organization's role in the comprehensive program and of how they could collaborate to achieve the overall objectives of the program.

At the Honduras workshop, for example, the Ministry of Health designed a subproject to strengthen its STD services. Other participating organizations then added an STD referral component to their projects to ensure that project staff and volunteers would encourage members of the target audiences to use these improved services.

Participants in all three countries appreciated the opportunity to learn from each other. "The interaction among all the institutions involved generated a search for better responses and strategies," said Juan Ram�n Gradelhy of Comunicaci�n y Vida, a Honduran HIV/AIDS prevention project sponsored by the municipality of San Pedro Sula. "All of those involved in this common effort shared experiences and helped each other."

This collaborative spirit served the organizations well as they carried out the projects they had designed. In Indonesia, Tanzania and Honduras, participants said that it strengthened their ability to coordinate their activities and to work together to achieve common goals.

Lessons Learned

Planning and Monitoring

A systematic planning process articulates a clear vision for a program, provides a framework for implementation and makes it easier to assess program progress.

In each of its 19 major country programs, AIDSCAP worked with representatives of the host-country government, USAID Mission, NGOs, community leaders, potential target audiences, influential stakeholders, other donors and technical experts to conduct needs assessment and develop detailed, multiyear strategic and implementation plans. This process ensured that programs were responsive to local needs, gave long-term direction to program efforts and enhanced donor coordination.

Joint planning by all of the organizations that will be involved in implementing a country program results in stronger individual projects and encourages valuable collaboration among the organizations.

AIDSCAP's experience in Tanzania, Honduras and Indonesia provides a model for such team building, with an intensive design process that brings together all the implementing agencies in a country to develop complementary projects (Box 8.3).

Effective project monitoring requires intensive on-site support but can be facilitated with appropriate, easy-to-understand tools.

Frequent site visits by program managers provide the best vehicle for monitoring activities in the field; however, such visits are not always possible given staffing limitations, geographic distance, travel costs and other constraints. One strategy is to complement visits to project sites with the use of process indicator monitoring forms that require implementing agencies to report monthly progress toward achieving previously agreed-upon project targets, such as condoms distributed, individuals reached through interpersonal communication, materials distributed and training sessions conducted. Monitoring such process indicators can help managers identify when it is necessary to modify the project approach (and budget) to ensure achievement of project objectives.

Mechanisms for reviewing and revising project objectives, strategies and activities are essential to ensure that HIV/AIDS interventions remain responsive to the evolving epidemiology of the epidemic and the changing needs of target audiences.

AIDSCAP found that requests by implementing partners to modify or augment project designs were often a demonstration of active, attentive program management and commitment to improving the effectiveness of activities.

Large national or regional programs can also benefit from periodic internal assessment and review. Reviews by senior managers of each of AIDSCAP's major country programs allowed program managers to make mid-course corrections to program strategies or management structures, incorporate innovative technologies and strategies from other programs, expand successful interventions and boost staff morale by recognizing program accomplishments.

In Jamaica, for example, the AIDSCAP program was expanded to reach people in the high-prevalence areas of western Jamaica as a result of a program review conducted in 1994. The geographic coverage of AIDSCAP's STD activities in Senegal was also broadened at the recommendation of a review team, and several full-time consultants were hired to meet the increasing technical and management needs of the program. The participation of senior program managers and representatives of the donor in these reviews allowed for rapid joint decision making.

Ensuring regular input from clients in project design and implementation is essential for effective programming.

AIDSCAP maintained communication with its target audiences through formative research and qualitative evaluation and by encouraging their participation as peer educators and project staff. The project found that peer education was not only a good way to reach target audiences, but also provided a regular source of valuable feedback about clients' needs and perceptions of prevention activities and services.

Forging Partnerships

Formal collaborative relationships among all the organizations working on HIV/AIDS prevention in a region can strengthen prevention efforts, create opportunities to share resources and reduce duplication of effort.

In Ethiopia, for example, AIDSCAP brought together NGO, community and industry representatives and federal and local government officials to coordinate HIV/AIDS prevention activities in four regions that were project "focus sites." Members of these "focus site intervention teams" carried out their own interventions, but met monthly to ensure that their individual projects fit within the larger regional HIV strategy, that the designated target groups were being reached and that efforts were not unintentionally duplicated. They also shared resources and planned joint events. Team members said that this collaboration and coordination enabled their organizations to accomplish much more than they could have done alone and built stronger, more productive relationships between the public and private sectors in the four regions.

Another effective mechanism for encouraging collaborative partnerships among organizations working in HIV/AIDS is the "cluster" approach AIDSCAP established in Tanzania (Box 8.1).

Programs can be structured to ensure collaboration between governmental and nongovernmental organizations.

A number of AIDSCAP country programs built such collaboration into their program designs and into their grant agreements with local organizations. In Honduras, for example, the project helped four regional health administrations of the Secretariat of Public Health strengthen STD services and created a referral system supported by the local NGO implementing partners. Similarly, AIDSCAP strengthened STD services at select district health clinics in Ethiopia and included STD prevention and referral in its agreements with NGOs working in those districts.

Linkages between international and domestic HIV/AIDS organizations can be mutually beneficial, particularly when the organizations work with similar populations.

AIDSCAP sponsored a number of exchanges between U.S. and developing country NGOs, including a project that paired NGOs from the Dominican Republic with U.S. NGOs that work with Dominican immigrants. NGOs from both countries were able to share intervention methodologies and materials developed for working with Dominican populations. They also identified opportunities for further cross-country collaboration. Participants in this exchange decided to form a coalition to work on issues of common concern, including providing referrals to support services for HIV-positive people who travel frequently between the two countries.

Mobilizing Communities

Working with existing organizations is generally more effective and sustainable than setting up new ones.

AIDSCAP found that organizations with established links to their communities -- even NGOs with no HIV/AIDS experience -- were generally better able to respond to changing community needs for HIV/AIDS prevention and care than new NGOs created in response to the epidemic. These organizations can mobilize quickly, possess a ready infrastructure into which they can incorporate HIV prevention and AIDS care, often have a shorter learning curve and are able to maintain their efforts with little technical assistance. Organizations that have deep roots in a community, such as the Family Guidance Association of Ethiopia and the Community Development Association in Thailand, are also in a better position to sustain recently integrated HIV/AIDS services.

Community-based groups with little or no previous HIV/AIDS experience can be mobilized to support HIV/AIDS prevention in their communities if the process is kept simple.

Donors must be careful not to overwhelm community-based groups with overly bureaucratic application, monitoring and reporting requirements. AIDSCAP found that small grants with streamlined application and reporting procedures are a good way to encourage innovative community-based approaches to prevention and to help community-based groups develop skills in HIV prevention and program management (Box 8.2).

Sustainability

The tension that often exists between achieving direct program results and building long-term capacity can be resolved, but only when capacity building objectives have been clearly stated and all the stakeholders have agreed that capacity building is a priority.

Better methods of defining needs and measuring improvements in capacity, such as the collaborative self-assessment and strategic planning process developed by AIDSCAP, could make it easier to strike an appropriate balance. Funding should be allocated specifically to achieve capacity building objectives.

Effective management of donor-funded national or regional programs requires a critical mass of local staff.

The initial design of the AIDSCAP Project called for a minimal country office staff of management (resident advisor) and administrative (finance officer and secretary) personnel. Local consultants or AIDSCAP regional and headquarters staff were expected to provide additional support. But senior managers soon recognized that AIDSCAP resident advisors needed additional long-term, on-site capacity to help them provide the necessary technical and program support to local organizations implementing AIDSCAP country programs.

All the country programs increased the size of their program management staff and some added full-time technical experts. Such investments made it possible to manage programs more efficiently and provide more responsive oversight and support. And by supporting and strengthening the capacity of local program management and technical staff, AIDSCAP contributed to the sustainability of HIV/AIDS prevention efforts in the host countries.

Recommendations

To ensure that programs are responsive to local needs and to enhance collaboration and sustainability, international HIV/AIDS programs should involve government and community leaders, influential stakeholders, other donors and technical experts, and all implementing partners in a systematic joint planning process.
Periodic opportunities to review and revise objectives, strategies and activities should be built into programs and projects.
International HIV/AIDS prevention programs should seek to work with existing organizations that already have strong links to their communities -- even groups with no HIV/AIDS experience -- rather than establishing new community-based organizations.
HIV/AIDS programs should consider creating formal collaborative relationships among all the organizations working on HIV/AIDS in a region to strengthen prevention efforts and reduce duplication of effort. Donors can use contractual agreements with government agencies and local organizations to encourage coordination of the HIV/AIDS services provided by the private and public sectors.
Donors, contractors, implementing agencies and beneficiaries should clearly articulate reasonable benchmarks and schedules for achieving both direct program results and long-term capacity building.

Future Challenges

Maintaining Momentum

With the realization that the epidemic is not a short-term crisis comes the challenge of maintaining the enthusiasm, energy and commitment that drove early HIV/AIDS prevention efforts. Program managers need to find ways to reduce "burnout" among staff whose work is difficult and often discouraging and to document slow but real progress in prevention to convince governments and donors of the importance of continued support.

Overcoming Adversity

The constraints caused by war, civil strife and natural disasters make it more difficult to manage effective programs. Yet the populations affected by these calamities are particularly vulnerable to HIV/AIDS due to displacement, disruption of families and lack of access to services. Program managers need to identify and document strategies for overcoming such constraints and implementing effective prevention programs.

Linking Prevention and Development

Building stronger linkages between HIV/AIDS programs and other development programs would make HIV/AIDS interventions more sustainable and enable them to address many of the social, structural, environmental and economic factors that influence sexual risk behavior. Governments, NGO coalitions, donors and other international organizations need to establish formal mechanisms for encouraging collaboration among people and organizations working in various development sectors.

Sustaining Prevention and Care

Perhaps the greatest challenge facing those who manage and support HIV/AIDS programs is sustainability. Stronger partnerships between donors, governments, NGOs and the private sector are needed to help sustain HIV/AIDS programs. Fostering greater community ownership of programs would also increase their sustainability by reducing dependence on outside donors.

Making Prevention WorkGlobal Lessons Learned from the AIDS Control and Prevention (AIDSCAP) Project 1991-1997

8. Managing HIV/AIDS Programs and Building Capacity to Sustain Prevention Efforts

Making Prevention Work
Global Lessons Learned from the AIDS Control and Prevention (AIDSCAP) Project 1991-1997