Experiments in fostering collaborative relationships among organizations involved in HIV/AIDS prevention are reaping benefits in two African countries.
MAY 2003 — In most parts of the world, local community-based groups have been the first to respond to HIV/AIDS. From AIDS service organizations formed by those directly affected by the epidemic to community groups to established health and development organizations, nongovernmental organizations (NGOs) have been at the forefront of HIV/AIDS prevention and care efforts.
Many believe that the key to sustaining prevention and care efforts is giving these grassroots organizations the resources and skills they need to design, manage and evaluate HIV/AIDS projects. Such capacity building is the central purpose of the programs carried out by the AIDS Control and Prevention (AIDSCAP) Project with funding from the U.S. Agency for International Development in more than 40 countries.
AIDSCAP recognizes that capacity building involves more than training in technical skills. Many NGOs also need help strengthening their organizational and management skills -- and their ability to work together.
"When resources are scarce and the need is great, competition is natural, even among the best-intentioned people," noted Penina Ochola, AIDSCAP's resident advisor in Tanzania. "Our challenge is to help NGOs organize complementary efforts that make the best use of the strengths of each group."
Communication and coordination among NGOs and between NGO personnel, representatives of other private organizations and government AIDS control staff are also essential for sustainability.
"The financial and material expenditures needed for HIV/AIDS prevention are beyond the capacity of an individual organization, and often scarce resources are wasted when organizations duplicate each others' efforts," said Mulunesh Tenagashaw, AIDSCAP resident advisor for Ethiopia.
Examples of mechanisms to help organizations coordinate prevention resources and activities include AIDSCAP-initiated "focus site intervention teams" in Ethiopia and NGO "clusters" in Tanzania.
Forming NGO Clusters
"Clusters" is the name the Tanzania AIDS Project (TAP), which is funded by the USAID Mission in Tanzania and implemented by AIDSCAP, has given to groups of NGOs working collectively in a region to carry out HIV/AIDS prevention and survivor support activities. More than 100 NGOs have joined TAP's network of NGO clusters in nine regions throughout Tanzania.
Each of the nine priority regions, which were identified by a National Institutional Needs Assessment in 1994, has more than 1 million people and a high HIV prevalence rate. Just over half the Tanzanian population lives in these regions.
NGOs in the nine regions were contacted in April 1994 to find out whether they were interested in participating in an HIV/AIDS prevention network. They were also asked to fill out a matrix to summarize their interest and experience in different types of HIV/AIDS interventions.
"It was important to consider the age of each of the NGOs and how much experience they were to bring to the cluster operations," Ochola explained. "Some of those who were very interested were young and inexperienced and had not yet understood the mechanisms of operating with donor funding. We also were wary of those whose interest was clearly to hijack all cluster powers, denying others access to funding while gaining more exposure and experience."
A lengthy series of TAP-facilitated workshops and meetings among NGO representatives in each cluster enabled them to develop a common understanding of the HIV/AIDS situation in their regions and the individual and collective strengths and weaknesses of their organizations. During this process, some NGOs decided that the cluster concept was not for them -- and opted out.
This "working through" of cluster purpose and expectations during the formation process later helped the founding members rapidly develop plans for comprehensive HIV/AIDS prevention and survivor support. Together they developed project goals and strategies and mapped out which target populations and technical areas each NGO would cover.
Since the vast majority of the estimated 400,000 new HIV infections in Tanzania every year are transmitted through heterosexual intercourse, each cluster project includes communication interventions to encourage people to adopt safer sexual behavior, efforts to increase condom accessibility through community-based outlets, and activities to help decision makers identify policies that support behavior change. Cluster NGO staff encourage people to seek effective treatment of sexually transmitted diseases (STDs) in the clusters where treatment services have been strengthened through separate, TAP-sponsored interventions.
Support for orphans and families affected by HIV/AIDS, including home care and counseling, is an important part of each cluster's activities. Over the past 13 years, an estimated 150,000 Tanzanian children have lost one or both parents to HIV/AIDS. By the year 2000, there could be 750,000 AIDS orphans in Tanzania.
Cluster Management
In each cluster, members chose an anchor NGO with proven financial and management ability to lead them. To be eligible to be an anchor NGO, an organization must be recognized as a leader in the community, able to establish an independent bank account for the cluster, registered under the Societies Ordinance in Tanzania, and willing to claim ownership of the project and its participants. It also must have a qualified accountant.
The anchor NGO is responsible for hiring staff to manage cluster activities, dispersing funds, overseeing financial management and execution of planned activities, submitting project reports, supervising cluster activities, and holding monthly cluster meetings.
Management of each cluster is facilitated by a five- to six-person steering committee of NGO representatives, which meets as often as monthly to review progress on scheduled activities, and by a subcommittee composed of two representatives from each NGO, which meets quarterly or semiannually.
Although the anchor NGO has the primary -- and contractual -- responsibility for managing cluster activities, member NGOs are accountable for their own plans of action and financial expenditures. Each NGO works with its own target group and in its own areas of expertise. For example, in the Tanga cluster the Tanga AIDS Working Group concentrates on home care and counseling while the Tanga chapter of the Society for Women Against AIDS in Africa (SWAA) specializes in peer education.
The role of TAP is to provide technical and material assistance to the clusters, facilitate meetings among representatives from different clusters, and provide training to strengthen NGO capacity in management, leadership, planning and evaluation. A TAP NGO coordinator is assigned to assist and monitor each cluster. TAP staff also provide guidance on policy issues and coordinate cluster activities with those of other institutions involved in HIV/AIDS interventions in Tanzania.
TAP has conducted training workshops for NGO staff to transfer skills in project design, training peer educators, materials development, accounting and financial management, syndromic management of STDs and condom social marketing. Follow-up training is provided through monitoring and technical assistance visits by TAP staff.
Lessons Learned
Forming the clusters -- and operating them successfully -- has required a great deal of time, patience, and energy. Continuing dialogue and interaction are essential: among member NGOs in each cluster, between each cluster and TAP management, and -- increasingly -- among different clusters.
Because phones are unreliable and electronic mail or faxes are rarely an option, the best way to communicate is simply to travel to each location, often over vast distances on roads that are in poor condition. Such time-consuming travel is a hardship for NGO personnel, who are often volunteers with other full-time jobs, but it is unavoidable.
The initial screening of NGOs was extremely important. Local NGOs are not homogeneous. They differ in experience, resources and scopes of work. While many of the NGOs considered for the clusters had a strong background in HIV/AIDS work or community development, others were opportunistic "briefcase NGOs" with no staff or relevant experience.
TAP learned the importance of clearly stating from the start the level of funding potentially available and the amount of serious work required to qualify for it. Because no specific budget figures were discussed as clusters began to form, disappointments were inevitable. Yet without some promise of funding, it would have been impossible to attract enough NGOs to form viable clusters. Many potential cluster members also had unrealistic expectations about the time they would need to contribute and the seriousness with which their efforts would be monitored.
Finally, personnel in all clusters required significantly more skills building than originally expected. Areas that required attention included: meeting planning and execution, proposal and report writing, activity and results monitoring, planning, and financial management and reporting.
Despite these difficulties, the participatory process has generated enthusiasm, responsibility and ownership of the cluster projects among the NGOs. They say they feel empowered to manage any project within their regions. Other positive results of the cluster experiment so far include less duplication of effort, less unhealthy competition for support and clients, and greater involvement and mutual support among the NGOs.
Intersectoral Teams
Another form of collaboration promoted by AIDSCAP among organizations working in HIV/AIDS prevention has also strengthened prevention and reduced duplication of efforts. Through "focus site intervention teams" (FSITs) in Ethiopia, AIDSCAP brings together not only NGO staff, but personnel from regional health and education bureaus, municipal governments, factories, religious groups and community organizations.
These intersectoral teams are part of comprehensive programs initiated by USAID and AIDSCAP in four regions where surveys have identified a high prevalence of sexually transmitted disease: Tigray, Amhara, Oromia, and the Southern Nation's, Nationalities and People's Regional Governments.
Each of the four FSITs is coordinated by a chairman and a secretary selected by members of the team. Team members meet at least once a month to discuss progress reports, divide tasks among themselves, and plan how to mobilize local residents for action against HIV/AIDS. Member organizations carry out separate interventions, but coordinate their activities to ensure that all target audiences in a focus site receive the information and services they need to reduce their risk of HIV infection.
In each focus site, AIDSCAP's strategy is to involve all the key actors, according to Tenagashaw. For example, factory representatives were invited to participate in the FSITs to help team members gain access to managers, whose support was needed for workplace prevention programs.
Some members were dubious when asked to join an FSIT.
"They told us, 'There are other regional committees that deal with health issues,'" Tenagashaw said. "But when we explained the purpose of the FSITs, they understood that this was something different -- not a policy-level committee, but an action-oriented grassroots team that is very close to the intervention."
FSITs at Work
In the town of Mekelle in Tigray, the FSIT consists of representatives of the youth club, the women's association, the municipality, the regional labor and social affairs office, the Mekelle branch of the Family Guidance Association, the Mekelle Flour Factory, the Organization for Social Services of AIDS (OSSA), the regional education and health bureaus and the Mekelle health center, as well as two international NGOs, Population Services International (PSI) and the Mekelle branch of the Red Cross Association.
Mekelle FSIT members meet regularly to report on activities, discuss problems encountered and seek common solutions. They develop joint action plans and lend each other cars, video recorders and other equipment. They also pool their resources to organize large public gatherings such as annual World AIDS Day events.
FSIT members believe that their collaboration is one of the main reasons for the success of efforts to promote safer sexual behavior among groups targeted by the program. Changed attitudes toward condom use are particularly noteworthy, according to one FSIT member.
"Until recently, people felt shy about carrying condoms in public," said Yirga Gebree Egziabher, OSSA representative for Tigray. "But now youngsters and adults -- men as well as women -- feel no qualms about carrying condoms in public. Even married couples were seen taking condoms from distributors without fear on World AIDS Day."
PSI reports that 50,000 condoms a month were sold in Mekelle in 1995. Monthly sales are averaging 60,000 in 1996, up from 20,000 in 1993.
In the southeastern town of Nazareth in the Oromia region, the FSIT promotes education about HIV/AIDS and other STDs, strengthens condom distribution, organizes seminars and meetings, and trains community health workers. Each member of the team plays an important role.
"The town council, a member of the FSIT, has been instrumental in helping the FSIT reach the people and in persuading bar and hotel owners to send commercial sex workers to us for education," said Sister Tayetch Lemma, a nurse who is the zonal STD/AIDS coordinator.
The FSIT has also organized anti-AIDS committees and carried out joint educational activities at schools and factories, she added. "The fact that members of the FSIT are working together has given strength to activities in focus sites."
One result is a steady increase in condom sales. Average monthly sales were 70,000 in 1995 and are expected to reach between 80,000 and 100,000 in 1996. PSI's agent in Nazareth estimates that 80 percent of the town's sexually active population uses condoms.
FSIT coordination has also strengthened the efforts of AIDSCAP and an NGO called Nazareth Children's Centre and Integrated Development (NACID) to reach two important target audiences -- ex-servicemen and the rural population. FSIT members providing HIV/STD education to these groups facilitate referrals to NACID and Ministry of Health clinics.
FSIT Results
Sharing resources and coordinating the activities of public and private sector organizations has enabled the FSITs to accomplish far more than would have been possible if each member organization had worked separately -- at far less cost. FSIT member Dr. Degefu Girmay, STD/AIDS coordinator of the Tigray Health Bureau, believes that the organizations would have had to spend ten times as much to get the same results.
Regular meetings keep FSIT members informed about the other organizations' activities, enabling them to avoid duplicating efforts. For example, an NGO dropped its plans to create new HIV/AIDS materials for youth when its FSIT representatives learned the education bureau had already developed materials they could share. In some sites, FSITs divide up responsibilities for monitoring workplace activities.
Bringing together FSIT members has also helped build better understanding and stronger relationships between the governmental and nongovernmental sectors in the four focus sites, Tenagashaw said. "The more people come together, work together and share experiences, the more they start to realize that this is an essential element of AIDS control and prevention activities."
-- Emily Nwankwo and Alemayehu Takele
Alemayehu Takele is a senior reporter for the Ethiopian News Agency. Emily Nwankwo is a program officer in AIDSCAP's Africa Regional Office in Nairobi, Kenya.
