Module 3: Operationalizing ECR: Administration and Management

Overview

• How are structures and systems determined based on local needs?
• Where will the money come from?
• How will accountability be ensured?

There are many complex questions to be addressed about putting an ECR into operation. This module will help stakeholders consider key issues for design, implementation and evaluation of HIV/AIDS programs. Module 3 is designed to facilitate dialogue among stakeholders and provide tools for making decisions when implementing ECR HIV/AIDS programs. This module:

• Presents guiding principles for ECR HIV/AIDS administration and resource management.
• Discusses decentralization aspects of planning, funding and programming.
• Explores resource transfer mechanisms to support ECR.
• Addresses resource management and accountability systems.
• Examines administrative and management level responses at the community, local, provincial and central levels.
• Discusses "mainstreaming" HIV/AIDS into development programs.
• Explores replicating best practices and models.
• Presents key questions for stakeholders to consider in implementing the operational aspects of ECR.
• Provides case study examples of putting an ECR into operation.
• Provides references and resources for further reading.

Guiding Principles

There are key principles to guide stakeholders in making decisions about how to implement ECR in their environments. Two key areas – participatory governance and accountability for resources and results – are important to consider in developing new and innovative administrative and resource management mechanisms.

Decentralization of Planning, Funding and Programming

Decentralized programs are being designed and implemented by governments throughout the developing world. These programs often include major structural reforms, particularly in the health and education sectors that are critical for implementing HIV/AIDS programs. The basic thrust of the reform is to transfer authority and responsibility for planning and funding programs from the central level to less centralized district authorities to establish delivery systems that are both cost-effective and equitable.

In response to decentralization initiatives, international donors are modifying their approach by supporting Sector-wide Approach Programs (SWAPs), in which governments and international donors work together to design and implement a strategic plan. SWAPs are intended to improve the efficiency and impact of development assistance by pooling resources and technical assistance in support of a common strategic plan. The SWAP concept is being applied to health, education and agricultural needs in many resource poor countries.

The ECR response can enhance and strengthen these decentralized approaches of governments and funders. The main sectors involved in the planning and funding of decentralized services include the health and education sectors in the particular country.

Decentralized Sector-based Systems to Support ECR

There are many decentralized sector-based systems that can support ECR, including:

• Strategic planning at the national, state and district levels
• Mechanisms to facilitate the transfer of funds to the community
• Financial and administrative management systems
• Health management information systems
• Development of human capacity
• Greater organizational, technical and operational capacity of public and private sectors
• Improved management of drug and commodity supply and use
• Community mobilization and involvement
• Enhanced public-private partnerships

Suggestions for best handling eight key ECR implementation priorities are described in the following chart.

When developing ways to optimize implementation of ECR for the eight mechanisms above, stakeholders and planners can consider the following guidelines:

• The ECR plan should be designed in an organizational framework that includes participatory strategic planning and management. It should define what actions to take, what resources are required and what results are expected.

• Stakeholders must invest sufficient resources and effort to develop a financial and administrative management system to monitor the flow of ECR resources from the national to the local level. Establishing and strengthening accountability mechanisms in these systems is very important.

• Agreeing upon a methodology for monitoring and evaluating results is crucial in designing a decentralized ECR. Existing health management information systems and standardized national surveys can be used whenever possible, although developing a unified ECR monitoring and evaluation system is ideal. The focus of monitoring and evaluation is more on measuring and monitoring outcome and impact indicators than on looking at process indicators.

• Designing an ECR requires procuring drugs, medical supplies and other commodities. Stakeholders must develop and support efficient and beneficial procurement mechanisms, such as purchasing in bulk. Many countries have parallel distribution systems run by NGOs and/or private sectors that can be considered for international investment support.

National-Level Resource Transfer Mechanisms to Support ECR
As countries prepare to mount an ECR, they should consider innovative mechanisms for transferring resources to field programs. Some governments have developed national Poverty Reduction Action Funds (PRAFs), such as in Uganda, or HIV/AIDS Response Funds, as in Ghana. While PRAFs usually are part of an overall government budget, they can be designed to ensure that resources are directed to decentralized implementation units at the district and sub-district levels — and can sometimes provide resources directly to decentralized NGOs and private sector partners. The reliability of resource transfer mechanisms affects a government's ability to implement ECR and to attract additional external support and resources.

Resource Management and Accountability Systems
Specific examples regarding particular countries' experience with accountability of HIV/AIDS funding do not exist at this time; however, as increased funding for HIV/AIDS is being mobilized, accountability becomes an increasing concern. Governments routinely establish independent anti-corruption units at the national level. In addition, civil society groups and international partners have designed and implemented anti-corruption programs in some countries. Accountability can be enhanced greatly by simultaneous implementation of government, civil society and international partner anti-corruption programs.

Civil society groups are developing accountability mechanisms to complement government anticorruption efforts in some countries. The Uganda Debt Network established district-level poverty monitoring teams (PMTs). Transparency International (TI), an organization that addresses anti-corruption, is active in more than 77 countries. TI national chapters are at the heart of the global anti-corruption movement and work to design national anti-corruption strategies by lobbying governments, educating the media and bringing together people concerned about corruption in their countries.

The Administrative and Management-Level Response to ECR

The administrative and management-level response to ECR is examined on four different levels: community, district/local, state/provincial and national/central.

Community-Level Response
One of the major constraints to using HIV/AIDS interventions is accessibility. Significant positive results can be achieved by moving interventions closer to target populations and actively involving target populations in service delivery. Decentralization and participatory development methodologies, such as participatory learning for action (PLA), offer new opportunities for establishing partnerships between service providers and communities. Key partners at the community level include traditional and religious leaders, NGOs, community-based organizations, community committees/structures and community development associations. In these new partnerships, communities can strive to:

• identify and solve problems;
• strengthen innovative partnerships between health and education sector services and community-based programs;
• increase access to interventions in high-risk areas and supply essential commodities to trained providers;
• expand referral systems; and
• develop inter-sectoral partnerships to deliver integrated interventions.

Many countries are developing community-based structures (or building on existing ones) to support HIV/AIDS interventions; Community AIDS Coordinating Committees (CACSs) are but one example.

District/Local-Level Response
The district-level response represents a critical operational strategy, particularly in countries with increasing HIV prevalence, because it prioritizes delivery of interventions by local-level stakeholders. A district-level response should:

• Establish an inter-sectoral district HIV/AIDS coordinating unit or task force with a common vision to mobilize for action against HIV/AIDS.
• Conduct a district-wide situational analysis that mobilizes stakeholders and helps to shape information for strategic planning.
• Develop a district-wide strategic plan that prioritizes interventions for specific target populations, defines sectoral responsibilities, develops necessary delivery resources and clearly outlines expected results.
• Enable districts to receive and manage resources that can be transferred down to local, community-based implementers.
• Ensure that district AIDS coordinators are responsible for monitoring and evaluating the impact of resources.

Source: Project Concern International 1998.

State/Provincial-Level Response
In many countries, the state or provincial government serves as an intermediary governing structure between the national and district levels. State/provincial-level officials have varying degrees of responsibility for planning, allocating resources and ensuring results. The following chart outlines some of the skills that can be strengthened at the district/local and state/provincial levels.

Central/National-Level Response
One critical component of developing an ECR is establishing and strengthening a national HIV/AIDS coordinating body. This body must have independent institutional authority that is directly linked to the highest political offices of the government.

A national HIV/AIDS coordinating body could help establish strategic linkages to the Ministry of Finance to ensure that HIV/AIDS programs are mainstreamed into development programs and the various sectoral programs. The Ministry of Finance also can be responsible for holding sectoral programs accountable for achieving results. It is important that national coordinating bodies have the capacity to implement and lead strategic planning processes, conduct policy analysis, design operational approaches for delivering interventions, and establish an information clearinghouse.

Mainstreaming HIV/AIDS into Development Programs

Stakeholders recognize opportunities for mobilizing resources and ensuring a political commitment to combat the HIV/AIDS crisis. In some African countries, stakeholders are working to define and implement mainstreaming of the HIV/AIDS response into the development agenda. One of their key objectives is to use debt-relief resources to expand the response. The following priority actions can be considered when mainstreaming HIV/AIDS into development programs.

• Make HIV/AIDS a super-sectoral priority and mainstream it into poverty reduction strategy papers (PRSPs) or interim PRSPs (iPRSPs). The World Bank and the International Monetary Fund (IMF) are helping governments develop comprehensive PRSPs, which are required for World Bank and IMF loan programs and debt-relief initiatives. The IMF implements its major loan program through the Poverty Reduction Growth Facility (PRGF), while the World Bank implements loans through the International Development Association (IDA).

• Complete national HIV/AIDS strategic plans. Be sure these plans clearly state goals, performance targets, prioritized actions and required budgets.

• Ensure that debt-relief programs, particularly under the enhanced Highly Indebted Poor Country Initiative (HIPC), contain major commitments to the performance targets contained in the PRSPs and national HIV/AIDS strategic plans.

• Fully integrate HIV/AIDS and OVC responses into country Medium Term Expenditure Frameworks (MTEFs).

• Establish a resource transfer mechanism to ensure that decentralized implementers in the public and private sector can make optimal use of the budgetary savings from debt relief and other sources.

The chart above outlines the mainstreaming of HIV/AIDS in development programs.

Replicating Best Practices and Models
A major challenge faced by countries that have begun to fight HIV/AIDS is how to effectively identify, disseminate and replicate best practices and models for districts and communities. The following actions are proposed from the ECR approach for replicating best practices.

• Select high-performing community and district-based programs or groups that offer the best examples of an ECR. The model sites should agree to become training and demonstration centers for their country and/or region.
• Have stakeholders invest in the model sites and transform them into ECR learning centers.
• Use ECR learning centers to train groups to apply the concepts in their local communities and programs.

Key Questions for Making an ECR Operational

What follows is a list of key questions for program managers and planners to consider when making an ECR operational. This list compiles all key implementation questions in this module.

Key Implementation Questions for Making ECR Operational – 1

Decentralization

What is the status of decentralization in the country?

• Is there a government-approved decentralization plan?
• Is decision-making authority being decentralized to district officials?
• Are resources being transferred to districts for local programming?

What opportunities and challenges does the overall decentralization program offer for designing and implementing ECR?

Is the country decentralizing its HIV/AIDS response?

• Are local authorities empowered to manage HIV/AIDS resources?
• Are local authorities working with non-governmental organization (NGO) partners to implement ECR at the local and community levels?
• Are persons living with HIV/AIDS (PLHA) included in the HIV/AIDS program design and implementation?

ECR and SWAPs

Are SWAPs being planned or implemented in your country:

• In the health sector?
• In the education sector?
• In other sectors?

Are HIV/AIDS interventions being mainstreamed in the sectoral plans?

Are SWAP resources earmarked for HIV/AIDS programs?

What opportunities and/or challenges to ECR implementation do SWAPS offer?

Optimizing Implementation of ECR

Have businesses, faith-based organizations and NGOs mainstreamed HIV/AIDS into their strategic plans?

Have partners agreed on a common monitoring and evaluation framework to assess progress?

What are the critical areas of the management structure (health and other sectors) that must be strengthened to succeed?

Key Implementation Questions for Making ECR Operational – 2

Community- and District/Local-Level Response

Can interventions at the district and community levels be implemented rapidly by existing administrative structures, or does ECR require a restructuring of governmental and non-governmental structures to ensure successful results?

Are district structures in place (for example, HIV/AIDS task forces) to mobilize public and private sector partners to develop an effective response?

Does the district have the capacity to implement and support community activation methodologies?

Mainstreaming HIV/AIDS into Development Programs

Has HIV/AIDS been mainstreamed as a super-sectoral priority in these national development instruments:

• the National Development Plan/Program?
• the Poverty Reduction Strategy Paper (PRSP)?
• the United Nations (UN) Development Assistance Framework?
• the World Bank Common Development Framework?
• the Medium Term Expenditure Framework (MTEF)?

Replicating Best Practices and Models for ECR

Is there a national or provincial mechanism to identify and replicate best practices for an HIV/AIDS response?

Can NGO networking organizations assume the responsibility for resource transfer and accountability for decentralized NGOs? How can these sub-granting organizations be strengthened?

Further Reading

1. Apuuli DK. 2000. Debt-for-AIDS: Uganda's Experience. Satellite Meeting on the International Partnership Against AIDS in Africa (IPAA). 13th International AIDS Conference. Durban.
2. Cassels A. 1996. Aid instruments and health systems development: an analysis of current practice. Health Policy and Planning 11 (4): 354—68.
3. Cassels A. 1997. A Guide to Sector-wide Approaches for Health Development: Concepts, Issues and Working Arrangements. Geneva: WHO.
4. Cassels A, Janovsky K. 1998. Better health in developing countries: are sector-wide approaches the way of the future? Lancet 352: 1777—79.
5. Decosas J. February/March 2000. The local response to HIV in Africa: a question of scale. AIDS Analysis Africa 10(5).
6. Harrold P and Associates. 1995. The Sector Approach to Investment Lending: Sector Investment Programs. Discussion Paper #302: Africa Technical Department Series. The World Bank.
7. Hunter SH. 2000. Reshaping Societies HIV/AIDS and Social Change: A Resource Book for Planning, Programs, and Policy Making. New York: Hudson Run Press.
8. Ministry of Health, Republic of Zambia. May 1997. Policy Guidelines on the Preparation of Health Sector Support Project Documents for All Cooperating Partners in Support of the Health Sector.
9. Pervilhac C, Kipp W, Babikwa D, et al. July 1998. The District Response Initiative (DRI): Missing Link in HIV/AIDS Control, A Situation Analysis in Uganda. 12th International AIDS Conference.
10. Peters D, Chao S. 1998. The Sector-wide Approach in Health: What is it? Where is it leading? Int J Health Plann Mgmt. 13: 177—90.
11. Project Concern International. December 1998. Evaluation of District HIV/AIDS Task Forces in Zambia. Report to USAID.
12. Slutkin G. 2000. How Uganda reversed its HIV Epidemic. Paper #23118. American Public Health Association.
13. Taylor-Ide D, Taylor CE. February 1995. Community-based Sustainable Human Development: A Proposal for Going to Scale with Self-Reliant Social Development.
14. Uganda AIDS Commission. May 2000. Summary of Recommendations for Mainstreaming the HIV/AIDS Response into the Poverty Eradication Action Plan (PEAP) and the Poverty Action Fund (PAF).
15. UNAIDS. May 1999. Guide to the strategic planning process for a national response to HIV/AIDS. Geneva: UNAIDS
16. UNAIDS. May 2000. The International Partnership Against AIDS in Africa. A Framework for Action. Geneva: UNAIDS.
17. UNAIDS. Undated. Resource Guide for Theme Groups: Working Together on HIV/AIDS. Geneva: UNAIDS
18. UNAIDS/WHO. November 1999. District Response Initiative: A Practical Guide to Implement an Expanded Response to HIV/AIDS at the Local Level. Geneva: UNAIDS/WHO
19. United States General Accounting Office. June 2000. Debt Relief Initiative for Poor Countries Faces Challenges. GAO/NSIAD-00-161. Washington: GAO.
20. WHO/SHS/83.6. Community Involvement in Health Systems for Primary Health Care. A report recommending specific policies and actions to promote and support implementing community involvement in health systems for primary health care with background information on community mobilization. Geneva: WHO/SHS.

Case Studies

Case Study 1: Creating District HIV/AIDS Task Forces in Zambia
In 1997, the Republic of Zambia began transferring the National HIV/AIDS, STD, TB and Leprosy Program (NASTLP) from the government's health sector to the multi-sectoral National HIV/AIDS Council and Secretariat (NHAC/S). The mandate was to mobilize a multi-sectoral capacity building in five districts – Livingstone, Lusaka, Kitwe, Nchelenge and Ndola – in program planning, implementation and monitoring and evaluation. Limited support was included for national policy and for the transition to the NHAC/S.

District partners from the government health sector and NGOs expressed the need for improved collaboration as a priority for strengthening HIV/AIDS programs. The goals were to develop models for inter-sectoral collaboration in programming and resource mobilization and to support the emergent collaboration bodies (the "District Task Forces" or DTFs) to become self-managing and self-sustaining.

Three steps were involved in building inter-sectoral DTFs in Zambia:

• Step 1: Forming and organizing the inter-sectoral DTFs, including increasing DTF group member skills for organizational and management systems development.
• Step 2: Increasing technical capacity of DTF member groups to plan, implement, monitor and evaluate HIV/AIDS interventions and HIV/AIDS interventions developed through the DTF approach.
• Step 3: Making improvements in the social and policy environment supporting DTF initiatives.

Case Study 2: Developing an ECR Administrative and Resource Management Structure in Response to the World Bank Loan Program in Kenya
The Government of Kenya has declared HIV a national disaster, and established the National AIDS Control Council (NACC), which has developed a National Strategic Plan for HIV/AIDS. The objectives of the Council are to mobilize resources and provide a framework for leadership and implementation at all levels.

The objectives of the Kenya National Strategic Plan for HIV/AIDS are to:

• arrest, stabilize and reduce HIV/AIDS prevalence by 20 percent to 30 percent among 15- to 24-year-olds by 2005;
• increase access to care and support for the infected;
• strengthen capacity for coordination and response;
• develop comprehensive management information systems; and
• develop appropriate policies to deal with HIV/AIDS-related stigma.

In addition to the NACC, the following have been developed to support an ECR in Kenya:

• AIDS Control Units (ACUs). ACUs will be established in each ministry and will be responsible for mainstreaming HIV/AIDS into the core functions of the ministries.
• Provincial, District and Constituency AIDS Control Committees (PACC, DACC, CACC). These units are responsible for coordinating implementation of HIV/AIDS activities. CACCs were initiated with unanimous agreement by the Members of Parliament to allow them to be agents of change for their constituencies.

The chart summarizes the structure that was proposed for Kenya.

Case Study 3: Mainstreaming HIV/AIDS into Development Instruments in Uganda
The Highly Indebted Poor Country Initiative (HIPC), launched in 1996, was the first multilateral approach to reduce the external debt of the world's poorest, most heavily indebted countries. The principal objective of HIPC is to bring a country's debt burden to sustainable levels (subject to satisfactory policy performance) to ensure that adjustment and reform efforts are not jeopardized by high debt and debt service burdens.

Uganda was the only country in sub-Saharan Africa that benefited from the original HIPC debt-relief mechanism. The 1999 Cologne Initiative significantly enhanced the original framework of the HIPC Initiative, which is deeper, broader and faster. To date, 33 countries in Africa are participating in the enhanced HIPC Initiative.

The Government of Uganda is scaling-up a multi-sectoral approach to support the prevention initiatives, care and support programs, and impact-mitigation interventions. As part of this process, the Uganda AIDS Commission is trying to leverage HIPC debt-relief resources to support the Uganda National HIV/AIDS Strategic Framework.

By mainstreaming HIV/AIDS as a supra-sectoral priority with the Uganda Poverty Eradication Action Plan (PEAP), all sectoral programs can consider developing sector-specific HIV/AIDS interventions. This will optimize implementation of a genuine multi-sectoral response. Prioritizing HIV/AIDS in the PEAP led Uganda's Ministry of Finance to incorporate HIV/AIDS into the Poverty Action Fund. In Uganda's MTEF 2000-2002 budget, $110 million (US) was allocated to support scaling-up of the national AIDS response. Before this, the government provided no resources in the MTEF for these priorities.

To address areas for improvement in government anti-corruption efforts, many civil society groups are developing complementary accountability mechanisms. The Uganda Debt Network, an independent NGO, established poverty-monitoring teams (PMTs) at the district level to monitor the use of PAF resources. Over the past two years, the PMTs have identified locally developed anti-corruption innovations. For example, the headmasters of primary schools are required to post their monthly budget publicly so all parents know what resources were allocated to the school. This intervention quickly abated corruption by headmasters who had been misallocating debt-relief resources.