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Implementing expanded responses

National strategic planning

A single, powerful national AIDS plan involving a wide range of actors – government, civil society, people infected with and affected by HIV, the private sector and (where appropriate) donors -– is a highly valuable starting point of a strong strategic response to the epidemic. The development of a country strategy begins with an analysis of the national HIV/AIDS situation, risk behaviours and vulnerability factors, with the resulting data serving to set priorities and focus initial action. It is essential to find out where people in the country are already infected, where they are most vulnerable, and why.

Effective strategy development then involves drawing on evidence-based methods of HIV/AIDS prevention, care and impact alleviation – "best practices"- recognising that some of these may be culturally sensitive (for example, accessible and confidential reproductive health services for adolescent girls) or require hard political choices (for example, needle exchange for injecting drug users). At the same time attention needs to be given to ensuring that the relevant services and commodities such as STI services or condoms are affordable and available.

Formulating a national strategic plan will also involve learning from those programmes which have successfully, though usually on a small scale, dealt with different aspects of the epidemic. The Plan should work towards incorporating or adapting elements from these best practice programmes and implementing scaled up versions of them, to eventually provide national coverage of, say, voluntary counselling and testing, or 100% condom use. Governments can effectively adopt policy changes and programme approaches that have "passed the test" at the local level.

These programmes’ staffs and volunteers have much to offer a national response. They can use their experiences and insights to train others so that the original programmes can be scaled up.

However, the process is not easy and requires patience and tolerance. Participation and consensus is essential, as opinions differ and it is important to listen to as many different points of view as possible and to take them into consideration during the planning process. While many countries have national strategic plans, they have often failed to act as a platform around which all actors have been willing and able to programme their resources. Impact on the epidemic is compromised by fragmentation. Different actors pursue different agendas in isolation from each other. Instead of working within nationally negotiated and agreed strategic agendas, actors – whether government or non government, UN or private sector – have tended to address HIV/AIDS as an area for designing and implementing multiple, often small-scale projects, with their own objectives, management, monitoring and evaluation systems.

The strategic plan must be implementable, given a country’s constraints. There must be earmarking of funds specifically for HIV/AIDS, and they should include financial resources for action at community level.

It must be possible to move from planning to effective strategic management. This involves a strong monitoring process, feedback to decision makers, holding key players accountable for activities which they are responsible for.

Malawi's experience shows how a broad-based national consensus can be built around a strategic planning process. The approach of using extensive workshops and community consultations proved effective as a means of gaining information about local situations. It also had the added benefits of informing a wide range of groups and institutions about AIDS as an issue, building a sense of ownership among these groups and institutions, capacity building, and giving the country's political leadership a high-profile document to commit to, with clear goals and principles.

Although the government has since 1985 undertaken a variety of HIV/AIDS activities, infection rates have not yet begun to slow down. Officials and donors have recognized that behaviour change is limited and a culture of silence is still a major factor. This has been compounded by weak institutional capacity to provide policy and technical leadership in such areas as surveillance, counselling, home-based care, civic education, and control of sexually transmitted infections.

Starting in 1998, Malawi created its Strategic Framework and Agenda for Action 2000-2005 with technical assistance from UNDP, UNICEF and UNAIDS. The process used was the Strategic Framework approach adapted from UNDP's HIV and Capacity Building Initiative, which emphasizes social mobilization and consensus building methods to create institutional involvement at the plan preparation stage. The Ministry of Health led the way by creating a Strategic Planning unit to manage the 18-month process, which proceeded as follows:

- Situation Analysis and Response Analysis (February-September, 1998) to estimate the current impact of the disease and document what the country was doing about it

- Strategic Plan Formulation (October 1998-April 1999) to decide what major actions had to be taken in response to prevaling conditions and estimated resource levels

- Consensus Building Phase (May-August 1999) to ensure that all significant partners (both existing and potential) in the response understood the plan and agreed with it.

These Situation Analysis and Response Analysis activities were conducted together through "issues workshops" aimed at gaining community input. This permitted an inventory of existing community actions against AIDS to be made. The resulting report was organised on thematic areas and provided a broad analysis of the existing strengths and opportunities in the national response. A total of 57 religious institutions, NGOs, and public and private organisations were involved in the process

The cost of the 18-month planning process was an estimated 1 million USD. A Resource Mobilisation round table (workshop) was held in March, 2000, during which partners pledged US$121 million.

The resulting Strategic Framework contains goals for nine major components of the response, guiding principles, broad objectives for each component, a budget estimate based on international partner pledges for the period, and strategic actions for each component. The nine components provide guidelines for districts or sectors rather than inflexible directives, with implementing agencies expected to prioritise actions based on their own capacities. With the Framework as a broad guide, the next step was to write a detailed National Agenda For Action defining specific activities and listing implementing agencies or partners.

The process has not been perfect. An initial review of the Strategic Framework and Agenda for Action noted that no provision for a reprogramming cycle was made in order to plan for the period 2004-2008, and implementation arrangements are unclear and complex. There are as yet no mechanisms to define multisectoral action.

Nonetheless, Malawi has clearly moved ahead by putting together its first comprehensive plan on mitigating the impact of the epidemic, and on breaking the silence surrounding HIV/AIDS. With a view to maintaining momentum and ensure follow up, a Cabinet Committee on HIV/AIDS Prevention and Care, chaired by the country’s Vice-President, was set up to guide policy formulation and implementation, speed up enactment of legislation on HIV/AIDS issues and ensure HIV/AIDS attains priority in all arms of government.

In countries facing an uncertain political situation, wide consensus is hard to build, donors are notably reluctant to commit funding, and government priorities may change rapidly and often, making planning difficult. The interaction of Cote d'Ivoire’s UN Theme Group on HIV/AIDS and its officials responsible for the national HIV/AIDS response provides a number of important lessons for coping with such circumstances and moving the response ahead.

Perhaps the most important lesson is the value of establishing close links between the Theme Group and the statutory national authorities responsible for AIDS. The links with Cote d’Ivoire’s Ministry of Health and the National Programme Against AIDS, STIs and Tuberculosis (PNLS/MST/TUB) are not just formal but based on real participation at different levels. At the highest level, the Executive Director of PNLS/MST/TUB has sat as a member of the Theme Group almost since its beginning. At the working level, PNLS/MST/TUB Technical Director participates as a member of the Theme Group 's Technical Working Group, and is thus kept abreast of all research and intervention activities, The benefits go both ways, for the national authorities have been able to contribute their own considerable knowledge to the Theme Group, and to provide services such as transportation, working space, and logistic support for workshops.

The Theme Group in Cote d'Ivoire benefits from the personal attendance of the UN agency heads at the monthly core group meetings. From time to time, the Theme Group sponsors retreats during which the agency chiefs (and sometimes other partners) can work more profoundly on specific issues or activities. This was the case with the country's National Strategic Plan in 1999, and with the country's participation in the International Partnership against AIDS in Africa.

In particular, the Theme Group has been able to formulate and adopt an Integrated Work Plan for the cosponor agencies (April 19, 2000). The Integrated Work Plan was the result of a strategic planning process financed by UNAIDS. The Technical Working Group (TWG) was chaired by the Country Programme Adviser and attended by the UN agency focal points and the Technical Director of the PNLS/MST/TUB. The TWG met six times, using the PNLS/MST/Tub’s operational plan for 2000-2001 as a base for analysis in order to identify ways the Theme Group could support in a joint fashion, and/or according to the specific mandates of each agency. Joint activities were listed, budgets specified and lead organisations formally designated.

As Côte d'Ivoire is currently directed by a transition government and the traditional international funders have frozen their activities, the Theme group provided a mechanism by which a formal relationship is maintained with important bilateral or multilateral actors in Cote d'Ivoire 's AIDS response, and close touch kept with their projects. Examples include: the microbicide research project of the Institute of Tropical Medicine, Antwerp , Belgium; - the French government's Solidarity Fund along with various French-supported research projects, including those on the use of cotrimoxazole against opportunistic infections , use of the antiretroviral ZDV against mother-to-child transmission, and several social science projects; USAID ’s involvement with Projet Retro-Ci 's HIV testing and research work.

In Malawi the problem of caring for AIDS orphans is already felt and is expected to worsen. Malawi’s HIV infection rates are among the highest in the world standing at 13.0% of the population. With such high infection rates, the problem of orphans is a significant national priority, and efforts have therefore been made to systematically address the problem.

In 1991, the Government of Malawi with the assistance of UNICEF organised a National Consultation on Children Orphaned by AIDS to plan in which a large number of children would be orphaned by AIDS. This gathering realised that they were dealing with a complex problem that requires careful planning. The Consultation produced a 12-point "Policy guidelines for the Care of Orphans in Malawi and the Coordination of Assistance", to guide the development of a national Programme based on building capacities for orphan-care especially at the community and at national level. The Guidelines are simple and brief, and over the years have often been used by the Government as programme development guidance for groups interested in developing orphan care programmes.

The consultation also created a National Task Force on Orphans (NOCTF) to ensure that the policy is implemented. It includes national and district government representatives from the Ministry of Women Youth and Community Services; the Ministry of Health and Population through the National Aids Control Programme (NACP); key NGOs and Community Based Organisations (CBOs); major religious bodies in Malawi, and UNICEF.

In Malawi there are many stakeholders in orphan care necessitating proper and effective coordination, without which chaos could result. The first task was to lay down clear guidelines as to how the various issues would be handled i.e. who was responsible for what at all levels. In Malawi’s case it was decided that there were already existing structures such as AIDS Committees, which would integrate, orphan-care rather than create new ones. These structures have been utilised ever since. Emphasis has been placed in building their capacity so that they can act independently and be self-reliant. This has been done through training and orientations, supporting networking and information sharing. Multisectoral approaches have also been given much emphasis.

Large numbers of orphans may be intimidating and lead to a programme that addresses only the immediate or survival needs of individual orphans such as shelter, homes, food and clothing and advocacy. In the early years, the Malawi Programme was unintentionally caught in this trap, where much attention was focused on these material and physical needs of orphans.

As the Malawi programme has grown it has increasingly began to recognise and address all the rights of children to survival, development, protection and participation. The integration of all rights has not come about deliberately but per-force of circumstances for example older orphans increasingly participate in orphan - committees in various capacities. Experience in Malawi shows that orphans are vulnerable to having their rights violated even by their own guardians, the community at large and the State. Therefore deliberate steps should be taken to ensure that orphans are protected in any way possible. The frequently violated rights include the right to be heard in situations which affect their lives e.g. in adoption cases, custody, the right to inherit property from their deceased parents, right to education and health care in certain circumstances.

The need for cost effectiveness has been a major influence in the development of approaches in the Malawi orphans’ programme. The current Orphan-care National Programme was estimated to require K20.0 million USD30 m) for the three years from 1996-1998, to meet the costs of capacity building at all levels, including that of the Ministry, NGOs, CBOs and village orphan committees, monitoring and assessment of the orphans, advocacy, policy and legal review. Experience has shown that funding from Government is lower than planned and erratic in the middle of economic restructuring. The Programme has relied heavily on donor funding as a result with Government providing support in kind, mainly manpower. Because of these constraints against a background of high demand for services, it is necessary to seek interventions that have a high impact at lowest costs.

The resultant approach therefore has been to target affected communities or those that show initiative, rather than individual orphans as this is an effective way of reaching the large numbers of needy orphans., The Programme has adopted the policy that the day to day responsibility for providing for children including orphans is that of the family or community, and should remain so. The Programme is therefore to strengthen this not substitute it. Targeting whole communities has the advantage of reduced per-capita costs, and therefore reaching more children.

The development of Uganda’s 2000-2005 National Strategic Framework for HIV/AIDS Activities is one example of the decisive role that can be played by national political leadership. The previous Framework (1998-2002) having been created but not implemented, President Museveni took personal charge of the planning process, which resulted in government-wide implementation of Uganda’s 2000-2005 National Strategic Framework.

The process to develop the 1998-2002 Framework started in 1996, and was planned as a two-year process of extensive consultations among stakeholders. A core group of representatives from eleven key organisations (called CG 11) involved in HIV/AIDS activities in Uganda undertook the task of drafting this framework. These were Uganda AIDS Commission, Ministry of Health, Ministry of Local Government, Ministry of Finance, Planning and Economic Development (MFPED), UNAIDS, UNFPA, the Islamic Medical Association of Uganda, The AIDS Support Organization (TASO), Joint Clinical Research Center, Medical Research Council, and Networks and Associations of PHAs. The CG 11 was later expanded to include a representative from UNICEF) and Uganda Youth network on AIDS and STIs. Situational information was obtained from a range of commissioned studies. Finally, the drafting exercise was achieved through a series of meetings of the CG 11 and its thematic sub committees.

The draft framework was refined during the two workshops in 1997 that involved major partners in the area of HIV/AIDS in Uganda.

After that, the process lost momentum. Among other problems, many Ministries had not fully understood or accepted their role in a multisectoral approach, and were not prepared to make new resources available for it. By 1999, the Framework had still not been adopted government-wide and, due to changing economic conditions and the development of the epidemic, was fast becoming obsolete.

At this point, the President intervened, emphasising his personal interest in this matter of national importance and insisting that the process be finished quickly. The Permanent Secretaries (heads of civil service) in all Ministries met to re-define their overall roles in the response, and the planning work was updated between September 1999 and March 2000. During that time, the Ministry of Health lent its AIDS expertise to other Ministries more actively than during the previous process, and this (plus the weight of the President’s interest) made a considerable difference. A three-day consensus meeting was all that was finally needed for the Framework to be updated and adopted.

It is not the purpose of this paper to go into the details of the Framework, but in the context of our discussion of public administration and governance it is worth noting some structural innovation in the Framework, which should help the efficiency of the response. This is the creation by statute of a new National AIDS Commission and supporting Secretariat.

Responsible for overall coordination of all AIDS activities in Uganda, and for periodic evaluation and monitoring of the national program, the Commission is composed of a chairman not belonging to any government ministry and a maximum of seven members who are men and women of integrity and influence and, with knowledge and experience in HIV/AIDS. These will include one PHA, youth and at least one woman. Appointment of Commissioners and Director General for the Secretariat will be done by the President through an transparent political procedure including approval of suitable candidates by cabinet. Among other duties, the Commission will institutionalise a national joint planning team (NJPT) for the purpose of over seeing the national HIV/AIDS programme, specify data needs for evaluation, convene quarterly meetings of the NJPT for purposes of planning and harmonising plans and reports, and effectively monitoring and evaluating the national program.

Support to Local Responses to HIV/AIDS

Support to local responses to HIV/AIDS is based on the empowerment of communities through the development of local partnerships consisting of social groups, service providers and facilitators. United in these local partnerships, people are gradually building socially acceptable actions that enable them to respond adequately to the epidemic.

Such support can only be based on decentralisation of the overall management of national responses.

The District Response Initiative is now underway in about 15 countries, which represents 50% of countries with national strategic plans.

Examples of Best Practice

 Gaoua: Consensus building of all actors

Leadership level: governmental and non-governmental organisations, communities, NGOs, religious authorities

Contribution to success: Agreement on a common plan, shared objectives and priorities, mobilisation of own resources

Opportunities: Expanding local responses on a national and international level

Since 1987, the country has set up large scale HIV prevention activities. The country has been exploring, since 1998, different new approaches to become more effective in responding to HIV/AIDS. Those are currently being formulated in the 2001-2003 National Strategic Plan that is in the process of being developed, and will be finalised by the year 2000. It involves the Health Sector and non-health public sectors, as well as the voluntary and private for profit sectors, who take the necessary time and attempt to define the best solutions to the problems and realities of the country, in contrast to quick fix solutions imposed from the outside. Several Ministries, in addition to the MoH, are presently directly involved in the planning of activities: Economy and Finances, Social Action and Family, Secondary Education, Higher Education and Scientific Research, and Communication and Culture.

Presently the intensification of the national response lies in four domains:

institutional strengthening (still heavily centralised health system and limited managerial capacity of NACP),

financial sustainability (increase the financial support for new strategies and the national and district levels, and finding mechanisms for effective transfer of funds to Districts),

HIV drugs procurement policies and strategies and kits and materials for safe blood transmission,

Necessary changes in law (for example in more effective channelling of funds).

Tanzania: A ground-breaking by-law

Leadership level: District Council, village governments, ward and village leaders

Contribution to success: Remedial measures to change behaviours

Opportunities: Decrease of vulnerability and risk

Socio-cultural factors that increase vulnerability to HIV/AIDS are being addressed by a number of district responses. Kyela District Council has passed a ground-breaking by-laws aimed at addressing local behaviours that increase vulnerability to HIV/AIDS. Following training sessions, Ward/Village leaders were challenged to identify cultural practices that increase vulnerability to HIV/AIDS and to propose remedial measures. This was done but later on it was decided by the District Council that all cultural practices that hamper development and not only those that increase vulnerability to HIV/AIDS, should be addressed. Village governments in Mbeya, Kagera and Mwanza have also adopted by-laws to fight HIV/AIDS. These by-laws usually discourage or sanction contexts that enhance sexual intercourse outside a monogamous marriage. The contexts identified vary by villages but include: widow inheritance, traditional ceremonies and festivities involving weddings, harvests and initiation ceremonies; alcohol consumption, collecting firewood by women late in evenings, men bathing near women in rivers or at the lake and the new disco culture. But risk factors associated with initiation rites at puberty do not seem to have been addressed anywhere. For example, initiation ceremonies for girls at menarche, which moulds them as subservient subjects for satisfying the sexual needs of their husbands, have not been addressed by the by-laws or other measures.

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