Issues Paper No. 33

MAINSTREAMING THE POLICY AND PROGRAMMING RESPONSE TO THE HIV EPIDEMIC

Mainstreaming: HIV as a Development Issue

It is now commonplace to argue that policy and programming responses to the HIV epidemic need to be multisectoral and multidimensional. But what has happened on the ground has generally been a far cry from this. There continues to be a narrow understanding of the epidemic, both its causes and its consequences, and policies and programming responses have in most countries continued to be focused on a narrow set of conditions and issues.

An important objective of UNDP's activities, undertaken as part of the UN system response, has been to strengthen understanding of the epidemic as a developmental issue. In pursuit of this objective UNDP established in 1992 the HIV and Development Programme with one of its strategic programming areas to "mainstream HIV....for example, in village self-help schemes, food security systems, regional planning approaches, etc., through studies, workshops, training and technical assistance" (HDP Strategic Programming Areas, 1992-1993). UNDP has argued that development is causally related to the spread of HIV infection; that development affects what is feasible in terms of the response to the epidemic, and that efforts to strengthen the development performance of countries can themselves worsen as well as improve the possible policy and programming responses to the epidemic. Unless these developmental parameters are adjusted, through a strengthening of national policy and programming responses, there will be an intensification of the social and economic costs of the epidemic which will increasingly undermine all of the national and international efforts to achieve sustainable human development. An important instrument for increasing understanding of these issues are UNDP?s national Human Development Reports.

To take a few examples related to UNDP's priority areas of focus.

• Poverty is clearly a major factor in leading to behaviours which increase the transmission of HIV, and furthermore the numbers of those destitute will be raised as a result of the epidemic - both directly and indirectly. Research undertaken as part of the UNDP Regional Project for Asia and the Pacific in Thailand and the Philippines on households affected by the epidemic, has established not only short-term effects on family incomes, but longer-term consequences caused by the erosion of assets and reduction in employment which threatens family survival.

• Creating the conditions essential for sustainable agriculture will become even more intransigent given the actual and predicted effects of changing agricultural labour supplies - particularly its gender and age distribution - on rural systems of production and infrastructure. That the effects are severe is confirmed by studies of the impact of HIV on agrarian systems in Africa undertaken by FAO, with financial and technical support from UNDP. The results of these studies are presently leading to a re-examination of agricultural policy and programming. As does the maintenance of human and institutional capacity in key development sectors such as health and education.

• Environmental objectives will become increasingly unattainable as the epidemic worsens economic performance and undermines the national capacity to respond not only to the epidemic but to other developmental priorities. In many countries, public services are now suffering the loss of skilled and professional labour which threatens their effective functioning at the same time as programmes of retrenchment are being put in place. How to mainstream HIV in programmes of public sector reform in high prevalence countries remains a critical challenge.

What is needed is a more complex understanding of the epidemic than has existed hitherto, together with an increased capacity for designing and implementing more effective policy and programming responses. All of these conditions need to be present for an effective worldwide response to the epidemic, of which UNAIDS is an important component. Mainstreaming HIV has to contain all of these - a more complex understanding; a capacity for improved design of programmes and projects through new processes which are socially inclusive; and new and different and more participatory systems for implementing programme responses.

If these conditions are not met then policies to mainstream HIV may produce outcomes similar to attempts to mainstream gender, where UNDP and others have much experience. At least one eminent development practitioner has argued that "Mainstreaming gender has been a way of forgetting about it". There is more than a grain of truth in this observation. The lessons of UNIFEM and others need to be captured in any attempts to mainstream HIV for, unless they are, then efforts to do for HIV what has too often failed for gender will lead to similarly disappointing and ineffective outcomes⁵.

An Example: Legal, Ethical and Human Rights

It may be useful to turn to the example of HIV and legal, ethical and human rights where UNDP has played a significant role in raising awareness of the central importance of an enabling framework of laws and rights, and in strengthening national capacity to respond. Too often policies for HIV are seen as having separate components, and human rights is sometimes just another of these elements. But this misses the essential point; that everything to do with HIV has to be founded in a set of appropriate ethical principles. This objective cannot be achieved through the imposition of "standards" from outside nor by setting up human rights watchdogs, although the latter may have some value. To be effective policies need to be based on a collaborative approach that seeks to protect human rights and establish supportive ethical principles through working with affected communities and their allies, irrespective of whether one is addressing issues of prevention, research, care or whatever.

Mainstreaming here entails a process - working collaboratively with the legal and affected communities to strengthen national capacity in the area of ethics. In so far as this process is successful there will be opportunities for improved programming across the range of development practice and NOT just in areas of narrowly defined projects for HIV. Thus non-discriminatory labour practices are relevant and important for all workers but they are absolutely crucial for effective workplace programmes for HIV prevention and care. Similarly, establishing new relationships of confidentiality and trust are critical for the kinds of socio-behavioural research on the epidemic which is needed for an effective programming response to HIV. This is also equally valid in other areas of development where research is too often extractive, externally defined and inadequately founded in any acceptable set of ethical principles.

Mainstreaming HIV: Some Practical Proposals

The final objective of mainstreaming HIV is self evident: to ensure a more effective policy and programming response to the HIV epidemic. How best to achieve this objective is much more problematic. UNDP has had much experience in this area in recent years upon which to build. There will need to be prior capacity building for a broad range of development practitioners in order to bring about the desired set of outcomes. This capacity for mainstreaming is not currently in place, and will need to be created and strengthened if a more integrated approach to HIV is to be feasible.

An intermediate objective, which is essential for achieving the objective of better programming for the epidemic, has to be to establish in development practitioners ways of reasoning and responding such that in their daily work they automatically understand the relevance of what they do for the HIV epidemic. This is quite different from proforma approaches to mainstreaming; it demands understanding of the issues raised for development by HIV, and a personal and professional commitment to pursue policies and programmes which effectively address the problems of the HIV epidemic.

How are these human capacities to be strengthened? This is the familiar problem of development; ownership of process and responsibility for outcomes, achieved through processes which are collaborative and supportive.

Many things can contribute to the achievement of the objectives outlined above. But it is important to realise at the outset that there is no single solution or way to proceed. As with much else in development there will have to be a process of trial and error, and it is crucial that there be opportunities for reflection and learning. There is no known technique for mainstreaming which is applicable everywhere, at all times and under all conditions. But there are ways of moving closer to both the intermediate objective of better development practice which integrates HIV, and thus to the achievement of better and more effective policy and programming responses. What are the steps required at the present time to move the UN system response towards mainstreaming for more effective programming? The following is an illustrative listing of some of the strategies currently followed by UNDP in pursuit of this objective.

Development practitioners need to start from a base of common understanding of the epidemic if there are to be genuinely collaborative solutions to difficult problems. This common base of understanding does not presently exist amongst the organizations of the UN system, nor within national governments, nor within the private sector (including NGOs, CBOs etc). Given that the Thematic Working Groups of UNAIDS are expected to work collaboratively in support of the National AIDS Strategy, there will have to be activities to create a common understanding both within the cosponsoring agencies (COs), other UN agencies and donors, and national organizations. This strengthening of capacities needs to relate both to specific HIV programming and to other development activities which affect the course of the HIV epidemic.

UNDP has attempted to move forward understanding of the epidemic and strengthen national capacity to respond through such activities as the HIV and Development Workshop where the participants have been drawn from across the development spectrum.⁶ An extension of these Workshops is essential for mainstreaming the epidemic; both specifically for the COs and for their counterparts in the national response. The Thematic Working Groups of UNAIDS stand little chance of succeeding unless they start from a common understanding of the epidemic, including how to mainstream HIV in their development activities. UNDP has an instrument (HIV and Development Workshop); extensive experience in capacity building for development, and, as the manager of the system the Resident Coordinator has the responsibility for an effective UN programming response to the epidemic across the spectrum of development within country.

There are UN agencies which are critical for effective responses to the epidemic and where mainstreaming HIV should have a central role. These include, FAO, IFAD, UNDCP and ILO. UNDP has involved some of these agencies in its training programme, with some success in raising awareness of how development is affected by the epidemic and what might be the feasible ways to mainstream HIV. An important instrument for mainstreaming has been the use of funds to support agencies so as to create conditions favourable for programme innovations (mainstreaming).

Attempts to mainstream are less than fully successful because those designing programmes and projects often do not have the capacity to mainstream HIV. By the time that programmes and projects are reviewed it is usually too late to influence what has been designed and will be implemented. In some ways this is the core of the problem: to try to ensure that programmes which affect and are affected by the HIV epidemic do take account of what needs to be done, and can be done. This is an intractable problem, but one which is amenable to solution. There is here a role for training, for programme staff in agencies and other donors, for consultants, in government and in NGOs etc. UNDP has been attempting to improve programming skills for mainstreaming through a number of training activities in many regions, including training of trainers workshops.

• A recent innovation has been the training of consultants for legal and ethical programming as a way of influencing a critical input in the design of programme responses worldwide. Developing better design skills for consultants and programming staff within COs is a minimum first step for effective mainstreaming. UNDP has some experience with this, and the appointment of National Professional Officers for HIV, and their training, has been an important step for more effective mainstreaming of HIV in UNDP's programming response to the epidemic.

• There are many other ways to generate insight and commitment to mainstreaming. These include activities to strengthen national capacity for applied socio-economic research, not just on the epidemic as traditionally defined, but on those structural conditions which often determine the speed of spread of infection and pattern of effects of the epidemic. Programming will remain narrowly focused as long as the research base remains limited. Once the data confirm the role of poverty amongst women as a factor in the spread of HIV infection, or the ways in which food security is affected by the epidemic, then and only then will it be feasible to determine what are the problems to be addressed and how to go about responding in ways which are effective. Some of these responses will be direct, such as nutrition programmes and scholarships for affected children. Some will be indirect, for example credit policies for women, along the lines of the Grameen Bank. UNDP has been engaged in refocusing analysis of the epidemic,in part through training, but also through capacity building for research in a number of African and other countries, with the expectation that programming will become more effective (mainstreamed).

• There is a need for examples of effective mainstreaming if development practitioners are to respond to recommendations that this is worthwhile. So documenting examples of what works and transferring the lessons is important. Publications are important in this respect, but even more critical are opportunities for discourse; talk can be an effective instrument for change, including changes in policy and programming, and opportunities need to be found for this to occur. Amongst the more important opportunities are meetings of Res Reps in UNDP and country team-building activities at the ILO Turin Centre. But there are also much lower level opportunities for meetings and discussions at national and sub-national levels where experiences are documented and explored. An activity used by UNDP has been that of facilitated study tours where inter-disciplinary national teams (from public and private sectors) have visited a number of countries, initially to observe what is happening, and then to build on that experience back home. Modalities which can be similarly used are Technical Cooperation among Developing Countries (TCDC) and Transfer of Knowledge Through Expatriate Nationals (TOKTEN) where the intention is to transfer south-south learning and experience so as to produce better development outcomes.

Conclusions

This note has explored some aspects of mainstreaming but in no sense is it intended to be exhaustive. It builds on some of the experience of the HIV and Development Programme of UNDP during recent years as a guide to how one might pursue the objective of mainstreaming for more effective policies and programmes. Several observations from the foregoing deserve repetition:

• there are no blueprints for undertaking mainstreaming that will be effective

• it is possible to avoid costly lessons by observing and internalising the experiences with mainstreaming gender

• effective responses to the HIV epidemic require mainstreaming throughout all development activities given the structural factors central to the epidemic

• process is crucial both for the design of how to undertake mainstreaming as well as in the implementation of programmes

• there are many innovative approaches to mainstreaming and these need to be explored, expanded and used

• the activities essential for mainstreaming need to be sustained over time and supported, and are not a once-for-all event.

UNDP has had much experience with mainstreaming HIV and in integrating it in a range of developmental activities. Much has been achieved both within the organization and through partnerships with others engaged in development. UNDP remains committed to the principle and practice of mainstreaming at all levels within the organization, and will continue to strengthen its capacity for more integrated responses to the HIV epidemic in all Regional Bureaux and throughout the organization. This will be achieved through the pursuit of all the strategies identified above, including training for UNDP and counterpart staff; training to consultants involved in programme design; support to UNAIDS Thematic Working Groups, and more specifically to the Resident Coordinator in her/his role in achieving integration of HIV in Country Programmes, and full participation of UNDP in the mainstreaming activities of UNAIDS and other partner organizations.

Endnotes - Bibliography

^1. See The HIV Epidemic and Sustainable Human Development (Issues paper No.29, UNDP 1998), and HIV/AIDS and Human Development in South Africa (UNDP/UNAIDS 1998).

^2. For a brief review of some of the poverty-related issues see Poverty and HIV/AIDS in sub-Saharan Africa (Issues paper No. 27, UNDP 1998). For the impact on households in Thailand and the Philippines see The economics of HIV and AIDS, ed. D. Bloom and P. Godwin (UNDP, 1997).

^3. For a discussion of the effects of HIV/AIDS on rural development see The Implications of HIV/AIDS for Rural Development (Study Paper No. 6, FAO/UNDP 1998).

^4. A brief summary of some of the problems facing educational systems is contained in The HIV Epidemic and the Education Sector in sub-Saharan Africa (Issues Paper No. 32, UNDP 1999).

⁵ For a summary of UNDP's activities see Building Capacity for General Mainstreaming: UNDP's Experience (GIDP/UNDP, 1998)

^6. For a report of a recent HIV and Development Workshop see Report of the 1^st Caribbean HIV and Development Workshop (UNDP, UNAIDS, CARICOM, UNDP 1999).

BIOGRAPHICAL NOTE

Desmond Cohen is an economist with university teaching experience in Africa, Canada, the UK and the USA. Formerly he was a Governor and Associate Fellow at the Institute of Development Studies, University of Sussex in the United Kingdom and, until 1990, he was Dean of the School of Social Sciences. He has both research and applied macro-economic policy experience in a number of African and Asian countries. Previously he was an adviser to the British Treasury on international financial policy. In 1997-98 he was Director of the HIV and Development Programme (UNDP), and currently he is Senior Adviser on HIV and Development.