Development and the HIV Epidemic: A forward-looking evaluation of the approach of the UNDP HIV and Development Programme 3. THE SPR-FUNDED ACTIVITIES 3.1 Overview The work of the HIV and Development Programme was guided by a set of related understandings about the nature of the HIV epidemic, the nature of development and the role of UNDP in the response to the epidemic. It took place in a context in which there was rapid and continuing spread of the HIV virus, no cure, and a potential for the HIV epidemic to impact on all aspects of human development. The issues to be addressed were complex and various: moral, social, cultural, religious, psychological, legal, political, strategic and economic factors had to be considered. The programming responses had to be sustainable for perhaps many years to come, resulting in development of the capacity of individuals, communities and nations to adapt to the changing circumstances which may arise through interaction between the epidemic and the ongoing challenges of human development. The HIV epidemic impacts on the broad range of human endeavour including social and economic development, welfare, education and training, employment, defence and law enforcement. The causes and consequences of the epidemic are closely associated with other challenges to development including poverty, unemployment, civil unrest, indebtedness and rural-urban movements. For example, HIV-related illness and death creates new poverty, deepens existing poverty and increases family and national indebtedness. This interaction between the epidemic and development demands a multi-sectoral and interdisciplinary response, with collaboration between many partners: governments, international agencies, community based groups, NGOs, research institutes, private sector groups and, most importantly, the people directly affected. The development of the Programme was based on a recognition that UNDP's role is to assist developing countries to accelerate the process of capacity building within both governments and nations, through support for human resources development, institution building, strategic planning and management, good governance, and the promotion of sustainable human development. The development and dissemination of models and guidelines was considered of limited effectiveness. New knowledge and skills needed to be developed collaboratively, and new issues needed to be addressed as they were identified. The Programme aimed:
The elements of the approach adopted by the Programme were:
Such an approach requires extensive communication amongst all concerned and consultation with people in their own environment. The Programme found it was important that, wherever possible, the occasions and spaces made for discussion and learning should be where people themselves live and learn rather than in institutional settings. The working principles of the Programme include the involvement of those directly affected by the epidemic in all activities and aspects of its work; gender sensitivity, representation and responsiveness; supportive partnerships with agents of change: individuals and community and non-governmental organisations; the strengthening of partnerships between the government sector and the community sector; sensitivity to ethical, legal and human rights issues; and the strengthening of partnerships across regional language groups. The areas of focus of the Programme have arisen from these interactive processes. They include:
The HDP is thus clearly situated within the overall conceptual and operational framework of UNDP's work. It adopts approaches consistent with this framework and is based on concepts of sustainable human development, especially human survival; social capital formation; capacity building; social learning and partnership (see Banuri, et al, 1994); expertise (see Chambers, 1994); gender responsiveness; process consultation (see Joy and Bennett, 1994); strategic questioning (see Peavey, 1994); and governance. Consistent with the principles of sustainable human development, the inclusion of the people whose lives are affected was considered essential and the Programme encouraged continual input from people directly affected by HIV and by development. This commenced with a workshop in New York in October 1992, in which a range of people directly affected by the epidemic worked with HDP staff, government officials, community workers, researchers and activists to develop general guidelines for the development of the Programme, including the identification of key issues to be addressed. The development of the Programme included ongoing interaction with these and other people, resulting in continual evolution of the Programme's approach, enhanced understanding of effective practices and the building of consensus on addressing a range of sensitive and complex issues. The relationship between the approach of the Programme and recent advances in UNDP's understanding of the nature of sustainable human development was reviewed as part of the evaluation process, and is summarised in Section 4 of this report. The rest of this section (Section 3) provides a concise summary of the major types of activities which have been undertaken by the Programme. Although activities are described separately, the inter-connected nature of the factors which were addressed by the Programme means that these activities were not always discrete. 3.2 Minimising the development consequences of the epidemic: exploring methods for planning With HIV prevalence amongst adults in some African countries now reaching 20 or 30 per cent of the adult population, there is intensified destruction of human and non-human capacity, and thus a new and critical need to find ways of addressing the consequences, not just measuring them. The HDP has supported many innovative processes in Africa and other regions to strengthen the capacities of governments, families and communities to mitigate these effects. The first step in this process was a consultative meeting in Vienna in 1992 attended by other UN agencies, academics and people directly involved in their national responses to the epidemic. This meeting mapped out the main direction for SPR activities around minimising the development consequences of the epidemic, and defining processes which would enhance effective responses. It was agreed that a shift in balance was required, away from describing the consequences and towards developing types of understanding which would lead to strategies to address those consequences. Many activities followed, and there is space here for only a few examples. - In collaboration with the International Institute for Applied Systems Analysis in Vienna, new computer software has been developed and made available at low cost to users. This makes it possible to access in a user friendly way the HIV data of the US Bureau of the Census, the largest data set available, and also to play interactive "games" which enable users to explore processes of HIV transmission and develop better undertanding of the dynamics of the epidemic. The software has been offered to UNAIDS to be used in furthering communication objectives. - An unsuccessful attempt was made to strengthen the regional planning capacity in the Kagera Region of Tanzania through the inclusion of activities which addressed the effects of the epidemic. This is an area where there is an existing UNDP planning project and where HIV prevalence is very high. Important lessons were learnt from this experience about the processes required for gaining commitment to programme development, together with improved knowledge of the constraints which affect what is possible under conditions of widespread denial. - Nicaragua is a country with low reported HIV prevalence in a region where other countries are already experiencing rapid spread of the epidemic, and where socio-economic factors may enhance further rapid transmission of the virus. Attempting to induce more effective prevention by government and others, the HDP, in partnership with a national NGO, cosponsored a workshop and follow-up activities to enhance understanding of developmental aspects of the epidemic. This strengthened local capacity to undertake economic analysis, to measure the effects of the epidemic and to identify appropriate responses to the needs of those affected. - A project was undertaken in several rural areas of Mexico, in collaboration with the National AIDS Programme and other partners including the NGO, Colectivo Sol. The project explored how to better use local structures and organisations, such as public libraries, to strengthen links between information providers and community-based service organisations such as health centres and women's groups. Important lessons were learnt about processes for building local trust as integral to and necessary for programmes relating to HIV prevention and care. 3.3 Capacity development through research An ongoing project explores how to strengthen national capacity to define, undertake and make use of research on the socio-economic causes and consequences of the epidemic. The project, in four African countries (Central African Republic, Kenya, Senegal and Zambia), has developed innovative processes to support national teams of researchers and others, working in partnership with National HIV/AIDS Programmes, affected individuals, researched communities and other potential users of data and analysis. Research is now underway and important insights have been gained about how to best ensure that research is timely and relevant to programme needs. Activities which build on the lessons of the project are being developed in other countries and regions, including Myanmar and Nicaragua, with proposals also under consideration in Vietnam and Botswana. This initiative is developing new approaches to technical cooperation, based on principles of process consultation which entail different relationships and use of new working methods between development partners. The SPR initiative has thrown light on how best to strengthen national research capacity through technical consortia; how to involve potential users throughout the research process; how to strengthen research skills and improve understanding of the ethical and development aspects of the epidemic; and how to ensure early discussion of, and improved methods for, the dissemination of research results and their effective use in programme development. Case Study 1 describes this project in further detail. SPR funds are also being used to explore how the processes of research can be used to stimulate solutions as well as to increase understanding of problems. Research on families of children left without social and economic support after the death of their parents is being undertaken in a seriously affected area in the west of Kenya. The research methodology is designed to lead to processes of discussion and consultation within families and communities and with local government so that adequate support can be provided to these children. The findings are also contributing to national policy and programme development. 3.4 HIV and development workshops Training materials and workshops have been developed focusing on the human, social and economic development dimensions of the epidemic. The workshops aim to increase awareness of the complex nature of the epidemic, to analyse approaches to strengthening community-coping responses and national responses, and to identify the policies and programmes required at all levels to respond to the epidemic. The belief that the epidemic can be overcome is central to the workshop. The workshop is based on three principles:
The workshop is designed for senior government officials particularly from ministries of planning and finance, the productive sectors (agriculture, mining, industries, transport, etc.) and the social sectors, for senior United Nations officials and for the organisations of civil society. In addition to the workshop itself, shorter workshops on HIV and Development have taken place at national level for politicians, community organisations, NGOs, the private sector and others. National and inter-country workshops organised by UNDP include workshops in Australia, Austria, Benin, Botswana, Cameroon, Central African Republic, Chile, Cote d'Ivoire, Gabon, India, Jamaica, Kenya, Madagascar, Malaysia, Mexico, Morroco, Nicaragua, the Philippines, Poland, Senegal, Uganda, the Ukraine, the USA, Zaire, Zambia and Zimbabwe. Many examples of flow-on effects from these workshops and the training materials used were reported during the evaluation process. Three training for trainers workshops have been held (Mombasa 1991, Agadir 1992, Kuala Lumpur 1994) and those trained have subsequently adapted and used the materials in many settings. The workshops have had an impact in enhancing people's understanding of what is needed and what is possible, on the development of effective strategies, in initiating the development of effective networks of people who may not otherwise have met, and in stimulating engagement amongst those who had previously not considered the epidemic relevant to themselves or their work. In the Philippines, participants reported that they often use components of the workshop in their work in rural provinces, as they have found this an effective way to engage people's interest and understanding as a prelude to acting in response to the challenges of the epidemic. In two states in India, the training materials are being used by women sex workers working in red light districts to increase the understanding of their co-workers of the epidemic and of the need for a collective response. Already by 1993, over 500 groups of women sex workers had seen and discussed the module on The Unfolding of the HIV Epidemic. In rural Zimbabwe, the materials have been incorporated into village theatre productions aiming to increase awareness of, and a commitment to respond to, the epidemic. In Senegal, it was reported that the workshop had created an emotional as well as an intellectual engagement amongst many people who were already engaged in responding but who, as a result of the workshops, now did so more vigorously and with much greater personal conviction. Thus, the workshops have been able to address needs in new ways which people find directly relevant across international boundaries. In many countries networks of NGOs have incorporated the development practice approaches and conceptual frameworks presented in the workshops into ongoing projects building local capacities to understand and respond to the epidemic. 3.5 Learning how to learn from and with others: facilitated study tours Exploration and testing out of new and innovative approaches to learning how to learn from and with others has been integral to the work of the Programme. One approach that has been developed, tested out and found to be effective is the facilitated study tour. This was first developed in response to a request from the National HIV/AIDS Programme in Djibouti for assistance in understanding and developing a community-based strategy to address the HIV epidemic. A multidisciplinary team from Djibouti, with participation from the Ministry of Health, counsellors, hospital administrators, the media, women's groups, community groups and lawyers, travelled first to Senegal. There the NGO, ENDA-Santé, ran a workshop to explore the lessons learnt to date about the centrality of the community response to the epidemic, including the importance of developing an appropriate legal and ethical framework to facilitate such a response. The workshop included visits to community groups and discussion with interested officials, researchers and activists in Senegal. Following this workshop, the Djibouti team and the ENDA-Santé facilitators proceeded to Zambia and Uganda. They visited selected community groups and then spent an additional day in each country to reflect upon the relevance for their own country of what they had seen and learnt. The team prepared a paper summarising the lessons learnt and their applicability for effective programme design and development in Djibouti. On their return to Djibouti, the team spent a week integrating their findings into the national HIV/AIDS plan and planning a pilot project to build national capacity to develop a community- oriented approach to the epidemic; to establish an appropriate legal, ethical and human rights framework for such an approach; to utilise existing resources for such an approach (including use of counsellors, local government structures and community leaders); to strengthen the trust between those individuals and families already affected by the epidemic and government and other community members; to delineate the roles and responsibilities of community organisations and government; and to develop participatory community-based monitoring and evaluation systems to capture the lessons and feed them into policy and programme development discussions. The approaches used in the facilitated study tour resulted not only in stimulating the national authorities to rethink and redesign their HIV/AIDS strategies, but were supportive of building national capacity and fostering exchanges of experience and learning amongst many African countries. Facilitated study tours were subsequently organised in response to requests from Swaziland, where the government wanted to explore and develop a national strategy for community- and family-based care and support, and from Vietnam, where the Vietnamese Armed Forces wished to strengthen their military HIV prevention programme and to develop stronger links between the military and civil society. 3.6 Ethical, legal and human rights networks Networks of activists and professionals have been established and supported as a means of building capacity to address legal, ethical and human rights issues. These networks, in Africa, Asia and the Pacific and Latin and Central America and the Caribbean, draw their members from legal, governmental and academic institutions as well as from organisations of civil society. They are active in addressing the legal and ethical issues central to responses to the epidemic, and in the provision of services to those affected. Indirectly, they contribute to institutional capacity building and to human resource development. These networks contribute to social capacity building through drawing together diverse groups of those interested or implicated to address issues of common interest. They broaden the base of discussion and contribute to consensus building within the community sector and amongst civil society, public and private sectors. They also advocate for law reform, changes in legal practices, the provision of appropriate services, policy and programme development, and they play a guardianship role in ascertaining the legal and ethical appropriateness of responses to the epidemic. The value of the networking approach is evident in an example given by Attorney Manual (Manny) Goyena, a lawyer from the Filipino NGO, AlterLaw. He talked in an interactive discussion with the evaluation team of how his organisation provided legal advice, but worked closely with other NGOs more able to be directly involved in social action. He had attended various regional meetings either in the law and human rights field, or as part of networking within the Asia-Pacific Council of AIDS Service Organisations (APCASO). He had been a participant at the first meeting organised by HDP for the Asia and Pacific region in Cebu, the Philippines, in 1993 and at the resource persons training workshop in Tarrytown, New York in April 1995. Many people from the Philippines are now engaged as "overseas contract workers", working in other more wealthy countries usually for lower wages than local people. A recognised difficulty is their lack of rights within those other countries. Through the APCASO network, contact had been made between the Philippines AlterLaw group and lawyers in Malaysia. Together, the two groups are now planning proposals to address the rights of Filipinos working in Malaysia. Manny explained: We got [a lawyer] to meet with the Philippine NGOs working in Malaysia. So, we tried to define a model, file a test case. For example, the government now is just assisting people on the receiving end of complaints, but we're moving them to assist with initiating cases ... For example, with trafficking of women, ... because there are international syndicates, therefore responses have to be international. Countries in which UNDP has supported networks and networking on ethics, law and HIV include, in Africa: Botswana, Burundi, Central African Republic, Côte d'Ivoire, Gambia, Ghana, Kenya, Rwanda, Senegal, South Africa, Uganda, Zaire and Zambia; in Asia and the Pacific: Bangladesh, Cambodia, China, Fiji, India, Indonesia, Malaysia, Myanmar, Nepal, Pakistan, Papua New Guinea, Philippines, Sri Lanka, Thailand and Vietnam; in Latin America and the Caribbean: Argentina, Barbados, Brazil, Mexico, Nicaragua, Paraguay and Venezuela; and in Europe and the Commonwealth of Independent States: Poland, Russia and the Ukraine. In response to requests from NGO partners for capacity building and skills development in this area, a legal and ethical resource persons workshop was held in Tarrytown, New York, in April 1995. The focus of this workshop was on the use of process facilitation and strategic questioning skills in network building. Participants came from all regions previously involved in legal and ethical networking. A manual of the workshop materials is being produced on the use of process facilitation for network building to address legal, ethical and human rights issues. 3.7 Networking: creating spaces for discussion, support and action In a similar way, networks of people living with HIV and AIDS assist in both building capacity for representation and participation in policy and programme development, and in ensuring that expertise and commitment contribute to the strengthening of local and national responses. Such networks are important vehicles for protecting the rights of those affected and for providing protection and sanctuary. They enable those affected to enter into partnerships and provide the possibility of continuing organisational effectiveness even when illness and death affect individuals' ability to continue. The Programme has provided a range of support to people living with HIV in their efforts to create national, regional and global networks, in advocacy of the principles of recognition and involvement, in the recognition of the particular expertise that living within the epidemic creates, and through involving them as partners in all its work. It worked with the UNDP Regional Project on HIV and Development for Africa to assist with the creation of the Network of African People Living with HIV and AIDS (NAP+). It has been active in the formulation and implementation of the UN Personnel Policy on HIV and AIDS. Assistance has been provided to the Global Network of People Living With HIV/AIDS (GNP+) through provision of training in strategic planning and programme development. Support has also been provided to the International Community of Women Living With HIV and AIDS (ICW) to report on the lessons learnt during a pre-conference meeting held prior to the VIIth International Conference for People Living With HIV/AIDS, in Capetown, South Africa in March 1995. In preparation for the Capetown Conference of People Living with HIV and AIDS, the Programme funded two GNP+ Board members to visit and work with groups of people living with HIV in Zimbabwe, Zambia, South Africa and Namibia. The Programme has also worked closely with networks and organisations providing care and support to those affected. In particular, it has strong and continuing partnerships with ICASO, especially through its regional councils. It has also worked with the International HIV/AIDS Alliance and its national linking organisations. 3.8 Understanding gender and HIV The work of HDP addressing issues of particular relevance to women has focussed in two main areas: creating a greater awareness and understanding of the gender dimensions of the epidemic and developing more effective strategies to assist women. From its start, the Programme has adopted the principles of gender sensitivity, representation and responsiveness to guide its work. It has sought an equitable participation of women in all its work and has played an important early role, especially through its publications and presentations, in drawing global and national attention to issues such as the epidemiology of infection amongst women, the susceptibility of young women to infection, the need for methods of protection that women can use in their socio-economic settings, the relationship between cultural and medical practices and infection rates amongst women, and the inequitable burden of care that communities and nations place on women. Analysis of the way in which social and economic policies and institutions increase the effect of the epidemic on women led the Programme to an understanding of the causes of men's vulnerability to HIV infection and of their critical role in any strategies for women. A number of publications and presentations have addressed this issue. There is now greater awareness of HIV infection rates amongst women and of the other ways in which the epidemic affects their daily lives but much more work is needed to develop effective approaches and practices to address these issues. The complexity of the analysis militates against narrowly focussed or single item responses. The Programme has worked closely with women, and with organisations working with women, to increase understanding of how initiatives directed specifically towards women can help. It has also considered areas in which approaches directed towards men, or towards the contexts in which male-female relationships occur, are needed in order to better assist women and those they care about and for. 3.9 Civil-military issues and HIV It is estimated that HIV prevalence in military populations in a number of countries may be as high as 50 per cent. Reliable information on infection rates is scarce because of the enormous sensitivity surrounding the topic. This has strategic, political, social, economic and security implications at both national and global levels. In some countries security forces have begun to take action by working with national HIV/AIDS programmes. However, HIV within the military will continue to pose very difficult policy dilemmas both in branches of the military and in national contexts. Issues of concern include the effect on civilian populations, the ethics of mandatory testing, civil-military collaboration for prevention and care, and implications for peacekeeping operations. Over the past few years, the HDP has been working in partnership with interested governments and institutions to explore civil-military issues around HIV. One outcome of these efforts has been the establishment of an international organisation, the Civil-Military Alliance to Combat HIV and AIDS, which now receives support from a number of UN organisations including UNAIDS and the World Bank, as well as from bi-lateral agencies including USAID. Within this context, the HDP has been providing technical support and guidance to countries through facilitated study tours, missions and consultations. It has participated in meetings and training workshops of the Civil-Military Alliance and is represented on the Board of that Alliance. In December 1995, at the request of the Vietnamese Armed Forces, the Programme organised a facilitated study tour to enable them to discuss policy and programme issues with neighbouring Armed Forces and to explore ways for civil organisations and the military to work together. A group of senior military and civilian officials from Vietnam visited Thailand and the Philippines. The study tour was facilitated by a senior military doctor from the Papua New Guinea National HIV/AIDS Programme, a partner of HDP. 3.10 Learning, advocating and disseminating: promoting more complex understanding and action The HIV epidemic is challenging accepted ways of understanding health and human development in our societies and demanding new forms of expertise and more integrated responses. It is raising conceptual, ethical and programmatic issues, many of which still need to be named, all of which need to be raised for discussion and exploration. The aim of the HDP publications and presentations has been to raise new or neglected issues, to encourage people to consider old issues in new ways, and to articulate the questions many of these issues raise about accepted ways of doing things. The publications policy has been to keep papers brief, simply written and limited to issues not addressed, or not addressed from the same perspective, elsewhere. Authors are asked not to outline solutions but rather to stimulate the reflection and discussion essential for well-informed processes of change to arise within their own contexts. Publications have included issues and working papers, research studies, posters, statements of principles, training materials and a book. Declarations drawn up at consultations and conferences organised by either the HDP or by UNDP's regional HIV and Development projects have been distributed in poster format, encouraging policy makers and practitioners to display them on walls of government offices, resource centres, clinics and other places used by people responding to the epidemic. These included the Statement of belief on behaviour change as a central issue in responding to the HIV epidemic, drawn up at an informal consultation hosted by the HDP in Senegal in December 1991, and the Dakar Declaration of the African Network on Ethics, Law and HIV. These short statements were widely distributed, both promoting and summarising new forms of discourse arising through sustainable human development responses to the HIV epidemic. Many other issues were covered in papers which examined the multisectoral nature of the epidemic's socio-economic causes and consequences, and the development of effective, sustainable and compassionate responses. These papers cover themes relating to all the areas of the HDP, and titles include: The HIV epidemic and development: the unfolding of the epidemic; The economic impact of the HIV epidemic; People living with HIV: the law, ethics and discrimination; Sharing the challenge of the epidemic: building partnerships; Young women: silence, susceptibility and the HIV epidemic; Children in families affected by the HIV epidemic: a strategic approach; The HIV epidemic in Uganda: a programme approach; The socio-economic impact of HIV and AIDS on rural families in Uganda. In order to diversify the voices of the HIV epidemic and to disseminate the lessons learnt thus far in developing countries, the HIV and Development Programme published a book entitled, HIV and AIDS: The Global Inter-Connection (Kumarian Press, 1995). The full list of the publications and presentations of the HDP is included as Appendix 5. In order to ensure that the issues are accessible, the HDP has worked in a number of collaborative ways to ensure that its publications are available in a number of languages. It is working with Spanish-speaking and French-speaking HIV support organisations to strengthen their capacity to translate and distribute relevant HIV materials. The partner organisation chooses material considered to be of relevance to the region and sets priorities for translation. It also identifies material for translation into English and other languages. The book, HIV and AIDS: The Global Inter-Connection, has been translated into Bahasa Indonesian, Bengali, Sinhala, Thai, Urdu and Vietnamese through a partnership programme with local publishing houses. It is presently under discussion for translation into French, Spanish, Japanese, and into Swahili by a consortium of people living with HIV or AIDS and government officials in Kenya and Tanzania. HDP materials have also been translated into Arabic, Russian, Chinese and Portuguese. HDP materials are considered as public domain materials and it is made clear that they can be reproduced in whole or in part by any person wishing to understand and explore these issues further. HDP asks only for some acknowledgement and for suggestions for further papers and for comments on the series. The HDP distribution policy is to distribute materials free of charge within UNDP programme countries, whenever interest is shown in receiving them. The materials have been widely distributed, in and outside of urban areas, to government and non-government organisations, to libraries and academic institutions. They have also been handed on from person to person. The value of these publications in catalysing the responses to the epidemic of people in their own contexts was highlighted in comments made by Eduardo Nierras, an evaluation participant in the Philippines:
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