Study Paper No. 1
THE
HIV EPIDEMIC IN UGANDA: A PROGRAMME APPROACH
By Desmond Cohen
Table of Contents
Introduction
I.
HIV AND AIDS IN UGANDA
A. Transmission of HIV
B. Transmission Projections and Scenarios
C. Impact Projections
II.
SETTING PRIORITIES
A. Capacity Development: General Considerations
B. Capacity Development under Conditions of High
Seroprevalence
III.
UNDP PROGRAMME INTERVENTIONS
A. Prevention of
HIV Transmission
B. Economic and Social Impact
C. Caring
D. Strengthening Organisational Structures
IV.
OPERATIONALISING ACTIVITIES
A. Programme Approach
B. Allocation of Programme Resources
C. Sequencing Interventions
D. Programme Implementation
References
and Biographical note
INTRODUCTION
In February 1992
UNDP sent a Programming Mission to Uganda to advise UNDP
on its activities in the area of AIDS for the years
1992-96. A Report was prepared, Uganda HIV and
Development Programme: UNDP Strategy For Co-operation,
which subsequently became, with modifications, the basis
for UNDP's programme in Uganda. This Working Paper is a
shortened version of the original mission Report; two
short Sections have been excised, that on the General
Country Situation and the other on the Overview of the
National Programme. Otherwise this Working Paper has been
left unchanged apart from a few textual revisions,
although much that is relevant to policy and programming
for HIV in Uganda could have been included. Rather the
primary purpose in issuing this Working Paper has been to
make available the mission Report as a demonstration of
one model of how to go about such an activity. It has
other merits, both as a substantive analysis of HIV in
Uganda, and as a statement of appropriate policy and
programming responses in a country with high levels of
HIV infection.
I. HIV AND AIDS IN UGANDA
The HIV epidemic in Uganda
has its origins in the early to mid Seventies, although
it was not diagnosed as such until 1984. The spread of
HIV in the population has been rapid. By the end of 1991,
30,190 cases of AIDS had been reported to the AIDS
Control Programme (ACP) surveillance unit, with cases
from almost every District in the country. This is
thought to be a significant under estimate of the true
number of cases as a result of under reporting. Modelling
of the epidemic suggests that the actual number of cases
of AIDS is some 6 to 7 times greater than reported cases.
In 1987/88 a national
serological survey was undertaken to establish the level
and distribution of HIV infection in the population. In
the event the survey was not fully representative, with
gaps in the data for the eastern and northern regions
particularly. The survey generated an estimate of an
adult HIV prevalence level of 9%, ie. some 800,000 people
were thought to be infected. There were wide variations
between regions and between urban and rural areas. In the
case of urban areas the rate was estimated to be as high
as 29% in some regions; much lower, but still
significant, in rural areas. Because most of the
population is rural [some 90%] even relatively lower
rural HIV rates implies high absolute numbers of people
who are infected. More recent data from ante-natal
clinics has yielded seroprevalence rates of 27% in true
urban areas like Kampala, to as low as 3% in some rural
areas [with the possibility that rates are even lower
than this in some parts of the country]. Using the
national serosurvey as the base, and applying the
evidence from sentinel sites, it appears that the current
numbers infected with HIV are about 1.3 million.
As noted above, the cases
of AIDS notified to the Ministry of Health (MOH) are
considered to be a massive underestimate of the true
numbers. This reflects the coverage and quality of health
care in Uganda, with many persons with HIV related
illnesses outside the reach of the formal health care
system. Many fall back on traditional healers for
assistance, and as such are never reported to the MOH. In
part also, the continuing stigma associated with HIV and
AIDS leads individuals and families to prefer some other
diagnosis. Nevertheless, the data on AIDS as reported has
some value in permitting analysis of the sex and age
distribution of those identified. About a third of the
reported AIDS cases are children under 5, reflecting the
frequency of paediatric cases. Otherwise there is a
bunching of cases in the ages 15-49, with a mean age for
adults of 27 years. The elderly and young adolescents are
more or less generally free of infection.
Of great importance are
differences in the median ages of infection of men and
women; for men this is 30 years, but for women is much
younger at 25. Not only are women infected at an earlier
age, but there is some evidence that infection rates are
higher than for men. Why this is so is far from clear,
and cannot simply be a reflection of males choosing more
youthful sexual partners. Many other factors must also be
operating, and these require analysis if there are to be
effective policies for prevention, for care and for
dealing with the impact of the epidemic on the social and
economic system. The gender dimensions of the problem
need to be constantly at the forefront of analysis and
policy, and not simply, although these are important,
because of the problems raised for perinatal transmission
and for the general health of mothers and children.
A. TRANSMISSION OF HIV
Much is now known about
HIV and AIDS and there has been immense progress made in
a remarkably short time in understanding transmission of
the virus. Nevertheless, there is much that is not known,
and there remain major areas of uncertainty. Why women
are infected at an earlier age than men is one area where
research is urgently needed. It seems unlikely that a
vaccine will be discovered, and be available, before the
end of the decade, but even then it is improbable that in
the conditions which exist in many developing countries,
including Uganda, that a vaccine will be sufficient to
prevent the continuing spread of HIV in the population.
The potential future discovery of a vaccine thus in no
way diminishes the need to put in place now effective
policies for prevention and care.
Having said this the ways
in which the virus is spread are now well understood. In
Uganda, as in much of Africa, the major mode of
transmission is sexual. Heterosexual transmission is
thought to account in Uganda for about 90% of cases, with
the other 10% of infections being from mother to child
[paediatric] and from infected blood. Securing the blood
supply is an important intervention, but given the
relative size of the contributing factors in transmission
it is of much reduced importance. Thus by far the most
significant risk factor in determining the spread of HIV
and the resulting size of the population which is
infected, are unsafe sexual practices. This is compounded
in the Ugandan case by social and cultural factors which
lead many men to have multiple sexual partners, and under
conditions where neither partner is protected from the
virus through the use of condoms. Evidence from Uganda
suggests that condoms are infrequently used; and it is
reported that only about 5% of women have ever used
contraceptives.
There is now a well
documented association between STDs and HIV infection,
with the probability of infection through sexual activity
being sharply increased where STDs are present. The risks
of HIV infection are much higher where standard STDs are
present. These risks can be substantially reduced, both
of HIV and of STDs, where condoms are consistently and
properly used. But this requires knowledge on the part of
users, a willingness to use condoms, as well as a regular
and affordable supply [conditions which are generally not
met at present in Uganda]. Studies carried out in Uganda
have shown that the presence of STDs in the population
has been a significant factor in transmission, as well as
confirming the widespread presence in both men and women
of standard STDs. It is clear from these studies that
STDs are a significant co-factor in the transmission of
HIV, and that control of STDs needs to be an important
element in any strategy for controlling HIV.
B. TRANSMISSION
PROJECTIONS AND SCENARIOS
The major forms of
transmission in Uganda are identified under I.A, as also
are estimates of the scale and distribution of HIV
infection and AIDS in the population. It is clear from
these estimates, and from the discussion of the processes
of transmission, that very little is known with certainty
about conditions in Uganda. Nevertheless, enough is known
about this issue for it to be possible to model the
progress of the epidemic over the next 10-15 years.
Bearing in mind that such modelling is bound to be
imprecise, and needs to be treated with circumspection.
Any predictions have to make assumptions about future
behaviour, particularly sexual behaviour, and this is
inevitably fraught with difficulties. Changing
assumptions does, of course, yield quite different paths
of HIV infection and mortality, and quite different
demographic outcomes. Of great importance for the future
size of the Ugandan population is the response of
fertility to rising paediatric and adult mortality, but
this is an area where knowledge is very uncertain.
Otherwise the most important behavioural assumptions
relate to the number of sexual partners, the number of
sexual acts per partner, the probability of condom use,
the presence of STDs, and the extent of blood screening
and blood usage.
Using the national
serological survey as the benchmark it is possible to
model the future course of HIV infection, and to then
vary the important behavioural parameters so as to
observe the relative contribution of these to the model
projections. Such a set of illustrative projections has
been undertaken by the World Bank (WB) [1991] [these are
presently being revised to take account of the recent
population census which estimated a current population
that is significantly smaller than had earlier been
predicted]. The worst scenario looked at by the Bank
assumes a continuation of present trends, and generates a
set of predictions which are highly unfavourable. In this
case, by the year 2010 there will be 1.7 million infected
adults; the proportion of adult females infected will
rise from 13.6% in 1991 to 17%; the number of HIV
positive children will double, from 50,000 to 100,000;
and AIDS deaths will rise from an estimated 34,000 adults
and 20,000 children in 1991 to 115,000 and 55,000 in
2010. Whereas in the absence of AIDS it would have been
expected that death rates would have declined, in the
presence of AIDS the crude death rate in 2010 is
predicted as actually higher than in the late 1980s.
Indeed if HIV adult infection is as high as 20% then age
specific mortality rates are trebled - being higher for
women than for men. Similarly for life expectancy, where
in the absence of AIDS this could have been expected to
improve substantially over the next 20 years, under the
"no change" scenario it is actually lower in
2010 than in 1985. In this model run the total population
continues to rise but at a slower rate.
The World Bank explores a
number of alternative projections so as to identify and
quantify the effects of parameter changes. Some of these
changes in parameter values reflect the impact of
policies on behaviour, and thus allow some estimation of
the effects both individually and in the aggregate. Thus
a model run which includes changes in sexual behaviour,
increased use of condoms and reduction in STDs, generates
a set of outcomes for HIV prevalence, AIDS mortality,
life expectancy and so on which are much more favourable.
What these estimates do is to illustrate the synergistic
impacts of multiple policy interventions which in the
aggregate are able to substantially reduce the future
levels of HIV infection and AIDS. They also illustrate
the crucial role which sexual behaviour plays in
transmission of HIV, and how critical for the future of
Uganda is the development of effective policies in this
area.
Epidemiological modelling
is in its infancy, and furthermore the Ugandan database
leaves much to be desired. Much, much more research is
needed into important relationships of an epidemiological
and demographic nature before reaching any firm
conclusions. Nevertheless, certain conclusions are more
or less well-founded in the available evidence. The
present level of HIV infection is high by the standards
of anywhere in the world, and there are no signs of it
levelling off. HIV and AIDS mortality is much higher than
officially reported data would suggest. As the WB model
projections suggest there is the potential for even
higher rates of HIV infection and mortality in the
future. To levels which will reverse much of the
improvement in social indicators, such as in infant and
maternal mortality, higher life expectancy, and rising
living standards.
Extremely worrying is the
evidence which supports the proposition that women are
more severely impacted by the epidemic than men, and that
in the future this gap will widen further. This means
that women will lose more healthy years of life than men;
that there will be further deterioration in the rate of
paediatric AIDS, and that many of the functions which
women are expected to perform as both producers and
carers are unlikely to be feasible. As noted above, the
gender aspect of the epidemic has received little
attention, both in terms of its causes, and in its
implications for the development of general policies for
prevention, care and socio-economic impact.
C. IMPACT PROJECTIONS
If epidemiological and
demographic modelling are uncertain in their methodology
and conclusions, and thus need to be treated with care,
then this is even more true when attention is turned to
the economic and social impacts of the epidemic. What is
now generally recognised is that the effects of HIV and
AIDS are certainly not confined to the health sector, but
rather that the channels of effects are multiple, and the
impacts extend throughout the economic and social system.
This being readily accepted it follows that the policies
called for by the challenges of the epidemic will be
complex in formulation, necessarily be innovative both in
content and implementation processes, and require a
multi-sectoral approach. It is this conclusion which has
guided Uganda in establishing its present AIDS strategy.
A taxonomy of the multiple
ways in which HIV effects the economic system is not too
difficult to construct. These can be stated in a
reasonably comprehensive way, and there is widespread
agreement about the channels through which HIV will
effect the performance of the economy. When it comes to
estimating the quantitative size of the economic effects,
and the distribution of these impacts on different types
of households [and within households], on different
sectors of production [and within sectors], on Government
as a sector of service supply and production, then there
are immense complexities and difficulties. This being
recognised as the position it follows that what can be
stated as the probable impact both now and in the future
is highly uncertain.
For Uganda at the present
it is impossible to go much deeper than generalities
about the likely economic and social impacts. That these
are already substantial, and will become even more so in
the future, is nevertheless demonstrable even given the
limitations of data, analysis, and understanding. It is
doubly unfortunate that these adverse impacts are being
imposed on an economy whose structure has been weakened
by decades of political, economic and social turmoil, and
which is only now gradually restoring its productive
capacities.
We have seen above that
HIV primarily effects those in the age groups which are
crucial to society as producers, as the suppliers of
social and economic support to both the young and the
elderly, and as the transmitters of much of the cultural
and social values which effectively define a society. Now
in trying to evaluate the economic costs of HIV it is
clear that once the full contribution of individuals is
recognised that standard estimates are inevitably going
to be partial and far too low. It is impossible to place
an economic value on the multiple and varied
contributions of individuals, other than in the narrowest
of terms, and attempts to estimate the economic costs of
HIV suffer from major limitations. As we have seen many
of the contributions of individuals to society have
economic and social value but these cannot be
established. Even in the narrowest of economic terms
these often cannot be estimated, and many productive
activities are often excluded on highly dubious grounds
from calculations of national production. This is most
obviously true of much of the output and many diverse
contributions of women in their multiple social and
economic roles.
There is a further major
conceptual problem with standard attempts to measure the
economic impact of HIV, by for example trying to
establish the present value of the output lost through
the early death of an individual caused by HIV related
illness. This approach in effect assumes that an
individual's contribution to output is independent of
others, which in the case of an epidemic it clearly is
not. The costs, narrowly defined in terms of the measured
contribution to GNP, will in the aggregate be greater
than the sum of the individual contributions to the
national output streams. Overall it can be readily agreed
that the economic, social and psychological costs of HIV
are likely to be very substantial, and much greater than
those which are conventionally identified and estimated.
Persons infected with HIV
will experience periods of higher morbidity which will
effect their productivity. If they are in formal sector
employment they may be subject to discrimination, and
possibly lose their job. In any case at this stage of the
illness they will have needs which are social - their
relationship to their family, and their relationship to
the community [defined as overlapping sets of social
interactions]. Here support which is other than economic
will be essential, and yet every bit as important. How to
meet these needs under severe resource constraints is one
of the major challenges of this epidemic. In purely
economic terms, at this stage of the illness, there will
be pressure on household resources, which may be
diminishing, at the same time as needs will be
intensifying. This stage, and the later one of AIDS, will
divert resources to health and care at the expense of
other less pressing wants. This increases the probability
of worsening nutrition for the household, poorer housing,
a reduction of schooling for children, reduced levels of
health services for the rest of the family, and so on.
All at a time when pressures will diminish the resources
available to the household, as labour productivity is
reduced, and with the certainty that women will be
diverted into caring roles and away from productive
activities.
These impacts are
happening now in Uganda; probably on a wide scale, but in
most districts largely undocumented and not measured. But
the tip of the iceberg can be observed in the medical and
social support activities of many NGOs, who are tackling
the best they can a problem which already exceeds their
capacities. Unfortunately, Uganda is only at the start of
a process of rising needs, social, economic and
psychological, which will inevitably intensify over the
coming years as more persons already infected with HIV
fall sick and die. The conditions observed in Rakai and
Masaka are of massive needs relative to available
resources, of intensified destitution, of increasing
evidence of family dissolution, of the elderly without
support, and large numbers of orphans who have multiple
needs for food, housing, schooling, training, care and
love. Here is the future for Uganda. But the scale of
these impacts can still be limited through social
mobilisation and more effective policies.
The foregoing can be
thought of as the impacts at the levels of the household
and the community, but there will also be aggregative
effects which will reduce the total output which can be
produced. There are the losses due to higher and earlier
mortality - the output lost to the economy through death.
This will be significant, in terms of the lost
contributions of men and women - particularly the loss of
the latter, who have such varied roles to play in Uganda.
But output will also be reduced through a diversion of
savings to "unproductive" uses - particularly
into health, and care for the sick. This reduction in the
level, and the reallocation of savings to consumption,
will take place in all sectors with Government, Business
and Households all affected. National output will grow
more slowly than otherwise because the savings available
for capital formation will be lowered. These negative
effects on national economic performance are not yet
evident and will take time to come through. At this time
it is difficult to predict the size of the losses of
potential output, but while these are inevitable as a
category, they are not inevitable in their scale.
Effective policies for prevention of HIV can reduce the
losses of human and non human resources, and thus
minimise the adverse general impact on the economic
system.
HIV is no respector of
social class, and there is some evidence that infection
rises with education and income. This seems also to be
the case in Uganda, where reports are now common of
losses of highly trained and scarce professional human
resources. True both of private and public employment,
and doubly serious for Uganda given the thinness of it's
existing human resource base. HIV and AIDS is eroding an
already depleted stock of educated and experienced
labour, and as such is confounding present attempts to
rebuild national capacity. These losses are not confined
to urban areas, but are reported also from quite remote
rural districts where HIV prevalence is generally low.
The costs are, of course, not simply the losses of human
capital that are entailed, but also the losses in terms
of management performance as persons fall ill, and the
higher health [and other social charges] which fall on
employers. But the impacts are much more general than
these; HIV and AIDS reduces the quality and the quantity
of human resources available to the society, in terms of
experience, training, knowledge, aptitudes, commitment -
across the board, and in all parts of the country. As HIV
spreads to previously low areas of prevalence, as it is
presently doing in Uganda, so also do these costs become
more general and pervasive.
No discussion of the
impact effects of HIV would be complete without some
discussion of the likely consequences for the
agricultural sector and those whose livelihood is
dependent on it. As noted above some 90% of the Ugandan
population is rural; agriculture accounts for about
two-thirds of GDP, and for virtually all exports. Most
output is produced on smallholdings, and women are
responsible for some 80% of total food supply and provide
most of the labour inputs. This dependence on women's
labour, for both food and non-food production, under
conditions where higher HIV infection rates for women are
observed, is an indicator of the vulnerability of this
sector. Women not only account for much of the direct
inputs into production but a good deal of indirect ones
as well [in marketing, processing, water supply, firewood
etc.]. To these functions are added those domestic
responsibilities of the household undertaken by women,
which are burdensome enough, and on top of these HIV
infection and AIDS impose yet further demands.
Since women are
disproportionately infected with HIV, and given the
dependence of the rural and household economies on their
labour, there are inevitably going to be significant and
serious impacts. These will not be confined to productive
effects, but also extend to those functions which are
integral to the survival of households. Under these
conditions it is not enough to know that some farming
systems are vulnerable to the losses of labour due to
higher morbidity, higher mortality, and the diversion of
women from productive roles to caring, but also to be
able to identify those households which are most
vulnerable. There is evidence that some households are
already suffering extremes of destitution, eg. in Rakai,
under conditions of high seroprevalence. Other regions of
the country, such as Apac and Lira Districts, where
poverty is persistent and widespread, will become even
more vulnerable if their HIV infection rates approach
those of Rakai and Masaka. In part the policy problem is
to avoid this outcome through effective programmes of HIV
prevention. Whether or not HIV transmission is reduced it
is crucial that vulnerable households be identified,
their needs be established, and structures be created for
delivering the goods and services they will require for
survival. This is true both for the urban and rural
populations; but in neither case will it be easy to
identify the poor and most vulnerable households.
There is rather more
information available about farm systems which are
vulnerable to labour loss, together with data on
particular crops where production is threatened. Tea,
which is a minor crop, is especially vulnerable given its
need for female labour inputs which are continuously
applied. Coffee, which is the main export, seems also to
be vulnerable to labour loss. Matooke [plantain], which
is the main staple food for most of the population, seems
already to be effected by falling labour supplies. Some
Districts are especially vulnerable at the present,
particularly those with high HIV infection rates, such as
areas to the west and north of Kampala [together with
Rakai and Masaka]. But all such estimates are based on
fairly superficial economic data and analysis, and it
would be unwise in these circumstances to base policies
on these. What is not in doubt is that HIV poses a major
threat to the maintenance of food and non-food output, so
as to threaten much of the rural population. These
impacts will extend well beyond the rural sector, given
the interactions between the rural and urban economies
[in terms of labour flows, food supplies, remittances
etc.], and even into international economic relationships
[given the dependence on a narrow range of export crops
for the foreign exchange needs of Uganda]. This is an
area of so over-riding importance as to be a priority for
policy; but policies need to have a firm foundation of
factual data on production conditions. It is not
presently the case that such information exists; efforts
need to be directed now to remedying this deficiency.
One sector is already
bearing the brunt of the HIV epidemic; unfortunately for
Ugandans the health care system is unable to cope with
even the present level of demands. This is unsurprising
given the deterioration of the system in the 1980s. Years
of neglect and underfunding had by the middle of the
decade turned what was once a comprehensive and effective
provider of services - with integrated hospital and
primary health care - into one of crumbling buildings,
weak management, inadequate [if any] supplies of drugs,
and a professional and technical staff which in large
numbers had deserted both the system and the country. In
spite of the attempts made in recent years the health
system remains underfunded, understaffed and
underprovided, such that rehabilitation will take many
years to achieve. Not only is the health care system
faced by growing demands from persons with HIV related
illnesses, but it is also having to deal with a set of
intensified health care needs caused by the collapse of
many other programmes over recent decades [such as
malaria and TB, where control programmes more or less
ceased]. Many hospitals do not have enough beds, drugs
and protective equipment to take care of their ever
increasing numbers of patients. For example, Lira
District Hospital has only 4 doctors to cater for a
population of 500,000.
It is natural that HIV
infected individuals and their families turn to the acute
care system for help, and seek medical attention and
drugs which they hope will alleviate their problems. But
in doing so they add to the problems of meeting health
needs generally in Uganda and in part divert resources
away from treatable and curable medical conditions. This
is evident from data on hospital admissions, where as
much as two thirds of beds are occupied by AIDS patients
and/or those admitted with illnesses such as Tuberculosis
(TB) [a common opportunistic HIV infection]. This state
of affairs is as much true of Government hospitals as it
is of the private sector. A state exists where the care
of patients with HIV related illnesses, particularly in
hospitals, is crowding out other patients in ways which
cannot be considered optimal from the national point of
view. That this should have occurred is reflective of
many factors; a health care system which at all levels
already cannot cope with demands and which has been faced
over a very short period of years with large scale growth
in HIV and AIDS related pressures. Such processes have
faced the MOH with problems it does not have the
capacities to meet - neither in medical nor non-medical
resources. In the event much of the burden of health care
has shifted to the private sector, which is itself now
overburdened, or is simply not being met at all by the
modern health care sector. There is much evidence that
many HIV infected persons are in receipt of little or no
care from the formal system, and have turned in many
cases [and in large numbers] to traditional healers.
Although Uganda has been at the forefront of the national
response to HIV and AIDS in Africa, it is disturbing to
note that there is no STD control programme in place.
This is particularly worrisome given the role of STDs as
a co-factor in the spread of HIV [noted above]. What is
needed is the development of a comprehensive STD
programme as a matter of great urgency, but this will
require putting in place a complex set of human and
non-human resources to be effective.
The present position in
terms of health care provision has little to commend it.
The system cannot cope with present demands and is
therefore doubly unable to deal with the projected
numbers of HIV infected persons. There is no alternative
to organisational reforms and the development of
innovative ways of meeting the real and genuine needs of
the population. To a degree these reforms have already
been implemented, in some parts of the private system,
where part hospital-based and part home-based systems are
already operating. What is needed is an extension of what
are currently small scale and pilot community based
schemes to a national programme. One which is sensitive
to the relative costs of alternative health provision and
linking both prevention and care in the community. Here
lies the challenge; but it is one which has to be faced
sooner or later.
II. SETTING PRIORITIES
A. CAPACITY
DEVELOPMENT: GENERAL CONSIDERATIONS
UNDP activities have as
their target the building of national capacity, and at
first sight this seems to be such an unambiguous concept
as to need no further examination. It is as if it is self
evident that this is desirable as an objective. But this
presumption leaves open many important issues. At the
minimum it can be assumed that donor activities aim to
strengthen national capacity in ways which permit a
country to achieve a preferred [better] level of
development. Trying to achieve this objective seems
reasonable enough as a guide to the selection of those
activities which are desirable and worth supporting, and
as an indicator of what ought not to be supported. But
there are many problems in practice with this simplistic
approach to capacity development.
- Resources are limited
so choices have to be made as to what activities
are more or less important. Who defines
priorities, and by what criteria are some
activities given preference over others? It is
unlikely that the exercise of preferences by
politicians and policy makers will coincide with
the selection of capacity building activities
which maximise development. Indeed, and
fundamental to conflict between preferences and
the selection of activities, will be dispute as
to the relationships between capacity building
and development in general, and between
particular initiatives and the achievement of
selected development targets.
- We have defined in an
unambiguous way the recipient of the additional
resources as "the country", and in the
case of UNDP this is assumed as identical with
the government of the day. UNDP deals mainly with
governments, and issues of representativeness
[how government came to power; does it observe
civil and political rights, does it have any or
much commitment to developmental objectives, and
so on, may not be considered relevant]. What
indeed ought to be the attitude of a development
agency such as UNDP in its dealings with a
government which is terrorising a segment of its
population? Destroying national capacity in the
process, as well as infringing basic human
rights. Or to take the example of Uganda, what is
the judgement to be of a government which
allocates some 40% of its Budget to military
expenditure, under conditions where real
expenditures on health and education together in
1989 were only a fifth of fiscal allocations in
1970? On a per capita basis health expenditures
were only 16% real in 1989 compared with 1970;
for education the decline was even worse to 13%.
Are such data to be taken as indicators of
government preferences; and can it really be the
case that internal and external security needs
always override social and developmental
priorities? Certainly such revealed allocations
of budgetary resources against social sector
expenditures in Uganda both contribute to the
economic and social problems the country faces,
and simultaneously constrain attempts through
capacity building to ameliorate these.
- What indeed is meant
by "preferred level of development"?
Does this mean a higher level of GNP? Is it a
matter of interest how this higher level of GNP
is achieved [by paying low wages to labour and
banning labour organisations]? Or through
policies which lead to environmental degradation,
both short term and long term [threatening the
sustainability of the process]? Are the benefits
of economic growth fairly distributed or do these
accrue to an elite which abrogates the benefits
of GNP growth for uses which have low social
value? Or is there an acceptable set of
development indicators which are the actual and
real foci of government activities, with which
capacity development can be aligned?
- Is the discussion
couched in terms of the short term, or is it
implicit in the process of capacity building that
policies are always about sustainability? But
this simply raises a further set of very complex
questions. These run like this. Development is a
process which takes place over time, and can be
judged as beneficial where a set of social
indicators can be shown to have shown
improvement. There may be problems in getting
agreement on what these indicators are, and there
will certainly be important issues which relate
to the conditions surrounding the achievement or
non-achievement of the selected indicators. Also
problematic is how to deal with the weighting
problem, ie. achievement of some indicators and
non-achievement of others. But it could, of
course, be precisely those countries
[governments] who are generally non-achievers who
are most in need of capacity building activities.
It may be the lack of capacities, whatever this
means, which prevents development as defined and
measured by social indicators.
- The object of donor
technical assistance is to support and strengthen
conditions in which a country can develop in a
socially acceptable way, so that over time the
need for transfers of resources from outside are
diminished [not necessarily to zero]. In this
case the meaning of sustainability, as far as
capacity development goes, is as follows.
Resources are made available to a country to meet
those needs which are essential for development,
but in a manner which over time leads to domestic
changes which make the transfers no longer
necessary. Transfers which are capacity building
do not generate a continuing dependence on
external support. This has to be one of the most
important criteria to apply to TA. Only if this
condition is met can capacity building
unambiguously be thought of as desirable.
- At the core of the
problem is not just what is meant by development
and how it is measured, but issues of how best to
bring development about. There are only too many
theories, too many ideologies, too many special
cases - and too many interest groups, both in
developing countries, in developed countries and
in international organisations [including UNDP].
At any one time there may be a dominant set of
beliefs, even occasionally some evidence to
support these, which sets the agenda for TA and
other assistance, such as those policies
currently peddled by the World Bank and the IMF.
These beliefs will often define what TA is
actually on offer, who is delivering it and to
whom, and under what conditions. Over time
beliefs will be modified, relative positions of
governments and organisations change, and with it
the concepts and practices of capacity building
[note that this is never a single valued
construct but is itself one which in practice
takes many forms].
B. CAPACITY DEVELOPMENT
UNDER CONDITIONS OF HIGH SEROPREVALENCE
Figure 1 ( not available)
sets out in a very simplified form a structure for
thinking about capacity building in Uganda - a country
facing an epidemic with all its consequences [as
identified in I.C above]. There are disadvantages in
setting out the problem and the choices as in Figure 1,
not least in that doing so suggests that the
relationships are linear and uni-directional. They
clearly are not, as will be seen later. Also implicit in
this representation is the assumption that we possess
sufficient understanding of what is an immensely complex
set of inter-actions as to be able to delineate these
into separable categories. This is acceptable, perhaps,
as a device for assisting exposition of the problems and
the choices, but cannot in any way be thought of as
descriptive of actuality. What the Figure does is to
place the policy problem within a framework which is
standard for economics, but this does not prove its
suitability for analysing the problem at hand. Time will
tell if this way of presenting choices is useful and adds
to our understanding.
The issue is that
described in II.A, ie. how to establish a set of
activities that will assist Uganda in developing those
capacities which will help it meet the severe
socio-economic problems raised for the country by the HIV
epidemic. Not in any detail, of course, but in very broad
brush terms, and building on the description of the
present and future position in Uganda as outlined in
Section I.
Final Targets
It is perhaps easiest to
start with the Final Targets, the achievement of which is
the purpose of development policy. Those identified in
Figure 1 are not intended to be comprehensive, but they
are the important ones. These include those targets which
are most threatened by the HIV epidemic [both now and in
the future]. In the ordinary course of events it would
have been expected that various mortality indicators
would improve, and in doing so raise life expectancy. The
HIV epidemic makes it unlikely that this will occur, and
that instead infant and maternal mortality, and adult
mortality, will be raised, and life expectancy probably
fall. Similarly with poverty, where the probability is
for an increase in destitution [with accompanying
worsening in other associated indicators of the standard
of living, such as housing and nutrition]. The overall
rate of economic growth would be lower than otherwise,
with significant losses of potential output, and the
external position of the economy be weaker - all because
of unfavourable impacts on the level and rate of change
of labour productivity, and lower rates of capital
formation [both in physical capital and in human
investment].
All of this was
established in Section I, and in some senses from the
viewpoint of meeting the development challenge of HIV and
AIDS we are not so much interested in Final Targets as
such, but in the complex ways in which these are made
unattainable by the epidemic. Rather the focii of policy
interventions are what are called in Figure 1
Intermediate Targets.
Intermediate Targets
Three categories have been
identified as being of over-riding proximate importance;
these are the Rate of HIV Transmission, the Care of
Infected Persons, and the Mitigation of Adverse Social
and Economic Impacts. These are probably not all of equal
social weight, and it would certainly be possible to
argue that reducing the rate of HIV transmission ought to
have priority in the allocation of resources [and in
capacity building activities]. It would not be difficult
to make this case, given the scenarios outlined in
Section I.B. Far and away the greatest benefit in
economic and social terms will come from those activities
which reduce HIV prevalence, through the minimisation of
future social and economic costs. It could also be argued
that some of the effects, particularly those on
macro-economic performance, will occur later and are thus
perhaps less urgent. This is partly true, partly untrue,
since some of the adverse economic responses are already
being experienced in Uganda.
What is undoubtedly the
case is that these Intermediate Targets are
interconnected; thus, a mitigation of the economic losses
caused by the epidemic will entail a higher level of
resources for meeting the care needs of the infected and
affected populations. Similarly, a reduction in the rate
of transmission of HIV will reduce the absorption of
resources into health care and raise the rate of return
on human investment [adult mortality will be lower, and
people will be productive for longer]. Again more will be
available for meeting the needs of the poor and their
dependents [there will be orphans and dependents anyway
who will need care, education and socio-economic
support]. More generally, since mortality will be lower
where HIV transmission is reduced, there will be a
greater capacity nationally to plan for the epidemic and
to implement activities in all areas of policy and
programming. Developing systems of care is more than just
delivering support and resources to those in need [needs
are complex, and not simply and not only economic], but
also become the mechanisms for the social mobilisation
which is needed for achieving the other two Intermediate
Targets. Prevention of HIV transmission and care in the
community are indissolubly related. In a nutshell; all 3
Intermediate Targets are important in themselves and need
to be pursued, but they are also mutually
self-supporting.
Herein lies the case for
capacity development which is multi-sectoral. But two
further points need also to be emphasised. Firstly, the
process of capacity building is also concerned with
maintaining capacity. The point has just been made that
the HIV epidemic reduces national capacity through
erosion of the human resource base, and so exacerbates
the direct impact of the epidemic through a downward
process of cumulative economic decline. Reducing HIV
transmission through effective policies for capacity
building slows, possibly halts this process, and at the
same time helps to maintain the national capacities for
management and organisation of national resources. Even
in relatively simple monetised economies there exist
important linkages at the levels of production and of
markets [both factor markets and output markets], such
that there will be adverse spread effects of the epidemic
on the economic system which need to be contained by
policies and programmes.
A second important point
is also being made here, which in some sense is in
fundamental conflict with the case made in II.A.4.
Capacity building is generally concerned with assisting
the development process in ways which are usually
measured by improvements in social indicators. But the
objectives of capacity building are different under the
conditions of an epidemic such as that being experienced
by Uganda. Here the policy problem is how to prevent, or
limit, a deterioration in the level of development, with
capacity building objectives seen in an entirely
different light. Success may be gauged not by the
increment of improvement in social indicators, but by the
degree to which deterioration in these has been
minimised. In these circumstances the whole process of
project design and evaluation needs to be re-assessed.
Thus, for example,to see income generation projects as a
means of preventing declines in living standards under
the impact of immiseration, rather than the conventional
approach where projects are selected in terms of their
ability to raise factor productivity and incomes.
Interventions
These are
multi-dimensional activities which are capacity building.
These could be about maintaining national capacity, or
its enhancement. Thus a programme of workshops for
different professional groups employed both by government
and NGOs which aimed to improve knowledge of the HIV
transmission process, and/or its social and economic
impacts, would generate new insights and improve economic
and social performance. These activities could be aimed
at raising the efficiency of existing interventions,
through for example training in management and
organisation, where the aim is to improve the use of
resources. Solutions in this area could themselves be
innovatory, and at the same time add to domestic
capacity. Thus existing NGOs, which are too small to
provide internally all the skills and services they need,
such as financial control and project evaluation skills,
could look to other more specialised institutions. The
latter might be in the public or private sectors, and the
process of capacity building be about the appropriate
development of service institutions where these are
currently missing or ineffective. The possibilities for
organisational innovation are legion; that these will be
important is also self evident. Again we are back with
issues of efficient resource allocation, and the need to
raise factor productivity - in these cases by removing X
inefficiency [the failure to maximise use of resources
caused by management and other internal practices which
are sub-optimal].
In evaluating national
needs for capacity building, it is important not to
misread signals which apparently support further
allocations of resources to a particular activity. This
may be best understood by looking at the example of the
Kampala AIDS Information Centre. This was established to
provide HIV testing and counselling services. It is about
to extend its activities to other parts of the country,
in response presumably to felt needs. Most of its costs
are met by USAID, and there is effectively no cost
recovery. An HIV test costs currently some $12 US, at a
time when per capita health expenditures in Uganda are
presently a mere $3 annually. Under what circumstances
can this allocation of resources be defended? A case
could perhaps be made, along the following lines. An HIV
test and its associated counselling, whether the result
is negative or positive, leads to such changes in
behaviour as to prevent further infection [of say
"n" persons]. If this is so then perhaps a case
can be made for subsidising HIV tests at the current
cost. But the case needs to be substantiated by evidence
and cannot be assumed. In this example the existence of
unmet demands [indeed any demand] does not prove that
creating additional capacity, in the form of testing
centres and in training more counsellors, is necessarily
justified. Of course other arguments in favour of HIV
testing centres can be made which do not depend for their
validity on demonstrating any effects on sexual
behaviour.
This example raises two
important principles. Are resources currently being
efficiently used, and does the existence of unmet demand
act as an efficient signal for further resource inputs?
Both of these need to be considered in decisions on
future capacity building activities.
No case can be made
"a priori" for or against private of public
sector interventions, and in practice there are
activities where in particular circumstances either or
both are best able to perform. Certainly the
effectiveness of certain interventions is constrained by
the weakness of public provision, irrespective of whether
the intervention is by an NGO or by government. A telling
example of this has been the enormous decline in the
quality and quantity of public educational provision in
Uganda; at the present only about one-third of the
relevant age group completes primary education, and very
few children proceed to later stages of education.
Something like one half of the total Ugandan population
is functionally illiterate. This decline in educational
achievement over recent decades severely constrains what
can be done through policy interventions in the case of
all three Intermediate Targets. Such a state of affairs
not only constrains what activities can be undertaken but
also requires that these factors be taken into account in
their design and implementation. Thus any Micro Projects
to combat AIDS have to assume as a basic fact that the
target population will not be able to meet sophisticated
project appraisal and evaluation requirements, and will
require intensive assistance by way of training in
management skills etc. Similarly with activities for
reducing HIV transmission where reaching the population
with relevant messages, and engaging them actively in
sustained behaviour change, will entail quite different
strategies [and be much more complex in design and in
processes of implementation].
The final point relating
to capacity building, which will repay emphasis, is that
most of the population is rural, so that the balance of
resource allocation in respect of all 3 Intermediate
Targets needs to be focused on this group. All of the
forces operating in Uganda will bias programmes against
rural populations, for reasons which do not need to be
explored here. The potential for disaster, both economic
and social if this urban bias is not addressed, is
potentially enormous. Similarly, with the gender
dimensions of HIV; as we have seen in Section I.B there
is an over-riding need to address all issues from a
gender perspective. It is perhaps enough to reiterate
that the single largest input into agriculture is women's
labour, that this is the scarcest factor of production,
whose availability for all uses in the society will
become increasingly problematic. How to respond to the
needs of women must be a major element in any choices
relating to capacity building, and to resource allocation
generally.
It can be concluded that
the overall objectives of capacity development in Uganda,
under conditions of high seroprevalence, are -
1. To improve the
functioning of existing institutions through raising
their efficiency in using resources.
2. To generate new
insights and develop new skills in understanding and
responding to the challenges posed by the epidemic.
3. To replicate those
approaches and institutional structures which are
successfully meeting the existing challenges to other
institutions and areas of the country.
4. To support
innovatory responses to HIV in all of its manifestations,
and to strengthen organisational developments, in both
the public and private sectors.
Knowledge Base
This is fundamental to any
policies of capacity development for any purposes. All
countries are resource constrained, and Uganda more so
than most. Over recent decades there has been immense
deterioration in the economic and social infrastructure,
so that effective responses to the HIV epidemic are made
doubly difficult. Even more important then in these
circumstances to ensure that what is done is well done.
Implicit in the approach outlined above is the assumption
of known links between Interventions and Intermediate and
Final Targets. In part the problem is that these linkages
are only imperfectly understood. This may be because a
knowledge base has yet to be established, or that where
this exists it is not being effectively used.
In part, knowledge and
understanding are independent of the activities being
followed, and in part these are the outcome of
activities. One example will suffice. The focus of much
effort presently in Uganda are IEC activities to change
sexual behaviour, since this is seen by Government and
others as the only effective way to slow transmission of
HIV. It would seem obvious in these circumstances to
relate IEC programmes to what is already known about
sexuality within the cultural context of Uganda. It is in
fact the case that Uganda for many reasons has available
a good deal of research on these matters, which ought to
have informed policies for IEC. But there is little
evidence that in fact these sources have been used in the
formulation of policies, and in the development of
interventions. Much of the IEC activity seems to have
been unproductive, in the sense that sexual behaviour has
not been changed in appropriate ways. There is some
evidence of both poor evaluation and ineffective
monitoring of IEC programmes, which has in turn led to
weakness in learning the lessons of what works, and what
does not.
Capacity building has to
be firmly based on what is known about economic, social
and cultural structures, if it is to be effective. Where
this knowledge of conditions, and structural and
behavioural relationships is inadequate for effective
policy making, then it will need to be addressed. In part
capacity strengthening is about developing insights -
without understanding there can be no effective policies.
Such insights cannot be assumed to be present,
particularly as in the case of an epidemic such as HIV,
where new analytical frameworks have to be developed and
tested against experience. In the case of Uganda the
early learning process is over; and now is the time to
ensure the full and rapid integration of experience in
policies for capacity development.
III. UNDP PROGRAMME INTERVENTIONS
OPERATIONAL PRINCIPLES
The general principles
which should guide UNDP have been established in Section
II on Capacity Development. These principles, in
conjunction with the analysis of the HIV epidemic and its
probable socio-economic impacts as detailed in Section I,
set a framework for the general allocation of UNDP
resources. But important as these principles are for
efficient allocation of resources they are insufficient
for the determination of priorities and spending
decisions. The definition of operational activities
requires the development of additional principles, and
the application of these in taking forward a programme
for UNDP assistance to Uganda.
The following are
important -
- The knowledge base
for interventions in many areas is imperfect and
inadequate, such that a crucial initial activity
will be to establish such a base. It is an
important role of the Uganda AIDS Commission to
define research priorities, and to direct
resources into consultancies, studies, task
forces etc. The output of such activities must
then inform policy formulation and the
development of specific interventions.
- Policy making is a
continuing process. Priorities will change
because governments come and go; because the
internal and external environments change; and
because of learning effects, ie. the
internalisation of experience and the embodiment
of this in policy.
- It follows from the
foregoing that the establishment of firm
allocations of UNDP resources for the period
1992-96 is neither desirable nor optimal. What
are feasible objectives at this point in time are
broad indications of priority areas, and
identification of initial activities. In effect,
what is proposed is a system of contingent
allocations, where the specific activities should
reflect changing needs and improved understanding
[what works, what does not work]. It is important
to note that a programme for UNDP requires a
framework which is more or less determined; it is
the activities whose relative balance should be
adjusted during the life of the HIV Programme,
through a process of consultations, taking into
account learning effects, changing needs, and so
on.
- UNDP resources are
limited so it is vital that these be used to
maximum effect. This means, in consultation with
the UAC, the identification of the points in the
economic, social and political systems where
activities can exert their greatest leverage; can
induce changes in behaviour and attitudes; shift
allocations of resources to areas of greatest
need, and support appropriate institutional
development. In a word, the activities of UNDP
need to be catalytic. Programmes must be
concentrated on the essential problems posed for
Uganda by the HIV epidemic. In part, this
requires a new focus - to see problems and their
solutions in different ways - together with an
intensification of efforts in respect of all
three Intermediate Targets. Critical to achieving
a new vision is a more general recognition of the
developmental relationships of HIV, and the
strengthening of activities for planning for, and
meeting, the expected social and economic
impacts.
PRIORITISATION OF
PROGRAMME INTERVENTIONS
A. PREVENTION OF HIV
TRANSMISSION
Certain features stand out
clearly in the present efforts to reduce HIV
transmission, and there are important matters here which
UNDP needs to address. Much has been done to increase
awareness in Uganda, and many activities are underway and
planned in this area by government, NGOs, UN agencies,
bilateral donors, and so on. Three observations merit
separate attention -
- The presumption that
awareness is generally high is almost certainly
unfounded, and the admittedly partial evidence of
the Mission field visit to Lira and Apac
Districts suggests that there are problems in
this area still to be addressed. Regions which
currently have relatively low infection rates,
and which for other reasons are difficult to
access, are in need of communication activities
to develop awareness at all levels about HIV
transmission and its prevention, and to raise
understanding of the deadly nature of AIDS. It is
certainly appropriate for UNDP to assist others,
such as UNICEF, in the identification of needs in
this area, and to collaborate in the development
of suitable forms of programme delivery,
including strengthening institutional structures,
training, etc.
- There is little
evidence for Uganda that sexual behaviour has
changed in the ways appropriate for a reduction
in transmission of HIV. Increasing awareness has
not been sufficient to induce sustained behaviour
change, so how to bring this about remains the
core of the problem for reducing the rate of
transmission. There is work proceeding currently
in this area, including a Report which is due
from AIDSCOM, and there is the development of new
approaches presently underway at Kitovo Hospital.
Others, such as UNICEF and DANIDA are active in
this field. It is clearly appropriate for UNDP to
collaborate with others in identifying why
activities for behaviour change have had such
little success; to support programme development,
probably on a pilot scale, and to then establish
joint programmes for training and other
activities.
- Doing the foregoing
would certainly be worthwhile but in crucial
respects would be inadequate to meet the
challenge. A point which is emphasised in Section
I is the absolute need to establish a gender
sensitive approach to this issue. Questions were
posed above of why women are infected with HIV at
a younger age than men, and why apparently there
is a higher rate of female infection.
At least three directions
for UNDP activities, of great importance, follow from
these observations on the roles of gender in relation to
the epidemic.
a. What
are the social, cultural and economic conditions which
explain the gender biases in HIV prevalence? This
requires detailed studies, either separately by UNDP or
in conjunction with other agencies with interests in this
area. It is obvious that any approach to this question
would need to address not simply behaviour change but
also, and crucially, the formation of behaviour.
b. How
can women protect themselves from infection? The
behaviour change activities undertaken in Uganda have
generally not addressed this question, but have
concentrated on the ways in which men through their
actions can reduce their infection rates. Thus activities
have concentrated on matters such as reduction in the
numbers of sexual partners, and use of condoms. Whereas
most women in Africa have one and only one partner, and
have little or no control over their male partner's
sexual activities, and so are not able to demand changes
in behaviour and insist on the use of condoms. Here there
is a major role for UNDP, and one which must have high
priority. The issue has received little or no attention
from the programmes designed and delivered by WHO, and
has been similarly neglected by the Uganda ACP. The
development of understanding of the ways in which women
can protect themselves from infection; the embodiment of
such understanding in programmes for behaviour change,
together with the establishment of service delivery
activities which make it possible for women to protect
themselves from infection. All are absolutely crucial for
success in reducing the rate of HIV infection in Uganda.
c. Unless
a. and b. are successfully addressed as matters of
extreme urgency, then it is difficult to see how Uganda
will be able to cope with the immense problems caused by
the epidemic. Women, as we have seen in Section I, are
central to almost everything - the care of the sick
generally, not just those persons with HIV related
illnesses; the maintenance of food and non-food
production; the care and support of children and elderly
dependents, and so on. It cannot be said that the crucial
role of women in the economic and social life of Uganda,
and the degree to which they and their contributions are
threatened by HIV, have been taken on board. UNDP has a
ensure that in its programme for Uganda, through
consultations with the UAC and other partners, that these
failures of programme design and delivery are rectified.
It follows that not only must the gender biases in
transmission be addressed, through changes in analysis,
policies and programmes, but that efforts be directed
into the assessment of the problems of high female
morbidity and mortality for the economic and social
system. Both aspects of the issue are important and
critical areas for UNDP programme support.
There are four other areas
where UNDP could have a role in relation to transmission
of HIV, possibly of secondary importance. These are -
d. In the
development of a programme for STDs which, as noted
above, have been identified as a major co-factor in the
transmission of HIV. Several agencies, including WHO,
USAID and possibly the World Bank, are interested in
establishing a programme for STDs. There is effectively
no programme at present in Uganda, and given the state of
general health services in the country it will be a
formidable task to set up an effective system for the
diagnosis and treatment of STDs. UNDP certainly has an
interest in seeing such a programme established, although
it would take it away from its developmental concerns,
and it would seem preferable to leave the analysis of
need and programme development to others. Except for a
particular concern which UNDP has and which is not
currently reflected in the approach of other agencies to
this matter. This relates to the concerns expressed
above, ie. the high level of HIV infection amongst women
and the need to reduce it. There is a good deal of
evidence that STDs [together with other physiological and
culturally determined factors] are important in
explaining high infection rates in women. Since most
women are never subjected to internal examination by
medical practitioners STDs and other infections remain
untreated as a consequence, and this raises the risk of
transmission of HIV. It is, unfortunately, only too
likely that a programme for STDs, if established in
Uganda, will neglect the critical needs of women. So UNDP
has an interest in being associated with the development
of a programme for STDs on these grounds alone, but in
order also to enable Uganda to better deal with the
economic and social impacts of the epidemic.
e. There
is one important sub-group in the population who are
perhaps peripheral to the main concerns of UNDP. This is
the military, who may have high levels of seroprevalence
and who may play a significant role in transmission. This
is an area where other agencies [USAID] are active, and
there may be little need for UNDP to become involved.
This is, nevertheless, one area where UNDP may want to be
involved in the process of training [counsellors
particularly], and perhaps in the development of care.
The military do have arrangements for those who are
infected and who at some stage are retired from the
service, but there is a need to look at how individuals
and their families cope. There is a complex set of issues
here; of IEC activities, STD programme development, HIV
testing and ethics relating to it, condom supplies,
counselling, care and medical needs. The military are
important because of their relationship to the rest of
the population; they are a mobile and sexually active
group of young men who wield a great deal of power, and
as such are in a position to do much harm to the ACP of
Uganda. It needs hardly to be added that they are also
deserving in their own right of a comprehensive programme
for HIV prevention and care.
f. There
are some 150,000 refugees in Uganda who are the
responsibility of UNHCR. Some are recent arrivals and
others have been long settled in Uganda. They are a
particularly vulnerable group for all sorts of reasons,
and there is the real possibility that their needs in
respect of HIV prevention, care and income support, will
not receive the attention these deserve. Many factors are
likely to combine to make refugees, and particularly
women and young adults, very vulnerable to HIV infection.
There seems to be little evidence that their multiple
needs are being addressed by UNHCR, who do not have the
capacity for dealing with these matters. This is an issue
requiring inter-agency discussions and consultations with
the UAC.
g. There
is a great deal of IEC activity already, and WHO has an
expert in the country and is considering the secondment
of another person in this field to the UAC. Others are
also active in the area, and UNICEF has announced that
this is a priority interest. Other UN agencies, such as
UNFPA have activities in progress and planned. Also
active in the area are NGOs such as The AIDS Support
Organization [TASO], The Uganda Red Cross, Experiment in
International Learning [EIL], and so on. There is no lack
of activity, but as we have seen above there can be
doubts as to its effectiveness. There are general
problems here, and they are not only those which are
raised above. These include constraints on the local
development and production of materials for IEC purposes,
and for use in training and counselling. This is raised
as a matter of considerable importance at this point in
the Report, rather than in the section below which deals
with organisational matters. This is certainly an area
where UNDP has an interest in the local development of
capacity, both of technical skills in developing
materials and in production, but only after a capacity
needs assessment. A related matter, but one which the
mission did not look at, is the role of the Media in IEC.
This is certainly deserving of separate study, since
capacity constraints in this area are undoubtedly
important.
There remain two other
areas where UNDP might have some involvement, but which
are judged to be of low priority. These are -
h. It is
the case that risks of infection with HIV through
contaminated blood and blood products are very high. It
is also true that in Uganda only a small percentage of
transmission is due to this factor and, as noted above,
about 90% is heterosexual in origin. At the present most
blood is screened for HIV etc., and the blood supply is
considered more or less secure. Most of the costs of this
programme are met by the European Community [EC], and
they are also meeting the costs incurred through the
setting up of extra blood screening centres. While the EC
has no firm plans for continuing support it is the case
that for the moment at least the system is being
financed, and is apparently working well. There is some
evidence that blood is not reaching hospitals in rural
districts, but this distributive problem needs to be
addressed by others. The cost of a unit of blood is very
high - a unit cost of 42$. This needs to be compared with
per capita health costs for Uganda of about 3$, and
recent estimates of the World Bank (WB) that the average
cost for drugs etc. per AIDS case are approximately 14$.
There would appear to be important issues here of the
efficiency of resource allocation. One conclusion is that
UNDP should not get involved in blood screening
activities. With one caveat; the Nakasero Blood Bank
hopes to establish a panel of donors [Clubs], which ought
to reduce the cost per unit, and act as a vehicle for
IEC. This is an interesting proposal and is one which
UNDP might well assist. The start-up funding ought to be
quite small, and there is the possibility of
piggy-backing this activity on more general IEC and
behaviour change interventions.
i.
Reference is made above to the AIDS Information Centre
(AIC), and doubts were expressed about the scale of
resources being absorbed into this activity. It is
suggested that UNDP should not support the AIC unless it
can be shown that various conditions are being met with
respect to behaviour change and other benefits from
testing. Carrying out such a Study would be a complex
matter, but ought to be a prior requirement for any UNDP
involvement. If it can be demonstrated that AIC
activities do have significant and worthwhile effects on
behaviour change or other important benefits then a case
might exist for UNDP support. Possibly UNDP could help
with limited finance for any study which is undertaken,
although this could perhaps be left to USAID and AIDSCOM.
B. ECONOMIC AND SOCIAL
IMPACT
The earlier Section I.C on
Impact Projections more or less sets out the agenda for
activities, but is no more than a brief summary of
possible outcomes. It should also be noted that the WB
Study [1991] has value mainly as a general statement of
the issues, and does not in any way take the analysis of
impacts sufficiently forward. It follows that detailed
studies of the economic and social impact of the HIV
epidemic are a pre-requisite for policy interventions by
UNDP and others. This requirement does not preclude all
activities for ameliorating the current impacts on the
economic and social system, such as for example the Micro
Projects Programme to Combat AIDS, but it does imply that
at this stage much of UNDP activity will be preparatory
rather than substantive. A constraint, which has to be
removed, relates to the national capacity to develop the
required insights, and to be able to undertake studies of
the multiple ways in which the social and economic system
is affected by HIV and AIDS. Developing these capacities
and professional skills is addressed below in the Section
on Strengthening Organizational Structures. Matters
relating to the Health Sector are partly dealt with here
but also in Section III.C. This may be confusing, but it
seems, on balance, preferable to organise interventions
on a functional basis.
1. Micro Projects
The Micro Projects
Programme to Combat AIDS [UGA/91/005] is a pilot project
which aims to reduce the adverse effects of HIV infection
through the provision of financial resources and
technical assistance. The target groups are those
households and communities considered to be most
vulnerable to the adverse impacts of HIV, and the Project
involves NGOs and CBOs actively in the identification of
appropriate and supportable activities, as well as in
their management and evaluation. This is a project which
is well deserving of support as an innovatory attempt to
meet the needs of vulnerable groups through income
generating and other activities. There are various ways
of strengthening the Project, including the following.
Firstly, it is absolutely crucial that the participation
of women be a requirement for both the National Steering
Committee and the District Selection Committees. This
should be achieved through a minimum percentage of the
membership, say not less than one-third of the total.
Secondly, the performance of this Project will depend on
the quality of the inputs from NGOs, CBOs etc [the
sponsoring organisations], and this is recognised through
the provision for some technical assistance to these
groups. This does not look as if it will be enough, and
provision needs to be made for much more than is
proposed. Furthermore, the planned technical assistance
is too narrowly focused, and the targeted beneficiaries
who are expected to identify projects, formulate and
effectively manage these, are going to need much more
assistance than is provided for in the Prodoc. It is well
known from other income generation projects that
weaknesses at the level of operation and control are a
major cause of failure. Finally, there are no convincing
grounds for the exclusion of Rakai and Masaka from the
Project, and given that they are currently facing severe
problems caused by the epidemic it is suggested that they
be included.
2. Sector Studies
It is urgent that Sector
Studies be commissioned on the impact effects of HIV. At
present what is available are studies which largely
depend on secondary information and the application of
intuitive reasoning. This is no substitute for empirical
research which directly addresses the important questions
raised by the epidemic. There are a number of key sectors
where the impact will be severe, which are critical for
the performance of the economic system, and including
sectors which are important for reducing HIV transmission
and for providing care for those affected.
The Sectors identified are
:
a. Agriculture
This supplies most of the
food and almost all the exports of Uganda; most of the
population is dependent directly or indirectly on this
Sector. So far the impact studies which have been done,
such as Barnett and Blaikie [1990] and the World Bank
[1991], provide little more than a sketch of the probable
responses and distribution of effects on Agriculture.
There is an immediate need for detailed analysis of the
ways in which production will be affected by changing
labour supply availabilities, including the effects on
factor utilisation, production technologies, crop
diversification, food availability, factor and output
prices, and so on. In part this means collecting and
analysing much new data, District by District. Plus
observing the ways in which farm systems are responding
already in areas with high HIV prevalence such as Rakai
and Masaka. These data are crucial for the formulation of
policies for meeting the needs of the agricultural sector
- both in terms of production quantities; changing
patterns of production [with additional needs for some
inputs, such as fertilisers and pesticides]; the impacts
on land use [with the possibility that land may be
uncultivated and untended causing land degradation]; and
the impacts on farm populations. The generation of
estimates of the most vulnerable systems of production
and most vulnerable households are crucial for effective
policies for planning for the impact of the epidemic
across a wide spectrum of concerns. The latter include
issues of nutrition, food security [and food storage],
the changing pattern of labour use [and the impact of
this on households dependent on rural labour markets],
changing patterns of land ownership [as assets are
liquidated to meet health costs in affected families, and
land is redistributed at death]. What are clearly needed
are integrated studies which identify the
inter-relationships, and establish the main areas where
policy interventions are needed. But time is important,
and it will be necessary to use Rapid Appraisal
Techniques wherever possible so as to get the information
and recommendations to policy makers without delay. The
focii for UNDP interventions would be Ministry of
Economic Planning and Development (MEPD) and Ministry of
Agriculture.
b. Health
We have seen above in
Section I.C on Impact that this sector is already facing
intense demands, such that many patients with HIV related
illnesses are largely untreated by the formal health care
sector. It seems also true that HIV-related illnesses are
crowding out other categories of treatment, with results
which cannot be considered optimal. This requires a
Health Sector Study which looks at the strategic options,
and assesses both the needs of HIV infected persons and
the best ways to meet these, given the expected resource
constraints facing the health sector [both governmental
and private]. Inevitably the formal health care sector
will be left with important responsibilities for
treatment, both in terms of demands falling on different
parts of the health care system [particularly on lower
level facilities], on essential drug requirements, and on
the training of doctors, nurses, etc. There is little
point in predicting forward the present state of affairs,
in that this would represent an abdication of
responsibility. What is needed is a full assessment of
health needs and the best ways to meet these, given both
human and non-human resource constraints. To this end
there will have to be a significant strengthening of the
MOH in terms of its planning capacities. It goes without
saying that one of the outputs of such a review would be
an assessment of the impact of HIV related illnesses on
the capacity of the health sector itself, given that
human resources will, indeed already are, being
diminished through morbidity and mortality. This is
perhaps an area where WHO and the WB may be thought to
have primary interests, but UNDP certainly ought to be
involved both in helping Government in activities aimed
at redefining strategic health care policy, and in
strengthening the general planning capacity of the MOH.
c. Education
This sector is facing huge
problems, and the existing challenges are already
enormous. As we have seen above the performance of this
sector in terms of enrollment and quality of education
leaves much to be desired. Yet, like Health, it is a
crucial service sector with critical responsibilities for
human resource development and its maintenance. As the
human capital of Uganda is eroded further by HIV and AIDS
the ability of this sector to educate for replacement of
lost skills will become even more important. It will,
like Health, be facing the problems of AIDS mortality, so
that its capacity to maintain activity will be declining.
Furthermore, this Sector has to play a major role in
creating awareness of HIV and in the forming of
appropriate behaviours amongst a critical segment of the
population - the next generation, which is as yet largely
uninfected. There are multiple issues here which need
attention; some are being addressed by others [such as
the programmes of UNICEF], but there are important
planning issues which are not. Planning for the Education
Sector has to be concerned with, for example, the effects
of the HIV epidemic on the school age population [the
numbers to be educated], the impact of HIV related
illnesses on the supply of teachers [and their training],
the need at secondary and tertiary levels to plan for
replacement of critical skilled and professional human
resources, issues to do with the financing of the sector
[under the general impact of HIV on the economy], the
particular problems of groups such as children who are
infected and affected by the epidemic, and increasing
numbers of poor families. There is a range of important
policy and programme matters where forward planning is
going to be essential, and UNDP should certainly assist
both the Ministry of Education and the UAC with technical
and planning support.
3. Community Monitoring
Much of the foregoing
reflects partial ways of measuring the impact of HIV, and
while it is essential to look at effects in this way it
is not sufficient to do so. What are also needed are
comprehensive methods of recording impacts and social
responses, ie. some kind of cross sectional picture which
integrates effects and responses within a defined space.
For most households this space is going to be the
community, which is itself a concept with ill-defined
boundaries. In a largely rural society such as Uganda
this will usually be co-terminus with the village, and
what are needed are methods for observing and recording
the multiple impacts at this level. Only at this level of
disaggregation will it be possible to identify affected
households with their specific needs, their problems as
they change over time; the inter-household relationships
and attitudes; the development of social caring
processes, including the activities of CBOs, NGOs,
churches and the like; and what is happening to rural
production and the use and distribution of resources. In
short to develop ways of representing and analysing
communities who are facing the social and economic
impacts of HIV. Since most of the adverse effects of the
epidemic are going to have to be handled at the community
level it follows that policy has to have detailed
pictures of the problems that communities are facing, how
they are coping, and what are the effective programme
interventions. To achieve this objective UNDP should
develop, in consultation with the UAC, a programme of
Community Monitoring, with an initial set of
differentiated communities as pilot studies. This will
require an initial piece of research into the problems of
establishing such a community monitoring programme.
C. CARING
This is in many ways the
most complex issue to address, and in many ways also the
most important. Many aspects of health care have been
raised above, particularly those dealing with the formal
health care system, both access to it and the quality of
care. It is not intended in this section of the report to
add further to what has already been written, for it is
obvious from the foregoing that, in the case of Uganda,
most of the care of the infected and the affected will
have to be at the community level. Indeed one of the
major challenges policy makers in Uganda have to face is
how to ensure that resources do reach communities and
households where they can have most impact, and where
needs are greatest.
In these circumstances the
activities of NGOs, CBOs, churches and other institutions
have critical and vital roles to play. These institutions
have already proven their value, being active in multiple
directions in meeting the needs of society. The objective
here is not to review their activities, and indeed much
that the Report has to recommend by way of specific
interventions is reserved for the following Section,
where attention is directed at ways of further raising
the effectiveness of the NGO sector broadly defined. But
there are three very important areas where NGOs are going
to be central to meeting the challenges posed by HIV, and
indeed where they are already demonstrating their ability
to innovate and be effective.
1. Community-Based Care
In an ideal world it would
be possible to wait for the results of any Community
Monitoring system such as recommended above, but the
problems are too urgent for this. Actions are required
now on how best to meet the medical, social and economic
needs of households and communities in an integrated and
sustainable way. Fortunately there are examples of how
this might be done, and these cases might provide the
basis for a national programme. The first step would have
to be a much deeper evaluation of the two cases to be
presented; to identify their strengths, and to consider
the problems facing Uganda in replicating these
"models" to other Districts. The initial focus
of UNDP would indeed be to undertake the commissioning of
such an evaluation, with the intention then of directly
funding the development of those capacities which are
essential for extending the programme to other Districts.
This ought to be a major area for UNDP activities in
meeting the challenges of HIV in Uganda.
Both of the cases are
based on non-governmental hospitals. They are Kitovo
Hospital in Masaka, a District of high infection and very
severe social and economic problems, and Aber Hospital in
Apac District where HIV infection is thought still to be
low . Both hospitals have had to face the same problems:
patient care needs which threatens to overwhelm the
facilities, crowding out other patients; a need to find
alternative ways of meeting the medical and social needs
of persons with HIV-related illnesses, within the bounds
posed by tight resource constraints of beds, drugs and
staff; and how to integrate health care and other needs
into a community framework. In part because there is no
real alternative to doing this, and in part because this
is actually better for the infected and affected.
Integration of care, the creation of support networks,
income generation schemes, IEC and behavioural change
activities, support for orphans and destitute families,
and mobile teams of trained personnel [both medical and
non - medical], have all formed part of their developing
response. What is being achieved is remarkable, but they
are of course also resource constrained in what they can
achieve, and the numbers they can reach. Their capacities
are clearly limited, and the constraints of space,
trained counsellors, IEC materials, transport, and the
like all need to be relieved. In part capacity building
is about relieving these constraints, and doing so for
these hospitals and others would in itself be a valuable
step forward. But what is being primarily recommended is
more than this: it is the evaluation of models of
integrated care which have evolved over time in the face
of the epidemic, and the replication of these models in
their primary elements to other areas of the country,
where the model can be effectively applied. This second
stage will require substantive capacity building
activities by UNDP and others. In a sense, it means using
these cases both as models and as centres which could be
given training and other responsibilities. In the latter
role, they could be seen as "poles of community
development", playing active roles in their own
replication.
2. Orphans
This problem figures in
all discussions of HIV in Uganda and as such can be
briefly dealt with in this report. The number of orphans,
as defined in Uganda as a child having lost one or both
parents, is thought to number somewhere between 600,000
and 1 million. Many of these are the result of war and
other factors, but this in no way changes the scale of
the problem which currently exists, and which will become
even larger in the coming years. There are many
activities already in this area; the UAC sees it as a
matter of great concern and a special committee will
develop policies and interventions; and there are NGOs
such as Uganda Community-Based Association for Child
Welfare (UCOBAC) and Uganda Women's Effort to Save the
Orphans (UCOBAC) who have focussed their efforts in this
field. The issues are highly complex and the potential
solutions by no means obvious. Some of the interventions
raised earlier in this Report, such as those for a
Community Monitoring System and impact studies of Health
Care and Education, will partially address the needs of
orphans, eg. in considering the issue of school fees.
Valuable as these interventions and insights might be
they are certainly not enough. This is an area where UNDP
ought to be involved in capacity building, but what to do
and how to do it is by no means obvious. There is a clear
preference in Uganda for non-institutional solutions to
the needs of orphans, although there can be no reason to
suppose that this is everywhere and for all children both
feasible and the best option. The national response has
so far been ad hoc, and what has been done is an
insufficient guide for future policy and appropriate
institutional structures for the delivery of support. It
is strongly recommended that before UNDP develops a
programme in this area that a comprehensive study be made
of the whole set of issues raised by the large and
increasing number of orphans. Such a study should not
focus to any degree on estimating future numbers [having
some idea of numbers and their distribution is not the
core of the problem], but on identifying needs and the
ways in which policies and institutional structures can
meet these. UNDP in consultation with the UAC should
urgently commission such a study, and then develop with
NGOs, government and other agencies, a programme of work.
3. Community
Development
This is not a useful
operational category, but it is desirable to identify it
nevertheless in order to re-emphasise its importance. In
practice much of the foregoing is about how to develop
and strengthen community involvement in all areas, and
the need to refocus the allocation of resources away from
urban to rural groups, and away from formalised
institutional structures to informal and localised ones.
How best to do this, and the identification of
priorities, will be the outcome of the recommended
studies and policy related discussions in Uganda. There
is much already being done at the community level, most
obviously by TASO, the Uganda Red Cross and by the
churches, which is extremely valuable, but highly
constrained in terms of geographic and functional
coverage. How to expand these activities, both spatially
and in other ways, is by no means obvious. What is
presently urgent is identification of needs and
constraints, so as to be able, for example, to expand the
numbers of trained personnel available for counselling
and for behaviour change programmes. This is a matter
which is also dealt with below under Organisational
Restructuring.
D. STRENGTHENING
ORGANISATIONAL STRUCTURES
This is potentially and
actually a hugely complex problem and the following
should be seen for what they are - tentative
recommendations based on unscientific observations. These
are thought, nevertheless, to be of value, not least in
pointing in the direction of positive and productive
change. For purposes of exposition only it has been
necessary to identify two categories - Government and
Non-Government - but obviously these are in many ways
overlapping in their areas of interest, and are and
should be seen as complementary. Many of the
interventions above entail new functions and changing
responsibilities for organisations, and the following
should be seen as only a sub-set of these changes which
are mainly organisational in their nature.
1. Government
The Uganda Government has
recently introduced major structural changes with the
establishment of the Uganda AIDS Commission and
Secretariat. This signals the commitment of the
Government, and its intention that policies for the HIV
epidemic be both multi-sectoral and multi-level. However,
there remain unresolved issues about structure and
function to which attention is turned below. The ordering
of the following discussion can be considered as
representative of the importance which is attached to
particular levels of capacity building activities.
a. Local Government
Structures
It is a historical fact
that most UNDP capacity building has been focused at the
level of Central Government, to the relative neglect of
Local Government. In the case of the HIV epidemic all
levels need to be strengthened, but the problems are much
greater at the local level. This is scarcely news, and
there are many existing proposals of a piecemeal nature
which aim to remedy the observed deficiencies of poor
policy formulation and implementation at District and
County levels. There is generally too little
understanding of the developmental effects of the
epidemic, and too little integration across programmes -
this is the familiar problem of verticality. The UAC is
considering the establishment of Field Offices in a
limited number of Districts; UNFPA has looked at the
desirability of locating Population Officers at the same
level, and there are proposals under consideration for
economists from the MEPD to be located at the District.
There are already many functions relating to health and
development located at District level, some of these
concentrating on the delivery of medical services and
health education. This is also the level at which, at
least in some Districts, NGOs are also operating, and
need to be encouraged to operate. It is also clear that
the Resistance Councils (RC) have, and are expected to
have, important functions and responsibilities, but that
these are not being effectively utilised. RC leaders in
particular need training, and especially leadership
training. The importance of community action and social
mobilisation is at the core of this Report, and for this
to happen there has to be a major strengthening of Local
Government structures. In part this means shifting more
resources, financial and human, to the local level, which
will require different organisational structures with new
perspectives and priorities. Effective structures have to
be built; in part through a comprehensive evaluation of
existing and proposed systems, and support for a process
of organizational reform. UNDP has an important role to
play in bringing about these very critical reforms.
b. The Uganda Aids
Commission
The Commission and the
Secretariat have been in existence for such a short time
that their roles, functions, resource constraints, needs
and responsibilities, are all still evolving. The WB has
been involved in needs assessment at the level of the
UAC, and in respect of proposals for the setting up of
AIDS Units in the various Ministries. In many senses,
therefore, this is the wrong point in time for UNDP to
assess what its contribution to the UAC and to individual
ministries ought to be. The role of UNDP in these
circumstances should be to continue with its general
support for the Uganda Government's initiative, and to
look positively upon requests for assistance. To a degree
any response will need to be set within a framework of
priorities, which is precisely the purpose of this
Report. What has been argued above is that effective
programmes across the spectrum of needs have to be
concentrated elsewhere, particularly at the community
level.
This leaves the UAC with
major strategic responsibilities which are important for
the development of effective policies for prevention and
care, and for responding to the multiple consequences of
the epidemic. To perform these functions the Secretariat
has to acquire a high level of professionalism in the
areas it has already identified as crucial; to utilise
consultants where internal skills are unavailable, but
generally to keep itself a lean and non-bureaucratic
institution. UNDP should, once needs have been formulated
in these terms, be willing to provide training and
consultancies. For example, assisting the UAC in
developing research programmes, especially in the social
sciences, and in helping the UAC acquire professional
understanding in the areas of project development and
evaluation. It being understood that these skills are
needed at the level of the UAC, but not so that these
activities are undertaken by the Secretariat. Thus the
UAC has to be able to advise on research priorities, to
be able to review research output, and to ensure that
this research informs policy formulation and programme
development. To become, in short, the centre in Uganda
for informed discussion of HIV, and the source to whom
those inside government and those outside government
naturally turn for advice on policy and programme
development.
c. Ministry of Economic
Planning and Development (MEPD)
This Ministry has critical
responsibilities and, as such, needs to be informed and
to have insights into both the causes and the effects of
the HIV epidemic. As a planning ministry it has to ensure
that other ministries are aware of the costs, social and
economic, which Uganda is both bearing now and will
inevitably also have to face in the coming years.
Government needs to plan both for the erosion of its own
capacities due to HIV and for the changing levels and
types of services which will face Departments. As noted
above the WB is considering the needs of various
Ministries, including those associated with the
establishment of AIDS Units. It is crucial that MEPD in
particular develop a programme of training for its
professionals, especially economists, so that it can
modify its internal planning activities to take account
of HIV, and ensure that this is also true of other
Ministries in their planning roles. Since the MEPD also
plays a major role in directing and co-ordinating donor
assistance it is doubly important that it be aware of and
understand the specific requirements for effective ACPs.
To this end it is essential that senior staff and
professionals be provided with the opportunity to
participate in workshops, etc. dealing with HIV, and to
undertake [participate in] studies of the socio-economic
effects of HIV.
2. Non-Governmental
Organisations
It is now readily agreed
by everyone that NGOs, CBOs, churches, etc. are central
to policies for prevention, for care, and for activities
which aim to limit the economic and social costs of HIV.
This is evident from both the analysis and the
recommendations made above. Organisations such as TASO
have become models for institutional developments
throughout the world. An example of what can be done for
the infected and affected, for prevention, for income
support - across the whole spectrum of activities - by
individuals of commitment and determination. Similar
qualities are present in other Ugandan NGOs, with the Red
Cross, the Catholic Church, UCOBAC, UWESO, and countless
others, active in many directions and many areas of the
country. A recent UAC inventory of NGO activities is
several inches thick - a testimony to their extensive
involvement at all levels.
Much has been done, which
needed to be done. But the growth of NGOs has been
organic, in some directions and not in others, with a
regional spread which is very uneven. So also with
performance, where it is evident that with growing
responsibilities and programmes, in areas such as
management and financial control [costing generally], and
in monitoring and evaluation, there have emerged real
weaknesses. This is unsurprising, and indeed some of the
NGOs have already undertaken internal evaluations,
restructured management, and considered strategic plans
for the future.
The issue for UNDP is how
can it help these organisations be more effective in
meeting the challenges posed by HIV, and at the same time
encourage independence and growth in response to needs.
What is undoubtedly a prior requirement is an evaluation
of what NGOs are presently doing; in what areas are they
strong and effective/ineffective; what are the current
constraints facing these organisations [of management, of
planning, of project evaluation, of research, of cost
analysis and control, etc], and how can these be tackled
[by whom? through collaboration? through establishing
specialised service agencies for management training,
project evaluation, performance monitoring?]. Where is
there a need for rationalisation of activity? Are there
activities which are underprovided and, if so, why, and
how can obstacles to provision be overcome? This is a
major task to undertake such an evaluation, and to ask
the questions, "What can NGOs do best?" and,
"How can performance be improved?". UNDP should
offer to finance such an evaluation, and then develop a
programme of support for such institutions through
consultative processes so as to improve their
effectiveness. These activities should have a very high
priority in any ordering of UNDP activities in Uganda.
IV. OPERATIONALISING ACTIVITIES
A. PROGRAMME APPROACH
The previous Sections have
dealt partly with description and analysis, and partly
with principles. So far there has as yet been no explicit
consideration of operational implementation of the UNDP
Programme on HIV for Uganda. The purpose of this Section
is to briefly rectify this omission, but to do so in a
fairly schematic form. The argument for not dealing in
detail with some aspects of the Programme are set out
above where it was suggested that flexibility in design
and in programme implementation are both desirable. While
the details of specific activities remain to be resolved
and will have to be established through programme and
project discussions, the overall balance of the UNDP
Programme - the areas for UNDP concentration of its
activities - have been strongly identified in Section
III.
It is possible for there
to be misinterpretation of what is being proposed by way
of a UNDP Programme for Uganda, and it may be useful to
state unambiguously what it is, and what it is not. The
Programme is not an alternative National AIDS Control
Programme (NACP); and it should not be seen as in any
sense a parallel programme. Nor is it separate from the
NACP, but should be viewed as integral to this, and
fundamentally part of the nationa |
