51705 Taking Stock of Community Initiatives In the Fight Against HIV/AIDS in Africa: Experience, Issues, and Challenges Africa Region Working Paper Series No. 116 June 2008 Abstract his paper clarifies the concepts of community initiatives since T organizations involved in the fight against HIV/AIDS use different definitions of "community." It presents several HIV initiatives taken by communities (including prevention, access to care and treatment, impact mitigation, and systems development) and analyzes them from a social capital perspective. The paper also analyzes the following issues and challenges: a) assessing the impact of interventions conducted in communities including the difficulty of integrating community initiatives within the national responses; b) sustaining community initiatives where strategies and funding are uncertain, and where initiatives depend on volunteers; c) cost effectiveness; and d) ensuring adequate representation of marginalized groups. Finally, the paper presents issues and trends for external assistance to community initiatives. This includes examining the role of community initiatives within national strategies, donor strategies for assisting communities, decentralization and community HIV/AIDS initiatives, performance or output-based grants, and the nature and use of impact evaluations. Author's Affiliation and Sponsorship Jean Delion Senior Operations Officer, AFTCS jdelion@worldbank.org Elizabeth Ninan Young Professional, ACTafrica eninan@worldbank.org The Africa Region Working Paper Series expedites dissemination of applied research and policy studies with potential for improving economic performance and social conditions in Sub-Saharan Africa. The Series publishes papers at preliminary stages to stimulate timely discussion within the Region and among client countries, donors, and the policy research community. The editorial board for the Series consists of representatives from professional families appointed by the Region's Sector Directors. For additional information, please contact Paula White, managing editor of the series, (81131), Email: pwhite2@worldbank.org or visit the Web site: http://www.worldbank.org/afr/wps/index.htm. The findings, interpretations, and conclusions expressed in this paper are entirely those of the author(s), they do not necessarily represent the views of the World Bank Group, its Executive Directors, or the countries they represent and should not be attributed to them. Taking Stock of Community Initiatives In the Fight against HIV/AIDS in Africa Experience, Issues, and Challenges Fragile States, Conflict, and Social Development Unit (AFTCS) AIDS Campaign Team for Africa (ACTafrica) Jean Delion Elizabeth Ninan June 2008 Acknowledgments T he authors are grateful to reviewers from AFTCS and ACT-Africa for their comments and advice. The main reviewers were Albertus Voetberg, Lead Health Specialist ACTafrica, Richard Seifman, Senior Adviser to ACTafrica, and Paul Francis, Senior Social Scientist, AFTCS. The authors also extend special thanks to Sandra Giltner for her assistance in final editing of the document and to Joseph Ellong, AFTCS, for his assistance in editing, translation, and publication. Foreword This paper takes stock of experiences in involving communities in the fight against HIV/AIDS in Africa. It draws extensively on the experience of the Multi- Country HIV/AIDS Program (MAP) in Africa. The paper it is written by and for practitioners. It aims to help share experiences, to learn from each other, and ultimately to assist in improving the effectiveness of programs against HIV/AIDS. The paper is part of a set of activities to document the efforts to prevent the spread HIV and to mitigate its impact by mobilizing grassroots organizations. It points to the critical social dimensions involved in fighting the HIV/AIDS pandemic: faced with illness and death, communities have developed innovative responses, influencing behavioral changes and strengthening their social capital to cope with both infected and affected members. Donors like the World Bank, through the MAP, have responded to the requests of National AIDS authorities. All around Africa, the MAP has made small grants to stimulate and support community responses. This was a new field, where there was no prior experience of national public health programs responding to a pandemic by supporting myriad community initiatives. The approach was multi-form and holistic by nature. It was inspired by the experiences of social researchers and workers investigating and assisting communities that were trying to improve their health. The paper refers to some of these rich analytical and operational foundations. The paper points out the difficulty of evaluating the impact of community initiatives using traditional World Bank instruments. It outlines some of the wide array of social initiatives undertaken by the communities addressing the causes and consequences of the pandemic, from risky sexual behaviors to stigma and exclusion of affected populations. After the first phase of MAP operations closed in 2006-2007, it was important to reflect on the experiences of communities in the fight against HIV/AIDS and to link these experiences to research on community health. The paper outlines some concepts and scope of activities undertaken by communities and presents the direction taken by some National AIDS authorities. It calls for more analytical work, in line with the new strategy for addressing HIV/AIDS in the Africa Region through the Agenda for Action (2007- 2011), in order to better understand what has worked, how it works, and at what cost. Steen Jorgensen Director, Social Development June 2008 i Abbreviations and Acronyms ACTafrica AIDS Campaign Team for Africa AfriCASO African Council of AIDS Service Organizations AFTCS Fragile States, Conflict, and Social Development Unit (Africa Region, World Bank) AIDS Acquired Immune Deficiency Syndrome ART Antiretroviral treatment Global Fund The Global Fund to Fight AIDS, Tuberculosis and Malaria CBO Community-based organization CSO Civil Society Organization CDD Community-driven development DHS Demographic and health survey GIS Geographic information systems HBC Home-based care FBO Faith-based organization HIV Human Immunodeficiency Virus ICASO The International Council of AIDS Service Organizations LQAS Lot quality assurance sampling MAP Multi-Country AIDS Program in Africa (World Bank) M&E Monitoring and evaluation NAA National AIDS Authorities NGO Non-government organization PEPFAR The U.S. President`s Emergency Plan for AIDS Relief OVC Orphans and Vulnerable Children PLWH People living with HIV PMTCT Prevention of mother-to-child transmission POL Popular opinion leader STIs Sexually transmitted infections UNAIDS The Joint United Nations Programme on HIV/AIDS UNGASS United Nations General Assembly (Twenty Sixth) Special Session (on HIV/AIDS) UNRISD United Nations Research Institute for Social Development VCT Voluntary counseling and testing ii Contents Foreword ......................................................................................................................................... i Abbreviations and Acronyms ....................................................................................................... ii 1. INTRODUCTION ...................................................................................................................... 1 2. WHAT ARE COMMUNITIES AND COMMUNITY INITIATIVES? ............................................... 2 3. THE WIDE SPECTRUM OF HIV/AIDS SERVICES SUPPORTED AT THE COMMUNITY LEVEL .. 3 3.1 Prevention ..................................................................................................................... 4 3.2 Access to Care and Treatment .................................................................................... 5 3.3 Impact Mitigation ........................................................................................................ 6 3.4 Systems Development .................................................................................................. 6 4. COMMUNITY INITIATIVES TO MOBILIZE AND STRENGTHEN SOCIAL CAPITAL TO COPE WITH HIV/AIDS ................................................................................................................... 7 5. ISSUES AND CHALLENGES ..................................................................................................... 9 5.1 Assessing the Impact of Community Initiatives ........................................................ 9 5.2 Monitoring and Evaluation (M&E) Systems ........................................................... 12 5.3 Integrating Community Initiatives in the National Response ................................ 13 6. SUSTAINABILITY CHALLENGES .......................................................................................... 14 6.1 Uncertain Strategies and Funding ............................................................................ 14 6.2 Volunteerism .............................................................................................................. 17 6.3 Adequate Representation of Marginalized Groups ................................................ 17 7. TRENDS FOR EXTERNAL ASSISTANCE TO COMMUNITY INITIATIVES ............................... 18 7.1 A More Prominent and Clearer Role for Community Initiatives in National HIV/AIDS Strategies ............................................................................................... 18 7.2 Clearer Donor Strategies and Coherent Interventions vis-à-vis Community Initiatives .................................................................................................................. 19 7.3 Increased Use of Performance or Output-based Grants to CSOs and Communities............................................................................................................. 19 7.4 Strengthen community capacity to monitor and evaluate their programs ........... 20 7.5 Increased Use of Qualitative Research..................................................................... 20 8. CONCLUSIONS ...................................................................................................................... 21 References .................................................................................................................................... 22 Figure HIV/AIDS SERVICES PROVIDED BY 96 FBOS IN SOUTH AFRICA............................................... 4 Boxes BOX 1. THE WORK OF THETA .................................................................................................... 6 BOX 2. MULTI-DISCIPLINARY FACILITATION TEAMS IN THE GAMBIA .................................... 7 BOX 3. COMMUNITY KNOWLEDGE OF NEEDS IN ETHIOPIA ....................................................... 9 BOX 4. MEASURING THE IMPACT OF INTERVENTIONS IN UGANDA ......................................... 11 BOX 5. THE BENEFITS OF COMMUNITY SECTOR INVOLVEMENT IN NATIONAL RESPONSES TO HIV/AIDS ........................................................................................................................... 14 BOX 6. INTEGRATION OF HEALTH INTERVENTIONS IN THE CENTRAL AFRICAN REPUBLIC . 18 BOX 7. A HIGHER LEVEL OF GRANT MANAGEMENT IN CAMEROON ...................................... 19 BOX 8. THE HIV/AIDS INTERVENTION MENU IN THE CENTRAL AFRICAN REPUBLIC ......... 20 iii This page intentionally left blank iv 1. INTRODUCTION 1. The response of communities in Sub-Saharan Africa to the devastating impacts of AIDS has been overwhelming. Communities have had to prevent propagation of HIV and to deal with the impacts of increasing morbidity and mortality among members. They have also had to cope with a growing number of orphans and vulnerable children. In response, communities have developed various innovative prevention and mitigation mechanisms to contain the spread of HIV and to avert the negative consequences of the epidemic. They do this largely in the absence of external assistance, through the commitment and dedication of a few like-minded people, often volunteers, who rely on their own ingenuity and financial resources. Communities are coping by adapting. They do not simply rely on existing customary systems, but respond to changing situations by developing new institutions. These include among others, home-based care institutions providing care and support for people infected and affected by HIV, institutions to care for orphans and vulnerable children, self-help groups, volunteer and burial associations, and institutions to fight stigma and discrimination. 2. Communities and their institutions must somehow cope with the illness, dependency, and death that HIV/AIDS causes. They are critical to creating enabling environments that can foster the behavioral changes needed to confront HIV/AIDS (Gorgens-Albino et al. 2007). Communities also play a major role in addressing behavioral change since most determinants of sexual behaviors are deeply rooted in cultural norms, social environments, beliefs, roles, and practices that are established, maintained, enforced, and changed at the local level. Individuals cannot change their behavior in a vacuum, but are heavily influenced by their social networks and group norms. Their very perceptions of risk are ordered and nurtured by the peer group and social context within which they operate. Behaviors have to be supported and reinforced by the value system of the society within which people (Gorgens-Albino et al. 2007) 3. There is now general consensus that community responses are a critical component in scaling up responses to HIV/AIDS in order to achieve universal access to prevention, treatment, care, and support by 2013. Similarly, the Three Ones concept namely a single national strategic framework, a single HIV coordinating entity, and a single monitoring and evaluation system, was developed in the context of a growing recognition of two particular issues: HIV/AIDS is a world-wide emergency, and responses need to be better coordinated to be more effective (ICASO, AfriCASO, and the International HIV Alliance 2007). Multiple stakeholders have recognized that the effective implementation of the Three Ones principle can be achieved only if the community sector is fully involved (ICASO, AfriCASO, and the International HIV Alliance 2007). 4. For the most part, however, initiatives, programs, and emerging community initiatives are hardly known outside of their immediate locale (Phiri, Foster, and Nzima 2001). There is need for much better understanding of how such initiatives begin, are 1 organized and develop, as well as the strengths and limitations of civil society organizations. Very little is known of the types and range of activities undertaken at the community level and even less is know about the quality, cost, and effectiveness of services provided. 2. WHAT ARE COMMUNITIES AND COMMUNITY INITIATIVES? 5. Organizations involved in the fight against HIV/AIDS use different definitions of community. The International Council of AIDS Service Organizations (ICASO) used the concept of community sector in a broad sense. In guidelines for working with communities, ICASO used the following definition: The term "community sector" covers a wide range and diversity of people, groups and institutions. The sector is not a single entity. Rather, it is a collection of different interests, opinions, capacities, resources and priorities involved in a variety of activities ranging from advocacy to service provision. In each country, this "sector" needs to be defined according to the characteristics related with the epidemic and the conditions that make certain communities more affected by HIV and AIDS. In these guidelines the community sector refers in particular to: People living with HIV, their groups and networks Community networks and community based organizations, including those that involve or support key populations Local, national and international non governmental organizations AIDS service organizations Faith-based organizations NGO networks NGO support organizations" (ICASO 2007) Programs addressing HIV/AIDS serve the same organizations under the concepts of support to local responses and support to the community sector. This paper uses ICASO`s definition of the community sector. 6. The Joint United Nations Programme on HIV/AIDS (UNAIDS) defines community in the widest and most inclusive sense: a community is a group of people who have something in common and will act together in their common interest. Many people belong to a number of different communities--examples include the place they live, the people they work with, or their religious group (UNAIDS 1997). UNAIDS Code of good practice for NGOs responding to HIV/AIDS (UNAIDS 2004), uses the term NGO to encompass the wide range of organizations that can be characterized as not and non-government. This includes community-based organizations (CBOs), faith- 2 based organizations (FBOs), and organizations of affected communities, including (among many others) people living with HIV/AIDS, sex workers, and women`s groups, all of which are responding to HIV/AIDS. 7. In defining affected communities, the UNAIDS Code uses the term to encompass the range of people affected by HIV/AIDS--people at particular risk of HIV infection and those who bear a disproportionate burden of the impact of HIV/AIDS. This varies from country to country, depending on the nature of the epidemic. In effect, communities are the backbone of what NGOs are and what they do. 8. The World Bank refers to local responses in its Multi-Country HIV/AIDS Program (MAP) for Africa. MAP channels funds to support various local initiatives addressing HIV/AIDS. This approach is built on community-driven development (CDD) programs. It empowers civil society organizations and communities to assess local factors fueling the epidemic and to address them. MAP provides them with small grants that are managed by the community itself to support community initiatives. 9. Regardless of how community is defined or segmented, what should be borne in mind is that communities are themselves part of the larger system or society in which they exist, and are thus subject to influences from outside forces. According to Link and Phelan 1995, the community intervention approach seeks to change not simply individuals but the distribution of risk (and by inference, the probability of disease and resulting morbidity and mortality) in the at-risk subgroup within the broader population. Interventions are targeted at structures or social networks rather than specific individuals. Programs supporting community initiatives assist community members to assess their vulnerability, at the individual and collective level. At the collective level, these programs assist the community to identify socio-economic factors that are likely to (a) predispose individuals to the adoption of risk behavior; (b) prevent individuals from adopting protective behavior; or (c) lead directly to increased risk for disease, regardless of the individuals` risk behaviors (Link and Phelan 1995, cited in DiClemente, Crosby, and Wingood 2005). 3. THE WIDE SPECTRUM OF HIV/AIDS SERVICES SUPPORTED AT THE COMMUNITY LEVEL 10. In a study of 96 Faith-Based Organizations (FBOs) conducted in South Africa, services ranged from HIV/AIDS awareness-building, testing, and counseling to care and support. Almost 50 percent of FBOs reported involvement in HIV/AIDS programs, behavioral change, and food security (food gardens and food parcels). Training on HIV/AIDS issues, home-based care, peer education, medical care, and condom distribution were less common among FBOs. 3 HIV/AIDS Services Provided by 96 FBOs in South Africa Source: CADRE 2005 p. 10. 11. Lwihula and Over (1995) found that communities have established ingenious coping mechanisms to deal with the adverse effects of HIV/AIDS such as self-help groups, burial associations, grain loan schemes and rotating credit and loan clubs. 12. Community initiatives through the World Bank`s MAP program can be organized into four categories: prevention, care and treatment, impact mitigation, and systems strengthening. Below are some of the activities undertaken in each of these broad categories. 3.1 Prevention 13. The most common activities undertaken by the community sector were for prevention. Many countries supported community mobilization and awareness campaigns to support behavioral changes. Activities included: Training influential leaders, teachers, and role models on confronting AIDS, including politicians, administrators, religious leaders, traditional and opinion leaders, traditional healers, and media stars. Targeted training to vulnerable populations such as sex workers, truck drivers, prisoners, populations at border points, fishermen, out-of-school youth, and migrants. Training and supporting peer educators such as youth counselors. Mass media campaigns, including production and dissemination of sensitization materials and information using tee-shirts and posters, competitions to prepare messages and images, interactive TV and radio programs, magazines, dance, and theater. 4 Intensive campaigns using motorbike caravans, music caravans, campaigns in trains and other public transports. Awareness-building, sensitization, and support for HIV/AIDS counseling centers, including door-to-door visits. Invitations to use Voluntary Counseling and Testing (VCT) and other work-place basedservices. Counseling for, among others, people living with HIV (PLWH) using free telephone numbers and cell phones. Social marketing of condoms, backed by promotion, demonstrations of use, and support to create or strengthen social marketing networks. Prevention coupled with access to VCT in mobile units, mainly for target groups and isolated populations. 3.2 Access to Care and Treatment 14. Although treatment was not a prime focus of the MAP program, there are some community sector activities funded to provide treatment for sexually transmitted infections (STIs), prevention of mother-to-child transmission (PMTCT), access to anti- retroviral treatment, and support for nutrition. Community activities have sought to support efforts to access these health services, which include: Support to access testing and treatment for STIs. Support to community organizations that care for community members with chronic illnesses (not just AIDS). Support for laboratory analysis required to access antiretroviral treatment (ART). Adherence support for people on anti-retroviral treatment. Specific mother/parent to child transmission programs, as an entry point for stimulating prevention, care and treatment for the whole population. Home based care. Support to orphans and widows. Support to PLWH and/or sex workers, including access to condoms, access to counseling and health services (on STIs for example) and grants for income-generating activities. 5 Box 1. The Work of THETA THETA (Traditional and Modern Health Practitioners Together Against AIDS) in Uganda used MAP funding to disseminate research findings on the use of traditional herbs in treating opportunistic infections and to formulate culturally appropriate prevention messages and means of communicating those messages. This was the work they believed needed to be done on the basis of their close collaboration with communities. 3.3 Impact Mitigation 15. Most countries invested in many activities involving PLWH, supporting their associations, federations, and involving PLWH in prevention and lobbying efforts. They also provided direct support to PLWH and their families and they contributed to support orphans and vulnerable children (OVC). Activities include: Specific campaigns to decrease stigma on PLWH through awareness- building and sensitization. Nutrition support to PLWH and their families. Support to associations of PLWH, including support for operational costs, sensitization campaigns, investments in income-generating activities or asset-building for the associations. Support to OVC, ranging from direct support (nutrition, school, etc.) to vocational training and insertion in social and economic activities. Support for self-help groups, burial associations, rotating savings and credit associations, income-generating activities, and asset-building activities such as grain loan schemes. 3.4 Systems Development 16. The MAP played a major role in developing systems to support community sector initiatives. In many countries the MAP was the first large-scale program to channel funds down to the community. Activities in the area of systems development include: Supporting legal changes to protect the rights of infected and affected persons. Setting up coordination committees at national, regional, district, and community levels. Organizing coordination activities, and developing instruments for planning, exchanges, and reporting, mainly on a myriad of community responses in different forms. Training of trainers to support the various activities above Training of mass media agents on HIV/AIDS. Training of medical staff on counseling and stigma. 6 Training of volunteers (often youth or PLWH) and peer educators on counseling, stigma, and home based care. Training of social mobilization agents. Box 2. Multi-Disciplinary Facilitation Teams in The Gambia In The Gambia, a municipal HIV/AIDS community program conducted capacity-building activities for "multi-disciplinary facilitation teams" on proposal development and writing, and on HIV/AIDS and STIs. In addition, the program trained resource persons in procurement, financial management, and monitoring and evaluation in addition to other basic aspects of project and program management. This was seen as important in the country's drive to sustain the response at all levels and to enhance the quality of information dissemination at the decentralized level. Finally, The Gambia trained traditional healers, religious leaders, CSO executives, and women's group leaders in participatory monitoring and evaluation, financial management, and procurement. 4. COMMUNITY INITIATIVES TO MOBILIZE AND STRENGTHEN SOCIAL CAPITAL TO COPE WITH HIV/AIDS 17. The communities themselves are the owners and custodians of their initiatives. Members of a community are in the best position to know which households are most severely affected by HIV/AIDS and what kind of assistance is appropriate. Community members know who is sick, who has died, who has been taken in by relatives, who is living alone, and who does not have enough to eat. (Child Protection Society 1999). Further, community members can agree among themselves who are the most in need of urgent assistance and can provide support. 18. Phiri et al. (2001), explored characteristics of community coping activities in a survey conducted in Malawi and Zimbabwe. They found that communities exhibited the characteristics discussed in the following paragraphs. 19. The principle of reciprocity is characteristic of people living within traditional societies where there is a long tradition of social support groups assisting its members in times of special need such as sicknesses, funerals, or marriages. This type of community safety net­formal or informal mechanisms that mitigate the effects of poverty and other risks on vulnerable households during times of severe stress­is a common response to both man-made and natural disasters (Foster 2005a). 20. A World Bank study in Tanzania of households that lost breadwinners through HIV/AIDS found that 90 percent of material and other assistance came from relatives and community groups such as savings clubs and burial societies, with only 10 percent of assistance supplied by NGOs and other agencies (Mutagandura et al. 1997 in Foster 2005a). 21. A study in Zimbabwe found that more than 60 percent of sampled households resorted to seeking help from relatives, friends and neighbors, particularly during hard 7 times. Extended family and community safety nets provided significant proportions of medical expenses (27-57 percent of households) and funeral expenses (59-85 percent of households). (Mutagandura et al. 1997 in Foster 2005a.) 22. The importance of community safety nets is accentuated by the inability, and sometimes absence, of public safety nets in Sub-Saharan African countries to reach extremely poor people and those affected by HIV/AIDS (Kadiyala and Gillespie, 2002). 23. Consensus-based decision making is a feature of community initiatives. Typically, community members take time to assess and discuss matters before they reach consensus. Through village councils or community meetings, members are able to prioritize what support is required to whom and how it will be delivered. However, there is always a risk that a few members dominate discussions and that decisions are taken without the active involvement of key stakeholders who are marginalized within their communities. This is particularly relevant to HIV/AIDS as many marginalized groups are those who are most vulnerable such as women, youth, sex workers, and refugees. 24. Self-reliance is another feature of community initiatives. As described above in the cases of Tanzania and Zimbabwe, resources for community initiatives are mobilized from within the community itself. Donations are obtained from local businesses, religious organizations, traditional leaders, and individual benefactors. Aside from financial resources, human capital is often found in well-meaning volunteers. 25. Volunteerism is the backbone of many community initiatives. Community initiatives often begin with well-meaning, motivated individuals or groups of individuals who become aware of a shared concern or common need, and decide to take action in order to create shared benefits. The fiscal contribution of faith-based volunteers throughout Africa was conservatively estimated to be worth US$5 billion per annum in 2006, an amount similar in magnitude to the total funding provided for HIV/AIDS by all bilateral and multilateral agencies (Tear Fund 2006). 26. Local leadership ultimately determines the quality and magnitude of the response and the possibility of broad participation. At the national level, political commitment at the highest level is required; similarly, respected community leaders have been crucial in mobilizing at their level. Leadership directly or indirectly affects the capacity of groups to undertake specified action in a sustained, accepted, coordinated and effective manner (Phiri, Foster, and Nzima2001). Kelly (2005), refers to popular opinion leaders (POLs) as drivers of change within communities. POLs influence change through the concept of diffusion theory which postulates that innovative new trends in population behavior are often instigated when enough of the opinion leaders--those population members who are naturally like, popular and likely to be emulated by others--establish, are seen, and are known to endorse a behavioral innovation. This is the model used in many peer-to-peer education programs. 27. Innovation is a key feature of community initiatives. The HIV/AIDS crisis in many countries has meant that communities need to urgently respond to rapidly changing 8 situations. This has often required going beyond traditional customary systems to establish new institutions and mechanisms to address an often dire situation. This is reflected in the many newly formed associations and self-help groups providing support to vulnerable children, child-headed households, PLWH, youth, and women. 28. Increased partnership with FBOs is a prominent feature of most community initiatives. Religion is an important, if not ­ in many cases- the most important part of a community`s life. It is central to all the critical milestones of a large majority of members of communities, including birth, marriage, and death. According to UNAIDS, the Christian associations in Africa provide about 40 percent of health services in Lesotho, 45 percent in Zimbabwe; 48 percent in Tanzania; 47 percent in Liberia; 30 percent in Zambia and 40 percent in Kenya (Dimmock 2005). FBOs have credible leadership, existing structures. and effective channels of communication within communities. Box 3. Community Knowledge of Needs in Ethiopia Ethiopia has benefited from the flexibility of drawing on communities' knowledge of what was needed and who was needy. This transparency had the added benefit of demonstrating to communities that civil society organizations could be trusted to provide valuable services and to manage funds appropriately. A key example is that of the Dawn of Hope/Nazareth Branch, a group of people living with HIV/AIDS. They identified three priorities: income-generating activities to help their members survive (and in some cases, to avoid resorting to sex work in order to feed themselves and their families); support to 380 AIDS orphans (who had to demonstrate proof of their status before being accepted as members of the group); and uniquely, establishment of a "recovery center", where people with HIV/AIDS who had been starving were literally fed back to life. Although most of the patients were receiving ART, their lives were at risk due to lack of food. Out of 190 patients referred to the center by the local hospital with just hours left to live, 180 have survived thanks to the excellent care and food they received at the recovery center. 5. ISSUES AND CHALLENGES 5.1 Assessing the Impact of Community Initiatives 29. In the late 1990s, donors realized that HIV/AIDS had become a major development issue in Africa and looked for ways to sensitize and mobilize the population against the pandemic. At this time, the focus was on mass awareness through community mobilization. Some donors, such as the World Bank through its MAP program, assumed that the communities in many African countries could be a cost-effective channel to move from isolated pilot initiatives to national scaling-up prevention efforts, principally awareness and behavioral change. The MAP looked to communities to stimulate and encourage behavioral changes, leading to less risky sexual behaviors, less stigma, and an increase in demand for care and treatment. In this mass awareness through community mobilization phase, the emphasis was on broad outreach programs rather than focused, evidence-based approaches on the impact of such initiatives. Limited efforts were made to measure outcomes or impact of interventions to support community initiatives. 9 Addressing the issues of quality of services and the impact of community initiatives remains problematic for several reasons discussed below. 30. The myriad community initiatives underway in different settings, addressing varying needs, makes comparisons across and within initiatives challenging. Most communities are reached by different programs and it is hard to find communities without community initiatives to use as control groups for rigorous evaluation. Many organizations contribute to the fight against HIV/AIDS and a control group can be contaminated by the introduction of new interventions between the baseline and the end-of-project studies. Furthermore, because community initiatives are so context- specific and usually arise locally, the same activity cannot have the same impact in different social contexts, and the minimal standards in terms of service provision vary from one area to another. In the absence of benchmarks, it is difficult to objectively measure the quality of services provided and the effectiveness of any given initiative. 31. Cost-effectiveness studies are even more challenging. A review of existing literature on costs of providing home based care (HBC) at the community level reveals a multitude of costing approaches on a variety of services to different populations in different time periods. This makes comparisons of data tenuous. Cost differences may not reveal differences in efficiency between programs, especially since most are working with scarce resources. The existing costing and evaluation studies in this area have been targeted toward CBOs that received funds from a specific donor. Often these studies estimate costs from a provider perspective (that is, the institution itself, the CBO) excluding the cost of time of the family and community members involved (Johnson et al., 2001). 32. In the end, communities have pursued multiple and varied holistic initiatives that respond to their unique environments. As a result, they are not necessarily replicable on a larger scale or in a different environment. While qualitative studies of the impacts of community initiatives may be indicative of how well an initiative is performing, the results will not necessarily be valid in other settings. 33. Singer and Marxuach-Rodriques (1996) summarize HIV/AIDS initiatives thus: The starting point for AIDS prevention is recognition that AIDS is only a cover term for a complex set of intertwined local epidemics that differentially impact diverse subgroups in varied local settings based on their socio-political location, social and sexual networks, specific configuration of risk behaviors (e.g. sexual practices and patterns), attitudes and beliefs, and prior health status (e.g. stressors, nutrition, exposure to other sexually transmitted diseases). 34. Producing community-level change through aggregation of impacts across subgroups presents particular challenges to evaluation in defining relevant subgroups and mapping differential risks, barriers, contexts and resources (Yoshikawa et al. 2005). Many community-level HIV prevention efforts are targeted toward specific subgroups 10 (vulnerable groups) based on age, gender, immigration status, sexuality, or employment. A question remains about how the impact of an overall community-level prevention package can be disaggregated by specific subgroups. The cumulative impact of multiple components of community initiatives, each targeting a different subgroup, is likely to be key to a community impact evaluation, yet it is very difficult to model when each component is contaminated by others (Yoshikawa, et al. 2005). Box 4. Measuring the Impact of Interventions in Uganda Uganda collected data on HIV/AIDS in three consecutive demographic and health surveys (DHS), in 1998, 1995, and 2002 (Trickett and Peguegnat 2005). Results show that HIV prevalence has declined significantly during the 1990s, accompanied by a somewhat smaller decline in HIV incidence in the latter half of the decade. However, Singh, Darroch, and Bankhole (2002) of the Guttmacher Institute showed that although studies could not attribute this reduction to specific interventions introduced by public services, a key factor in the decline in incidence of HIV in Uganda seems to have been the strategic policy approach to enable non- state actors in their individually targeted messages about prevention. Parkhurst (2006) confirmed this analysis. It was not possible to correlate declines in incidence or use of condoms or access to tests or changes of number of sexual partners with specific interventions such as support to community sector initiatives. Still the Guttmacher Institute report shows that the process of social change involved in confronting HIV/AIDS is complex. Some categories of population increased their numbers of sexual partners (apparently feeling safer as they were trying to use condoms), while others such as some youth categories delayed their first sexual relations. The evolution was complex and differentiated, in a country with one of the highest prevalence rate in the world. It is hard to describe causes and effects. Still, the report concludes that: Many indirect forces formed a context for and contributing to, the decline: Broad social factors including political commitment and support at the highest level, Widespread media campaigns, various types of interventions to educate all sectors of population and to fight stigma and discrimination against PLWHA, and Some have argued that abstinence and monogamy played a much more important role in the decline of HIV prevalence and incidence in Uganda than has condom use. 35. A further concern with community-level impact evaluations is the independence of observations (in this case, the communities), and high likelihood of spill-over effects. The assumption that a community with no HIV/AIDS prevention activities would act as a reliable comparison group, unaffected by a nearby community`s HIV/AIDS initiatives is highly unlikely given that members in a community may frequent multiple settings. Moreover, it is very difficult to match communities far apart. Similar initiatives in comparison communities create a bias toward the null hypothesis (that is, no difference between the intervention and comparison communities) and result in type-2 error (DiClementi, Crosby, and Wingood 2005). 11 36. Community-level impact evaluations are unique in that they typically involve few units of analysis. Though the units of observation are individuals, who may be numerous, these comprise the unit of analysis (the community) which is usually limited in many studies. The few units of analysis of community initiatives imply low statistical power, since there are insufficient numbers of assignment units to ensure that randomization has the opportunity to evenly distribute potential sources of bias across intervention conditions (DiClementi, Crosby, and Wingood 2005). Despite methods of compensating for low statistical power, the majority of community intervention studies have been underpowered resulting in only modest evidence to support effectiveness. According to Fishbein 1999 this means community interventions often lack power to determine even medium effect sizes, let alone small sizes, which is unfortunate because small effect sizes in community interventions may be very meaningful at the population level. 37. Research on all these factors in community initiatives may benefit from the application of multiple research methods and techniques, including ecological assessments of community settings; multi-level quantitative analyses taking into account within and across setting variation; ethnographic and other qualitative methods; policy analytic methods such as cost-benefit analysis; and most importantly, collaborative approaches to working with community members and institutions (Fishbein, 1999). 5.2 Monitoring and Evaluation (M&E) Systems 38. A review of MAP, which channeled over 40 percent of US$1.5 billion through NGOs and CBOs to implement HIV interventions, found that the existing capacity of NGOs to design, implement, and evaluate AIDS interventions was overestimated in virtually all countries receiving Bank HIV/AIDS assistance. Further, the efficacy of NGO and CBO efforts is rarely measured. To the extent that Bank-sponsored NGO HIV/AIDS activities have been monitored, results are generally measured in terms of outputs. The first MAP project in Africa clearly stated that the first four to five years would focus on awareness, sensitization, and social mobilization and it would not measure impact attributable to the specific interventions supported by the program. The fight against HIV/AIDS will continue to focus on prevention, on increasing access to health services, and on treatment care and support to affected populations. More rigorous impact evaluations will be needed in future investments, which has started in many African countries. 39. During the first phase of MAP, communities generally assessed the outcome of their initiatives very positively. There was a great difference between the way communities assessed the benefits of their initiatives and what donors expected in terms of reporting. According to Wassana (2008), local monitoring is different from that required by donors. It is an ongoing, informal process that allows frequent program adjustments to be made based on a trial-and-.error assessment of impact. It is far more flexible than the mid-project evaluations generally used by donors to make major program corrections. Moreover, community activities do not come to an end or wind down at the end of a specified period as is the case with donor-funded projects. 12 40. Some countries used lot quality assurance sampling (LQAS). The approach is well described in a report from Uganda: LQAS measures whether a program catchment area has reached a performance target. The primary role of LQAS is to serve as a performance assessment tool for managers at the implementation level and secondly to provide data for national and donor reporting. LQAS will aid local managers to understand the status of their programs by establishing a baseline measure for key indicators of performance and quality of HIV/AIDS interventions... In Uganda LQAS has been renamed the Local Quality Assurance and Supervision Method (Uganda Aids Commission 2003). The approach is one option to guide implementation and traces some local outputs. It does not substitute for the overall program M&E. The benefits of such an approach are that beneficiaries are steering the monitoring process and are able to collect information in a timely manner which allows for learning and adapting the program accordingly.. 5.3 Integrating Community Initiatives in the National Response 41. At the April 2004 Consultation on Harmonization of International AIDS Funding, bilateral and multilateral agencies agreed with national leaders to apply the Three Ones principles at the country level. The Three Ones principles advocate (a) one national HIV/AIDS action framework that provides the basis for coordinating the work of all partners; (b) one national AIDS coordinating authority, with a broad-based multi-sectoral mandate; and (c) one agreed country-level M&E system. 42. Although the community sector`s involvement in the initial development of the Three Ones principles was limited, the sector has gradually become more engaged in order to ensure it is well represented and respected as a full partner in the fight against the epidemic. However, in many instances, the sector remains an outsider or has been co- opted as an extension of government and excluded from decision-making (ICASO, AfriCASO, and HIV/AIDS Alliance 2007). This has resulted in further centralization of decision-making and funds within government structures, thus reducing accountability, transparency, representation, and coordination of the national response. 43. The community sector can play a vital role in the effective implementation of the Three Ones principles. First, the active and meaningful representation of the community sector within national coordinating bodies will ensure that the sector shares ownership, responsibility, and commitment to delivering on the national HIV/AIDS framework. Second, it will foster a culture of equity and transparency and support the community sector in performing a watchdog role over other sectors and holding them accountable to their commitments. Third, by coordinating and collaborating with other sectors, the community sector is able to draw on technical expertise and information it would otherwise not have access to. Finally, it is crucial to include monitoring information from community responses on one national database. 13 Box 5. The Benefits of Community Sector Involvement in National Responses to HIV/AIDS The community sector has great potential to influence behavioral change and provide local support to infected and affected populations. Community sector involvement can help ensure that national responses are: Based on real needs and strategically focused. The community sector understands the needs of people most affected. Its hands-on work and technical knowledge are instrumental in identifying the services and support that will make a difference. In particular, the sector has strong links with, and includes, marginalized groups that are key to the dynamics of HIV/AIDS and that other sectors are often unable or unwilling to reach effectively. Far-reaching, flexible, and responsive to crises. The community sector can often reach and engage a broad range of individuals, groups and communities, including those in remote areas and those that are not usually involved in HIV/AIDS work. As such, it can recognize and respond rapidly to changes in local environments and epidemics and can adapt its approaches and priorities accordingly. It is also often able to remain engaged in extreme situations, such as war, where government activities may not be possible. Creative and effective. The community sector has developed ground-breaking and risk taking responses to HIV/AIDS, often in difficult environments and with few resources. Many of these have been carefully monitored and improved over the years and are now recognized as global good practice. Non-stigmatizing or non-discriminatory. The community sector is best placed to mobilize action against stigmatizing attitudes and behaviors by tackling the root causes within communities. It is also often willing to identify and challenge discriminatory practices and policies. Rights-based. The community sector has been at the forefront of promoting rights based approaches to HIV/AIDS that, in particular, respect and protect people living with HIV/AIDS and other marginalized groups. Participatory. The community sector has pioneered empowering approaches to HIV/AIDS that encourage the participation of a broad range of individuals, groups and institutions in all stages and levels of responses. Accountable and transparent. The community sector has increasing experience of using systems to ensure that its activities are ethical and accountable, and also of playing a watchdog role, holding other sectors to account for their actions. Cost-efficient. The community sector is accustomed to making the most of limited funding and developing cost-effective approaches that maximize and complement existing local resources. 6. SUSTAINABILITY CHALLENGES 6.1 Uncertain Strategies and Funding 44. International funding for HIV/AIDS programs has increased dramatically since 2001 through the advent of institutions such as the U.S. President`s Emergency Plan for AIDS Relief (PEPFAR), the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund), and the World Bank`s MAP. By 2005, the Global Fund, PEPFAR and MAP were transferring more than US$3 billion per year (Bernstein and Sessions 2007). However, expanded resource availability for HIV/AIDS did and does not always translate into increased funding at the community level. The MAP program has devoted approximately 40 percent of the US$1.5 billion allocated to date to civil society organizations, essentially supporting local responses. The Global Fund also supported 14 local responses, mainly through grants managed by NGOs. FBOs provide considerable support to community responses. National AIDS authorities and donors have clear strategies to continue supporting prevention, while scaling-up access to care and treatment. Many national HIV/AIDS strategies call for continued support to community mobilization but the implementation modalities and the needed resources are not clear. Some countries, such as Cameroon, decided that once MAP 1 grants had reached more than 6,000 communities; this was sufficient, and the National AIDS authorities (NAA) decided to stop providing direct funding to grassroots communities. The Cameroon NAA uses Global Fund resources to support NGOs, contributing to social mobilization. In the Democratic Republic of Cong, the government decided to use only NGOs to contribute to social mobilization as opposed to grants to grassroots communities. 45. In a rapid in-country review of community-level organizations in Mozambique, South Africa, Swaziland, and Zimbabwe, Foster (2005b) identifies the following obstacles faced by communities in obtaining funding: (a) small, rural communities often find it hard to identify funders; (b) respondents felt that there was a disconnect between what communities felt was needed and what the funders were prepared to grant in terms of target populations and services; (c) communities felt that the application process was cumbersome and budgeting requirements tilted the application process in favor of established NGOs; and (d) communities felt they received little or no feedback from funders following submission of applications. 46. From the donors` perspective, Foster (2005b) reports that (a) donors believe that community groups lack capacity to account for funds, and (b) funders have difficulty administering small grants. This is an issue related to donor capacity, since it is often uneconomical to provide small grants in view of high transactions costs. 47. Another challenge is determining the amount of funds that actually reach the community level following disbursement by donors. Tracking resources for HIV/AIDS is poorly developed in many African countries. For example, there is a serious problem in tracking Global Fund resources beyond national level disbursements. According to Taylor (2005) senior staff at the Global Fund indicate that the Fund`s commitment is to maintain transparent monitoring related to principal recipients only (in this case national- level entities) and that it is the role of in-country civil society to follow up on the use of funds. Furthermore, while the U.S. President`s Emergency Plan for AIDS Relief`s (PEPFAR) multimillion dollar initiative monitors a broad range of indicators, tracking the amount and proportion of resources reaching affected communities is not one of those monitored (Foster 2005b). 48. The MAP financed small grants to Civil Society Organizations (CSOs) such as NGOs and to communities directly. Each country sets up its own disbursement arrangements. In many countries, HIV/AIDS committees at the community level or CBOs can receive and manage small grants. The MAP and other World Bank investments allowed flexible reporting procedures, based on outputs, as in some Community Driven Development (CDD) or social fund operations. The recipient CSO or communities get advances (in many countries six months` worth of activity costs). They 15 undertake a small budget activity and deliver a report indicating the use of funds for the advance period, which is usually around six months. In most cases, the total amounts of the six-month advances are very small (often between US$1,000 and US$5,000 per advance) and there are very limited purchases. As in other output-based grants, the World Bank focuses on the achievement of expected outputs. NAAs use various mechanisms to verify these outputs. The CSO and the communities keep simple accounts of their expenses, and file all their receipts. NAAs, World Bank supervision missions, and MAP auditors typically inspect financial and procurement documents and processes (they often take a sample of around 10 percent of all community grants, sometimes up to 30 percent mainly at the beginning of a MAP). 49. Many outsiders criticized the MAP for insufficient fiduciary controls on the actual use of grants at CSO and community levels; but they rarely examine the many inspection reports, technical supervision and support reports, and regular follow-up communications by support agencies. Moreover, criticisms have not assessed small grants in the context of output-based aid. Donors are increasingly focusing on measures of outputs, without entering into the details of the financial expenses. CSO and community grants must be viewed in the context of the current paradigm shift in the way donors disburse funds. The Global Fund is also moving in the direction of output-based grants. 50. There are many questions about the sustainability of the community initiatives, given the short-term infusion of funds by various donors. The lack of a long-term vision in supporting communities can often result in the opposite of the desired effect by undermining community coping mechanisms. Foster (2005b) gives the example of how a remote rural community that mobilized volunteers to support vulnerable children was undermined by a city-based organization that trained and made substantial payments to community members to establish support activities for orphans and vulnerable children, but only for a limited period. This undermined the volunteerism within the community and risked compromising community ownership for child support activities that had been painstakingly established over time. 51. Empowering communities and their initiatives involves designing programs and processes geared toward enhancing community capacity. External agencies should focus on linking programs with community resources in a way that builds capacity. This involves adopting a time frame that supports local-level planning that is significantly longer than current donor funding cycles. Increasing community capacity and developing resources to serve communities requires a long commitment. 52. Given that community initiatives generally begin with a few motivated people assisting a small number of others (in other words the initiatives are often very small- scale), a question remains about the long-term strategy for supporting community initiatives. The hypothesis that communities with higher levels of social and economic capital are more likely to engage in community mobilization has not been investigated across communities (Yoshika et al. 2005). In this regard, an assessment of community characteristics associated with effective mobilization to support HIV initiatives could be linked to ongoing surveillance data (such as number of community initiatives) to explore 16 such hypotheses. While external agencies need to make decisions on where their funds would have the most impact, people in communities without strong social and economic capital are in dire need of assistance. This possibly calls for a different approach, such as individually-focused interventions. 6.2 Volunteerism 53. Many community initiatives depend heavily on the participation of volunteers. Many NAAs and other organizations use volunteers without a clear strategy for payment of incentives or an exit strategy. In a six-country study of 690 FBOs, over 9,000 volunteers were reported to be involved in the care and support of some 156,000 orphans and vulnerable children. The vast majority of home-based caregivers are women between the ages of 25-50 who belong to FBOs (Foster 2004). 54. In developing countries, these volunteers often have a low socio-economic status and must balance the time they spend volunteering with the time they need to spend working in order to feed themselves and their families. Sometimes volunteers are unemployed persons whose first priority is to find a job (UNAIDS 1997). Most community initiatives are at some time or another forced to find new ways to keep volunteers` enthusiasm high and to help them continue to identify with the problem and their importance in alleviating some of the impacts of HIV/AIDS. This issue is amplified by the fact that many of the volunteers themselves are infected with HIV. It is hard to maintain motivation when highly valued colleagues become ill. 55. Providing incentives and support networks to volunteers and increasing the number of volunteers could both help to improve quality of community services and scale-up the community initiatives. This would have major implications in terms of sustainability, however. It could also undermine altruistic motivation and require capacity at the community level to manage increased numbers of volunteers. 56. The various MAP countries have different approaches on the use of volunteers, incentives, and exit strategies. Many NAAs avoid payment of incentives to volunteers, leaving this to community organizations. Some NGOs offer volunteers small incentive packages but not a formal salary, thereby turning them into quasi-professional social workers. Several national HIV/AIDS strategies call for involving more volunteers without being able to mobilize the resources to provide incentives to these volunteers. 6.3 Adequate Representation of Marginalized Groups 57. Aggleton et al. (1993) reinforce the notion that communities are not homogenous but rather socially and culturally fragmented--by age, by class, by culture, and in some cases by gender. External organizations need to take heed of these differences and be sensitive to competing political agendas and power structures that may exist within a community. If the idea of CDD is to enable the community to decide what priorities to focus on, there needs to be sufficient emphasis on eliciting the views of the community at large rather than simply the views of influential people such as gatekeepers within the community. In the case of HIV interventions at the community level, care must be taken 17 to ensure the optimal representation of marginalized groups, especially those with a higher risk of contracting HIV such as sex workers, refugees, youth, and women. 58. UNAIDS recommends as a first course of action widening the established discussion or decision-making mechanisms of the community (for example the village council or community meeting) to accommodate marginalized groups. In some cases, reserving seats for marginalized persons at these meetings or on the governing bodies of community organizations may be all they need to participate fully. 7. TRENDS FOR EXTERNAL ASSISTANCE TO COMMUNITY INITIATIVES 7.1 A More Prominent and Clearer Role for Community Initiatives in National HIV/AIDS Strategies 59. During the MAP 1 and 2 operations (2002­07), the specific tools in the fight against HIV/AIDS were mainly a massive increase in awareness and knowledge to build acceptance that HIV was a reality in most populations. MAP 1 also focused on reducing the stigma of HIV/AIDS and on increasing access to care and treatment. During this phase, community initiatives contributed to these objectives through disparate initiatives to encourage their members to confront HIV/AIDS. 60. During the next phase (2007­11) the fight against HIV/AIDS is likely to focus on slightly different objectives. Communities will continue to be a mainstay of future Africa Region Bank efforts, with new products providing support for, and recognizing the need to significantly engage CSOs as an integral part of the national solution (World Bank, Agenda for Action, 2008). However, support for civil society activities will focus on specific and clearly articulated results expected from non-state actors, based on the most important epidemiological determinants of the epidemic. Further, the Bank has already begun to focus on impact evaluations of HIV/AIDS programs, which includes the impact of community HIV/AIDS initiatives, in order to improve prioritization, decision-making and program design (World Bank, Agenda for Action, 2008). Box 6. Integration of Health Interventions in the Central African Republic The Central African Republic decided that it could not continue with parallel vertical health interventions, especially vis-à-vis interventions at the community level. It could not have some volunteers supported by one organization to work on tuberculosis, another effort and organization working on malaria, another one on orphans and vulnerable children and another on HIV/AIDS. It decided to concentrate management of major Global Fund, World Bank, African Development Bank and other donor efforts on tuberculosis, malaria, orphans and vulnerable children, and HIV/AIDS in one single agency. It is hoped that this will lead to integrated teams working on these issues with the communities, in close coordination with the health services. 18 Box 7. A Higher Level of Grant Management in Cameroon After a successful massive community grants programs to mobilize the whole country against HIV/AIDS, Cameroon decided that it needed a different approach. It is planning to use the administrative districts called communes to channel grants for various activities to CSOs. The activities range from rural programs to basic health services and multi-sector AIDS services. The communes will channel grants for these activities through existing health center committees, which will involve other sectors the battle against HIV/AIDS. The long-term objective is to empower and develop decentralized services, and the management of various activities, rather than having specific organizations channel grants and support directly to communities. 7.2 Clearer Donor Strategies and Coherent Interventions vis-à-vis Community Initiatives 61. Donors are increasingly applying the Three Ones principles: namely a single national strategic framework, a single HIV coordinating entity, and a single monitoring and evaluation system. Donors should apply the same underlying principles to their efforts vis-à-vis community initiatives. However, to date each donor has had its own way of supporting community initiatives, without much attention to what other donors are doing. 62. The NAAs are increasingly seeking support from specialized and experienced organizations in HIV/AIDS prevention and local responses in order to prepare guidelines for channeling donor interventions. Recipient governments should consolidate institutional arrangements to ensure coherence of donor interventions. 7.3 Increased Use of Performance or Output-based Grants to CSOs and Communities 63. World Bank HIV/AIDS products (in Kenya and Botswana, for example), are considering using performance-based grants to support CSO and community initiatives. Some countries like Ghana used calls for proposals from CSO and communities on specific themes, for example on stigma reduction. The World Bank is moving toward programmatic lending performance based support which may ultimately provide more flexibility for Governments to support CSO and community initiatives, while requiring additional reporting on outputs or performance indicators. These indicators should be directly aligned with the indicators of the national HIV/AIDS strategy. Because donor programs will be based on the national HIV/AIDS strategy, indicators at all levels­ communities, donor programs, national efforts­should be coherent. 64. Output-based financing for community initiatives are new and require a period of testing in order to ascertain its effectiveness. Outputs at the community level need to simple and easy to measure. This may not be possible for some services such as outputs related to care and support, psycho-social and spiritual support. However, preventive services provided by communities may be more easily measured such as the number of people who get tested for HIV, or the number of condoms sold by social marketing organizations. External funding agencies should also bear in mind that the costs of 19 providing services varies between communities and hence, grants cannot be uniform across communities for specific services. Box 8. The HIV/AIDS Intervention Menu in the Central African Republic In the Central African Republic, the NAA prepared a menu of possible interventions to youth organizations. The interventions contribute to key indicators of the national strategy. For example such indicators could be the number of youth who received voluntary counseling and testing (VCT) and went to receive their results, or the number of sick patients benefiting from home based care provided by the youth organization. As the fight against AIDS moves toward access to tests, care, and treatment, there will be fewer awareness-raising activities. New indicators will be for example the number of pupils who attended sensitization sessions on HIV/AIDS involving people living with HIV/AIDS in schools, organized with the youth organization, or the number of condoms sold by the youth organization under social marketing schemes. The youth organization will decide which indicators of the national strategy they want to contribute to and how to do it. The organization will get a six month advance on an output-based grant. After six months, it will report on activities, progress on key indicators , and basic use of the funds. This report will be evaluated and, if satisfactory another six month advance will be provided, with output indicators for that period. The organization will be free to use the grant as it wishes. However, FBOs, NGOs, and the NAA would advise the organization to avoid as much as possible paying incentives. Following common practice in CAR, the youth organization would aim at building its assets: it could use a small portion of the grant (capped to 30 percent) to buy collective assets, such as equipment for sports, a video player, etc. 7.4 Strengthen community capacity to monitor and evaluate their programs 65. External agencies should work with communities to identify what M&E processes already exist and how these can be strengthened to provide information to the communities which is critical its program development. Capacity should be built in a collaborative manner with a long-term perspective of what information would be useful to the communities after the completion of a donor funded project. Further, there should be adequate focus of both quantitative and qualitative M&E indicators which would give a holistic picture of the effectiveness of a program. External agencies should work within the ambit of what communities are willing and able to collect in terms of data, and monitoring systems strengthened through a bottom-up approach rather than being dictated by international donor requirements. More effort should be placed on understanding the various community initiatives which exist, determining the costs of such initiatives and evaluating its effectiveness. Funding agencies should be cautious of trying to extrapolate such information within different local settings and should appreciate and embrace diversity amongst programs. 7.5 Increased Use of Qualitative Research 66. The surveys discussed above would provide information on program impact, but would not explain what happened or how it happened. In order to understand this, some NAAs are using qualitative surveys. Niger, for example, used a national beneficiary assessment, allowing time for surveyors to get close to the population and to hear the stories behind the facts. This type of qualitative survey offers the potential to explain why some people continue to engage in sexually risky behaviors, or continue to fear being stigmatized, or what allowed some of them to change behavior or attitudes. 20 67. Other countries, such as Senegal, are supporting social sector students in conducting participatory research with the community, under the direction of experienced participatory research specialists. The objective is not to provide a national explanation of what happened and how but to analyze local conditions by and with the local population and to feed the results to the population in order to improve efforts to confront HIV/AIDS. 68. Many NAA are trying to better analyze what is really happening behind the data collected in the national surveys. Such analysis can guide the NAAs in the use of specific tools. For example, such an analysis can report that a large segment of the population took HIV/AIDS tests after a person living with the disease had quiet interactions in small groups. In comparison, limited change occurred after a series of sensitization meetings. These studies can also predict the evolution of specific age groups. They can report, for example, that some young people increasingly want to challenge adults by having sex with multiple partners without condoms, or that husbands are now forbidding their wives to get tested when they are pregnant, as they fear that they could learn that one of them is (or both of them are) seropositive. 8. CONCLUSIONS 69. Communities will continue to play a major role in the fight against HIV/AIDS. They will continue to influence their individual members in order to reduce the risks of transmission and to mitigate the impact of HIV/AIDS, especially on PLWH, orphans, and vulnerable children. Community initiatives against HIV/AIDS are evolving. The majority of the population in several African countries are now aware of the epidemic and informed about it. In this context, communities are placing more efforts on access to Voluntary Counseling and Testing, treatment of STIs and opportunistic infections, access to care and treatment, and support to PLWH, orphans, and vulnerable children. Such activities require more capacity than the initial awareness efforts. Communities are moving from massive informal initiatives to more specialized interventions such as home-based care. 70. Instruments to support community initiatives should also evolve. Donors supporting community initiatives might consider supporting the more targeted intervention towards high-risk groups within their national strategies. These efforts are likely to target high-risk groups identified in recent studies. National strategies still however call for continuing efforts at the community level, particularly on prevention of HIV/AIDS. Some programs might continue to provide grants directly to communities. 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New York: Oxford University Press. 24 Africa Region Working Paper Series Series # Title Date Author ARWPS 1 Progress in Public Expenditure Management in January 1999 C. Kostopoulos Africa: Evidence from World Bank Surveys ARWPS 2 Toward Inclusive and Sustainable Development in March 1999 Markus Kostner the Democratic Republic of the Congo ARWPS 3 Business Taxation in a Low-Revenue Economy: A June 1999 Ritva Reinikka Study on Uganda in Comparison with Neighboring Duanjie Chen Countries ARWPS 4 Pensions and Social Security in Sub-Saharan Africa: October 1999 Luca Barbone Issues and Options Luis-A. Sanchez B. ARWPS 5 Forest Taxes, Government Revenues and the January 2000 Luca Barbone Sustainable Exploitation of Tropical Forests Juan Zalduendo ARWPS 6 The Cost of Doing Business: Firms` Experience with June 2000 Jacob Svensson Corruption in Uganda ARWPS 7 On the Recent Trade Performance of Sub-Saharan August 2000 Francis Ng and African Countries: Cause for Hope or More of the Alexander J. Yeats Same ARWPS 8 Foreign Direct Investment in Africa: Old Tales and November 2000 Miria Pigato New Evidence ARWPS 9 The Macro Implications of HIV/AIDS in South November 2000 Channing Arndt Africa: A Preliminary Assessment Jeffrey D. Lewis ARWPS 10 Revisiting Growth and Convergence: Is Africa December 2000 C. G. Tsangarides Catching Up? ARWPS 11 Spending on Safety Nets for the Poor: How Much, January 2001 William J. Smith for How Many? The Case of Malawi ARWPS 12 Tourism in Africa February 2001 Iain T. Christie D. E. Crompton ARWPS 13 Conflict Diamonds February 2001 Louis Goreux ARWPS 14 Reform and Opportunity: The Changing Role and March 2001 Jeffrey D. Lewis Patterns of Trade in South Africa and SADC ARWPS 15 The Foreign Direct Investment Environment in March 2001 Miria Pigato Africa ARWPS 16 Choice of Exchange Rate Regimes for Developing April 2001 Fahrettin Yagci Countries ARWPS 18 Rural Infrastructure in Africa: Policy Directions June 2001 Robert Fishbein ARWPS 19 Changes in Poverty in Madagascar: 1993-1999 July 2001 S. Paternostro J. Razafindravonona 25 Africa Region Working Paper Series Series # Title Date Author David Stifel ARWPS 20 Information and Communication Technology, August 2001 Miria Pigato Poverty, and Development in sub-Saharan Africa and South Asia ARWPS 21 Handling Hierarchy in Decentralized Settings: September 2001 Navin Girishankar A. Governance Underpinnings of School Performance Alemayehu in Tikur Inchini, West Shewa Zone, Oromia Region Yusuf Ahmad ARWPS 22 Child Malnutrition in Ethiopia: Can Maternal October 2001 Luc Christiaensen Knowledge Augment The Role of Income? Harold Alderman ARWPS 23 Child Soldiers: Preventing, Demobilizing and November 2001 Beth Verhey Reintegrating ARWPS 24 The Budget and Medium-Term Expenditure December 2001 David L. Bevan Framework in Uganda ARWPS 25 Design and Implementation of Financial January 2002 Guenter Heidenhof H. Management Systems: An African Perspective Grandvoinnet Daryoush Kianpour B. Rezaian ARWPS 26 What Can Africa Expect From Its Traditional February 2002 Francis Ng Exports? Alexander Yeats ARWPS 27 Free Trade Agreements and the SADC Economies February 2002 Jeffrey D. Lewis Sherman Robinson Karen Thierfelder ARWPS 28 Medium Term Expenditure Frameworks: From February 2002 P. Le Houerou Concept to Practice. Preliminary Lessons from Robert Taliercio Africa ARWPS 29 The Changing Distribution of Public Education February 2002 Samer Al-Samarrai Expenditure in Malawi Hassan Zaman ARWPS 30 Post-Conflict Recovery in Africa: An Agenda for the April 2002 Serge Michailof Africa Region Markus Kostner Xavier Devictor ARWPS 31 Efficiency of Public Expenditure Distribution and May 2002 Xiao Ye Beyond: A report on Ghana`s 2000 Public S. Canagaraja Expenditure Tracking Survey in the Sectors of Primary Health and Education ARWPS 33 Addressing Gender Issues in Demobilization and August 2002 N. de Watteville Reintegration Programs 26 Africa Region Working Paper Series Series # Title Date Author ARWPS 34 Putting Welfare on the Map in Madagascar August 2002 Johan A. Mistiaen Berk Soler T. Razafimanantena J. Razafindravonona ARWPS 35 A Review of the Rural Firewood Market Strategy in August 2002 Gerald Foley West Africa P. Kerkhof, D. Madougou ARWPS 36 Patterns of Governance in Africa September 2002 Brian D. Levy ARWPS 37 Obstacles and Opportunities for Senegal`s September 2002 Stephen Golub International Competitiveness: Case Studies of the Ahmadou Aly Mbaye Peanut Oil, Fishing and Textile Industries ARWPS 38 A Macroeconomic Framework for Poverty October 2002 S. Devarajan Reduction Strategy Papers : With an Application to Delfin S. Go Zambia ARWPS 39 The Impact of Cash Budgets on Poverty Reduction November 2002 Hinh T. Dinh in Zambia: A Case Study of the Conflict between Abebe Adugna Well Intentioned Macroeconomic Policy and Service Bernard Myers Delivery to the Poor ARWPS 40 Decentralization in Africa: A Stocktaking Survey November 2002 Stephen N. Ndegwa ARWPS 41 An Industry Level Analysis of Manufacturing December 2002 Professor A. Mbaye Productivity in Senegal ARWPS 42 Tanzania`s Cotton Sector: Constraints and December 2002 John Baffes Challenges in a Global Environment ARWPS 43 Analyzing Financial and Private Sector Linkages in January 2003 Abayomi Alawode Africa ARWPS 44 Modernizing Africa`s Agro-Food System: Analytical February 2003 Steven Jaffee Framework and Implications for Operations Ron Kopicki Patrick Labaste Iain Christie ARWPS 45 Public Expenditure Performance in Rwanda March 2003 Hippolyte Fofack C. Obidegwu Robert Ngong ARWPS 46 Senegal Tourism Sector Study March 2003 Elizabeth Crompton Iain T. Christie ARWPS 47 Reforming the Cotton Sector in SSA March 2003 Louis Goreux John Macrae ARWPS 48 HIV/AIDS, Human Capital, and Economic Growth April 2003 Channing Arndt Prospects for Mozambique ARWPS 49 Rural and Micro Finance Regulation in Ghana: June 2003 William F. Steel 27 Africa Region Working Paper Series Series # Title Date Author Implications for Development and Performance of David O. Andah the Industry ARWPS 50 Microfinance Regulation in Benin: Implications of June 2003 K. Ouattara the PARMEC LAW for Development and Performance of the Industry ARWPS 51 Microfinance Regulation in Tanzania: Implications June 2003 Bikki Randhawa for Development and Performance of the Industry Joselito Gallardo ARWPS 52 Regional Integration in Central Africa: Key Issues June 2003 Ali Zafar Keiko Kubota ARWPS 53 Evaluating Banking Supervision in Africa June 2003 Abayomi Alawode ARWPS 54 Microfinance Institutions` Response in Conflict June 2003 Marilyn S. Manalo Environments: Eritrea- Savings and Micro Credit Program; West Bank and Gaza ­ Palestine for Credit and Development; Haiti ­ Micro Credit National, S.A. AWPS 55 Malawi`s Tobacco Sector: Standing on One Strong June 2003 Steven Jaffee leg is Better than on None AWPS 56 Tanzania`s Coffee Sector: Constraints and June 2003 John Baffes Challenges in a Global Environment AWPS 57 The New Southern AfricanCustoms Union June 2003 Robert Kirk Agreement Matthew Stern AWPS 58a How Far Did Africa`s First Generation Trade June 2003 Lawrence Hinkle Reforms Go? An Intermediate Methodology for A. Herrou-Aragon Comparative Analysis of Trade Policies Keiko Kubota AWPS 58b How Far Did Africa`s First Generation Trade June 2003 Lawrence Hinkle Reforms Go? An Intermediate Methodology for A. Herrou-Aragon Comparative Analysis of Trade Policies Keiko Kubota AWPS 59 Rwanda: The Search for Post-Conflict Socio- October 2003 C. Obidegwu Economic Change, 1995-2001 AWPS 60 Linking Farmers to Markets: Exporting Malian October 2003 Morgane Danielou Mangoes to Europe Patrick Labaste J-M. Voisard AWPS 61 Evolution of Poverty and Welfare in Ghana in the October 2003 S. Canagarajah 1990s: Achievements and Challenges Claus C. Pörtner AWPS 62 Reforming The Cotton Sector in Sub-Saharan Africa: November 2003 Louis Goreux SECOND EDITION AWPS 63 (E) Republic of Madagascar: Tourism Sector Study November 2003 Iain T. Christie D. E. Crompton AWPS 63 (F) République de Madagascar: Etude du Secteur November 2003 Iain T. Christie 28 Africa Region Working Paper Series Series # Title Date Author Tourisme D. E. Crompton AWPS 64 Migrant Labor Remittances in Africa: Reducing Novembre 2003 Cerstin Sander Obstacles to Development Contributions Samuel M. Maimbo AWPS 65 Government Revenues and Expenditures in Guinea- January 2004 Francisco G. Carneiro Bissau: Casualty and Cointegration Joao R. Faria Boubacar S. Barry AWPS 66 How will we know Development Results when we June 2004 Jody Zall Kusek see them? Building a Results-Based Monitoring and Ray C. Rist Evaluation System to Give us the Answer Elizabeth M. White AWPS 67 An Analysis of the Trade Regime in Senegal (2001) June 2004 Alberto Herrou-Arago and UEMOA`s Common External Trade Policies Keiko Kubota AWPS 68 Bottom-Up Administrative Reform: Designing June 2004 Talib Esmail Indicators for a Local Governance Scorecard in Nick Manning Nigeria Jana Orac Galia Schechter AWPS 69 Tanzania`s Tea Sector: Constraints and Challenges June 2004 John Baffes AWPS 70 Tanzania`s Cashew Sector: Constraints and June 2004 Donald Mitchell Challenges in a Global Environment AWPS 71 An Analysis of Chile`s Trade Regime in 1998 and July 2004 Francesca Castellani 2001: A Good Practice Trade Policy Benchmark A. Herrou-Arago Lawrence E. Hinkle AWPS 72 Regional Trade Integration inEast Africa: Trade and August 2004 Lucio Castro Revenue Impacts of the Planned East African Christiane Kraus Community Customs Union Manuel de la Rocha AWPS 73 Post-Conflict Peace Building in Africa: The August 2004 Chukwuma Obidegwu Challenges of Socio-Economic Recovery and Development AWPS 74 An Analysis of the Trade Regime in Bolivia in2001: August 2004 Francesca Castellani A Trade Policy Benchmark for low Income Countries Alberto Herrou- Aragon Lawrence E. Hinkle AWPS 75 Remittances to Comoros- Volumes, Trends, Impact October 2004 Vincent da Cruz and Implications Wolfgang Fendler Adam Schwartzman AWPS 76 Salient Features of Trade Performance in Eastern and October 2004 Fahrettin Yagci Southern Africa Enrique Aldaz-Carroll AWPS 77 Implementing Performance-Based Aid in Africa November 2004 Alan Gelb Brian Ngo Xiao Ye AWPS 78 Poverty Reduction Strategy Papers: Do they matter December 2004 Rene Bonnel for children and Young people made vulnerable by Miriam Temin 29 Africa Region Working Paper Series Series # Title Date Author HIV/AIDS? Faith Tempest AWPS 79 Experience in Scaling up Support to Local Response December 2004 Jean Delion in Multi-Country Aids Programs (map) in Africa Pia Peeters Ann Klofkorn Bloome AWPS 80 What makes FDI work? A Panel Analysis of the February 2005 Kevin N. Lumbila Growth Effect of FDI in Africa AWPS 81 Earnings Differences between Men and Women in February 2005 Kene Ezemenari Rwanda Rui Wu AWPS 82 The Medium-Term Expenditure Framework: The April 2005 Chukwuma Obidegwu Challenge of Budget Integration in SSA countries AWPS 83 Rules of Origin and SADC: The Case for change in June 2005 Paul Brenton the Mid Term Review of the Trade Protocol Frank Flatters Paul Kalenga AWPS 84 Sexual Minorities, Violence and AIDS in Africa July 2005 Chukwuemeka Anyamele Ronald Lwabaayi Tuu-Van Nguyen, and Hans Binswanger AWPS 85 Poverty Reducing Potential of Smallholder July 2005 Paul B. Siegel Agriculture in Zambia: Opportunities and Jeffrey Alwang Constraints AWPS 86 Infrastructure, Productivity and Urban Dynamics July 2005 Zeljko Bogetic in Côte d`Ivoire An empirical analysis and policy Issa Sanogo implications AWPS 87 Poverty in Mozambique: Unraveling Changes and August 2005 Louise Fox Determinants Elena Bardasi, Katleen V. Broeck AWPS 88 Operational Challenges: Community Home Based August 2005 N. Mohammad Care (CHBC) forPLWHA in Multi-Country Juliet Gikonyo HIV/AIDS Programs (MAP) forSub-Saharan Africa AWPS 90 Kenya: Exports Prospects and Problems September 2005 Francis Ng Alexander Yeats AWPS 91 Uganda: How Good a Trade Policy Benchmark for September 2005 Lawrence E. Hinkle Sub-Saharan-Africa Albero H. Aragon Ranga Krishnamani Elke Kreuzwieser AWPS 92 Community Driven Development in South Africa, October 2005 David Everatt Lulu 1990-2004 Gwagwa AWPS 93 The Rise of Ghana``s Pineapple Industry from November 2005 Morgane Danielou Successful take off to Sustainable Expansion Christophe Ravry AWPS 94 South Africa: Sources and Constraints of Long-Term December 2005 Johannes Fedderke Growth, 1970-2000 30 Africa Region Working Paper Series Series # Title Date Author AWPS 95 South Africa``s Export Performance: Determinants December 2005 Lawrence Edwards of Export supply Phil Alves AWPS 96 Industry Concentration in South African December 2005 Gábor Szalontai Manufacturing: Trends and Consequences, 1972-96 Johannes Fedderke AWPS 97 The Urban Transition in Sub-Saharan Africa: December 2005 Christine Kessides Implications for Economic Growth and Poverty Reduction AWPS 98 Measuring Intergovernmental Fiscal Performance in May 2006 Navin Girishankar South Africa David DeGroot Issues in Municipal Grant Monitoring T.V. Pillay AWPS 99 Nutrition and Its determinants in Southern Ethiopia - July 2006 Jesper Kuhl Findings from the Child Growth Luc Christiaensen Promotion Baseline Survey AWPS 100 The Impact of Morbidity and Mortality on Municipal September 2006 Zara Sarzin Human Resources and Service Delivery AWPS 101 Rice Markets in Madagascar in Disarray: September 2006 Bart Minten Policy Options for Increased Efficiency and Price Paul Dorosh Stabilization Marie-Hélène Dabat, Olivier Jenn-Treyer, John Magnay and Ziva Razafintsalama AWPS 102 Riz et Pauvrete a Madagascar Septembre 2006 Bart Minten AWPS 103 ECOWAS- Fiscal Revenue Implications of the April 2007 Simplice G. Zouhon- Prospective Economic Partnership Agreement with Bi the EU Lynge Nielsen AWPS 104(a) Development of the Cities of Mali June 2007 Catherine Farvacque- Challenges and Priorities V. Alicia Casalis Mahine Diop Christian Eghoff AWPS 104(b) Developpement des villes Maliennes June 2007 Catherine Farvacque- Enjeux et Priorites V. Alicia Casalis Mahine Diop Christian Eghoff AWPS 105 Assessing Labor Market Conditions In Madagascar, June 2007 David Stifel 2001-2005 Faly H. Rakotomanana Elena Celada AWPS 106 An Evaluation of the Welfare Impact of Higher June 2007 Noro Andriamihaja Energy Prices in Madagascar Giovanni Vecchi AWPS 107 The Impact of The Real Exchange Rate on November 2007 Mireille Linjouom Manufacturing Exports in Benin AWPS 108 Building Sector concerns into Macroeconomic December 2007 Antonio Estache Financial Programming: Lessons from Senegal and Rafael Munoz 31 Africa Region Working Paper Series Series # Title Date Author Uganda AWPS 109 An Accelerating Sustainable, Efficient and Equitable December 2007 Hans P. Binswanger Land Reform: Case Study of the Qedusizi/Besters Roland Henderson Cluster Project Zweli Mbhele Kay Muir-Leresche AWPS 110 Development of the Cites of Ghana January 2008 Catherine Farvacque- ­ Challenges, Priorities and Tools Vitkovic Madhu Raghunath Christian Eghoff Charles Boakye AWPS 111 Growth, Inequality and Poverty in Madagascar, April 2008 Nicolas Amendola 2001-2005 Giovanni Vecchi AWPS 112 Labor Markets, the Non-Farm Economy and April 2008 David Stifel Household Livelihood Strategies in Rural Madagascar AWPS 113 Profile of Zambia`s Smallholders: Where and Who June 2008 Paul B. Siegel are the Potential Beneficiaries of Agricultural Commercialization? AWPS 114 Promoting Sustainable Pro-Poor Growth in Rwandan June 2008 Michael Morris Agriculture: What are the Policy Options? Liz Drake Kene Ezemenary Xinshen Diao AWPS 115 The Rwanda Industrial and Mining Survey (RIMS), June 2008 Tilahun Temesgen 2005 Survey Report and Major Findings Kene Ezemenari Louis Munyakazi Emmanuel Gatera AWPS 116 Taking Stock of Community Initiatives in the Fight June 2008 Jean Delion against HIV/AIDS in Africa: Experience, Issues, and Elizabeth Ninan Challenges 32 WB21847 C:\Documents and Settings\WB21847\My Documents\Working Paper Series\AWS # 116 -Delion 6.12.08\Community HIV AIDS paper final version June 12 2008.doc 06/12/2008 12:23:00 PM 33