~~~21 271 OCIAL DEVELOPMENT NOTES ENVIRONMENTALLY AND SOCIALLY SUSTAINABLE DEVELOPMENT NETWORK Note No.47 May 1999 NGO Participation in HIV/AIDS Control Project in Brazil Achieves Results According to the World Health They focused primarily on fighting social Organization's Global Program on AIDS, Brazil exclusion and pressuring the state to be more remains among the four countries with the responsive to the unfolding crisis. It was NGO highest number of reported AIDS cases, leadership, for example, that was instrumental although annual incidence rates rank the in creating the legislation to mandate country somewhere between 40th and 50th on nationwide HIV testing of blood donations. a world scale. The AIDS/STD Control Project They also created home-care programs, demonstrates that Brazilian government/ NGO established HlV support groups, and launched partnerships can work well and benefit all preventive/educational efforts. parties involved, particularly project beneficiaries. The project contributed to efforts Enlightened leadership of the government's underway throughout the country to prevent national program in the early 1990s led to the the spread of HIV/ AIDS and confirmed that establishment of cooperative working stakeholder participation improves project relationships between NGOs and the performance and increases impact. NGOs government. An NGO Liaison Office was provided the link to people at the local level created within the national program to expand and helped the government reach vulnerable the participation of civil society in the struggle populations, such as homosexuals, drug users, against the AIDS epidemic. At the time of sex workers, and street children. A successor preparation for the AIDS/STD Control Project project (AIDS/STD II) is continuing to foster in 1992, the World Bank provided draft terms collaboration between government officials, of reference in which it stated that the active NGO practitioners, and donors to reduce the involvement of NGOs should become a key incidence and transmission of HIV/ AIDS component of the loan agreement. throughout Brazil. Project Overview Bringing Together Government and NGOs The objective of the AIDS/ STD project was NGOs working on AIDS issues in Brazil to reduce the incidence and transmission of started to proliferate rapidly a decade ago. HIV and sexually transmitted diseases (STDs) This note was prepared by writer Barbara L. Boyd in collaboration with John Garrison. The team leader for the AIDS/ STD Control Project was Theresa Jones. For more information, contact John Garrison, Banco Mundial SCN Q.2 Bl.A S/304-305, 70.712-900, Brasilia Distrito Federal. Fax: (061) 329-1010; E-mail: jgarrison@worldbank.org The views expressed in this note ate those of the author(s) and do not necessarily reflect the official policies of the World Bank. followed by information, education and Box 1. Why the World Bank Wanted communication initiatives (31 percent), NG O Participahon support to persons living with AIDS (29 NGOs had played an important role in percent), and a small number of institutional AIDS prevention and care from the onset strengthening activities (6 percent). of the epidemic in Brazil. Organizations funded included traditional AIDS service NGOs, research centers, and NGOs often complement government social movement, such as an association of sex action by their flexible, innovative, and workers, indigenous tribal councils, and cost-effective approach. commnunity groups. Preliminary findings show that during the four-year project period these NGOs can reach and work effectively organizations distributed more than a million with people at the comnmunity level, condoms, disseminated educational material to especially with vulnerable segments of more than 500,000 persons, provided society. specialized orientation to more than 200,000 individuals, and trained 2,000 community NGO involvement is in keeping with the health agents. World Bank's stakeholder participation policies geared to improving implementa- Project Results tion performance and promoting project ownership. The AIDS/ STD Control Project contributed to a significant decline in new AIDS cases over the past five years, as well as an estimated 30 percent decline in morbidity levels among by promoting prevention and treatment leading risk groups. The widespread programs as well as strengthening the public distribution of AZT and other anti-retroviral and private institutions responsible for disease medication and the expanded national control. The active participation of civil society network of treatment centers are prolonging was sought to link the project to people at the lives of AIDS patients. There has also been a local level and help the government reach decline in the reporting of new HIV cases people most at risk. NGO involvement, among traditional risk groups such as therefore, was included in three of the homosexual males. This decline is apparently project's components: prevention efforts, the result of well-targeted behavior change treatment services, and institutional campaigns which resulted in a threefold development increase in condom sales over the life of the NGO Activities project. In light of these important results, the global During the 1993-97 period, 427 NGO United Nations AIDS Program (UNAIDS) activities worth US$18.1 million and involving selected the Brazilian AIDS program as one of 175 implementing organizations were the "best practice" examples in the world. The financed by the AIDS/STD project. The project also has had a considerable impact on majority of these activities (62 percent) were NGOs working on AIDS issues in Brazil. Their located in the Southeast, but 20 percent and 9 ranks grew from 120 registered with the percent respectively, took place in the Ministry of Health in 1992 to more than 500 in Northeast and South, regions with fewer 1998, in part due to the increased influx of government services. NGOs focused their Bank and government funds. efforts on behavior intervention (34 percent), 2 Box 2. Beneficiary Populations Reached by NGOs second US$300 millon, four-year loan encountered resistance from some parts of the Persons living with HIV/AIDS 30% government, it was the commonality of Adolescents 13% interests between the national government's Sex Workers 12% AIDS staff and NGO representatives that won Women 9% out Homosexuals 7% General Public 3% While the OED's assessment of the project Others (for example, students, was very positive, stated objectives were not street children) 21% met in the areas of surveillance and impact assessment. Evaluators found that data regarding the impact of the NGO work or - for that matter - the project as a whole were difficult to obtain. Few baselnes or other types Outcomes? of systematized information were available. The problem was, in part, inherent in AIDS An Operations Evaluation Department work since it is difficult to quantify how many (OED) study looked at the AIDS/ STDs lives are prolonged or saved through Control Project as part of an effort to interventions. understand what differences NGOs make to the performance of World Bank-supported projects. The study hypothesized that NGO Box 3. Government/NGO Partnership effectiveness is the product of: (1) the Consolidated existence of an enabling environment for their participation; (2) a positive relationship The Brazilian Ministry of Health and the between NGOs, governments, and the World World Bank have adopted several key Bank; and (3) NGOs' local knowledge, participatory mechanisms to enable flexibility, and innovation. government/civil society collaboration to grow and solidify. They include: Despite the lack of hard impact evidence, one of the clearest messages from both World * Five NGO representatives now serve on Bank staff and government officials is that this the National AIDS Council, which project's important prevention initiatives could monitors Brazil's AIDS policies. not have succeeded without NGOs. These * NGO researchers were hired for such organizations demonstrated their ability to project-related tasks as designing the reach groups of at-risk individuals whose small-grants program; providing needs the government was less able to address. technical assistance to recipient They also helped the government to increase organizations; monitoring project the capacity and coverage of its AIDS activities; and carrying out the social prevention and treatment efforts. Staff in Rio analysis of the new AIDS/STD loan. de Janeiro, for example, described NGOs as "fundamental" to their work and pointed out * NGO leaders actively participated in a that their office had only three people to cover seminar with government officials and the entire state. NGOs were also found to be donors to evaluate the project's activities less costly than government programs in most and plan a new project. The NGO cases. These operational results fully bore out delegation included representatives from the original justification for working with groups increasingly exposed to HIV/ NGOs. Furthermore, when the proposal to AIDS, such as low-income women, rural amend the original AIDS/ STD project for a workers, and indigenous populations. 3 The NGO Perspective parties involved. Some specific lessons learned include: The maiority of NGOs welcomed the project. Their representatives reported that it * In the inherent conflict of systems and undoubtedly had a significant and positive approaches between the two very different impact on the fight against AIDS in Brazil by cultures of the World Bank/ governmnent providing a much-needed injection of funds on the one hand and NGOs on the other, for their efforts. Many NGOs, however, NGOs are often at a disadvantage. To be criticized technical aspects of the funding successful partners in these collaborations, process. They objected to the extensive NGO funding mechanisms need to be - . , flexible enough to accommodate their proposal forms, slow disbursements and diversity and informality while meeting difficult procurement norms. Other, more adequate reporting and accountability financially fragile groups had weak issues management/administrative skills and found it difficult to operate within a large project. A careful assessment of both absorptive They expressed a need for more technical and management capacity of NGOs is assistance and capacity building in such areas essential prior to channeling funds to as general administration, proposal writing them. They generally need technical and financial reporting. assistance geared to institutional capacity- building skills, such as training for staff in Some NGOs also expressed concern about computer skills, record keeping, and the dilution of their independent public policy proposal preparation. advocacy role. Paradoxically, their shift in focus to prevention and service provision is a * Information disclosure and frank dialogue direct result of their successful efforts to among donors, government officials, and influence policy. While this expansion of their NGO representatives yield results leading role has indeed occurred, key policy-oriented to increased trust and consensus building. NGOs seem to have maintained the independence needed to maintain their * There is a need to identify and disseminate government watchdog function. best practice examples of government/ NGO collaborations to encourage Fostering Effective Government/NGO replication of successful methodologies. Collaboration Initiatives need to be undertaken by the Although government/NGO relations can government, donors, and NGOs be difficult and characterized by themselves to promote the financial misunderstandings and conflict, this project sustainability of NGOs by diversifying their demonstrates that partnerships are indeed funding sources. possible and that such cooperation benefits all Social L)evcloprnenl Notes are published informally by the Social Development Family in the Environmentally and Socially Sustainable Development Network of the World Bank. 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