33008 SD Note No. 96 /October 2004 Scaling-up a Community-Driven HIV/AIDS Program in Malawi This note is part of a series that examines factors that facilitate the scaling up of Community Driven Development (CDD) What Is Community-Driven Development? programs. The note describes the factors that enabled and constrained the scaling up of a community based HIV/AIDS Community-driven development is an approach to intervention in Malawi - Scaling-up HIV/AIDS development that supports and empowers Interventions Through Expanded Partnerships (STEPs). The participatory decision making, local capacity STEPs initiative assists local HIV/AIDS committees with building, and community control of resources. The community mobilization and capacity building so that five key pillars of this approach are community communities become empowered to act collectively to address empowerment, local government empowerment, their own problems. decentralization, accountability and transparency, and learning by doing. With these pillars in place, Background CDD approaches can create sustainable and wide- ranging impacts by mobilizing communities, and In Malawi, HIV/AIDS accounts for 70 percent of all giving them the tools to become agents of their own hospital admissions, and for the recent drop in life development. expectancy of parents and other adults from 43 to 39 years. As the crisis worsened, and with the growing number of AIDS orphans (projected to reach 20 to 25 million children throughout Sub-Saharan Africa by What Is Scaling Up? 2010i), the Government began to focus on creating an enabling environment in which a wide spectrum of Scaling up is a multi-dimensional process through public, private, civil, and faith-community actors could which the impact of a community-driven programs participate in addressing the problem. Since 1999, is broadened and deepened. Dimensions of scaling these actors have been operating within a strategic up that have been identified include quantitative framework that emphasizes: (i) local action through (physical replication); programmatic (new activities district, community, and village-level AIDS and programs); social (increasing the capacity of the committees (established by the National AIDS community to engage in development activities, and Committee and UNICEF in 1994); and (ii) facilitated mobilization of increasing numbers of local community-driven programs that promote behavior residents, including the vulnerable and change, care and support activities, effective mitigation marginalized); organizational (increasingly plans, and community and home-based services. Most effective internal management and financial of these programs have been small in scope, and viability); and political (incorporation of the CDD experiences with scaling up have been limited. The approach by higher levels of government, and the STEPs program is the notable exception. By end of its direct entry of grassroots organizations into second phase (1997-2002), STEPs had scaled up to politics). more than 300 communities in four districts, covering 12 percent of the population. The program now aims to down approach, lack of support, and insufficient expand to six districts and reach 75 percent of the resources to fulfill their mandate of identifying population, directly and through partnerships, by 2005. problems and developing responses to problems faced by AIDS-affected families in their areas. With The STEPs Program: Evolution of the community program support, NAC mobilized 16 village AIDS mobilization model committees with 229 active members; and then mobilized another eight villages after the program STEPs began in 1995 as a two-year pilot in three withdrew. (Subsequently, committee staff working on communities in Malawi, carried out by Save the the pilot left to form their own community-based Children U.S.A. and supported by a half-million dollar organization.iii,iv) grant from USAID's Displaced Children and Orphan's Fund. The pilot had a difficult beginning. Designed as A post-evaluation of STEPs Phase I found that while a program of input-intensive, multisectoral participating villages had become more committed to interventions, it was unable to scale up, even locally, thinking about the impact of HIV/AIDS on orphans beyond its primary focus of identifying orphans and and other vulnerable groups and more aware that providing them with psychosocial and material caring for the vulnerable is a community, not just a support. Two reasons for this difficulty were family, responsibility; the mobilization effort should identified: (i) the extremely high cost per beneficiary have further developed community capacity, (estimated at US$162); and (ii) uncertainty as to knowledge, and networking capability; and that the whether community volunteers would continue the program phase-out should have taken place gradually activities once the program staff withdrew, which was and included a one-year follow-up period to monitor a disincentive for other organizations to become community performance and help in solving ongoing involved. problems. Phase I: From implementer to agent for change Phase II: Refining the approach to community mobilization and scaling up Based on this evaluation, the second year of the pilot ­ here called Phase I of STEPSii ­ adopted a Based on these lessons, STEPs refined its approach to dramatically different approach. It changed its focus community mobilization and fully consolidated its role from an implementer to that of an outside change as a change agent during Phase II. Working in four agent: assisting communities with community districts, and guided by the underlying principles of mobilization and capacity building so that communication, respect for culture, and involvement of persons living with HIV/AIDS, the program communities become empowered to act collectively to redoubled its efforts to build the capacity of the AIDS address their own problems. The program worked committees and their technical subcommittees (Home- through the decentralized AIDS committee structures Based Care, Youth, High-Risk Group, and Orphans). of the National AIDS Committee (NAC) to accomplish this goal Instead of acting as implementer of the program. The new goal was to empower the AIDS The STEPs community mobilization model is a committees, and the communities they served, to: (i) six-part community action cycle: identify problems resulting from the AIDS crisis; (ii) develop action plans to address the problem; (iii) § Preparecommunityleadersfor mobilize internal resources; (iv) implement activities; mobilization (v) advocate on their own behalf; and (vi) establish § Organizethecommunityforaction linkages with government offices, NGOs, donors, and § ExploreHIV/AIDSissues,focusingand other organizations. In addition, the program facilitated setting priorities for action the formation of partnerships between the National § Planincollaborationwithcommunity AIDS Committee and organizations that could provide and STEPs-Malawi staff necessary resources. § Implementcommunityactionplans § Collaborativelyevaluatetheprogram's This approach infused new life into the AIDS impact on the community's ability to committees, which had been languishing due to a top- prevent and respond to HIV/AIDS- related problems . 2 results in the four districts were promising. By the end The main role of the district STEPs staff can be of Phase II, 38 community committees and 700 village summarized as facilitators for development of committees had been mobilized (4 and 49 of which had networking, resource mobilization and leadership skills formed spontaneously). A series of assessments also at district, community, and village levels. found that the community mobilization and capacity building effort had a considerable impact on the ability The District AIDS committee (DAC) included district of communities to organize themselves to address health, education, agriculture, social welfare, and HIV/AIDS and other problems. While the outcome in youth officers; assembly members; business, religious, terms of AIDS prevention and mitigation has not yet and political leaders; NGOs; and people living with been demonstrated, the initiative reduced the stigma HIV/AIDS. Their responsibilities included attached to HIV/AIDS, and increased communities' coordinating and monitoring the quality of HIV/AIDS willingness to provide care and support to those activities in the district; building the capacity of affected by the disease. In addition, the STEPs villages to address their HIV/AIDS needs; facilitating programs helped build social capital in these community and village-level access to financial, communities, which in turn enabled VACs to resolve technical, and other resources; and helping village their governance problems; mobilize funds and committees to identify and address their problems. resource people and expand their care giving activities. The Community AIDS committee (CAC) included community health, education, agriculture, social Factors in Scaling Up welfare, and youth officers; traditional leaders; religious and political leaders; village AIDS committee STEPs was designed, from its inception, to address the representatives; business leaders; CBOs; and people HIV/AIDS crisis over the long term. It was this long- living with HIV/AIDS. Their responsibilities included term vision that enabled the program to switch from its monitoring the quality and reach of activities at the unsustainable, input-intensive approach to the more community and village levels; facilitating village-level dynamic and sustainable role of outside change agent, access to financial, technical, and other resources which in turn enabled it to expand to more districts. through funding proposals or community-based The program used a multi-pronged approach to scaling fundraising; advocating for the needs of the village up collective action. In addition to engaging committees to the district committee; and facilitating communities through the AIDS committee structure, the exchange of lessons learned among the different STEPs actively participated in shaping national community and village committees. HIV/AIDS policies and strategies; and intensified its strategic partnerships with civil society to reach The Village AIDS committee (VAC) included people national scale. Further, the program's development and families affected by HIV/AIDS; traditional over the years was informed by regular reviews of the leaders; representatives of village organizations; factors affecting successful implementation and traditional healers, initiators, and birth attendants; replication. The most important of these were: youth. These committees were responsible for developing village-level action plans and delivering services directly to the vulnerable. Services addressed · The creation of and response to community a wide variety of needs, from cultivating communal demand. Initial discussions with community plots to feed HIV/AIDS affected persons, to members revealed that they felt helpless and establishing village-based childcare centers for needy ineffective as the scourge of HIV/AIDS children, to behavior change campaigns, to providing progressed. Many were coping with the problem home-based care and medication, to psychosocial in a disjointed fashion, but as they witnessed the assistance. more coordinated effort of STEPs-mobilized community and village AIDS committees, they Findings from STEPS Phase II began to demand STEPs' services to strengthen their own AIDS committees. Although the program was unable to scale up to two additional districts due to the ongoing food crisis, the · A flexible, multisectoral, and proactive approach. The first phase of the pilot was 3 primarily an orphan support program, but food commitment of the current government to a multi- insecurity was found to be a major barrier to sectoral approach of combating HIV/AIDS. However, placing the orphans with new families. Therefore, important challenges still remain. Lack of adequate food security and other income-generating funding, the magnitude of the epidemic, the ongoing activities were incorporated into subsequent food crisis, and the overall context of poverty and phases. The program also came to recognize underdevelopment are factors that are undermining the home-based care as a way to prolong parents' scaling up potential of STEPs. lives and support children before they became orphans. STEPs is now planning to initiate systems to protect children from violence and abuse ­ a key element of the program's evolving rights-based approach. · Intensification and expansion of partnerships. In its initial stages, the program did not envision This Note is based on the study, Scaling-Up HIV/AIDS the intensification of partnerships, but focused on interventions through expanded partnerships (STEPs) in its own internal development as late as 2001. At Malawi, by Suneetha Kadiyala, produced by the that point, informed by assessments and International Food Policy Research Institute for the Social discussions with the National AIDS Committee, Development Family of the World Bank. Additional copies can also be requested via e-mail: the program decided to focus on partnerships with socialdev@worldbank.org NGOs, including prominent international NGOs, as a way to build the capacity of local structures (district, community, and village AIDS i UNAID/UNICEF/UNAIDS (2002). Children on the committees, and district assemblies) to absorb brink 2002: a joint report on orphan estimates funds and scale up responses. and program strategies. Washington DC. ii The pilot and second phases were originally called · Replication. Over the past few years, the COPE I and COPE II, respectively. For program has trained a number of NGOs and convenience, this report refers to the pilot as Stage I and the following stage as Stage II of STEPs. CBOs in the STEPs approach, to enable these iiiJ. Williamson and J. Donahue (1998). Community organizations to carry out similar interventions in mobilization to address the impacts of AIDS: a their own districts. In response to the growing review of the STEPS II program in Malawi. demand for replication of the STEPs model, a Washington DC: Displaced Children and Orphans national implementing partnership was initiated in Fund/War Victims Fund, USAID. September 2001, with the aim of achieving iv S. Phiri, G. Foster, and M. Nzima (2001). national coverage of community-based Expanding and strengthening community action: A HVI/AIDS programs by 2005. To date, 15 study of ways to scale up community mobilization organizations have joined this partnership. interventions to mitigate the effect of HIV/AIDS on children and families. Washington DC: U.S. Agency for International Development. Conclusions The STEPs experience shows that scaling up multisectoral, community-driven responses to HIV/AIDS is possible, even in resource-poor settings. Some key success factors for scaling up include a well trained and motivated staff, adoption of a community mobilization model through capacity building of the district, community and village AIDS committees, its commitment to document and disseminate lessons learnt; and reaching more affected populations through partnerships. Contextual factors critical for scaling-up include an enabling policy environment with a strong 4