Jean Delion Addis-Ababa MAP workshop, February 2005 “Summary from a regional review“

1. EXPERIENCE IN SCALING UP SUPPORT TO LOCAL RESPONSE (LR)IN MULTI-COUNTRY AIDS PROGRAMS (MAP) IN AFRICA Jean Delion Addis-Ababa MAP workshop, February 2005 “Summary from a regional review“

2. MAP projects channel around 40 to 60% of their funds to support LR initiatives • LR components provide grants to support HIV-AIDS interventions prepared/implemented by : • Community-based organizations • Other civil society organizations: FBOs, NGOs, Private firms, Unions, PLWHA associations. • Around $380 million allocated for LR under MAPs ($150 million disbursed – June 2004) • After a slow start LR funds now disbursing faster than the public sector in most MAPs Page 2 of 19

3. Diverse practices, rich experience • Flow of funds slow during Project Year 1, steadily increasing after; • Country-specific practices determine more or less emphasis on grants to NGOs, to other CSOs or CBOs • Convergence evident after three years • Participants have rich experiences with specific tools, we need to facilitate exchanges Page 3 of 19

4. Example 1: Support to Communities • CDD approaches & rapid support to community-based organizations (CBOs) • Initial weaknesses • Corrections made with guidance on • Results: Better governance, more participation, diverse activities, improved effectiveness (simple measurable results) Page 4 of 19

5. Example 2: Support to various CSOs • Providing grants to different CSOs • Initial weaknesses (mostly similar to CBOs) • Corrections made (mostly similar to CBOs) • With evidence of demonstrated cost-effective results for some CSOs, the MAP scaled up their programs • Many MAPs now have good experience on eligible activities, criteria for selection, etc. Page 5 of 19

6. Pilot phases proved to be very useful • Several MAPs used pilot phases in communities (up to 600) or with a few CSOs, either during preparation with PPF or PHRD resources or during PY1 • Pilots were open to explore various innovative options that could be scaled up during project implementation • MAP learned a lot from these pilots, project staff acquired ownership, implementation manuals were refined on the basis of pilot experiences and decentralized staff were trained Eg: the Burkina Faso MAP launched a pilot phase in 600 communities in one region for 6 months Page 6 of 19

7. Empowerment of decentralized institutions • LR grants can be successfully managed by capable decentralized administrations • Eg. Ghana is successfully using District Assemblies • LR grants can also be successfully handled by well functioning agencies managing social funds or CDD funds • Eg: the Benin MAP contracted AGEFIB, which hired 2 additional staff in each region and took responsibility for management/supervision of funds • Many MAPs likely to transfer increased responsibilities to local governments or municipalities in their second project Page 7 of 19

8. Example: “cascade” approach in Cameroon • PY1: Evaluation of pilot activities under the MAP and under other programs (UNFPA, UNICEF, FBOs, etc.) • Foundation workshop: building a consensus among key actors on a first version of “Guidelines to support LR” • National CB workshop: Training trainers from each region, from organizations already active against HIV/AIDS • Regional workshop: Contracting above trainers to train 10 local organizations in each region • PY2: Expansion around the first communities, use local organizations at lower costs to reach 2,000 more communities. Page 8 of 19

9. Need for more integration between health and local responses activities • CBOs and CSOs need to go beyond IEC/BCC -- provide psychosocial support, HBC services, orphan care & assistance, & maintain close linkages with health centers • Health centers need to go beyond testing and treatment: they need “intermediate community health agents” to serve as interface between the communities and the centers • Community health agents Page 9 of 19

10. Lessons learned in the regional review of LR Action plans: • Importance of deep situation analysis, identifies local causes on which the community can act • Usefulness of providing some guidance or priorities Time Frame: • Thoughtful preparation results in rapid scale up in PY2 on • Scaling-up does not always allow high quality in PY1 but can make adjustments in PY2 based on actual experience • Focusing on rapid results can direct project staff attention to concrete actions and accelerate scaling-up Page 10 of 19

11. Moving Forward with LR Activities (i) Shifting from IEC to effective BCC & services to infected or affected people is difficult and requires TA (ii) Moving from IEC to BCC, care and support services, NGOs need to provide technical and financial support to complement the work done by communities (iii) Combining social mobilization and increased access to health and social support is crucial (iv) MAPs moved aggressively in subsidizing access to all HIV-related services LR assisted people to access and use HIV services or supplies, available at low prices Page 11 of 19

12. Implementing Organizations • Communities, if well trained, have advantages for simple tasks at low cost, such as IEC, support to infected or affected people (orphans), home to home sensitization • FBOs, private firms and other CSO have advantages for more difficult tasks: access to VCT, PMTCT, & ARVs • Some FBOs and NGOs ask for cars, equipment and salaries leading to expensive sub-projects in limited areas • However, some FBOs and NGOs only ask support for additional costs (tests, drugs, limited allowances), leading to cost-effective interventions Page 12 of 19

13. Implementing Organizations (Contd.) • NGOs have advantages: • to provide TA and training • to design and launch new approaches • to organize social marketing of condoms. • In countries with very low capacities of CBOs, NGOs can be used as implementing agencies & the MAPs are using NGOs and FBOs to implement LR activities & provide assistance to CBOs Page 13 of 19

14. Implementing Organizations (Contd.) • Private firms are increasingly mobilizing their resources. • Some MAPs successfully support over 100 firms, & more tools are available to support them, but generally the MAPs are still hesitant. Many Best Practices are available. • Communities need to use simple tools to evaluate the usefulness of their activities, good governance inside their community organizations and the quality of services from supporting organizations. Page 14 of 19

15. Financial Lessons • Most MAPs moved to simple results-based grant agreement, following Johannesburg’s guidelines: communities do not need to send detailed justification to get their next payment • Some MAPs use simple norms, for example 1$/ inhabitant or $5, 10 or 20 maximum per orphan per month • Contracting out financial management tasks accelerates disbursement on LR and facilitates control of the LR grants Page 15 of 19

16. Financial Lessons (Contd.) • MAPs need to produce guidelines on access to grants by different actors; without this, NGOs are in better position and get the lion’s share • Different financial controls provide good control • random or systematic audit (by geographic areas) • internal controls by project • detailed controls by supervision missions in visited communities • missions by Ministry of Finance Page 16 of 19

17. Monitoring & Evaluation of LR • Use combinations of M&E tools: • simple indicators at micro level, from household level (self assessment tool - UNAIDS) to community (report cards) • district (process indicators combined with access to condoms) • health services (sentinel surveillance, DHS results, etc.) • regional and national level (same as district) • Finance BC surveys, on target groups • Contribute to DHS every 5 years to get a clear picture at national level and details from the local level • Ensure aggregation of data from various sources (private firms, FBOs, etc.) mainly at local/regional level Page 17 of 19

18. Results/ impact of LR? • Communities, CSOs and health centers can report on simple results such as: • No. of condoms sold in their area • No. of people tested & # of PLWHA living positively in public • use of artificial milk for PMTCT • No. of PLWHA under ARVs & adherence to treatment • No. of orphans attending school & accessing basic health services, etc. • Proxy impact indicators: reduction of No. of girls 15-19 who gave birth Page 18 of 19

19. Results/ impact of LR? (Contd.) • Macro level, DHS results: • changes in knowledge on AIDS (above 95% in recent surveys) • prevalence rates 15-19 (ex. less than 2% in a country with 5.5% prevalence) • Correlations between effective use LR grants (measured through simple results indicators), access to test, care and adherence to treatment: LR can create a supportive context, encouraging people to talk and act. Page 19 of 19