THE DECENTRALIZED RESPONSE TO HIV/AIDS IN UGANDA : Progress, challenges and lessons learned

1. THE DECENTRALIZED RESPONSE TO HIV/AIDS IN UGANDA :Progress, challenges and lessons learned Patrick . K. Mutabwire Ag. Director Local Government Administration/ Chairperson, Decentralized Response Entity Ministry of Local Government Lake Victoria Serena Resort 27 April 2010

2. The HIV Situation at LG Level – Background • The impact of HIV/AIDS on the community is noticeable at individual, family and community levels. • At individual and family level, nearly every family has been affected by the epidemic in some way. • Most of these individuals live in the rural areas where access to basic social services is extremely low • Moreover support to communities to enhance their competence in dealing with the epidemic is extremely inadequate, despite communities being closest to the people. • Variations and disparities in HIV prevalence exist in different regions and districts, with urban centers reporting the highest prevalence rates – 10.1% as compared to 5.7% in rural areas (MoH, 2005). • The current National HIV/AIDS Strategic Plan emphasizes the need to deepen the AIDS response to the lower levels based on the fact that this level is closest to the population, and as such best suited to understand the challenges they face, and in return support them design appropriate strategies to address the AIDS challenges.

3. The Policy Framework (1) • The HIV/AIDS response in Uganda is guided by the Decentralization framework. Implementation and coordination of the epidemic follows the decentralization policy. • This is because Decentralization is a key vehicle for improving service provision, promoting democratization, and ensuring good governance. • The LG Act 1997, mandates LGs to directly manage and monitor delivery of services, including those for HIV/AIDS within their areas of jurisdiction • The Act also under Section 81, also provided for the delegation of responsibilities from the higher to lower LGs, as long as any extra obligation is fully financed • The response in LGs has over the years evolved from small, spontaneous self-help initiatives to a now structured response • The structured AIDS response dates – as far back as 1995 - ACP desk created in the Ministry. • ACP Desk -since been the reference point for the coordination & management of HIV/AIDS activities in the Sector and also linking with the Line Ministries Self-Coordinating Entity under the AIDS Partnership coordination arrangement

4. Policy Framework (2) • Sector developed first strategic plan in 2000. This has guided the sector’s HIV/AIDS efforts since – World Bank Support • 2000- MoLG , UAC and stakeholders developed and issued LG HIV/AIDS coordination guidelines • 2006 - HIV/AIDS was made part of the LG Sector Strategic Investment Plan (a 10 year Investment Plan), - aim to ensure that resources required to manage the epidemic in the LGs are mobilized. • Currently, the MoLG Revised HIV/AIDS Sector Strategic Plan’s primary focus is to strengthen coordination mechanisms and to ensure that at all levels, capacity to plan, implement and manage HIV/AIDS interventions is built • This legal framework presents an opportunity to manage HIV/AIDS among other problems facing LGs, but also provides an avenue through which higher LGs or Central Govt could delegate a lower LG to undertake certain activities

5. The LG AIDS Response - Stakeholders • A wide range of players in the LG AIDS Response - Policy Making/ Legal Framework : Ministry of Local Government, other sectors, UAC - Local Government Associations – ULGA, UAAU - LGs themselves – Leading LG response, providing - Wide expanse of Civil Society – mainly involved in Prevention, care and treatment and social support services - The Communities - - Community Groups – community sensitization - People Living With HIV/AIDS – Advocating for the rights of PHAs, providers and beneficiaries of services - Faith- Based Institutions - International NGOs - involved in Prevention, care and treatment and social support services and provision of AIDS Development assistance - The UN and Bi-laterals - AIDS Development assistance • All, led by Ministry of Local Government

6. The LG AIDS Response – Funding Support • Government with Development Partners and Civil Society have over the years supported community responses to HIV/AIDS in various ways, including development of systems and structures that have resulted into improved responses to HIV/AIDS at LG level. • Major funders - USAID - one of the largest bilateral support agencies in the fight against the HIV/AIDS pandemic in Uganda, through such projects as AIM, UPHOLD, NUMAT, STAR E, STAR EC, as well as direct support to institutions. • Other donor agencies : - Irish Aid - Under programmes like “Deepening Mainstreaming of HIV/AIDS in LGs” - the European Union - DFID - DANIDA - The Italian Government through AVSI (The Association of Volunteers in International Service); - the World Bank through projects like STI project, Uganda HIV/AIDS Control Project, and LGDP. • Above donors- funded various components of the HIV/AIDS National strategic Framework at district level and the Local Government sector Strategic Plan, complementing Government efforts.

7. The LG AIDS Response – Progress • So many successes registered in the various aspects of the AIDS response at LG level • However, focus here is on the Coordination and Management aspect of the AIDS response at LG level

8. Coordination and Management of the LG HIV/AIDS Response – Progress (1) Establishment of Coordination structures and Partnerships • AIDS Coordination structures established at District, sub-county level and in the Municipalities in 80 Districts in line with the Partnership principles–UAC, USAID, Irish Aid, World Bank support • CSO District Umbrella bodies established in over 45 districts • PHA District Networks and Forums established in over 70 Districts Annual Dialogue at LG level • Initiation of Annual District AIDS Forums at Local Government level since 2008 and facilitation of their implementation –Irish Aid support

9. Coordination and Management of the LG HIV/AIDS Response – Progress (1) Improving capacity of Office of the AIDS Focal Person Improved capacity of the Local HIV/AIDS Coordination office as a result of provision of computers and accessories to District AIDS Focal offices & Urban Local Coordination offices; as well as provision of monthly communication and transport facilitation towards coordination in the Local Governments –Irish Aid and World Bank support Inter- district and Municipal Learning and Sharing Visits Improving learning and sharing between Local Governments, through inter-district and municipal visits - Irish Aid support

10. Coordination and Management of the LG HIV/AIDS Response – Progress ( 2) Regional Dialogue between LGs and the Centre • Building a closer relationship with Local Governments, as a result of regular interaction with them through such forums as the regional dialogue of the DR SCE - Irish Aid support Documentation of Good HIV/AIDS Coordination Practices • Documentation of good HIV/AIDS Coordination practices to promote wider learning between Local Governments - Irish Aid support Multi-sectoral Planning • Improved multisectoral planning and mainstreaming of HIV/AIDS in Local Governments through development of guide for HIV/AIDS Strategic Planning in Local Governments and facilitating development of district HIV/AIDS Strategic Plans in 58 districts-–Irish Aid and World Bank support

11. Coordination and Management of the LG HIV/AIDS Response – Progress ( 2) Budgeting Resources budgeting and allocation to HIV/AIDS Coordination by sectors in some LGs Some LGs through own initiatives attracted/ lobbied and obtained donor funding – by committed and pro-active Leadership Budget lines introduced LG Mapping Local Governments facilitated to develop own local referral inventories of AIDS services in their localities - UAC and Irish Aid support

12. Coordination and Management of the LG HIV/AIDS Response – Progress ( 3) Monitoring and Evaluation • Standard M&E AIDS Data Collection Tools developed for capturing Data in LGs – UAC & USAID support • M &E HIV/AIDS Indicator Database for LGs developed – UAC & USAID support • Joint Monitoring of Local Governments in Some districts • HIV/AIDS coordination - an assessment area in the LG annual assessment • Some LGs undertaken Lot-Quality Assurance Sampling ( LQAS) studies in their LGs ( these have assisted in obtaining baseline data and also traking progress on achieving targets – World Bank and USAID Support Community Empowerment • A lot of community mobilization, empowerment, capacity building and sensitization between 2000-2006 – with support of the World Bank National Facilitation Team • Establishment of a National HIV/AIDS Facilitation team, charged with mentoring, capacity building, technical facilitation, monitoring and support supervision of Local Governments - Irish Aid support

13. Coordination and Management of the LG HIV/AIDS Response – Challenges (1) HIV/AIDS Coordination and Management AIDS Coordination structures • Limited implementation by the district AIDS Coordination structures of their stipulated functions. Despite the nationwide induction, the structures, and particularly the Political/Policy remain not effectively- blame on the absence of facilitation to perform stipulated roles Interaction between the District AIDS Focal Person and UAC • Limited deliberate interaction between the District AIDS Focal Person and UAC, which officer is “supposedly the link between UAC and the districts as per the district HIV/AIDS Coordination guidelines” undermines their ability to spearhead the AIDS agenda at district level, as majority of them remain with limited capacity and knowledge on critical prevailing and emerging AIDS aspects concerning both the National and district level

14. Coordination and Management of the LG HIV/AIDS Response – Challenges (2) Planning, budgeting & mainstreaming of HIV/AIDS in LGs District Budget allocations and Releases: • Districts budget allocations in most cases are not realized. Funds budgeted for are rarely released for implementation of planned and budget activities. In addition allocations for HIV/AIDS coordination activities are still very limited. Districts still look at HIV/AIDS as “a should-be donor-driven intervention”. District HIV/AIDS Strategic Planning • Lack HIV/AIDS Strategic Plans in esp the new districts. • Expired plans for those based on the last National HIV/AIDS Strategic Framework. - This impacts on effective planning and mainstreaming of HIV/AIDS and reviewing performance in the face of a changed environment. - Creation of new districts - require such critical guiding frameworks to facilitate their own local responses.

15. Coordination and Management of the LG HIV/AIDS Response – Challenges (3) Advocacy for HIV/AIDS in Local Governments District-specific HIV/AIDS advocacy strategies • Lack of district-specific advocacy strategies - hampers leadership ability to promote critical HIV/AIDS services and issues. Mainstreaming of HIV/AIDS in districts’ development activities is also affected. - Partly contributed to by lack of a national advocacy strategy which should have been the reference point and also guide for all the country’s advocacy efforts - Districts too have not been availed the opportunity to have own advocacy strategies to aid even simple advocacy efforts at this level Data Management, Monitoring & Evaluation System District-level data collection format and centralized data management system • Non-implementation of the institutionalized standard data collection format and centralized data management system for HIV/AIDS in the districts - constraining effective data collection, sharing and subsequently poor planning for HIV/AIDS interventions.

16. Coordination and Management of the LG HIV/AIDS Response – Challenges (4) Streamlining and Coordination of the Decentralized Response Capacity of the Central level Decentralized Response institutions • Limited facilitation of the DR SCE to manage the Decentralized Response yet its activities involve frequent interaction with Local Governments in terms of technical support to programme activity implementation, dialogue with Local Governments, capacity building and mentoring, as well as support supervision and monitoring. • Transport, communication facilities, as well as a budget line for the operations of the National HIV/AIDS Facilitation Team Social Infrastructure Development • Weaknesses in social Infrastructure to mobilize communities and undertake actual service provision. Networks of PHAs, Post-Test Clubs, women, men, youth and other groups need to be strengthened, empowered to strengthen their involvement in the AIDS response at community level. Resources Mobilization and Management • Mobilization and Management of HIV/AIDS resources in LGs is largely affected by lack of costed HIV/AIDS strategic plans, the lack of resources mobilization strategies, as well as poor resources tracking system at this level

17. Coordination and Management of the LG HIV/AIDS Response – Lessons Learned (1) • Strong coordination is seen to facilitate active involvement of various categories of stakeholders in the AIDS response at LG Level. • There is evidence of increased leadership involvement especially at sub-county level, following the induction of AIDS Taskforces and Committees at district and sub-county level. PHA involvement has also improved • Involvement of PHAs in the coordination role in LGs enables faster action in addressing PHA needs by district leadership • Districts have embraced the Annual AIDS partnership approach to HIV and AIDS coordination in the districts. It has been reported as the beginning of bringing together all AIDS actors in the LG

18. Coordination and Management of the LG HIV/AIDS Response – Lessons Learned (1) A good number of LGs are allocating an amount of money towards HIV/AIDS Coordination in their budgets, and also mainstreamed HIV/AIDS in some sectors – following issuance mainstreaming guidelines to them, as well as MoFPED directive on a 10%b allocation of funds by districts. The absence of advocacy strategies at district level has resulted into adhoc, piecemeal, and disjointed efforts in responding to HIV/AIDS and this therefore impacts on Local Governments’ attitudes, especially the leadership to the epidemic, many of who still do not yet appreciate HIV/AIDS as a serious development issue. This in return impacts on the mainstreaming, budget allocations, and service delivery at Local Government level-increase in dialogue

19. Coordination and Management of the LG HIV/AIDS Response – Lessons Learned (2) • Mapping of HIV/AIDS interventions by districts facilitates building of resident capacity, and generation of data for reference on service provision, guides planning, monitoring of HIV/AIDS activities, guiding resources allocation and facilitates easier information sharing within the districts. This should be institutionalized so that it can be done regularly by Local Governments. • The involvement of LGs in the management of HIV/AIDS resources and programmes, builds their capacity, interest, and ownership of the response. With their capacities built and interest vested in the response, LGs are in position to take the response forward even when external resources wane. • In light of the large expanse of LGs, the National Technical Facilitation Team has proved a very beneficial approach to providing technical support to LGs. Several activities can be implemented at ago with the use of this team, making it possible to produce many outputs in a short time.

20. Coordination and Management of the LG HIV/AIDS Response – Lessons Learned (3) • In-district interactions can create greater impact, build targeted capacity and also enhance ownership of a problem. This can be seen from such interventions as the Annual District AIDS Forums, which have been embraced by LGs as very innovative and useful fora which provide a unique opportunity for districts to meet as an entity, dialogue, plan and review performance jointly at a limited cost. • LGs currently face a big resources gap, particularly for the management of the AIDS response in their localities as well as mobilization of communities for service delivery and uptake.

21. Coordination and Management of the LG HIV/AIDS Response – Which Way to Go? (1) Strengthening coordination structures and partnerships at all LG levels Facilitating the stipulated HIV/AIDS Coordination functions: A unanimous call for the Central government to provide conditional grants to the DLG for HIV and AIDS Coordination activities, so as to boost government’s watch dog role in the AIDS response • Emphasize the building of capacities and involvement of the Political/policy body as the body responsible for decision making in the district • In all Districts, establish District level Networks of PHAs, CSOs and FBOs • Attention to sub-county and lower levels AIDS Coordination structures to boost the link between the district and the communities • Strength Public-Private Partnerships in delivery of HIV/AIDS Office of the District AIDS Focal Person : • Issue clear and standard ToRs and procedure of appointment of District AIDS Focal Persons, as a gateway to strengthening HIV/AIDS coordination in Local Governments • Strengthen link between the district and urban LGs to facilitate ease of sharing available resources, as well as flow of information in a District LG Urban LG HIV/AIDS Coordination structures also require critical attention. • Provide more support beyond that provided by the AMICAALL programme to ensure a more comprehensive response in these Local Governments

22. Coordination and Management of the LG HIV/AIDS Response – Which Way to Go? ( 2) Monitoring the HIV/AIDS Response in Local Governments: • Emphasize joint monitoring for the public private partnership approach. • Strengthen and establish trust with CSOs and PLHIV organizations to ensure adequate information sharing, joint monitoring and evaluation and harmonization for interventions to avoid duplication and wastage of resources. • Regularly update District, and AIDS service organization directories • District proactively perform its monitoring role of the existing NGOs and their areas of operation and interventions on HIV and AIDS. District Budget allocations and Releases: • Districts need tougher assessment and monitoring to ensure greater allocation and the actual use of funds for the planned HIV/AIDS coordination interventions • Equip all Districts without HIV/AIDS Strategic Plans and support the review of those that have expired to align to the changed situation and the current National HIV/AIDS Strategic plan Advocacy and resources mobilization: • Support Districts to develop own advocacy strategies to boost their ability to lobby, mainstream HIV/AIDS and also resource HIV/AIDS resources

23. Coordination and Management of the LG HIV/AIDS Response – Which Way to Go? ( 3) Collection, Analysis and use of accurate data for planning local HIV/AIDS interventions • Institutionalize data capture, management and sharing in LGs, with central data/information management units established , preferably strengthen the HIV/AIDS Focal Point Office to play this role. • Induct all relevant sectors and District stakeholders on the standard data collection format, and indicators of performance at district level to ease data collection, sharing and reporting • There is need for a sustainable training strategy which will professionalize M&E through involvement of National Institutions of Higher Learning as one of the outcome of the National Capacity development strategy. Role of the DR SCE, MOLG, and Associated Institutions (ULGA, AMICAALL, UNASO, NAFOPHANU, IRCU ) • Strengthen the monitoring and support supervision of LGs, to ensure that planned activities are implemented and in line with set guidelines • More facilitation is required for especially MoLG, UAC, AMICAALL, ULGA, UAAU, UNASO, and NAFOPHANU in terms of transport to effectively monitor Local Government performance. ULGA as the secretariat to the DR SCE should also be equipped well enough to enable in effectively perform its role • The National Technical facilitation team’s method of work requires further streamlining, especially in terms of regular interactions, to share experiences, review performance and capacity building of the team

24. Conclusion • The sustainability of the response to the HIV/AIDS epidemic requires the involvement of Local Governments because they are closer to the local communities where service delivery takes place and, therefore, are best suited to manage HIV prevention, care, social support services, as well as capacity building and monitoring of HIV/AIDS activities. • Need to therefore equip/ build the capacities of institutions at this level, to match the demands at the level • This should be matched with the necessary Policy, technical and monitoring guidance from the National level

25. Conclusion Rallying Points One coordination body-District council One planning framework-District Development Plan linked to NDP One M&E framework- District based Harmonized financing framework

26. District HIV/AIDS Coordination Structures District Level District AIDS Taskforce Chair: District Chairperson Secretary: CAO Membership: max 23; District executive, RDC, Speaker, reps of CSOs, PHAs, FBOs Meets: At-least twice annually District AIDS Committee Chair: CAO Secretary: District AIDS Focal Person Membership: max 23; heads of departments, reps of CSOs, PHAs, FBOs Meets: At-least Quarterly SC AIDS Taskforce Chair: Sub-county Chairperson Secretary: Sub-county chief Membership: max 15; SC executive, speaker, reps of CSOs, PHAs, FBOs Meets: At-least twice annually Sub-county Level SC AIDS Committee Chair: Sub-county Chief Membership: max 15; heads of sub-county departments, reps of CSOs, PHAs, FBOs Meets: At-least twice annually Parish AIDS Taskforce Chair: Parish Chairperson Secretary : Parish Chief Political and administrative arm combined. Membership: max 15; Parish executive, representatives of PDC, CBOs, PHAs, FBOs Meets: At-least twice annually Parish Level Village Level Village AIDS Taskforce Chair: Village Chairperson Membership: max 15; Village executive, representatives of VDC, CSOs, PHAs, FBOs Meets: At-least twice annually

27. Structure of the Uganda AIDS Partnership Uganda AIDS Commission & Secretariat THE HIV/AIDS PARTNERSHIP COMMITTEE Media AIDS PARTNERSHIP FORUM