Impact Reviews Investments in Public Health and Basic Education ,-..-.,- 1992-Present USAID Africa Bureau's Office of Sustainable Development • • ~ I ''""' IMPACT REVIEWS Investments in Public Health and Basic Education: 1992-Present USAID Africa Bureau's Office of Sustainable Development INTRODUCTION A. Background- Impact Assessments Phase One (1992-1998): Since 1992, the Human Resources Development (HRD) Division of the Sustainable Development (SD) Office ofUSAID's Africa Bureau has invested in research, development of tools, and dissemination and advocacy to inform policy and program development in Africa in the areas of public health and basic education. The goal of these efforts has been to inform and influence key actors involved in promoting policy and program changes, including African organizations, governments, USAID missions, and other international donor agencies. AFR/SD/HRD has supported different funding mechanisms to achieve these objectives. The previous SD strategy, from 1992 to 1998, was implemented through the HHRAA (Health and Human Resources Analysis for Africa) project. The SARA (Support for Analysis and Research in Africa) project was asked by AFR/SD to review the impacts of SD activities to provide insights into how those investments influenced policies and programs, identify lessons that could be shared within the Agency, and docun1ent strengths and weaknesses of the activities to guide future planning. A review methodology was developed that included a description of what happened during activity implementation, outcomes (research findings and products), results (impacts) of the activity, lessons learned, and suggested next steps. The methodology is based on a model laid out by Robert W. Porter and Irwin Hicks in Knowledge Utilization and the Process of Policy Formation (January 1995). The n1odel points out that the policy change process is not a simple linear progression (conducting research, sharing results, identifying policy options, choosing an option, and assessing the effectiveness of the selected policy). Instead, the model holds that changes in policy and policy implementation typically occur as a result of "iterative interactions" among activities in three main "streams" of defining the problem, identifying solutions, and obtaining political consensus. The reviews were first called "Impact Assessments." Thirty-nine assessments were completed under SARA I, some of which covered more than one discretely funded activity. Inforn1ation for the reviews was gathered through interviews with staff at SD, Cooperating Agencies, SARA, African partners, and donor partners either in person or through e-mail or telephone exchanges. Existing documentation on the activity was also reviewed. Activities for the original round of assessments were selected to represent the diversity of the SD portfolio: Other criteria used to select the activities for assessment included the size of the investment, the importance of the activity as perceived by USAID task managers, and the extent to which reliable information was available. While not full evaluations, the impact assessments were judged to provide useful and credible conclusions about the processes undertaken through activities and the resulting policy and program impacts. They provided concrete examples to share w.ith stakeholders and other audiences. Some of the impact assessments have been repackaged for different audiences in the fonn of shorter briefs (e.g. the basic education and reproductive health assessments). B. Impact Reviews Phase Two (1998-present): AFR/SD/HRD's current strategic plan, which covers 1998-2003, is organized around key strategic objectives in the areas of: so 18 so 19 so 20 so 21 Basic Education Health Services Reproductive Health HIV/AIDS The HRD strategic plan also encompasses health-related activities in the area of crisis prevention and mitigation that are currently incorporated under SO 22 (selected aspects of which will ultimately be merged into SO 19). Finally, the polio eradication progran1 is supported through a special objective (SPO). AFR/SD/HRD, through the follow-on SARA II project, is continuing to sponsor assessments of activities, now termed "Impact Reviews." The SARA project provides resources to undertake new impact reviews as they are needed to assess particular activities across all areas of the SD/HRD portfolio. Seven impact reviews are currently in production (during the first quarter of FY 2001 ). SO core temns may request assistance through SARA to undertake an impact review of any of their activities. The SARA M&E Advisor will work with the CTO to ensure that all of the SO temns have the opportunity to undertake reviews of their activities. Impact Review Notebook: The thirty-nine impact reviews that were completed under the first SARA project are included in this notebook, which is being distributed to all AFR/SD/HRD technical staff. The contents of the notebook are arranged first' by Strategic Objective area and, within those areas, by Results Packages. The intention is for SARA to distribute a hard copy of each new in1pact review that is cmnpleted under SARA II to all SD/HRD staff to add to their notebooks. That way each staff person will have access to the entire set of activity docun1entation. Comments and questions are welcon1e. Decetnber 2000 II Education Identifying Elements of Policy Formation Main significance and results of activity • Two sets of country case studies (11 case studies total) on education policy formulation produced. • The case studies and analysis of themes identified key elements for effective policy development. • The information generated by the activity built research capacity within ADEA member states and provided substantive information for advocacy. • Ghana, Malawi and Uganda ministries of education have used information generated by the activity to help frame education strategies and interactions with international donor agencies. • The studies and analysis have contributed to debates within the donor community on best approaches to support for education policies and program reforms. , • The research added to the overall collection of information generated by USAID/ AFR/SD on policy development and reform. Dates of activity: Locations: Implementing agencies: Total HHRAA funding: Leveraged funding: 1991-1996 Washington, DC; Paris, France US AID/ AFR/SD; Association for the Development of African Education Education 2 What was the problem or gap being addressed? e The core recommendation of the World Bank's 1988 policy study on education in sub-Saharan Africa was that each country embrace the task of formulating and implementing an internally coherent set of policies in the education and training sector. According to recommendation, effective development of education systems in Africa ultimately depended on the ability of African governments to develop a workable process for formulating coherent education policies and the capacity to translate policy into realistic investment and implementation plans. Donors working in African education are realizing that having a viable national education policy framework is an essential prerequisite for effective donor-government cooperation in education. Officials in the Donors to Education in Africa (which later became the Association for the Development of African Education, ADEA) perceived that key policy makers in some ministries of education in Africa did not know the essentials of effectively formulating policy: issues to consider, stakeholders to include in deliberations, fora and action sessions to convene, and so on. ADEA and its AFRJSD colleagues thought that these individuals would benefit from studying the history of policy formation in their own countries and in other African countries. What was the purpose of the activity? The activity was a part of Strategic Objective 6--the adoption of policies and strategies for increased sustainability, efficiency, and equity of basic education services. More specifically, the • activity fell under IR 6.1 : disseminate and promote knowledge and guidance on policies, strategies, approaches, methods and tools for increased sustainability, efficiency, and equity in the provision of basic education services. The purpose of this activity was to set the stage for assisting African countries in formulating reform policies and programs. More specifically, the research was intended to describe in some detail the process and shape of policy development and thus to provide policy-makers with historical and analytic accounts of how reform policies have been formulated in selected African countries. What were the specific objectives of the activity? • Prepare summaries of key events in five African countries in the evolution of education policies, going back to the colonial era and Independence; • Identify patterns over time of education policy formation in Anglophone and Francophone countries; • Conduct additional, more targeted research and analyze on recent policy formulation process in six African countries; • Engage selected African policy makers in research on current policy formulation processes; • Extract lessons learned from the cases studies; • Education 3 • Use this information to continue policy formation dialogues with African policy makers. What took place during the activity? Research and analysis The initial components of the activity were two studies of policy formulation, both done in collaboration with the Association for Development of Education in Africa (ADEA). AFR/SD published the first study, ADEA the second. The first study conducted resulted in five case studies of policy formation: Botswana, Tanzania, Uganda, Mali, and Senegal. Because resources did not allow for field work, the studies were done by U.S.-based researchers who had enough in-depth experience with education policy formation in the country to write the study without field investigation. Wherever possible, a senior educator from the country wrote the case or worked as a co-author. The cases were published collectively. with analytic chapters on education policy formation in Anglophone Africa and in Francophone Africa. The subsequent study was conducted by ADEA and involved six case studies on the formulation of education policy in Benin. Ghana, Guinea, Mauritius, Mozambique, Uganda. A researcher in each of the six countries conducted the work. An international technical review committee helped shape the research design and conceptual framework for analysis during two workshops in 1995. Dissemination The studies were published by AFRISD and distributed through the document dissemination channels ofUSAID and ADEA's networks, which was composed of a mailing list of5,000 names, including key individuals in all funding agencies and African governments. AFR/ SD staff have also made copies of the documents available at conferences. The ADEA also translated into French and distributed at its 1994 conference in Tours the analytic chapters of the earlier of the two policy formulation documents. Capacity building To produce the second set of case studies, published by ADEA, an education policymaker from each country worked with AFRISD staff to research and write a study. This exercise was intended to help improve the research and writing skills of those policymakers as well as to help enhance the institutional memory of events that had taken place. What were the outcomes of this activity? Two collections of studies (one of five cases, the other of six) were published and distributed with the intent of creating a foundation for dialogue with African policy makers. Education 4 Research findings e The case studies permitted AFRISD and ADEA staff who had organized the case studies to draw some generalizations about the historical policy formulation processes in Africa. In brief, the researchers, through discussions with members of ADEA Working Groups at the 1995 bienniel meeting, proposed six requirements of an effective policy formation process, including: • A good knowledge base • Strong, stable leadership • Consultative and participatory • Realistic priorities and forging compromises between competing goals • Effective funding and government-wide collaboration • Generation of a social learning process and marketing of the national education vision • Continuity and interactive--even at the stage of implementation. Fulfillment of objectives Objectives Met, Not Met, Exceeded Comments/sources Prepare summaries of key Met report education policy events in five African countries Identify patterns in education Met report policy formation Prepare additional six country Met report case studies Engage African pol icymakers in Met interviews research on policy formulation processes Extract lessons learned from the Met report cases studies Use lessons to continue policy Partially met dialogue Products Evans, David R., ed., Education Policy Formation in Africa: A Comparative Study of Five Countries, ARTS Technical Paper No. 12, 1994. • Education 5 Debourou, D., and K. Fobih, P. Kamano, P Selwyn, F. Massingue, K. Amoti Wa Irumba, ADEA, SD, Formulating Education Policy: Lessons and Experiences from sub-Saharan Africa, 1995. What complementary efforts contributed to the results of this activity? Two kinds of complementary efforts have contributed to the results of this activity. First, this activity is intricately related to the broad scope of Education Sector Support (ESS) research, analysis, and technical assistance activities, which touch on many aspects of education reform, and as such, cannot be separated from education policy formation. Second, and more precisely, AFRISD has undertaken two empirical research activities that aim to shed light on the process of policy and reform implementation. The earliest of these (in the final editing process) is a study of how four selected policy mandates in Namibia and in Malawi were actually implemented at the school level. The other (still in the data collection phase) is a study of how broad reform plans have been implemented in Benin, Malawi, Uganda, Guinea, and Ethiopia. It has become a platitude that policy formation and implementation are interrelated; these two implementation studies help to unravel that relationship. What were the results of this activity? As a result of this and complementary activities, the policy formation process has received more attention from ministry policy-makers and the community of donors and lenders. In several countries (Ghana, Malawi, and Uganda), the formulation of education reform policies and programs has been renewed with a better understanding of their essential elements. Understanding the problem Changes in Policies and Programs l_delltifi,cathm of ...,.A.llt .. r,,.ntiv .. Solution.~ h f c . '!be process of policy and progrcUil change involves lhe Per aps the aspects O policy !Ormation which interaction of describing problems. identifying solutions. and have received the most attention and advocacy. clarification are ( 1) the importance of determining how policies will be financed, (2) the need to involve all stakeholders throughout the formation and implementation process, and (3) the critical relationship between policy-makers and donors/lenders. While there might not yet be agreement on solutions to problems in these areas, the problems themselves have been uncovered and, in some cases, better defined. Identification of alternative solutions In regard to relationships between policy-makers and donors/lenders, two viewpoints are emerging. At a recent meeting in Munich of the International Working Group on Education (IWGE), donors and lenders debated a key issue in how to best offer support to the education sector. On the one hand, the European Union has issued guidelines and a code of conduct for donors and lenders, urging them to work together in supporti:.g national plans by offering Education 6 budgetary support for agreed-upon sector-wide policies. On the other hand, the World Bank is • backing off from such an approach to sector support, arguing that comprehensive and coordinated sector support is far too ambitious for lots of countries in Afric~ which do not have a credible sector policy that can be supported. The two sets of case studies produced by ADEA and USAID have informed these discussions, because they help clarify what constitutes a viable sector plan. Advocacy Many of the issues of policy formulation and donor-ministry relations are far from resolution. On the key issue of whether donors should cooperate in urging governments to adopt sector-wide policies, AFRISD and ADEA staff haye used the two studies on policy formulation to advocate sector-wide budgetary support. Such advocacy took place when the draft of the second ADEA report was discussed at Working Groups at the biennial meeting in 1995. Also, as we just discussed. the issue arose again at the July 1998 Munich conference. Changes in policies or programs In general, it is impossible to trace a cause and effect relationship between AFR/SD's support to ADEA' s research, and ADEA' s findings to activities at the level of national ministries of education. It is possible, however, to claim that recent activities in some countries reflect policy- • makers' awareness of the issues raised in the research. Thus, the ministries of education in Ghana, Uganda, and Malawi have entered into extensive negotiations with funding agencies and, to some extent, communities, in reformulating education reform plans. In Ghana, the minister of education had moved by 1997 from a series of bilateral relationships with each donor and funding agency to one in which he negotiated with donors and lenders as a group and in which he saw himself as taking the lead in coordinating that group. In Uganda, the ministry agreed in 1997 to work with a technical working group put together by donors (but consisting largely of ministry staff) to draft a new strategic plan for the education sector. Previously the ministry had negotiated one on one with donors and lenders for circumscribed programs and projects. In Malawi, the ministry had agreed by 1998 to work with a group of donors to prepare a policy framework and a sector investment program that reflected the lessons of ADEA's research on conditions needed for policy formation. Capacity building The analytic activity helped build the capacity of organizations to formulate policy only to the extent that policy-makers learned something from reading and discussing the case studies. In a more indirect manner, the researchers selected to conduct the studies, each have played important roles in the education sectors of their own countries. Presumably, they will continue to have an active voice in policy formation; thus, the lessons learned from the research will be articulated by these individuals as well as (or instead of) Westerners. :. Education 7 What lessons have we learned from this activity? A knowledge and understanding of how policies have been developed historically in a particular country or region can clarify for policy makers, advocates and donors key features of national processes. Thus, case studies are a useful first step in understanding national policy making processes; additional discussion and application of the findings with advocacy groups and other policy-oriented groups can expand the usefulness of the research. The process of collaborative research and writing (African researchers and USAID researchers) also reaffirmed the capacity￾building benefits of such collaboration. What are the next steps to capitalize on the activity? The information generated in this and the complementary activities on policy development and reform processes is very valuable for a wider audience than has been the case to date. Along with information and experiences gained on policy development in the public health sectors of AFRISD and through the SARA Project, hands-on manuals and short summaries are options for consolidating the information. Resources consulted Documents Evans, David R., ed., Education Policy Formation in Africa: A Comparative Study of Five Countries, ARTS Technical Paper No. 12, 1994. Debourou, D., and K. Fobih, P. Kamano, P Selwyn, F. Massingue, K. Amoti Wa !rumba, ADEA, SD, Formulating Education Policy: Lessons and Experiences from sub-Saharan Africa, 1995. Interviews Ash Hartwell, Senior Researcher, Center for International Research Prepared for SARA by Jeanne Moulton Latest Revision, March 2, 1 999 Research and Analysis • Case studies on education policy formulation prepared for I I African countries. review of policy What Dissemination •· Two reports pub I ished and distributed by AFRISD and ADEA Identifying Elements of Policy Formation happened Advocacy Capacity Building • ADEA researchers and select policy makers involved in policy case study research and analysis. TA and Other Activities What changed • International Understanding the problem advisory group • Issues of policy financing, provided input to implementation and research design and donor/government relations all analysis. clarified with the information generated by this activity. process. . : . ies informed the debate . ... . '• . .. . . ~ ~- . • e e Co • Related research on education policy formulation conducted by AFRISD Advocacy • AFRISD and ADEA used information from activity to advocate sector-wide budgetary \ support for education refonn. Changes in policies and programs • In Ghana, Malawi and Uganda governments have used lessons of ADEA 's research to help shape the conditions and strategies for policy fonnation. Capacity building • Researchers who conducted the studies have played important roles in the education sectors of their own countries. e I Education Promoting Reform in Basic Education Main results and significance of activity • An Africa Bureau strategy and framework for action were developed to guide USAID Mission support for improvements in primary school education. • The strategy and framework emerged from initial research and analysis, derived from case studies from 12 African countries focusing on USAID experiences with leveraging country policy refonns. • Extensive documentation on education policy refonn experiences was developed and disseminated to USAID missions through a variety of channels. • The activity provided an analytical structure for other AFR/SD activities which focused on elements of education refonn, including improving education opportunities for girls, community involvement in education refonn, and decentralization. • Africa Bureau and USAID strategy to education reform adopted as a result of the research and analysis. • USAID missions in Namibia, Benin, Mali, and Malawi revised their education support based on evidence. • Evidence generated by USAID/AFR Bureau influenced strategies ofDfiD, World Bank and CIDA. Dates of activity: Locations: Implementing agencies: Total HHRAA funding: Leveraged funding: 1992 to present Washington, DC; sub-Saharan Africa AFRISD c. $2 million n/a Education 2 What was the problem or gap being addressed? The achievement of universal primary education has been a high priority for African nations since the era of Independence in the 1960s. Few countries, however, have reached this goal. In many countries, enrollment grew steadily during the 1960s and 1970s, but with the severe slump in the global economy, a consequent sharp decline in revenues of African governments, and continuing high rates of growth in population during the 1980s, enrollment rates declined during that decade. Primary school systems were inefficient, and, in many schools, the quality of instruction deteriorated. In the late 1980s As researchers and economists identified important linkages between educational attainment and improvements in family health, namely, that women with some years of education are more likely than women with no education to practice family planning and to provide appropriate care for their children's health and nutrition. Several constraints existed for acting on this infonnation. Governments and the international funding agencies that assisted them faced fonnidable challenges in providing enough classrooms, teachers, textbooks for growing numbers of children and in managing the huge bureaucratic procedures entailed in primary schooling. The second-level problem was to discover and devise strategies that governments could use to tackle the interrelated problems of inadequate access, poor quality, inefficiency, poor management, and irrelevance of primary schooling. The third-level problem-and that which this activity addresses directly-is the need for USAID education officers to devise programs and strategies that would stimulate and support major policy reforms within African ministries of education. The U.S. Congress's Development for Africa mandate and budget allocation in the late 1980s and 1990s obliged USAID to make large grants to African governments. The agency determined that the best way to administer these grants was to provide general budgetary support in accordance with conditionalities that governments must meet--otherwise known as non-project assistance. Education officers, then, were compelled to engage in the policy-making process of these governments, and this required them to understand policy options and strategies. USAID Missions needed help from AFR/SD in answering questions about how to support a reform: What is essential to reform primary education systems? Where have ministries of education experienced success? Where have obstacles seemed intractable? How can governments best use the assistance of international funding agencies? What was the purpose of the activity? The activity began well before the Results for Planning framework, but it eventually was conducted within the context of Strategic Objective 6 (Adoption of policies and strategies for increased sustainability, efficiency, and equity of basic education services). It sought to partially • • fulfill IR6.1.1-Education sector reform support and policy formation. • Education 3 The broad purpose of the set of activities called Education Sector Support (ESS) has been to assist USAID missions, other international organizations, and non-governmental organizations as they help governments develop strategies to improve primary education. Included in this purpose was assistance to missions in how to deal with policy approaches advocated by US AID. Activities, including the publication of guidance and findings from reviews of programs, workshops dedicated to this topic, and workshop and conference panels, stemmed from the technical assistance that AFR/SD staff provided to missions. The targets that the AFR/SD staff set in its 1995 analytic agenda were to help US AID missions: • develop national programs of educational reform • improve instructional systems encourage the participation of stakeholders in reform • improve management of reform • improve the equitable distribution of goods and services • increase availability and accessibility of school places. What were the specific objectives of the activity? The specific objectives of this set of activities have been to • conduct research and analytic activities that would help USAID and other education specialists improve their own programs; • provide written guidance to missions on education policy reform, including promoting shared language, values, and goals among AFR/SD and its partners; • help mission staff and their ministry colleagues share information and experience with each other and with AFR/SD staff; • share information about ESS with other donor and lender agencies, academic institutions, and NGOs engaged in basic education reform. What took place during the activity? The activity has had a broad scope. It also has a broad range of tasks and events, through which these topics have been researched, disseminated, and, in some instances, advocated. Thus, the following categories of tasks and events show some overlap. Research and analysis The AFR/SD staff and consultants conducted research on and analyses of various aspects of primary education reform, particularly on trends, problems, and solutions in countries where USAID has had education programs (Ethiopia, Uganda, Malawi, Mali, Benin, Guinea, Ghana, Namibia, Swaziland, Lesotho, Botswana, and South Africa). The research has included analysis of the experience of missions and ministries with formulating and implementing basic education · Education 4 refonn policies. At the heart of the AFR/SD staff's interest in primary education reform was its analyses of the use of non-project assistance (NP A) as an instrument for encouraging governments to spend more of their budgets on primary education. NP A is a budgetary support component of the mission's education program. Money is disbursed to governments in tranches against mutually established conditions reflecting the implementation of key policy, institutional, and budgetary reforms. NPA is an essential component ofthe ESS approach. USAID gave NPA to eight governments (Benin, Ethiopia, Ghana, Guinea, Malawi, Mali, Namibia, Uganda). The AFR/SD staff studied the effects of this policy instrument in each of these eight countries. In 1996, the staff published a preliminary comparative analysis of the impact ofNPA, delineating both its successful impact and unresolved or anticipated problems. A single-country analysis of the impact of non-project assistance, in Uganda, was published in Aprill995 as part of the mid-term assessment of Uganda's SUPER project. This was a thorough analysis of the Uganda case to date. AFR/SD staff began work in late 1993 on the production of a 160-page synthesis report of USAID's five years of experience (1988-1993) in supporting basic education programs in Africa. The report was intended to share information and experience among USAID education officers and with other donors. It helped AFRISD staff synthesize what they had learned and written in • various program design, evaluation, and other docwnents addressing activities of missions. The •.. analytical component of the report looks at the process of reforming an educational system, which is based on a review of the literature as well as the experience of the authors and their colleagues. In particular, the report looks at the mixed success of the non-project assistance (NPA) strategy in promoting educational reforms. The report was published in September 1995. Dissemination Through its contractors,.the AFR/SD staff has used three main channels to provide information and technical support to USAID education officers in Africa and the officials they work with in ministries of education. These channels are printed reports, the USAID Africa Bureau web site, and regional conferences. The staff have also participated in other conferences on international education to disseminate research findings and its positions on various issues. AFR/SD has also held three conferences on basic education for USAID education officers and their African colleagues. The first was held in Togo in 1990 (prior to the startup of the HHRAA project). This Togo meeting preceded any formal program of the Africa bureau to meet the tenns of the funds earmarked by Congress for education in Africa, and the excitement and determination generated by that conference influenced events that followed. The second conference, which was limited to USAID officers, took place in Kadom~ Zimbabwe, in January 1994. The main purpose of the conference was to share a broad framework for USAID's support to basic education with education officers posted in missions. The third conference, which also • included individuals invited from ministries of education served by USAID, took place in Brits, · Education S South Africa, in July 1996. The conference proceedings were documented and sent to participants. AFR/SD staff have also attended other international education professional fora, where they have shared infonnation about the Education Support Sector approach. These have included include the annual conferences of the Comparative and International Education Society (CIES), various meetings of donors sponsored by the World Bank on its Special Programs for Africa (SPA), and other formal and informal meetings at the World Bank, including the annual education fair the Bank holds for its staff and partners and the annual meetings of the African Studies Association. To disseminate information on its programs in a handy format for a wide variety of interested parties, AFR/SD has published two editions ( 1993 and 1996) of an Overview of the basic education programs in Africa. The overview provides important facts about the social and economic context of the program, the Strategic Objective and Results Framework of the program, and achievements to date. A third edition for 1998 is in draft. AFRJSD also published Kids, Schools, and Learning: African Success Stories, a compilation of case studies of basic education reform in Africa (see subsequent section on Advocacy). A number of documents were written as part of program planning but not published for a general audience. These include program design work in Ghana and Malawi and program evaluations in Uganda, Malawi, and Ethiopia. In cooperation with the Economic Development Institute (EDI) of the World Bank, AFR/SD produced two videos on basic education reform in Uganda. One video is for broadcast to a general audience, aimed to inform them of the successes and issues in the reform. This video will be part of the Bank's Global Links television series, with broadcast contracts already signed in over 88 countries, including the United States and many in Africa. The other video, a training video, is for use in advising US AID, World Bank and other program planners of what key components comprised Uganda's reform . What were the outcomes of this activity? Research findings In their capacity both as analysts and as technical assistants, the researchers concluded the following about the effectiveness ofESS: • Accurate assessment of government commitment and capacity to carry out reforms is essential to determining whether the ESS approach is appropriate and how the assistance modality should be structured. • A clear understanding of national objectives and stakeholder consensus on strategy are Education 6 essential elements of successful educational reform. • • Getting the right mix of non-project and projectized assistance must be based on a calculus of government commitment, resource availability, and institutional capacity-too little technical assistance can result in poor reform implementation, while too little non￾project assistance reduces USAID's ability to leverage policy reform. • The mechanisms selected for providing budgetary support-general cash transfers, debt service repayments, cash transfers to special education accounts--have sustainability and management implications that may involve trade-offs. • The principal responsibility for donor coordination should be with the government and the ministry of education; donors should assist governments to develop mechanisms for · donor management. • ESS programs are management intensive, requiring new management skills, the involvement of senior Mission personnel, and clear communication among the numerous players within USAlD. In their preliminary assessment in four countries (Benin, Guinea, Ghana, Malawi) of the effectiveness of NPA in supporting education reforms, the researchers found that • NP A had had the desired effect of increasing education's share of government allocations and expenditures to desired levels, increasing primary education's share of the larger education budget, and increasing non-salary expenditures. • Increased expenditures on non-salary items did not necessarily translate into improved • . programs, because the items purchased may be of dubious pedagogical value, not effective in and of themselves, or not able to reach the classroom. • There were trade-offs in budgetary support: while it forced governments to adjust their own budgetary practices and allocations in order to improve support to education, it left budget transactions less auditable to USAID, thus raising the chance that USAID support did not result in more resources for primary schools. • NP A is premised on the country's macroeconomic growth, which will allow it to pay off debts and budget more to education. Where this premise has been false (Guinea, Mali), the government has faced political difficulties in reallocating money from other sectors, notably, higher education, to primary education. Another problem with NP A was that governments sometimes received and disbursed the funds too late in the school year for use. • Governments have had difficulty moving funds through the system quickly enough to absorb large chunks of NP A. • NP A management requirements have sometimes overloaded the capacity of government officials. In 1997, after several years of experience with the ESS approach-and subsequent to the publication of Basic Education in Africa: USAID 's approach to sustainable reform in the 1990s- -AFRISD staff presented further conclusions about the conditions under which non-project (NPA) and projectized assistance were useful: • Education 7 • NP A has been most useful when the ministry has the capacity and structure to deliver education services (as opposed to a country whose government has collapsed); adequate government management and accounting systems are in place; the government is committed to supporting reforms and prepared to provide adequate public financing; and government and donors agree on perfonnance conditions that reflect the country's education policy framework and strategy. • Projectized assistance has been most useful when it is strategic, that is, aimed to support the provisions of services central to the educational reform; focused on strengthening institutional capacity to create better functioning systems; and supportive, in that it provides for special studies, workshops, and technical assistance not routinely covered by the education budget. Fulfillment of objectives The ESS activity is ongoing in many countries and in many components of programs in each of those countries. It is also an ongoing effort at building partnerships with other international organizations. Thus, objectives will never be fully achieved. Significant progress, however, has been made toward fulfillment of each objective. T a bl e 1 F : u Ifill I ment o fOb. JeC f aves Objective Met, Not Met, Exceeded Comments/Sources Conduct research and analytic Met Strategic Framework activities to improve USAID mtsston programs Provide written guidance to Met On-going missions on education policy reform Facilitate sharing of Met On-going information and experiences between missions and African colleagues Share information about Met On-going education policy reform with other donors Products USAID/ AFR/SDIHRD (July 1995), Setting priorities for research, analysis, and information dissemination on basic education in Africa. Washington, DC: Bureau for Africa, Office of Sustainable Development, Health and Human Resources Analysis in Africa Project. Education 8 DeStefano, Joseph, Ash Hartwell, Karen Tietjen (September 1995), Basic Education in Africa: e USAJD's approach to sustainable reform in the 1990s. Washington, DC: USAID/AFRISD DeStefano, Joseph, and Karen Tietjen, Budgetary Impact of Non-Project Assistance in the Education Sector: A Review of Benin, Ghana, Guinea, and Malawi, 1996. Tietjen, Karen, and Ash Hartwell, USAID's Strategic Framework for Basic Education in Africa /Cadre Strategique deL 'USAID pour /'Education de Base en Afrique (Resume), 1997. Moulton, Jeanne, Report on the Basic Education Workshop, Brits, South Africa, 1996, March 1997. Moulton, Jeanne, Report on the Workshop on Basic Education Programs, Kadoma, Zimbabwe, 1994, 1994. Christensen, Philip, Aly Badra Doukoure, Peter Laugham, Talaat Moreau, Jeanne Moulton, Joshua Muskin, Michel Welmond, Kids, Schools, and Learning: African Success Stories, 1997. Gilmore, Julianne, Phoenix Rising: Success Stories about Basic Education Reform in Sub￾Saharan Africa/Le Phenix Renaissant:l'Education en Afrique, 1997. What complementary efforts have contributed to the results of this activity? The analytical activities described above have been complemented by technical assistance from AFR/SD. Analysis and technical assistance are intertwined, with each supporting the other. Often, the theory underlying the analytical work is influenced by the practical experience of technical assistance. And, more to the point of impact, technical assistance is guided by the analytical work, thus conveying the "message" of analyses to ministries of education and USAID education offices. Between 1993 and 1998, the analytical work described above had a particularly notable impact on the USAID offices and ministries of education in three countries: Ghana, Malawi, and Uganda. AFR/SD staff and consultants who participated in the designs and evaluations of these education programs were, during the same years, participating in analytic activities. Finally, most other analytic activities of AFR/SD have been complementary to the ESS activities. As a systemic and comprehensive approach to education reform, ESS embraces research and · analysis in policy formation, girls' education, cross-sectoral activities, decentralization, community involvement, education planning, and the work of the African education networks the ADEA and ERNW ACA. • • What were the results of this activity? The activity in Education Sector Support has had an impact in several arenas: • National programs in primary education in Africa • The international donor, lender, and NGO community in education • U.S. policy on assistance to education. Understanding the problem Understanding the Problem Education 9 ~dC11tifilt:atiC)D of -'A.llt.ortruati"P Solutions The process of policy and program change involves the interaction of describing problems, identifying solutions, and advocacy. Following several decades ofUSAID assistance to education in which projectized assistance was the only available modality, the Africa Bureau introduced the new modality of non-project assistance in the late 1980s. AFR/SD's research and analytic work has defined the issues that arise with NPA and has presented evidence from missions' experience. AFR/SD research and analysis has also raised issues of support to primary education reform that go beyond NPA. Among the issues where options have been reviewed are: balance of project and non-project assistance, decentralization of financing and administration of basic education, cross￾sectoral cooperation in education (health and environment}, strengthening the demand for education as well as enlarging the supply , increasing stakeholder participation in policy-making, engaging communities in school accountability, and improving the balance between better quality and increased access (most of these issues are discussed in detail in other impact assessments). Identification of alternative solutions The research and analysis carried out within these sets of activities have provided valuable information on trade-offs to be expected in promoting policy reform and identified factors that need to be considered in designing policies and programs. Advocacy As suggested in the discussion above on research and analysis activities, the documents produced as analytic studies go beyond the articulation of findings. They also strongly advocate an approach to education reform. This approach is presented in some detail in Basic Education in Africa: USA/D's Approach to Sustainable Reform in the 1 990s, published in 1995. After 1995, the strategy continued to evolve, and AFR/SD continued to work on advocating the strategy. It is presented again in a more succinct and coherent document published in 1997, USAID's Strategic Framework for Basic Education in Africa. In preparing this framework, Education 1 0 AFR/SD staff and a consultant conducted interviews with more than 80 individuals, both within • USAID and in the broader education and foreign assistance community. Those interviewed included USAID education officers, Africa bureau officials, education and other officials at the World Bank, UN organizations, NGO staff, and consultants whom the interviewers considered knowledgeable about and/or influential in AFR/SD's approach to basic education (five of the individuals representing donor organizations were Africans). Those interviewed were asked their opinions of the ESS approach to education reform. The findings from these interviews fed into the first draft of the framework. Thus, the process of producing the framework was in itself an advocacy action, engaging a broad group of people in the process of formulating strategy. The framework is intended as the office's centerpiece in advocating its approach to reform. AFR/SD has advocated the ESS approach to a broader audience, including those who influence U.S. foreign policy and those interested in USAID's activities in Africa. Since this audience is not necessarily well versed in the need for basic education in Africa, messages aimed toward the audience advocate basic education in general, as well as the ESS approach specifically. The first of these documents is Kids, Schools, and Learning: African Success Stories, an account of basic education reforms in six countries in which USAID has provided assistance. The second is a condensed version of the first, entitled Phoenix Rising: Success Stories about Basic Education Reform in Sub-Saharan Africa. Finally, AFRJSD has advocated its ESS approach to education reform in the process of reviewing annual reports from education officers in USAID missions (the "R4" reports). In this process, • staff members use the ESS framework, implicitly or explicitly, to respond to missions about the report and to assess the mission's programs, as they are described in the reports. Changes in policies or programs AFRJSD' s own approach has been influenced by the evolution of research and findings in this area. In particular, while the agency began the decade with heavy reliance on non-project assistance (NPA), it has learned the limitations of this policy instrument. In Namibia, Benin, Mali, and Malawi, where AFRJSD staff and mission education officers determined that the conditions necessary for NP A (see research findings, above) were not in place, NP A has been terminated (or suspended, in the case of Malawi). In the arena of U.S policy on assistance to education, AFR/SD has been able to advocate successfully to policy-makers and those who influence them that U.S. support to basic education in Africa is worthwhile and should be continued. The Congressional earmark for education in Africa rose from approximately $56 to $76 million between 1996 and 1997. The agency itself added a new goal of basic education and training. ESS has been used by other agencies, including CIDA, World Bank, and DflD, to formulate their own policies and strategies. Capacity building • Education 11 AFRJSD helps build the capacity of USAID education offices to plan, implement, and evaluate their programs by providing technical assistance directly to the missions. As described above, the impact of this assistance cannot be separated from the impact of the research and analysis that guides it. What lessons have we learned from this activity? The activity has demonstrated the need for a conceptual framework to guide sector support work. ESS works as a framework because it is not a lockstep linear approach but a process of interdependent activities that are mutually reinforcing. The process of developing ESS has highlighted the importance of a Washington-field relationship in developing USAID policies and strategies. Another lesson is the importance of extensive planning and involvement of participants in planning for workshops. What are the next steps to capitalize on the activity? With the SD strategic developed, the focus should now move towards applying and operationalizing ESS within country programs. AFR/SD needs to become more cognizant of the challenges to ESS inherent in USAID contracting. Also, AFR/SD must push for clarification by USAID on the review and approval process for revising Results Frameworks, Strategic Objectives, and Reporting processes (R4s). Until this is clear, it is difficult for AFRJSD to help missions use the Strategic Framework (of ESS) in framing their objectives, indicators, and reports. In addition, AFR/SD needs to promote the ESS approach through various regional organizations, such as the ADEA and its Working Groups, and to enlist USAID bilateral programs to help in this regard. Resources consulted Documents USAID/ AFR/SD/HRD, Setting priorities for research. analysis, and information dissemination on basic education in Africa. Washington, DC, 1995. DeStefano, Joseph, Ash Hartwell, Karen Tietjen, Basic Education in Africa: USAID 's approach to sustainable reform in the 1990s. Washington, DC, 1995. TvT Associates, Midterm assessment of the Health and Human Resources Analysis for Africa Project (HHRAA), Washington, DC, 1995. Tietjen, Karen, and Ash Hartwell, USA/D's Strategic Framework for Basic Education in Africa /Cadre Strategique deL 'USAID pour /'Education de Base en Afrique (Resume), 1997. Interviews Ash Hartwell Joe DeStefano Prepared for SARA by Jeanne Moulton Latest revision: 2/24/99 Education 12 • • • Promoting Refi n Basic Education Research and Analysis What Dissemination • Research • An extensive conducted in 12 publications list African countries distributed through on experiences AFRISD channels. with education • Three conferences policy refonn held in Africa to • Effectiveness of discuss policy non-project refonn with assistance (NPA) USAID mission reviewed and staff and African happened Advocacy • Publications and conferences served as mechanisms to advocate for education policy reform per AFRISD approach . Capacity Building • USAID missions staff and African MoE staff exposed to policy reform analysis and received infom1al training in promoting reforms. TA and Other Activities • Extensive T A by AFRISD staff and consultants, to miss ions and governments, to support pol icy reform. analyzed. MoE staff. . . . . :· . :o:r interviews \~ith: 0 , •• :o· professional . ... , ~; . o• ... 1' 0 . 0 • o! · · · USAID 'o taff 0 ~o ·. :,· meetings by · . 0 .,: 0 ; ! • o,. 0 • : • . . s 0 • ,o h~ .' · · tr'b t. d. t ;~ • •• • ' AFRJSD staff and ·. ' l ·: con a u e o. 0 , : What changed Understanding the problem • Research and analysis defined the issues related to policy reform. Alternative solutions • AFRISD developed a focused, research-based strategy for promoting education policy refonn, replacing approaches whose impact were not well understood . • • .:•, 0 • • • • • researchers. . 0 o .' ; • 0 • · · drafts of~ strategac · Complementary Advocacy regularly occurred, · ~ ·& roacli· :~: ·· · . . · · 0 Activities o, • fonnally and informally, with published as Basic miss ions and governments. Education in ' Africa. . . Policy and program changes b1lateral donors m methods to promote education reform. • Africa Bureau and USAID strategy to education refonn adopted. • USAID missions in Namibia, Benin, Mali, and Malawi revised their education support based on evidence. • Evidence generated by USAID/AFR Bureau influenced strategies .of Dfl D, World Bank and CIDA. Education Developing an Approach to Constituency-Building for Policy Reform: Education Reform Support Main significance and results of activity • The published findings offer one of the most complete evidence-based statements for effective policy development and advocacy, for use by senior ministry of education officers and USAID and other donor agency staff. • The Education Reform Support (ERS) activity has helped to define the complex set of actions needed to formulate and implement education policy. • 1brough workshops, staff of two regional networks--ERNW ACA and ERNESA--have been exposed to the ERS approach of policy development. • During technical assistance visits, the approach to policy development has been informally introduced in Ethiopia, Ghana, Guinea, and South Africa. Dates of activity: Locations: Implementing agencies: Total HHRAA funding: Leveraged funding: 1995-1997 Washington, DC; Raleigh-Durham, NC US AID/ AFR/SD; Research Triangle Institute Approximately $350,000 Approximately $100,000 from ABEL to disseminate information Education 2 What was the problem or gap being addressed? • Through studying the process of policy formulation, researchers, policy makers, and other education professionals have learned that effective policy formulation requires the informed deliberation of all stakeholders--those who will influence the implementation of policy and those who will be in other ways affected by policy decisions. However, the strategies and methods for facilitating such participation of stakeholders were not well known or available to policy-makers in Africa. What was the purpose of the activity? The activity was a part of Strategic Objective 6--the adoption of policies and strategies for increased sustainability, efficiency, and equity of basic education services. More specifically, the activity fell under IR 6.1: disseminate and promote knowledge and guidance on policies, strategies, approaches, methods and tools for increased sustainability, efficiency, and equity in the provision of basic education services. The purpose of the activity was to create a framework and set of practical tools for engaging high-level stakeholders in a deliberative and informed policy process. The tools were intended to help policy-makers and those who influence them to bring together the individuals who are affected by pending policy decisions and to facilitate a process to solicit and present the •. · information they have that is relevant to the policies being formulated. The approach to policy development outlined through this activity is intended to help those who formulate and implement policies and programs to: • Recognize and counterbalance the political interests that accompany reform; • Build the capacity of diverse actors to participate in the policy process; • Reassert and redefine the role of information in policy making; and • Create networks and coalitions that can sustain the dialogue and learning that are essential to educational development. What were the specific objectives of the activity? The objectives were to: • Publish guidelines and tools for use by policy makers to foster "informed, representative deliberation;" • Disseminate the guidelines to policy makers and to international agencies and groups who work with policy makers; • Provide training in the approach to groups at the national and/or subnationallevel. • Education 3 What took place during the activity? Research and analysis AFR/SD staff and contractors used their knowledge of the literature and their experience with getting stakeholders involved in an informed, deliberative policy-making process to write a six￾volume set of concepts, guidelines, and practical tools for others engaging in this process. The ERS approach to policy formulation and implementation is data-driven, participatory, and transparent. Dissemination The ERS methodology has been distributed through a six volume written report and through the authors' participation in a number of conferences. The written reports have been distributed through AFRISD' s channels. The authors presented workshop sessions for US AID education officers and ministry officials • For USAID education officers and their counterparts in ministries at the July 1996 workshop in Brits, South Africa; • For USAID Human Resource Development staff and related contractors at a July 1997 conference in Washington, DC; • For a joint ERNWACA-ERNESA meeting held in Abidjan in August 1996; • For an ERNESA initiative on policy-research held in Lesotho in November 1997; • For World Bank staff on two occasions; • For ERNW ACA members at an advocacy workshop in 1998; • In consulting with officials in Mali planning the government's new PRODEC education program; • For USAID education officers at a Global Bureau!HCE conference in Bamako in 1998. What were the outcomes of this activity? The activity led to the production of six volumes of a largely theoretical nature, targeted toward officers in donor agencies and ministry of education decision makers. Research findings The analysis of policy development assumes that change results in winners and losers, thereby making policy change a dynamic and very political process. The ERS approach emphasizes the importance of a flexible strategy to guide policy involvement. The analysis derived from a review of prior experiences in education and other sector policy reform. Thus, the findings are based on evidence. Education 4 Fulfillment of objectives • Objectives Met, Not Met, Exceeded Comments/Sources Publish guidelines and tools for Met publications use by policy makers Disseminate the guidelines to Met interviews policy makers and to international agencies Provide training in the approach Not met interviews Products Crouch, Luis, Joseph DeStefano, and F. Henry Healey (February 1997), Education Reform Support, Volumes 1-6. Washington, DC: USAID, Bureau for Africa, Office of Sustainable Development. What complementary efforts contributed to the results of this activity? AFR/SD staff have undertaken two research projects on policy formulation, each involving a • series of case studies (covered in another Impact Assessment). These were related to the ERS activity, which is also about getting stakeholders together to formulate policies. USAID's ABEL project, in the Global Bureau, is offering training in ERS methods to ministries, USAID and contract personnel. This effort is in an early stage, and so far there have been no requests from USAID missions for assistance. Also, the ERS activity is closely related to the basic Education Sector Support (ESS) activity described in another Impact Assessment. The ERS activity helps policy makers and others formulate the kinds of policies advocated in the ESS activity. Since AFR/SD staff and former staff have presented the ERS approach and materials at a U.S. Governor's conference attended by educators in Colorado, the materials may be getting some use in this country. What were the results of this activity? Understanding the problem The ERS activity has helped to define the complex set of actions needed to formulate and implement education policy: gathering and using information; including all stakeholders in • policy making; and conducting dialogue that is purposeful, deliberative and productive. Central to the ERS approach is the process of "clearing" space for high-priority issues and problems. Alternative Solutions The approach stresses that there are no short cuts to effecting policy reform, that it is a Education 5 1be process of policy and program change involves Lhe interaction of describing problems, identifying solutions, and advocacy. complex and difficult process. This frank assessment was definitely an alternative to many of the efforts of donors which were based more on using financial leverage to stimulate reforms than strengthening local organizations to engage in long-term advocacy and policy promotion. Advocacy The published volumes are advocacy tools in themselves, arguing for greater attention than has usually been the case to the internal dynamics of policy changes. Changes in policies or programs The authors and their colleagues worked with USAID education programs in Ethiopia, Ghana, Guinea, and South Africa, where they helped program participants adopt and adapt the ERS methodology. • In Ghana, program and ministry staff brought together district education officers, whose experience was used to generate information that became the basis for basic education policy at the national level (in ERS terms, they identified stateholders and brought them into a national-level dialogue). • In Guinea, the statistics and financing units of the ministry were assisted in putting together information in ways to engage a broad spectrum of people in policy issues. • In Ethiopia, program staff developed a planning simulation model at regional and national levels. • In South Africa, the ERS methodology, which was entirely consistent with the government's own approach toward engaging all the people in policy-making, was used to devise an education data management system that reflected and influenced government's affirmative action policies in providing educational opportunities. • In Malawi, AFR/SD staff have used ERS principles to help design the new Sector Investement Plan. No missions, however, have requested workshops in ERS. The concepts have generally been disseminated through technical assistance in the context of mission program development. Education 6 Capacity building • The workshops conducted for ERNW ACA and ERNE SA have helped build the capacity of those organizations. What lessons have we learned from this activity? AFRISD staff have learned from attempts to apply ERS in ministries of education that to effectively use ERS it is necessary to have skilled facilitators and technicians that understand the context in which this kind of product has use. What are the next steps to capitalize on the activity? ERS materials could be made available at the next AFR/SD workshop for USAID education programs. Also. missions need to be told that they can get from one to five free workshops in ERS through the ABEL 2 project. AFR/SD might introduce ERS to the ADEA Working Group on Education Sector Assessment. The Research Triangle Institute, whose staff have done most of the work on the six volumes described herein, have also developed software to help ministries plan large-scale policies and programs. This software needs to be integrated with the six volumes and perhaps used in the .•. __ - production of training modules in ERS. Finally, the concepts and principles of ERS need to be explicitly aligned or reconciled with those of ESS (see separate impact assessment). In doing so, AFR/SD should consider re-packaging the materials for ready access to African audiences. Resources consulted Documents Crouch, Luis, Joseph DeStefano, and F. Henry Healey (February 1997), Education Reform Support, Volumes 1-6. Washington, DC: USAID, Bureau for Africa, Office of Sustainable Development (AFR/SD). Interviews Joe DeStefano Jenny Spratt Jim Hoxeng Developing an Approach to CO:'-_ Jency-Building for Policy Reform: Research and Analysis What Dissemination Education Reform Support happened Advocacy Capacity Building TA and Other Activities What changed • Prior experiences • Published reports • The reports make a • Limited~ some may • Policy change II Understanding the problem in policy change (6 vols) distributed strong case for the have occurred approach reviewed. through AFRISD approach during workshops introduced during 11• Complexity of policy development 1 • Evidence-based and SARA developed. with ERNW ACA T A in Ghana, outlined approach to networks. and ERNESA. Gui Ethiopia promoting • Workshops in and South ; Alternative solutions •• • • t • • · ~t~i~lif~:Jlt:~· ~. ;e~i1f~~ ~~:i·~,::~;;t\}J~?~~~~ }:t, ·... ::w ··;\:?; ·~:U -~ ::~,·\.~~t.tf~~~-:~1 policy approach made at several USAID, World Bank and conference meetings. Comp~ activities • Informally, during TA by AFRISD staff and consultants. Changes in policies and programs • In 4 African countries, the policy approach was used in spt.cific program settings. Capacity building • No USAf D miss ions have requested training in the approach. ~ I Education Improving Equity in Educational Systems Main results and significance of activity • Two thorough analyses of US AID experiences in promoting African government reforms for greater equity for girls in the education system identified constraints facing USAID-supported reform efforts. • Factors that can contribute to greater opportunities for equity in education were identified in the analyses. • The research helped to define the AFR/SD's Education Sector Support (ESS) approach, throwing light on what is essential to education reform and to donors' support for reform. • Although critical of US AID experiences and not well received by missions, the review of US AID project support for reform did produce changes in mission approaches. • AFR/SD's own approach to working with missions was informed and revised, based upon the findings of the two studies. Dates of activity: Locations: Implementing agencies: Total HHRAA funding: Leveraged funding: 1991-1997 Washington, DC; Ghana; Malawi; Brits, South Africa AFRISD; ABEL (Creative Associates) Education 2 What was the problem or gap being addressed? . • From the broad perspective of economic and social development, millions of children are deprived of access to a basic education because they are girls or they live in remote rural areas. Representing a large portion of the population, these children do not learn to read and write, do not learn basic skills that will make them better community members, wives, and mothers. Education specialists have been challenged to devise strategies and interventions that increase the access, persistence, and achievement at the primary school level of under-reached groups: girls and rural children. However, information on inequalities and on past efforts to promote equity has not been readily available to planners. What was the purpose of the activity? The activity was a part of Strategic Objective 6--the adoption of policies and strategies for increased sustainability, efficiency, and equity of basic education services. More specifically, the activity fell under IR 6.1: disseminate and promote knowledge and guidance on policies, strategies, approaches, methods and tools for increased sustainability, efficiency, and equity in the provision of basic education services. The purpose of the activity was to highlight strategies-drawn from USAID experiences--that help improve the equity of educational opportunities between girls and boys and between rural • . . and urban children. What were the specific objectives of the activity? • Study and report on multi-country experiences of education equity reform at primary school levels which had been supported by USAID in order to identify outcomes and impacts of those interventions. • Study the effectiveness of USAID non-project assistance as a means to influence the design and implemen~tion of reforms to improve girls' participation in schooling. What took place during the activity? Research and analysis Two studies were undertaken within the context of this activity. Both studies looked at prior experiences by USAID to influence equity considerations through both specific projects and non￾project aid designed to influence policy change. The first study, undertaken in 1995, used ethnographic interview methods to gather information in Malawi, Ghana, and Namibia. The study occurred during a period of education reforms in each country and sought to document and explain the impact (or lack thereof) of the reforms on equity issues. Also in each country, USAID sought to inform and influence the reforms and that aspect of the process was a • Education 3 component of the review. The second study occurred in 1997 and involved a desk review of relevant data from USAID programs as well as some field research. It sought to determine some of the factors contributing to greater opportunities for girls, or constraints to those opportunities, in education projects sponsored with USAID NP A funding. Dissemination The two research reports were published and distributed through AFR/SD' s channels. The Namibia portion of the multi-country study was not published because it contained sensitive material. ABIC records from Spring 1997 show that during that season, a request for the Tietjen report came from Togo. Findings from both studies were presented a several international conferences. What were the outcomes of this activity? Research findings The findings of the studies varied in their scope. One looked at all the equity programs for girls sponsored by USAID in Africa. The other reported on USAID programs in two countries. The latter study looked at urban/rural inequities as well as gender inequities, and found only minimal and unsuccessful efforts to improve urban/rural inequities. USAID programs in Africa - Problems with non-project assistance (NPA) have included an insufficient amount of donor guidance in meeting conditions, imprecise language on what is expected, inflexible disbursement deadlines, and acceptance of unfulfilled or inadequately met conditions. In addition to recognizing these problems, AFR/SD and missions learned: (i) policy and program formulation are better set as NP A conditions than designed as donor projects, because this encourages the ministry to elevate the programs to some importance and increase active ministerial participation; (ii) there is no single or universal policy lever to improve girls' educational participation; (iii) NP A is often more effective when accompanied by projectized support. Projectized assistance has also fallen prey to weaknesses in conceptualization and implementation. These include inadequate design, evaluation, and analysis of research to determine policy options select interventions, and develop strategies; inadequate dissemination and discussion of research findings; lack of synchronization of gender activities with other program interventions; segregation of girls' activities from other operations; sacrificing ministry participation so that mission and contract officials can meet deadlines and contractual obligations; and undervaluing the role of technical assistance to girls' activities in relation to other interventions. Education 4 Overall, it was concluded that girls' education should be addressed within an overall context of • education reform. Equity within specific country settings-- This study reported four variab.les that seemed to influence the effectiveness of equity policies adopted in Ghana and Malawi: the timing of the policy reform in the political context of the country; government's attitude toward donor interventions; the priority given to the policy reform by the government; and the process by which the policy was formulated. In the historical context, the timing of gender policy reforms was better in Malawi than in Ghana Education officials in Ghana were preoccupied with the critical tasks required in rehabilitating a nearly defunct education system and not willing to make extra efforts for special programs for getting more girls into school. In Malawi, USAID benefitted from the opportunity to put gender equity on the policy agenda when drastic political change swept through the country with its first democratic election. In the timing of policy reforms, USAID met with resistence from Ghanaian officials; who had begun to develop a strong sense of their own agenda and a dislike for donor intrusion. They did not see gender equity as high priority. In Malawi, government officials were ready to accept donor initiatives, and during the election of 1993, in the face of popular support for fee waivers for girls, they were happy to take credit for the policy. • The equity intervention supported by USAID in Ghana suffered because ministry officials recognized that US AID itself placed lower priority on equity than on quality and efficiency interventions: the equity intervention was small, limited to a remote geographic region, and did not lend itself to popular support. In contrast, in Malawi, US AID clearly placed high priority on its gender equity interventions, and the policy reform--fee waivers--gave politicians much to sell, nationwide. Neither the new policy in Malawi to allow pregnant girls to attend school nor the limited pilot interventions in Ghana to get more girls and rural children into school were implemented to any significant degree. In neither case were those responsible for implementing the policy at the school level brought into the process of formulating the policy. The pregnancy policy encountered obstacles to implementation at every level of the system, which the force of advocacy measures were too weak to overcome. The pilot programs in Ghana had no enforcement power behind them; USAID's support was conditioned only on the ministry's present a plan for the programs. They were not required to implement them, which would have required major operational measures in many schools. • Education 5 Fulfillment of objectives Objective Met, Not Met, Exceeded Comments/Sources Study and report on experiences Met report of education equity reform at primary school levels which had been supported by USAID Study the effectiveness of Met report USAID non-project assistance on reforms to improve girls' participation in schooling Products Wolf, Joyce M., An Analysis ofUSAID Programs to Improve Equity in Malawi and Ghana's Education Systems, SD Technical Paper 10, September 1995. Washington, DC: SD Publication Series, Office of Sustainable Development, Bureau for Africa. Tietjen, Karen, Educating Girls in Sub-Saharan Africa: USAID 's Approach and Lessons for Donors, Technical Paper No. 54, June 1997. Washington, DC: SD Publication Series, Office of Sustainable Development, Bureau for Africa. What complementary efforts contributed to the results of this activity? AFR/SD has undertaken research and advocacy in other aspects of girls education (the private and social impacts of girls' education, and tactics for improving girls' experience in the classroom--reported in other Impact Assessments). This research on girls education is also complemented by the support AFR/SD has given to the Forum for African Women's Education (FA WE), an NGO that got its start from an ADEA Working Group (see the Impact Assessment on ADEA). In addition, AFR/SD has supported the activities of the USAID Women in Development Office's project, Girls' and Women's Education, which began in 1996. Ronald Ridker' s study of determinants of attainment and achievement, like Tietjen's 1991 literature review, analyze research findings in terms of supply and demand. Tietjen's 1997 study is integrally related to the extensive work on AFR/SD's basic education sector support (ESS) approach. Understanding the problem By analyzing USAID experiences in education reform, it was possible to conclude that, in most instances, such assistance did not contribute significantly to greater equity for girls or rural children in the education systems. Factors that facilitated opportunities for promoting equity were identified. Identification of alternative solutions Education 6 lbe process of policy and program change involves the interaction of describing problems, identifying solutions, and advocacy. The research has contributed to the efforts undertaken to increase understanding of what strategies work for improving girls' participation in school and under what conditions. It has also helped to define the AFR/SD's Education Sector Support (ESS) approach, throwing light on what is essential to education reform and to donors' support for reform. As a result of improving knowledge in these two areas, AFR/SD has continually refined its advice to USAID missions, other donor agencies, NGOs and ministries of education. Non-project assistance and related projectized support have gradually changed their shape, following lessons learned from this • research and practical experience that it reflects. Advocacy It is not known what, if any, advocacy has occurred as a result of the findings generated by this activity. It is known that the findings for the portion of the study in Namibia were considered too sensitive to publish, thereby limiting public advocacy. Changes in policies or programs These studies contributed significantly to incremental changes in USAID's use of non-project assistance as a policy instrument, especially in Ghana and Malawi. In Ghana, USAID dropped the strategy of pilot programs, largely because the field research revealed the difficulty of isolating pilot activities and preventing them from attracting teachers and students from other schools. This made it impossible to compare rigorously the effects of pilot programs in comparison with other schools. AFR/SD found the findings important as it developed and revised its approach to supporting educational reforms. The findings were incorporated into AFR/SD' s Strategic Framework on Education. • Education 7 Capacity building The research was conducted primarily by North Americans and was generated primarily for use by USAID missions and AFRISD. What lessons have we learned from this activity? Both studies highlight the importance of implementation of policies. In particular, the use of NPA to encourage policies of equity is wasted unless these policies are implemented. The field study was not well accepted by the USAID missions in Ghana and Malawi, even though they benefitted from its conclusions. We learned that it is risky to reveal the "dirty laundry" of a country program by widely distributing information about program faults. It might have been better to keep the findings confidential. What are the next steps to capitalize on the activity? As a result of these studies' pointing toward policy implementation as a critical issue, two studies of the implementation process are already well underway. The field study of implementing policies in Malawi and Ghana, which was inspired by the researcher's study on equity, is in final editing. The study of case studies of implementing reform is moving into the data analysis phase. Resources consulted Documents Wolf, Joyce M., An Analysis of USAID Programs to Improve Equity in Malawi and Ghana's Education Systems, SD Technical Paper I 0, Washington, DC, 1995. Tietjen, Karen, Educating Girls in Sub-Saharan Africa: USAID 's Approach and Lessons for Donors, Technical Paper No. 54, Washington, DC, 1997. Interviews Joy Wolf Diane Prouty Research and Analysis What Dissemination Improving Equity in Educational Systems happened Advocacy Capacity Building TA and Other Activities ... What changed • Field studies in • The field study • Limited to I I II Understanding the problem Ghana, Malawi (excluding presentations on and Namibia Namibia portion) findings • Limitations ofUSAID-supported identified and the program programs for promoting equity 1 t~nstraints to ~·:.. !· :~·. reV1ew stu y ~ · -r .:~· ::·,·.. . ·:.. , . identified. t{ ~ ~ ·. d•,rilral··· f'.,, :;.·, ~! ".• ;:• , , ~~. th :.": ~~ · ;.; ,( I : • • 'I • 0 ' '!,: .. :, ~ ':'·~· gtrSB:D . ·. {=··, ;~~ ~~rebO .. :~::···· :·. .. ·· :· ·:·· .. .... . . . . . ;;;· ·: · · .. tY. · · ( .: ::··i'. ·::· ! t-:~ ;··· -- · br h. d :..· : -.~: 3 • · . • · •• • .:- ·. ; • ave solutaons 1denhfied ~~-~l~~}? : "~~ ~· ~~{1- ~~ ~- P~ . ..1~ .· .=.< ;-.'··::;~~ i :~~-:. :. Jg .. -.; t·~j~~:..'·;,::_~~~~~ .. ~' )\-.. .-:< ::. .-(. :~.- · .. _: ;-t ' ~ • • • .. , • • r . ~ .;. . ; ~ • .. • • ! . - . . \ , ., ' •. .- ' •' • l education reform AFRISD and . . ·~· .. :. rff.#) rJ ;~ · , IIAdvocacy programs SARA networks. .. identified lost • Findings II Little or limited advocacy was planned opportunities for presented at two or occurred. promoting equity. international conferences. • • Changes in policies and programs ~ • Helped define AFRISD's approach to supporting educational reforms. • Influenced direction of USAID/Ghana and Malawi education programs. Capacity Building African institutions not closely involved in activity . • . ... . • .. -·" ' . • J. f~ ·. -r · t,.n ....!.. ... • Education Research to Determine How Education Affects Girls' Lives Main results and significance of activity • A review of existing literature on girls education affirmed the close correlation between education and life skills for girls and women. • An ethnographic study in Ghana found that basic knowledge and skills that a women receives in school gives her the ability to move in and out of the village, including trips to clinics and hospitals. and to make better judgements on what health practices are safe and effective. • Non-formal education appears as effective as formal education in preparing girls and women for live skills. Dates of activity: Locations: Implementing agencies: Total HHRAA funding: Leveraged funding: 1996-1998 Washington, DC AFRJSD; ABEL (Creative Associates); SARA (AED) Education 2 What was the problem or gap being addressed? • Extensive survey research that shows correlations between literacy rates for girls and subsequent birth rates, and between literacy rates for girls and rates of sickness and death of their children. Educating girls is widely accepted as a critical link for health outcomes and economic and social development. "Literacy" is always measured in terms of how many years a girl has attended school. Many of these studies make no attempt, however, to explain the correlations. While some studies do look at the variables mediating literacy rates, birth rates, and morbidity/mortality rates, almost all such studies use survey data and establish conclusions using statistical analyses of data gathered through questionnaires. What is missing are studies that use ethnographic methods to magnify the intricate causal connections between a girls' education and her behavior as a wife and mother. What was the purpose of the activity? The activity was a part of Strategic Objective 6--the adoption of policies and strategies for increased sustainability, efficiency, and equity of basic education services. More specifically, the activity fell under IR 6.1: disseminate and promote knowledge and guidance on policies, strategies, approaches, methods and tools for increased sustainability, efficiency, and equity in the provision of basic education services. The purpose of this activity was to examine more closely the mechanisms through which • education affects girls' lives and to publicize the need for a better understanding of these mechanisms. The activity comprised two separate research studies, one of field research and one of a review of the literature. What were the specific objectives of the activity? The objectives of the activity were: • Conduct a review of the literature on the effects of educating girls in non-formal as well as formal (school) settings. • Conduct an ethnographic study in one African locale to identify why and how education affects women's behavior in family planning and health care. • · Disseminate the findings in order to stimulate further research on the mechanisms through which education changes the social and economic behavior of girls and women. What took place during the activity? Research and analysis The literature review focused on girls' education and participation in associations to discover • Education 3 how researchers hypothesize and demonstrate what actually happens during the education process to change girls' behavior. It was assumed that both settings affected social change by empowering women and that non-formal education and participation in associations were important aspects of overall education for girls and women. A theoretical framework for identifying and describing mediating variables was proposed, based upon the literature analysis. The ethnographic study involved three generations of women in an extended Ghanaian family. The research involved local researchers who conducted 150 interviews of family members. Interviewers used anthropologists' techniques as well as those of a structured social survey. Data were coded according to 134 variables and entered into a computer program for quantitative analysis. The report presents findings in both qualitative and quantitative terms. In the course of her work, Wolf developed a methodology for studying girls' education that shifts from quantitative analyses of survey data to quantitative analysis of data obtained through open￾ended interviews. She devised coding techniques that allowed her to move from an interview to statistical analyses of data. These techniques are useful in putting data that can best be obtained through ethnographic methods into formats that are credible among academicians used to working with statistical analyses. Dissemination Both publications were disseminated through AFR/SD channels. What were the outcomes of this activity? Research findings The research added to the increasing body of literature that demonstrates the effects of basic education on how girls think about bearing and raising children. It supports earlier findings that the mediating variables between girls' receiving education and behaving as a wife and mother differ from one community to the next, and that the local cultural context must be understood. The study in Ghana looked at evidence of three hypotheses on which mediating variables are important: age and type of marriage, empowerment, and information and skills. • The age of a girl at marriage was not a significant factor, educated girls tended to become the first wives of their (polygamous) husbands and that they mutually decided with their husbands to marry, rather than permitting an arranged marriage. Both factors seemed to give these women more decision-making authority within the household. • In terms of empowermen4 education seems to give women greater confidence and the necessary skills to act on their own or to negotiate decision-making power in the domains where women have traditional power, such as fertility, care of children, and education of Education 4 children. In contrast, education does not give women more power outside the household, since, in the Dagomba culture of the family studied, women already have a fair amount of autonomy in the larger community. • The basic knowledge and skills, such as reading, writing, and math, that a women receives in school gives her the ability to move in and out of the village, including trips to clinics and hospitals ~ and to make better judgements on what health practices are safe and effective--often choosing those put forward by trained care givers rather than traditional shamans. The other study looked at the evidence that non-formal education and participation in associations has the same empowering effects on girls and women as schooling has been demonstrated to have: • Although there are no large-scale survey data on non-formal education such as those that have been collected on schooling, isolated studies, a few of them quite rigorous, demonstrate that non-formal education deserves closer attention as an empowering process. • More research is needed to define what happens in school to empower girls. Non-formal education and association settings seem to provide the same "modernizing" environments as schools do, thus having the same empowering effects. Fulfillment of objectives Objective Met, Not Met, Exceeded Comments/sources Conduct a literature review of Met report the effects of educating girls Conduct an ethnographic study Met book in one African locale Disseminate the findings Partially met interviews The objective of disseminating the findings in order to encourage further studies, particularly of non-formal education and associations, has not been met. Products Wolf, Joyce, and Martina Odonkor, How Educating a Girl Changes the Woman She Becomes: An lntergenerationa/ Study in Northern Ghana, ABEL Project, ABEL Technical Paper 8, 1998 . • • • Education 5 Moulton, Jeanne, Formal and Nonformal Education and Empowered Behavior: A Review of the Research Literature, SARA Project, 1997. What complementary efforts contributed to the results of this activity? AFRISD has undertaken research and advocacy in other aspects of girls education (strategies for improving support for girls' education, and tactics for improving girls' experience in the classroom-see appropriate Impact Assessments). The research in this activity on girls education is complemented by the support AFR/SD has given to the Forum for African Women's Education (FA WE). an NGO that got its start from an ADEA Working Group (see the Impact Assessment on ADEA). In addition, AFRISD has supported the activities of the USAID Women in Development Office's project, Girls' and Women's Education, which began in 1996. What were the results of this activity? Understanding the problem The research has contributed to our understanding of the effects that basic education has on girls and women. Within this broad area, it has helped to identify what it is about the education process that influences the behavior of girls and women in child bearing and child raising. The research has also highlighted the value of ethnographic studies of how education affects girls. Identification of alternative solutions Changes in Policies and Programs lternotive Solutions lbe process of policy and program change involves the interaction of describing problems, identifying solutions, and advocacy. The research proposes that non-formal education and participation in associations may be an alternative to formal schooling for the purpose of changing girls' and women's behaviors related to child bearing and child raising. The health and population office in USAID/Ghana found Wolfs study useful because of discussions of the uses of traditional medicine. Advocacy Changes in policies or programs Capacity building The outline used by Wolf is being adopted in Ghana by a former minister of basic education. Education 6 What lessons have we learned from this activity? • We have learned that the findings of this research, though interesting and potentially important in designing policies and programs, have not been used by the missions or ministries. The research has not been well disseminated nor its recommendations advocated. We must make more of an effort to involve missions in the research, from design to dissemination. Also, in dissemination, a common vocabulary between researchers and policy and program specialists is needed to convey infonnation. What are the next steps to capitalize on the activity? The next steps would be to repackage the researchers' conclusions and advocate more strongly for programs and/or activities outside the formal system that educate and empower women. A second step would be to pursue further research on the education-related mechanisms that empower women. so that we gain a better understanding of how schooling empowers women and what other activities or environments might do the same. Resources consulted Documents Wolf, Joyce, and Martina Odonkor, How Educating a Girl Changes the Woman She Becomes: An Intergenerational Study in Northern Ghana, ABEL Project, ABEL Technical Paper 8, 1998. Moulton, Jeanne, Formal and Nonformal Education and Empowered Behavior: A Review of the Research Literature, SARA Project, 1997. Interviews Joy Wolf Jeanne Moulton Prepared for SARA by Jeanne Moulton Latest revision: 311 /99 • • How educat tfects girls' lives What happened What Research and Dissemination Advocacy Capacity TA and Other changed I Analysis Building Activities I • Literature review • Reports from both • The studies both Understanding the problem studies published. argued for the Activity helped to identify I conducted of • I benefits of non- aspects ofthe education I formal and non- I formal education formal education. process-eg. teacher behavior-- impacts on girls that influence learning of girls and women. and women. • Ethnographic in Ghana identified study ~ Alternative solutions I' .. · · , :· .. lil\;lUil> UliiL ~~education shown to be · r,:· infonned women· · ' . : ; . -: . ' . . . . :. _;·: and improved : to formal schooling in . h·ealth-seeking g fe skills. • . 1 .L ' ~- ·~ ~·· Co~ Advocacy ac1 v1ties No advocacy planned or knowingly . conducted. ' · Changes in policies and programs • USAID/Ghana found the ethnographic study useful because of discussions of the uses of traditional medicine. • Informed AFR/SD thinking about emphasis on girls education. Capacity Building Minimal, at best, as African institutions not closely involved in activity. Education Improving the Experience of Girls in the Classroom Main results and significance of activity • A complementary set of resources-documentation, strategy, training manual-developed, using evidence-based research of discrimination against African girls in the classroom. • The ethnographic methodology to study classroom interactions and behavior have been validated for some situations. • USAID/W omen in Development office has used the methodology in other projects. • The World Bank adopted the strategy to reduce classroom discrimination developed during this activity to inform its own strategic planning. • The reports have been used in teacher education in the US. Dates of activity: Locations: Implementing agencies: Total HHRAA funding: Leveraged funding: 1996-98 Washington, DC AFR/SD Education 2 What was the problem or gap being addressed? • Within the broad-based efforts to improve girls' participation in school (to enroll more girls and help them complete a primary education), relatively little attention has been given to changing teachers' attitudes and behavior toward girls. There is little empirical research on how African teachers--men and women--treat girl students differently than boy students, although it was widely assumed that such differences worked against the scholastic performance of girls. Nor has there been much guidance for those who would train and assist teachers in changing their behavior. What was the purpose of the activity? The activity was a part of Strategic Objective 6--the adoption of policies and strategies for increased sustainability, efficiency, and equity of basic education services. More specifically, the activity fell under IR 6.1 : disseminate and promote knowledge and guidance on policies, strategies, approaches, methods and tools for increased sustainability, efficiency, and equity in the provision of basic education services. The purpose of the activity was to document how teachers interact with girls in the classroom and to present guidance for teachers to monitor their classroom behavior with the intention of increasing the support for girls. What were the specific objectives of the activity? The specific objectives of the activity were to: • Produce and disseminate a video and a brochure for district-level policy-makers and "gate-keepers" about the discriminatory treatment of girls in the classroom; • Publish and disseminate to school inspectors, researchers, and other officials a portrayal of the problems girls face in the classroom and a strategy for planning instructional activities that would eliminate or reduce these problems. • Publish and disseminate a manual for teachers' use in observing attitudes, expectations, interactions related to girls in the classroom.; • Train educators at the district and school levels in how to minimize discrimination against girls in the classroom. What took place during the activity? The AFR/SD analysts made a videotape of teachers' behavior in the classroom and produced a summary brochure describing the videotape. The analysts then proposed a strategy called GAP, or Gender-based Approach to Planning, for changing how teachers interact with girls. A manual for teachers and teacher trainers was prepared on how to look at interactions in the classroom . • • Education 3 Research and analysis The eight-minute video, A View from the School: Classroom Experience for Girls, was developed from tapes of classroom activities made for other purposes during the course of the Improving Educational Quality (IEQ) project in Uganda, Guatemala, Mali, and Ghana. An African specialist in Participatory Learning and Action (PLA) methods reviewed the tapes and identified factors that affected girls' experiences: the number of girls and boys in each classroom, the number of times teachers called on girls and on boys, the kinds of incidents that signified preferential treatment for boys, and who got positive and negative feedback from the teacher. The analysts used the specialist's report to edit the videotapes, selecting evidence that confirms what the literature says on classroom experience of girls. They also wrote a brochure that summarizes the information in the videotape. Fallowing the videotape, the AFRJSD analyst worked with a consultant to document further how teachers interact with girls in the classroom. They gathered the few ethnographies on teachers, particularly women teachers, in developing countries (the richest source was Africa). They summarized the findings in a paper entitled, Schools are for Girls Too, and developed a strategy (GAP) to help instructional planners avoid or resolve the problems in the classroom that hinder girls' ability to learn. A manual was written for teachers, teacher trainers, and others who want to look at classrooms for the purpose of improving teacher-student interactions, particularly interactions with girls. The manual offers basic guidance in classroom ethnography: how to observe what takes place in a classroom and how to conduct PLA activities that shed light on girls' experience in the classroom. The manual was field tested in Malawi. Dissemination The poor production quality of the video, which was not originally intended for broad circulation, limited its use. Three copies were produced and shared with some of the groups that have requested a viewing. The brochure has been widely disseminated through AFR/SD channels. Schools are for Girls Too was disseminated as an AFRJSD Technical Paper and disseminated through AFRJSD channels. Several U.S. universities are known to have used it as teacher material. The manual, IEQ Project Classroom Observations and Participatory Learning for Action Activities: A View to the Experiences of Girls, is available on demand and is currently being reproduced under another title. AFR/SD staff presented it at the gender workshop of a Comparative and International Education Society meeting in Mexico City in 1997. Education 4 What were the outcomes of this activity? • Research findings The analysts found many documented instances of girls in the classroom who suffer from the teacher's discrimination, conscious or unconscious (negative feedback, failure to recognize, without books, and so on). They also came across other factors that discourage girls from doing well in school (pilot testing of the manual in Malawi revealed that girls get three or four hours a night less sleep than boys). Fulfillment of objectives Objective Met, Not Met, Exceeded Comments/sources Produce and disseminate a. Met video, brochure video and a brochure about the discriminatory treatment of girls in the classroom Publish and disseminate a Met report portrayal of gender discrimination in the classroom and a strategy for planning to eliminate or reduce these problems. Publish and disseminate a Partially met limited dissemination manual for teachers Train educators at the district Not met and school levels to minimize discrimination against girls Products Prouty, Diane, and Haddy Sey, A View from the School: Classroom Experiences for Girls (videotape and accompanying brochure), IEQ Project, 1996, 10 minutes Miske, Shirley, Diane VanBelle-Prouty, Schools are for Girls Too: Creating an Environment of Validation, SD Technical paper 41, 1997. Prouty, Diane, and Haddy Sey, IEQ Project Classroom Observations and Participatory Learning for Action Activities: A View to the Experiences of Girls, June 1997, 65 pp. • • Education 5 What complementary efforts contributed to this activity? AFR/SD supported the publication of another handbook for teachers on girls in the classroom, entitled Beyond Enrollment ( 1996). This one aims to raise awareness of teachers and students of gender issues. What were the results of this activity? Understanding the problem As a result of this activity, more individuals in the international community are paying attention to what goes on in the classroom that affects girls' learning. The broad movement toward improving girls' education now has a new dimension. As a methodology, classroom ethnography is gaining importance. The analysts concluded that changes in Understanding the Problem Changes in Policies and Programs Ide11tincation of -A ,nPrnnnve Solutions 'lbe process of policy and progrdD'l change involves the interaction of describing problems, identifying solutions. and advocacy. teachers' behavior and in school environments that have a positive effect on girls will have a positive effect on boys too, and their proposed strategy addresses such changes. Identification of alternative solutions Advocacy A current USAID/WID project is advocating the use of classroom ethnography to improve teachers' interactions with girls. The advocacy comes through training educators in this methodology. Changes in policies or programs The World Bank used the summary report and strategy document in planning its own strategy for girls' education in Africa. USAID/Women in Development (WID) office is using the manual in a project to train teachers in classroom observation techniques and analysis. It has also been used on another USAID/WID project in India, as well as in some universities. Capacity building Teachers are being trained in classroom observation by USAID/WID contractors (see above). What lessons have we learned from this activity? Education 6 Videotapes that are to be widely disseminated need to be high-quality production. (This lesson • was fed into the production of the ESS videotape on Uganda). Attention to the issues, in this case classroom discrimination against girls, can be substantively enhanced with greater attention to targeted dissemination of materials produced. A dissemination strategy will include a realistic budget, targeted mailings, and follow-up with key individuals. What are the next steps to capitalize on the activity? The materials need broader dissemination, including to USAID missions. Training activities should be organized at the district level to help school officials help teachers reduce discriminatory practices. Resources consulted Documents Miske, Shirley, Diane VanBelle-Prouty, Schools are for Girls Too: Creating an Environment of Validation, SD Technical paper 41, 1997. Interviews Diane Prouty Prepared for SARA by Jeanne Moulton Latest Revision: March 1, 1999 • • Research and Analysis • Video tapes of classroom behavior reviewed and analyzed. • Literature on teacher class behavior toward boys and girls ~ . '.' ·-: ; Improving the Experience of Girls in the Classroom What Dissemination • Video, summary brochure, report, strategy document and training happened Advocacy Capacity Building TA and Other Activities What changed • Teacher training II Understanding the problem manual field tested in Malawi II • Teacher behavior has a strong influence on girls' in the classroom manual to reduce • The ethnographic methodology for classro~m . studying teacher behavior has discrimmallon gained attention and favor. strongly affinned. against girls .~ . ~ , . . .. . .· . ··'. '· L. "ted · ·· · -. ~ ·: ;i · l. ·: ~: • ;. • UDI : • ,d.' , ~ · . , dissemination,' . especially to . :· • A MoEs. nother study on girls advocating the use of classroom Training did not education conducted. ethnography to improve teachers' occur. interactions with girls Changes in policies and programs • World Bank adopted the strategy developed by the activity. • USAID/Women in Development (WID) office is using the manual to train teachers in classroom observation techniques and analysis. Capacity building l ·~ Education Determinants of Educational Achievement and Attainment Main significance and results of the activity • Nine case studies examined factors that influenced school attendance and quality of education. • In several instances, the findings provided evidence that could be used by decision makers in determining budgetary and program priorities. • This activity demonstrated the value of using empirical research on small-scale interventions and on existing survey data to guide policy-formation in basic education. • Careful targeting of subsidies for school fees or supplies is needed to affect attendance or quality. Dates of activity: Locations: Implementing agencies: Total HHRAA funding : Leveraged funding : 1994-1997 Washington, DC, Kenya, Mali, Malawi, Tanzania, Egypt, South Africa Institute for Policy Reform $60,000 (for AFR/SD staff salaries and the December 1996 workshop) Education 2 What was the problem or gap being addressed? • Committed to providing all children with a good-quality basic education yet strapped for the resources to do it, governments in Africa have faced critical choices in investing scarce resources in basic education. Similarly, international fundirig agencies that support these governments want to know how different budgetary allocations within the sector will affect educational and developmental outcomes. This knowledge requires accurate information on cause and effect links within the education system (for example, the links between availability of textbooks on student achievement, of different kinds of training on teachers, of classroom facilities on enrollment). In the 1980s, some institutions, notably the World Bank, began intensive research on these questions, but the variation in context from country to country is vast, and data were far from sufficient to generalize conclusions in Africa. There was (and is) a need for more empirical data on factors that affect the demand and supply of good quality schooling. What was the purpose of the activity? The activity was a part of Strategic Objective 6--the adoption of policies and strategies for increased sustainability. efficiency, and equity of basic education services. More specifically, the activity fell under IR 6.1: disseminate and promote knowledge and guidance on policies, • strategies, approaches, methods and tools for increased sustainability, efficiency, and equity in the provision of basic education services. The purpose of this activity was to provide empirical data about operationally relevant (factors that governments and funders can control) detenninants of school achievement (student learning as measured by tests and other assessment methods) and attainment (the numbers of students achieving different levels of learning). What were the specific objectives of the activity? The objectives of the study were to: • Use existing studies and data sets to analyze demand and supply factors in increasing access to primary education • Generate findings based on empirical quantitative evidence of student achievement and attainment • Present findings in a format useful to policy-makers. What took place during the activity? Research and analysis • Education 3 AFR/SD contracted with the Institute for Policy Reform to manage the development of nine case studies, to publish reports on each study, and to publish a synthesis of findings. Each case study was conducted by a different researcher or research team. In all cases but one, the researchers used data sets acquired for other purposes. Four of the studies based their analysis on national sample surveys (Egypt, South Africa, Tanzania, and Kenya). The other five studies built on evidence from field investigations of specific interventions. These included, in Kenya, two different evaluations of primary education programs operated by non-governmental organizations; in Mali and Malawi, evaluations of community schools, also operated by an NGO; and an assessment of a government program in Tanzania. Dissemination AFR/SD published the results of each of the nine case studies and a synthesis report. The synthesis report was listed in the Office's catalogue of publications and distributed to its mailing list. The individual research reports are listed in the AFR/SD bulletin of publications and are available on request from USAID/CDIE. Finally, in December 1996, AFR/SD sponsored a workshop in Washington, DC, of researchers who reviewed the technical aspects of the research. Except for the synthesis report, none of the research reports have been disseminated by US AID. The Institute for Policy Reform has reproduced and disseminated the reports through its own channels. What were the outcomes of this activity? Research findings The four studies that use existing sample survey data all looked at the broad question of whether socio-economic conditions (influencing demand) or school quality conditions (supply) have a greater effect on student achievement in school and in the workplace. Some of the studies looked more closely at the supply question: what particular factors of school quality affect student achievement? • In Egypt the study focused on why education indicators of enrollment, completion, and test scores had declined since the mid-1980s. The study concluded that most of the change in these variables could be accounted for by "socio-economic and context" variables rather than school-level variables. The deteriorating standards of living for most households forced parents to keep their children out of school and in the labor market more often and to pay fewer expenses associated with schooling. • In South Africa researchers asked what effects school quality have on various educational outcomes. They found that as pupil:teacher ratios improve, so do enrollment rates, persistence rates, test scores, and parents' expenditures on education. In regard to the effects of schooling on opportunities in the labor m:.rket, they found that hourly earnings Education 4 and family income increase with test scores, years of schooling, and household head's • schooling. • In Tanzani~ the researchers concluded that private rates of return to both primary and secondary schooling were low enough to perhaps lower demand for schooling, even if supply were adequate. In particular, while parents can often afford the direct costs of primary (though not secondary) school, they cannot afford the opportunity costs, especially of girls. • In a complex study in Keny~ the research questions sought to identify (1) what were the effects of school costs on a decline in primary enrollment since the early 1990s, (2) the trade-off between investing in more schools and lowering the pupil:teacher ratio, and (3) how these effects vary with levels of income. The researcher found that investing in more schools raises the enrollment rates among poor families, but that improving pupil:teacher ratios lowers the enrollment rate among these same families. The five evaluations of specific interventions asked various questions about the effect of those interventions on student achievement. • In Kenya, a program that offered textbooks and uniforms to randomly chosen primary schools in a rural area had a positive effect on enrollment, attendance, and dropout rates, • but did not affect test scores. • In Malawi and Mali researchers sought to compare cognitive achievement of students in pilot rural community schools with those of students in government schools and to look, among other things at the effects of community participation and at cost-effectiveness. In both countries, children in the community-based schools performed as well or better than children in government schools in core subjects. Repetition and dropout rates were lower, and progression rates were higher in the community-run schools. In Malawi, these results appear attributable to better and more frequent supervision, smaller class size, better use of instructional time, and emphasis on core subjects. • Another study in Kenya looked at a program designed to help teachers use child-centered techniques to develop pupils' cognitive and problem-solving abilities. This was done by providing teacher training in a workshop setting, classroom-based coaching for teachers, and instructional materials. The impact of the program on test scores was mixed-- significant at some grade levels and with the application of some regression analyses. High costs of the program make it doubtful that it can be sustained. • The study in Tanzania assessed a pretest of a Community Education Fund (CEF) that would encourage communities to improve their schools, thus shifting the burden of expense partially from the national government to communities. The pretest took place in four schools. The researcher found that parents' contributions increased substantially • Education 5 in response to the incentive matching grant offered by the fund; teachers, as directed, did develop acceptable plans and kept detailed records of expenses; the scheme generated enthusiasm among teachers and parents. Due to the expense and logistical requirements for monitoring the program, however, the author doubts that it could be implemented on a large scale. The activity manager reported, however, that it was difficult to derive comparisons and contrasts between the studies because of their complexity and special circwnstances surrounding each. Fulfillment of objectives The research objectives were met insofar as each of the case studies was completed, and their findings were synthesized. He was able to discuss findings in terms of two major themes. Although the research reports were published, only the synthesis report was distributed. No steps were taken to advocate action based on findings. The fulfillment of the objectives is summarized in the following table. Fulfillment of objectives Objective Met, Not Met, Exceeded Comments/Sources Analyze demand and supply Met case studies factors in increasing access to primary education Generate findings based on Met published reports quantitative evidence of student achievement Present findings in a format Partially Met only the synthesis report was useful to policy-makers distributed Products Ridker, Ronald G., Determinants of Educational Achievement and Attainment: Findings from Nine Case Studies. Washington, DC: Institute for Policy Reform Project (February 1997), 25 pp., PN-ACA-323. Fergany, Nader, Ilham Farmaz, and Christiane Wiss~ Enrollment in Primary Education and Cognitive Achievement in Egypt, Changes and Determinants. Case, Anne, and Angus Deaton, School Quality and Educational Outcomes in South Africa. Education 6 Mason, Andrew D., and Shahidur R. Khandker, Household Schooling Decisions in Tanzania. • Deolalikar, Anil B., Increasing School Quantity vs. Quality in Kenya: Impact on Children from Low- and High-Income Households. Kremer, Michael, Sylvie Moulin, David Myatt, and Robert Namunyu, Textbooks, Class Size, and Test Scores: Evidence from a Prospective Evaluation in Kenya. Hyde, Karin A.L., Esme C. Kadzamira, Juliet C. Sichinga, Mike P. Chibwana, and Ronald Ridker, An Evaluation of Village Based Schools in Mangochi, Malawi. Muskin, Joshua, An Evaluation of Save the Children 's Community Schools Project in Kolondieba, Mali. Capper, Joanne, An Evaluation of the Aga Khan Foundation's School Improvement Program in Kisumu, Kenya. Sumra, Suleman, An Assessment of the Community Education Fund in Tanzania, Pretest Phase. What complementary efforts have contributed to the results of this activity? The community schools program in Mali was described in detail in a separate report, which is • discussed in the impact assessment of community schools and participation. What were the results of this activity? The research added to an overall understanding of the issues, however, the lack of an advocacy and dissemination strategy limited the application and use of the findings. Understanding the problem This activity demonstrated the value of using empirical research on small-scale interventions and on existing survey data to guide policy-formation in basic education. Taken individually, the case studies did provide additional insights into factors that Understanding the Problem Changes in Policies and Programs The process of policy and program change involves the interaction of describing problems, identifying solutions, and advocacy. influence educational opportunities and educational achievements. Within the specific countries and communities concerned, the information was relevant and, in some cases, could be used by decision makers in program and budget preparation. However, the information was not widely disseminated or used which limited its usefulness in defining education problems and opportunities. • Education 7 Identification of alternative solutions The local specificity of the research findings and limited dissemination of the reports excluded local, regional or national activities to process the information and identify options. The findings from a couple of the studies that the interventions could not be sustained at a larger, non-pilot level, did help narrow the range of choices for improving school attendance and quality. Advocacy No steps were taken to advocate action based on findings. Capacity building Some of the report authors have used the expertise they gained doing the research in further work in development education. Two have worked for the \Vorld Bank. What lessons have we learned from this activity? Although the research produced some interesting results, the studies do not seem to have been designed with clear policy issues in mind. It would be better to invest in studies that are clearly related to pressing issues than to use existing data that is off the issue. In general, the studies of specific interventions appear to be more useful for policy-makers than do the studies of survey data. What are the next steps to capitalize on the activity? The findings from this empirical research would seem to have some value in guiding policy and programming, but the findings need to be related more explicitly to policy issues. One task would be to establish such links, using either a small workshop format or assigning individual analysts. Another task would be to disseminate the research studies to a targeted audience for specific advocacy purposes. In regard to the identification of this initiative, AFR/SD took it on because funds were available for such a project. However, the lack of clarity of purpose led to problems in using the results. Resources consulted Documents Ridker, Ronald G., Determinants of Educational Achievement and Attainment: Findings from Nine Case Studies. Washington, DC: Institute for Policy Reform Project (February 1997}, 25 pp., PN-ACA-323 . Interviews Joe DeStefano Ron Ridker Prepared for SARA by Jeanne Moulton Latest revision: 3/3/99 e e e Determinants of educational achievement and attainment What happened What I Research and Dissemination Advocacy Capacity TA and Other changed I I Analysis Building Activities • 9 case studies • synthesis study • None planned or c~ Understanding the problem I I produced distributed through occurred ) e S llnth~"'i"' C't· ~~h A J:'U/c;:.n m!:lil inn Constraints to school attendance -..~ -o ~roduced list identified by demand and supply • c pun try-specific • summary workshop ~cors, although findings were quite f ndings offered held in ~ cific to countries. useful infonnation Washington, DC . . . 1 LJI Alternative !olutions making ~tary s v Some approaches were determined not Research on to be financially sustainable. community schools Changes in Policie! and Program• produced separately No evidence of changes. - - - - --------- Education Improving the Health of School Children Main results and significance of activity 0 The issues in school health and the range of interventions that have been undertaken have been more clearly defined and categorized. 0 International organizations, including USAID have more effectively advocated for particular program components in particular situations. 0 AFR/SD was instrumental in the creation of the International School Health Initiative, along with the \Vorld Bank and UNICEF. The Initiative has been a mechanism for donor information sharing and advocacy. 0 A growing number ofU.S.-based NGOs have begun to think about introducing school health programs and have created a working group to coordinate activities. 0 AFRJSD has developed a position paper on school health. 0 AFR/SD staff have worked with USAID/Zambia to develop a school health component of the mission's program. Within Zambia, the mission has become the lead agency in multi-donor cooperation on school health. 0 USAID missions in Ethiopi~ Benin, and Jamaica have introduced nutrition components into their education programs. 0 The pharmaceutical company Smith Kline Beecham will donate enough deworming drugs for children in Africa for 20 years. This program will be launched first in three countries, possibly including Uganda and Zambia. . 0 Significiant funds for school health have been leveraged as a result of the activity and AFR/SD close involvement with other major international donors. Dates of activity: Locations: Implementing agencies: Total HHRAA funding: Leveraged funding: 1996-present Washington, DC; Zambia SARA project/AED, Education Development Center Not available, but significant Education 2 What was the problem or gap being addressed? Many children suffer health and nutritional problems and these have a severe impact on their ability to do well in school. Because children grow slowly and languish, they enter primary school at a late age, repeat levels, and either finish school at late age or drop-out before finishing. When their physical stamina and mental alertness suffer, children pay less attention in class and perform badly. Those from poorer environments have greater nutritional deficiencies and thus less equitable opponunities to perform well in school. Schooling becomes much more costly to families and to the government when unhealthy children repeat grades and take longer to complete school. What was the purpose of the activity? The activity was a part of Strategic Objective 6--the adoption of policies and strategies for increased sustainability, efficiency, and equity of basic education services. More specifically, the activity fell under IR 6.1: disseminate and promote knowledge and guidance on policies, strategies, approaches, methods and tools for increased sustainability, efficiency, and equity in the provision of basic education services. The purpose of the activity has been to increase USAID's presence in the dialogue and actions of • the international community (UN organizations, bilateral donors, and NGOs) and to advocate for and • facilitate interventions in Africa that improve the health and nutritional status of school children. What were the specific objectives of the activity? The specific objectives of the activity have been to: 0 Document the state-of-the-art in donor support to school health activities in Africa; 0 Develop a position for AFR/SD on its support to school health initiatives; 0 Help build support within the international community of donors and lenders for school health initiatives; 0 Support USAID missions that develop school-health interventions. What took place during the activity? Research and analysis The activity began in 1994 with the writing and publication of Lessons Learned on the Integration of Health, Population, Environment, Democratization, and Privatization into Basic Education Curriculum in Africa. This report was based on a variety of secondary and grey literature sources. In 1996 a collaborative expert meeting on primary education, health, and nutrition, held in Washington, DC. AFRISD conducted and published a literature review and • Education 3 prepared a state-of-the-an paper of school health initiatives for use at the meeting. One major outcome of the meeting was the establishment of the International School Health Initiative, centered at the World Bank. The Initiative has been a mechanism for donor coordination, information sharing and advocacy. AFR/SD has supported the development by Yale University of an instrument to measure the effect of nutrition and health interventions on cognitive ability of school children. The instrument tests a child's ability to follow instructions, which become increasingly more complex as the test progresses. The instrument, which will be used first in Zambia, will be replicable and usable throughout Africa at low cost. To gain a clearer idea of the link between child health and education, an AFR/SD consultant evaluated the impact of a child deworming program in Ghana on education attainment. Dissemination The collaborative meeting took place in Washington, DC, in May, 1996, with representation from UNICEF, WHO, the Partnership for Child Development at Oxford University, the Education Development Center (Newton, MA),the World Bank, other organizations from the Washington, DC area, and US AID staff. At that meeting, background documents were distributed. These included two state-of-the-art guides (Education, Health/Nutrition/ Population Linkages: A Guide to Resources; Using Schools to Improve Health.~ A Map of Informative Interventions), and two technical background papers, (Nutrition, Health, and Learning in Africa, and Critical Transitions: Home to School). Representatives of participating organizations also distributed draft or completed documents. Following the meeting, in July 1996, AFRJSD made a presentation on the linkages between health and education at its biennial conference, held in Brits, South Africa. AFR/SD staff participated in March 1998 on a panel on school health at the World Bank's annual Human Development week. What were the outcomes of this activity? Research findings The evaluation in Ghana found a strong and positive effect of deworming and health education programs on children's achievement in school (measured by standardized tests). The effect was particularly strong for nutritionally disadvantaged children and for girls, especially adolescent girls. Attendance rates were not affected, and effects on persistence rates could not be determined. In terms of health and nutritional outcomes, the deworming treatment resulted in sharp reductions in prevalence and intensity of schistosomiasis and hookworm but little or no consistent reductions in ascaris, trichuris, or strongyloides (other worms). The treatments also Education 4 appear to have affected the nutritional status of children, as measured by increases in their • heights and weights. Fulfillment of objectives Objective Met, Not Met, Exceeded Comments/sources Document the state-of-the-art in Met report donor support to school health activities in Africa Develop a position for AFR/SD Met interviews on its support to school health initiatives Help build donor support for Met interviews school health initiatives Support USAID missions that Met interviews develop school-health interventions. Products Creative Associates International, Lessons Learned on the Integration of Health, Population, Environment, Democratization, and Privatization into Basic Education Curriculum in Africa, 1994. Washington, DC: USAID/ARTS. Seifert, Kim, Early Intervention: HIVIAIDS Programs for School-aged Youth, ABEL Project, 1997. Christopherson, Kaaren, Education, Health/Nutrition/Population Linkages: A Guide to Resources, SARA Project, 1996. (A sourcebook of projects and programs, organizations and networks, and journal literature related to collaborative work between education and these sectors.) Moulton, Jeanne, Collaborative Programs in Primary Education, Health, and Nutrition: Proceedings of a Collaborative Meeting, Washington, DC, 1996, SD Technical Paper 38. Moulton, Jeanne, Using Schools to Improve Health: A Map of Informative Interventions, SARA Project, 1996. • Israel, Ronald C., Nutrition, Health, and Learning in Africa. Newton, MA: Action Group for • International School Nutrition and Health, Education Development Center, 1996. Education 5 Levinger, Beryl, Critical Transitions: Home to School. Newton, MA: Action Group for International School Nutrition and Health, Education Development Center, 1996. Williams, James H., and Kay Leherr, Children's Health and Nutrition as Educational Issues: A Case Study of the Ghana Partnership for Child Development intervention Research in the Volta Region of Ghana. Washington, DC: Ghana Partnership for Child Development, Harvard Institute for International Development, 1997. USAID/ AFR/SD, "Improving Educational Quality and Equity Through School Health Interventions," Position Statement, 1997. USAID/ AFR!SD, "USAID/ Africa Bureau, School Health and Nutrition Activities," 1998. What complementary efforts have contributed to the results of this activity? The ADEA Working Group on Early Childhood Development works on school health issues; AFRJSD suppons that group. What were the results of this activity? The activity has drawn greater government and donor attention to the relationship between student performance and nutritional well￾being. AFR/SD has developed a close working relationship with the World Bank to promote the issue through the International School Health Initiative. Understanding the problem The literature review and subsequent donor and donor/ government discussions renewed attention on the effects of poor health and Understanding the Problem Changes in Policies and Programs The process of policy and program change involves the inLeraction of describing problems, identifying solutions, and advocacy. nutrition on children's performance in school. The issues in school health and the range of interventions that have been undertaken have been more clearly defined and categorized. This process of defining and categorizing has helped international organizations, including USAID/ AFRJSD advocate with more clarity particular program components in particular situations. Identification of alternative solutions No major alternatives, but a renewal of attention to the issue. Advocacy Education 6 Coordinating its effort through the International School Health Initiative, AFR/SD has helped to • bring other international agencies into the dialogue. 0 The World Bank has been a strong partner from the beginning. 0 A growing number ofNGOs have begun to think about introducing school health programs. Save the Children Foundation is taking the lead in an NGO working group; CARE and Africare have been brought into the working group. 0 AFR/SD staff have established a link with the Center for Disease Control and Prevention (CDC) in Atlanta. The CDC is conducting research that ties in directly to the Initiative's work, and it has hooked up with the Carter Center and its programs in Africa The work of these organizations will add to the resources of the Initiative. · The school-health theme is a prominent feature in the video on primary education in Uganda, produced by USAID and the World Bank for national and international television audiences. Changes in policies and programs AFR/SD's strategy for promoting school health programs has been to cooperate directly and actively with other international agencies. Beginning in 1996, AFR/SD has co-sponsored with the World Bank and UNICEF the International School Health Initiative. This program consists of an office at the Bank, directed by AFR/SD staff and staff of the Partnership for Child Health at • Oxford University. This Initiative allows US AID and its partners to support budding efforts at building school-health programs in developing countries; to date, most of these are in Africa. The Initiative has collected other documents, including reports from the Partnership's programs in Ghana and Tanzania. AFR/SD has helped produce a web page on school health, which is now in prototype form but will eventually be available on the Internet through the Bank's Global Knowledge Data System. AFR/SD also supervises the services of an intern at the Initiative, who collects resources and responds to requests from USAID missions and others for information and services. Thus, the Initiative has become a clearinghouse for materials and information. The establishment of the Initiative has given AFR/SD the capacity to build on opportunities to promote school health program components. Through cooperative efforts at the Initiative, AFR/SD developed its position paper on school health, a paper on examples of programs, and guidance in conducting a situational analysis. The Initiative's strategy is to advocate for school health activities, to stimulate discussion, and to build consensus on what can and should be done. AFR/SD staff have worked with USAID/Zambia to develop a school health component of the mission's program. Staff and consultants proposed a school health intervention, which has become part of the mission's Strategic Objective in education, complementing a girl's education component. Within Zambia, the mission has become the lead agency in multi-donor cooperation on school health. In particular, the mission, with continuing support from AFR/SD, is negotiating with JICA (Japan's development agency) to cooperate on a school health program that will feature dewonning, micro-nutrients, hygiene and sanitation education. The curriculum • Education 7 component will have a strong community outreach dimension, linking to other environmental health issues. A third related activity is the help that AFR/SD plans to give to Zambia's Environmental Council and environmental clubs. Through USAID's GreenCom project, AFRISD will assist these groups in putting together instructional materials on handling hazardous waste (including lead) in settings where children play. A number of US AID programs have introduced school health activities: 0 Following AFR/SD staffs 1996 intervention, the BESO (education program) in Awassa, in southern Ethiopia, has cooperated with the BASICS (health program) to incorporate a health education unit in the primary school curriculum and materials. In addition, the community schools component ofBESO will use a school health approach to mobilize parents to support schooling for their children. 0 The phannaceutical company Smith Kline Beecham has recently agreed to donate enough Albendezole to deworm children in Africa for 20 years. This program will be launched first in three countries, possibly including Uganda and Zambia. 0 USAID staff in Benin are using the school health position paper developed through the Initiative by AFRJSD to help the ministries of health and education write a new national policy on school health (this led AFR/SD to translate the documents into French). 0 World Bank staff have used the French translations of position papers to help adapt school health programs developed in Ghana and Guinea in other countries in West Africa. 0 As a result of his work in Zambia on school health, a USAID education officer has introduced a significant school health program in Jamaica and is working in a Latin American regional forum to help introduce a ministerial declaration on school health. What lessons have we learned from this activity? The strategy of working from the "ground up" has been successful in several ways. First, collaboration with the World Bank and other agencies in the International School Health Initiative, which is a relatively small operation that draws on the resources of partners and others, has worked well. It has allowed USAID to use the resources of others in supporting small mission efforts, particularly Zambia and Ghana. Policy is being formulated on a basis of empirical evidence of demonstration activities, and advocacy is founded on concrete evidence. Every intervention should also be a research activity; for some, the evidence of the impact of nutrition and health interventions is not clear enough to forge ahead without documentation. Education 8 What are the next steps to capitalize on the activity? • 0 We should stay the course, encouraging missions and ministries to adopt small-scale school-health activities. 0 We should give more support to the ADEA Working Group on Early Childhood Development. 0 We need clear documentation that children's cognitive abilities are improved by better nutrition and health care. For this purpose, the collaboration with cognitive measurement specialists at Yale should be pursued. Other suggestions are to (I) produce a video on health education, (2) reserve funds to encourage pilot activities of missions and/or PVOs, (3) tap the private sector for resources, such as Merck s contribution to deworming drugs, ( 4) fund a PVO working group in school health. Resources consulted Documents Creative Associates International, Lessons Learned on the Integration of Health, Population, • Environment, Democratization, and Privatization into Basic Education Curriculum in Africa, 1994. Washington, DC: USAID/ ARTS. Seifert, Kim, Early Intervention: HIVIAIDS Programs for School-aged Youth, ABEL Project, 1997. Christopherson, Kaaren, Education, Health/Nutrition/Population Linkages: A Guide to Resources, SARA Project, 1996. (A sourcebook of projects and programs, organizations and networks, and journal literature related to collaborative work between education and these sectors.) Moulton, Jeanne, Collaborative Programs in Primary Education, Health, and Nutrition: Proceedings of a Collaborative Meeting, Washington, DC, 1996, SD Technical Paper 38. Moulton, Jeanne, Using Schools to Improve Health: A Map of Informative Interventions, SARA Project, 1996. Israel, Ronald C., Nutrition, Health, and Learning in Africa. Newton, MA: Action Group for International School Nutrition and Health, Education Development Center, 1996. Levinger, Beryl, Critical Transitions: Home to School. Newton, MA: Action Group for International School Nutrition and Health, Education Development Center, 1996. • - Education 9 Williams, James H., and Kay Leherr, Children ·s Health and Nutrition as Educational Issues: A Case Study oft he Ghana Partnership for Child Development Intervention Research in the Volta Region of Ghana. Washington, DC: Ghana Partnership for Child Development, Harvard Institute for International Development, 1997. USAID/ AFR/SD, "Improving Educational Quality and Equity Through School Health Interventions," Position Statement, 1997. USAID/ AFR/SD, "USA.ID/ Africa Bureau, School Health and Nutrition Activities," 1998. Interviews Brad Strickland Jim Williams Improving the Health of School Children Research and Analysis What happened Dissemination Advocacy Capacity Building • Literature review • Literature review • International • International documented past and several other School Health · School Health donor support for publication Initiative has Initiative created school health. distributed. been a to help coordinate • Evaluation of a mechanism for international dewonning • Information AFRISD and donor school project in Ghana shared at international health efforts. demonstrated workshop in donor advocacy. ~~·:childretl~~, ~: ·' · · : ·:· SolutioM l'be process of policy and prognun change involves lhe interaction of describing problems, identifying solutions. and advocacy. The activity helped to clarify the institutional needs of ERNW ACA as a regional network. Also, it became clear that moving research findings into policy and program reform was very dependent upon the backgrounds of the researchers and their links to the policy-making structures. Identification of alternative solutions Advocacy 1996 was declared the Africa Year of Education by the Organization of African Unity Summit of Heads of States. As a member ofthe Observatory ofthe Segou Prospects, ERNWACA (and ERNESA) played a key role in the implementation of the Year's activities. Members helped • identify issues in maternal languages, did research, and made presentations on the topic. Changes in policies and programs There were no specific changes, but ERNW ACA and its members were better placed to inform and influence national policies as they arose. Capacity building ERNW ACA has a charter, an equipped office in Bamako for its secretariat, and a funded director. National chapters and the secretariat are equipped for email. One of the founders of ERNWACA is now at the OAU and is calling on ERNW ACA members for their support during the decade of education. A team commissioned in June 1996 by USAID's REDSO (West Africa Regional Office) to evaluate the progress of ERNW ACA found that the organization's capacity had not been strengthened as planned. The one transnational research project that had begun had been suspended due to lack of financing. In general, financial support was fragile and wavering. The organization had still not achieved the grantee status it needed to attract certain donor funding, and the planned Board of Directors and Scientific Council were still not in place. Finally, the Education 7 team found no plan outlining procedures for ERNWACA's institutional development. Nonetheless, the team concluded that ERNW ACA was an "active group that met a need both at the level of researchers and national educational organizations and at the level of international institutions." Its presence was felt increasingly, and it remained the only organized and effective entity in education research in the region. A significant portion of its research was useful. What lessons have we learned from this activity? The first lesson comes from SARA's 1997 Annual Report: In carrying out the study on conditionality, "since most of the researchers were ministry people, not in the academic structure that rewards an objective scientific approach, their ability to work from a disinterested research posture was curtailed. Even with many academics in the developing world, their links to the political world may militate against the kind of assertiveness that we might expect from a 'pure' scientific piece. We need to reflect on this lesson as we commission future research in Africa." We have also learned that the ERNWACA network can only be as strong and productive as its individual country members. These country groups did not receive the financial support from USAID (REDSO) that they expected. Also, with changes in secretariat directors, managerial support has not been what was expected. Thus, if investment in ERNW ACA is to pay off in terms of good policy research, AFR/SD must help to ensure that the secretariat, IDRC (which is a large funder and supporter), and its own staff do what is needed to provide managerial, financial, and technical support to the country groups. What are the next steps to capitalize on the activity?AFR/SD is currently working with IDRC and ADEA to ensure continued and more effective support to ERNW ACA. Resources consulted Documents Compaore, Siguian, Maurice Garnier, and Luc Gilbert, "Evaluation ofERNWACA," Executive Summary. [np] International Development and Research Center and U.S. Agency for International Development. Overlooked and Undervalued: A Synthesis of ERNW A CA reviews on the state of educational research in West and Central Africa. Washington, DC: Support for Analysis and Research in Africa (SARA) Project, 1997. Support for Analysis and Research in Africa (SARA)(December 1996), Annual Report, Project Year 4 (FY96). Washington, DC: Academy for Educational Development SARA project. Support for Analysis and Research in Africa (SARA)(December 1997), Annual Report, Project Year 5 (FY97). Washington, DC: Academy for Educational Development SARA project. Education 8 Trip reports of Jean Georges Dehasse. • Interviews Ash Hartwell Joe DeStefano Prepared for SARA by Jeanne Moulton Latest revision: 3/3/99 • • Research and Analysis • Two transnational research studies and eight national studies conducted. • Literature review j :~ Ji~,,,.;;( ,;:Q:~' :.~.r ~~··~· : · .• .- ·,~· ~~ .(·l · ,,! · ·;· ':.oo:·:: r.·;·._,'!t··:·.·'·,. · ·· :·· ~i~·· :i ~ tiairung of30 , ... · !·. research ERNWACA able to t.!-'!i!>J. . - · •. ~: ·;. _ ... ·.· .. .. ·4· , .~" ~ •J .~·~ :·· . ,.•·:· •• . • ~· ! ,• :,'!. ~ -~ ~;~ • ~ : ·, ' · advocate for changes in education systems. • ERNW ACA and members • ERNWACA identified issues and conducted became an affiliate of of the OAU and contributed to OAU events. extensive advocacy during the Africa Year of Education. Changes in policies and programs Capacity building • ERNW ACA and its members better able to define research issues and develop proposals. • Regional network strengthened to address education issues. ~ .. ... :: " .J/tl'l -~. ... ~ " .. . , Education Community Involvement in Education Main results and significance of activity • Research and support had a strong influence on AFRISD education strategy. • USAID/Malawi supported follow-up study. • Fairly strong demand for software package on community schools. • World Bank sufficiently impressed by the software package to support development of a similar one on girl 's education. • Filled need within missions and governments for more information on effectiveness of community-supported schools. • Complemented on-going social sector reforms and decentralization being undertaken by many African countries. Dates of activity: Locations: Implementing agencies: Total HHRAA funding: Leveraged funding: 1996-98 Washington, DC; Bamako, Mali AFRISD Education 2 What was the problem or gap being addressed? • School is not an integral part of community life in many rural, and urban, areas of Africa Frequently, it is an institution that draws a child out of the community and, if the child succeeds in school, into jobs in the modem sector. Likewise, the school does not support the community by feeding back children who can contribute to its maintenance and development. There is a growing recognition of the problems caused by this disjuncture between the community and the school and of the need to bring the two closer together. From another, theoretical, perspective, community schools help alleviate the financial burden born by the government for schooling by transferring some of the costs to communities. The question has been: how to create schools that provide good quality education that is affordable to local communities? While well-known community schools projects were established in Bangladesh, Pakistan, Egypt, Colombia, and Guatemala. few existed in sub-Saharan Africa, and none were known to be receiving international support. While descriptions of BRAC and other large, successful programs have been published, that information often does not reach the grassroots level. Information about many other programs has been much less disseminated. The problem addressed here is the inaccessibility to program planners in Africa of information on what has been tried in increasing community participation in schooling and a growing number of requests from the field for information about community participation. • What was the purpose of the activity? The activity was a part of Strategic Objective 6--the adoption of policies and strategies for increased sustainability, efficiency, and equity of basic education services. More specifically, the activity fell under IR 6.1 : disseminate and promote knowledge and guidance on policies, strategies, approaches, methods and tools for increased sustainability, efficiency, and equity in the provision of basic education services. The purpose of this activity was to help education professionals in ministries, non-governmental organizations (N GOs ), and international assistance agencies working in Africa get information about strategies for integrating the school into the community and helping the community support the school. What were the specific objectives of the activity? The specific objectives of the activity included: • Conduct reviews of community schools projects in Mali and Malawi to evaluate their cost-effectiveness, sustainability, and pupils' ability to move into the regular school system for higher grades; • Education 3 • Compare cognitive achievement in community schools with that in government schools and determine why these results were obtained; • Share infonnation about community schools programs with educators and others interested in how community schools function. • Develop a software package on experiences with community participation for use by program planners. What took place during the activity? Research and analysis Both the reviews of projects and the development of the software package entailed research and analysis. AFRISD staff visited a community schools project in Mali for the purpose of reporting to a broad audience information about this reputedly successful innovation. AFRJSD also financed two other reviews, one of the same community schools in Mali, and the other of community schools in Malawi. AFR/SD produced two kinds of reviews of community schools projects. The first of these was a · twelve-page paper that described the Basic Education Expansion Project (BEEP) in Mali and briefly described a number of critical issues and lessons learned from a project that had been underway for several years. At the time of the review, the project had supported the creation and development of over 60 community schools in one district in Mali. The researcher's intent was not to evaluate the project but to write a coherent description for use by a broad audience. The researchers in Mali and Malawi developed and administered a set of achievement tests, observed classroom activities, and conducted interviews with teachers, school administrators and supervisors, pupils, parents, and community leaders. The more quantitative materials were subjected to statistical analysis to separate program from non-program influences on pupil performance. The development of the community participation software program involved a thorough search for "grey" and published literature on community participation activities. The information was categorized around three dimensions: goals, strategies, and context. The user is able to search for particular goals (such as increase efficiency or improve quality), context (cultural factors, government practices), and strategies (improving the teacher, improving community infrastructure and technologies). The researchers also wrote complete case studies of the larger projects. Dissemination The review of the BEEP project in Mali was published as a single docwnent. The evaluations of Education 4 the community schools projects in Africa were incorporated into a larger study of the • detenninants of education achievement and attainment. The community participation software was put onto floppy disks and inserted into a 45-page manual, most of which is information and guidance on developing community participation projects. Each of these publications was distributed through AFR/SD's document distribution channels. Records of requests for documents from Spring 1997 show requests from Malawi, Benin, South Africa, and Mozambique for the report on BEEP in Mali; requests for the community participation software came from South Africa, Gabon, Benin, Lesotho, and Zimbabwe. AFR/SD also has records of request in Fall 1998 from NGOs in Kenya and Tanzania. The authors of the community participation software and others have presented it in several fora: • July 1996 at a workshop in Brits, South Africa for USAID education officers in Africa and their colleagues in ministries. • May 1998 at the WID international conference on girls' education held in Washington, DC. • March 1997 at the Comparative and International Education Society conference in Mexico City. • March 1998 during Human Development Week at the World Bank. • USAID Global Bureau staff workshop, 1997. • Academy for Educational Development workshop for new chiefs of party. • • Academy for Educational Development workshop for consultants. • USAID in Jamaica (through the Advancing Basic Education and Literacy (ABEL) project The author of the BEEP project description presented it at a panel at the 1996 meeting of the Comparative and International Education Society in Williamsburg, VA. In December 1996, a workshop was held to discuss the nine studies, including the evaluations of community schools projects in Mali and Malawi. What were the outcomes of this activity? Research findings In general, the research on community schools and community participation in schooling shows that results of these experimental efforts are positive. The Mali and Malawi evaluations found that while test scores in both government and community schools were generally low, in both countries children in the community schools performed as well or better than children in government schools in all core subjects. In addition, repetition and dropout rates were lower, and progression rates were higher in the community schools. The researchers did regression analysis in an attempt to isolate factors that account for the differences between government and community schools. They were able to rule out household and child characteristics. School￾level effects, including teaching methods, teacher supervision, class size, and use of instructional • Education 5 time, seemed to affect test scores. lnfonnation on costs was inadequate, so the researchers could not draw conclusions about either immediate costs or financial sustainability. Table 1: Fulfillment of objectives Objectives Met, Not Met, Exceeded Comments/Sources Conduct reviews of community Met reports schools projects Compare cognitive achievement Met reports in community and government schools Share information about Met dissemination info community schools with educators Develop a software package on Met package and interviews experiences with community participation Products Williams, Jim, and Brad Strickland, Field study of Malawi community schools (Save the Children, in Mongochi), December 1996. DeStefano, Joseph, Community-Based Primary Education: Lessons Learned from the Basic Education Expansion Project (BEEP) in Mali, SD Technical Paper 15, 1996. USAID (February 1997), Planning for Community Participation in Education. Washington, DC, SD Publication Series, Office of Sustainable Development, Bureau of Afric~ USAID. What complementary efforts contributed to the results of this activity? AFR/SD commissioned a research study of data that shed light on determinants of student achievement and attainment. Much of the data from these studies came from evaluations of community school projects (in Kenya, Mali, Malawi, Tanzania, and Egypt). What were the results of this activity? The activity responded to demand for information on the role and effectiveness of community schools in Africa. Both governments and USAlD missions sought that information as a part of decision making about expanding the quality and availability of primary school education. There has been limited use of the information developed. Understanding the problem The research in Mali and Malawi demonstrated that community-supported schools did offer viable alternatives to government-supported schools. Requests for Understanding Lhe Problem Education 6 Changes in Policies and Programs The process of policy and program change involves the interaction of describing problems. identifying solutions, and advocacy. copies and other anecdotes provide evidence that the community participation software is reaching people at the grassroots level for whom it was intended. Non-governmental organizations are sharing the package with each other and their clients, as it can be easily copied between even the most rudimentary computers. Information comes from Guinea, Egypt, and Yemen, that people are consulting the software in their planning. Identification of alternative solutions • Prior to the time period of the report on Mali's community schools (1993-97), there were no documented community school projects in sub-Saharan Africa that received donor attention or support. This activity brought to the attention of those concerned with primary education in • Africa a case in which community schools offered an alternative to some of the difficult problems of school finance, relevance of curriculum, and quality of instruction. That alternative is community schools. Advocacy The report on Mali's community schools and the software package on community participation have been used to advocate this model of education reform. They have contributed to a much greater interest in community schools and in the importance of community support to schools. Changes in policies or programs The interest in community schools and community participation in schooling that developed during this period of AFR/SD's research and support had a strong influence on that office's own strategy. \Vhile the earlier conceptualizations of education reform focused primarily on change at the central level in financing and information management, later statements of strategy, notably the Strategic Framework, emphasized school- and community-based changed and school effectiveness. The results of the research on Mali and Malawi persuaded AFR/SD to look more closely at village schools. Thus, the mission commissioned an assessment of village schools in Malawi • Education 7 (Williams and Strickland) and a study on learning gains in these schools (Miske). Neither of these reports has been distributed. The World Bank was sufficiently interested in the software package that it offered funding to do a girls' version. AFRISD attempted to work with ABEL (an education project in USAID's Global Bureau), and the World Bank to organize a workshop in Ghana for people at the district level to discuss community participation. But the workshop has not yet taken place. Capacity building While some capacity building is likely to have occurred as people used the software package, the evidence is not available to indicate specific instances. What lessons have we learned from this activity? Studies done in Malawi and Mali were not widely publicized. Missions and ministries involved may be sensitive to critical findings, so they should be publicized with caution. Preparation of a dissemination strategy may overcome some of the reluctance to share information. We need to continually update information on what is happening with innovative interventions. The community schools in Mali have raised an issue of continuity with the school system: students are not passing the sixth grade leaving exam and thus not qualifying for secondary school. Thus, on-going tracking of projects will continue to inform other initiatives. Likewise, the community participation software needs more follow-on monitoring and integration with programs. Community schools are introduced and supported in different ways, depending on the environment. Policies must be based on knowledge of these differences; no single policy can be promulgated throughout Africa. What are the next steps to capitalize on the activity? AFRISD has already embarked on a follow-up software package that will guide planners in actually putting together a program: collecting data, and mobilizing support. The World Bank has also commissioned a similar tool for girls' education. New software packages should incorporate up-to-date information and lessons. AFR/SD is completing a comparative study of two models of community schools (Save the Children and World Education), including their costs. This needs to be published, distributed, as used as appropriate to influence policy decisions. Education 8 Other suggestions include (I) repackaging the fmdings from these studies for wider distribution, • and (2) producing a video on community participation. Resources consulted Documents USAID (February 1997), Planning for Community Participation in Education. Washington, DC: SD Publication Series, Office of Sustainable Development, Bureau of Africa, USAID. DeStefano, Joseph (February 1996), Community-based primary education: Lessons learned from the Basic Education Expansion Project (BEEP) in Mali. Technical Paper No. 15. Washington, DC: SD Publication Series, Office of Sustainable Development, Bureau for Africa. Ridker, Ronald G., Determinants of Educational Achievement and Attainment: Findings from Nine Case Studies, 1997. Interviews Joe DeStefano Joy Wolf Prepared for SARA by Jeanne Moulton Latest revision: 2/24/99 • • Community involvement in education Research and Analysis What Dissemination happened Advocacy • Two country • Reports on • Research findings studies on country used by AFRJSD community- experiences and a to advocate for supported schools synthesis greater attention Capacity Building • Little evidence available TA and Other Activities What changed Understanding the problem • Research defined strengths and weaknesses of community schools. produced. pub I ished, but to and • Assessment limited development of II Alternative Solutions Identified conducted of dissemination. community _learnin of • Software ro ram schools. ,, .. ... . ;. . . • Research filled knowledge gap, "1.}\ f:~:t ;,.~ ..... . ''·""': ·.· :···- .::")' · 1 •" ' •• , .. .... . .. .... ~ .. .... . . .. ... , '•'• . '.,,. '• .. ~ •• ,. •'I ~~~<~ :···:ot·: .. ~t. :• th . d' . I . 1!;.~:-· tstudentsJn l · '"~1· .::t ~ l'-·IJI~ has· . ..~.~::J· ..... ::..r~ [ -·~··N~: ,,"····,;··· ...... •·:, .. , .... ·t·,~ .. •. ''· ·b··. · .. ;r:·,.r····· .. ·,·. . ,,., . ,·,:·:"·~ ··· •: .• ·.· . ... :.. ... .._ . ~ :.:: ~· . . us m 1catmg a temat1ves to :; \':lf l"'· ., .•• w •• ,. . ·l · .: ~; ·,.': ... ," lo~ :< ."·.' ... AL~~ t' :i-• i· .. · .,,..~· ~ . .'. , ;·:·:... · ·.!"; .• : :·•: r'·:::·: 1...-· ~~ :.t,.,£' .::: .. ·~:·· ..... •.· · ·'r,•·, .. ·!·•~· :.:-· ,'·r .. • -: .. ~r·.r ;· ., , .... ~~filb'hiiliilhi\Y.'itti~ : . nu~s: OJ"ilrld'f"l '1N~' · n:~.? *iilr~':"l':il-~.; ''\;l!!·!p ; .,,. :. . . ' ,',~' !.': .. Jr: : ;•;,:{ ..,,,, ~-: :; ,,, {i''' government-sponsored schools ~ti;.¥t!1~f?~;i1~~ ~~ ~~~~~~t ~:/;~ ·.p: .~;:FVr:;:~l~~~t~~I ~ ; ;, ~·~~~ -Thi! ! ·~: · : ~ ,~~: ::~?A: ~; : :,:·:·: ~~ ::~~!~~~ .;, >I· t;: · , . ~JJUvr.::J;-- -~1\'-1'-J\ LU • Community demand. ' - ------------- · ·· • As a part of AFRISD overall participation in • Findings I I ~ ... · ... ""' II education strategy. schools software presented at a program variety of developed conferences. Education reform being reviewed by many governments and donors. Changes in Policies and Programs • Studies informed and influenced AFRISD Strategic Framework on education. • USA I D/Malawi commissioned follow-up study. • World Bank adopted approach in developing parallel software. Capacity Building Education Research on Decentralizing Education Services Main results and significance of activity • A review of existing literature and project experiences demonstrated that decentralization of education services is complex, highly political, and difficult to achieve. • A sense of local ownership probably was achieved in the field research in Ethiopia through an action research methodology. • However, a plan did not exist for transforming the local participation in the research and analysis into local advocacy. • The USAlD Mission in Ghana found the research in Ethiopia useful, although their counterparts in Ethiopia did not nor did the Ministry of Education in Ethiopia. . Dates of activity: Locations: Implementing agencies: Total HHRAA funding: Leveraged funding: 1995-97 Washington, DC; Tigray region, Ethiopia HHRAA Education What was the problem or gap being addressed? The decentralization of education services often has been viewed by donor and lender organizations as a solution to a wide range of problems, including: • Insufficient government responsiveness to local education needs; • Poor popular participation in improving schooling, especially among disadvantaged ethnic and social groups; • Inflexible planning and implementation, due to poor knowledge of regional and local conditions; • Managerial overload at the central level; • Failure to tap resources at the regional and local levels; • Inadequate support for non-governmental organizations and private enterprises in education. 2 • On the heels of a wave of enthusiasm among donor and lender organizations for decentralization came a growing number of questions about the feasibility and benefits of such a policy. Its application was sometimes misdirected by donors and lenders. Some advocates suggested that decentralization was a panacea or at least a broad swipe at alleviating with a single policy a number of politically, bureaucratically, and economically based problems. The opinions of people and organizations in favor or skeptical of decentralization often were supported by little evidence, making appropriate decisions on the broad policy and more specific approaches more • difficult. What was the purpose of the activity? The activity was a part of Strategic Objective 6--the adoption of policies and strategies for increased sustainability, efficiency, and equity of basic education services. More specifically, the activity fell under IR 6.1: disseminate and promote knowledge and guidance on policies, strategies, approaches, methods and tools for increased sustainability, efficiency, and equity in the provision of basic education services. The purpose of this activity was to help policy-makers in ministries and donor agencies gain a better understanding of the meaning and complexities of decentralization of education services and to give them some operational guidance based on documented experiences. Researchers also aimed to define what operationalizing a decentralization policy would mean in one country-Ethiopia. What were the specific objectives of the activity? The specific objectives were: • Conduct a review of the literature about education d~centralization efforts in Africa and • Education 3 US AID's plans for and experience with decentralization. • Present a framework for analyzing decentralization policies and activities in the eleven countries in which USAID had education programs. • Conduct participatory research on decentralizing primary education in the Tigray region of Ethiopia and to model a new, decentralized process for addressing the problems of Tigray' s education system .. • Develop a model of a decentralized process for addressing the problems ofTigray's education system. • Disseminate the information and lessons gained to government and international agency policy-makers. What took place during the activity? The study evolved in a context in which the Ethiopian central government had promulgated a policy of decentralization in education and other sectors, whereby many of the functions previously carried out by the central government were turned over to the regions. Methodology Using a "research-and-discussion approach," the study aimed to identify major problems that affect classroom instruction and explore how decentralizing the regional education system could best address those problems. Study designers chose this "action research" approach over a more typical design that would have confined itself to collecting and analyzing data and making recommendations to a few decision-makers. Instead, they attempted to involve people at all levels of the education system not only in gathering and providing data but also in analyzing those data and deciding their meaning and use for improving the system. Research and analysis The researchers reviewed documents from USAID education projects in Africa, case studies on decentralization (primarily from the World Bank and USAID) and the theoretical literature on decentralization. The literature review fed into the formulation of a preliminary analytic framework, consisting of a series of guiding questions that helped determine the status of a decentralization strategy in a particular country. The researchers used the framework to analyze accounts of decentralization in eleven countries in which USAID has supported education projects within the last decade: Benin, Botswana, Ethiopia, Ghana, Guinea, Lesotho, Malawi, Mali, Namibia, Uganda, and Zimbabwe. To conduct the research in Tigray in January-February 1995, the researchers sought to gather Education 4 data in a way to model a process for establishing a decentralized management system to support • Tigray's educational objectives. Within a fifteen-week time period, the research team designed the study, first with Washington officials and then in Ethiopia, trained data collectors, collected, translated, and analyzed data in the Western Zone; held a workshop with participants to analyze the data in regard to the specific problem of textbook distribution. They repeated this process in the Eastern and Southern zones, and then in the Central Zone. They finalized results in a fifth workshop and asked participants to use the data to construct a basic vision of the future of the Tigrayan educational system. The researchers wrote a thorough account of their activities, and the SARA project produced a summary account. Dissemination SARA published and distributed 500 copies of the literature review and 800 copies of the Ethiopia case study through it's and AFR/SD's mailing lists. Lessons learned in Ethiopia were disseminated to Ghana through the technical assistance of the decentralization research project manager (AFRJSD staff). The summary of the Ethiopia case study, according to ABIC records of requests for documents in Spring 1997, came from South Africa, Mexico, and Israel. The report on work in Ghana (which occurred after this activity) was not widely disseminated. The research studies were completed and distributed. but there is little evidence that they have been put to use in policy-making. The lead researcher on the Tigray study presented the findings to World Bank staff who were undertaking similar studies. What were the outcomes of this activity? Research findings The researchers of the literature and project review concluded: the case materials and the literature serve as a reminder that decentralization of education systems is not as easy as the rhetoric makes it sound. Decentralization is an extremely complex process that must be approached more thoroughly than has been done in the past. Large information gaps remain. In regard to USAID's education projects, while almost every project identifies decentralization as a priority objective, only a few have analyzed the process of decentralization (including the capacity and politics of key actors) or examined the education sector in a systematic way. Second, the term •decentralization' is used to describe everything from community power sharing to installing a new computer system to localizing instructional materials. Finally, few results are described, either because the results occurred at some subsequent time or because the expected results did not in fact occur. • • Education 5 The literature and project review summarized the findings within four categories: • Assumptions and views: Decentralization is viewed as an end, rather than as a means to an end, and as finite, rather than as an ongoing process; it is assumed to always be good and to have popular support; in fact, it has many, often conflicting definitions. • Process: Decentralization often emerges from crisis; it is rarely designed with popular participation, rarely builds new organizational linkages or taps into indigenous social institutions~ it rarely extends to the school level. • Support: A bener point of entry is often with NGOs than with the government; support and opposition are highly politicized; it is maximized if good local management practices are established~ it is favored by donors, yet donors rarely fund broad decentralization efforts. • Evaluation: Evaluations of decentralization efforts are virtually non-existent, beyond simple description: they focus on formal plans rather than how plans were implemented; they fail to discuss the costs of decentralization. Implementing decentralization policies has shown that these policies are mired in other political and economic agendas. Decentralization is not as universally acceptable a solution as some have thought, and k~y stakeholders often have something to lose by its implementation. The researchers in the Tigray project reported a number of findings: • Communication flows down, not up, drastically reducing the awareness among people at higher levels of conditions facing schools or differences between them. • Within the region, teachers, textbooks and other resources were unevenly distributed among schools, with access largely detennined by access to main roads. • With decision-making authority over even relatively small concerns in the hands of the few, regional and zonal officials were simply overloaded with work, and woreda and school officials had to wait months for responses to even routine requests. • Regional officials and school officials had different priorities: the former wanted to speed up construction of school buildings, while the laner wanted more books and teaching materials. • Male-female enrollment ratios generally favored males; the ratio of girls was lower in the higher grades than in lower grades (where it was even), and ratios varied from school to school. • Woreda officers had only the most basic training for their jobs, and there was little consistency in their day-to-day activities. The job was not well defined. Education Fulfillment of objectives Objective Met, Not Met, Exceeded Comments/sources Conduct literature/project Met reports review Develop a framework for Met report analyzing decentralization policies and activities Conduct research on Met report decentralizing primary education in the Tigray region of Ethiopia Develop a model of a Partially met model not widely accepted decentralized process Dissemination findings Met interviews The research studies were completed and distributed, but there is little evidence that they have been put to use in policy-making. Products Whitacre, Paul~ and Manish Jain, Education Decentralization in Africa: As Viewed through the Literature and USAID Projects. Washington, DC: Support for Analysis and Research in Africa (SARA) project, Academy for Educational Development, 1997. Whitacre, Paul~ and Marc Sommers, Decentralizing Education: The BESOffigray Case Study: A Summary. Washington, DC: Support for Analysis and Research in Africa (SARA) project, Academy for Educational Development, 1996. What complementary efforts have contributed to the results of this activity? The research, dissemination, and advocacy on decentralization is one aspect of the broader effort of AFR/SD to study and promulgate the an approach to education reform, known as Education Sector Support (ESS)--the topic of another impact assessment. Also, since decentralization is largely an implementation function--operationalizing decentralization policies-this activity is complemented by research on implementation, particularly, the Education Reform Support (ERS) activity and two ongoing studies on implementation of policies and of reforms. In May-June 1995 an opportunity arose to conduct research in Ghana on how the ministry might 6 • • • Education 7 decentralize education services in order to improve its management of resources. AFRISD sponsored a trip by the principal research on decentralization in Ethiopia to Ghana, where he helped USAID conduct a management audit at which some of the same issues in decentralization arose. In Ghana, the research team focused more on determining what resources schools lacked than on the problem of reorganizing to make more efficient use of resources they had. What were the results of this activity? The activity, particularly the action research in Tigray, produced interesting findings. However, the activity research approach seems to have been developed without serious attention to the interests and needs of the Ethiopian government or USAID/Ethiopia.planning. The result was that the findings were not utilized within Ethiopia. Understanding the problem In general, the activity helped to distinguish between the various potential benefits of decentralization. to clarify its limitations, and to point to difficulties in implementing decentralization policies. In Ethiopia, participants in the decentralization research and workshops learned more about conflicting perceptions of the purpose and process of decentralization. Identification of alternative solutions Understanding the Problem Changes in Policies and Programs ·ve Solutions The process of policy and program change involves the interaction of describing problems, identifying solutions, and advocacy. In Ethiopia, participants in the decentralization research (some of whom were regional-level policy-makers) became aware of the "regionalist" and the "localist" alternatives to decentralization. They did not, however, have the opportunity either to resolve these differences or to choose between the two alternatives. Advocacy The researchers in Ethiopia urged the USAID education team, which arrived upon completion of the decentralization workshops, that the team pursue the issues raised in the study and help the regional education office in Tigray (and in the Southern region, where USAID was working) to improve management through decentralizing authority and resources. They urged the team to help the education ministry continue involving officers at every level, including teachers, in the resolution of issues and the implementation of specific decentralization policies. It is not known whether Ethiopian participants in the research or workshop used the information generated to advocate for particular approaches to decentralization. Education 8 Changes in policies or programs When the researcher who had taken the lead in this research left the office, activity lagged. Thus, fmdings were never turned into policy guidance or advocacy materials. Although decision￾makers who are interested in formulating decentralization policies can find guidance in the two publications from this activity, they cannot get from it a comprehensive presentation of design and implementation issues as they might apply to more contexts than Ethiopia. In Ethiopia, the participatory research on decentralization in Tigray had little impact other than what participants learned and might have applied later in their work. The research ended just as USAID's large BESO project (support for basic education) was being launched, and decentralization activities of the kind addressed in the workshops were not high priority for USAID mission or project staff. The findings contributed significantly to studies that World Bank staff were undertaking on decentralization. Capacity building The BESO program and USAID mission education project team in Ethiopia chose not to follow the guidance developed by this activity on building capacity within the Tigray region to decentralize management functions. At the central level, they chose to foster decentralization by • working with central-level officials, rather than zone, woreda, and school level officials. At the regional level, they chose not to pursue decentralization issues. What lessons have we learned from this activity? Decentralizing basic education services requires severe changes in power and authority relationships. The work in Ethiopia showed that it may be too much to expect that people will lay down their job descriptions and reorganize, simply because research shows alternatives that may be more efficient. We have learned the limits of what US AID and other outside agencies can do to effect the implementation of structural changes decreed by decentralization. What are the next steps to capitalize on the activity? AFR/SD needs to decide whether to pursue research and technical assistance in decentralization. If so, staff must work with ministry officials to further explore feasible means of devolving structures of authority for specific purposes. AFRISD' s service will be most effective where ministry officials take the lead. Also, AFR/SD might consider using the research reports from Ethiopia and Ghana to develop training materials on decentralization for wider use in Africa. Resources consulted • Education 9 Documents Whitacre, Paula, and Manish Jain, Education Decentralization in Africa: As Viewed through the Literature and USAID Projects. Washington, DC: Support for Analysis and Research in Africa (SARA) project, Academy for Educational Development, 1997. Whitacre, Paul~ and Marc Sommers, Decentralizing Education: The BESO/Tigray Case Study: A Summary. Washington, DC: Support for Analysis and Research in Africa (SARA) project, Academy for Educational Development, 1996. Interviews Jim Williams Prepared for SARA by Jeanne Moulton Latest revision: 3/2/99 Research and Analysis What Dissemination Research on Decentralizing Education Services happened Advocacy Capacity Building TA and Other Activities What changed • literature review • report distributed • Lead researcher • Action research I '""-- II Understanding the problem • analytic through AFRJSD was advocate for methods engaged framework and SARA stud man Ethio ians I I ~ II• Complexities of education :. ~~:veloped · . ·. · ... .\~ :. ~~-.: networks. :·.,:.:"-·..- .· _, .. methodology . but skill-building ~ . c~ion~ri~n~e~ i. F ~, Filtdings n~t ~J:~· · ~ Li~~e or no · probably limited II 1 ~~ • • .;·: · · · hii' · ::= .• 1>i._ .~~ * d, t db . -. ~·- ·. ·. d · · . A ternatlvc..wuluhons Identified .:, ~~arc t. ·~· ·.' ;tf ~: ". ··~-~. . ope y:. Y,. . a vocacy .. ·~·- . .. ,. . . ·:~f .; conducted. in··;}t~~~ ·;;., :} ~ USAID/Ethiopia · occurred by: v· .. ::. < .. '. Act'•on research meth d rat d . . . , ". . .. \ . . . . . . .. . . . .. , . . . . . . .. o s gene e . . . . findings which were probably Ethtopta. parttcapants locally relevant, but findings were • • Complementary not adopted by central government. Activities • Complemented other AFRISD educational refonn activities. Advocacy Changes in policies and programs • No substantive changes, as findings were not utilized. Capacity building • Education Tools for Educational Information Management Main significance and results of activity 0 Two computer programs were developedOone a database of education statistics, the other f~r analyzing country-specific education dataOto assist ministries of education to process and use data. 0 The programs have been applied in Benin, Ghana and Guinea. 0 The activity strengthened the ability of a working group of the Association for the Development of Education in Africa (ADEA) to promote infonnation-based decision￾making in African countries. Dates of activity: Locations: Implementing agencies: Total HHRAA funding: Leveraged funding: 1993 (?) - 1998 Washington, DC; Paris, France; Cotonou, Benin AFR/SD; UNESCO Division of Statistics; ABEL (AED); SARA(AED) Education 2 What was the problem or gap being addressed? The lack of reliable data on education systems and difficulties in collecting and analyzing those data have plagued ministries of education for decades. In many countries, the ministry of education does not know how many children are in school, where schools are located, how many teachers are actually in the classrooms, what the student: teacher ratio is in each school, how many children are progressing, repeating, dropping out, and so on. Without such information, planners cannot project with any accuracy the costs of providing education to children nor anticipate changing needs. Nor can they make thoughtful decisions on how to allocate scarce resources. At the international level, education professionals require good data to make comparative analyses among countries and to help governments determine macro-level policies for providing education. Thus, AFR/SD staff felt that ministries need guidance in collecting, analyzing, and reporting on data resource-poor situations. What was the purpose of the activity? The activity was a part of Strategic Objective 6--the adoption of policies and strategies for increased sustainability, efficiency, and equity of basic education services. More specifically, the activity fell under IR 6.1: disseminate and promote knowledge and guidance on policies, strategies, approaches, methods and tools for increased sustainability, efficiency, and equity in the provision of basic education services. The purpose of the activity has been to help ministries of education collect, analyze, and share data on their education systems. For this purpose, AFR/SD developed two supportive programs (or tools ), and it gave technical and financial support to the National Education Statistical Information System (NESIS), a program of the Association for the Development of Education in Africa (ADEA). What were the specific objectives of the activity? The specific objectives were to: 0 Provide technical and financial assistance to NESIS to develop a program of support for ministry of education planning offices; 0 Help NESIS and the USAID mission in Benin produce a training module in the use of Fundamental School-Level Quality (FQL) indicators; 0 Develop a computer-based guidance program to aid ministry staff in data collection, analysis, and reporting (ED* ASSIST); 0 Develop a database on educational statistics in Africa (SPESSA). What took place during the activity? • • • Education 3 Research and analysis To support NESIS, AFRISD has given financial and technical support to ADEA's Working Group on Education Statistics (WGES). NESIS has worked with over 20 ministries in Africa to develop a training module on an aspect of planning and information management. The NESIS training package is intended to provide ministries with practical, cost-effective, and field-tested methods to improve the functioning of the education information system. AFR/SD supported the development of one such module on Fundamental School Level Quality Indicators (FQL). The module, which has not yet been completed, is based on work in Benin. The FQL Indicators system is a methodology for linking national education policy resource allocations to school-level improvements. ED* ASSIST is a computer program designed to assist in the collection, analysis, and reporting of data. Beginning in 1 996, ED* ASSIST was pilot tested in Benin at the invitation of the Ministry of Education. There, in less than a year, and with limited programming and staff, the Ministry was able to catch up with a three-year backlog of reporting. The knowledge gained from this on-the-ground experience led to upgrades to the software. In 1998, two ministry staff from Lesotho were trained in the use of the software. It is expected that similar training will be provided to groups in Kenya and Uganda. To develop the Statistical Profile of Education in sub-Saharan Africa (SPES SA), AFRISD assisted ADEA in compiling and disseminating cross-country and within-country comparative data sets. The first step in this process was the publication of a booklet "Statistical Profile of Education in sub-Saharan Africa in the 1980s." The second step was the creation of a computerized, Windows-based program. SPESSA provides the user with access to data, in an interactive fonnat, compiled from UNESCO and World Bank sources. Dissemination ED* ASSIST and SPES SA have been distributed by AFRISD and ADEA to ministries of education in Africa. What were the outcomes of this activity? ED* ASSIST and SPES SA have been fully developed and distributed. ED* ASSIST is a software package to designed to assist education planners to: 0 gain faster access to information 0 support decentralized information processing and access D Integrate the key components of the information processing cycle 0 Increase the ease of use and dissemination capacities of information systems so that Education 4 current non-participants - such as schools, provincial and district education offices, • NGOs, etc.-- can become active participants in the information flow 0 Increase the sustainability of the system. SPES SA (Statistical Profile of Education in sub-Saharan Africa) is a computerized database of education data which gives planners and others in education: 0 Easy access to the ADEA s database of 80 indicators related to education in sub-Saharan Africa 0 A program to create graphics comparing data across years and across countries NESIS has been strengthened and produced many modules. These products, however, have not been used as much as AFR!SD anticipated they would be. One of the problems in their use is that donor agents who assist the ministry tend to use or develop their own products rather than those that come from other sources~ such as ADEA, which does not generally offer technical assistance in the implementation of its products. Fulfillment of objectives Objective Met, Not Met, Exceeded Comments/sources Provide technical and financial Met interviews assistance to NESIS to strengthen ministry of education planning offices. Help NESIS and the USAID/ Met materials Benin to produce a training module in the use of Fundamental School-Level Quality (FQL) indicators. Develop a computer program Met program for ministry staff in data collection, analysis, and reporting (ED• ASSIST) Develop a database on Met reports educational statistics in Africa (SPESSA). Products • • Education 5 The products that have resulted from this activity are the ED• ASSIST and SPESSA computer programs. What complementary efforts contributed to the results of this activity? The Global Bureau of US AID has adopted SPES SA as a model for developing a worldwide database on education. The Education Reform Support (ERS) activity (see separate Impact Assessment) includes a number of tools to help education policy-makers include high-level stakeholders in policy formulation. Key to the ERS strategy is that a broad group of stakeholders should make informed. decisions; thus, data collection and analysis guidance, such as is available through ED* ASSIST, SPESSA, and other modules produced by NESIS, are complementary to the ERS activity. What were the results of this activity? Understanding the problem The activity sought to bring appropriate data to education planning by developing a set of tools and training modules for data collection and analysis. By developing tools intended to bring more contemporary evidence on school systems and students to program managers and policy makers, the tools generated by activity could offer data to clarify issues of school performance, student in-take and drop￾out rates, and student achievement. Identification of alternative solutions Within schools systems where little reliable data was available for planning and resource Understanding lhe Problem Changes in Policies and Programs 'lbe process of policy and prognmt change involves lhe interaction of describing problems, identifying solutions, and advocacy. allocation, the tools developed within the activity offered opportunities for gathering, analyzing and comparing data. In the context of educational decentralization and reform, data could guide and monitor the process. Advocacy Reliable data held the potential for program managers, school authorities and supervisors to point to specific achievements and deficiencies and advocate for supplemental assistance and changes in resource allocation. However, there is no evidence that such advocacy has yet occurred. Changes in policies or programs For each school year, the Beninese can interactively select from core indicators (access, Education 6 efficiency' quality' equity' etc.) by different categories (private/public/both, • national/regionaVsub-prefecture ), in different data display formats (tabular/graphical) aimed at different users for strategic planning, management, or operational purposes. Benin began in 1998 to use the FQL system and the ED* ASSIST tool to decentralize its data collection and management system, allowing region and district offices to better process data. Benin has also begun to develop a training module on FQL as a planning and management tool. The ED* ASSIST and FQL tools are closely related conceptually in Benin. The ministries in Guinea and Ghana have also adopted and adapted FQL as a planning tool. Capacity building NESIS has become an active program of the ADEA Working Group·on Statistics. NESIS has developed modules for planners to use in building the Education Management Information Systems (EMIS), promoted contacts between planners in different countries so that they can share experience with their use of tools, and served as a clearinghouse for agencies seeking to cooperate. ADEA members now have at their disposal the support packages developed by NESIS, including ED* ASSIST, and the SPESSA database. To date, Benin has used ED* ASSIST to build its capacity to manage education data. What lessons have we learned from this activity? 0 AFR/SD staff and consultants have found that getting ministries to use SPESSA, ED* ASSIST, and other NESIS products is more difficult than they first envisioned. ED* ASSIST requires a high level of technical support for both product development and application. Yet, contractors tend to use their proprietary products, which makes inter-organization collaboration difficult. In general, no one has figured out how to develop a useful and sustainable EMIS. 0 Good products take a long time to develop. To help ensure that they are developed in a way useful to ministries, and that ministries actually use them, ministry staff need to be more fully involved in their development. 0 Regarding FQL, it is important not to reify FQL; the processes, outcomes and use ofFQL is more important than the "thing" that is FQL. 0 We also need to reconsider the extent to which barriers to improving planning and EMIS are political, not technical. What are the next steps to capitalize on the activity? AFR/SD needs to look closely at the barriers blocking ministries from using these support • • Education 7 packages. It then needs to develop workable procedures for identifying what kinds of needs, including technical assistance, the ministries have for getting the packages into use. The packages need to be shaped, promoted and disseminated accordingly. AFRISD could help AD EA in these tasks. Resources consulted Documents Institute for International Research (nd), Statistical Profile of Education in sub-Saharan Africa (SPESSA), Version 1. User 's Guide. UNESCO, Division of Statistics (nd), National Education Statistical Information Systems. Ministry of Education, Benin, USAID!Benin (draft, August 1994), The School Fundamental Quality Indicators System. Interviews Ash Hartwell Johnson Sikes, AED Prepared for SARA by Jeanne Moulton Latest revision: March 1, 1999 Research and Analysis What Dissemination Tools for Educational Information Management happened Advocacy Capacity Building TA and Other Activities What changed • Two computer • The computer • Benin and Lesotho II Problem definition programs programs used in officials trained in developed-one a Benin, Ghana and use of programs. group • Tools permitted education data to 1 , ata ase o ::~: · · umea. . : -~ ailable more quickly and · ~ducatio11 statistics; • ADEA working • TA to Benin decision making. · the other a tool for · • Programs : . . group on education officials ·· .· :analyzing country- disseminated . educational in use of software. ldentifica.timlof alternative solution• :;.· ____ :£!.::. _:: _. ____ ... : __ :.· .. ... t.: ____ ..:..L AF'R/Sn ---------~----,------- 0 data. networks • The analysis tool tested in Benin and revised accordingly. e strengthened with new tool. e V ':·: . · .: .. -i· . . Complementary activities On-going support to ADEA. • The tools offered alternative to decision making based on little or no data or very old information. Advocacy Changes in policies and programs • Benin MoE cleared a backlog of data. • Ghana and Guinea adopted software for own use. • ADEA expanded its set of analytical tools to offer African MoEs. Capacity building • Benin MoE able to access and use education data . • r I I Malaria Research on the Home Management of Malaria Main results and significance of the activity • The research yielded the n1ost con1plete findings available about how households interpret and respond to n1alaria in children. • The findings established directions for improving early recognition of uncomplicated malaria and its case management in the home and informal sectors and identified interventions for subsequent research trials. • The early results of the iron supplementation trial for prevention of severe anemia and malaria in infants "fundamentally changed WHO policy on iron supplementation in malaria endemic areas," according to Dr. Melba Gomes ofWHO!fDR. WHO will prepare a new pol icy document in 1998 to reflect the findings from the research. • The results of the malaria studies have led to changes in nutrition programs. For example. UNICEF is implementing iron supplementation through their regular programs. • Dramatic improvements in proper drug dosage purchases and course completion were seen following a community-based training of shopkeepers in Kenya. • The HHRAA-funded Shopkeeper Training Pilot Project in Kenya leveraged full funding from DFIDIUK as a result of the successful pilot intervention. • Research institutions in Ghana. Malawi. and Kenya have developed capabilities in anthropological research. Dates I 993- I 998 Locations: Implementing Agencies: Total HHRAA Funding: Leveraged Funding: Kenya. Malawi, Ethiopia, Ghana World Health Organization, through the UNDP/World Bank/WHO Special Program for Research and Training in Tropical Diseases $1.900.000 not known Malaria 2 What problem or gap did the tlctivity lid dress? Every year two million children die in Africa from malaria-related illnesses, yet many of these deaths are preventable. About 80o/o of malaria cases are treated outside of health facilities. Many children are inadequately treated and develop severe and complicated forms of malaria. Of children admitted with these conditions. 1 0-40o/o die within 48 hours. Although home management of childrens· malaria had been advocated by some authorities, too little was known about household and community beliefs and knowledge about the illness. Data were unavailable across many sites which could offer a profile of common home care management practices that resulted in delays of medical treatment of uncomplicated malaria. Nor was there a single study protocol which would provide consistent information about a large population across geographic areas in a cost effective manner. Moreover, the best ways to promote home management had yet to be identified. Key questions which required study were : • What were the best ways to optimize management of uncomplicated malaria? • How can the time lag bet\\een initial symptoms and treatment or health facility admission • be reduced for patients at risk of severe malaria and death? • • How can the private sector-often the point for first contact with care givers-be engaged to improve home management of n1alaria in children? In addition, answers to several clinical questions were needed: • What was the risk of death from iron deficiency anemia related to malaria? • What was the value of iron supplementation in malaria endemic areas? • Could iron status be increased without increasing the risk of malaria? • Was acquired imn1unity essential to reducing mortality risk? What was the purpose of this activity? The activity supports Strategic Objective 7 which will lead to the adoption of policies and strategies for increased sustainability, quality. efficiency, and equity ofhealth services. More specifically, the activity contributed to attainment of IR 7 .2.1--i.e., develop improved policies and strategies for areas of special in1portance. which includes malaria and IR 7.2.3--i.e., develop effective approaches to in1proving child health care in the home and community. The purpose of the activity was to impro\'e home care management of malaria in sub-Saharan Africa in order to reduce malarial complications and mortality among children. • Malaria 3 The World Health Organization (WHO)--through the UNDP/World Bank/WHO Special Program for Research and Training in Tropical Diseases (TDR)--proposed developing and testing a Focused Ethnographic Survey (FES) protocol to gather data on household recognition and interpretation of and response to symptoms when their children have any form of malaria. The FES was expected to provide data which when analyzed would improve health workers' understanding of household malaria symptom recognition and decision making, steps taken in care giving of children, and reasons for time lags between initial symptoms and treatment￾seeking behavior. Once the protocol of the Focused Ethnographic Survey was completed in 1995, it was necessary to test its application for early, in1proved case management of uncomplicated malaria through community-based intervention trials. It was expected that the field trials would provide information to help shape appropriate policies on drug use and aid program managers to design strategies to impro\'~ both care seeking behavior and health services in the private and public sectors in order to reduce malarial complications and mortality among children. The researchers also sought to demonstrate that improved home management of illness would result in more effective use of household financial resources and a decrease in the acute case loads and case fatality rates in clinical settings. What were the specific objectives of the activity? The objectives of this set of activities included: • Developing of a Focused Ethnographic Survey protocol, so that it was broadly applicable and specifically adaptable. • Testing of the tool in at least three countries, under varying situations and in different communities. • Revising the protocol based on initial field testing and disseminating it to country levels. • Providing data on existing hon1e management practices and beliefs, including common elements across countries. such as: • household access to and use of malarial medications, • place of first treatment consultation (shop, drug vendor, traditional healer, primary health clinic). • locally recognized terms for signs and symptoms of malaria. • Developing the capacity in African institutions to develop, field test and revise similar qualitative protocols. Malaria 4 What took place ill implementi11g the activity? Research and Analysis The activity occurred in two stages. The first involved the preparation by WHOn"DR of a data collection protocol--the Focused Ethnographic Survey instrument--and field testing of the instrument in four sites in Africa. The second involved (a) the synthesis and dissemination of the original study and (h) follow-on applied research using the FES in pilot interventions. The process of designing the protocol Focused Ethnographic Survey (FES) relied on adapting a WHO treatment diarrhea protocol. This was followed by field testing in Kenya in 1993/94. Based on this experience. the tool was revised as a manual with guidelines on conducting research on case management of malaria. It was made available in draft form as "Guidelines for Conducting a Rapid Ethnographic Study of Malaria Case Management." A complementary video demonstrating symptoms of malaria was prepared with the assistance of AMREF. WHOffDR provided technical support and training to the local institutions and/or researchers on the use of the FES package. The pilot studies using the revised protocol were conducted in Kenya (1994) with the Kenya Medical Research Institute (KEMRI); Ghana ( 1 994-1995) through the Navrongo Health • Research Center: in Malawi (1995-1996) through the Center for Social Research; and in southern • Ethiopia ( 1995-1996) with a single researcher. Further revisions to the protocol were made and it was later used in Zambia and northern Ethiopia, with subsequent refinements to make the Guidelines more user-friendly. The following inten·cntion trials occurred : • Field trials in Kenya from 1995 to 1997 to: ... identify cost and marketing factors to increase care giver compliance with drug usage, ... identify I EC messages that contribute to timely and appropriate drug purchases, ... identify ability of shopkeepers and traditional healers to identify symptoms of malaria in children and offer appropriate advice. and ... design packaging drug combinations and/or pediatric formulations for anti-malaria treatments. • A randomized placebo-controlled trial was conducted in Tanzania, 1995 -1997, to resolve a fifteen year debate whether iron supplements for anemia reduce mortality risk or exacerbate malaria in infants. • Formative research was conducted in Zambia in 1996 on how and whether mothers recognize early signs associated with coma and severe anemia and on action they take, if any, in relation to early signs of illness. • An intervention study took place in Nigeria to improve compliance with first line treatment with chloroquine. • Changing treatment-seeking behavior of parents whose children were suspected to have • Malaria 5 cerebral malaria: Tanzania and Burkina Faso. Dissemination Four case studies were produced from the research in Kenya, Nigeria, Tanzania and Zambia. A synthesis of all the field studies was completed, with some comments on lessons learned. Dissemination of the FES field study results and of the draft "Guideline for Conducting a Rapid Ethnographic Study of Malaria Case Management." occurred primarily in response to requests from researchers and malaria control programs. Also, some dissemination occurred through presentations at professional meetings and conferences. The FES findings from Kenya were presented at the 1 997 Second Global Meeting on Parasitic Diseases in Hydcrahad. India. The protocol. findings, and interventions identified for testing have been shared with the \\'H 0/UNI CEF Task Force on Integrated Management of Childhood Illness (IMCI) through the Task Force for Home Management of the Sick Child--Malaria. A regional conference is planned for dissemination of the FES tool and findings. On the basis of regular feedback, the FES manual is being revised to focus separately on uncomplicated and severe malaria. It will be published in a shorter, more user-friendly style and presented in three self-contained modules: • Symptom recognition and beliefs related to symptoms; • Care-seeking for severe malaria; and • Home case management of malaria. What were the outcon1es from this activity? The activity represented an effort to use a multi-method (triangulation) approach to gather qualitative data. primarily from care givers (overwhelmingly women), on malaria in children. The data generated during the testing of the FES draft were often compelling, although presentation of the findings was confused by weaknesses in the structure of the draft "Guide." The subsequent research provided answers to the questions being posed by each of the trials. The findings in the shopkeeper training showed an improvement in pharmacist and client compliance and the iron supplement trial yielded findings which have convinced WHO to re-write its existing policy on supplements. Methodology The 'Guide" was drafted on the basis of an existing WHO manual and received extensive testing over two years in four sites. On the basis of the research reports, it was realized that the "Guide" had to be further revised to yield information which could be effectively presented. Malaria The pilot interventions were developed through standard scientific methods, with peer reviews, revisions and re-submissions, including within the countries in which the studies were to take place. Research Findings In addition to testing the accuracy and reliability of the protocol, the field tests yielded data on household knowledge and beliefs of malaria. Major findings from those field tests are described in Table 1. Table 1: Summary of.Rescarch Findings from testing ofFES Protocol 1. Household Responses to Uncomplicated Malaria among Children • Illness usually not perceived as serious • Managed at home and home remedies used • Treated with over-the-counter drugs (many and often) plus herbal medicines • Full course of antimalarials/antibiotics seldom bought or administered by parent(s) • No faith in services of health sector where fees are charged but drug shortages are frequent • Shopkeepers/private practitioners preferred: closer to home, give injections 2. Household Responses to Severe Malaria among Children • Illness not perceived to be associated with malaria • Child never treated quickly with an antimalarial • Child usually given treatment by traditional healer, but failures referred to clinic/hospital • Western medicine often halted • Delays in antimalaria treatment for the non per os child and transportation problems often result in acute hospital admissions and high mortality rates Research supported by HHRAA/ AFRISD also yielded important findings. For example, in Kenya research was designed to detern1ine if shopkeepers could accurately diagnose malaria symptoms and provide appropriate advice and treatment to care givers. A baseline survey was followed by training of shopkeepers to diagnose malaria symptoms, provide a full treatment of chloroquine, and advise mothers on appropriate care-giving behavior. Two evaluations were conducted at six month intervals. There was an increase in the provision of accurate advice to care-givers on dose and regimen and a significant increase in sales of full courses oftreatment (see Table 2). 6 • • • Table 2: Results of Malaria Drug Dispensing Study, Kenya, 1995-97 Shopkeeper training results from baseline survey to six months after retraining: • Mothers \vho bought proper drug dose increased from 32% to 90% • Mothers who gave adequate dosage increased from 4% to 75% • Mothers given accurate dose advice increased from 2o/o to 84% • Mothers given accurate regimen advice increased from 4% to 92% Iron supplememsfor anemia in Tan=ania Malaria 7 Research in Tanzania sought to resolve a long-standing issue of whether iron supplements for anemia reduce mortality risk or exacerbate malaria in infants. The research involved a randomized placebo-controlled trial. Over 1200 infants in four groups were followed, using iron plus chemoprophylaxis. chemoprophylaxis alone. iron alone, and a placebo. The main finding was that iron supplementation does not exacerbate malaria but does prevent death from anemia. Table 3: Fulfillment of Objectives Objectives Met, Not Met, Exceeded Comments/Sources Develop the FES protocol Met "Guide" Test the tool in at least three Met USAID memos of countries understanding, 1993-97 Revise the protoco I hased on Partially Met "Guide" exists but is being field testing and disseminate to revised for easier and more country leve I. focused use Provide data on existing home Met country reports and synthesis management practices and report beliefs Develop capacity in African Met interviews institutions to develop. field test and revise similar qualitative protocols Malaria 8 Products • The completed FES package included: .. "Guideline for Conducting a Rapid Ethnographic Study of Malaria Case Management," a manual describing how to conduct community-based research (focus groups and individual interviewing) on the household case management of malaria, the questions that should be asked, and a methodology for analyzing responses. .. a video depicting the signs and symptoms associated with life-threatening illness that can be shown to mothers to establish whether those symptoms are recognized and managed. • Four country case studies on popular. care-giver knowledge of malaria in children. • One synthesis report. • Training of four country research teams. • One article published in Lance/ (vol. 350, September 20, 1997). What complementary efforts have contributed to results of this activity? The HHRAA activity manager is a member of the WHOffDR Task Force and the IMCI Task Force and shares research findings with members of these groups to promote the protocol and results of trial interYcntions. Through ancillary funding, WHO/TDR has been working on similar activities in Cambodia, China, Laos, Myanmar and Thailand. These countries share an interest in developing an integrated action plan for improving case management for malaria. Findings are exchanged between locations through WHOffDR thus saving time and resources. What results were achieved? Researchers have been interested in the FES, but it has not gained wide application within African malaria control programs. The protocol is considered too complex for ready use in most field situations. The field testing of the protocol did stimulate interventions which were evidence based, such as by BASICS for use in AIMI districts. The four research activities (the fifth is still Changes in Policies and Programs lternotive Solutions "I be! process of policy and program change involves lbe interaction of describing problems, identifying solutions. and advocacy. underway) provided very useful evidence which has been used to inform policy makers and program managers. As a direct result of the studies, WHO is changing its policy on iron supplementation for anemic children and another donor has taken on support for expanding • • • Malaria 9 shopkeeper training in Kenya Understanding the problem The FES has stimulated interest among researchers as a means to better understand local knowledge and beliefs about malaria and care of children with malaria. As more people have used the instrument. greater clarity and specificity about popular beliefs and attitudes (as well as in the use of the instrument) have emerged. Despite the usefulness of the research findings, it does not appear that there has been wide acceptance of the instrument as either a rapid data gathering tool or cost-efficient tool. Program specialists have been most interested in applying the initial findings from the field testing rather than utilizing the instrument for baseline data gathering for new target populations. Two issues. in particular. have been validated for expanding home-based management of childhood malaria: early case management is feasible by training shopkeepers; provision of iron supplementation pn:vents severe anemia (the primary cause of early death in some areas) without increasing the sevcri ty/risk of malaria. Alternative solutions The research findings of the FES field testing supported the assumption that improvements in home and community management of malaria could be designed and would have a significant impact on reducing early childhood mortality from malaria. The subsequent pilot interventions (see impact assessment on Malaria Trials) demonstrated the accuracy of the assumption .. AdvocaC)' Advocacy has been slow to develop, in part because the research findings were slow to reach program managers and policy makers in formats to meet their needs. This has not been a weakness in AFR/SD, but a reflection of the approach ofTDR. Efforts were made through meetings and conferences to increase awareness of the need for improved home management of malaria and of the FES which can provide reliable data for planning of interventions. Special efforts have been made to engage WHO, UNICEF and other funding organizations involved in child health. However. there has not been an advocacy strategy which could lead to adoption of the FES by those organizations. Where USAID/ AFR/SD has been an effective advocate is in keeping the research agenda focused on research questions with practical field relevance. Changes in policies and programs FES findings established the direction for improving early recognition of uncomplicated malaria and its case management in the home and informal sectors. The change in the "environment" led to subsequent pilot interventions that affirmed that options exist for expanding home management of uncomplicated malaria. • Malaria 10 With the additional attention to malaria and community-based approaches to managing the illness, the UNDP/\Vorld Bank/WHO Special Programme for Research and Training in Tropical Diseases formed a Task Force on Home Management of the Sick Child--Malaria. The British foreign aid program, DFID, expanded funding of the shopkeeper training trial in Kenya, not only endorsing the program approach and moving it closer to institutionalization, but freeing USAID funds for use elsewhere. In 1998 WHO will formalize a new policy on iron supplementation and malaria. Also, a new round of intervention studies focused on severe and complicated malaria have been funded. A new WHO Task Force has been established to look at differential mortality impacts of various home management approaches. Finally. a WHO Task Force on Malaria and Health Sector Reform has been set up. UNICEF is adding iron supplementation to its regular programs as a result of the WHOrrDR trials in Tanzania. In addition, the size of trial required support from several donors, thereby widening the constituency for adopting and promoting the results. Capacity Building All of the interventions were African investigator-initiated. Technical assistance was provided for development of protocol, the implen1entation of interventions, and data analysis and reporting. The principal investigator for research in Kenya on shopkeepers and optimization of ·drugs is now serving on the Task Force for Home Management of Malaria. Social scientists in the countries in which the protocol was tested were trained in research design, qualitative data gathering and analysis. Three of these people were assisted by TDR to obtain doctorate degrees. WHO/AFRO is den:loping the capacity for implementing home management interventions for malaria and IMCI. What lessons hal'e been learned front this activity? • Developing and refining qualitative data-gathering protocols can be time-consuming and subject to continuous revisions. The result in this case is an instrument which has not gained wide acceptance and use. Some people indicate that a lesson gained from this activity is not to wait for a survey protocol to be completed before testing interventions arising from early results. Others suggest that without fully defining and understanding the problem--existing beliefs and practices--programmatic interventions may rernain fragmented and not be incorporated into wider policy or program development considerations. The latter argue that the absence of a sound database and • • • Malaria 11 institutional commit1nent which could be raised through use of the FES does leave gaps in the advocacy framework. Other lessons deal with the nature of the organizational relationship with WHO !fOR: • Once it has transferred funds, USAID/ AFR/SD has only limited control over developn1ent and implementation of the scope of works prepared for the use of the funds. Only about one-quarter of funds to TDR can be "hardwired" for specific activities. • In order to move research findings and recommendations more quickly into program design, dissemination planning should occur while the research is underway and be implemented quickly after the research findings become available. • Communication between WHO/TDR and WHO/AFRO would benefit from more frequent contact. Staff with the role of dissemination and advocacy for both organizations would sh O~~en~tiOn of ;· <, l ·;,;.! . ·;:.:A'I.lllanagers, heal~ .. ·'.\·:· ~ .. !~ r ~~ ~ .. -~<1\~:: -~-~ ~z';i, :.: i~ l •. · ~ . . F." ,~;...i ~ .-.s':-.·Jf ··· ·~ ~-. .. : ; .; 1,, -:·~· ; ' . • ~ J. ,' ·~ ... .!:. ·- ··: -- ; ·: ~ -; ........ ·; . . ;: .. . .. . .. . ' ···"''; ~ ..... ~ .... ~ .. \ ... ~: . • ''~· • • • .... . ),_ • ... ··=r' ., .~"-· ·\: ·· LT v·· f.' ·.c·~ · ;-.. .• ~ ... ·. , .... : :1-?ti~ :J~~~~~'::4~L_ · ~\#..,~ . ~r~ .: . .:.;-Ji. ·.i~/i ·l~ ;~ \.<\ J~~ ! .(· strategy ·< .;. ··.fr· ~. :· ..~ ;Jr, mfonnahon t~ -::r l.> ·.!· . ~- -. ·~ 1-! . ·~,· :. ;;· :j ,, :.:l ~· ~;:· ' ;~~~~~:<:•;... ~ t! :>f~~~-;· .·. >~ : .·: · · .: . ~.!: ·~-. : ·~ · b . . •.: h -'d··:: ... ·:'{'· ;-:J~~~~.:.~~t:k ~·td~i~~~ =·"~i · 'Ibree technacal \,...:·, . , · . . ; ··J ·I ·-~ ~~i: ... : . ..\_.; .. :,· .. J .. · .... {~systems managers ·.. ·.;_.,, on~r:s .r? . . ,,:,~';;':~ ., papers on malaria and scientists in s.::were ~ ·· .;:~_ .. . ,··. ·· • published in three malaria policy and mzed languages and planning, M&E, disseminated in the operational region. • During 1996 meeting on Antimalarial Drug Sensitivity and National Drug Policy, Malawi shared its experience in antimalarial drug efficacy. research for management, drug sensitivity testing, and drug policy. • 600 people trained as trainers for work with district-level staff. • 17 African scientists funded to conduct operations research. ____ ____.. __ ___.._ • • WHO/AFRO's leadership drew new or additional support from other donors into malaria control initiatives. What changed Changes in policies and programs • 38 of 42 countries developed malaria control strategies and action plans. The seventeen countries with action plans in 1994 strengthened those plans with target-oriented and quantifiable objectives. • 25 national M&E programs initiated • 4 countries increased/ added budget line items for malaria control. 1 I national malaria control officers ·\•'1' ~~tl~~ .. . ed by WHO and 3 more are tl~o~iri "f-'- ' . 8 • ~rcrru_ ... ~ .. ,. ~~!~~p unproved .,, , .... t :·· 1 , • ~, ....... ,. , • le~entary ' . i:{J~~ ; ) : ' . 1g practices as ·· courses. 1 I part of a larger RH ========= related to STis. • USAID, PVOs, universities, donors, and key African institutions received copies. • Multiple copies provided to BASICS and Linkages projects. project. Complementary • A training activity with the guide, Activities organized by SOMA-NET, yielded 8 • Following the regional training in West Africa, materials were also used for country￾level training activities in Morocco, Senegal, and Benin. • IMCI development in Africa requires nutrition studies and has generated demand for Designing by Dialogue. research proposals of which 5 were funded. • Manual used extensively by BASICS and Manoff Group in Madagascar, Zambia, Senegal, Mali, and Morocco to adapt the IMCI food box and in Madagascar, Zambia, Benin, and Bolivia to improve nutrition counseling. Using Nutrition Data for Policy Development: Workshop on the Use ofDHS Data to Influence National Nutrition Policies Main results and significance of the activity Nutrition • The was the earliest HHRAA/SARA activity to train Africans to use and re-package existing data for advocacy and policy dialogue. • 18 participants from 6 Eastern and Southern African countries were trained in data synthesis, preparation of data-based presentations for use with policy makers, and advocacy planning. • Following regional training by two African institutions, five of the participating institutions prepared and received support for project proposals. • SARA revised its approach to the data-policy change continuum to give greater emphasis to the processes of change and advocacy. Dates of Activity: Location: Implementing Agency: Total HHRAA/SARA Funding: Leveraged Funding: 1993-1994 Entebbe, Uganda SARA (Commonwealth Regional Health Community Secretariat, Makerere University) >$60,000 n/a Nutrition What problem or gap did the activity address? Declines in child nutritional status were observed in many African countries during the 1980s and 1990s. At the same time, while nutritional well-being had rarely been a high priority, national nutrition programs often experienced some of the earliest cuts in budgets as structural adjustment programs were implemented. The Child Health Development Centre (CHDC) at Makerere University in Uganda had been successful in raising awareness of child nutrition issues with the country's senior policy makers. Presenting an analysis derived from DHS data, the CHDC gained a commitment from policy makers to make child nutrition a national priority issue. 2 CHDC proposed to host a workshop for national nutrition specialists from other Eastern and Southern African countries with recently completed DHS surveys. The workshop would use CHDC's experience as a model for training other specialists in the analysis and presentation of DHS data to stimulate policy changes. SARAIHHRAA supported the activity, as it represented a successful example of the projects' overall goal of utilizing data to affect policy making. This was one of the first opportunities to build upon a successful effort and was, at the time, the most explicit activity to promote evidence-based policy change within a HHRAA/SARA priority area . What was the purpose of the activity? Although the activity occurred before the formulation of Strategic Objectives, it would have occurred within SO 7--adoption of policies and strategies for increased sustainability, quality, efficiency, and equity of health services. More specifically, the activity would have contributed to attainment of IR 7.2.1--i.e., develop improved policies and strategies for areas of special importance, which includes nutrition. The purpose of the activity was to transfer "intellectual ownership" ofDHS data from demographers to nutrition policy specialists. That transfer would occur through the training of national nutrition specialists in the synthesis and presentation of data dealing with child malnutrition so they could sensitize policy makers to the extent of the problem and stimulate policy and/or programmatic actions. For SARAIHHRAA, the purpose of the activity was the spread to other countries of a method for policy change which had been successful in Uganda. The activity became a means to validate the premise upon which the projects were built. What were the specific objectives of the activity? • Prepare and conduct a workshop for nutrition specialists from at least three Eastern and Southern African countries to build skills in child nutrition data synthesis and presentation to decision-makers; • Have workshop participants develop data-based advocacy action plans on child nutrition • • • Nutrition 3 in their own countries; and • Apply the data-to-policy process methods which CHDC had successfully used in Uganda. What took place in implementing the activity? The activity took nearly 18 months to move from initial concept to the regional training workshop. Although CHDC proposed the workshop, its staff were too busy to prepare a formal proposal. SARA became involved in providing technical assistance to CHDC in preparing the proposal. SARA also contributed to development of the agenda and methodology and provided technical assistance during the workshop itself. Eighteen nutrition specialists from six countries (Kenya, Uganda, Tanzania, Malawi, Zambia and Namibia) attended the week-long workshop. The Commonwealth Regional Health Community Secretariat (CRHCS) identified participants from each country, seeking representatives from a national nutrition program, a person involved or familiar with the DHS data, and a person with experience in nutrition policy development. Participants had been sent the relevant DHS data for their respective countries and the DHS chartbooks and graphs for their countries. Participants were asked to study the materials and prepare a report on the basis of the data and their experiences prior to the workshop. During the workshop, participants received PROFILES projections (based on DHS data) on the relationship between nutritional status and mortality and morbidity for their respective countries. Data Analysis and Presentation The country teams had initiated work on their country nutrition situation assessments, and completed those profiles early in the workshop. On the basis of the data synthesis and participants' knowledge of national priorities and needs, each country team identified advocacy objectives to advance nutrition awareness and action in their countries. The teams from Zambia and Malawi prepared key messages, using DHS data as appropriate, designed to achieve their advocacy objectives. Teams from the other countries had more difficulty in formulating such concise and positive messages--a situation seen in similar training activities. Visual materials to support the key advocacy messages were prepared for specific target audiences. Action Plans On the basis of their data synthesis, identified priorities, messages and target audiences, each country team prepared an advocacy action plans. These ranged from quite general to moderately specific. As a follow-up to the action plans, one year after the workshop questionnaires were mailed to workshop participants to gather information on activities or changes that had occurred. Responses were received from two countries. Nutrition 4 What were the outcomes of the activity? The activity provided participants with some of the skills for policy-oriented data analysis and presentation. Most participants evaluated the workshop as useful for skill building. SARAIHHRAA received good feedback on some of the content used in the workshop and on the process being fostered by the workshop. There appears to have been different views between SARA and CHDC on the objectives and content emphasis of the workshop. SARA gave more emphasis to applying data to advocacy messages and the methods to present those messages for policy impact. CHDC emphasized more the interpretation of the DHS nutrition data and spoke in terms of communication and dissemination, rather than advocacy. Further, key individuals responsible for facilitating the workshop either were sick or had dropped out of the process, leaving people who were to run one or two sessions largely responsible for the entire week. The DHS chartbooks were considered either too complex or too general to be directly relevant in preparation of presentations. Finally, the plans of action were welcome by participants, but, as noted, some would be difficult to implement as they lacked specificity or were too ambitious. No follow-up funds or technical assistance were to be provided, which also hampered implementation in some cases. Analysis There were no research findings per se within this activity. However, the advocacy objectives formulated by each of the country teams indicates, in part, the conclusions derived from analysis of the DHS data. The advocacy objectives for each country included: • Kenya: reduce undernutrition in rural areas by improving small fanners' access to credit and agricultural loans; • Malawi: gain momentum for implementing existing plan to improve feeding practices among young children; • Namibia: create the human resource capacity in the area of nutrition at institutional and community levels; • Tanzania: increase NGO and private sector involvement in the implementation of the National Plan of Action in Nutrition by 20 percent over 5 years; • Uganda: formulate state, national feeding guidelines for pregnant and lactating women, and for children less than 3 years old, over two years; and • Zambia: formulate a national food and nutrition policy. The action plans developed by participants from Namibia and Uganda were feasible and based on appropriate analysis of the available data. The plans from the other countries, however, included advocacy objectives which were either too vague or too ambitious and without a firm base in the data. • • • Nutrition 5 Table 1: Fulfillment of Objectives Objectives Met, Not Met, Exceeded Comments/Sources Prepare and conduct a Exceeded--6 countries involved workshop reports workshop for nutrition specialists from at least three countries to build skills in child nutrition data analysis and presentation Have workshop participants Met workshop reports develop data-based advocacy action plans on child nutritional status Test the data-to-policy process Met workshop reports which CHDC had successfully used in Uganda Products • workshop organized • 18 national nutrition specialists from 6 countries trained in data presentation for advocacy • nutrition advocacy plans developed for 6 countries • post-workshop and 12-month post-workshop evaluations conducted. What complementary efforts contributed to the results of the activity? The DHS division of MACRO International prepared concise summaries (known as African Nutrition Chartbooks) of nutrition indicators for 18 African countries, with graphics and data, some of which were presented in overhead formats. In-depth reports on 6 countries had also been prepared by DHS. It was expected that the chartbooks would be used by country nationals in presentations. Both the relevant chartbooks and the in-depth reports were used as resource materials in the workshop. What results were achieved? Results can be considered on two levels. On the immediate level of the workshop, participants acquired knowledge about re-packaging and presenting data in forms designed to inform and influence policy makers. They prepared advocacy action plans to apply those skills and two of the country teams implemented portions of their plans. On the longer-term level, SARA/HHRAA gained valuable experience in how to formulate the data-policy process and recognized that building and apply skills for use in that process usually requires more than one week of intense training. Understanding the problem The activity sought to build skills to use data for nutrition advocacy. Country teams used DHS data to define nutrition problems in their countries and expressed those problems in the context of action plans for gaining policy Nutrition 6 Changes in Policies and Programs lternative Solution." '!be process of policy and program change involves lhe interaction of describing problems, identifying solutions, and advocacy. support for change. By analyzing existing data and applying it to select nutrition problems, the activity provided participants with an approach to clarifying problems. Alternative solutions The workshop was designed to familiarize participants with a data-based approach to nutrition advocacy--an approach which offered policy makers and planners a more tangible and "objective" basis for viewing options. Thus, the workshop was intended to widen the scope for effective planning. Advocacy The workshop sought to build advocacy skills in the context of presenting appropriate nutritional status data. Workshop participants from Namibia and Uganda subsequently developed portions of the action plans which had been drawn up during the workshop, including the use of data for advocacy. Changes in policies, and programs Follow-up through correspondence found that some progress had been made by the participants from Namibia and Uganda in implementing their action plans, but details were not readily available. • • The biggest change occurred in the thinking and approach of SARA. Interest in short training that encompassed two major disciplines (in the case of this activity, nutrition data analysis and development of advocacy presentations) was reconsidered and agendas re-structured. SARA began giving much greater attention to documenting the importance of the policy development process. It subsequently published a theoretical overview of the use of knowledge for policy change and a guidebook for preparing and conducting advocacy work. Increased emphasis was given to follow-up activities after a training event to reinforce the idea of the process of policy change. The shift in SARA's thinking and approach is reflected in the three-ring diagram, illustrated at the beginning of this section: policy change occurs as a result of the interaction of problem definition, identifying alternative solutions to address the problem, and advocacy to gain • Nutrition 7 the understanding and support of decision makers. The revised policy approach corresponds to prevailing understanding and is sufficiently flexible to be adapted to many specific political and bureaucratic situations. Capacity Building Most of the 18 participants came away from the workshop with a more thorough understanding of the use of data for policy advocacy. An evaluation at the end of the week's events found most participants satisfied with the workshop and the skills they acquired. What lessons were learned from the activity? Among the lessons learned were: • The workshop provided SARAIHHRAA with field experience in applying its model of use of data for policy and program changes. Both projects learned that the process was neither as self-evident or as easily understood and applied as had been thought. That experience, especially with feedback from participants, encouraged SARA to consider alternative ways of promoting its approach to policy change. • Data analysis, re-packaging, presentation and advocacy are parts of a policy development process. Those parts, and others, usually are needed in order to secure policy changes. • Moving data into policy advocacy is more demanding and requires a wider set of skills than can normally be acquired within a one week workshop. Thus, SARA developed An Introduction to Advocac.:r. a guide designed to introduce and build skills for public health advocacy; • Greater emphasis is needed on the policy development/advocacy process than had been considered; • Resource materials (e.g., the DHS data) need to be carefully tested with appropriate audiences to assure than effective usage; • Fallow-on T A and perhaps funding support for groups acquiring new skills in policy development often is required to reinforce learning and assist in adapting those skills to local realities. What were the next steps? The activity ended late in 1994. There were no proposed next steps directly arising from this activity, but, as noted above, SARA revised its approach to policy development. Nutrition Resources Consulted Written Jessica Jitta and Souise Sserunjogi, Proceedings of the Regional Workshop on the Use of DHS and other Nutritional Data to Influence National Policies. Entebbe: Makerere University, Child Health and Development Centre, 1994. Ellen G. Piwoz, et al., Makerere University Workshop on the Use of DHS and other Nutrition Data to Influence National Policies. Washington, DC: SARA, 1994. 8 Ellen G. Piwoz, et al., Planning the Makerere University Workshop on the Use of DHS and other Nutrition Data to Influence National Policies. Washington, DC: SARA, 1994. Marita Marx, An Assessment of the Dissemination and Use of DRS-Related Nutrition Documents in Africa. Washington, DC: SARA, 1995. Informants Ellen Piwoz, SANA/AED Suzanne Prysor-Jones, SARA/ AED Prepared by SARA: Bill Rau Latest Revision: July 3, 1998 • • • Analysis and Training • Analysis of existing country DHS data and formulation of action plans arising from the analysis. • Approaches to What Dissemination • Activity sought to train participants in and dessirninate a medthodology for using data for policy change that had been developed Using Nutrition DaflJr Policy Development: Workshop on thCUse of DHS Data to Influence National Nutrition Policies happened Advocacy • Themes selected for advocacy by each country team and an advocacy action plan developed for each country. Capacity Building • 18 nutrition specialists from 6 African countries trained in analysis of DIIS data for use in advocacy. TA and Other Activities • SARA T A from AED, DHS/Macro and PRB was What changed Changes in policies and programs • Namibia and Uganda teams implemented portions of their plans (information not available for other countries). • The workshop experience influenced SARA's approach to ;Jr -.' ... • __ J __ -_ :t:e~ult __ - --•. :-• .v _o····.-c.· a . ··c:··.y . ._ .. ·_and greater advocacy attentiOn t~aining, to t: pf~t~\ :: ~ at produce changes. ·· .. · - ntributed to development of An Introduction to Advocacy Training Guide. Health Care Financing and Refonn Public-Private Partnerships for Public Health Main results and significance of the activity • Four African country case studies were prepared. Together, these represented a significant body of information available on issues regarding public-private partnerships for health. • The research showed the extent to which the private sector already contributes to public health. The evidence illustrated the diversity of public and private contributions to health delivery. • A methodology was developed for assessing the role and extent of private sector contributions to public health. • In Zambia, the Ministry of Health used the results in its health care reform efforts. The research generated enthusiasm and the findings became a useful policy formulation and advocacy document. Also, MoH officials persuaded the USAID mission to add public-private partnerships to its portfolio. Dates: Location: Implementing Agencies: HHRAA Funding: Resources Leveraged: 1993-1997 Kenya, Senegal, Tanzania, Zambia Data for Decision Making project (Harvard University), Health Financing and Sustainability project (Abt Associates), and African Medical Research Foundation (AMREF) c.$600,000 nla Health Care Financing and Reform 2 What was the problem or gap to be addressed? Financial and quality constraints on African countries' health services had led to numerous efforts to reform both the provision and financing of those services. User fees were widely adopted and changes in management and procurement systems to improve quality were implemented. USAID, the World Bank, other international donors advocated shifting some functions of public health provision to the private sector. Consumers use private sector providers at different points within a continuum of care seeking behavior--from point of first contact (often with traditional health providers), to use of private clinics and hospitals, to purchase of drugs or injections through pharmacies or street-level merchants. However, too little was known about the diversity of private sector health options in most African countries and the ability and willingness of private sector health care providers to address public health concerns. In order to identify appropriate policy responses, more information was needed on the type and level of health services provided through the private sector and the potential of private sector providers to contribute to national health goals. What was the purpose of this activity? The activity contributed to Strategic Objective 7 which deals with the adoption of policies and strategies for increased sustainability, quality, efficiency, and equity of health services. Under • S07, IR 7.1.4 addresses the development of strategies for increased public-private sector . -- partnerships. The purpose of the activity was to provide a more complete understanding of alternatives to public financing of health care. By examining the extent to which private sector health providers and institutions contribute to public health (by providing, for example, immunizations and prevention education), the activity sought to identify policy options which could both improve public health services and diversifying the funding base for health care. It is generally known that up to half of all health expenditures in African countries are made within the private sector (see impact assessment on Resource Mobilization). This activity was expected to add depth and breadth to existing knowledge with a clearer statement of "private sector" contributions and constraints in health provision and financing. It was expected that general lessons would arise from the research about the potential for public-private partnerships in promoting public health. What were the specific objectives ofthe activity? The activity had three objectives: • Develop a topology of "private sector" health providers and provide a methodological context for preparing country case studies; • . - _ • Collect data for and prepare four country case studies (Kenya, Senegal, Tanzania, Health Care Financing and Refonn 3 Zambia) which illustrate the experiences with private sector health provision and which identify areas for potential increases in private sector contributions to public health; and • Disseminate the results in order to inform and stimulate government-level reforms. What took place with this activity? Research and Analysis A topology of private sector health care provision and financing was developed. The topology is very complete and provides a framework for further analysis, if it were to occur. The field research was conducted in Kenya and Zambia by the Data for Decision Making (DDM) project at Harvard University and in Senegal and Tanzania by Abt Associations through the Health Financing and Sustainability project. In Zambia a local private research firm was contracted to assist in the data gathering. In Kenya, DDM collaborated with the African Medical Research Foundation (AMREF) for data collection and analysis. In Tanzania, collaboration was obtained from university researchers, primarily in adapting the research design to local conditions and in collecting the data. In Senegal, data that had been previously collected, some with African researchers, were the primary sources for the case study. Each of the country studies sampled a range of private and public health providers: mission and religious-based facilities, workplace clinics/hospitals, for-profit and non-profit facilities, traditional healers, pharmacies and street vendors. Dissemination Both USAID and DDM distributed the country case studies and the summary document. USAID hosted a regional conference in Nairobi to present and discuss the findings within the general theme of "How can countries make better use of public and private health resources to further national health goals?" The conference also sought to have the African participants, who represented 14 countries, identify follow-up actions. The conference was attended by 77 participants from 14 African countries the U.S. and European countries. Participants worked in both private and public health sectors as providers, policy makers, and researchers. What were the outcomes of this activity? The research illustrated the diversity of private sector providers and the level of involvement of clients with private providers. The information found in the case studies was solid, detailed and could be used to guide identification of policy options, including those recommended in each country case study. However, more vigorous dissemination of the findings and reports through in-country discussions was needed to stimulate broader policy action than occurred. In order to do this, preliminary consultations with government officials, USAID, other donors and NGO health providers would have laid the ground for the post-research application of the findings and recommendations. Health Care Financing and Reform 4 Research Findings The country case studies showed the diversity in types, location and services offered by private sector providers. Generalized findings from the four country case examples are shown in table 1. Table 1: Private Sector Provision of Health Care 0 /o coverage Level of Private sector Opportunities identified for by private demand contributions to policy action sector: for public health* hospitals/ private Country out-patient services treatment Kenya 50/51 high medium different by type of provider, but potential for subsidies and credit for rural practices Senegal 8/c.50 low- limited, curative subsidies to private sector for public medium oriented health interventions Tanzania 44/rapidly medium c. 20-25o/o seed capital for and removal of high growmg and taxes on private practices; removing growing legal and regulatory constraints Zambia n/a low, due to unknown, c. 30o/o; relax· restrictions on private practice economic urban bias constraints * Public health, in these instances, encompasses immunizations, FP, children's illnesses, STDs, TB. Source: "Summary of Country Studies .... " • • • Health Care Financing and Reform 5 Table 2: Fulfillment of Objectives Objective Met, Not Met, Source/Comments Exceeded Develop topology of the "private Met Methodology report; the sector" health providers and a topology is analytically methodology for preparing useful, but too complex for country case studies. field application. Prepare four case studies of Met Case studies; informants country experiences with private sector health provision. Disseminate the results in order Partially Met Conference report. to inform and stimulate government-level refonns Products • four country case studies • one paper describing the methodological framework • one summary report • a report on the dissemination conference. These documents were published by DDM in a working paper format. What complementary efforts have contributed to the results of this activity? There have been extensive changes in African social services systems in recent years. Privatization of industrial, distribution, and service activities once run by government or as parastatals has moved forward in many countries. Thus, the overall climate among donors and many governments emphasized both structural and institutional reforms, including privatization of some institutions. Privatization in the health field has occurred, with privately operated, for￾profit clinics, hospitals and drug outlets growing in number. The World Bank commissioned several country studies on the issue about the same time as this activity. Also, the World Bank (more specifically, the International Finance Corporation of the Bank) has provided loans to private companies to establish or expand health care operations. For example, early in 1998 the IFC provided $500,000 to a private health provider in Kenya to expand the number of facilities it operated. What results have been achieved to date? The country case studies provided the fullest collection of data available in Africa on private contributions to public health. Zambian health authorities quickly applied the findings to on-going health care reforms. Other countries showed less interest. At least some of the reluctance or indifference could have been overcome if, from the beginning of Hc:!lth Care Financing and Reform 6 Changes in Policies and Programs Jternntive Solution.c; 'I be process of policy and progr.un change involves the interaction of describing problems. identifying solutions, and advocacy. the research activity, greater attention had been given to country priorities and greater involvement of local researchers and policy collaborators. Likewise, without incorporating an advocacy or a policy development strategy into the research design, follow-up was constrained. Understanding the problem The research helped to clarify the type and level of use of private sector health services. In an environment where it was widely assumed that governments are the overwhelming financial supporters of health systems, the research showed instead that many health systems are financed through a variety of sources. A more balanced view of health system funding emerged from the activity. Identification of alternative solutions The individual case studies suggested actions for countries to consider and the international conference yielded six "prevailing views". The identification of these views does not offer alternative solutions, as they are too broad and general, but they help establish a context within which further clarification and specificity could arise. Subsequent debate about policy options and program direction occurred in Zambia. Advocacy An advocacy strategy was not developed by or with interested in-country partners. However, Zambian officials involved in the study used the findings for advocacy within the MoH and with their donor partners. Changes in policies and programs MoH officials in Zambia found the study very useful and it had a significant influence on health system reform in that country. The case study identified many of the problems to be addressed in public-private collaboration and responses to the problems were either incorporated into the • • reform legislation or guided planning and administration. It is interesting to note that the case • study on Zambia was ambivalent in its recommendations for policy action. Yet, for Zambian Health Care Financing and Reform 7 officials, the data and analysis addressed issues important to them and verified the importance of expanding opportunities for private sector contributions to public health. Zambian officials found the study very useful as it provided information that was considered during health system reforms. The Zambian officials persuaded the USAID mission to add the issue to its portfolio In the other countries, health reform debates and activities have occurred, but there is no evidence that the HHRAA case studies have contributed significantly to those processes. Capacity Building The activity was carried out largely by DDM and Abt Associates. African collaborators were used primarily for data collection. Thus, the activity made little contribution to capacity building. What lessons have been learned from this activity? • Assure that the research topic is situated within the active agendas of country partners or seek to make it so prior to or during the actual research Although there was enthusiasm for the activity within USAID/ AFR and endorsement from the consultative group which reviewed the process and proposed research in September 1993, two of the four US AID missions where case studies were planned did not consider the research a priority nor relevant to their programs and a third placed it as a low priority. While the research proceeded in all four countries. the findings from the case studies appear to have had little impact on USAID mission priorities in the three countries that considered public-private partnerships of little relevance. In those countries, it is not known if the findings were utilized by ministries of health, all of which are undergoing various forms of reforms. However, the IFC loan to a private health provider group for work in Nairobi (see section on Complementary Efforts) is likely to have involved some discussions with the central or municipal government. In addition, undertaking a large research activity which is expected to produce results to inform and influence policy and program decisions relies on fitting into national and institutional priorities and forming partnerships with researchers, advocates, program manager. A suggestion made by the USAID task manager to do more effective pre-research preparation with governments, the USAID missions and others would have been helpful for this activity. Only one mission was represented at the September 1993 consultation that set the overall research agenda for USAID/AFR/SD's Health Financing and Organizational Reform activities, but that country was not selected as a target for a case study. • Without in-country collaboration, opportunities are greatly diminished for this or related activities to contribute to building a constituency to carry the issue. Health Care Financing and Reform 8 • More aggressive dissemination of fmdings and policy implications can increase interest • and support for the issues. What are the next steps for this activity? Ideally, the country case studies would provide a basis for greater consideration by both missions and governments of the issues and problems involved in public-private collaborations. For example. the Tanzania government is seeking to reduce its role in direct health provision. It is encouraging a greater presence by the private sector in health care delivery. Thus, this case study could be an important contribution to Tanzania's policy change process. The Senegal country study recommends a more modest and cautious approach to the issue. In fact, the report~ s authors suggest that investments in private provision of preventive health care will be risky and investments should be carefully monitored and evaluated for impact and cost effectiveness. They indicate that social marketing of contraceptives, condoms, ORS and iron supplements may be feasible. Delivery of public health services through private providers is likely to require government subsidies. Both recommendations suggest that key next steps rest with government, in terms of setting priorities and strategies for partnerships and addressing legal constraints (p.52). If public-private partnerships for public health is a priority for USAID/Senegal or the Senegalese government a next step to consider would be support to policy reform/advocacy initiated from within the private sector itself--e.g., a medical and/or • pharmacists association. However, as noted in the following section, neither the Tanzania nor Senegal missions were supportive of the research in the first place and have shown little interest in including the issue within their portfolio or applying the results. A related option is for US AID/ AFR/SD to team with other international organizations and African governments to define appropriate next steps for this activity. One information tool for interaction with missions, governments or private sector providers would be a Policy Brief which describes the concept of public-private partnerships, analyzes some of the key issues, and suggest directions for further activities. • Health Care Financing and Reform 9 Resources Consulted Written Peter Berman and Kara Hanson, Assessing the Private Sector: Using Non-Government Resources to Strengthen Public Health Goals; Methodological Guidelines. Data for Decision Making Project, Harvard School of Public Health, Boston, MA, 1994. Peter Berman, et al., Kenya: Non-Government Health Care Provision. Data for Decision Making Project, Harvard School of Public Health, Boston, MA, 1995. Peter Berman, et al., Zambia Non-Government Health Care Provision. Data for Decision Making Project, Harvard School of Public Health, Boston, MA, 1995. Kara Hanson and Peter Berman, Non-Government Financing and Provision of Health Services in Africa: A Background Paper. Data for Decision Making Project, Harvard School of Public Health, Boston, MA, 1994. Gerald Hursh-Cesar, Private and Nongovernment Providers: Partners for Public Health in Africa; Conference Report. Data for Decision Making Project, Harvard School of Public Health, Boston, MA, 1994. Gerald Hursh-Cesar, Summary of Country Studies: Private Providers' Contributions to Public Health in Four African Countries. Data for Decision Making Project, Harvard School of Public Health, Boston, MA, 1994. James C. Knowles, et al, The Private Sector Delivery of Health Care: Senegal. Abt Associates, Bethesda, MD, 1994. Gaspar K. Munishi, et al, Private Sector Delivery of Health Care in Tanzania. Abt Associates, Bethesda, MD, 1995. World Bank/IFC, "Kenya--AAR Health Services." Abstract on World Bank web site at: www. worldbank.org/cgi-bin. Informants Abraham Bekele, USAID/ AFR/SD Suzanne Prysor-Jones, SARA/ AED Prepared by SARA: Bill Rau Latest Revision: May 29, 1998 Research and Analysis • Methodology prepared. • Four country case studies prepared. ~l~n~,~~~· • What Dissemination • International dissemination workshop held in Nairobi, with 77 participants from 14 African countries. . •,,: About 300 copies · .,~r;~~ of case studies, . . : -~~ :.·::l' rltethOdology~· , .· .· ~- conference reports distributed. Public-Private Partnerships for Public Health happened Advocacy • Not planned, but Zambians authorities found case studies important and used findings to advocate changes m neann system . . .:~;.· Capacity Building ' ( ,;) ~ ~ o; ..... ~;: .. '· .:4::. ~::·. ~ •• TA and Other Activities What changed Changes in policies and programs • Zambian health authorities used findings to influence health sector reforms and USAID mission portfolio. • Some recommendations formulated for individual countries, but not odressed. • Health Financing and Organizational Reform Resource Mobilization for Health Financing: Case Studies Main results and significance of the activity • Identified experiences in three African countries with various resource mobilization approaches, including comparison with countries outside of Africa. • Research findings showed a greater diversity of funding sources for health care than had been assumed. • To date, fee-for-service schemes have yielded only a small portion of overall health budgets. • Most countries lack a comprehensive strategy for achieving health financing reforms. Dates of Activity: Locations: Implementing Agency: Total HHRAA Funding: Leveraged Funding: 1994-96 Zimbabwe, Senegal, Cote d'Ivoire, Sri Lanka and Bolivia Harvard University, Data for Decision Making project $300,000 n/a Health Financing and Organizational Refonn 2 What gap or problem did this activity address? African governments have been hard pressed to fulfill their commitments to providing health care to most citizens. Economic recession and structural adjustment programs have weakened both the quantity and quality of public-funded health care. By the mid-1980s, an increasing number of African countries had adopted some form of cost recovery scheme--and in some cases, several schemes--designed to generate additional revenues for health care. A good deal of reporting noted the advances and problems associated with cost sharing. However, little systematic research had looked at the experiences with various resource mobilization strategies or the combination of strategies adopted by individual countries. The research associated with this activity sought to fill that gap by documenting country experiences with resource mobilization. What was the purpose of the activity? The activity contributed to Strategic Objective 7 which calls for the adoption of policies and strategies for increased sustainability, quality, efficiency, and equity of health services. Under S07, the activity contributed to IR 7 .1.1 which deals with developing innovative financing strategies. • In order to assist African governments to identify new or improved methods to generate financial • resources, or more efficiently use existing resources, the activity sought to identify successes and constraints which had been faced as various resource mobilization strategies were adopted. The research was expected to generate sufficient information to describe common lessons across several strategies which would be useful for policy makers. What were the specific objectives ofthe activity? The objectives of the activity were to: • prepare for five countries case studies that incorporate a review of national strategies and implementation experiences with cost recovery/resource mobilization in the health sector; • identify commonalities and lessons learned on the effects of different types of resource mobilization strategies and on implementation issues associate with various strategies; • develop guidelines for use by decision makers on selecting appropriate resource mobilization strategies. • Health Fin::.~cing and Organizational Reform 3 What took place during the activity? Research and Analysis The Data for Decision Making project at Harvard University developed methodological guidelines, conducted research to produce five country case studies--Zimbabwe, Senegal, Cote d'Ivoire, Sri Lanka and Bolivia--and prepared an overview that summarized the findings. The non-African countries were involved to provide comparative examples. Dissemination The findings from the studies were presented during a regional workshop in Dakar, in 1996, and in Harare and Nairobi in 1997. As with other studies presented at the workshop, the findings were of interest to African participants--they were an "eye opener" for the policy and decision makers in attendance, according to the USAID task manager. About 300 copies of the various reports were printed and distributed, during the workshop and subsequent meetings, visits and in response to requests. What were the outcomes of this activity? Methodology A research methodology was prepared that sought to examine four general questions: 1) What was the overall impact on health care resources of the strategies adopted? 2) What was the relative effect on government and non-government sources of finance? 3) Can the contributions of specific resource mobilization strategies be identified? 4) What was the effect on resources for public goods and primary health care services, if any? The research methodology included a literature review from which were identified six approaches to resource mobilization: • increased allocations from government revenues • targeted public revenue-raising • contributions from donors • social health insurance • private health insurance • user fees Health Financing and Organizational Reform 4 Research Findings The research confirmed that health care funding comes from a mix of sources, as shown in Table 1 (non-African examples are excluded). Table 1: Sources of Funding for Health Care Country Revenue Out of pocket spending Social Private NGOsand from taxes insurance insurance donors Private user fees Cote d' I voire <50o/o >40% <4o/o <3% Senegal <46°/o >25% <3% -10% 3-4% 17o/o Zimbabwe 39% 30% negligible 17% 13% In all three countries, public spending and out-of-pocket expenses by individuals and households accounted for the major sources of funding. To date. user fees provided some, but very limited, revenues to the overall mix. Perhaps more significant is the generally high level of out-of-pocket expenses most citizens incur to receive health care. • The findings on spending patterns and other issues left US AID/ AFR/SD with the conclusion that • it was not possible, in policy or program terms, to suggest one common approach to effective resource mobilization. On one hand, that is a positive finding, for a cookie-cutter approach to policy promotion would not be effective or successful. On the other hand, the diversity makes it more difficult for non-specialists to grasp key points and concepts. Adding to the problems of identifying a common approach and guidelines for policy makers is the fact that most resource mobilization initiatives a product of ad hoc decisions and changes rather than conscious strategy. The researchers write: " ... there does not seem to be any evidence to indicate that [governments] have thought of a comprehensive strategy .... " Health Financing and Organizational Reform 5 Table 2: Fulfillment of Objectives • Objective Met, Not Met, Source/Comments Exceeded prepare five country case studies Met Case studies that review national strategies and implementation experiences with health sector cost recovery/resource mobilization identify lessons learned on the Met Case studies; project reports effects of different types of resource mobilization strategies develop guidelines for use by Not met Information too diverse to decision makers on selecting draw common attributes appropriate strategies Products Resource Mobilization: Methodological Guidelines. Data for Decision Making project (DDM), • 1996. Experiences with Resource Mobilization Strategies in Five Developing Countries--What Can We Learn? DDM, 1996. Health Reform Initiatives in East, Central and Southern Africa. Proceedings of a consultative meeting held by the Commonwealth Regional Health Community Secretariat, Nairobi, 1995. HHRAA, A Strategic Framework for Setting Priorities for Research, Analysis, and Information Dissemination on Health Sector Financing and Sustainability in Sub-Saharan Africa. 1995. Quality of Health Care and Cost Recovery in Africa: Evidence from Niger and Senegal. ABT Associates/Health Financing and Sustainability project, 1994. Plans to prepare guidelines for policy makers were dropped, given the difficulty of generalizing from the diverse findings. What complementary efforts have contributed to the results of this activity? Resource mobilization for health is a topic of concern to most African governments and many international donor agencies, as suggested by the organizations that provided supplementary funding for this activity. Part of the on-going interest is due to the divergence of opinions about the impact of cost recovery mechanisms, particularly on lower income groups. Thus, advocates and analysts from the World Bank and major bilateral donors have stressed the importance of diversifying the funding for health in order to improve quality and quantity of services; • Health Financing and Organizational Reform 6 community-based groups, NGOs and some international agencies have argued that the costs of health resource mobilization fall most heavily upon lower income groups and the improvements have not occurred. This activity fell into this lively debate, giving the research and subsequent discussion of the findings a tangible context. In Zimbabwe further detailed research on both private and social insurance schemes has been undertaken, complementing the review that occurred during this activity. What results have been achieved to date? Understanding the problem According to the DDM methodological statement, this activity was unique in focusing on country strategies and implementation experiences. Earlier studies had deal with a single strategies and their implementation, the impact of a single strategy, or concurrent changes in health systems. As noted earlier, the findings showed a great diversity from country to country. In terms of defining the problem of resource mobilization, the diversity of the case studies adde~ depth to earlier studies. Both for implementing governments and donor advocates, the case Understanding the Problem Changes in Policies and Programs lternative Solutions 'lbe process of policy and progrcUil change involves the interaction of describing problems. identifying solutions, and advocacy. studies suggested that single-solution approaches are unlikely to achieve their intended objectives. However, the studies did illustrate two forms of resource mobilization considered "innovative." The first were private insurance scheme in southern Africa which have been able to incorporate a sizeable proportion of formally employed people. The second were the mutuelles, community￾based risk sharing schemes found in West Africa. The latter continues to receive attention from USAID and other donor groups. Further, the case studies pointed to the importance of effective management of the implementation of resource mobilization strategies and schemes. The mutuelles and insurance schemes offer opportunities for expanding the base of resources, but poorly implemented activities will discredit either approach. It is noted in the overview conclusions that improvements in efficiency of health system operations are likely to have a greater impact on cost than the cost recovery mechanisms already put in place in most countries. Health Financing and Organizational Reform Alternative Solutions Some further study of mutuelles has been suggested, but remains to be undertaken. Likewise, further work on insurance schemes--community-based, private sector, or social insurance-- remains to be developed in detail. In Zimbabwe, one result of the research was that the government has examined more closely both private and social insurance approaches. Advocacy There has been some advocacy with several international organizations (UNICEF, Africa Development Bank, Economic Commission on Africa) to test possibilities for partnerships between these organizations and USAID. USAID missions in Africa have shown only slight interest in the studies and the issue. Changes in policies and programs There have been few substantive changes in the policy environment of any of the studied countries or of countries at the dissemination workshops as a result of this research, although, as noted, the government of Zimbabwe has continued to study both social and private insurance 7 • schemes with the aim of instituting health financing reforms. However, that country has been • very slow to adopt health related policies. Also, Mozambique which requested technical assistance as it developed a resource mobilization strategy. If changes have occurred in the policy environment it is more likely to have been the result of on-going experience and political pressures; the research undertaken with this activity may have contributed to those internal debates, but as in the two West African countries, debate did not lead to policy or program changes. In West Africa, CESAG was stimulated by the research and dissemination workshop to incorporate health care financing in its training curriculum. Capacity Building African institutions were not involved in the research activity nor was subsequent training provided for African institutions in the application of the findings. CESAG was able to use the findings to refine a proposal for including health financing within their curricula. What lessons have been learned from this activity? • In some cases, it will be necessary to spend time and resources sensitizing and gaining the interest and support of in-country partners before the research begins. For example, research, even when designed within overall USAID priorities, may not coincide with specific mission portfolios or government implementation priorities, and thus receive minimal attention until the mission becomes more aware of the importance of the issue . • Health Fin.:.'"lcing and Organizational Reform 8 • When it became clear that missions were not interested or only marginally committed to hosting resource mobilization research, planning should have begun to promote the findings in ways to overcome likely obstacles. • Also, given the limited mission interest, post-research pilot implementation activities could have provided field-tested options, built local capacity, and provided a basis for solid advocacy. • Involvement of local institutions in the design and implementation of the activity would have helped build local ownership as well as local capacity. What are the next steps for this activity? During the portfolio review on health sector reform (January 1998), participants identified the following next steps for resource mobilization: • Update the World Bank study by R.P. Shaw and Charles C. Griffin, Financing Health Care in Sub-Saharan Africa through User Fees and Insurance (1995). • Update 22 Questions. • Develop a menu of options on specific aspects of resource mobilization for specific audiences. Other suggestions raised during that meeting are encompassed under the following categories: • Engage US AID missions, REDSOs. and other parts of the agency on the issue. • Develop regional and national capacity to monitor resource mobilization and assess options. • Using marketing strategies and public relations methods, disseminate best practices to policy makers and public health officials. • Conduct research to determine necessary and sufficient conditions for successful social and private insurance schemes. • Define and follow an advocacy strategy for internal promotion of the issue. It seem unnecessary to up-date the Shaw/Griffin study. While current and cumulative information is important for understanding systems and social experiences with forms of resource mobilization, producing another book for a narrowly targeted audience seems less useful than generating wider interest and involvement in the issue. Most critical for US AID/ AFR/SD is to clearly define what it wants to do with the issue of resource mobilization and develop a strategy to do so. Without a strong push or other inducement, missions are unlikely to adopt the issue. Likewise, funding regional and national capacity building is difficult without mission support. There is likely to be value in popularizing I ' Health Financing and Organizational Refonn 9 and promoting the issue, focusing on stimulating interest and awareness in one or more aspects of resource mobilization. As the issue of resource mobilization touches on and is related to other issues in the health reform portfolio, it seems possible to shape a message and dissemination and advocacy strategies which embody most or all of those issues. Perhaps the proposed association with other institutions will add impetus to consideration of the research findings. One or more pilot activities in the areas of insurance or community-based funds, with multi-agency support, could demonstrate their feasibility. Other next steps include: • Identify where in Africa and in what ways US AID/ AFR/SD can strengthen understanding of mutualles and insurance schemes, if these are considered viable resource mobilization options. • Prepare a list of options for discussion purposes among policy makers. The case studies and summary report were too diverse to develop commonalities, but a list of options, with accompanying rationale, is feasible. • • Health Financing and Organizational Reform 1 0 Resources Consulted Written Mukesh Chawla and Peter Berman, Resource Mobilization: Methodological Guidelines. Data for Decision Making project (DDM), 1996. Mukesh Chawla and Ravindra Rannan-Eliya, Experiences with Resource Mobilization Strategies in Five Developing Countries--What Can We Learn? DDM, 1996. Health Reform Initiatives in East, Central and Southern Africa. Proceedings of a consultative meeting held by the Commonwealth Regional Health Community Secretariat, Nairobi, 1995. HHRAA, A Strategic Framework for Setting Priorities for Research, Analysis, and Information Dissemination on Health Sector Financing and Sustainability in Sub-Saharan Africa. 1995. Annemarie Wouters, Quality of Health Care and Cost Recovery in Africa: Evidence from Niger and Senegal. ABT Associates/Health Financing and Sustainability project, 1994. Informants Abraham Bekele, USAID/ AFR/SD Suzanne Prysor-Jones. SARA/ AED Mukesh Chawla. Harvard University Prepared by SARA: Bill Rau Latest Revision: May 7, 1998 Resource Mobilization for Health Financing: Case Studies Research and Analysis What Dissemination happened Advocacy • Methodology • Findings presented "Quiet advocacy" to developed for at three foster future Capacity Building TA and Other Activities What changed Understanding the problem assessing forms conferences in collaboration with • Range and size of resource and levels of Africa with over UNICEF and ECA. mobilization mechanisms resource 200 participants. documented. ;.i ir~·~hl!~~~~:# :, t:::J:~:~!~iJ;; . . ~t .. : . , . ·~: '1 lJ. · . . · .. : .·' Iternative solutions analysas on · ;:·•<: ·'>· :,. - ·.: , and the summary ,, ,.,, · · • Two potentially viable options identified by research: private insurance schemes in southern Africa and mutue/les, community￾based risk sharing schemes found in West Africa. • ''• 'f o~' J·.': f · : . ; ;"'_.•:~~ ~ ,_( I ( 0 • ( : '' :;;~ J~ expenences m JIVe I overvaew were countries. distributed. • Case studies prepared from data. • Broad conclusion was that effective management of resources can yield greater savings than revenues that can be generated through resource mobilization programs. • • Changes in policies and programs • Mozambique requested TA in designing resource mobilization strategies. • Zimbabwe has continued to study insurance options for health care financing. • CESAG used results to refine proposal for including health financing in curricula . • ::J: 0 VJ '"C ~ r )> c d z 0 3: -< Health Financing and Organizational Refonn Hospital Autonomy for Health Reform: Case Studies Main results and significance of the activity • Five case studies on hospital autonomy contributed the most extensive and methodologically coherent body of data available on the topic for Africa. • The activity increased our understanding of autonomy issues by discussing a range of situations found in programs to establish and maintain hospital autonomy. • Hospital autonomy is often approached as a means of increasing available resources and quality of care. The study found in1provements in management structures and processes--i.e., efficiency--within hospitals may be more important than autonomy per se as a means of cost savings in excess of income from cost recovery mechanisms. • Also, the study argued that autonomy in public sector hospitals had not yielded many of the expected benefits in terms of efficiency. quality of care, and public accountability. Dates of Activity: Locations: Implementing Agencies: Total HHRAA Funding: Leveraged Funds: 1994-1997 Ghana, Kenya, Zimbabwe, Indonesia, India Data for Decision Making project, Harvard University $300,000 n/a Health Fir.ancing and Organizational Reform 2 What was the problem or gap being addressed? Hospitals in Africa tended to consume half or more of ministry of health budgets, no matter at what level they operated, but served a proportionately smaller part of the population. It was sensed, but not known, that increased autonomy for hospitals could (and would) lead to financial and delivery efficiencies and free up resources for clinics and other primary health care services. Efficiencies in service delivery and resource use were of major concern. Financial constraints on public-supported health facilities and declines in the quality of service delivery since the early to mid-1980s were widespread across Africa. An increasing number of countries imposed fees (in some form) for use of public health facilities. Proponents of fees have argued that fee-for-service arrangements would supplement public funding and result in improvements in quality of care. At the same time, a number of African governments were considering the decentralization of a number of public functions and the deregulation of others. In most African countries, district and/or provincial hospitals would likely become the local center in decentralized systems. How those hospitals were integrated into the decentralization processes would shape their roles and influence their autonon1y. Hospital autonomy (or hospital management, as it has become known within USAID) was considered one of the key issues in health system reform, but little was known about existing experiences. The Data for Decision Making Project at Harvard University, with HHRAA funding, developed research guidelines. gathered information and experiences from three African countries on hospital autonomy, and compiled three case studies and a summary paper on the issue. What was the purpose of this activity? The activity occurred within the context of Strategic Objective 7 which calls for the adoption of policies and strategies for increased sustainability, quality, efficiency, and equity ofhealth services. Under S07. the activity contributed to IR7.1.1 which focuses on developing innovative financing strategies. The purpose of the activity was to assess the experiences of six large public hospitals, in Ghana, Kenya and Zimbabwe, where autonomy had been instituted to varying degrees and in varying forms. Two additional .case studies were prepared to provide comparative experiences in India and Indonesia. Lessons derived from these reviews were expected to aid policy makers with managing the autonon1y processes, particularly the financing of health care in hospitals. • • • Health Financing and Organizational Refonn 3 What were the specific objectives of the activity? The objectives ofthe .country studies were: • to provide specific case examples which could assist policy makers in each country to evaluate policies on hospital autonomy and determine the feasibility of full implementation; • to assess the effects of autonmny on resource mobilization, efficiency, equity, and quality of care; • to provide lessons for other countries on the issues of and optional approaches to public hospital autonomy; • to provide guideline for implementation of hospital autonomy; and • to provide guidance to donor organizations in their support for similar initiatives. What took place in implen1enting this activity? Research and Analysis The research was planned and conducted by the Data for Decision Making (DDM) Project at Harvard University. A case study methodology was adopted for the research in this activity. Guidelines were developed for assessing through a case study methodology hospital autonomy along four criteria: efficiency, equity, public accountability, quality of care, and resource mobilization. The case study n1ethodology included a brief, but useful, discussion on approaches to hospital autonomy. For example, the researchers noted that autonomy covered a spectrum of forms within both public and private sectors, and a spectra of functions--e.g., decision making related to financial, human resource, management, and operations functions. The case studies added to an existing sn1all sample of hospital autonomy studies, most of which have been focused on developed country experiences. The case studies were relatively short, used comparative hospital data when possible, and provided recommended steps for further policy actions for the respective countries. Altogether, 8 hospitals were studied, 6 of those in Africa at national and provincial levels Dissemination Three workshops were held in Africa--Dakar, Harare, Nairobi--to disseminate the findings of the activity. Over I 00 participants included senior decision makers and national policy makers. About 300 copies of the various reports generated by the activity have been distributed. What were the outcomes of this actil,ity? Hospital autonomy has been a topic of much interest among governments and donors, but little Health Financing and Organizational Reform 4 had been written about experiences or the impact of autonomy. The case studies prepared for this activity represented the most extensive, methodologically coherent body of data available for Africa on both experiences and in1pact of hospital autonomy. Methodology A literature review was conducted but found little evidence from developing countries. The methodology developed sought to review the impact of hospital autonomy from five inter-related perspectives: efficiency, quality of care, accountability, equity, and mobilization of resources. Methodological guidelines were prepared. Research Findings While some positive effects of hospital autonomy efforts were identified, the "overall conclusion ofthe ... case-studies undertaken ... is that autonomy in public sector hospitals has not yielded many of the hoped-for benefits in terms of efficiency, quality of care, and public accountability .... " (Recent Experiences .. . , p.4) Only in the area of resource mobilization did autonomy show a strong positive correlation; otherwise the relationship was weak or negative. The most adverse impacts of autonomy efforts were on equity. More specifically, the summary report of the case studies discusses the impact of autonomy, using the five assessment criteria: • The studies noted improvements in technical efficiency, as hospitals were able to order drugs, equipn1ent and repairs n1ore readily than under the previous systems. Changes in management and personnel recruitment and retainment efficiency were mixed, depending upon the institution. • The gualitv of care improved in parallel to improvements in drug and equipment supplies, but there were few changes in staff attitudes or involvement. • Financial accountabilitv within hospitals showed signs of improvement, but accountability to the public changed little. • On the criteria of eguitv, the case studies indicated that "equity and access issues have either worsened or not in1proved after autonomy," this primarily due to introduction or increases in user charges. • Finally, autonon1y led to improvements in hospital mobilization of resources, although the record varied from institution to institution. The reasons that the benefits of public sector hospital autonomy had not been realized, according to the researchers, were: • the conceptual basis of autonomy was easily misapplied in practice--notably the application of private sector structures and incentives to the public sector; • poor implen1entation, for numerous reasons, including institutional conflicts and • • • Health Financing and Organizational Reform 5 management inertia; • limited management and decision-making capacities within hospitals; and • inadequate information and accounting systems. The case studies identified a continuum in autonomy situations, often with the process still evolving, suggesting that other changes and improvements could arise in the future. One finding from this activity was that in1provements in management structures and processes-- i.e., efficiency--within hospitals n1ay be n1ore important than autonomy per se. Table 1: Fulfillment of Objectives Objective Met, Not Met, Sources/Comments Exceeded Provide case examples which could Met Project publications assist policy makers to evaluate policies on hospital autonomy Assess the effects of autonomy on Met Project publications resource mobilization, efficiency, equity, and quality of care~ Provide lessons for other countries Met Lessons described and discussed at regional meetings. Provide guidelines for Partially met Informants; guidelines for implementation of hospital methodology, but case studies did autonomy not provide information to develop policy guidelines Provide gu idancc to donor Partially met As above organizations Products • Five case studies publications • One methodological publication • One overview publication • Three dissemination workshops What complementary efforts have contributed to the results of this activity? The Francophone hospital association, with CESAG and PHR have identified development and implementation of a management inforn1ation system (MIS) as a strategic entry point for further Health Financing and Organizational Reform work on hospital autonomy. The MIS will provide hospital administrators with basic data from which they can make decisions. What happened as a result oft/tis activity? Problem definition, identification of solutions, and advocacy are all needed to produce changes in policies and programs. Understanding the problem Developing the methodology helped to define the issues in a clearer and more specific way than had been the case. The research provided information not readily available about hospital autonomy. Alternative solutions U nderstandiog the Problem 'lbt: process of policy and program change involves lbe interaction of describing problems, identifying solutions, and advocacy. There is no evidence that the research contributed to identification of new options for hospital autonomy. USAID/Washington has organized an informal group to identify next steps for the 6 • issue, which may inc] ude suggestions for alternatives. • Advocacy There was no organized or specifically planned advocacy associated with this activity. Changes in policy environment, policies and programs Although the dissemination workshops provided theretofore unavailable information about hospital autonomy and its relation to other aspects of health care reform, it appears that only a very limited use of the findings has occurred. US AID missions have not demonstrated strong interest, although apparently some missions have requested technical assistance from REDSO offices for religious-based hospitals. Zan1bian authorities requested T A to make improvements in the management of the University Teaching Hospital. It is not known if individual hospitals have used the information or requested assistance from other sources. Capacity Building The research was conducted prin1arily by U .S.-based organizations, with little input from or to African institutions or researchers. • Health Financing and Organizational Refonn 7 What lessons have been learned from this activity? • Assure that the research topic is situated within the active agendas country partners or seek to make it so prior to or during the actual research Within the realm of health sector reform, hospital autonomy has not drawn substantive attention from national policy makers, USAID missions or most donors, although it has been much talk about the issue. One obvious lesson, then, is to carefully lay the groundwork for research to assure that the information generated will find a fertile ground for discussion, study and action. Planning and preparation of the research and of the potential application of the findings are critical steps to promote policy and programmatic changes. National governments. USAID n1issions and other donors have seen hospital autonomy as a means to reduce the burden on governments of health care financing. However, they have been far less interested in the impact of the in1plementation autonomy initiatives. Ways to built in￾country interest in proposed research include: partnering with local organizations; conducting a "state-of-the-art" pre-research workshop; pre-research advocacy with key activists within the targeted research community (i.e., in this case, hospital administrators). • Take advantage of positive, if unexpected, findings to draw attention to the issue and stimulate discussion. Evidence of improven1ents in technical efficiency within hospitals--due, in part, to changes in resources levels and procurement procedures--offers an opening for stressing both positive outcomes of autonomy and future areas of program support. The case studies suggest that research is of lesser priority than changes in management approaches and structures, e.g., changes leading to improvements in efficiency of operations. • Involvement of African institutions may have added credibility and a sense of local ownership to the issue. Policy change is most likely to occur as dedicated advocates promote an issue. While this activity generated son1e useful data, that information was largely detached from national or local policy processes. To generate greater interest, it is necessary to assure that African institutions and/or researchers in each country were fully involved in the design and implementation of the research and subsequent translation of the findings into a policy framework. • The comparative case studies provided useful information, but such information was not used by USAID missions in Africa or by African governments or hospitals to shape change. While a good idea to have comparative examples, in this activity the non-African case studies had little evident impact on African governments, USAID, local institutions or other donors. . Health Fiuancing and Organizational Reform 8 What are the next steps for tit is activity? Given the case studies and the portfolio review, several follow-on activities have emerged from discussions. • Focus on institutional capacity building in one or two technical and/or hospital management areas. As technical efficiency was identified as an area that demonstrated quick change, further emphasis in this area is likely to yield further positive changes. Also, while institutional change is more difficult to achieve than knowledge changes of individual managers, it is the forn1er which is in most need of attention and further support. • Do not develop managen1ent tools. Review already existing tools and concentrate on getting them used through exchanges, networks and T A. • Review and identify a basic "package" of regulatory guidelines for use by governments in dealing with autonomous and private hospitals. • Prepare a brief fact sheet to inform and sensitize missions, other donors and governments to the issue. • The fact sheet could be written in the context of health sector decentralization, privatization. and equity (e.g., hospitals absorb 40-70% of MoH budgets). • Monitor the in1plementation by CESAG and PHR to improve management information • systems in the Francophone West Africa region. • As alternatives to the non-African case studies consider facilitation of personnel exchanges or study tours and promotion of regional or sub-regional networking around the issue. • Health Financing and Organizational Reform 9 Sources Consulted Written Mukesh Chawla and Peter Berman, Improving Hospital Performance through Policies to Increase Hospital Autonomy: Methodological Guidelines. 1995. Ramesh Govindaraj and Mukesh Chawla, Recent Experiences with Hospital Autonomy in Developing Countries--What Can We Learn? 1996. Case Studies: David Collins, et al., Hospital Autonomy in Kenya, 1996. Jack Needleman, et al., Hospital Autonomy in Zimbabwe, 1996. Ramesh Govindaraj. et al., Hospital Autonomy in Ghana, 1996. Thomas Bossert, et al., Ho.\pital Autonomy in Indonesia, 1997. Mukesh Chawla and Alex George, Hospital Autonomy in India, 1996. HHRAA, A Strategic Framework for Selling Priorities for Research, Analysis, and Information Dissemination on Health Sector Financing and Sustainability in Sub-Saharan Africa. 1995. Informants Abraham Bekele, USAID/AFRISD Suzanne Prysor-Jones, SARA/ AED Joseph Coblentz, SARA/ AED Prepared by Sara: Bill Rau Latest revision: May 27, 1998 Hospital Autonomy for Health Reform: Case Studies What happened What Research and Dissemination Advocacy Capacity TA and Other changed I Analysis Building Activities • Methodological • Three regional Understanding the problem guidelines workshops held to prepared. share results. ~ • Issue and problems defined in more detail than had been the case. : • . Data collection and · •. :.A,b9ut 300 copies : t " ~ in policies and programs ', analysis of ~ight , .. ,. · of each of the case· . .. I • • • • l • ') ~ ··hospitals with · studies and I,! t .. • • "'"~ '., > • _. ~ •,. I • ' · '. varying degrees of ' I I • ~ summary • Lule change recorded or noted at IJ . r. I VI \..JIJl .J' !L ll./Ul'-'\..1• ..J. ... :: ..• ~~:·!:;\: ... · .... ::. ~ country levels; case studies may national ~entary have given some intellectural government support and credibility to overall conducted in five Activities health reform efforts at country countries. levels. • CESAG was • Findings provided already working • PHR and CESAG have built on solid evidence of with the West research to hold consultations in varying degrees of African Hospital Africa and initiate intervention effectiveness of Association and research on hospital MIS--a priority autonomy, introduced RHR to identified by the West African especially re. I this network. Hospital Association and the resources and research. equity. • • • b' c ~~ J>- zz r2:c Zrn G1)> ~ Health Financing and Organizational Reform Equity in Health Care Financing Main results and significance of the activity • The activity provided five country case studies focusing on experiences with implementing mechanisms (i.e., waivers and exclusions) to maintain equity in access to health care services within the context of cost recovery. • The case studies offered data-based, country-specific, detailed findings on a key aspect of health care reform implemented during the late 1980s and early 1990s. • The research affirmed that lower income people often pay for health services intended to be free and if they did not have money, they would postpone or forego medical care. • USAID used the findings for advocacy in international conferences. • While the issue of equity has wide interest among NGOs and CBOs in Africa, it has generated less interest within USAID and notably USAID missions. • The activity has not gone beyond its original objectives, primarily because application of the research findings was not adequately considered in the research design stage. Dates of Activity : Locations: Implementing Agencies: Total HHRAA Funding: Leveraged Funding: 1995-1997 Kenya, Tanzania, Guinea, Indonesia, Equador HHRAA, BASICS $300,000 n/a Health Financing and Organizational Refonn 2 What was the problem or gap being addressed? The introduction of user fees within public health systems in the 1980s and early 1990s was done primarily to increase revenues available to the ministries of health and/or local health institutions. Most international donors and many African health authorities argued that user fees would generate more resources and could make health systems more efficient and effective. They doubted that the fees would seriously impinge on public access, especially access for lower income people. Early evidence from cost recovery schemes indicated that many lower income people were not using the health facilities as frequently as before the introduction of fees. Concerns about equity across class lines were raised. If lower income people could not access the health system, not only would their individual health suffer, but public health likely would suffer. As a part of its Health Financing and Sustainability portfolio, US AID/ AFR sought to look at the issue of equity within the context of cost recovery programs which it has supported in most African countries. What was the purpose of this activity? The activity occurred within the context of Strategic Objective 7 which calls for the adoption of • policies and strategies for increased sustainability, quality, efficiency, and equity of health services. Under S07, the activity contributed to IR 7 .1.3--develop appropriate targeting, subsidies, and means-testing mechanisms and strategies. The purpose of the activity was to provide information on the impact of health system user fees, particularly on lower income users, within five countries. When user fees had been instituted in health systems which had generally been free, protective mechanisms for low income users also were implemented. The activity sought to assess the impact of the protective mechanisms for lower income and select target groups. Findings from the country studies were expected to yield options for consideration by national policy makers. The studies addressed the following questions: • Are the poor who visit government health facilities receiving wavers from paying fees? • Are there poor people who are eligible for waivers who do not receive them? • If so, where do these people seek care? • Are non-poor people receiving waivers for which they are not eligible? What were the specific objectives of the activity? Specific objectives were to: • Health Financing and Organizational Reform 3 • assess the effectiveness of waiver and exemption systems to user fees; • review and contrast public and private sector waiver systems; • look for lessons from other sectors (e.g., education and agriculture); • identify key policy options; and • identify basic management guidelines to implement and manage cost sharing programs. Originally, US AID planned to draw evidence and examples from the case studies to develop guidelines which would identify the implications and trade-offs of particular policy choices. What took place duri11g the activity? Research and Analysis The research was carried out by the BASICS project. BASICS prepared a methodological framework, conducted a literature review, conducted data collection in five country, generated case studies on each of the countries and produced a summary report. The methodology offers a useful set of definitions to distinguish various forms of exclusion from payment of user fees. The two key terms used throughout the studies were: • waiver • exemption a targeted exclusion based on an assessment of ability to pay. exclusion based on select characteristics (age, pregnancy, communicable illness) in order to encourage health seeking behavior or to benefit select groups (e.g., military, civil servants). The countries selected for study were Guinea, Kenya, Tanzania, Indonesia and Ecuador (the latter two for international con1parison). The summary analysis focused on the two East African countries. Dissemination The case studies and summary overview were disseminated within each of the five countries and to all USAID missions in Africa. The findings from the case studies were presented at three international conferences, both in Dakar, Nairobi, and Harare. Participants at the fora agreed to disseminate the principles, but a process for follow-up with participants or a mechanism to monitor changes was not put in place. What were the outcontes ofthis activity? Research Findings Major findings from the studies included: Health Financing and Organizational Reform 4 • Low income people often pay for health services even when services are intended to be free. • Guidelines for health facility staff on cost sharing and exclusions are often vague or inadequately described. • Revenue generation has taken precedent over assessing qualifications for and granting exclusions at health facilities. • Public information about fees and exclusions often are inadequate. The studies affirmed that lower income people were foregoing medical care because of cost and quality factors. Also, the cost recovery efforts in the studied countries had not resulted in improvements in quality or efficiency of health services. The guidelines for policy makers were not prepared, as USAID found that the country experiences were too diverse to draw general statements. Broad principles were outlined in the summary document about equity and mechanisms to assure access in the context of cost recovery programs. Table 1: Fulfillment of Activit)' Objectives Objective Met, Not Met, Source/Comments Exceeded Assess effectiveness of waiver Met Activity reports and case studies and exemptions systems for user fees Review and contrast public and Met Activity reports and case studies private sector waiver systems Identify lessons from other Met partially Case studies sectors Identify key policy options Met partially Options remain to be drawn out from case studies and summary Identify guidelines to implement Not Met Researchers felt there was and manage cost sharing insufficient data to prepare programs guidelines Products • Five country case studies • One methodological report • One summary overview report • Three international dissemination conferences. • • • Health Financing and Organizational Refonn 5 What complementary efforts have contributed to the results of this activity? There has been extensive pron1otion of cost recovery programs from both ministries of health and international donors. Thus, this activity occurred within a context in which cost recovery and health system reform were major topics of discussion and debate at both national and international levels. Less attention has been given to the issue of equity in the context of health system reform. Much of the attention has come from NGOs or academic institutions, although WHO and UNDP have n1ade son1e reference to the issue. What were the results oft/tis activity? While the term equity is frequently used in development, it is rarely understood in specific circumstances. The data generated by this activity was very useful in understanding how existing mechanisms operated to protect low income or other specific target groups. This was one activity where substantial follow-up could have occurred with interested national groups. Understanding the problem The case studies provided a body of specific evidence that contributed to a better understanding of the outcomes of policy Understanding the Problem Changes in Policies and Programs '!be process of policy and program change involves the interaction of describing problems, identifying solutions, and advocacy. decisions made in the 1980s and 1990s about cost recovery and equity. The research noted that many governments have policies to assure access to health care for lower income people, but that public awareness of the policies is low as is health care provider knowledge of the mechanisms to assist lower income people. The findings make it clear that the current problem facing African health systems is in the implen1entation of the two mechanisms--waivers and exemptions-- designed to increase equity in health care. Alternative solutions One of the realities encompassing the issue of equity is a major difference of opinion about the impact of cost recovery programs and the wider socioeconomic changes which have occurred as a result of structural adjustment programs. The differences in views usually fall between international financing and grant organizations, on the one side, and NGOs/CBOs with direct field presence, on the other side. The value of this US AID activity was its focus on the effectiveness of specific mechanisms which had been designed by governments to assure access to health care for low income people and groups whose needs were of public health concern. The activity yielded findings which served both sides in the debate. The research showed that the mechanisms were not flawed, but their implementation was weak. The basic recommendations of the researchers were to increase public awareness of the existence Health Financing and Organizational Reform 6 of and means of access to use the mechanisms and to provide training for health care providers in implementing the p-olicies. Advocacy The research results did not generate noticeable advocacy within the countries in which the case studies were conducted to improve protection mechanisms within cost recovery programs or to further examine the issue from a policy perspective. However, the case studies provided data￾based evidence for advocacy during an international forum on cost sharing, held in Addis Ababa, Ethiopia in June 1997. The principles on cost sharing which were endorsed during the forum provide a base upon which fuller and more structured reviews of cost sharing and exclusion mechanisms can be built. Changes in the policy environment, policies and programs While the collection of case studies represent useful information, that information has not been widely applied. African governments and NGOs which would have the greatest interest in the findings seem not to have applied the research findings to improve equity in their health care systems. USAID missions have not, apparently. incorporated the information into their portfolios and there is little evidence that other researchers or policy/advocacy organizations have incorporated the findings into their work. However, an agreement between USAlD and UNICEF is under review. Under the agreement, USAID and UNICEF will develop a strategy to promote cost sharing in ways that protect vulnerable groups in • those schemes. Capacity Building Because the activity was conducted primarily by the BASICS project, opportunities for African institutional capacity building were minimal. What lessons have been learned from this activity? • Partnerships--most particularly with committed African institutions and researchers-- should be formed before or at the beginning of an activity. This is especially true for activities on issues lacking consensus and/or ones which are controversial, such as cost recovery and equity. • Partnerships with African institutions and researchers could have assured that the research findings were considered by health care institutions. • Policy option guidelines are not easily derived from case studies. However, rich details could generate a list of options, and rationale for each, for consideration by policy makers. • The case studies did provide data which could have been used for advocacy within the countries studied or as models for similar studies in other countries. • Case studies are more likely to be useful for stimulating discussion on the issues and • options for action when there is interest within the country among government officials and policy makers, donors, and implementing agencies. Health Financing and Organizational Refonn 7 Jfhat are the next steps for this activity? • Identify organizations with an interest and policy-related skills to effectively move the issues raised through the case studies. Those organizations could be ones that approach equity from a development, economic. or gender perspective. There is a strong interest among some NGOs in documenting the impact of health financing reforms on lower income groups and groups with clear public health needs. • With in-country partners, develop options for the effective implementation of waiver and exclusion mechanisms for low income people for consideration by policy makers and program managers. • While the case studies are too few in number to develop policy guidelines, the findings have been effectively sun1marized in the overview paper. A greater effort can be made to disseminate that paper. but even more importantly, to promote with missions and regional offices the main points raised in the overview. • With in-country partners. develop a strategy for promoting greater dialogue on the issues raised within the case studies. • Examine if and how UNICEF and UNDP indicators used in their annual State of the World's Children and Human Development reports, respectively, can provide monitoring information for equity issues. Other monitoring data may be available from UNFPA. Health Financing and Organizational Reform Resources Consulted Written David H. Collins, Equity in the Provision of Health Care: Ensuring Access of the Poor to Services under User Fee Systems: A Case Study--Ecuador. BASICS, 1996. Donna M Gibbons, Equity in the Provision of Health Care: Ensuring Access of the Poor to Services under User Fee Systems: A Case Study--Indonesia. BASICS, 1995. HHRAA, Setting Priorities for Research, Analysis, and Information Dissemination on Health Sector Financing and Sustainability in Sub-Saharan Africa. USAID, 1995. William Newbrander, Equity in the Provision of Health Care: Ensuring Access of the Poor to Services under User Fee Systems: A Case Study--Kenya. BASICS, 1995. William Newbrander and Stephen Sacca, Equity in the Provision of Health Care: Ensuring Access of the Poor to Services under User Fee Systems: A Case Study--Tanzania. BASICS, 1996. William Newbrander, David Collins and Lucy Gilson, Equity in the Provision of Health Care: Ensuring Access oft he Poor to Services under User Fee Systems [Overview report]. 1997. R. Paul Shaw and Charles C. Griffin, Financing Health Care in Sub-Saharan Africa. World Bank, 1995. Kevin Watkins, "Cost-recovery and Equity in the Health Sector: Issues for Developing Countries," WIDER, 1997. 8 Portfolio Review of Health Care Financing, US AID/ AFR/SD and SARA, 1998. Bound notes on presentations and discussions. Report of an International Forum, "Consensus on Principles of Cost Sharing in Education and Health in Sub-Saharan Africa," 1997. UNICEF, Regional Office for West and Central Africa, "Report of the Workshop of the Network on Economic and Social Policy in West and Central Africa," 1997. Informants Abraham Bekele, Health Economist, USAID/ AFR/SD, 1 April 1998. Suzanne Prysor-Jones, Director, SARA Project/ AED, I April 1998. Prepared by SARA: Bill Rau Latest Revision: May 7, 1998 • • Equity in He Care Financing What happened What Research and Dissemination Advocacy Capacity TA and Other changed Analysis Building Activities • Case studies of • Three inter-country • Limited to Understanding the problem health user fee dissemination international protection systems conferences in conferences • Case studies added specificity on in five countries. Africa. ~ the limited effectiveness o f user fee protection mechanisms, resulting in • Overview analvsis • 300 conies of case lower income people foregoing or from case studies. studies and other E:ical care. documents distributed at rnative Solutions · dissemination .C. _) C'nrn~ lementary uggested strategies to ~UIII~I~ ~~~,:) Cli 1\.1 per requests. Activ~ improve user fee protection mechanisms to promote equity. • Bamako Initiative acti vities have Changes in Policies and Programs stimulated UNICEF interest in • No significiant changes noted. this area. • Negotiations underway with UNICEF to have that organization take up the issue. - Health Financing and Organizational Reform Decentralization and Health Sector Reform in Africa: Case Studies Main results and significance of the activity • The research generated the largest and most systematic body of knowledge about current decentralization policies and practices in Africa and elsewhere. ' • Decentralization policies were influenced both by the research agenda and findings in at least three African countries (South Africa, Uganda, Kenya). • The topic of decentralization gained greater policy attention in a number of countries as a result of the studies. For example, national workshops to analyze the issues raised by the studies were held by four African countries. • The research generated a framework for the analysis of decentralization issues, which has been used to date in 27 countries world-wide (8 in Africa). • The research increased the capacity of over twenty African investigators to analyze issues of decentralization and health systems performance. • The case studies provided comparative information for the sharing of experiences across countries. Countries involved in policy formulation (e.g. South Africa) took particular advantage of the opportunity to learn from the experiences of others. • The case studies provided the basic information for valuable comparative analysis, enabling a more sophisticated understanding of decentralization policies and processes. Dates of activity: Locations: Implementing Agency : Total HHRAA funding : Leveraged funds : 1994- 1997 Burkina Faso, Mali, Ghana, Kenya, Uganda, Botswana, Zambia, South Africa HHRAA (World Health Organization) $400,000 Approx. $1,350,000 Health Financing and Organizational Refonn 2 What was the problem or gap being addressed ? A lack of clarity about the meaning of decentralization--in terms of both objectives and strategies--has hindered analysis and implementation of health system changes. Most countries in Africa are currently undergoing some type of decentralization process. However, there is little information available about those experiences or about the comparative lessons to be learned in forms that are useful to decision makers as they consider the policy options available to them. There is some controversy about the effects of decentralization on health system performance. Ideological positions are sometimes adopted and available data has been interpreted in different ways. In some cases, the absence of data or information available from the field has hindered meaningful discussion. In other cases, contradictory findings suggest that decentralization results are dependent upon a variety of factors. What was the purpose of this activity? The activity contributed to HHRAA's Strategic Objective 7-- Promote improved policies and strategies for innovative health financing and organizational reform--and to IR 7.1.2--the development of state-of-the-art knowledge and best practices for decentralizing health care • systems and organizational reforms. • The purpose of the activity was to document for the first time in a systematic fashion how and why decentralization reforms were taking place, the necessary preconditions for successful reforms, and the impact of decentralization on health system performance. The results of the activity were to provide guidance to USAID and to countries on how better to craft decentralization policies and related programs, as well as to implement the reforms. As the first systematic and comparative study of health system decentralization in Africa, the activity was expected to provide a coherent body of information from which reform lessons and strategies could be drawn and impacts on health delivery assessed. As such, it provided the state￾of-art knowledge and examples of best practices called for in IR 7 .1.2. of SO 7. What were the specific objectives of the activity? • Conduct a review of existing literature on decentralization and produce a state-of-the-art report which clarifies the different definitions of decentralization and explores the variety of objectives and strategies being discussed at country levels. • Conduct research in four African countries on experiences with decentralization. • Produce four case studies on decentralization, based on the African data, which illustrate how decentralization policies were formulated and what factors influenced whether or not the policies were/are being implemented. • Health Financing and Organizational Refonn 3 What took place in implementing the activity? Research and Analysis The World Health Organization (WHO) drafted a conceptual framework for analysis and guidelines for implementing the study. These documents were presented, discussed and revised with researchers from the eight participating country--Burkina, Mali, Ghana, Kenya, Uganda, Zambia, Botswana, and South Africa--during a workshop in Capetown, South Africa. WHO provided grants to the eight national governments which, in four cases--South Africa, Ghana, Botswana--contracted with universities for the their studies and Kenya contracted with a regional NGO for its study. Ministries of health conducted the studies in the other countries A majority of the local investigators were decision makers in their countries. An international consultant provided technical assistance for each country investigator. Dissemination The grants from WH 0 to researchers did not specify expected forms of dissemination of results. South Africa, Burkina, Kenya, and conducted large workshops that generated national-level discussion on the issues surrounding decentralization. The other countries held less formal meetings with policy makers and donors. WHO organized a regional workshop--"Decentralization in the context of Health Sector Reform in Africa"--in Bamako, Mali, for presentation and discussion of the results of the decentralization studies. Eighteen countries were represented at the meeting--the eight which had conducted case studies and Mozambique, Angola, Senegal, Madagascar, Ethiopia, Eritrea, Mali, Guinea, Guinea Bissau, Zimbabwe, and Cameroon. A background paper was prepared for the regional dissemination workshop, entitled "Decentralization and health systems change: an Overview of Eight African Countries" . A collection of articles on decentralization, many based upon the studies in this activity, will be published in a special issues of Health Policy and Planning (forthcoming). South Africa printed and distributed over 200 copies of its report throughout the country. The WHO principle investigator (PI) and one of the study consultants held a seminar for Task Managers at the World Bank on Sector Wide Approaches (SWAPS) and decentralization issues, using findings from the decentralization case studies, along with other information. Health Financing and Organizational Refonn What were the outcomes of this activity? Methodology Studies were carried out according to the consensus guidelines. The process included: - analysis of existing documents - data analysis from management information systems - field visits - key informant interviews. Research Findings Key findings from analysis of decentralization studies • Clarifying the goals of decentralization .. Decentralization often has two broad objectives: a political objective designed to increase local empowerment and control (e.g. Uganda), and a technical objective intended to improve services and service delivery (e.g. Zambia). .. The primary objectives of the decentralization policies adopted in a country will influence the functioning of the health system. • The implementation of decentralization policies .. Factors influencing whether decentralization policies are actually implemented are quite context-specific and closely linked to the commitment of decision-makers. .. The studies affirmed the findings of other research that management systems must by in place for decentralization policies to be implemented effectively. .. Too often, decentralization processes do not address the redesign and strengthening of management systems. Training is sporadic and focused on district plan development. .. In some cases, decentralization may be better implemented by starting with strengthening management systems, even if the policy framework is not yet fully defined. 4 • • • Health Financing and Organizational Refonn 5 Findings [continued] • Capacity building ~ There are very few capacity building efforts underway to help national level technicians re-orient their work in support of decentralization. Most capacity building has been training for district-level staff, but even that was usually insufficient. ~ Training for capacity building is ineffective and incomplete without concurrent work on decentralized management systems. • Measuring the effects of decentralization ~ In most countries it is not possible to evaluate the effects of decentralization (on quality of services, distribution of services and equity, and efficiency of services) because systems are not in place to monitor trends or see how a health system is performing in the context of decentralization. Table 1: Fulfillment of Objectives Objective Met, Not Met, Exceeded Comments/Sources Conduct a literature review of Met report decentralization and produce a state-of-the-art report which clarifies the definitions of the issue. Conduct research in four Met case studies and summary African countries on decentralization Produce four case studies on Met publications decentralization, based on the African data, which illustrate decentralization policy formulation Products Decentralization and health systems change: an Overview of Eight African Countries. Health Financing and Organizational Reform What complementary efforts have contributed to the results of this activity? Technical assistance was given by the WHO PI to 5 countries (Kenya, Uganda, Ghana, South Africa, Tanzania). This T A provided follow-up guidance to the countries on developing their decentralization policies and implementation plans. It was also provided an opportunity to disseminate the broader lessons learned derived from the study. 6 Findings from the research on decentralization has fed directly into the current work taking place through SWAPS, an international initiative involving multilateral and bilateral donors and host countries. The Principal Investigator of the study is now Secretary of the International Technical Working Group on SWAPS, and findings from the studies have informed the "Guide to sector￾wide approaches for health development," published in 1998 by WHO, DIFD, EU, and DANIDA. In Kenya, the decentralization process within the Ministry of Health complemented district-level implementation of HIV I AID SISTI prevention. The process permitted rapid disbursement of funds to districts, thereby strengthening the planning functions of district health management committees and overall prevention efforts. What results have been achieved to date? The activity stimulated interest in several African countries which were involved in processes of decentralization. Countries were eager to learn from one another and share experiences as they sought feasible approaches to designing and implementing decentralization programs. There has been less interest or adoption of aspects of the activity findings among USAID missions. Understanding the problem The research has generated the largest and most systematic body of knowledge about current decentralization policies and practices in Africa and elsewhere. It has allowed the comparative analysis of different policy options and models, thus advancing global knowledge in this field. Alternative solutions Changes in Policies and Programs IdeJltincatitt»o of "''u".-.... uve Solutions 'lbe process of policy and program change involves the interaction of describing problems, identifying solutions, and advocacy. • National-level workshops, using the findings of the country reports, with key decision makers in the ministries of health, finance, local government, planning, etc. were held in • • Burkina Faso, South Africa, Kenya, and Uganda. Alternative policy options were • Health Financing and Organizational Refonn 7 discussed during these events, allowing countries to use their own case studies to infonn national debate. • Decision makers in several countries, including Ghana and South Africa, have requested information about decentralization policies and their implications in other countries, thus making use of study findings to explore alternative options for their own country contexts. The Zambia case has been particularly useful for this purpose, since the country has had more experience than most with the formulation and implementation of innovative decentralization policies (the "new public management" model). • Technical support from WHO to assist with the development and continuing analysis of decentralization policies has been requested by South Africa, Kenya, Uganda, Tanzania and Ghana. The study findings were an important component of the subsequent analysis .. Advocacy Although the research was not carried out with a view to subsequent advocacy for particular decentralization policies, it has provided information for the reconsideration of current courses of policy action in some cases. In Uganda, for instance, an analysis of study findings were presented by an influential investigator in a memorandum to top-level policy makers. Changes in policies and programs • Findings from the Kenya case study on decentralization were incorporated into the 1994 health policy reform document. The policies in this document were ratified in 1998 in the context of the ongoing work on developing a sector-wide approach to health reform in Kenya. [check the 1998 date and indicate who ratified and what policies] Also, the MoH commitment to decentralization provided an opening for specific actions to transfer funds to districts for HIV I AID SISTI programs, a process achieved in a few months and one which the task manager indicated had previously taken years. • In Uganda, the case study process promoted increased dialogue on decentralization issues between the Ministry of Health and the Ministry of Local Government and a review of their working relations. ln addition, the MOH now has a stronger information base to advocate for policies to address the adverse effects of decentralization on health service financing and performance. • In Ghana, the study generated increased dialogue between local government and health authorities. Ghanaian policy makers reviewed the examples of decentralization in other countries, based on the case studies from Zambia, Uganda, and Kenya, in formulating their own policy options. Health Financing and Organizational Reform 8 • In South Africa, one of the study investigators was hired from a university setting by the Ministry of Health to direct district health systems, partly owing to his prominence in conducting the study and discussing its findings, and also due to the sensitization to the study findings of the Chief Director for Health Policy. Capacity building Over 30 researchers from the 8 African countries involved in the study participated in the development and application of the framework for analysis of decentralization issues. Several of these investigators are still, or have moved into, key positions in their respective governments (e.g. Permanent Secretary of Local Government, Uganda; Director of Medical Services, Kenya; Director of District Health Services, South Africa; Director of Medical Services, Ghana; Secretary General of the Ministry of Health, Burkina Faso). The research has contributed to the formation of a cadre of researchers/policy makers who are able to pursue the next steps of monitoring and evaluating the implementation of decentralization policies and their effects on the health system. It has also influenced a number of senior decision makers, who are now sensitized to the issues surrounding decentralization and better able to explore options and analyze the effects of their country policies. What lessons have we learned from this activity? A. The impact of the studies varied according to the context of the countries where they took place • Study findings were most likely to be used by countries in the process of developing policy options, e.g. South Africa. • Countries that already had policies on decentralization but were not implementing them, e.g. Kenya, or countries that had many ongoing activities, studies, etc. on decentralization, e.g. Zambia, often found the studies of less immediate use. In some cases, however, these were the case studies that were of use to other countries as they looked at options taken, difficulties encountered, etc. B. The impact of the studies varied according to the position and abilities of the investigators • Countries where investigators included decision-makers (or became decision-makers), e.g. Uganda, Burkina, S. Africa, Ghana, were more likely to use the study findings. Conversely, countries where investigators were more removed from decision-making process were, on the whole, less successful in using the study findings to influence • • Health Financing and Organizational Refonn 9 policy. • Occasionally, however, the direct involvement of decision makers as investigators inhibited critical discussion of policy options. • Countries where the studies were less complete or analytical tended to make less use of the findings. What are the next steps to capitalize on the activity? • Follow up support to countries that request it for further analysis and policy formulation, e.g. in South Africa. • Advocacy by USAID and its missions, WHO officials, and country study leaders and international consultants in international and country-level fora for the development of systems to monitor health sector performance in the context of decentralization and health sector reform, including analysis of changes in cost of health care delivery, changes in access to health care, and changes in quality of care. • USAID/ AFR/SD follow-up on original case studies, with similar case studies conducted every 18-24 months, to trace changes in implementation of decentralization and factors contributing to the processes. For example, Zambia faces internal dissent, delays, and managerial problems as it proceeds with its health decentralization program. • Active dissemination of summary and country reports to USAID missions in Africa. • Publication of the overview paper as a stand-alone study, with comparative analysis of all 27 studies, lessons learned, etc. • Incorporation of decentralization issues in the development of SWAPS .. Health Financing and Organizational Reform 10 Sources Consulted Written Decentralization and health systems change: an Overview of Eight African Countries. Informants Katia Janovsky, WHO Alex Ross, USAID/ AFR/SD Prepared by SARA: Suzanne Prysor-Jones Latest revision: June 2, 1998 • • • Decentralization and Health S r Reform in Africa: Case Studies Research and Analysis • Literature review • Qualitative data collection in eight African countries What Dissemination • 3 countries organized dissemination workshops • WHO conducted a • Production of case disseminatiOn .. studie~ based on 'workshop attended happened Advocacy • Numerous discussions held by WHO/Geneva staff and consultants to sensitize policy makers to the study momgs. ·data · ., . ·~: · · · ·. . by representatives .,_,.-~ ' ' .. $ii~G::t~i, , ~~; ~~.;::~!~t;;, S1': ''"'"" ' "' • WHO introduced findings during World Bank workshop. Capacity Building • Over 30 researchers from 8 African countries gained experience in research and/or analysis of data related to decentralization . TA and Other Activities . ' : . :· ·. ~:; . • T A provided to 5 countries on decentralization planning. What changed Understa nding the problem • Case studies documented policy and programmatic processes related to health decentralization. Alternative solutions ative policy options ·scussed in national workshops in Burkina Faso, South Africa, Kenya, and Uganda. Changes in policies and programs • Findings from the Kenya case study were incorporated into the 1994 health policy reform document. • In Ghana and Uganda, the case study process promoted increased dialogue on decentralization issues between the ministries of health and local government. • In South Africa, one of the study investigators hired by the Ministry of Health to direct district health systems; Chief Director for Health Policy used findings. • USAID funds for five country case studies helped WHO leverage other donor funds for additional 17 countries. Reproductive Health Post-Abortion Care in East and Southern Africa Main results and significance of activity • REDSO/ESA has developed a coherent regional strategy for the systematic promotion of PAC in ESA. based on information from HHRAA-funded research • For the first time, a coordinated approach to PAC is being implemented through regular meetings of a Regional Working Group, involving major donors and cooperating agencies (CAs) in the ESA region • An attractive advocacy brochure has been developed and 4000 copies disseminated in the region . The brochure is being reprinted owing to continued demand . • Advocacy presentations have been developed and used in Kenya, Zambia, Uganda, Malawi. Ghana, Zimbabwe and Tanzania • Assessments on PAC have been carried out in Zambia, and Uganda, requested by USAID Missions and Governments • The assessment in Zambia paved the way for a comprehensive pre- and in-service training program in Zam~ia • Uganda has launched a new PAC intervention with USAID bilateral project funding, to test new approaches and feed into the process of updating national policies • USAID/Kenya and Malawi have also asked for assistance with PAC plans • Policy makers and health providers from Zambia. Tanzania, Uganda and South Africa visited PAC services in Ghana. Study tour delegates now fonn a core network intent upon continuing to exchange information in support of PAC • Policy on enlarging midwives scope of work for PAC has been updated in Zambia Dates of Activity: Location: Implementing Agencies: HHRAA Funding: Leveraged Funding: November 1996 - present (July 1998) East and Southern Africa ? POLICY Project and REDSOIESA $300k $lOOk of POLICY Project core funds, $200k of REDSOIESA/PHN funds, $1 million of JHPIEGO core funds Renroductive Health What gap or problem did this activity address? The study carried out in 1995-95 on the "Consequences of Unsafe Abortion" by CRHCS/ECSA and funded by HHRAA/SARA had defined the nature and magnitude of the problem in the ECSA region. It showed that between 15 and 30% of maternal mortality was due to unsafe abortion The evidence generated by the report remained to be absorbed into programmatic and policy terms. The situation in ESA at the start of these activities could be characterized by: • increased attention from health specialists and women's groups to Post Abortion Care (PAC) emerging from the International Conference on Population and Development (IPCD); • a lack of awareness and misunderstandings at the USAID Missions about the problem and the low-cost interventions that are not in contradiction with US policy; • little policy dialogue within USAID and between USAID and African governments; and • existing US expertise, but limited funding to access it. What was the purpose of this activity? 2 The activity was carried out in partial fulfillment of Strategic Objective 7--to adopt policies and strategies for increased sustainability, quality, efficiency, and equity of health services--and Strategic Objective 8--to adopt policies and strategies for increased sustainability and quality of family planning programs. More specifically, it addressed IR 7.2.4 which called for the development of practical guidelines for improved care of emergency obstetric complications, and IR8. The purpose of the activity was to sensitize USAID missions and governments to the reproductive health problems associated with unsafe abortions and to increase both financial and technical support for post-abortion care. What were the specific objectives of the activity? • To increase the investment in PAC ~rom USAID implementing agencies, other donors and governments. • To increase the awareness ofUSAID missions, governments and CAs about unsafe abortion and PAC, using a mix of print and presentation resources and TA. • To strengthen regional and local capacity to advocate for PAC issues and plan PAC programs. Reproductive Health • To identify two countries for policy/advocacy assistance. What took place in implementing tile activity? In 1995, REDSO/ESA organized a Post-abortion Care Working Group for East and Southern Africa, with representatives from multilateral donors. African regional organizations, Kenyan health organizations and USAID collaborating agencies (CAs). With assistance from the POLICY Project, REDSO/ESA developed a regional strategy for PAC advocacy and the coordination of acti\·ities among donors and CAs. The strategy includes ways to provide assistance to USA I 0 Missions in developing PAC interventions. Meetings of the working group have been regularly convened and have help guide implementation of the regional strategy. A brochure, "What Can You Do?" was developed by REDSO and the POLICY Project. It summarized RED SO· s PAC strategy. An initial 400 copies were distributed, and I 000 more are being printed, owing to high demand. 3 REDSO!ESA staff visited seven USAID missions (Kenya, Zambia, Zimbabwe, Uganda, Tanzania, Malawi. Ghana) to sensitize them on PAC issues; a slide presentation developed by the POLICY Project was made to USAID PHN officers in each of the missions and their counterparts. A presentation was made to all PHN Officers in the SOT A course helped increase awareness to PAC. As mission awareness increased, requests for technical assistance followed. PAC assessments/ situational analyses were conducted in Zambia and Uganda, with local counterparts. An intervention was designed in Uganda, as part of the bilateral DISH Project, and a proposal for PAC in the private sector has been developed in Kenya. Funds were allocated to JHPIEGO, INTRAH and IPAS to participate in Mission support activities, along with REDSO and POLICY Project staff. Participants funded hy HHRAA attended a meeting and study tour convened by MotherCare and IPAS in Ghana in October, 1997. The twin events provided 20 participants from four countries (Zambia, South Africa, Uganda, and Tanzania) with the opportunity to observe Ghana's experience with the use of the manual vacuum aspiration (MV A) technique for the repair of incomplete abortions and the training of non-physician providers in use of this technique. Participants heard how physicians and midwives worked together in Ghana, resulting in a national referral network for post-abortion care. In the process, participants prepared action plans for strengthened PAC in their own countries. Reproductive Health 4 Wh~t were the outcomes oftllis activity? The activity built upon and extended evidence presented in the CRHCS study on unsafe abortions and interest reflected in the statement made by ministers of health of east and southern Africa during their 1995 meeting. The activity added two important elements to expansion of the issue: a strategy for gaining donor (primarily USAID) support for interventions; and advocacy to move that strategy. REDSO/ESA took an active interest in the issue and took the lead in pulling together interested groups to develop a regional strategy for PAC advocacy. As noted above, a Post-abortion Care Working Group for East and Southern Africa was organized and has provided guidance for implementing the regional strategy. Research findings Although not a research activity, two national assessments were conducted, in Zambia and Uganda. The Zan1bian assessment found, on the one hand, fairly liberal abortion laws, but, on the other hand, very limited access for women to safe and legal abortions. Both service access and cost were identi tied as constraints which contributed to unsafe abortions and post-abortion complications. Hospital admissions for incomplete abortions were high--in excess of 16,000 annually throughout the country--putting a costly strain on medical facilities. The majority of post-abortion patients were young women, often teenagers who faced expulsions from school if • found to be pregnant. It was found that limited access to family planning services, especially for .,, people in rural areas. was a contributing factor to the high rates of unsafe abortions in the country. Care for emergency rost-abortion admissions was constrained by limited staff in many Zambian health facilities and I i mited knowledge about manual vacuum aspiration (MV A) method for treating such cases. In Uganda, data indicated that over half of women 20-24 years old had had an abortion, resulting in many post-abortion infections and related complications. Although MV A was known, its practice depended upon individual doctor knowledge and experience. In both countries, there was strong interest in improving post-abortion care services and improving family planning services in order to reduce the number of unwanted pregnancies and abortions. • Reproductive Health 5 Table 1: Fulfillment of objectives Objecth·cs Met, Not Met, Exceeded Comments/Sources Increase the investment in PAC Met Funds have been allocated by from USAID. CAs. other USAID Uganda donors and governments Increase awareness of USAID Met 7 countries visited, missions, governments and CAs presentations made; exchange about unsafe abortion and PAC, visit by 20 Africans from 4 using print and presentation countries to view experiences in resources and T A Ghana. Strengthen regiona I :111d local Met REDSO coordination meetings capacity to advocate for PAC have taken place with donors issues and plan PAC programs and CAs Identify two countries for Exceeded 4 missions (Kenya, Uganda, policy/advocacy as!\i~1ance Zambia, Malawi) requested assistance for PAC Products REDSO promotional brochure: "What Can You Do? Post-abortion Care in East and Southern Africa." Presentation package. "What can you do?" "The situation of post-abortion care in Uganda," Policy Project, 1997. "The situation of post-abortion care in Zambia" USAIDIREDSO and Policy Project, 1998. What complementary efforts ltave contributed to tlze results of this activity? The HHRAA/SARA funded research and advocacy activity, carried out by the Commonwealth Regional Health Community Secretariat from I 993- I 995, culminated in the presentation of a policy booklet on the consequences of unsafe abortion to the ECSA Minister of Health Meeting in 1995. Also, in 1996-98, HHRAA/SARA-funded dissemination centers in five countries in the region distributed thl! CRHCS monograph and policy booklet, organized national symposia on maternal mortality and the consequences of unsafe abortion, and carried out complementary activities, e.g. the theater presentation in Zimbabwe. What results have heen achieved to date? The REDSO/ESA initiative has had a strong influence on USAID missions and CAs operating in the region. This, in turn, has helped to support existing and generate further country interest and, Reproductive Health in particular, translate general interest in the area into programmatic strategies and interventions. However, because the activity has been implemented primarily with and through USAID missions and U .S.-hcadquartered CAs, there has been less advocacy with ESCA health ministers who had supported the policy recommendations raised thought the CRHCS research. Understanding the problem The REDSO/ESA in itiative has helped to publicize existing findings on the magnitude and issues of unsafe .1bortion as a public health concern in the region. It also clarified USAID policy on P:\C. added new information about co untry-specific situations, identified mechanisms for donor assistance, and options for promoting and implementing PAC activities. Alternative solutions Changes in Policies and Programs ~derltific::ati<)D of IA llt,.r• ... nti•.,,. Solutions ·nlt: ru c:: ~ uf policy and program change involves lhe interaction of describing problems, identifying solutions, and ac..l wx::1cy. 6 The policy brochure .1nd presentation package drew attention to the different aspects ofPAC-the • linkages to famil y planning services and other reproductive health services as well as the .• curative care component-thus clarifying feasible approaches for USAID support within its Strategic Objectives. Eight policy makers and health providers from Zambia, Tanzania, Uganda and South Africa participated in a study tour to look at alternative approaches to PAC care in Ghana Advocacy There has been a strong advocacy component in this activity. designed primarily to inform and sensitize USAID n1issions and their counterparts in Keny~ Zambia, Zimbabwe, Uganda, Tanzania, Malawi, Cihana to PAC issues. Personal visits, discussions and formal presentations were collectively used. Also, all USAID PHN officers were sensitized during a presentation at the 19.96 SOTA course. Several other presentations were made at key donor and CA meetings, such as CARE staff and their counterparts attending an all-Africa meeting on maternal mortality, donors and national counterparts during REDSO/ESA regional Quality of Care and Guidelines and Standards meetings in 1997 and 1998, and to World Bank staff in Washington. PAC was the theme of a Women's Action Group workshop in Zimbabwe which provided training to Group members in the use social theater as an advocacy tool with communities. • Reproductive Health Changes in policies and programs • REDSO/ESA has developed and is implementing a coherent regional strategy for the systematic promotion of PAC, based on information from HHRAA-funded research. 7 • Assessments on PAC have been carried out in Zambia, and Uganda, requested by USAID missions and Governments. The assessment in Zambia paved the way for a comprehensi\'e pre- and in-service training program in Zambia • Uganda has bunched a new PAC intervention with USAID bilateral project funding, to test new approaches and feed into the process of updating national policies. • USAID/Ken ~ and Malawi have also asked for assistance with PAC plans. • Eight study tour delegates Zambia, Tanzania. Uganda and South Africa and their colleagues in Ghana now form a core network intent upon continuing to exchange information in support ofPAC. • A proposal has been developed with the PRIME Project in Kenya to train private Nurse/Midwi\'es to provide PAC services. advocacy, and community data collection. • US AID fund s have been made available for PAC through INTRAH ($1 OOk). • Core funds hnve been allocated to the PAC initiative by JHPEIGO ($1 million) and PRlME/INTRAH ($30k for Kenya and $100 for Uganda). AVSC and PCS are also contributing. • In Zambia. the policy on what role midwives can play in PAC has been updated, at least in part due to USAID-1ed advocacy in the region. Capacity building • The PAC initiative has provided evidence-based presentation materials and coached nationals in their use, thus strengthening regional and local capacity to advocate effectively for PAC and other programs. • Country professionals participating in assessments (Uganda and Zambia), program development (Kenya, Uganda) and study tours (S. Africa, Uganda, Tanzania, and Zambia) have strengthened capacity to pursue PAC activities. I / Reproductive Health 8 What lessons have been learned from this activity? • The adoption of policy recommendations (in this case, by the CHRCS health ministers of recommendations on unsafe abortion) can be supported with well-designed advocacy to increase resources for implementing the recommendations. • USAID Missions are receptive to PAC programming, once they fully understand the magnitude of the problem, the implications of US AID policy, as well as feasible program options that fit with their Strategic Objectives. • REDSO leadership can be extremely effective as a catalyst, through frequent contacts with missions. donors, and CAs. • RED SO is I so able to play an important role in coordinating the efforts of CAs and donors at a regional level, thus allowing for a more systematic and rational strategy. What are the next steps for this activity? • Continue to support REDSO activities in this area, especially the coordination of CA and donor activiti<.:s in the region. • Assist REDSO to document better practices and address some of the outstanding technical issues, such as • integrating PAC into existing services • moving PAC into peripheral health facilities and communities • approaching communities on PAC issues • developing alternative service delivery strategies • Encourage and assist REDSO to join with African regional institutions in promoting appropriate PAC services/ • ,. • Sources Consulted Written Michelle Folsom, et al, The Situation of Post-abortion Care in Zambia: An Assessment and Recommendations, USAIDIREDSO, Nairobi, 1998. Michelle Folsom, et al, The Situation of Post-abortion Care in Uganda: An Assessment and Recommendations. USAIDIREDSO, Nairobi, 1997. REDSO promotional brochure: "What Can You Do? Post-abortion Care in East and Southern Africa." Policy Project presentation at AFR/SD review in January 1998 Informants Michele Folsom. REDSO/ESA, written notes e-mailed 7/1198 Phyllis Oestrin. AFR/SD, interviewed July 3, 1998 Prepared by SARA: Suzanne Prysor-Jones Latest Revision: August 31, 1998 Research and Analysis • Assessments in Uganda and Zambia identified situation of unsafe abortions and level and quality of emergency services provided . .. : t. ·' · • ·; • . ;s; ~ .. ::. ~. · • • ": : • l~...,i ..... ~ 1 •. , ... ~ ~~ .. , "·i·· .). ~~ :j- :ti ~. · . Post-Abortion Care in East and Southern Africa What Dissemination • A brochure developed ("What Can You Do?") by REOSO to summarize REDSO's PAC strategy. • An initial 400 copies were distributed, and I 000 more are l ·' given to dissemination of CRHCS policy booklet and monograph on Consequences of Unsafe Abortion. happened Advocacy Capacity Building • Strong advocacy • Nationals coached component in this in use evidence￾activity to inform based presentation t1nd sensiti1.e materit1ls. thus USA I[) missions strc1tgtltclli11g and their regional and local counterparts in capacity to Kenya, Zambia, advocate for PAC. Zimbabwe, Uganda, Tanzani~ • Country Malawi to PAC professionals issues. Personal involved in visits, discussions .. assessments '. and fonnal · ·r ~ · : :·· <· ~~t. (Uganda and ,- /. _· . . .: presentations ~er~ ~: ~~~ ~mbia), program .;i. ,· used. i· .. . . ~~· '~~ · ~~v~lopment . ' . : . . . : ~~ ' - • All USAID PHN officers were sensitized during a presentation at the 1996 SOT A course. and study tours (S. Africa, Uganda, Tanzania, and Zambia) have strengthened capacity to pursue PAC activities. TA and Other Activities Extensive T A by REDSO, Policy Project, and AFRISD for ad\'ncacy. assessments. and program development. HHRAA support. • HHRAA-funded Information Dissemination Centers. What changed Understanding the problem • Activity helped publicize size and issues of unsafe abortion in ESA. • Clarified to missions USAID policy on PAC. Alternative Solutions • MV A strengthened as emergency treatment procedure Advocacy • Advocacy conducted by activity implementors, but adoption of advocacy by Africans unclear. hanges in policies and programs • REDSO/ESA developed and is implementing a regional strategy for the promotion of PAC. • USAID/ Kenya, Malawi, Uganda and Zambia asked for assistance with PAC plans. • Uganda began a new PAC intervention with USAID bilateral project funding. • Study tour delegates and their colleagues in Ghana form an informal PAC network. • Core funds have been allocated to the PAC initiative by JHPEIGO and PRIMEIINTRAH. • Zambian policy on role of midwives in PAC updated, at least in part due to US .A •n-Jed advocacy in the Reproductive Health and FP Research to Stimulate Policy Dialogue on Unsafe Abortion in East and Southern Africa Main results and significance of activity • For the first time, the magnitude and dimensions of the problem of unsafe abortion in East and Southern Africa were defmed by a literature review and given sharp focus by hospital-based data collection. • An African organization, the Commonwealth Regional Health Community Secretariat, initiated and led the research and then guided the process leading to a ministerial resolution to adopt the recommendations on mitigating the problems of unsafe abortion and for post-abortion care. The ministerial acceptance of the recommendations contributed to a climate in the sub-region in which discussions and programs on post￾abortion care issues were welcome. • The research findings were compiled and published in a detailed monograph, Complications of Unsafe Abortion in Africa. • A summary pamphlet based on the data was prepared for and introduced and discussed by policy makers at three policy-level Commonwealth Regional Health Community Secretariat meetings. • In South Africa. a women's advocacy group presented to a parliamentary subcommittee data from the monograph which led to the adoption of new laws for maternal services. • The publication and its dissemination both influenced and led into programmatic and policy support on post-abortion care by international donors, including USAID/Washington, REDSO/ESA, and individual country missions ofUSAID. • REDSO/ESA region arranged for a staff person to target post-abortion care as one of her major program responsibilities and developed an action plan for working with donors and contracting agencies to coordinate activities. Dates of activity: Locations: Implementing Agencies: Total HHRAA funding: 1994-1996 Malawi, Uganda, Zambia; Tanzania Commonwealth Regional Health Community Secretariat/East, Central and Southern Africa; SARA/JHPIEGOIIPAS $300,000 Reproductive Health and FP 2 What were the problems or gaps being addressed? An estimated 1.5 million abortions annually occur in Africa. Most of these occur without adequate medical attention for the women involved, resulting in increased morbidity and mortality among women. About 30 percent of maternal deaths in eastern and southern Africa were attributable to complications of unsafe abortions. However, there had been insufficient recognition of the magnitude of the problem of unsafe abortion (both spontaneous and induced) and a lack of attention to post-abortion care within African ministries of health in East and Southern Africa and among donor organizations, including USAID. For example, little attention had been given to: • the impact of the problem of unsafe abortion for women's health and for African health care budgets and resources; • the range of prograrri. options available to mitigate these problems, including: .. emergency treatment for abortion complications .. post-abortion family planning counseling and services .. links between emergency treatment and other reproductive health services; • the need to expand PAC beyond physicians (usually working in urban-based secondary￾and tertiary-level hospitals) to midwives at lower levels of the health system. In addition, many USAID missions did not fully appreciate: • that USAID laws and regulations actually did enable missions to support selected activities in the field of post-abortion care'; • that post-abortion care was not identified specifically by any USAID mission results packages in this region. What was the purpose of this activity? The activity fell within both Strategic Objective 7--to adopt policies and strategies for increased sustainability, quality, efficiency, and equity of health services--and Strategic Objective 8--to adopt policies and strategies for increased sustainability and quality of family planning programs. More specifically, it addressed IR 7 .2.4 which called for the development of practical guidelines for improved care of emergency obstetric complications, and IRS. The purpose of the activity was to provide sufficient data on the magnitude and consequences of • In ~dprihl, I9 1 th94, President Clintohn issue~ a policy which perm 1 ittefd use ~f UbS~D funds •. · to prov1 e ea care to women w o require treatment as a resu to unsa1e a ortlon. Reproductive Health and FP 3 unsafe abortion and the importance of post-abortion care for women's health and to present that data to inform and influence policy makers within the ESA region to address identified issues. What were the specific objectives of the activity? The objectives of the activity-research and policy maker awareness--were to: • perform a review of published and gray literature from the 13 member countries of the ECSA region on the topic of abortion and post-abortion treatment; • conduct research in hospitals in three African countries on the extent, cost and quality of services on post-abortion care~ • disseminate the findings in ways to sensitize policy- and decision-makers in the region to the importance of unsafe abortion as a public health problem~ • draw implications from the findings to prepare a set of practical recommendations for consideration at CRHCS fora. • stimulate the interest of US AID and other donors in supporting the recommendations. What occurred during the activity? Research and analysis The Commonwealth Regional Health Community Secretariat (CRHCS) raised the issue and developed the proposal. Under a sub-contract with the SARA project, CRHCS led the research activity, which was divided into two parts. The first part--assisted by IPAS--was a review of published and unpublished literature on the issue of unsafe abortions, for the years 1980-1994, to provide a knowledge base of what was known and not known. The literature indicated a serious public health problem and helped define the types of questions to ask and information gaps to examine during the data collection phase of the activity. The second part was the field research. With technical assistance from SARA/JHPIEGO/IPAS, CRHCS worked with researchers in three countries--Malawi, Uganda and Zambia--to design instruments for collecting date in hospitals. These added patient record reviews to observations and interviews with service providers, patients and hospital administrators (for cost-related information). Epilnfo was used to manage the data. In each of the three countries quantitative and qualitative data were collected from four hospitals, including district, provincial and national teaching or referral facilities. Following analysis of the data, CRHCS--again with assistance from SARA/JHPIEGO/IPAS-- produced a report entitled, Monograph on Complications of Unsafe Abortion in Africa. It was the most comprehensive study published in East and Southern Africa on the issue. In order to reach policy and decision makers with the information generated by the research, a summary pamphlet with the findings and program and policy recommendations was published under the title Addressing Complication of Unsafe Abortion in Sub-Saharan Africa: Programme and Policy Actions. Reproductive Health and FP Dissemination of findings Five hundred fifty copies of Complications of Unsafe Abortion in Africa were printed for distribution in sub-Saharan Africa and the U.S. Copies were distributed to people and institutions thought to influence policies, strategies, programs and/or allocation of resources in the region through the CRHCS dissemination centers. professional meetings in Africa, and policy dissemination seminars organized in Uganda and Zimbabwe. Presentations were made at two APHA annual meetings for U.S.-based audiences. Three hundred copies of either the monograph or advocacy pamphlet were distributed at the Pan-African Federation of Child and Maternal Health Conference held in Joharmesburg in September, 1996. The country-specific reports from Malawi, Uganda and Zambia on the impact of unsafe abortion on maternal mortality and morbidity were distributed to national policymakers and program managers. Findings of the research were published by JHPIEGO in the journal, Health Policy and Planning. The advocacy pamphlet. Addressing Complications of Unsafe Abortion in Sub-Saharan Africa, was particularly important in reaching the policy-making groups associated with CRHCS's 13 member countries: the advisory group composed of ministry of health permanent secretaries; the 4 • Directors· Joint Consultative Committee; and the Council of Health Ministers. CRHCS staff • worked through and with each of these progressively responsible groups to have a set of recommendations refined and eventually adopted as a resolution at the 1995 conference of health ministers. The ministers also asked for assistance in implementing the recommendations which set the stage for USAID/ AFR/SD to begin planning such assistance. What were the outcomes of these activities? The research was initiated by CRHCS to inform health authorities in member states of the extent of the problem of unsafe abortion and to promote program and policy changes to address the problem. Like other activities along the research-policy change continuum, the research had to be carefully designed to make the findings credible. Also, the wealth of data generated by the research had to be synthesized and focused on practical and feasible recommendations for use by policy makers and program managers. • Reproductive Health and FP 5 Findings from the studies Table 1: Findings from Research on the Consequences of Unsafe Abortion Magnitude of Unsafe Abortion • A large numbers of women with complications of unsafe abortion receive treatment. In Kampala, for example, abortion cases accounted for 53 percent and 64 percent of annual gynecological admissions in two hospitals. respectively. In one Malawi district hospital, 70 percent of the total annual gynecological cases admitted were for complications of abortion. • Abortion complications are an important contributor to hospital-based maternal mortality and morbidity (accounting for more than half of all maternal deaths in a few studies). • Community-based studies also suggested that abortion complications are a leading cause of overall maternal mortality. • Young unmarried women with few children are over represented among abortion patients studied in hospitals. Cost • Treatment of abortion complications represents a significant cost to health care systems in sub-Saharan Africa (as measured by the use of resources such as staff time, medications and space). In Malawi, for example, the cost of treating one incomplete abortion was approximately US$3.00, as compared to the annual per capita budget ofUS$2.55 for full health coverage. Contraception and Abortion • Contraceptive use among women experiencing abortion is relatively low. • Post-abortion family planning services/linkages are limited. Abortion Laws • In most countries, restrictive laws foster the existence of clandestine, poorly performed abortions. • In Zambia, more liberal laws existed, but most health workers and members of the public were unaware of the laws. Reproductive Health and FP 6 Table 2: Fulfillment of Objectives Objective Met, Exceeded Not Met Comments/Source Perform a literature review Met 24 7 documents identified and abstracted Conduct research in hospitals in Met Monograph and informants three African countries on the extent, cost and quality of services on post-abortion care Disseminate the findings to Met Informants; agendas of CRHCS sensitize policy-makers in the meetings region to the importance of unsafe abortion. Draw implications from the Met Policy pamphlet; reports of findings to prepare CRHCS fora recommendations for consideration at CRHCS fora Stimulate the interest of USAID Exceeded Informants; USAID interest and other donors expressed in practical, resource support terms Products • Monograph on Complications of Unsafe Abortion in Africa, Arusha: Reproductive Health Research Programme of Commonwealth Regional Health Community Secretariat for East, Central and Southern Africa, 1996. • A policy pamphlet entitled, Addressing Complications of Unsafe Abortion in Sub￾Saharan Africa: Programme and Policy Actions ( 1996). • A ProCite bibliographic database was created for storing all the abstracts which were created from literature in the field. These abstracts were also made available on the Population Communication Services' bibliographic data base, POP LINE. What complementary efforts contributed to the results of this activity? • Another HHRAA/SARA activity focused on strengthening the capacity of CRHCS member states to disseminate findings of unsafe abortion and other research to country￾level decision makers. • ,. ,. Reproductive Health and FP 7 What results have been achieved to date? The activity was led by an African institution and made a major difference in both policy and programmatic responses to unsafe abortions in the ECSA region. The fmdings of the research immediately were fed into policy dialogue, resulting in adoption of a resolution by member countries on the issue. Also, the findings fed into a growing concern about the issue among donors, particularly USAID, which capitalized on the research to affect programmatic changes. Understanding the problem The research findings. as reported in Complications of Unsafe Abortion in Africa, provided the first systematic. comprehensive description of abortion-related problems, including morbidity and mortality, clinical issues, cost issues. contraception and abortion, male perspectives. and legal aspects. The problems for women· s health and health services were greater than most authorities has expected before the research. Changes in Policies and Programs ltemotive Solutions 'lbe process of policy and program change involves the interaction of describing problems. identifying solutions, and advocacy. The first issue of the African Journal on Fertility, Sexuality and Reproductive Health focused on PAC with articles using data from the study. Alternative Solutions The pamphlet, Addressing Complications of Unsafe Abortion in Sub-Saharan Africa: Programme and Policy Actions, set out eight broad recommendations for governments and another eight for donors and development partners. The endorsement of the recommendations by the Council of Ministers brought the issue and recommended responses back to country level for consideration and practical application. Advocacy Detailed research results were extracted from the Monograph, distilled into a more concise "policy-friendly" pamphlet, and widely disseminated to African policy makers and USAID missions in Africa. Results of the consequences of unsafe abortion studies were presented at the annual meetings of CRHCS's advisory and executive groups, including the Council of Ministers of Health. CRHCS staff effectively managed the advocacy process to have its study recommendations endorsed by the ministerial council in November, I 995, adding impetus for programmatic improvements, especially in eastern and southern Africa. Reproductive Health and FP 8 In South Africa, a women's advocacy group, Women in Action, prepared a presentation for a ;._ parliamentary subcommittee with data from the Monograph which resulted in the adoption of new laws for maternal services. Changes in policies and programs The environment for addressing post-abortion care as a public health priority has definitely changed over the past five years, in part because of the research undertaken within this activity and the ready application of the findings for promoting changes in programs and policies. These changes are evident in Africa as: • Health ministers of the Commonwealth Secretariat adopted recommendations to mitigate the problems of unsafe abortion and for post-abortion care and sought assistance in implementing the recommendations. • South Africa adopted new laws relating to maternal health services, at least partly on the basis the research findings. • The Society of Obstetrician/Gynecologists in Francophone Africa included post-abortion care in its priority list of strategies, in part as a result of HHRAA/SARA advocacy efforts. • HHRAA/SARA funds for support to the Information Dissemination Center in Zimbabwe were used to hire an acting troupe to create and perform a play on the consequences of unsafe abortion. It is believed that this informal communication is effective with audiences who may be hesitant to discuss the topic in more formal settings; ., • A USAID Post-abortion Care Regional Initiative was launched in 1996 to increase the . level of advocacy around the issue (this will be described in a subsequent impact assessment). • WHO, UNICEF and the ICM issued statements and guidelines calling for increased participation of midwives in the provision of PAC services, which lends international support to USAID's work in this field. Capacity building The project trained a cadre of Africans in Malawi, Uganda and Zambia to develop and use research tools, to undertake assessments of consequences of unsafe abortion, and to use policy￾oriented presentations to effectively influence abortion-related funding, policy, and laws. The network of Africans which have become skilled in this area will continue to share information and, as a result, extend the reach of this enhanced capacity. What lessons have we learned from this activity? • Advocacy efforts at a number of different levels are important, particularly in politically￾sensitive fields and new fields for which there is a paucity of program experience, such as post-abortion care. • The activity affirmed the important of a champion or core group of concerned people to Reproductive Health and FP 9 move an issue. In this case, the activity benefitted from the efforts of committed individuals within CRHCS to identify the problem, gather the data to demonstrate the magnitude of the problem, offer solutions and manage a multi-layered advocacy campaign to have their recommendations adopted by appropriate policy and decision makers. • The activity affirmed that working with a regional research and advocacy institution such as CRHCS/ECSA improved chances of affecting policy and program changes by: • ensuring the lead role of Africans in design and implementation of research; • encouraging positive policy changes in areas of reproductive health by reaching African policy-makers directly and with credible data; • presenting a set of feasible recommendations to policy makers. • To take further advantage with US AID and other donors of the research findings, the ministerial adoption of the recommendations. and the improved climate for addressing unsafe abortion issues, follow-on activities had been planned and were quickly initiated. • Demand for information about post-abortion care is strong and growing. What are the next steps to capitalize on the activity? • Complete post-abortion care assessments in additional countries, and collect primary data, where necessary, to inform both national policy makers and program specialists. • With CRHCS, organize a regional workshop to share lessons learned. • Document what has been accomplished at country level in the field of post-abortion care. • Monitor, by CRHCS, through periodic discussions with Ministers of Health in the region of policy and program change in the abortion area. Abbreviations CRHCS DISH ECSAHC HHR HHRAA ICM IPAS JHPIEGO MVA PAC REDSO/ESA Reproductive Health and FP I 0 Commonwealth Regional Health Community Secretariat Delivering Improved Services for Health East, Central and Southern Africa Health Community Health Health and Human Resources Health and Human Resources Analysis for Africa International Confederation of Midwives International Project Assistance Services Johns Hopkins Program for International Education in Reproductive Manual Vacuum Aspiration Post-abortion Care Regional Economic Development Support Offices/East and Southern Africa Resources Consulted Written • Stephen N. Kinoti, et al., Monograph on Complications of Unsafe Abortion in Africa. Arusha: CRHCS/ECSA, nd [1995]. • Lawrence Gikaru and Stephen Kinoti, Addressing Complications of Unsafe Abortion in Sub￾Saharan Africa: Programme and Policy Actions. Arusha: CRHCS/ECSA, 1996. Lynne Gaffikin, "Progress Report: Monograph on Complications of Unsafe Abortion in Africa," 3/1996. USAIDIREDSO/ESA/PH, "Post-abortion care activity work plan," draft, 25 October 1996. "POLICY action plan for post-abortion care advocacy in East and Southern Africa, November 1996-April 1997. II POLICY Project, "Workplan for the East and Southern Africa Post-abortion Care Initiative, November 1, 1996-September 30, 1998." SARA Task Orders, 108, 109, 262, 282. Informants Phyllis Gestrin, US AID/ AFR/SD Suzanne Prysor-Jones, SARA/ AED Marge Koblinsky, MotherCare Deborah Billings, Prepared by SARA: Beth Preble Latest Revision: August 17, 1998 • Research to Stimulate Policy Dialogue u What happened atsafe Abortion in East and Southern fr,~ What Research and Analysis Dissemination Advocacy Capacity Building • Literature review • Monograph • Advocacy strategy • Africans in • Quantitative and produced and moved results and Malawi, Uganda qualitative data distributed in recommendations and Zambia trained collection at 4 Africa and U.S. through CRHCS to develop and use hospitals in each • Advocacy booklet channels. These research tools on of three countries. produced and were endorsed by unsafe abortion and • Literature and data distributed widely ministers of health of post-abortion analyzed to assess to decision-makers of the CRI~CS care, and to use magnitude of in 13 countries member countries. policy-oriented TA and O ther Activities • Intensive TA from SARA/JIIPIEGO on research methodologies and analysis. • TA from SARA/AED for changed Understanding the problem • First systematic, comprehensive description of abortion-related problems. Alternative solutions • 8 recommendations for African policy makers and 8 for donors and development partners. unsafe abortion, covered by presentations to CRDCS. • South Africa influence abortion- 'Changes in policies and programs ~· J~t rvice :/ •.: .::., ... ~)._ _ ~; ;,~·:.; .. l ·,: ... ~: .' :·· i: women's ~dvocacy ;~. ~lated funding, ·:.; . • Commonwealth health ministers ' p J;. , '• • I • ''''f. •' ~' ~ \ t~ ' ; • 4lf • f I • I ·· ~ ... ~ 1· · :: .. ;.\'•."' .~.,.,.. ·•"250 eppes o ·' ·· ... :; ;••. ~ 'Y ~I'Y, ~!I.r'; :: . .l~< ·· ,li.. • . . ·; i:;·'1':·:·! ·.·:x ~.::.t· .:· ' ·f !~ . · > 11• ~d ocacy booklet ; · ·;,_ ~f:t · ·· ... ; . . . ; . -~. .. ·:requested by South 1• • I ~ • JO. ,._ • • I I • • • I ... I"'V"t • I f\IIII,;a a1011e. 1 suucmuminee, stan rmpruveu • Commonwealth health ministers leading to adoption there skills in . . requested assistance to implement of new laws for packaging results A actiVIty recommendations; USAID \ maternal health for policy makers. focused on. responded with its Post-abortion services. streng_themng the Care Regional Initiative, launched capacity of CRHCS in 1996 and assigned a staff person member states to to PAC. disseminate findings of unsafe abortion through country Information Dissemiantion Centers (I DC). • South Africa adopted new laws for improved maternal health services. • Contributed to change in climate for discussions and interventions on unsafe abortion. • Society of Obstetrician/ Gynecologists in Francophone Africa included post-abortion care in its priority strategies, in part as a result of HHRAA/SARA advocacy efforts. • Contributed to change in policy in Zambia on midwives' role. -< 0 c -; :r: :r: :::o . fTl IT1 . )> -c · r :::0 -; 0 . :r: a c:::: (") -1 < fTl Reproductive Health and Family Planning Introducing Adolescents to Reproductive Health Issues through Social Marketing Main results and significance of activity • Targeted social marketing messages and services for adolescents can produce important initial changes in behavior in both females and males. • At modest cost. the first set of quasi-experimental research activities for reaching adolescents about HIV I AIDS prevention through social marketing methods were conducted. • Lessons from an initial pilot test in Botswana were incorporated into a pilot intervention with females and males in the South Africa. Positive behavioral changes were noted in half the variables. • Resources for targeted social marketing for adolescents have been leveraged in the four countries involved in the study. One hundred percent of required funding is being contributed by the Government of Botswana, and the Department of Health in South Africa is also making a significant contribution. • As a result of PSI's operations research in Botswana, an adolescent reproductive health component was added to the social marketing program in Zambia. • HHRAA funding was instrumental in changing PSI's approach to social marketing for targeted audiences. The fact that special funding was made available for targeting adolescents allowed the organization to experiment with new approaches and conduct more rigorous impact evaluations. Dates of Activity: Location: Implementing Agencies: HHRAA Funding: Leveraged Funding: mid-1994- present (mid-1998) Lobatse-Botswana, Soweto-S. Africa, Bafia and Edea￾Cameroon, Conakry and Kankan-Guinea PSI Total: $686,000-- $177,000 for Botswana, $171,000 for South Africa, $13 8,000 for Cameroon, and $200,000 for Guinea c. $300,000/year from GOB; unknown levels from Department of Health, DIFD et al. in South Africa; USAID/FHA Project in Cameroon; and USAID and KfW in Guinea. Reproductive Health and Family Planning What gap or problem did this activity address? Young people are at high risk of HIV IS Tis; experimentation is normal, sexual knowledge is limited, and information and other services that adolescents will and are able to use are incompletely developed. In southern Africa, many adolescents are sexually active by their mid￾teens. A study in Lusaka, Zambia found 6o/o of 15 year old girls to be HIV infected. The age group 15-24 tends to have the highest HIV infection rates of any age group. 2 There was a felt need among many HIV I AIDS service organizations, national HIV I AIDS programs, some government authorities and others that young adults needed both more and more accurate information and effective reproductive health services. However, targeting youth with sex and reproductive health information and services has not been without controversy and thus slow to emerge. Activities and messages appealing to and influencing adolescents remained unclear. Means of marketing condoms to adolescents generally was little understood. Where they could get accurate information, few adolescents seemed to take the steps needed to protect themselves from HIV infection or pregnancy. In 1991. in response to the growing AIDS epidemic in the country, the Government of Botswana (GOB) asked PSI to create a condom social marketing campaign for the country with USAID financial assistance. PSI designed and implemented a nationwide condom sales and promotion program. known as the Botswana Social Marketing Program (BSMP). By 1995, Lovers Plus condoms were the most successful condom social marketing product in the world in terms of capital sales. With this experience, USAID/ AFR/SD contracted PSI to design an operations research project that would identify a workable approach or approaches to providing reproductive health information and services which would influence adolescent sexual behavior. The questions to be addressed in the operations research and pilot interventions were: can HIV I AIDS and contraceptive messages be designed and delivered to young adults through social marketing mechanisms? If so, what will those messages and the scope of supporting services look like? What purpose did this activity contribute to? Within the context of Strategic Objective 8--Adoption of policies and strategies for increased sustainability and quality of family planning programs--and IR 8.1.1--develop policies and strategies for addressing underserved populations--the purpose of the activity has been to promote policies and programs that 1) prevent unwanted pregnancies in adolescents, and 2) prevent sexually transmitted infections (STls) which contribute to increased morbidity and, in the case of HIV I AIDS, premature death in adolescents. • • • Reproductive Health and Family Planning 3 The purpose of the activity was to test the hypothesis that young adults could be reached and influenced to change their sexual behavior to reduce the risk to HIV/AIDS/STis and pregnancy. The activity sought to demonstrate improvements in adolescents' awareness and use of reproductive health services and products through the use of teen-targeted media campaigns, teen-targeted condom distribution networks, and adolescent peer education and promotion activities. Both Francophone and Anglophone countries were selected for the OR, with the choice of countries partly determined by the openness of society to providing reproductive health information to youth. What were the specific objectives ofthe activity? The objectives of the activity were to: • Test the effectiveness of targeted sexual changes messages on adolescent awareness and behavior. • Develop at least three pilot interventions and field test in both Anglophone and Francophone countries, with different audiences targeted sexual risk messages on HIV/STis among youth. • Disseminate sexual behavior changes messages targeted to youth through multiple channels. • Target to youth the distribution of condoms. • Sensitize health workers, pharmacists and school teachers to the needs of adolescents for reproductive health information. What took place in implementing the activity? Research and analysis A methodology was developed based on the Health Belief Model (HBM). Pre- and post￾intervention surveys were conducted in both the intervention area and a comparison/control area in each of the countries. The post-intervention survey took place about eight months after the project launch. A focus group study was used to clarify and illustrate the findings from the surveys. Although four countries were selected to take part, the research got off to the quickest start in Botswana. Some of the lessons gained from that experience were incorporated into the design in South Africa, Cameroon, and Guinea. Reproductive Health and Family Planning 4 lntenrentions The behavior change communication activities involved the design and production of a variety of educational materials targeting youth, containing messages on reproductive health protection through abstinence, condom use, female-controlled contraception, use of clinic facilities for screening for hormonal contraception and for early diagnosis of STDs. The messages were developed and produced with the active participation of young people from the target groups, then disseminated through promotional events targeting youth, peer counseling, radio talk shows, brochures. and other media. There was targeted distribution of condoms and infonnation on other contraceptives. Efforts were made to assure distribution of condoms through channels that would facilitate their access by young people. This involved using peer educators as mobile salespeople, and opening up sales points in areas frequented by young people. The interventions addressed the transition from information to behavior change by adding an action component--a referral network with trained partners in the community. Specific activities during the interventions included: • Involvement of parents and community leaders~ • • Training and education of teen peer educators who were responsible for promoting youth- •. to-youth communication ; • Establishment of an advisory task force; • Development an production of teen-oriented promotional materials; • Development of radio shows with a call-in or talk show format. Dissemination To date, thirteen PSI Working Papers have been developed on the basis of the studies in Cameroon. South Africa, and Botswana. Others are in development. One PSI Research Brief, Impact of the Botswana Tsa Banana Program on Adolescents' Health Beliefs, was also produced. All of these have publications been distributed through a mailing list of approximately 150 academic institutions, donor project offices, and researchers, and in response to numerous requests from individuals. About 500 copies of the Research Brief have been disseminated to date. One of the working papers, based on the Cameroon data, was revised and submitted for publication in the next issue of The African Journal of Reproductive Health. In addition, the publication Adolescent Sexuality in Southern Africa: Cultural Norms and Contemporary Behavior was prepared for the 23rd General Conference of the International • Reproductive Health and Family Planning 5 Union for the Scientific Study of Population, Beijing, 1997. 1 This is included in a three-volume conference proceedings to about 2000 people, primarily Africans, published by the International Union for the Scientific Study of Population in Liege, Belgium. To date, 10 presentations on data from the activity have been made at conferences and seminars: In addition, PSI Research Director served on two consensus panels2 at the 1997 Pathfinder FOCUS on Young Adult Program, where he presented findings from Botswana. What were the outcomes of this activity? This activity addressed the general problems related to adolescent reproductive health, and tested the extent to which social marketing could affect the behavior of teens in a given community. Research and implementation overlapped in several cases. but the activity's focus was on determining what worked and what did not in reaching adolescents with safe sex messages and servtces. Methodology Analysis of the research findings is based on the Health Belief Model (HBM), which attributes changes in individuals· behavior to their beliefs about: • the severity of the health threat; • their susceptibility to it; • the benefits/effectiveness of protective measures; • the barriers/negative implications of taking protective action; • a trigger which leads individuals to act on these beliefs. Research findings In the Botswana study, targeted messages and services for adolescents in the intervention location produced positive changes after eight months in 4 out of 17 variables for females, and 4 out of the 17 for males. It should be noted that there were no changes noted in the area of Sexual and protective behaviour for either males or females. Males showed improvements in the area of 1 Meekers, Dominique and Ghyasuddin Ahmed. "Adolescent Sexuality in Southern Africa: Cultural Norms and Contemporary Behavior". In: Proceedings of the XX/1/rd General Conference of the International Union for the Scientific Study of Population, Beijing, China, October 11-17, 1997. Liege: International Union for the Scientific Study of Population. 2 Consensus Panel on Social Marketing and Media Communications Programs for Young Adult Reproductive Health, and Consensus Panel on School-Based Reproductive Health Programs Reproductive Health and Family Planning 6 self-efficacy. • Table 1: Changes in Knowledge, Attitudes and Practices of Botswana Adolescents Health Belief and Behavior Post-intervention positive changes obtained compared with control group Males Females Perceived severity of sexual risk Believe AIDS cannot be cured X Perceived susceptibility to sexual risk Sexual risk of contracting HIVIAIDS Perceived benefits of Prevention Condoms help avoid risk X X Abstinence reduces sexual risk X Avoiding casual sex reduces risk Perceived Barriers to Prevention Hard to convince partner Women who initiate lose respect Sex is good because it confers status Sex is good because it lead to marriage X Few friends use condoms Self-efficacy Shy to buy in public X Shy to buy from health worker X In the South African study. the variables evaluated had more emphasis on family planning. The knowledge, ani tude and practice (KAP) of females in the intervention area compared with those of the control area were found to have improved in 11 out of 22 variables, while they worsened on 4 variables. • • Reproductive Health and Family Planning 7 Table 2: Fulfillment of Objectives Objective Met, Not Met, Exceeded Comments/Sources Test the effectiveness of Met PSI interviews and working targeted sexual changes papers messages on adolescent awareness and behavior Develop at least 3 pilot Exceeded 4 interventions implemented interventions targeted to youth Disseminate sexual behavior Met PSI working papers change messages targeted to youth through multiple channels Target to youth the distribution Met On-going reports of condoms Sensitize health workers. Met Interviews pharmacists and school teachers to the needs of adolescents Products The following publications were produced: Meekers. Dominique and Ghyasuddin Ahmed. 1997. Adolescent Sexuality in Southern Africa: Cultural Norms and Contemporary Behavior. PSI Working Paper No. 2 Meekers, Dominique, Guy Stallworthy, and John Harris. 1997. Changing Adolescents' Beliefs about Protective Sexual Behavior: The Botswana Tsa Banana Program. PSI Working Paper No.3 Meekers, Dominique and Anne-Emmanuele Calves. 1997. Gender Differentials in Adolescent Sexual Activity and Reproductive Health Risks in Cameroon. PSI Working Paper No.4 Parker, Warren. 1997. Action Media: Consultation, Collaboration, and Empowerment in Health Promotion. PSI Working Paper No. 8 Meekers, Dominique. 1997. The Implications of Free and Commercial Distribution for Condom Use : Evidence From Cameroon. PSI Working Paper No. 9 Meekers, Dominique, Ghyasuddin Ahmed, and M. Tinah Molatlhegi. 1997. Understanding Constraints to Adolescent Condom Procurement: The Case of Urban Botswana. PSI Working Paper No. 12; Reproductive Health and Family Planning Meekers, Dominique. I 998. The Effectiveness of Targeted Social Marketing to Promote Adolescent Reproductive Health: The Case ofSoweto, South Africa. PSI Working Paper No. I6 Meekers, Dominique, Guy Stallworthy, and John Harris. 1997. Impact of the Botswana Tsa Banana Program on Adolescents' Health Beliefs. Research Brief No. I Meekers, Dominique and Ghyasuddin Ahmed. "Adolescent Sexuality in Southern Africa: Cultural Norms and Contemporary Behavior". In: Proceedings of the XXI!Ird General Conference of the International Union for the Scientific Study of Population, Beijing, China, October 11-17, 1997. Liege: International Union for the Scientific Study of Population. What complementary efforts have contributed to the results of this activity? Ongoing PSI social marketing programs in other African countries contributed to the design and implementation of these activities. Other donors and CAs were interested and involved in adolescent reproductive health and were planning possible interventions and support. What results have been achieved to date? Far more is known in the late I 990s about African youth sexual behaviors and attitudes than had been the case in the early and mid-1990s. This particular activity contributed to provider understanding of youth and helped shape subsequent interventions targeted toward adolescents. In addition, the activity helped establish the appropriateness and feasibility of providing HIV IS Til contraceptive information and services to youth--an approach which has been very emotionally charged across the continent. Understanding the problem The studies have contributed greatly to understanding the complexity of changing adolescent knowledge. attitudes, and behavior Understanding the Problem Changes in Policies and Programs Identification of temotive Solutions The process of policy and progr.mt change iovol ves the interaction of describing problems, identifying solutions, and advocacy. about sexuality. Program managers and information service providers have a clearer idea of the types of safe sex messages which will appeal to youth and the range of services they need and seek. Alternative solutions Where many HIV /STI/pregnancy prevention messages had been very general and definitely not targeted to youth, this activity was one of several across Africa that demonstrated that the information needs of youth and the ways to provide that information were particular to that segment of the population. Policy makers and program managers have a body of information 8 • • • Reoroductive Health and Family Planning 9 from which options for reaching youth can be drawn. Advocacy Several international audiences have been reached, both in Africa and elsewhere, through the presentation of research findings in l 0 seminars and conferences (seven of the 10 were international fora). A total of five of the presentations were in Africa--three in Botswana and two international. Changes in policies and programs Resources for targeted social marketing for adolescents have been leveraged in all of the countries concerned by the study. In Botswana, the government is contributing all the funding for continuation of PSI" s overall program, the overwhelming portion of which is targeted to adolescents (about $300.000 per year). In South Africa the Department of Health, DFID and others are contributing. while in Cameroon, the USAID Family Health and AIDS Project is supporting the activity. In Guinea, funding is coming from ongoing USAID programs and is being negotiated with KFW programs. Significant leveraged funding indicates changes in several programs and at least the tacit agreement of policy makers that reaching youth with safe sex information and services is important. HHRAA funding has been instrumental in changing PSI's approach to social marketing for targeted audiences. The fact that special funding was made available for targeting adolescents allowed the organization to experiment with new approaches and conduct more rigorous impact evaluations. Capacity building In Cameroon, a number of the peer educators trained have moved on to similar positions in like organizations. One of peer educators in Botswana is currently doing graduate work at Johns Hopkins University School of Public Health. In Guinea and Cameroon national family planning or AIDS agencies participated in the design and implementation of interventions, and local research organizations and advertising agencies recruited by PSI took part in most of the field work. A program staff member and a staff person from the national AIDS control program visited South Africa to observe the activities in that country which are targeted toward youth. What lessons have been learned from this activity? • Targeting youth through social marketing techniques can yield positive behavior changes to reduce risk to HIV I AID SIS Tis and pregnancy. • HHRAA funding was instrumental in changing the approach of one of the leading Reproductive Health and Family Planning 10 organizations involved in social marketing. The fact that special funding was made available for targeting adolescents allowed the organization to experiment with new approaches and conduct more rigorous impact evaluations. • The Botswana study showed the importance ofmonitoring the effects of interventions, in order to understand and counteract undesirable trends. • The "piecemeal" nature of the funding limited comprehensive follow up. • Although the Botswana study demonstrated that it is possible to have a positive effect on some variables ( 4 out of 17) in only eight months after the .launch of activities, it is also clear that a longer time is needed to more accurately measure behavior change impact. • It is relatively easy to change health beliefs; to change actual behavior takes longer. • Involving the target audience in the development of project messages and project activities is one of the best ways to assure that they will be effective and will solicit participation by the target group. What are the next steps for this activity? PSI's work plan for 1998-99 includes the completion of data analysis for Cameroon and Guinea and the preparation of a technical syntheses of all projects, an overall synthesis publication, and an advocacy brief. Dissemination and advocacy workshops will be held in Washington, Botswana, South Africa, Cameroon, and Guinea. One feature of the workshops is that local • groups will be given seed money for advocacy, a very positive response to move agendas. This • assessment will be updated when these next steps are completed. USAID/ AFR/SD can take a more direct role in disseminating the findings of the activity to USAID missions, particularly in those countries with a known interest in adolescent issues. Toward that end, AFR/SD and PSI are developing materials to fit the needs of different audiences (research, program, advocacy). This segmentation of findings is to be encouraged for other activities within AFRISD. Dissemiention can be expanded to African governments and institutions--i.e., family planning association--and other organizations involved in social marketing with adolescents. • Reproductive Health and Family Planning 11 Resources Consulted Written PSI. The Botswana Social Marketing Program: Final Report of Activities. July 1996. Washington, DC: PSI. Meekers. Dominique, Guy Stallworthy, and John Harris. 1997. Impact of the Botswana Tsa Banana Program on Adolescents' Health Beliefs. Research Brief No. 1 Meekers, Dominique and Ghyasuddin Ahmed. "Adolescent Sexuality in Southern Africa: Cultural Norms and Contemporary Behavior". In: Proceedings of the XXI!Ird General Conference of the international Union for the Scientific Study of Population, Beijing, China, October 11-17, 1997. Liege: International Union for the Scientific Study of Population. Presentation notes Presentations on the activity included: The Implications of Free and Commercial Distribution for Condom Use: Evidence from Cameroon. Poster presented at the 12th World AIDS Conference, Geneva, June 28-July 3, 1998. The Implications of Free and Commercial Distribution for Condom Use: Evidence from Cameroon. Poster presented at the 126th Annual Meeting of the American Public Health Association, Washington D.C., November 15-19, 1998. Roles of Sugar-Daddies and Mummies in AIDS Spread and Teenage Parenthood in Botswana: Urban Adolescents Speak. Paper presented at the National Conference on HIV/AIDS in Botswana, held in Gaborone, Botswan~ August 6-9, 1997. Condom Culture Among Urban Botswana Adolescents for the Prevention and Control of AIDS and Unwanted Pregnancy. Paper presented at the National Conference on HIV/AIDS in Botswana, held in Gaborone, Botswan~ August 6-9, 1997. Adolescent Sexuality in Southern Africa: Cultural Norms and Contemporary Behavior. Paper presented at the XXIIIrd General Conference of the International Union for the Scientific Study of Population, held in Beijing, China, October 11-17, 1997 Understanding Constraints to Adolescent Condom Procurement: The Case of Urban Botswana. Paper presented at the National Conference on HIV I AIDS in Botswana, held in Gaborone, Botswan~ August 6-9, 1997. Changing Adolescents' Beliefs about Protective Sexual Behavior: The Botswana Tsa Banana Program. 8th International Congress of the World Federation of Public Health Associations, held in Arush~ Tanzania, October 12-17, 1997. Changing Adolescents' Beliefs about Protective Sexual Behavior: The Botswana Tsa Banana Program. Poster presented at the International Conference on STD/ AIDS in Africa "AIDS and Development", Abidjan, Cote d'Ivoire, December 7-11, 1997. Reproductive Health and Family Planning 12 Improving Adolescent Sexual and Reproductive Health in Urban Botswana. Paper presented at the Hopkins Population Center Seminar, School of Hygiene and Public Health, Johns Hopkins University, Baltimore, September 22, 1997. Action Media: Consultation, Collaboration, and Empowerment in Health Promotion. Second International Conference on Entertainment-Education for Social Change, held in Athens, Ohio, May 7-10, 1997. Informants Guy Stallworthy, PSI director Dominique Meekers, PSI director of research Nils Gade, PSI program manager Florence Zake, PSI program manager Brian Smith, PSI program manger Sean Cantella. PSI program manager Danielle Ring. PSI program manger Prepared for SARA by: Arin Farington Latest Revision: November 2, 1998 • • • Introducing Adolescents to Reproduct'rve Health Issues through Social Marketing l What happened What ! Research and Dissemination Advocacy Capacity TA and Other changed Analysis Building Acti\·ities • Operations research • 13 PSI Working Advocacy training • Local staff hired • OR occurred Changes in policies and programs in 4 countries to Papers and I and seed money for and trained for the within context of I measure impact of Research Brief sent local groups to activity. ~ • Leveraged government, donor and BCC messages and to mailing list of c. conduct advocacy is USAID Mission funds. service availability 500 acadern ic and built into the activity . I on youth program plans. • Influenced PSI's own approach to specialists. ~al marketing for youth. • Baseline and follow-up KAPB • One Working ~ vernment of Botswana has data collected in Paper submitted for adopted the youth-oriented Botswana and publicatiOn approach within its national South Africa HIV/AIDS prevention efforts. (Cameroon and • I 0 conferences and Guinea, in semmar progress) presentations on findings Capacity Building I I I • Peer educators trained in Cameroon have joined various BCC organizations. Reproductive Health Adolescents and reproductive health in the Sahel: Research, dissemination and advocacy Main results and significance of the activity • The study generated the first and most comprehensive demographic and reproductive health data relating to adolescents in Francophone West Africa, showing: .,. age at first marriage in the Sahel is among the lowest in the world; .,. lack of information and services targeted toward and available to adolescents are barriers to their health; .,. negative attitudes on the part of service providers further discourage youth from accessing information and services. • The qualitative research component was key: it ilium inated youth, parent and service provider beliefs and attitudes and guided the development of recommendations for action. • Data from the research quickly influenced the policy environment. Findings were synthesized into a popular booklet. of which I 2,000 have been distributed. The booklet and the findings it received extensive attention from African decision-makers, donors, CAs, health ministries, and the media. • USAID and CAs have allocated additional resources to support dissemination and advocacy efforts that have been undertaken with CERPOD support. • CERPOD's advocacy efforts has generated local ownership in Burkina, Senegal, Mali, and Niger--of the issue of adolescent reproductive health and of the process of policy change. • CERPOD acquired new skills in the areas of qualitative research, dissemination, and advocacy, allowing it to play an expanded role as mentor and trainer for other institutions in the region in using data to affect policies and program. • CERPOD has increased its commitment to adolescent reproductive health and is planning new country support activities in the area ofHIV/AIDS prevention. Dates of Activity: Locations: Implementing Agencies: Total HHRAA Funding: Leveraged Funding: June 1994- on going Sahel SARA (CERPOD, AED, Tulane, PRB, DHS/MACRO, ACI), PCS $553,000 $ 40,000 (PPPD and USAID/Mali) Reproductive Health 2 What was the problem or gap being addressed? The Africa Bureau's HHRAA Strategic Framework for Research, Analysis and Dissemination on Population and Family Planning in Africa, developed by SARA through a participatory process, identified adolescent reproductive health (ARH) as a top priority issue that needed to be addressed in Africa. Data on youth tended to be too general for program planning or policy development. It was known, however, that: • Between one-third and one-half of young African women have a child by age 19. • A high proportion of adolescents in most African countries are sexually active and are exposed to unwanted pregnancies, induced abortion, the transmission of STis, including HIV I AIDS, and curtailed schooling. • Health facilities in four Sahel ian countries serve less than half of the population, thereby further marginalizing adolescents. • Changes in sexual attitudes and behaviors result from the provision of information, counseling, and family planning and other reproductive health services for pre-teen and teenage youth. • Adolescent reproductive health was not fully on national agendas in Africa nor had programs been clearly defined or implemented. Although there was existing quantitative data on reproductive health, mainly from DHS reports, that information was not presented so to derive specific conclusions about adolescents. Also, there was little qualitative data available on adolescent, parental, and professional attitudes toward reproductive health care for young adults. To address these gaps in the da~ HHRAA/SARA and the Centre d'Etudes et de Recherche sur Ia Population pour le Developpement (CERPOD) developed a joint proposal to study the "Tendencies and Determinants of Modem Contraception and Reproductive Health Behavior in Adolescents in the Sahel... CERPOD is an entity of the regional organization CILSS (Comite de Lutte contre Ia Secheresse au Sahel) and is based in Mali. What was the purpose of the activity? Within the context of Strategic Objective 8--Adoption of policies and strategies for increased sustainability and quality of family planning programs--and IR 8.1.1--develop policies and strategies for addressing underserved populations--the purpose of the activity has been to promote policies and programs that 1) prevent unwanted pregnancies in adolescents, and 2) prevent sexually transmitted infections (STis) which contribute to increased morbidity and, in the • • • Reproductive Health 3 case of HIV I AIDS, premature death in adolescents. It was anticipated that preparation and presentation of appropriate quantitative and qualitative data relating to adolescent reproductive health would sensitize and motivate decision/policy makers in Francophone West Africa to address those issues. It was expected that the findings would generate debate and discussion and lead to a set of recommendations for action by policy makers and program implementors. What were the specific objectives of the activity? • To analyze existing DHS data from West African countries in order to develop profiles of the demographic and health characteristics of the problem of adolescents. • To gather knowledge-attitude-belief-practices (KABP) information in tlrree countries on ARH and identify the barriers to access and use of RH services. • To disseminate widely findings of the studies among decision-makers in the Sahel. • To expand CERPOD's capacity to integrate quantitative and qualitative analysis, produce policy-relevant recommendations, and bring its research findings effectively to the attention of decision-makers. What took place during the activity? Research and analysis CERPOD researchers and country collaborators, with technical assistance from SARA/PRB, Johns Hopkins University (JHU), SARA/DHS/MACRO, analyzed existing quantitative DHS (Demographic and Health Survey) data on married and unmarried adolescents in Burkina Faso, Mali, Niger, Mauritani~ and Senegal. The qualitative research was carried out by CERPOD staff, with TA by Tulane University, and two researchers identified by CERPOD in each of three countries: Mali, Niger, and Burkina Faso. Key informant interviews and focus group discussions were held with urban and rural adolescents, parents, health providers, teachers, and community leaders. In October 1995, at the completion of the studies, CERPOD held a 4-week analysis workshop for all the researchers. Participants analyzed and interpreted the results of the two sets of research, finalized individual reports, and integrated the findings into a common synthesis document. A CERPOD journalist participated in this effort, working with the researchers to draft a readable booklet--Les Jeunes en Danger/Youth in Danger--that would adequately reflect their work. Reproductive Health 4 Dissemination Following the analysis workshop, a multi-disciplinary dissemination meeting was held with over 45 quantitative and qualitative researchers, family planning directors (public and private sector), and journalists. The meeting exposed participants to the findings of the research and engaged them in defining the study's key policy and program implications. Participants revised the draft swnmary booklet before its final preparation, assuring that program implications were incorporated into the draft .. Participants prepared plans for in-country dissemination of and advocacy around the results. CERPOD staff and SARA/ ACI revised the summary booklet, Les Jeunes en Danger/Youth in Danger. A first printing in French was completed by mid-1996. The attention-getting booklet mixes quantitative data with qualitative information, newspaper articles, cartoons, graphics, and boxed questions for reflection. Core groups formed in each country have taken the lead in distributing the document to national decision-makers, while CERPOD has targeted the Africa donor and CA communities, regional meetings, CERPOD training courses, and journalist networks. Due to high demand, HHRAA made additional funds available through JHU/PCS to cover a • second printing of the booklet, adding 5,000 to the original 3,000 in French, and printing 2,000 • copies in English for U.S. and Anglophone African audiences. USAID/Mali printed and distributed 2000 copies, as a part of its youth strategy, and USAID/PPPD/Mali funded an additional 2000 copies in French. To date, 12,000 copies of the booklet have been printed. What were the outcomes of this activity? Research Findings Major findings of the two sets of studies are summarized in Table 1. • Reproductive Health 5 Table 1: Key Findings on Adolescent Reproductive Health in the Sabel • the age at first marriage in the Sahel is among the lowest in the world, especially in rural areas ( 19% of girls in Senegal and 45% in Niger are married by age 1 5) • the proportion of single adolescents who have experienced a birth varies between 9% and 18o/o • between 22% and 48% of women in capital cities admit to having pre-marital sex before age 20- -these figures are probably higher in reality • an increasing number of urban women are single at 20, exposing them to the risks of premarital sexual activities • the percentage of married adolescent women who approve of family planning is much higher than that of their spouses • adolescents' knowledge of STis and HIV I AIDS is often superficial and inaccurate • parents recognize that there is a lack of communication between themselves and their children, as well as between themselves • "shame", "lack of anonymity" ,"lack of money", and "the attitude of the medical staff' are cited by adolescent as obstacles to their seeking treatment of STis The activity met or exceeded its four objectives, as is summarized in Table 2 .. Table 2: Fulfillment of Activity Objectives Objective Met, Not met, Evidence/Sources Exceeded Analyze DHS data Met Project reports KABP survey in 3 countries Met Project reports Disseminate findings Exceeded Printing history; requests for publications; project reports Expand CERPOD's research Exceeded Informants and advocacy skills Reproductive Health 6 Products • The activity yielded the following products: • Quantitative and qualitative methodologies developed and applied • CERPOD and country researchers trained in qualitative research • Five country reports of quantitative analysis • Three country reports of qualitative analysis • One summary booklet targeted to decision makers produced and widely disseminated • One dissemination workshop • One advocacy training for CERPOD and REDSO/W A • Advocacy plans developed in three countries • Advocacy efforts conducted in two countries • Evaluation of impact in process (as of May 1998) in Burkina Faso What complementary efforts have contributed to the results of this activity? In 1996, CERPOD, in collaboration with SARAIPRB and SARA/ ACI, launched a special initiative titled POP' MEDIAFRIQUE. The project sought to expand and sustain media coverage of important reproductive health issues by providing periodic forums where senior￾level print and broadcast journalists (the "gatekeepers") and health professionals could be • informed and share perspectives about the implications of current research. The frrst seminar, held in 1996, focused on adolescents and used the findings of CERPOD's research. Burkina Faso, Cote d'Ivoire, Mali, Mauritania, and Senegal sent participants, who returned home to produce press articles and radio broadcasts with both global and local perspectives. What happened as a result of this activity? The objectives set for the activity were met and exceeded, in part because CERPOD took ownership and moved beyond its traditional research role to become strong advocates for adolescent reproductive health. They conveyed their commitment in the issue to policy makers and national counterparts. Also, the booklet was written in an accessible form, presented compelling information, was packaged with decision makers in mind, and was widely distributed and demanded. Understanding the problem • The research resulted in the first Understanding the Problem Changes in Policies and Programs The process of policy and progr.ml change involves the interaction of describing problems. identifying solutions, and advocacy. systematic description of the demographic characteristics of Sahelian youth and their • Reproductive Health 7 sexual behavior, and identified the gaps in their knowledge about reproductive health and access to appropriate services. • The study demonstrated that lack of information and services targeted at adolescents, as well as negative attitudes on the part of service providers, are major barriers to adolescent reproductive health. Identification of alternative solutions Findings from the qualitative research allowed CERPOD to present solutions identified by adolescents themselves and adults in the community. The booklet Les Jeunes en Danger includes several recommendations on how to expand appropriate reproductive health services for adolescents. Advocacy Although advocacy around the recommendations was not planned in the original objectives, it was clear to CERPOD and dissemination meeting participants that extensive efforts would be needed to sensitize to and motivate program and policy makers on the issues identified by the research. Country core groups identified advocacy activities they wished to carry out. The importance of advocacy was underlined by the unexpected financial support from several collaborating agencies and USAID/Mali and USAID/PPPD for promotion of the research findings. The dynamism of the core groups for country-level dissemination /advocacy has been varied, depending largely on the presence of one or more "policy champions", individuals who are fully motivated to carry forward the planned activities. The following advocacy efforts have taken place within individual countries: • The Burkina Faso core team, with leadership from the local Reproductive Health Research Network chapter, took the lead in organizing the first in-country planning session. A week-long series of seminars, cultural events and media coverage involving both youth and influential leaders were held in Bobo Dioulasso in February 1997 to showcase the study and advocate for ARH. • The Mali team had more difficulty mobilizing its efforts, but organized a week-long workshop in November 1997 to plan advocacy activities. • In Senegal, the issues were taken up by the Groupe pour l'Etude et l'Enseignement de Ia Population (GEEP). Although not originally involved in the research study, GEEP works with over 300 schools and youth groups family life education activities. In November Reproductive Health 8 and December 1997, GEEP organized eight workshops on adolescent reproductive health • in different regions of Senegal as well as a national weekend celebration. Key issues from the CERPOD study were thus brought to the attention of students, youth association members, parents, religious and community leaders, and health workers, promoting both reflection and action. High school students were encouraged to take responsibility for further dissemination and advocacy activities. • Activities in Niger have been slow, mainly because USAID/PPPD/CERPOD funding could not be used to support CERPOD visits and financial support for advocacy activities. Attempts have been made to leverage UNFPA funds for the activities. Changes in Policies and Programs As a result of these elements, there were changes in the policy environment, policies and programs. The availability of reliable data and information on ARH provided a base for changes that affected the policy environment at several levels: regional, national, and local. By bringing attention to bear on the issues across these levels, rather than just at one level, awareness to the issues increased more rapidly and deeply. In addition, country core advocacy groups have, with varying degrees of success. sustained attention on the issues. Specific examples of changes in the policy environment included: • USAID has committed additional funding to promoting advocacy on adolescent reproductive health, based on the CERPOD study. • Burkina and Senegal have identified specific follow-up activities to improve reproductive health programs. The adoption by GEEP in Senegal is an indicator of the importance of the issues and the impetus that this activity provided to increased advocacy. • CERPOD itself has brought issues of adolescent health onto its agenda and is planning new country support activities in the area of HIV I AIDS monitoring and evaluation. Capacity Building Extensive training contributed to significant capacity building of CERPOD as an organization. The training included: • CERPOD's senior investigator worked with DHS/MACRO and JHU staff to learn new quantitative analysis skills, current methods of preparing data tables and developing computer models. • CERPOD staff (2) and country teams (9) were trained by Tulane University staff in qualitative research methods, including drafting focus group guides and informant • • Reproductive Health 9 interviews, standardizing methodology for participant selection, and the TALLY computer qualitative-data analysis tool. • CERPOD staff(l5) and members ofthe Reproductive Health Research Network (10) from Burkina, Cameroon, Cote d'Ivoire, Guinea, Mali, Niger, and Senegal were trained in advocacy. Teams in Burkina and Mali planned advocacy efforts, with CERPOD support. • CERPOD journalists and researchers gained new skills in the presentation of research findings for wide distribution, working with SARA/ ACI to develop Les Jeunes en Danger booklet. This style of publication was a first for the institution and is seen by the researchers as important in helping to capitalize on their work. Capacity Building The data gathering, analytical and advocacy planning skills of CERPOD have greatly expanded. CERPOD had applied those skills in its work with ARH country core groups, providing technical assistance in data analysis, presentation of findings, and advocacy. For example, CERPOD is using the qualitative research methods learned to develop a regional course to train others. The booklet, Les Jeunes en Danger, represented a unique style of presentation for the organizations. The high demand for the booklet reinforces the skills learned in its production, and CERPOD staff recognize it as a key tool to capitalize on moving research findings to a policy plain. CERPOD follow-up and assistance would be needed to stimulate the implementation of country advocacy plans. In order to strengthen its institutional ability to develop and guide systematic advocacy approaches, CERPOD requested and received training in advocacy methods and processes. Members of the West Africa Reproductive Health Research Network (from Burkina Faso, Cameroon, Cote d' I voire, Guinea, Mali, Niger, and Senegal) also participated in this training. What lessons have we learned from this activity? • Working with a regional institution to carry out research and advocacy had clear advantages: • CERPOD identified appropriate participants for qualitative research training, dissemination planning and advocacy; • Ownership of the results spread across the countries involved; • CERPOD's credibility allowed its staff to take a pro-active role in promoting country advocacy efforts; • CERPOD leadership in this activity facilitated the involvement of other African institutions. Reproductive Health I 0 • CERPOD's flexibility and commitment to utilizing new methodologies (e.g advocacy) • with participating institutions, despite the unforseen effort required, has been key to obtaining the unexpectedly high level of interest and activity to date. • The policy development/advocacy approach adopted in this activity affirms experiences from elsewhere. • Dissemination and advocacy require considerable financial resources, technical expertise, and time (almost 50% of the total effort in this case). Each of these components must be built into the design of research activities and adequately funded. • Public health policy/program advocacy requires on-going funding which will be generated only in part from fee-for-service technical assistance or sale of materials. External support is likely to be required for several years into the future. What are the next steps to capitalize on the activity? • Support CERPOD in evaluating the impact of the advocacy activities to date in Burkina and Senegal. • Provide technical support through CERPOD for advocacy activities in Mali and Niger (if • possible). • Expand advocacy and policy development skills of CERPOD in preparing analyses of and recommendations for specific ARH issues, through adaptation of social marketing and behavior change approaches to regional and local conditions, and strengthening of regional and national networks. • Continue to support CERPOD to take advantage of opportunities to share findings with interested parties in the region, in particular USAID-funded HIV/AIDS activities. • Use study findings and advocacy efforts to leverage resources to implement improved services for adolescents (UNFPA, West Africa Project, Focus Program, PSI, CEDPA, SO MARC, FHI, SEATS, etc.). • Work with CERPOD to create the organizational conditions (staffing, proposal development, resource mobilization, etc.) that will facilitate the continued use of new skills developed and consolidate its role in using data to affect policy. • Collaboration with other USAID 80s-governance and democratization, NGOs-should be actively pursued in order to draw upon a wider skill base and leverage additional funding for ARH advocacy. • Resources Consulted Written Youth in Danger!Les Jeunes en Danger. Bamako: CERPOD, 1996. Rhonda Smith, "Trip Report: CERPOD Visit," May 1995. Reproductive Health 11 "Summary of CERPOD's Adolescent Booklet Dissemination Plan," SARA, unpublished memo. SARA Task Orders, Nos. 91, 124, 126, 169,238,283, 241,342,431. Informants: Suzanne Prysor-Jones, SARA/ AED Phyllis Gestrin, USAID/ AFRJSD Rhonda Smith, PRB Abbreviations ARH CERPOD CILSS DHS GEEP JHU KABP PBR STI(s) adolescent reproductive health Centre d' Etudes et de Recherche sur Ia Population pour le Developpement Comite de Lutte contre la Secheresse au Sahel Demographic and Health Survey Groupe pour !'Etude et l'Enseignement de Ia Population Johns Hopkins University knowledge-attitude-belief-practices Population Reference Bureau sexually transmitted infection(s) Prepared by SARA: Diana Talbert, Suzanne Prysor-Jones, Bill Rau Latest Revisions: 7/16/98 Adolescents and Reproductive Health in the Sahel: Research, Dissemination and Advocacy What Research and Dissemination Analysis • Analyzed existing • Multi-disciplinary DHS data on dissemination married and meeting with 45 unmarried youth researchers, FP in 5 countries directors, and journalists. • Qualitative data • Publication of collection in three Sahel countries Youth in Danger; high demand across • CERPOD held a 4- I sub-region; 12,000 copies printed. e happened Advocacy • Country core groups formed for dissemination /advocacy in Mali, Burkina, Niger and Senegal. • "Policy champions" became key to carrying forward planned activities. • In Burkina, a week￾lo support 8 regional seminars. • In Mali, an advocacy plan was developed. • In Niger, there are plans to carry out advocacy activities in 1998. Capacity Building • Data gathering, anal ytical and advocacy planning skills of CERPOD have greatly expanded. • CERPOD with Tulane trained 6 or 8 researchers in four countries in qualitative methods. • CERPOD staff were trained in advocacy, with l 0 RESAR members. I TA and Other Activities • CERPOD and SARA worked with country core teams to develop plans in Mali and Burkina. iOtiV~timulate sharing and improved coverage of health issues in the media--the first round of activity focused on adolescent RH. What changed Understanding the problem • First systematic description of demographic features of Sahel ian youth and their sexual behavior; • Identified the gaps in adolescent knowledge about reproductive health and access to appropriate services; • Demonstrated that lack of information and services targeted at adolescents are major barriers to ARH. Alternative Solutions lutions identified by adolescents themselves and adults in the community. • Les Jeunes en Danger recommends expansion of reproductive health services for adolescents. Changes in Policies and Programs • USAID committed additional funding to promoting advocacy on adolescent reproductive health • Burkina and Senegal have identified specific follow-up activities to improve reproductive health programs. • CERPOD has brouPht issues of adolescent healthA s agenda. Reproductive Health Improving Reproductive Health Policies and Programs th rough the Media: Pop'Mediafrique Main results and significance of activity • Improved communication between the media, regional health researchers and local health specialists has yielded expanded and more in-depth media coverage of key reproductive health issues and contributed to spin-off program actions. • Fifteen senior editors and reproductive health specialists from five West African countries met annually for three years. They received new information about reproductive health issues and developed approaches for the preparation of evidence￾based health stories. • An informal regional network of editors and researchers has emerged in Francophone West Africa. The network permits on-going exchanges of information between editors and between editors and public health researchers. , • The ability of C ERPOD to act as a regional catalyst for increased media attention to adolescent reproductive health and STDs including HIV/AIDS has expanded. • The success of the experience has encouraged CERPOD to expand its institutional agenda to include more media outreach and training. Dates of Activity: Location: Implementing Agency: HHRAA Funding: Leveraged Funding: 1995-1998 Francophone West Africa HHRAA-SARA-PRB (in collaboration with CERPOD and ACI) $260,000 (PRB ); $50,000 (SARA) N/A Reproductive Health What was the problem or gap addressed by the activity? Reproductive health issues have been low priority in West Africa national agendas. Health systems have lacked the resources and political will to fully address the range of reproductive health issues of women, men and youth. Moreover. public awareness of many reproductive health issues was low. Although the popular media offered effective ways to reach policy audiences and the public, little had been done to systematically mobilize this powerful communication channel. Earlier efforts to sustain a regional network of "beat-level" reporters had lapsed, and inter-country contacts and partnerships were primarily on an individual basis. Changes in the relationship of the press to government and society were evident by the mid￾1990s. Regional constraints on the press were relaxed and new opportunities appeared for using the media to convey important health messages. 2 Previous HHRAA-supported research in West Africa had identified significant reproductive health problems for ~dolescents. Initial dissemination of the research findings by CERPOD had generated extensi\'c interest and concern. CERPOD wanted to follow-up its initial dissemination with a strong medi~ campaign but felt that many editors and reporters had an incomplete understanding of the key reproductive health issues. What was the purpose of the activi(J'? This activity served to support Strategic Objective 8 (adoption of policies and strategies for increased sustainabi lity and quality of family planning services) and IR 8.2.2 (develop and promote innovative advocacy strategies to increase support for expanded family planning programs.) The purpose of the activity was to increase the knowledge and appreciation of reproductive health issues among media gatekeepers--senior print editors and broadcast producers--in order to gain more attention to those issues in the popular press. Not only would there be more public information, but the attention to reproductive health issues in the media was expected to accelerate policy dialogue and encourage new constituencies for programs in those areas. What were the specific objectives of the activity? • Conduct a survey of existing media activities in Francophone West Africa related to coverage and presentation of reproductive health issues and identify potential participants for an editor-research exchange activity in the region. • Conduct three seminars to strengthen the relationships and communication between national print and radio journalists, health officials, and regional research institutions; • • • Raise the public profile of health and population issues by expanding and sustaining quality, data-based reporting; and • Reproductive Health 3 • Engage civil society and leaders in discussions and debates on reproductive health and other social issues. What took place in implementing the activity? The Population Reference Bureau conducted a survey of existing print and radio outlets in Burkina Faso, Cote de'Ivoir, Madagascar, Mali, and Senegal, of African and CA opinion about the feasibility of mounting an activity to bring together senior editors and public health researchers as a way to improve journalistic coverage, and to gain impressions about existing media training. The report endorsed the idea of developing a project, with an African institution, to improve media coverage of public health issues. SARAIPRB worked with CERPOD to develop a proposal to expand communication between public health specialists and researchers and senior print media and radio authorities. CERPOD had both the research capacity and recent experience of investigating adolescent reproductive health knowledge and behavior in Francophone West Africa. HHRAA/SARA saw the CERPOD's invoh·crnent as an opportunity to strengthen a regional organization and improve and popularize media coverage of reproductive health issues. By working with senior-level editors, the activity sought to inform and sensitize key media gatekeepers who often make the final decisions about whether to cover topics and publish stories. Many "beat-level" reporters had been trained, but had had trouble getting their stories run. As a vehicle for the activity, CERPOD and SARA staff brought the journalists and health specialists together for annual seminars on selected themes. To expand media coverage, participating journalists were requested to produce local newspaper supplements and radio programs following each seminar. Training/Exchanges The first media seminar occurred in June 1996, in Saly, Senegal, with support from PRB. Fifteen high-level journalists and health specialists from five countries (Burkina Faso, Cote d'Ivoire, Mali, Mauritania, and Senegal) participated. The topic was adolescent reproductive health, and CERPOD's lead researchers on its study of the issue in the region shared their findings and worked closely with the journalists to clarify the key issues. The second media seminar was held in Abidjan in 1997. The same fifteen senior journalists and health professionals attended, on this occasion focusing on HIV /AIDS. The seminar identified strategies and methods to engage civil society more quickly and effectively in responding to the epidemic and to stimulate changes in public policy and legislation that support programs. The third seminar was held in June, 1998, on STDs other than HIV I AIDS. One of the highlights of this activity has been the use of some very innovative workshop techniques to draw the senior editors and health staff into each theme. During each seminar, Reproductive Health 4 workshop facilitators introduced exercises and events to help each participant personally connect e to the topic. A good example of these dramatic interventions was the inclusion oftwo persons who had created NGOs to support HIV /AIDS victims and their families at the second seminar. It wasn't until the third day of the seminar that these participants revealed that they were HIV positive. That revelation stimulated several hours of candid and poignant discussions about the impact of the media (both positive and negative) in the lives of persons living with HIV. Many of the journalists stated that they would never look at their role and responsibilities with this issue in the same way again. The seminars were high points in the activity, but these events were followed up and sustained with several other inputs. Stories on health issues were prepared for use by radio and print media and compilations of news coverage of health stories from across Francophone West Africa were distributed to other journalists and policy makers. What were the outcomes oftlze activity? The activity occurred at a time when changing political conditions in the region provided greater openness for print and radio journalists to raise issues that previously had been sensitive. Editors and researchers exchanged information on their own working methods and worked together to translate research findings into formats relevant to the editors. Table 1: Fulfillment of Objectives Objective Met, Not Met, Exceeded Comments/Sources Conduct survey of tnedia Met Report coverage of reproductive health issues in F runcophone West Africa Conduct three seminars to Met CERPOD and SARA reports strengthen the relationship and communication bet ween national journalists and health officials Expand and sustain the quantity Met SARA reports; Media print and quality of media coverage articles and radio programs on reproductive health themes Engage the public and decision Met Compilation notebooks makers in debate on reproductive health issues. • Reoroductive Health 5 Products • Three inter-country media seminars for 15 journalists and health specialists. • Over 30 high-quality, data-based articles, newspaper supplements, and radio broadcasts on adolescent RH, HIV/AIDS, and STDs. • Compilations of media stories on health issues. • "'Africa Edition': Francophone Africa Media Project Assessment," PRB, 1995. What complementary efforts contributed to the results of the activity? CERPOD's research on adolescent reproductive health issues in West Africa provided an initial, credible and tangible topic for discussion between journalists and health specialists. Also, CERPOD's advoc~ cy training and leadership in using research findings to inform and influence policy makers in the region complemented the increased and more accurate media attention to health issues which arose from this activity. What were the results of the activity? CERPOD staff took advantage of the growing influence of the print and radio media to initiate dialogue between hc~lth specialists and senior media staff across Francophone West Africa. As a result, the journalists who participated in the workshops have become better informed on reproductive health issues, which is reflected in both more frequent and accurate coverage of those issues. The health researchers and managers have more fully recogni zed the importance of the media in sensitizing the public and lobbying policy makers. Also. the cross-country exchanges among print editors added new perspectives and interests, as they read one another's stories. Advocacy Changes in Policies and Programs 'l111! process of policy and progrcliil change involves the interaction of describing problems, identifying solutions, and advocacy. By improving media-health partnerships, the activity provided journalists with credible contacts for gathering information for stories and health professionals had a means to promote the application of new research findings. Also, program managers and researchers learned how to make their findings 1nore accessible to non-technical readers. The activity widened and deepened the support at country levels for reproductive health policy changes and program improvements. Both researchers and journalists gained a better appreciation of the power of the media to convey information and sway opinion, this latter being Reproductive Health 6 particularly evident in coverage ofHIV /AIDS after the second workshop, which included input ·• by people living with AIDS. The activity demonstrated the importance of linking health research findings with under-used (or dormant) dissemination channels. Whereas in the past, when health research findings usually did not find their way into newsworthy stories, this activity took advantage of changes within the media to quickly disseminate findings to a far broader audience. In addition to general dissemination, the activity explicitly sought greater media coverage of the policy and program implications of recent reproductive health research to sway public opinion and generate discussion among policy-level audiences. Changes in policy and programs • Many of the stories appearing after the 1996 seminar utilized local examples and data to reinforce the story line. Journalists consulted health specialists for information and interpretation on stories they were developing. • Requests for media coverage of critical social issues by groups not involved in the seminars w~1s generated as a direct result of articles produced under the activity. • For CERPOD, the activity has had important results. The organization has added policy • advocacy to its agenda in recent years. The link with journalists expands opportunities . for using a range of tools for advocacy campaigns. Further, as a regional organization, CERPOD is now better positioned and able to share information and experiences across borders through their new media contacts. CERPOD itself has become more interested in promoting policy and programn1atic changes. It is seeking to hire staff to expand its ability to work with the media and train others to do so. • CERPoo·s expectation that improved media attention to health issues would inform and influence national policy makers was fulfilled. For example, • Yedal i r all (editor-in-chief from Mauritania) is now publishing special supplements of reproductive health issues on days when there is a political event to take advantage of large number of sales, thus increasing the audience. He is working with World Vision on a new community project to raise awareness ofHIV/AIDS, and, in collabor~ltion with the participating health official, conducted a national seminar on adolescents and HIV/AIDS. • Also in T\1auritania, one of the journalist participants wrote an extensive article on adolescents (a very sensitive issue in Mauritania) and was subsequently asked by the Secretary of State on Women to cover all seminars on women's issues and UNFPA asked him to write a special series on education of girls. • Yamaha Yameogo (editor-in-chief from Burkina Faso) has increased the number of journalists reporting on HIV/AIDS from two to four, and now searches UNAIDS • Reproductive Health 7 internet I ine for information to report each morning. ~ Nicholas Sagou (editor-in-chief from radio Cote d'lvoire) has initiated regular information flashes on HIV/AIDS during his radio station's weekly health journal program and provided training to staff to change negative attitudes and improve responsible reporting on HIV/AIDS. Capacity Building Over fifteen journalists and health specialists have become more familiar with one another's knowledge and processes. That is evident in improvements in the content of media stories on reproductive health and f-:IIV/AIDS and CERPOD's desire to add staff for media work. A recent participant evaluation documents how journalists and the participating health official within each country have forged new relationships built on a common purpose. The result has been a dramatic improvcml·nt in their ability to communicate and work together- a stark contrast to the two very separate ~nJ often antagonistic groups that met for the first time in Saly in 1997. What lessons ha1·e been learned fronl the activity? • Implementat ion of journalist seminars through a credible regional (or local) research institution gi\·es impetus to the application of new skills and information. • Implementation through CERPOD provides a channel for expanded dissemination of current and emerging research findings. • Given accur~tte information presented in innovative formats, senior media leaders are prepared to give greater attention to health issues and provide responsible, data-based coverage of issues in greater depth. • Structured c:x changes between health professionals and journalists can be very productive in strengthening relationships and contributing to creative actions. What are the next .~reps? • Support the strengthening ofCERPOD's media and advocacy agenda. • Provide T A to CERPOD for continuing evaluation activities on the Pop'Mediafrique initiative. • Explore the possibility of continuing this initiative with a greater focus on policy and program advocacy per the request of current participating journalists and health officials. • Based on the Pop'Mediafrique model, support another series of seminars to support women journalists. - Reproductive Health 8 Abbreviations CERPOD IEC Center for Applied Research on Population and Development Information, Education, Communication Resources Consulted Written SARA Annual Reports, project years 4 and 5. "'Africa Edition' : Francophone Africa Media Project Assessment," PRB, 1995. Victoria Ebin, SARA Trip Report, April 15-May 14, 1996. Victoria Ebin, SA R:\ Trip Report, June 25-27, 1996 Victoria Ebin, "Pop· Mediafrique Project Summary of the HHRAA/SARA Project's Senior Journalist and Health Professional Seminar on HIV/AIDS," June 1997. Informants Renu Bery, SARA! A ED Rhonda Smith, Population Reference Bureau Prepared for SARA: Bill Rau Latest Revision: October 4, 1998 • • • 9 Improving Reproductive Health Policies and Programs through the Media: Pop'Mediafrique What happened What Training and Dissemination Advocacy Capacity TA and Other changed Dia logue Buildi ng Activities • CERPOD • Supplements and • Acti vity engaged • 15 senior • lntensi\'e TA Adn•cacy organized three subsequent articles journalists and journalists and gi ven by SA RA, inter-country published in print reproductive reproductive PRB, and ACI to • Public health issues more fully workshops during media in at least health program health program organize and completely understood by which health four countries. managers in managers have workshops, editors. researchers, advocacy through been exposed to provide packages • Influence of media on public program • Radio programs print and radio on the latest research of materials, track attitudes better appreciated by managers, and developed on public health and program outputs and researchers. senior print and adolescents and ISSUeS. issues on three impacts, etc. • Editors sensitized to key RH radio journalists IIIV/AIDS and key Rll issues. issues, eg., 1-liV/AIDS. exchanged inf£ t.dtion views, and aired COIIIlfric(\ in several c,~ Activities Changes in policies and program~ I , . . · 1 ' ideas to create . . . . . : data-based storie~ .: . • . ~upplement~ and .. •; II;,. • • · CERPOD's · . :· ~erage (print and radio) . ~;:{ ' ; . ·~· L : ~~ :. \' ~J! ! -~ ;. ·:. :'· .:· :-_, ~~~ . ll. : F''·.·;:•i: '~ !!:' ' ,~ ~~~·~~ ~~mPi !~d:} . .. ( t:!;;_' .: ;.··,· .:·,r:;: ·~:~~;:; ;:: . ,~i; : '· · . . • • . ): ~ :. ~ • .- ed--more accurate and ~J ... on .. . , ,y}~.~ ;~ .. ... ·)·:( . ,.. "f. .f '1'·"· n·" ··· ~i ·f ~~,...,1 c . ~'t',.:'~· .... :'1-~~J~s~ch ~:m ~ ,~· .~~ l ~ ~ ~(ld~i~~~~t RH:14 ·~ rM~r , :a/ i . :~{;f- •. ?.i·· ·~•"' ... ~. ..... . . 'iirY ·~ . "' . d ' " d' ~r~·.-.! '. 1!1•· . ..,._ ••• '"' ;o • .• , .. • , •.•. . . - . "L ,. ~. ·~ ~ .. ma. e \~ ~.;..~.: '\ ~~·~.~ ;Sf h Y~~ :;(;: :~~:t~~ r ~· 1 p ~ir ~: ~\.;.,. •/; : : . r.} tt .~ 1',.~ q • HIV/AIDS ava1lable to • Contacts between researchers and · • STis. participants' hea rov ided a editors strengthened; an informal network. opic for network has been formed. discussion for • CERPOD has added media work journalists and to its agenda health specialists. Capacity building • CERPOD's advocacy training • IS senior journalists and health and leadership in researchers trained. using data to influence policy complemented the media attention to health issues. ' . Reproductive Health Family Planning in African Cities Main results and significance of activity • As a set of pilot activities sponsored by AFR/SD, the overall initiative was effective: it developed or modified research tools that were used by municipal officials for program design and management of reproductive health and family planning services; it leveraged significant mission support which led to major service delivery activities in Zimbabwe and Zambia; and it identified cutting-edge issues relevant to urban consumers of health services. • Studies in five urban centers provided many municipal officials with the first reliable data on public and private reproductive health delivery systems within their jurisdictions. • Three USAID missions and REDSOIESA were strongly influenced and have added urban family planning to their portfolios and committed funding for programs. • Local task forces were formed in at least five cities. These sustained interest, built collaboration with other authorities and the private sector, lobbied donors, and oversaw project implementation. • The studies created opportunities for testing approaches to integrating STIIHIV I AIDS treatment and prevention services into FP services and approaches to service provision for adolescents. • The activity developed analytical tools that strengthened the ability of municipal health officials to oversee health care delivery and to offer South-South technical assistance on key issues. • The activity contributes to the dual strategic objectives of decentralization and democratization by putting quality FP and RH services on the local (mayoral) political agenda. Dates of Activity: Locations: Implementing Agency: Total HHRAA Funding: Leveraged Funds: 1993-present Mombasa (Kenya), Bulawayo, Chitungwiza and Gweru (Zimbabwe), Blantyre (Malawi), Lusaka (Zambia), Dakar and Louga (Senegal) phase 1: HHRAA, JSI, CAFS; phase II: JSI, ZNFPC, Lusaka Urban district council, PP AZ, CARE; phase III: $975,000 $3,219,000 (SEATS, $724,000; REDSOIESA, $235,000; USAID/ Zimbabwe, $1 ,500,000; FOCUS, $200,000; USAID/Zambia, $450,000; USAID/Senegal, $30,000; other, $80,000) Reproductive Health 2 What was the problem or gap to be addressed? As urban populations in Africa grow, family planning (FP) services face increasing strain to deliver quality information, health care and health commodities. Also, as governmental decentralization progresses, local governments are expected--in many cases--to assume responsibility for managing clinics and service delivery with their own resources and staff. However, the ability of municipal governments to sustain and expand family planning services is constrained by economic, human resource and infrastructure factors. Although many African cities had become large and sprawling metropolitan areas, USAID and other donors tended to place greater emphasis on rural health programs. However, there was limited data and analysis to assess how urban FP services were coping with the growing population pressures and to make informed judgements about the balance of investment in FP services between urban and rural needs. In order to sustain national FP programs. a new vision of urban FP service delivery was needed. To develop that vision. lessons were needed on past experiences and existing situations in metropolitan areas. The activity sought to provide that information to African urban authorities and assist them as they applied the information to city-specific situations and to inform donors about the needs of urban FP services. What was the purpose of the activity? The activity fell within the context of Strategic Objective 8 (Adoption of policies and strategic for increased sustainability and quality of family planning programs), and more specifically IR8.1.2 (Develop new strategies for improving urban family planning services). The purpose of the activity was to generate data about the level and quality of FP services in African urban settings. Analysis of the data would identify problems from which municipal authorities could undertake reforms in FP program delivery, advocate for greater involvement of private sector providers and government in supporting urban FP, or seek donor support for mounting improvements in infrastructure and service delivery. What were the specific objectives of the activity? The objectives of the original research (Phase I) were: • to measure the extent to which men and women in select African urban centers are under￾served for their contraceptive needs; and • to assess the ability of urban FP service delivery systems, both public and private, to respond collaboratively with adequate facilities, commodities, staff, and an acceptable level of quality, to meet the needs of a growing number of people. • • •• Reproductive Health 3 A second phase was added; the additional objectives in that phase were: ... to develop new urban reproductive health and family planning programs in selected African cities; ... to design, monitor and evaluate these new programs using data-based approaches and assessment tools (such as the FPPMES); and ... to continue to promote inter-city technical exchanges to build, and build on, local capacity for urban FP. A third phase has begun which seeks to: ... expand the number of cities involved in the Urban FP Initiative; ... design and implement programs that addressed the needs of youth and that integrated HIV I AIDS prevention with FP~ and ... identify lessons from urban FP projects and propose a model for similar projects. What took place during the activity? The activity was headed by the SEATS project of John Snow. Inc., in collaboration with the Centre for African Family Studies (CAFS), the Population Council, and Columbia University Center for Population and Family Health. During the original study in SEATS I, HRRAA's plan was to study three Anglophone and three Francophone cities, but USAID missions in Francophone Africa were not interested. Thus. only three cities participated --Bulawayo, Blantyre, and Mombasa. The fourth and fifth cities, Dakar and Louga, became a focus for study after gaining mission support in 1997. Research and Analysis The activities. though different in some ways betWeen SEATS I and SEATS II, were generally structured around five inter-related steps: ... An assessment of urban health services and collection and analysis of the data; ... A workshop with municipal officials to present and discuss the findings; ... Technical support to municipal governments in proposal preparation; ... Finalization of municipal action plans and leveraging of resources; and ... Implementation of interventions. Using both qualitative and quantitative methods which SEATS had developed and pre-tested, the research was conducted in three cities: Blantyre, Bulawayo, and Mombasa. CAFS was largely responsible for the field research. That organization worked with local researchers and municipal authorities in each city to design the data collection process. For example, the Zimbabwe National Family Planning Council reviewed the survey instruments, contributed to its design, organized the data collection, identified the sample sites, participated in training the survey Reproductive Health 4 workers, and supervised the data collection. • In addition, activities involved pilot projects to test new approaches and gather additional information on the functioning of FP services through community mapping exercises. Especially useful for municipal authorities in the mapping was the identification of private sector service providers. In many cases, municipal authorities were both surprised by the extent of the private sector and enlightened by the existence of what they considered non-traditional parts of the private sector. Between SEATS I and SEATS II there was a shift in study methodology from primary data collection to use of the "quick study" methodology. This methodology uses secondary analysis of existing data, such as recent DHS and situation analyses, to provide baseline information which can then be supplemented by mapping of public and private service delivery points, the Capacity Estimator, and small, targeted studies. Dissemination Results of each urban study was written up and discussed with municipal authorities who were encouraged to present those findings at a workshop in the respective cities. At least 50 participants attended each of the three city workshops, including municipal authorities, national, district and provincial officials, NGOs, university medical faculty, donors, and private sector representatives. The workshop agendas were developed by CAFS and were structured not only to present data, but to encourage participants to analyze the data so to define priority issues . A regional workshop was held in Blantyre in 1995 to "foster a shared vision among Municipal and National Officials and donor agencies of the policy, service delivery, and management improvements" that would meet urban FP and RH needs into the 21st century.' Special emphasis was given to city-specific approaches. The concept of a vision statement was new to many of the participants and the final statement--very general and vague on means--reflects some of the difficulties in working with the concept. The Senegal dissemination workshop attracted 1 7 mayors from arrondissements in and around Dakar, a municipal team from Louga, and representatives from more than eight NGOs and CAs. Participants at that workshop agreed to collaborate to address priority reproductive health issues that affected their constituents. Presentations on the activity and municipal research findings were made at there successive annual conferences of the American Public Health Association ( 1994-96) What were the outcomes ofthe research? The data generated by the city studies was, for many urban health officials, the first comprehensive overview of the family planning/reproductive health delivery system within their • jurisdictions. In some cases, the findings quickly were applied to address identified problems, • and in other cases, the findings were used to prioritize issu~s and develop action plans. Reproductive Health 5 Research Methodology Six research tools were important for data collection during the activity, including: .. Population Council Situation Analysis; .. Family Planning Program Monitoring and Evaluation System (FPPMES)- to estimate city specific CPRs~ • Client Capacity Estimator (CCE)- to estimate the service delivery requirements in the 21st century under different assumptions of CPR and method mix; .. Community Mapping; .. Focus Groups: and .. Analysis of existing data (DHS, Census, etc). Research Findings Major findings of the research included: .. The capacity to maintain current contraceptive prevalence levels will be severely strained as urban populations grow. .. Urban FP method mixes are primarily re-supply methods (e.g., pills); long term and permanent methods (e.g., Norplant) which would place less pressure on clinics and on clients' time now and in the future are only a small proportion of methods. .. Quality of urban FP services is mixed; provider training and service delivery point supervision need improvement, as does provider training on HIV I AIDS/STDs. .. Many women are currently paying for FP services; those who are not report they would be willing to do so. .. Services other than FP are available at many SOPs, but referrals to other services are infrequently made. Table 1: Fulfillment of Objectives Objective Measure the extent to which contraceptive needs of urban populations are under-served Assess the ability of urban FP service delivery systems to meet future needs. Apply the FPPMES to monitor and evaluate urban projects Promote inter-city technical exchanges Implement programs that address youth and that integrate HIV I AIDS prevention with FP Identify lessons from urban FP projects and propose a model for similar projects Products Four urban dissemination workshops. One leveraging workshop. One regional conference. Client Capacity Estimator FPPMES Dakar and Louga Final Report (in draft) Reproductive Health 6 Met, Not Met, Evidence/Source Exceeded Met city reports Met city reports Met SEATS Database Mgmt. System (DBMS) Met Further exchanges were desired Met Results to be assessed On-going Proposed model likely to be on "ownership" process rather than on content. Presentations at three annual conferences of the American Public Health Association. Martin Gorosh, Findings from the Sub-Saharan Africa Urban Family Planning Study: Overview. 1995. A.B.N. Maggwa, et al., Findings from the Sub-Saharan Africa Urban Family Planning Study: Blantyre City Report. 1995. A.B.N. Maggwa, et al., Findings from the Sub-Saharan Africa Urban Family Planning Study: Mombasa City Report. 1995. I. Muvandi, et al., Findings from the Sub-Saharan Africa Urban Family Planning Study: • • • Reproductive Health 7 Bulawayo City Report. 1995. Family Planning Program Monitoring and Evaluation System (FFPMES): User's Manual. Arlington, John Snow Inc., 1996. What complementary activities supported this activity? The activity occurred as both the FP and HIV/AIDS sectors discussed the feasibility of integrating services. SEATS had the opportunity to test dual methods (eg., oral contraceptives and condoms for disease prevention) and provide guidance on when and how to recommend dual protection (see below) and address adolescent reproductive health in urban settings. What were the results of the activities? As a pilot designed to inform and motivate both municipal officials and USAID missions, the activity was effective: it gave new impetus to FP within city health departments; it demonstrated a methodology for gathering appropriate data; it engaged African collaborators; it leveraged both in-country resources and mission and REDSO funding: and it stimulated attention to cutting edge issues. Local ownership of the activities provided a tangible focus for urban government officials and community groups. The problem-solving process, in turn, became a means for addressing other problems. Understanding the problem The individual urban studies provided Understanding the Problem Changes in Policies and Programs The process of policy and program change involves the interaction of describing problems. identifying solutions, and advocacy. information and data that municipal officials used, in conjunction with support from the USAID SEATS project, to redesign FP services. The problems which were identified were particular to each city and stimulated local ownership. The first projects designed under SEATS II in Bulawayo, Lusaka and Blantyre were developed with local partners to directly address findings from the original study. Also, during Phase II, the FPPMES was used to monitor changes and identify on-going constraints and effective operations in the delivery of FP services. In Bulawayo, SEATS II gave increased attention to risk assessments for women because of the urban antenatal HIV prevalence rate above 30%. During Phase III (c. 1997-present), increased attention was given to both adolescent RH needs and dual methods of protection. Although it took a year of active discussion because of the sensitivity of providing RH services to young people, in Gweru, Zimbabwe, the youth council group of the city's health task force eventually adopted a peer counseling approach for addressing the needs of the city's youth. Alternative Solutions The research suggested that the most promising venues for increasing capacity are private sector Reproductive Health 8 providers (particularly pharmacies) and community-based distribution. Notably in the • Senegalese cities of Dakar and Louga, identification of private sector service delivery points for RHIFP stimulated urban officials to think of new forms of collaboration with and involvement of the private sector in addressing public health and other problems. Projects developed under SEATS I specifically sought alternatives to earlier urban FP programs. Two issues in particular, emerged during SEATS II: integrated HIV I AIDS prevention with family planning service delivery, which, in turn. raised the issue of dual protection (contraception and disease protection)~ and, addressing the needs of youth for FP information, services and commodities. Research in SEATS II switched to the use of the quick study methodology which greatly decreases the cost of launching an Urban Initiative for RH and puts the information in the hands of municipal authorities and their partners very quickly- unlike waiting for major original research to be completed. Advocacy Following the urban studies and dissemination workshops, an effort was made to form municipal task forces to sustain multi-sectoral collaboration and advocacy. The task forces became the groups that during SEATS II designed and monitored implementation of urban FP • programs. Through this local ownership of the process, local officials also became advocates with district and central government authorities and with private sector partners. The task forces in Gweru. Dakar, Louga. and Lusaka, have become active forces for change, advocating for support from government, international donors, and the private sector. The Blantyre workshop included opportunities for city representatives to outline priority activities and develop action agendas. Both of these activities were oriented toward advocacy which would strengthen local-national partnerships, increase resources for urban FP, and lead to changes in the efficiency and quality of urban FP service delivery. However, as an advocacy tool, the "new vision" was incomplete and weak. It was incomplete because there was no follow￾up planned; participants were left to their own initiative to work with the statement. It was weak because of the original confusion about the concept and absence of a process (or training about such a process) to translate the "vision" into practical actions. As has been seen in many instances in Afric~ advocacy is an activity outside the general work experience of most public health program managers and technical specialists. An important lesson learned from this was that, not only does advocacy have to be brought closer to the experiences of these groups, but additional training is often necessary to put advocacy efforts into effect. There was an expressed desire by municipal and national officials, including those from Tanzania and Zambia who attended the Blantyre inter-country conference, to create an Urban Family Planning and Reproductive Health Network as a way to promote collaboration and inter￾city T A. Such a network could be a useful mechanism for building support for the issue, not • Reproductive Health 9 only by sharing information and skills between cities, but for advocacy. Unfortunately, the network idea has not generated sufficient interest or support to emerge. The Senegal workshop participants produced Action Plans within which resource needs were identified. The participants (which included 80% of Dakar's mayors) outlined a time line for the identification of potential donors and a process for advocating with those donors to raise funds for the urban FP projects. In addition to donors, mayors have encouraged and cultivated private sector participation in projects. During the workshop a formal "Mayors' Follow-up Committee" was formed, with the most powerful and prominent mayor of Dakar selected to chair the· committee. The committee is tasked with promoting coalitions, encouraging community and private sector participation, and leveraging resources from a variety of resources. Changes in Policies and Programs According to SEATS. the changes in the approach of urban FP arising from the research and subsequent sub-project implementation represented a "paradigm shift" for the field. The USAID task manager offered a more modest assessment of the impact of the research, indicated that several of the urban research activities stimulated new approaches to local problem-solving. Among the local program changes were: • Expansion of FP services in Lusaka Urban District; • Expansion of VSC services in Bulawayo; • Training for quality improvements in Bulawayo, Chitungwiza and Gweru; • New services for youth in Gweru; • Mobilization of civic authorities to address a range of infrastructure and service delivery issues in Dakar and Louga; and • Increase in analytic skills and access to data for civic authorities. As noted, REDSO/ESA adopted the approach as a part of its regional agenda and several cities in Kenya and Mozambique had, by early 1998, requested technical assistance to set up new programs. The USAID mission in Zimbabwe committed $1.5 million for urban FP projects in several cities in that country. USAID/Zambia, too, has added the issue to its portfolio. Municipalities themselves have invested resources in sustaining their FP activities. These resources are primarily in the form of improved facilities and staff commitments and represent an important contribution directly attributable to the HHRAA activity. Capacity Building The Family Planning Monitoring and Evaluation System (noted above) was found by many municipal officials to provide useful data on the operations of single health delivery points (clinics or hospitals). Particularly in Zimbabwe the information derived from the system enabled program managers to identify and act to correct problems. Reproductive Health 10 The situation analysis approach to gather data on the efficiency of health systems also was found • useful by local officials. In Nairobi, for example. health officials used the fmdings of the situation analysis conducted during the activity to address identified problems. The activity encouraged capacity building through inter-country technical assistance. Although Zambia was not involved in the original set of activities. both Lusaka health officials and the US AID mission were impressed with the results from the city studies. At the request of the Lusaka municipal officials, US AID/ AFR/SD provided about $80,000 for city to city exchanges in order for officials to share experiences and lessons learned. An informal, but strong, collaboration has emerged between Senegalese and Guinea/Conakry, as the latter has gained insights on the Urban Initi~tive in Dakar and Louga. Municipal officials V-'ere motivated by their involvement in this activity to address non-health issues. This spill-over effect is one sign of empowerment. as authorities assumed the responsibility to use new skills. new organizations. and new energy to deal with a wider range of problems. What lessons have been learned from this activity? • Reaching missions with new findings and information about effective activities often requires budgeting up-front for dissemination by CAs. • Empowered implementing authorities (in this case, urban authorities) can reach USAID missions and other donors and influence their programming decision. • Urban FP and the analytical tools developed or used in these activities have given new impetus to the work of municipal health officials as they seek to promote changes in quality of service delivery. • Urban FP has the opportunity to act as a gateway to addressing a variety of issues: integration of FP with STIIHIV services~ reaching men; reaching adolescents. • \Vhen effectively developed, the processes of building skills, problem-solving and encouraging empowerment often carry over into issues and topics beyond the health issue of initial concern. • Inter-country exchanges are a relatively inexpensive, but effective method to generate interest, share experiences and build national and local skills for urban FP. What are the next steps? • • Continued implementation and monitoring of spinoff subprojects in Gweru, Bulawayo, • Reproductive Health 11 and Chitungwiza, Zimbabwe; and Lusaka, Zambia--giving particular attention to acceptance of and constraints to dual protection methods and adolescent service prOVISIOn. • Dissemination of the findings from SEATS, to other municipal authorities, US AID missions and international donors, is occurring, but can be expanded with added focused support (advocacy) from USAID/AFR/SD. • Consider an additional three or four inter-country exchanges, with one purpose being to stimulate advocacy. Resources Consulted Written Martin Gorosh. Findings from the Sub-Saharan Africa Urban Family Planning Study: Overview. 1995. A.B.N. Maggwa, et al.. Findings from the Sub-Saharan Africa Urban Family Planning Study: Blantyre City Report. 1995. A.B.N. Maggwa. et al.. Findings from the Sub-Saharan Africa Urban Family Planning Study: Mombasa City Report. 1995. I. Muvandi. et al.. Findings from the Sub-Saharan Africa Urban Family Planning Study: Bulawayo City Report. 1995. Family Planning Program Monitoring and Evaluation System (FFPMES): User 's Manual. Arlington, John Snow Inc., 1996. US AID/ AFRI AR TS/HHR, "Memorandum of Understanding," 17 June 1993. "A New Vision for Urban Family Planning Programmes in Sub-Saharan Africa: Workshop Report," March 1 995. Informants Diane Hedgecock, SEA TS/JSI Elaine Rossi, SEATS/JSI Alix Grubel, SEA TS/JSI Timothy Williams, SEA TS/JSI Martin Gorosh, SEATS/JSI Lenni Kangas, US AID/ AFRISD Prepared for SARA by: Bill Rau Latest Revision: August 19, 1998 Research and Analysis • Extensive data collection in 6 African urban areas. • Data and analysis often the first complete picture of FP/RH services for urban officials. What Dissemination • Findings presented at four country dissemination workshops, with at least 50 participants attending each workshop. Family Planning in African Cities happened Advocacy Capacity Building TA and Other Activities Mun icipal task forces • Over 200 African SEATS gave TA to became advocates mun icipal officials C/\FS and country What changed Changes in policies and programs with district and became more teams for research, • REDSO/ESA adopted the approach central government familiar with FP organization of of urban FP/RI-I. authorities and with service data. dissemination • Strategies have changed and/or private sector workshops, and services expanded in 3 countries: partners. The task • Activity supported follow up. • FP services expanded in Lusaka forces in Gweru, capacity building Urban District; Dakar, Louga, and through inter- • VSC services expanded in • Regional workshop Lusaka, have actively country technical Bulawayo; ~. r:.: ~l.t.;~:i~: !·~ ··"'; ~-. ·· ( . ... ,, ... , . 1 J ; .:·(: .. · . t . : .. .f:t •:~f • :rainingdone~or quality :· Qrl~Orripqftar1e~{•;t::· ;· q ; fr~m firstt~r~ !~· ~ovem~en, · : · ! ··~J} : : .. _ lm~rovem.ents m u awayo, fi· 10c·d· ~· .- r. ·r.p-·14' 0 · ~e .. .i~ J i·~·.: studies. :~~~ -t:: TV· \'·~· · .!nternat1onal donor~,-~~ :. · :.• : ~ .: 1 .. ungwaza and Gweru; .. , _m .~o ,· ·~~ .. ·;·~· j..:. • ;• ·t'' t'P'.'i ' r ·r ~', .. d . · "'·'.'.t ' '•" ,, J ···,-: · ~~ F • · , .. b·· . .ll; ·.·.··.ffi· .. ?J·• _':' t·_· • :._· .. ! ··. , ( ~~~.·.::; ·. :·y ·. '· .• ~ !.~ ' -~. i _ ..... , .. · an . pnvate sect_ or.•··_:._ ... ,;:-;. f_._. · · t ~ ~.i; strategy and services for · ur an o tela s was - ~r. · •· • •· · · i'··' '· ~ ... ... , ~· : ·*'. · . · · - ....... ,. • . ··.·:. • .. . . I ,,, . · .· .• : I . : \ ' ' ~: ·~·:: ; ·· l' • .. ;, I : .• ' . • .~, .. :t• .. j ·; )'[ ' · idb~tiflc~tibf{olan ·:;~ ·; Pres~ntati~ns at ··r->:: ~~. · ( · ·;·· : ... ·. .;~~: ~f~ ·.: · youth in Gweru followed year- . ~~te~~~~~ r~up 0 · · · · · ·• .r · long debate. private sector • Several cities in Kenya and providers. Mo.zambique requested technical assistance to set up new ~ rograms. • • interventions. • SEATS existing work in all the countries studied, which facilitated follow-up actions. • Civic authorities in Dakar and Louga were mobilized to address a range of infrastructure and service delivery issues. • Urban officials in Senegal are planning new collaboration with the private sector. Changes in Institutional Capacity • Urban task forces have given impetus to local problem-solving . • Male Involvement in Family Planning and Reproductive Health Main results and significance of activity Family Planning • The activity confirmed and built upon significant interest across Africa and from donors among men in fatnily planning and reproductive health issues. • Two regional conferences provided fora for participants from 25 African countries to share infonnation. develop strategies. and move agendas for expanding program and policy support for involving men more directly and equitably in family planning and reproductive health issues. • The conferences became mechanisms to operationalize the concerns of African authorities about issues of male involvement in family planning. • An extensive review of the literature and of programs targeted at men created a framework for debate and subsequent advocacy. • Mainly through leveraged funds. sports figures and events, messages about male involvement in fan1ily planning have been brought to thousands of men in four African countries. • By linking evidence with targeted advocacy, it is possible to move an agenda quickly and have an eff~.:ct on country programs. • Significant funding was leveraged from NGOs and UN agencies to implement country￾level interventions. Dates of Activity: Locations: Implementing Agencies: HHRAA Funding: Leveraged Funds: 1994-1998 regional SARA and Johns Hopkins University $300,000 $4 7,000 (FP Association of Kenya); subsidized radio and TV coverage in Ghana, Kenya and Zambia; $6,500 (Football Association of Zambia); other: >$150,000 from UNFPA, CARE, A VSC, Population Council and IPPF. Family Planning 2 What problem or gap did the activity address? For three decades. family planning programs in Africa have been directed primarily at women. Few programs were specifically targeted toward men and few services existed for men to gain knowledge about family planning issues, acquire skills to be co-partners in decision making about family planning. or access condoms or vasectomies. Likewise, it was only in the mid- to late-1980s that family planning progra1ns for won1en had become institutionalized in Africa, although fewer than half the countries had appropriate national policies and effective programs. New impetus for family planning emerged in the late 1980s and early 1990s. One aspect of the changes was a desire to engage men more aggressively in family planning and reproductive health programs. However, to achieve that goal, it was necessary to learn more about the attitudes and needs of men, including young men. Also, the policy base for family planning/reproductive health differed widely across the continent, but was often weak. There was a need to learn fron1 the handful of countries in which there was policy support for family planning/reproducti,·c health in order help strengthen the policy structures for programs in that sector. What was the purpose oftlte activi~r? • The activity occurred within the context of Strategic Objective 8 (Adoption of policies and • strategies for increased sustainability and quality of family planning programs), and more specifically IR8.1.1 (Develop new strategies for addressing underserved populations, including men). The activity sought to sensitize men of reproductive age to family planning (FP) and reproductive health (RH) issues, promote their active involvement in those issues, and provide information so that men could become equitable partners in RH/FP decisions and practices. What were the specific objectives of the activity? • To conduct a literature and progran1 review on male involvement in RH/FP in order to identify major issues, existing knowledge and experiences, and gaps in program services and policies~ • To conduct at least two regional conferences on male involvement in RH/FP; • To identify from prior or existing programs best practices for involving men in RH/FP and support the design and implementation of new programs. What took place in implementing this activity? In response to HHRAA interest in male involvement in family planning and subsequently in all reproductive health issues, SARA carried out the following activities: • Family Planning 3 • A seminar held in Washington, DC to identify priority research issues and questions related to male involvement in FP. Representatives from twelve U.S.-based organizations with extensive experience or strong interest in the topic attended the meeting and reached consensus on a list of twelve issues. Subsequent consultations with participants helped refine the issues and define follow-up steps. • A review of relevant literature and of program initiatives in Africa dealing with male involvement in FP. Subsequently, the review was revised and expanded to include summaries of major findings, a list of lessons learned and suggestions for next steps. • A presentation on the role of men in reproductive health at the annual Francophone Reproducti\'c Health Network Scientific Meeting in November 1995. The presentation was well rccci\'ed and RH Network decided to add a special one-day seminar on the topic to its 1996 m~eting. In fact, the seminar was expanded to two days, with presentations and discussions among the 26 participants on several aspects of male involvement in RH/FP. A consensus was reached to launch a multi-country research activity on male involvement: a proposal has been written and will be finalized at the 1998 annual meeting ofthe RH 1\:ctv;ork. • A presentation at a data analysis workshop organized by WHO/MACRO on the male role in FP and Rl-1. Researchers from nine West and East African countries were at that workshop. During the same workshop, SARA linked evidence-based research with two days of training in advocacy skills, using the results of data analyzed earlier in the workshop by participants and linking research to action .. In 1995, funding was allocated to JHU/PCS to plan and conduct two regional workshops for government and NGO authorities on male involvement and to provide follow-up support for organizations engaged in implementation of field programs. The first conference occurred in December 1996, in Harare, Zimbabwe. Sixty-six participants from 15 African countries addressed ways to engage men fully and effectively in FP and RH issues. The conference was hosted by the Zimbabwe National Family Planning Council, and co￾sponsored by JHU/PCS, SARA/AED and IPPF. During the conference, participants presented a number of examples of programs and pilot efforts to involve men more fully and effectively in RHIFP activities. Action plans were designed, some of which received subsequent support from JHU/PCS, SARA/ AED, IPPF and other donors. The second conference was held in March/ April 1998, in Ouagadougou, Burkina Faso. Designed for participants from Francophone Africa, the conference drew over 100 representatives of government and NGO groups. A consensus was reached on a standard definition of "male involvement in RH"--a point that had led to confusion and debate. Participants developed country specific action plans, with input from SARA on advocacy. Family Planning 4 While there has been follow-up activities by participating groups in the conferences, most of those activities have gone unreported. Funding was leveraged to engage Kenya and Zimbabwean male sports figures as role models for FP. Dissemination An English and a French version of the literature and program review, "Male Involvement in Family Planning," was disseminated by SARA. The findings from that review, with a special emphasis on policy change and advocacy, were presented during the Reproductive Health Network Scientific tv1eeting in 1995 and at the two regional conferences. What were the outcomes of the activity? Through a set of activities at fairly modest cost. USAID/AFR/SD and JHU/PCS and SARA tapped into a topic that had not received extensive attention, but was of wide interest among both men and won1cn in Africa. The activities stin1ulated discussion around RHIFP messages and services for both men and women and set the groundwork for practical interventions. Methodology The literature and intervention review focused on resources which would illuminate male attitudes about fan1ily planning, identify service availability and gaps, and suggest lessons learned from past activities. The review gave special attention to the work of JHU/PCS, the DHS surveys, workplace interventions and social marketing activities. The two regional conferences (Harare and Ouagadougou) were week-long events, structured to share information and gain commitments of participants to apply that information in specific activities within their own organizations or countries. Prior to the conferences, participants were asked to identify challenges in their own countries and organizations to male involvement. The responses were tabulated and analyzed and became one of the resources used during the conferences. Research Findings The literature and intervention review affirn1ed the widespread assumption that African men are the primary decision-makers in matters of fan1ily planning. Men tended to consider financial factors--of contraception and child-rearing--above health factors. Among the general lessons that emerged in the literature and intervention review were: • Well-designed and focused IEC campaigns can have a positive impact on men, but carry the risk of reinforcing the stereotype of male decision-making authority; • • • Workplace interventions are usually well-received by companies; • • Male peer education, sporting events. and involvement of male opinion leaders all Family Planning 5 showed positive impacts; • Condom social marketing had good results. but perhaps as a result of the focus on disease prevention rather than contraception; • Men prefer clinics that offer a range of RH services; and • Young males are rarely targeted for FP messages or services. Table 1: Fulfillment of Objectives Objectives Met, Not Met, Exceeded Comments/Sources Conduct a literature and Met publication program review on male involvement in RII/F J> Identify from prior or existing Partially Met infonnants; conference reports programs best practices for involving men in RII/FP and support the design and implementation of nC\\ programs Conduct at least two regional Met reports conferences on male involvement in RH/fP Products Two regional conferences, with over 75 participants at each. Lalla Toure, Male Involvement in Family Planning: A Review of the Literature and Selected Program initiatives in Africa. Washington, DC: SARAIAED, 1995. Better Together: A Report on the African Regional Conference on Men's Participation in Reproductive Health. Baltimore: JHU/CPS. 1997. Men: Key Partners in Reproductive Health: A Report on the First Conference of French￾Speaking African Countries. Baltimore: JHU/CPS, 1998. What complementary efforts contributed to the results of the activity? The International Conference on Population and Development (Cairo, 1996) added momentum to greater programmatic and policy attention to reproductive health, the vulnerability of women to STI/HIV infections. and the inequity in male-female decision making on reproductive health issues. Public debate continued after the conference and influenced, to some degree, the interest shown in the conferences and interventions of this activity. Family Planning The leveraging of funds for implementation of field activities is one indicator of complementary interest in the issues of male involvement from other donors and organizations. What results have been achieved? As noted, the acti vities tapped into a topic of wide interest in many African countries. The literature ·review/summary was a key document in the overall process, especially its focus on what worked. lessons learned from programs. and recommendations for next steps. Both of the regional conferences were built around the findings in that document; in tum, the conferences have generated new activities. Understanding the problem Changes in Policies and Programs lternotive Solutions ·1111: prm:t:s.s of policy and progrcun change involves lhe intc:racuon of describing problems. identifying solutions, and The interest generated on male involvement in ad \'ocacy. RHIFP at the Francophone Reproducti ve Health Network Sci entific meeting in 1995 and at the two regional conferences demonstrated that the issues were of concern to many program managers and policy makers. Although there had been a handful of male involvement 6 • projects in the 19gos and early 1990s. there remained a widespread perception that FP messages • were to be targeted overwhelmingly toward women. Also, it was widely assumed that male involvement was limited to male contraception. The literature review presented a wider definition. Male involvement is a set of activities designed to increase the acceptability and prevalence of famil y planning practice of either sex. The concept deals not only with contraceptive techniques. but issues of partner communication and decision-making, equitable access to infom1ation and services, and changes in attitudes and behavior. The set of activities noted here have gone a long way to alter the more narrow perception and to define the issue of male involvement in terms of male RH needs. couple communication, and as a complement to services for women. Alternative solutions The conferences helped to operationalize general interest and concern and focus efforts. Conference participants, in two separate declarations. outlined collective actions and pledges to expand male involven1ent in FP/RH. These proposed actions and pledges included: • introducing the concept of male involvement in RH through appropriate channels; • designing communication programs to address the diverse needs of various male audiences in order to encourage couple communication and shared decision-making; • linking communication programs with service delivery; • training for service providers; • advocacy for policies that encourage and sustain male involvement; • Family Planning 7 • conducting qualitative research to better understand men's needs and the social determinants of involvement in RH/FP. Advocacy Advocacy was integral to all the activities discussed here. Presentation of the findings of the literature review. for example, outlined the situation and suggested a set of policy and program responses to address male motivation and services delivery. Both of the regional conferences included sessions on skill building for advocacy. The conferences generated resolutions for expanding male involvement in RH/FP which participants were expected to pursue within their own countries and organizations. Changes in policies and programs There were clear changes in the environment for considering male involvement in RHIFP as a result of the set of activities described here. The activities stimulated wide interest, discussion and pledges to action across the continent. For example, participants at the two regional conferences produced country workplans to guide subsequent activities. What had been a peripheral topic in FP meetings and discussions. quickly assumed a more central focus. For example, the Francophone Reproductive Health Network added a two day seminar to its regular meeting in 1996 to discuss the issue of male involvement and included the issue on the agenda of the subsequent two annual meetings. Both of the regional conferences (Harare and Ouagadougou) issued declarations in support of much more extensive advocacy and programming to support male involvement. Four countries (Ghana. Kenya, Uganda. and Zambia) have implemented the "Challenge Cup Initiative", a project run by local sports organizations with support from JHU/CPS. The initiative uses soccer personalities, matches and motifs to promote a positive image of male involvement in FP. Unfortunately. it is not known if other plans designed at the Harare conference have taken root and been implemented. Many donors have added support for male involvement programs and training. These include UNFPA, IPPF, CARE. GTZ, and the Population Council. Capacity Building About 200 participants at the two regional conferences and over 50 at RH network annual meetings have been exposed to the concept of male involvement in RH/FP and advocacy skills. All of the participants in the conferences committed to applying what they had learned when they returned to their own institutions and countries. Family Planning 8 What lessons have been learned from the activity? • The activity stimulated latent interest of RH and FP groups in male involvement and provided solid evidence of key issues and experiences to guide that interest in operational directions. • By linking evidence with targeted advocacy. it is possible to move an agenda quickly and have an effect on country programs. • Creating and sustaining the con1munication between couples about FP probably require collaboration with non-traditional partners. such as religious groups, non-formal adult educators. sports authorities. What are the next steps? • AFR/SD follow-up with JHU/PCS to assess the extent to which conference participants' action plans were implemented and to assess progress made and lessons learned. • Follow-up with other donor agencies to see if they have added male involvement to their RH/FP portfolios. • Examine options for collaboration with religious groups and non-formal adult education programs for expanding and sustaining couple communication on FP and RH. • Assess effectiveness of "Challenge Cup Initiative." especially from the perspective of • promoting positive change. Share findings with USAID missions. • • Family Planning 9 Sources Consulted Written Lalla Toure, Male Involvement in Family Planning: A Review of the Literature and Selected Program lniriariFes in Africa. Washington. DC: SARA/AED, 1995. Lalla Toure, Trip report for attendance at the annual meeting of the Reproductive Health Research Netv.:ork. November 1996. Better Together: A Report on the African Regional Conference on Men's Participation in Reproductive Health. . Baltimore: JHU/CPS, 1997. Men: Key Parrners in Reproductive Health: A Report on the First Conference of French￾Speaking African Countries. Baltimore: JHU/CPS, 1998. Memo, Susan Krenn. JHU/PCS, to Phyllis Gestrin, USAID, re. "Follow-up to Men's Participation in Reproductive Health Conference [Harare]," 4/16/97. Informants Lalla Toure. SARA/Morehouse Lenni Kangas. USAID/AFRJSD Prepared by SARA: Bill Rau Latest Revision: September 28, 1998 Male Involvement in Family Planning and Reproductive Health What happened What Research and Dissemination Advocacy Capacity TA and Other changed Analysis Building Activities • Expert panel of • Two regional Advocacy was Training provided in SARA and JIIU/PCS Understanding the problem participants in U.S. conferences inherent in all aspects advocacy methods for provided TA in identi tied major ( llarare and of the activity. conference organizing • Defined "male involvement" in issues related to Ouagadougou) on Rccommendat ions for participants. con fcrcnces and terms of male Rll needs, couple male involvement. male involvement action were made in program design. communication, and as complement in RWFP the literature review ~ to services for women. • Literature and conducted, with and solicited and nf' nuor l/;.ll ...J rlurina__tk ···; . ~ ... '0', ., .• . : . . • •. , • • . : ' < ' t • • • ..,\ ; ': :. j, •. ~: I -o ·-· :·:o -·- Alternative Solutions R~i ~ ·;~~ ::~· ~ .. . • :;fi ~ male' involyement : conferences~·.~ ... <. '· ~;;_: • • j ~lion men's needs and issues . · ·· part1c1pants. , · · 'j ·:. ·. I .,. • ' . • . l " ,.' (t ~ in FP. and R I I programs. . . • Presentat!on to I . ~~ I • • . • r- If' .. Advocacy • · IUt:llllll\,;dliUII IIUIII dlllllJdl prior or existing Francophone • Need for advocacy received programs "best Reproductive extensive attention during practices" for Health Network Complementary conferences; subsequent actions not involving men in Scientific meeting. Activities reported, however. RHJFP activities. • Presentation to International Changes in policies and programs WHO/MACRO Conference on • Francophone Reproductive Health workshop for Population and Network Scientific included participants from 9 Development added sessions on male involvement in 2 West and East momentum to annual meetings. African countries attention on RH and • Participants in two regional on men and RH. male involvement. conferences proposed actions and pledges to increase advocacy and improve programs. • Four countries have implemented sports-based IEC programs targeted toward men, with leveraged funds. I • UNFPA, IPPF, CARE, GTZ and Pop Council have added financial support for male involvement ......... ~ programs. ~ --- • • • HIV/AIDS Economic Impact of AIDS in Sub-Saharan Africa: A Field Research Study in Tanzania Main results and significance of activity • The data collected during the study has begun to influence changes in the global approach to AIDS. Whereas AIDS had been thought of as an epidemic, from a vertical, medical point of view. the study highlighted HIV I AIDS as an endemic problem, shaped by horizontal, economic, social, and education issues, with implications beyond the health sphere. • This new conceptual framework informed and influenced World Bank thinking across the continent of Africa, in tum affecting World Bank regional and national HIV I AIDS prevention strategies. • The study provided valuable data on the economic impact of AIDS on households. these data were used in the 1997 World Bank publication, Confronting AIDS: Public Priorities in a Global Epidemic. Locations: Implementing Agencies: Total HHRAA Funding: Dates of Activity: Kagera, Tanzania, Kampala, Uganda The World Bank $851,886 1991 - 1995 HIV/AIDS 2 What was the problem or gap being addressed? e During the late 1980s and early 1990s, several economists attempted to quantify the potential impact of HIV I AIDS on national economies. These projections relied on weak or incomplete data and provoked extensive debate among specialist. Without more reliable data, projections of national economic impact lacked credibility with national policy makers and leaders. Also, by the early 1 990s there was growing interest and concern about the potential impact of HIV I AIDS on households and communities. Few data existed to even suggest a range within which impacts could occur. Without good data and projections, it was very difficult to work with already skeptical policy makers. The need to understand the microeconomic impact of HIV I AIDS in African countries was a prerequisite for making meaningful projections of the impact of HIV I AIDS at the macroeconomic level. Data on the household economic effect of HIV I AIDS were needed to estimate the macroeconomic effects of the AIDS epidemic. What was the purpose of the activity? The activity contributes to Strategic Objective 9--to promote the adoption of cost-effective strategies to prevent the spread and mitigate the impact of HIV I AIDS--and more specifically, IR 9.1.2--to evaluate and improve interventions to reduce the impact ofHIVIAIDS. Its purpose was to examine the economic impact ofHIVIAIDS on individual households and identify the economic coping mechanisms used by household survivors. The activity also sought to assess cost-effective programs that assist households and individual survivors. The emphasis of the research was on the household survivors of people infected with HIV I AIDS, not on persons with AIDS. Specifically, the study addressed two broad research questions: What are the economic effects of AIDS-related illness and death among adults living in households in northwest Tanzania? And what are the implications of these effects for survivor assistance programs? The research built upon preparatory work for World Development Report 1993 on the importance of adult health and on the allocation of resources among interventions to prevent and treat AIDS. The study included analysis ofthe distribution of income, how AIDS causes poverty, and the impact of survivor assistance programs. It was expected that the study would identify conditions and criteria for program development for household survivors or communities and describe the costs and benefits of survivor assistance programs. In addition, it was expected that the data from the household-level impact could be used to project macro-level impact, and offer insights into the relationship between AIDS mortality and poverty. HIV/AIDS 3 What were the specific objectives of the activity? The specific objectives of the activity permitted the researchers to: • collect data to directly measure the effects of HIV on the economic behaviors of households and household productivity; • measure the economic costs and impacts of the AIDS epidemic on households; • identify which groups of people were the most severely affected; • design cost-effective policies to mitigate the impact of the epidemic on survivors; and • present the findings of the research and the analysis in a final report, a short brochure, and a book. What took place in implementing tile activity? Research and analysis The study was implemented in August 1991 in northwest Tanzania, an area of high HIV/AIDS prevalence. Data was collected in four waves between 1991 and 1994 using an annotated household questionnaire. The questionnaire was adapted from the questionnaire of the World Bank's Living Standards Measurement Survey to measure the well being and coping behaviors of individuals and households in response to fatal adult illness among adults. Key innovations in the household questionnaire included: adaptation for a longitudinal research design, including "inter-wave" consistency checks; an expanded set of questions on acute and chronic illness and their costs; a module on the mortality of household members and relatives; a consumption module that allowed for seasonality; and collection of more data at the individual level, to facilitate analysis of intrahoushold distribution of resources. The survey was administered to a stratified sample of approximately 800 households (51 clusters of 16-20 households). The survey was administered four times, at six-month intervals, between mid-1992 and late 1993 by six researchers; two from the World Bank, three from the Muhimbili University College of Health Sciences, and one from the University of DarEs Salaam. Data collection was followed by intensive analysis from 1994 to 1996. Dissemination A policy workshop for Tanzanian policy makers was held in September 1992 to present preliminary results from the first wave of data collection. Results from the final round of data collection were disseminated at three policy workshops in Tanzania in December 1995, and September 1996. Preliminary findings were offered during three oral presentations and two HIV/AIDS 4 posters at the IXth International Conference on AIDS, Berlin, Germany, June 1993. Preliminary results of the study also were presented at three professional conferences in the U.S. in 1993 and 1995, at three international conferences on AIDS in Africa (1993, 1995, 1997) and at the 12th International Conference on AIDS in 1998. By 1996, the final analysis and write up of the research findings were, according to one of the researchers, overtaken by "the larger World Bank project leading to publication of the book," Confronting AIDS: Public Priorities in a Global Epidemic. The book, published in 1997, includes analysis of the impact of AIDS on poverty, based largely on the findings from the Tanzania study. Within the next 12 months, reports on the analysis of the project data will be completed and the data from the study will be made available on the worldwide web. What were the outcomes of the activity? Methodology The study collected quantitative and qualitative data from households and community health facilities. schools, markets, traditional healers. and survivor assistance agencies in the Kagera region of northwest Tanzania, an area severely affected by the AIDS epidemic. The household survey used a stratified sample of approximately 800 units (51 clusters of 16-20 households). The survey was administered four times, at six-month intervals. Research Findings The research confirmed that adult mortality and morbidity rates are extremely high in Kagera. The economic consequences for households of the high mortality can be summarized under three general themes, each with implications for policies related to AIDS and poverty alleviation in Kagera and Tanzania. These themes are: • Although many households cope successfully, some are more vulnerable. ... Not all households experiencing an adult death need assistance; ... Targeting assistance to the more vulnerable is the major challenge of survivor assistance policy. Unless assistance is successfully targeted to the most vulnerable, there is a risk that it will do more harm than good; ... Assistance will do the most good in the months immediately following the adult death. It need not be permanent. • People are not passive; they respond to shocks by altering asset levels and consumption patterns. However, household coping strategies succeed in limiting the short-term impact of an adult death only at the expense of serious longer-term consequences. • • • HIV/AIDS 5 • AIDS is only one among many problems facing national policy makers, and is not the most important cause of poverty in Kagera Region. .. The challenge of estimating the impact of adult death is to separate its impact from that of all the other shocks to African households. .. The challenge of designing policies to assist the survivors is to decide when scarce resources should finance a safety net and when they should instead be used to push forward on general development goals. The analysis of the Kagera survey data shows that per capita consumption in the better-off households is not depressed by an adult death and that many poor households have had no adult death. The research findings results do not support the idea of targeting assistance to all Kagera households that have suffered an adult death. Using adult death in a household as a criterion for support assistance for households would lead to inefficient distribution of the scarce resources available to fight poverty. Nevertheless, the findings suggest an important synergy between AIDS mitigation and antipoverty programs. For example, the finding that poor households are more vulnerable to the impact of an AIDS death implies that general antipoverty policies can also be AIDS mitigation policies. If general antipoverty policies strengthened poor households, they would be able to cope with AIDS deaths at a smaller cost to the survivors. But the finding that an adult death depresses the per capita food consumption of the poorest households by 15 percent implies that AIDS deaths in poor households exacerbate poverty. So when AIDS mitigation policies are targeted to households that were poor before an AIDS death, they are likely to prevent the households from slipping even further into misery as a result of a death. In sum, the preliminary results of the research project suggest integrating antipoverty and AIDS mitigation programs in Kagera Region. Table 1: Fulfillment of Objectives -- I Objectives Met, Not Met, Exceeded Comments/Sources I Collect data to measure effects Met I of HIV on the economic status and behaviors of households Measure the economic costs Met and impacts ofthe AIDS epidemic on households Identify which groups of people Met 1 are most severely affected Design cost-effective policies Partially met Policy recommendations made to mitigate the impact of the I in book, Confronting AIDS epidemic on survivors Present the findings of the Not met as ofmid-1998 publications delayed by other I research and the analysis in a work; source: researcher final report, a short brochure, and a book I I HIV/AIDS Products One working paper on methodology Three presentations to Tanzanian policy makers Seven presentations at professional and international HIV I AIDS conferences What complementary efforts have contributed to the results of this activity? A number of other UN and bilateral funded activities were examining the impact ofHIVIAIDS and the policy implications. UNDP sponsored African researchers to develop proposals, methodologies and conduct research on the impact of HIV I AIDS on development-oriented sectors. F AO sponsored research on the impact of HIV I AIDS on agricultural output. UN AIDS incorporated the research findings from a number of sources in building their arguments for policy responses to the epidemic. Finally, AIDS CAP sponsored research on the economic impact of HIV I AIDS on national economies and on private sector profits. What results have been achieved to date? The research generated extensive data on household economic responses to HIV I AIDS, particularly to illnesses and deaths due to the disease. Initial and preliminary final findings were presented to Tanzanian authorities, but without a strategic plan for follow-up with decision makers on applying the results. Also, preliminary results were shared at several international conferences, but most international HIV I AIDS authorities found the information incomplete, less than compelling, and without feasible recommendations. Understanding the problem The data on impact at the household level did make it clear that the problem of AIDS extends far beyond the health sphere alone. It Understanding the Problem Changes in Policies and Programs ldelltifi,cati~[)n of IA.IIuarJnnuve Solutions lbt! proct!ss of policy and prognm1 change involves the interaction of describing problems, identifying solutions, and advocacy. had been assumed by other researchers that households faced major losses of assets and income because of the illness and death of a family member; this research has provided data to demonstrate the degree, duration and diversity between households of that impact. Alternative Solutions 6 Before solid research findings were available, many researchers and program specialists had assumed that large and costly mitigation efforts would be needed to assist households effected by HIVIAIDS. Such sweeping responses were countered by the research in this activity, which suggested that careful targeting of assistance to select household for about two years would be sufficient to mitigate the losses due to an AIDS death in the household. • • • HIV/AIDS 7 Advocacy During the presentation of findings, the researchers put forward proposals for programmatic and policy changes. However, there was no systematic advocacy connected with or arising from this activity. Changes in policies and programs The shift in thinking about AIDS in Africa as an endemic problem beyond the health sector alone led the World Bank to develop new prevention and mitigation strategies focusing on economic, social, and education issues, as well as medical issues. The research is also related to ongoing efforts by the Poverty Reduction and Economic Management (PREM) network to understand household coping behavior and to define the concept of the "vulnerable household" for the purposes of improving the efficiency of antipoverty programs. Capacity Building An important goal of the project was to strengthen the collaborating units in the University of DarEs salaam (UDSM) and the Muhimbili University College of Health Sciences. Four members of the six-person study team were Tanzanian. All research products were to be jointly produced and authored by at least one person from Washington and one from the UDSM. What lessons have we learned from this activity? • Complex research activities may not lead to nice, neat answers~ • Without mechanisms to ensure publication and dissemination of research findings in a timely manner, long delays may occur. making the findings less relevant and applicable; • Prevailing wisdom around HIV I AIDS issues is often incomplete until focused research is conducted and results published~ • Coping strategies in African societies continue to provide a major bulwark against short and long-term crises. What are the next steps to capitalize on the activity? In the absence of a written report detailing the research methods, the findings and programmatic and policy responses, outlining next steps is problematic. If there is a means to do so, US AID/ AFR/SD can set a deadline on the researchers for submission of a report--that is, for completion of the objectives. HIV/AIDS 8 Resources Consulted Written Confronting AIDS: Public Priorities in a Global Epidemic. Washington, DC: World Bank, 1997. AIDS Prevention and Mitigation in Sub-Saharan Africa: An Updated World Bank Strategy. Washington, DC: World Bank, 1996. Measuring the Impact of Fatal Adult Illness in Sub-Saharan Africa: An Annotated Household Questionnaire. Living Standard Measurement Study Working Paper 90. Washington, DC: World Bank, 1992. Informants Sambe Duale, SARA/AED Bill Lyerly, US AID/ AFR/SD Mead Over, World Bank Prepared by SARA: Arin Farrington Latest Revision: June 18, 1998 • • Economic Impact of AIDS in Sub-Sahar Africa: A Field Research Study in Tanza Research and Analysis W hat Dissemination happened Advocacy Capacity Building • A four- wave • Incomplete survey Strengthened the community-based findings reported to research capacity of TA and Other Activities W hat changed Understanding the problem data collection Tanzanian two Tanzanian • Provided specific evidence to survey of c. 800 decision-makers. clarify different degrees of impact . . of and coping with AIDS deaths · ~ ~n omple~e survey . socio-economic lines. . t. on economic . . :: '' ~ .. findings reported in • , ·!'"' ' . ' . ' ·~·~:. impact of AIDS on . s~veral : settings. • Findings played large role in • Fu II report expected by mid￾1999. production of World Bank Complementary advocacy book, Confronting AIDS. Activities • Research has implications for formulation of policies related to AIDS and poverty alleviation. For example, the findings suggest an important synergy between AIDS mitigation and antipoverty programs. HIV/AIDS Private Sector AIDS Policy (PSAP): Research and Resource Materials fo r HIV/AIDS Prevention by Businesses Main results and significance of the activity • The activity produced the first comprehensive set of resource materials designed for use by businesses in Africa to develop HIV/AIDS prevention programs and policies. • Quantitative and qualitative research provided detailed infonnation on the economic impact of HIV I AIDS on select businesses and on specific company responses to the epidemic as it effected their operations, specifically in Kenya, Senegal and Botswana. • The research findings used for advocacy and program design in Kenya, Nigeria, South Africa, Nepal. Brazil and Honduras. • A draft of the materials was adapted by local organizations to provide technical assistance to businesses in Tanzania and Kenya. • A methodology is now available for assessing the economic impact ofHIV/AIDS on individual companies. • The materials can be used in training situations with or as a stand-alone reference guide for business managers. • Most major players in Africa (USAID missions, /Family Health Intemational/AIDSCAP regional and country offices, UNAIDS country offices, and select NGOs dealing with AIDS in the workplace) have the materials in English. • Follow-up training in the use and application of the materials occurred only in one African country, despite efforts to organize regional trainings. Dates of Activity: Location: Implementing Agencies: Total HHRAA Funding: Leveraged Funding: 1994-1997 Regional (with emphasis on Kenya, Senegal, Botswana) Family Health lntemational/AIDSCAP, SARA/ACI c. $300,000 n/a, but not significiant 2 • • • HIVIAIDS 3 What problem or gap was being addressed by this activity? The HIV I AIDS epidemic presents the commercial private sector with numerous challenges, not the least is managing the potential impact on productivity and profits of employees becoming ill and prematurely dying. In many African countries, the commercial private sector has been susceptible to prolonged recessions, numerous official and unofficial restrictions and constraints, and, in their opinion~ high taxes and levies. HIV I AIDS became an additional factor confronting managers in the late 1980s and early 1990s. In an era when African economies were becoming more open to competitive market factors, the contributions of businesses and workers were critical to overall national interests. A handful of companies--both affiliates of multinationals and indigenous enterprises--responded to the epidemic by adopting prevention interventions and developing policies. Some of these workplace-based interventions had been described in the literature and offered models for others. The majority of African companies, however, were felt by many observers to consider the epidemic of no direct concern to themselves. As of the early 1990s, very little quantitative or qualitative information was available on the impact of HIV I AIDS on business operations. Nor was there much evidence of existing workplace policies or programs at specific work sites. · Finally, although private sector initiatives were a high priority for USAID, there was too little specific information available to assist missions and central bureaus in designing programs to assure that private sector support was not undermined by the existing and potential impact of HIVIAIDS. What was the purpose of this activity? The activity fell within Strategic Objective 9, as a part of the effort to adopt cost-effective strategies to prevent and mitigate the impact ofHIVI AIDS. More specifically, the activity addressed IR 9.2.3 which intends to strengthen African regional and national capacity to plan, manage, and implement HIV I AIDS programs. The purpose of the activity was to develop resource materials that would engage the African commercial business community more fully in HIVIAIDS prevention efforts. It was expected that the materials would sensitize business managers to the potential impact of HIV I AIDS on company productivity and profitability. The materials would then guide managers to design HIVIAIDS prevention programs and policies for the workplace. HIVIAIDS 4 What were the specific objectives of the activity? The objectives of the activity were: • to gather and analyze data on the economic impact of HIV I AIDS on at least six companies in Africa. • to gather information from at least ten companies in Africa on existing HIV/AIDS policies and prevention programs and to compile that information into case study formats. • to utilize the research results to prepare a set of resource materials that business managers can use to develop appropriate policies and effective prevention programs for their workplace. • to complement the resource materials for business managers with a training component. The finished materials would be professionally packaged to appeal to business managers. Business users could consult the materials in a selective· manner to deal with specific issues or tasks they faced. Trainers could use the materials to sensitize human resource, ~nance, medical, and other senior business managers to HIV I AIDS prevention in the workplace and guide them through design of policies and prevention programs. What took place during this activity? Research and Analysis Through a series of key informant interviews with business managers and HIV I AIDS program managers in Kenya, Senegal and Botswana. qualitative information on contemporary business ·attitudes, practices and policies in the workplace was derived. In Kenya, the collaborating institution was HEDRA [full title} and in Senegal it was Africa Consultants International (ACI). In Botswana, an individual consultant with access to businesses conducted the research. The research was the first comprehensive study in Africa on HIVIAIDS and businesses. Information of adequate quality was collected from a total of 15 businesses in the transportation, agri-business, banking, mining, and small service sectors. The companies surveyed ranged in size from fewer than 50 to over 3000 employees. Most companies did not have specific policies related to HIV I AIDS and few has sustained, comprehensive prevention programs. Some of the same companies involved in the qualitative research were asked to collaborate in data collection and analysis on the economic impact of HIV I AIDS on company operations and profits. Eight companies agreed to provide the necessary data, but data of sufficient quantity and • • • HIV/AIDS 5 quality for analysis was available from only five of those companies. In addition to the field research, a review of existing literature on AIDS in the workplace was conducted by the Center for AIDS Policy (CAPS) of the University of Califomi~ San Francisco. The survey confirmed that little had been published on the issue. The research findings were used to shape the PSAP resource manual in several ways: • To provide businesses with tangible data on the economic impact of HIV I AIDS, the methodology for collecting and analyzing appropriate data was included in the form of a spreadsheet~ • To learn from the experiences of others, a set of company case studies provided users with examples of how other businesses were responding to the epidemic; • To help design effective workplace prevention packages, extensive guidelines were included to guide users in the development of HIV I AIDS programs and policies. A draft of the manual was tested with company managers, NGO program officers, and national AIDS control program officers in Nigeria and Kenya. In addition, feedback on draft materials was obtained from the AIDSCAP program in Tanzania. The field testing led to extensive revisions of the trainers component of the materials and refinement for clarity and flow of the other materials. Dissemination 1000 copies of the manual were printed in English. Original plans for a print a run in French were abandoned mid-way through the activity because of time constraints. AIDS CAP distributed 350 copies to its country and regional offices; requests from Africa country offices, especially, for additional copies were met when possible. Where requests could not be met, photocopying was encouraged. UNAIDS requested and was provided with 500 copies for distribution to their country representatives. USAID missions in Africa each received one copy of the manual. AIDS CAP included the entire PSAP manual on a CD-ROM it produced of its publications. Also, AIDS CAP noted the availability of the manual in its quarterly publication, AIDSCAPTJONS. About 50 requests from around the world came in for the manual. Results from the economic impact research were published in several journals (AIDS Analysis Africa) or presented at several international and Africa regional HIV I AIDS conferences. Informal sharing of the results occurred through the US AID/ AIDS CAP sponsored "AIDS and Economics Network." IDV/AIDS 6 What were the outcomes of this activity? The activity provided the most extensive data available at that time on the cost ofHIV/AIDS to businesses in Africa and offered a profile of select company responses to the epidemic. The research and subsequent resource materials development allowed program managers. advocates and businesses to move well beyond speculation about AIDS in the workplace. The package was more evidence-based. contained more complete program development guidelines, and offered a wider range of company examples than any similar product, in developing or developed countries. Methodology A generic approach to analyzing the economic impact of HIV I AIDS was adapted and elaborated for use by or with individual businesses. The methodology is in the form of a spreadsheet. It allows businesses to use data derived from their normal operations (e.g., average salary levels, number of employees. level of absenteeism, etc) to estimate the current and future costs of HIV I AIDS among employees on company profits. A second spreadsheet allows businesses to estimate the cost of developing or expanding a HIV/AIDS prevention program for their workplaces. Both a hard copy and a software version of the spreadsheets are included in the manual. Research Findings The major findings of the research are summarized in the following figure. • • • HIV/AIDS Figure 1: Impact ofHIV/AIDS on Commercial Businesses in Africa Increased Expenditures • Health Care Costs • Burial Benefits • Recruitment • Pension Benefits (?) Ripple Affect of AIDS • National revenues decline Reduced Revenues • HIV Absenteeism • AIDS Absenteeism • Funeral Attendance • Lost Productivity during Recruitment • Lost Productivity during Training • Lost Productivity Following Training (and prior to working being fully productive) • Increased demands on social services (health care, orphans) • Consumers shift purchasing patterns • Agricultural production changes • National security threatened • More difficult to remain competitive Table 1 : Fulfillment of Activity Objectives Objectives Met, Not Met, Exceeded Sources/Comments Gather and analyze data on the Met PSAP manual, publications economic impact ofHIV/AIDS on at least six companies in Africa. Gather information from at least Exceeded PSAP manual (case studies) ten companies in Africa on existing HIV/AIDS policies and prevention programs and adapt as case studies. Prepare resource materials for Met PSAP manual business managers to develop prevention policies and programs for their workplace. 7 IDVIAIDS 8 Complement the resource Met PSAP manual materials for business managers with a training component. Products The completed Private Sector AIDS Policy manual is composed of four components: • A guide for business managers. The guide provides a rationale for AIDS prevention in the workplace, provides guidelines for developing company policies related to HIV I AIDS. and offers a step-by-step framework for developing and monitoring workplace prevention interventions. • A set of case studies describing the responses to HIV I AIDS of 17 African businesses. • A facilitators ~ guide for use by outside organizations to provide training on HIV I AIDS prevention to businesses. • • Two spreadsheets, in hardcopy and on computer disk. One spreadsheet permits companies to input relevant data to determine the likely potential impact of HIV I AIDS on • company profits--i.e. the economic impact of AIDS. The second spreadsheet can be used by companies to determine the cost of mounting workplace-based prevention interventions. What complementary efforts have contributed to the results of this activity? There have been several efforts by international donors to engage businesses in dialogue on HIV/AIDS prevention. The executive director ofUNAIDS spoke to the issue during a meeting of global business executives early in 1997, for example. As a result, UN AIDS is considering adopting aspects of the PSAP materials as a part of its "Best Practices" series. The World Bank organized a workshop on AIDS and the workplace for business and governmental leaders in southern Africa. By contrast, there has been only minor involvement of the International Labour Office on AIDS in the workplace, a reflection of the fact that organized labor in Africa (and elsewhere) has not made workplace prevention a priority issue. FHI' s AIDS CAP project commissioned a study in Zimbabwe and Brazil of business manager attitudes and responses to HIVIAIDS. The findings from that study identified gaps in existing approaches to engaging the private sector. What results have been achieved? • fllV/AIDS 9 The activity generated strong interest from program managers and several country programs used the data on the economic impact of AIDS on business for local advocacy. Tanzania adapted the draft materials to support a sub-project offering technical assistance to businesses. South Africa adapted the policy component of the draft materials for advocacy and negotiations with businesses. However. there was insufficient follow-up built into the activity, and the potential has not been realized for expanding private sector involvement in HIV I AIDS prevention. Understanding the problem There is a wider and deep body of knowledge about businesses in Africa and their response to HIV I AIDS than had been the case in the early 1990s. A few other in-depth case studies appeared while the PSAP materials were in preparation, but the economic impact data and the company response case studies remain the most accessible information available. Many companies either explicitly or implicitly argue that the labor supply situation in Africa made it easy to replace workers lost to HIVIAIDS. The PSAP findings suggested otherwise, even in low skill industries. Alternative Solutions The materials provided both a conceptual framework for engaging businesses operating in Africa in AIDS prevention and practical guidelines for developing or expanding prevention programs and policies in the workplace. Advocacy Changes in Policies and Programs ldeJtltification of /A.I.tfl'r11nti•vp SolutioM 'lbt! proct!ss uf policy and progr.un change involves the interaction of describing problems. identifying solutions, and advocacy. The findings on the economic impact of HIV I AIDS on businesses have been used to a limited extent by advocacy groups in Tanzania. Zimbabwe, Ethiopia, South Africa, Senegal, Nigeria, Brazil, Honduras and Nepal to bring greater clarity to the debates. In Kenya, where the draft materials were tested in-depth, the Family Health International (FHI) office used the research findings to persuade business managers in Eldoret to expand their prevention programs; FHI and USAID/Kenya have continued to support advocacy by NGOs with the business community. As far as is known, no company or business association has promoted the PSAP materials nor have any consulting firms or NGOs actively advocated for greater private sector involvement in HIV I AIDS prevention by using the PSAP kit as a standard or model. Changes in Policies and Programs The AIDSCAP program in Tanzania adapted a draft version of the PSAP materials for use with HIV/AIDS 10 businesses in that country. One of the implementing agencies in Tanzania negotiated to provide technical assistance to companies on a subsidized fee-for-service basis. Over ten companies were reached and prevention programs were set up. The AIDSCAP program in Kenya utilized the policy component of the PSAP manual to assist businesses which had prevention interventions in place to develop complimentary workplace policies. Subsequently, two of the implementing agencies {lAs) in Kenya added policy development with businesses to their agendas. Early in 1998 one of those lAs began an intervention with mission funding to expand the dialogue between businesses, unions, government and NGOs about private sector involvement in HIV I AIDS prevention. The objective was to motivate businesses to adopt appropriate policies and programs. The PSAP materials were used to help structure the agenda for the dialogue and the research findings were incorporated into the discussions. The end of the AIDS CAP project in December 1997 left incomplete further use of the PSAP materials. FHI interest in private sector issues was limited largely to workplace interventions rather than policy development and leveraging private sector resources to support those interventions. Opportunities for applying the PSAP materials to HIV I AIDS prevention in African businesses remain. The Policy Project includes the commercial private sector in its portfolio. The new HIVIAIDS Division projects (Horizons and Impact) are likely to include some work with the commercial private sector in their portfolios. The PSAP research findings and materials provided substance and credibility to the growing concerns of HIV I AIDS program managers that the commercial private sector was not contributing adequately to national prevention efforts. With the PSAP materials, it became easier to approach, sensitize and work with businesses, although the reality is that little application of the materials has occurred .. Within US AID, the HIV I AIDS Division portfolio provides a slightly higher priority to working with the commercial private sector than had been the case in the mid-1990s. However, the division continues to use the term "private sector" to refer primarily to NGOs, rather than commercial or parastatal businesses. Capacity Building Training was provided to NGO representatives in Kenya, Nigeria, and Zimbabwe in the use of the PSAP materials. As noted, a draft of the materials was adapted for use by a Tanzanian trade union federation. • • HIV/AIDS 11 What lessons have been learned from the activity? • Without active promotion, a well-researched and attractive document alone is not enough to stimulate policy development or programmatic changes. Fallow-up to distribution of the PSAP kits is necessary to stimulate greater interest from businesses, associations, missions. and governments. Types of follow-up activities include: .. Identifying local or regional organizations willing and able to aggressively market HIV I AIDS prevention to the commercial private sector; .. Field-based training for select audiences in the application of the materials or portions of the materials; .. Correspondence with recipients of the materials to assess their use. • African governments, USAID missions. other donors, and most worker associations have not assertively sought to engage the commercial private sector in HIV/AIDS prevention. Thus. there is little impetus for businesses to actively support and invest in workplace-based prevention. • Although there is concern among many business managers about HIV I AIDS in the workplace, most are reluctant to invest their resource in prevention without further evidence that prevention interventions result in changes in sexual behavior. • The value for program development is in selective use and adaptation of the PSAP materials to fit local needs and conditions. What are the next steps? • Develop African capacity to promote the materials: .. One option that has been aired, and which has been endorsed by several African NGOs, is for missions to provide support to a NGO or management institute for two or three years as it develops the capacity to commercially market its HIV I AIDS policy and program skills to businesses. Financial support in the range of $100,000 to $200,000 per year would permit an African organization to preparing marketing materials, to advertise to companies, to travel nationally, to adapt the PSAP to their needs and develop other training/resource materials, and to sponsor initial workshops. • Within USAID: .. Reach agreement with the HIV I AIDS division of US AID on division of labor for IDV/AIDS promoting AIDS in the workplace issues in Africa, including application of the PSAP materials and findings. • Follow-up with US AID missions to determine if the PSAP materials have been used within African countries. • Bring the PSAP materials to the attention of the Policy, Horizons, and Impact projects and discuss how the materials can be incorporated into their portfolios. 12 • Engage UNAIDS and the ILO more fully in application of the PSAP materials and concepts. including developing sub-regional or country strategies for reaching and motivating businesses, associations, unions, and interested NGOs. The Africa Regional Office of Family Health International and UN AIDS are planning a workshop in September 1998 on workplace issues. • Making a good product better: .. Incorporate into the PSAP materials--perhaps as a separate module--examples of effective prevention interventions, with cost analysis when possible. This is possible at low cost from documentation developed primarily by the AIDSCAP project. • Up-date the case studies and economic impact studies for countries with a strong commitment to AIDS in the workplace programs and policy development. • Include sections on emerging or continuing business and labor concerns--e.g. employment-based HIV testing, confidentiality, community outreach, insurance provision and protections, taxes and subsidies related to workplace prevention programs. • • Sources Consulted Written: Private Sector AIDS Policy. Completed kit. Informants Duale Sambe. SARA/AED John Paul Clark. US AID/ AFRISD Suzanne Prysor-Jones. SARA/ AED Prepared by SARA: Bill Rau Latest Revision: May 11, 1998 IDV/AIDS 13 Research and Analysis • Qualitative research in three countries to identify prevailing HIV/AIDS programs and policies in businesses. • Quantitative economic impact of HlV I AIDS on 8 businesses in • Methodology developed for analyzing economic impact data and refined for use with commercial businesses. • Package of resource and training materials developed to assist businesses and consultants to address HIV/AIDS issues. Private Sector AIDS Policy (PSAP): Research and Resource Materials for HIV/AIDS Prevention by Businesses What I Dissemination I • 1 000 copies of the package printed in English; 300 copies distributed to AIDSCAP field offices. • 500 copies provided to field offices I • 1 00 copies ided to USAII missions, AFRJSD, and HIV/AIDS division. • 100 copies provided in response to NGO requests. • Package described and discussed at two international conferences. I" Economic impact findings published in newsletters and book (AIDS in Kenya). happened -- Advocacy • Little advocacy occurred to engage businesses in use of package for AIDS prevention. Capacity Building • An African research organizations (IIEDRA) gained skills in qualitative and quantitative research with commercial sector. • T A and ()ther Activities • AIDSCAP prov ided TA to Tanzania, Zimbabwe, Kenya, Nigeria on both adapting content of package for local si~nsand ado lying • Complementary Activities • AIDSCAP carried out in-depth case studies of business leader views on HIV/AIDS and prevention in Brazil and Zimbabwe. What changed Understanding the problem • Specific, detailed data on economic impact of HIV I AIDS on businesses and the range of costs to businesses were generated. Alternative solutions Detailed guidelines for businesses are HIV/AIDS policies and nrnnra.~~re now available. • In Kenya, USAID mission had early interest in the economic impact research and subsequently has supported two program interventions to involve businesses in HIV/AIDS prevention. • UNAIDS, USAID/Kenya, FHI workshop to develop advocacy strategies drew upon the PSAP materials. • HIV/AIDS Preventing and Mitigating AIDS in Sub-Saharan Africa: A Study on Social and Behavioral Research Needs Main results and significance of the activity • The activity achieved consensus among a group of internationally-recognized specialists on research priorities for HIV/AIDS prevention and mitigation. • The activity resulted in a publication of a book by the National Academy of Sciences entitled, Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences. • The book represented a state-of-the-art synthesis of disparate information on HIV/AIDS prevention from a multi-sectoral perspective, especially regarding the social context and epidemiology of the pandemic in Africa. • The report changed the way donor agencies think about the AIDS epidemic in sub-Saharan Africa, giving particular emphasis to a spectrum ·of social and economic factors that influence its course. • The book reports on encouraging evidence that intervention programs to change sexual behavior can be effective in preventing the spread of HIV. ' • For the first tin1e in the international response to the impact ofHIV/AIDS, the report formally discussed "mitigation" in relation to AIDS prevention strategies. • The report re-affirmed USAID's approach to prevention and influenced the redesign of the USAID Global Bureau HIV/AIDS Results Framework, UNAIDS's prevention strategy, and informed a World Bank report on HIV/AIDS, Confronting AIDS (1997). Dates of Activity: Locations: Implementing Agencies: Total HHRAA Funding: De~ember 1 993 to August 1995 U.S., and briefly in Zambia, Tanzania, and Cameroon National Research Council of the National Academy of Sciences $400~000 HIV/AIDS 2 What was the problem or gap being addressed? An estimated II million adults and up to one million children in sub-Saharan Africa had been infected with HIV by the mid-1990s. Although there is significant diversity in the progress of the epidemic across Africa, in many countries the disease continues its assault. Many experts felt that insufficient attention was being paid to the longer term (e.g., 10-30 years) impact of HIV I AIDS in Africa. especially on the non-health sectors. It was felt that there existed potential for mitigating the impact of the epiden1ic through stepped-up prevention efforts and preparing non-health sectors of society to .more effectively cope with the changes arising from AIDS. Also, USAID \vas interested in clarifying what is known about how social, cultural and behavioral factors shape the nature of the epidemic in Africa; identifying strategic opportunities for USAID, other donor agencies, and African governments to develop effective intervention programs; and, elucidating the most pressing research and capacity building requirements in these areas that will facilitate the development of more effective prevention and control strategies. What was the purpose of the activity? The activity contributed to Strategic Objective 9 which deals with the adoption of cost-effective • strategies to prevent the spread and mitigate the impact ofHIVIAIDS. More specifically, the activity was a part of IR.9.1.1--evaluating and improving interventions for preventing HIV/STI transmission--and IR 9.1.2--evaluating and improving interventions to reduce the impact of HIV/AIDS. The purpose of the activity was to provide a major policy document which would guide the design and implementation of HIV I AIDS research strategies and intervention priorities for donors, African policy makers, and researchers. It was hoped that the information would stimulate readers to address and support HIV I AIDS prevention and mitigation, to redesign HIV prevention progran1s away from vertical to more integrated multi-sectoral approaches, and to develop and/or modify policies and programs to mitigate the effects ofHIV/AIDS on African development in general, and on the social sectors in particular. What were the specific objectives of the activity? The objectives of the activity were to: • produce a state-of-the-art study that identified what was known and the gaps in the knowledge of the social and behavioral aspects of the HIV and AIDS pandemic in Africa; • identify effective strategies to prevent and mitigate the spread of the pandemic; and • recommend future research and capacity building priorities for African governments, • HIV/AIDS USAID, and other donor agencies to develop effective intervention and mitigation programs. What took place in implementing the activity? Research and analysis 3 Under the auspices of the National Research Council of the National Academy of Sciences, a panel of sixteen n1edical, behavioral and social scientists gathered on four occasions to identify major data and research needs to address the HIV I AIDS epidemic in Africa. The panel included four African members, two of whom worked directly in Africa. To gather information on the epidemic and responses, the panel adopted a meta analysis of existing data and information. The activity was not desi gned to generate original research. Information was collected through preparation of several background papers, documents provided both by and to the panel members, a written survey sent to NGOs in Africa, and interviews with HIV I AIDS program managers, health authorities, researchers and program specialists in Tanzania. Zambia and Cameroon. The visit to these three countries was also used to brief Africans on the NAS study and, as the study states, to gain some African participation in the process. Individual members of the panel assumed responsibility for preparing draft chapters which were critiqued and then revised. Dissemination The report was released in December 1996, at a White House Conference on AIDS as part of USAID's international initiatives. The release generated much media interest: the following day the NAS Office of News and Public Information received calls from a number of major broadcast and print news agencies, including Science , which subsequently ran an article (vol. 274; November 8, 1996). Dr. James Trussell. one of the panel co-chairs, was interviewed on National Public Radio. Dr. Barney Cohen, NAS principal investigator of the report, and Dr. Mead Over, a panel member, were interviewed on MSNBC. In addition to those who obtained copies of the report or the news release during the week of release, the publication announcement was sent to more than 1,000 reporters in the United States. A total of 200 copies of the full report, in English, and 1500 copies of the executive swnmary, in French and English, were acquired and distributed by the SARA Project. One full report and five summaries were sent to each PHN Officer in USAID missions, in the WCA and ESA REDSOs, and one copy went to each USAID mission. Individuals with USAID/AFR distributed copies and the National Research Council promoted the book through its advertising channels. HIV/AIDS 4 Two days after its release in Washington, the report was presented at the Ninth International Conference on AIDS and STDs in Africa (ICASA), in Kampala, Uganda. Research panel members Dr. Peter Lamptey and Dr. Daniel Tarantola, presented the report on behalf of the panel at a special pre-conference symposiun1 organized by Family Health International and Harvard University, that was attended by about 150 people. Dr. Barney Cohen presented the report at a pre-conference workshop sponsored by USAID/AFR on the policy implication ofHIV/AIDS research in Africa. Six hundred fifty copies of the executive summary were distributed at the Africa regional HIV/AIDS conference and 200 requests were submitted for copies of the entire report. Because of overwhelming demand for copies of the sun1mary (over 250 were distributed in the first five minutes), they were made available only at selected times throughout the conference. NAS sent the full report to all the UN AIDS officers in Geneva, and the African country program advisors. NAS also sent the full report to all African research/university libraries and select U.S. libraries. The report was also disseminated at seminars given by Dr. Barney Cohen at Johns Hopkins University and at the World Bank. and presented in a poster session at the June 1996 Xlth Annual International AIDS conference in Vancouver. Finally, the report was distributed at the Third International Conference of the Social Science and Medicine African Network (SOMA-NET), held in July 1997 in Harare. What were the outcomes of the activity? The findings of the panel's work were incorporated into the published report and offered a useful summary of current global knowledge about the HIV/AIDS epidemic, the effectiveness of prevention interventions, and identification of future social, behavioral and data research issues and priorities. Research Findings Against the reality of the rapidly spreading HIV I AIDS epidemic, the study reported that support for African AIDS research appeared to have hit a plateau because agencies and governments in developed countries are beginning to suffer from "donor fatigue." It attributed this fatigue to three key factors: I) the realization that the epidemic was unlikely to affect the developed world as badly as was initially feared; 2) an inability to see how the money and effort expended on AIDS prevention had affected the course of the epidemic; and 3) the fact that many of the region's governments had contributed little to AIDS research. In order to support choices that had been made for use of 1 imited resources, the report argued that • • • HIV/AIDS 5 changing individual behavior to slow down or limit HIV transmission is the best defensive action to take against HIV/AIDS in sub-Saharan Africa. It was found that public awareness of the epidemic is high and condom sales had risen dramatically across the continent during the first half of the 1990s. Also, the report noted the positive findings from other research: a reduction in the prevalence of HI Y -1 infection among young males in rural Uganda; evidence that treating sexually transmitted diseases in rural Tanzania may reduce the spread ofHIV. However, many interventions to date have been experimental and too small scale to have significant impact on the course of the epidemic. At the same time, discovery of an effective vaccine or treatment appeared improbable within the near future. But even if a cure were discovered, it would probably not be sufficient to bring a swift end to the epidemic, due to predictable difficulties in effectiveness, cost. distribution and acceptance. In addition, there remain millions of people already infected with HIV and unaware of their status, capable of transmitting the disease to others. Table 1: Fulfillment of Objecth·cs Ohjcl·tive Met, Not Met, Comments/Source Exceeded Document v.:hat was known Met The published report includes about social. cultural and this sections on these factors behavioral factors influencing the epidemic Identify effective strategies to Met Pilot and small scale prevent and mitigate the HI VI AIDS prevention spread ofthe pandemic strategies reported in the book. Recommend future research Met Key recommendations and sub￾priorities recommendations made in the report Produce a state-of-the-art Met The published book. study that idcnt i fies effective interventions and gaps in knowledge of the social and behavioral aspects of the HIV/AIDS Products The book, Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences, was the distinctive product of the activity. IDV/AIDS What complementary efforts have contributed to the results of this activity? The activity capitalized on the state of the art information and knowledge of the expert member panel, as well as information derived from the published and unpublished literature. Among the 16 panel members were Dr. Daniel Tarantola, Harvard University, who was a co-author of AIDS in the World, Dr. Peter Lamptey, director of Family Health International's AIDSCAP Project (funded by USAID). and Dr. Mead Over of the World Bank, who was funded by USAID/AFRISD through HHRAA Project to conduct another study of the economic impact of HIV/AIDS in Tanzania. Dr. Benoit Ferry, World Health Organization, added a multilateral donor perspective and in this way, cross linkages across other AFR and Global activities were maximized. In addition. Global PHN/1-IN/HIV/AIDS and Global PHNIHN/PSHR staff regularly attended the open meetings of the expert panel. What results were achieved by this activity? The activity achieved consensus among a group of internationally-recognized specialists on the research being done in HIV I AIDS prevention and mitigation. a not unimportant outcome in a field which has experienced some controversy. USAID and UNAIDS, in particular, used the results in the design of both policy and programmatic strategies. Despite the influence of the report on donor community programs and policies, there is no evidence that the study influenced programs or policies in Africa. although eventually donor approaches will be reflected in conditions in Africa. Understanding the problem Understanding the Problem Changes in Policies and Programs ltemotive Solutions ·nu: process of policy and program change involves the interaction of describing problems, identifying solutions, and advocacy. The report changed the way donor agencies, non-governmental organizations and governments think about the AIDS epidemic in sub-Saharan Africa. The change in perception could be described as a move1nent away from thinking of AIDS as a vertical epidemic rising from and contained. within the health sector to understanding it better as a horizontal endemic problem related to an entire spectrum of social and economic factors. Also, for the first time in the international response to the impact of HIV I AIDS, the report formally discussed "mitigation" in relation to AIDS prevention strategies. Finally, the report identified the needs for capacity building of African professionals and institutions for social and behavioral research. 6 • • • HIV/AIDS Alternative solutions The report did not present original alternatives, but endorsed prevention approaches which had demonstrated impact on the epidemic, although many of these had been small scale or of limited duration. In noting the effectiveness of these prevention approaches, the report recommended they be scaled up and intensified. The report made the following key recommendations: • Strengthen and improve HIV epidemiologic and behavioral surveillance systems to monitor the prevalence and incidence of the disease and thereby determine whether intervention programs are working. • Improve e\'aluation of intervention programs. Program evaluations often lack precision. Rigorous scientific studies are needed to assess reliably the effectiveness of prevention strategies. 7 • Expand research that targets women and adolescents. For example, the panel urged research on and development of a female-controlled vaginal microbicide that would allow women to protect themselves against sexually transmitted diseases without their partners' participation. • Expand studies to help improve care for people with HIV and AIDS. The challenge for researchers and the medical community, the report says, is to devise ways of treating people with AIDS at a lower cost without seriously compromising the quality of their care. Advocacy Advocacy was not built into the activity. The only evidence available for possible advocacy resulting from the report occurred during the 1996 IXth Annual AIDS in Africa Conference in Uganda. USAID distributed a questionnaire asking respondents how they would use the report. The 31 respondents. predominantly from university and non-governmental settings, indicated their intent to use to the findings of the report to: prioritize their research efforts (75 percent), educate the public (50 percent), and argue for additional resources for research (62 percent). Changes in policies and programs As a result of the publication of the report, the following occurred: • The USAID Global Bureau used the report to help develop the current USAID Results Framework ( RF) for HIV I AIDS. This framework provided the basis for significantly HIV/AIDS enhancing the scope of US AID's work in HIV I AIDS to include, for the first time, work on mitigating the impact ofHIV/AIDS and addressing many ofthe social and behavioral science aspects of the epidemic. The RF guided US AID's procurements for HIV I AIDS work into the 21st century. • The report influenced the 1997 World Bank report, Confronting AIDS: Public Priorities in a Global Epidemic, which provides a combination of epidemiological and economic arguments and advocates a broad strategy for dealing with AIDS. It also influenced the 1998 World Bank Discussion Paper No. 298, Uganda's AIDS Crisis: Its Implications for Development. This report traces the social and economic channels through which AIDS is likely to have its impact on the development prospects of Uganda, and recommends that key pol icymakers in ministries other than health factor in the consequences of AIDS when considering development strategies. • For UN AIDS. the report affirmed the policy and programmatic recommendations which had been maJ e to governments and donors. 8 • • Based on the study 's recommendations for monitoring behavior change, two African regional institutions--SOMA-NET and CERPOD--are planning to look for support to build their own capacity to respond to requests for assistance with monitoring and evaluation or behavior change interventions. • • USAID/Kenya used 40 copies of the report in a workshop of the HIV/AIDS/STD Working Group--of which USAlD was the chair and the UNAIDS program advisor the secretary at the time. The workshop helped in the planning of the re-design of the mission's HIV/AIDS strategy. Capacity building There is no evidence of capacity building of African institutions as a result of this activity, although, as noted. some institutions may use the findings in their programs. What lessons have we Jearned[ron1 this activity? • As a document prepared primarily by panel members from U.S. institutions with information assembled and analyzed in the U.S., its greatest influence was with USAID and other donors rather than African governments or African organizations. • The impact of the report was limited by three factors: .. The involvement of African institutions from the beginning and better dissemination methods would have increased the credibility of and interest in the final report within .• HIV/AIDS 9 Africa. ... The multi-sectoral approach led to a document considered "unwieldy" by some, unmanageable in its breadth of research and data. A series of shorter, targeted reports would have been useful, according to some people. ... No plan existed to promote further consideration of key issues by and through African institutions. What are the next steps? The rapidly changing nature of the HIV/AIDS epidemic in Africa, the evolving learning that occurs with prevcnti.on, care and mitigation interventions, and the changing political and economic environment which helps frame social responses to the epidemic--all these factors make the NAS study a historical document. Thus. there are no next steps for use of the study, other than to learn from that experience when and if a similar study is suggested in the future. HIV/AIDS References Consulted Written Barney Cohen and James Trussell (eds.), Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences. Washington, DC: National Academy Press, 1996. "Bolstered Behavioral, Social Research Needed to Help Stem Spread of AIDS in Sub-Saharan Africa," NRC Press Release, 6 December 1995 . Cohen, Barney to Committee on Population. "Dissemination of Report on AIDS in Africa," Memorandum. 23 January 1996. Corey, Charles""'· "Panel Releases New Report on AIDS in Sub-Saharan Africa," USIA Press Release. 7 December 1995. Population Reference Bureau. Bulletin (52.4) excerpts from Main Chapters. World Ban1<. CoJ?fronting AIDS: Public Priorities in a Global Epidemic. Oxford University Press Books. 19(>7. USAID. AFR/SD/IIRD Tropical and Infectious Diseases Portfolio. "Improving Policies and Strategies for HI VI AIDS Prevention and Mitigation," Report, August 1995. "AIDS Epidemic R~l\ aging Parts of Africa," Reuter News Report, 6 December 1995. 10 "NRC Panel Recommends Establishment of HIV and AIDS Research Institution in Sub-Saharan • Africa," Che':" C 'hase Weekly, 13 December 1995. • Holden, Constance ( cd.) "Scourge of Africa," Science 274 (November 1996). Informants Barney Cohen. NRC Peter Lamptey. Fl-11 James Trussell. Office of Population Research, Princeton University Alex Ross, USAID/AFRJSD, Bill Lyerly, USA I 0 / AFR/SD Jean Paul Clark. USAID/ AFR/SD Neen Alrutz PHN Officer, USAID/Nairobi Sambe Duale, SARA/Tulane University Gail Goodridge. Fl-1 I/ AIDSCAP Peter Piot, UN AIDS Judith Wasserheit. CDC Prepared by SARA: Arin Farrington Latest Revision: June 15, 1998 • Preventing and Mitigatiil};dl 4/DS in Sub-Saharan Africa: A Study on Social and Behavioral Research Needs What happened What I Research and Dissemination Advocacy Capacity TA and Other changed Analysis Building Activities I • Panel of 16 experts • Report released at lligh-level Changes in policies and programs ( 4 of whom were White 11ousc prcsentat ion of report Africans) on Conference on gave some • USAID Global Bureau used the I HIV/AIDS AIDS and prominence to its report to help develop the USAID I reviewed generated much recommendations, but Results Framework for HIV I AIDS. information on U.S. media no organized I HIV/AIDS attention. advocacy conducted. ~ • World Bank incorporated some of .•. the findings in its major study, ..- interventions and • SARA prepared a Confronting AIDS. strategies. summary ofthe . . . r> .. report. ~ • UNAIDS's recommendations to I • Interviews L country programs were supported conducted with • 200 copies of the by the report 's findings. HIV/AIDS policy full report and makers, program 1500 Eng1 ish and Complementary • CERPOD and SOMA-NET I managers, and French summary Activities incorporated recommendation on researchers in three verstons were behavior change monitoring into African countries. distributed by activity proposals. SARA in Africa I and U.S. • Report presented at 9th AIDS in Africa Conference in Kampala. I • Copies of report sent to all USAID missions and UNAIDS offices in Africa. ----- - HIV/AIDS Promoting Multi-sectoral Planning for HIV/AIDS: AIDS Briefs Main results and significance of the activity • AIDS Briefs encourage a multi-sectoral response to HIV /AIDS prevention by providing program managers and planners with basic checklists and examples for integrating responses to the epidemic into their planning processes. • The checklists are globally applicable, easy to use and can be adapted for targeted sectors. • To date, program planners in Botswana and South Africa have used the AIDS Briefs in their planning activities. • The AIDS Briefs have been widely circulated . • Other donors have supported translation of the AIDS Briefs in French, Spanish and Portuguese. Dates of Activity: Locations: Implementing Agencies: Total HHRAA Funding: Leveraged Funding: 1996-97 USA SARA/ AED, University of East Anglia (UK), University of Natal (South Africa) $6,000 NORAD funded translations into French and Spanish; a South African insurance company funded preparation of Briefs on two additional topics HIV/AIDS What was the problem or gap being addressed? During the first decade of the HIV I AIDS epidemic the disease was seen primarily as a health issue and health ministries were expected to "solve the problem." By the early I 990s, many international donors, national AIDS control programs, and NGOs argued that the control of and responses to the epidemic required a multi-sectoral approach. However, incorporating new and non-traditional issues into prevailing sectoral strategies and programs was not easy. It became apparent that the key to getting HIV I AIDS issues into non-health sector planning and policy making was to provide a methodology and ways in which it could be incorporated. 2 Preparation of drafts of the AIDS Briefs were supported by WHOIGPA. However, with the institutional transition from WHOIGPA to UN AIDS, support ended. Rather than allow the series to languish, USAID and SARA assumed responsibility for finalizing, printing and disseminating the [x number] of Briefs. What was the purpose of the activity? The activity contributed to Strategic Objective 9 which deals with the adoption of cost-effective strategies to prevent the spread and mitigate the impact of HIV I AIDS. More specifically, the activity was a part of IR. 9. I. I --evaluating and improving interventions for preventing HIV ISTI transmission--and IR9. I .2--evaluating and improving interventions to reduce the impact of HIV/AIDS. The AIDS Briefs are designed to provide a clear rationale and broad guidelines to integrate HIV I AIDS issues into health and non-health sectoral planning. The briefs are a tool for strategic planning and program design, written for people who are not HIV I AIDS specialists. They can be used both for policy development and program design. What were the objectives of the activity? • Publish eight AIDS Briefs • Disseminate the AIDS Briefs to governments, NGOs, donor agencies and the private sector. What took place in implementing the activity? USAID, through SARA, assumed the responsibility of publishing and disseminating eight AIDS Briefs which originally had been prepared under WHOIGPA. The topics were Commercial Agriculture, Subsistence Agriculture, Education, Health, Manufacturing, Mining, Tourism, and Military Populations. SARA produced 1500 copies of each Brief and collected them within a packet. SARA arranged for the translation into French for distribution in West Africa, and through its mailing list disseminated the Briefs across Africa. • HIV/AIDS 3 What were the outcomes of the activity? Dissemination was the major component of this activity, as SARA and USAID did not support the initial research upon which the AIDS Briefs were written. Dissemination SARA disseminated the brief to over 1500 people in AIDS organizations, NGOs, other groups working in Africa, USAID Missions, and other donor agencies. These included targeted individuals at African ministries of health, universities, the military, hospitals, and training schools. Also, SARA maintains the full text of the briefs on the HHRAA web site. Table 1: Fulfillment of Objectives Objective Met, Not Met, Exceeded Comments/Sources Publish eight AIDS Briefs Met SARA records Disseminate to governments, Met SARA distribution records NGOs, donor agencies and the private sector in Africa Products • AIDS Briefs: Integrating HIVIAIDS into Sectoral Planning, 1996. ... Commercial Agriculture ... Subsistence Agriculture ... Education ... Health ... Manufacturing ... Mining ... Tourism ... Military Populations Wha_t complementary efforts have contributed to the results of this activity? The AIDS Briefs were translated into French by a Norwegian NGO with funding from the Norwegian Agency for Development Cooperation (NORAD). The French translation was distributed by SARA and is available on the web site of the University of Bordeaux II, Societies D'Afrique et SIDA. A Spanish translation was also funded by NORAD. In addition, some of the Briefs have been translated into Portuguese by an independent consultant in Mozambique. HIV/AIDS A South African Insurance company, Metropolitan Life, supported preparation of additional briefs on the Finance and Transport sectors. These are to be fmished by mid-1998. What results have been achieved to date? HHRAA/SARA took a limited role in this activity, but there have been some results for which they can assume credit. HHRAA/SARA did not go as far it they might in taking advantage of the AIDS Briefs. Their use as an advocacy tool was not discussed, planned or implemented. Understanding the problem Understanding the Problem Changes in Policies and Programs ltemntive Solutions lbe process of policy and program change involves Lhe The AIDS Briefs themselves emphasize the interaction of describing problems, identifying solutions, and difference between individual vulnerability of advocacy. HIV I AIDS infection and socio-economic groups susceptibility to HIV I AIDS. The distinction is important as it removes full responsibility from individuals for prevention. A balance between individual and organizational responsibility can aid planners to design projects or programs that reduce susceptibility, such as providing 4 • condoms at construction or harvest sites for workers away from their homes. Also, the intended ., - use outside of the health sector reinforces the multi-sectoral involvement in HIVIAIDS prevention and mitigation. Alternative Solutions As a program design tool, the AIDS Briefs were not intended to offer alternative solutions, per se. However, the focus on multi-sectoral responses to the epidemic, while frequently given rhetorical support, is here given practical guidance. Advocacy The briefs are good advocacy tools: short, concise, with clear statements of particular problems and guidelines for addressing those problems. However, it is not known if or how the AIDS Briefs have been used to advocate for incorporation of HIV I AIDS issues into non-health sector planning. Changes in Policies and Programs The AIDS Briefs reflect the concern about multi-sectoral responses to the HIV I AIDS epidemic. There are indications that publishing and disseminating the briefs contributed to changes in policies or program design. For example, the Gauteng department of health in South Africa has used the Brieft in developing a provincial HIV/AIDS plans. Also, the Botswana National AIDS • HIV/AIDS 5 Commission used the Briefs as part of its annual planning process. Capacity Building The Briefs have been used by the University of Natal, Durban, for training purposes with HIVIAIDS program managers from South Africa. Also, since 1995, they have been used at annual training workshops on HIV I AIDS planning held at the University of East Anglia. Over 200 participants have attended the latter workshops and have included senior-level NGO program managers from Africa and other regions. The Briefs also were used in India at three HIV I AIDS planning workshops, with support from the British Council and the European Union. What lessons have we learned from this activity? • Small sums of money, invested in a timely manner, can result in production of a written resource that sets out approaches and/or guidelines for re-designing programs. • However, use beyond training activities conducted by the writers of the Briefs has not been extensive. • The usefulness and applicability of the AIDS Briefs to African program managers and planners could have been enhanced by if the briefs were linked with specific HIV I AIDS policy and program design training activities. • Unless there is an advocacy plan and an attempt to introduce materials to appropriate audiences in a timely manner, the impact on decision makers of such a resource will be limited. What are the next steps? • Given that HHRAA funding is going toward the preparation of eight more AIDS Briefs, review means to achieve their full impact, such as assuring the incorporation of the new and the original AIDS Briefs into specific policy and program planning training activities. • Consider revising the eight original AIDS Briefs in light of new developments in the field, but only if they will be fully and effectively used. • Completion of the two sector briefs on Finance and Transport, financed by Metropolitan Life, a South African insurance company by mid-1998. HIV/AIDS Resource Consulted Written Tony Barnett, Alan Whiteside, and Erik Bias (eds.), AIDS Briefs: Integrating HIVIAIDS into Sectoral Planning. 1996. Lieve Fransen and Alan Whiteside, Considering HIVIAIDS in Development Assistance: A Toolkit. Commission ofthe European Communities, 1996. Internet Website ofHHRAA and the University of Bordeaux, France. AIDS Briefs, French and English versions Informants Sambe Duale, SARA/Tulane University Bill Lyerly, US AID/ AFRSD Alan Whiteside, University ofNatal Tony Barnett, University of East Anglia Josef DeCosas, Independent translator, Chimoi, Mozambique Jim Black, European Commission evaluator Prepared by SARA: Arin Farrington Latest Revision: June 29, 1998 6 • • • Promoting Multi-sectoral Planning for HIV/AIDS: AIDS Briefs Research and Analysis What happened Dissemination Advocacy Capacity Building TA and Other Activities What changed • Publication of 8 • Over 1500 English • Good advocacy Did not occur. II Changes in policies and programs short guidelines for and French tools; so far used multi-sectoral informall . • Used in HIV/AIDS planning in ,, :;~~ · lllV/AIDS ·' 1 :<·i., :. ;. _j, ~; '. distributed. : >· · · · .. -.. · · ... South Africa and Botswana. ~~ P,r~y~~t~~~ :@l~i~~~ ~~W;· ~lr::·c:;~:~~:;.; )<·:~· ./:~ ·: .. ~·.· ;;·_:.·: :· :·: r ·. -~·· ~: ·~·· i:~~ >J , .. ... ·: · planning . . ~ ·· ·>' ~- · !~ ~ext mcluded on · · encourage multi-sectoral ,. ~· ~; ·. :-: !j ;. : ;:.::··~ --~; ;.:~,: · .. : ·:i··.'· ~~~e~ site. . .; _; .: . . . ·. Complementary .. ; nses to HIV/AIDS to reduce · :. ·: :'' ~~ ·Jt:·" · 5 ~'· :~ :~ .'\ ~.~ •. ,.>· -:: .~ .-; · -~:.., ·; ~ '' · -. · :" · · j., . : · :.: • ' :• ,.. : • •• A. .. ivities ( . ~ ~ · Ot er ors • Training courses in Africa, Asia and supported translation Europe used the Briefs with over into French and 200 NGO and AIDS program Spanish and leaders. publication in those languages. Crisis Prevention and Mitigation Capacity Building for Improved Preparedness and Response to Diarrheal Disease Epidemics in Southern Africa Main results and significance of the activity • Improvements in response capabilities from 1994 and 1996/97 contributed to far fewer cases and deaths than in previous outbreaks of diarrheal diseases in Malawi and Zambia. • Where in the past there was little professional guidance for health workers to deal with outbreaks of Shigella dysenteriae type I (SD I: epidemic dysentery), the activity has produced appropriate treatment procedures which are in place in all affected countries. • District level training materials on cholera and dysentery were developed and two workshops for the field testing of these materials were conducted in Southern Africa. • Laboratory capacity is being developed. including the preparation of laboratory manuals, and inter-country networks established through technical visits to Malawi, Swaziland, Zambia, and Zimbabwe. • Institutional capacity of the WHO/AFRO office in Harare has been strengthened by the establishment an intercountry team to work with ministries of health and other involved national government sectors, international agencies (such as the UNHCR, UNICEF and DHA), bilateral donors, and non-governmental organizations. • Materials on cholera and dysentery developed in southern Africa became a model for developing other training materials on integrated epidemic preparedness and response. Workshops were held in West Africa and in Ethiopia, Eritrea and Kenya with the materials. • Several countries have been served with emergency supplies of drugs from the sub￾regional emergency stores for epidemic response established in Harare, Zimbabwe. Dates of activity: Locations: Implementing Agency : Total HHRAA funding : Leveraged funds : 1993- 1998 Malawi, Swaziland, Zambia, Zimbabwe, Mozambique, South Africa WHO/AFRO, CDC $1,000,000 Swiss Disaster Relief: $1 ,000,000; Australian AID: $500,000; Italian AID: $205,000 Crisis Prevention and Mitigation What was the problem or gap being addressed ? For several years, the monitoring and reporting of and response to epidemics of cholera (especially in Eastern and Southern Africa), yellow fever, meningitis and measles in Africa (particularly West Africa) has been ad hoc and short-term in nature. This lack of systemic tracking, reporting, and response by African countries and international agencies contributed to high levels of fatalities in epidemics of cholera in 1992 and 1993 and of meningitis in West Africa in 1995 and 19.96. 2 Since the start of the 1990s, coincident with the most severe drought o(the century, countries in East and southern Africa have had to cope with recurrent epidemics of severe diarrhoea due to both cholera and bacillary dysentery. These diseases have taken a heavy toll, costing the lives of thousands of people during the epidemic period and, in the longer term, through the impact on national economies. Epidemic diarrhoea can be controlled with existing technical and programmatic interventions, provided that a carefully coordinated, multi-sectoral plan can be successfully implemented. In many African countries, case fatality rates (CFR) due to epidemic diarrhea have been as high as 40 percent in the acute phases of cholera epidemics, and CFR from cholera and, occasionally from dysentery, have averaged close to 1 0 percent. With rapid and effective responses to epidemic diarrheal disease outbreaks, experience has shown that CFR can be kept as low as 1 percent. Although many countries have preliminary emergency preparedness plans these are often incomplete and difficult to implement. This activity was developed following an analysis by AFRJSD of the effects of poor management and lack of effective treatment due to drug resistance of the predominant strain of dysentery in that sub-region. What was the purpose of the activity? The activity falls under SO I 0 which deals with policies, strategies, and programs to improve the prevention, mitigation. and transiting out of crisis. More specifically, it addresses IR 10.2.2-- strengthen capacity to implement and coordinate responses to epidemics. The purpose of the activity was to develop and implement effective responses to cholera and dysentery epidemics in order to lower case fatality rates during disease outbreaks. It was felt that reducing epidemics would improve the environment for a variety ofdevelopment activities and for regional economic integration and growth. What were the specific objectives of the activity? • To reduce case fatality through improved case management of epidemic diarrhoeal diseases; • • • Crisis Prevention and Mitigation 3 • To increase the ability of front-line health workers to respond rapidly to epidemics; • To identify and quantify the long-term developmental needs for reducing the occurrence of epidemic diarrhoea by: • increasing the understanding of epidemic dysentery to improve preventative and control measures, • identifying and testing interventions for cholera prevention. What took place in inzplen1enti11g the activity? Research and analysis Several technical assistance visits have been made by the WHO/ AFRO intercountry team and consultants to Malawi. Swaziland, Zambia, Mozambique, and Zimbabwe to assess needs and identify priorities for preparedness and response to epidemic diarrheal diseases. These assessments provided the data and information for the development of country action plans and related policy formulation plans. In addition, several operations research studies were conducted on the following topics: • Social and environmental factors influencing the transmission of shigella dysentery in rural and urban areas of Zimbabwe. • Treatment of dysentery in health centers in Mozambique. • Dysentery incidence in Kwazulu-Natal Province, South Africa and modes of transmission of dysentery in K wazulu-Natal, South Africa. • Clinical trial of ciprofloxacin for the treatment of dysentery due to SDl in children. This is a multi-center study taking place in Durban, South Africa and Harare, Zimbabwe. WHO/ AFRO provided technical assistance to individual countries designed to training national program staff, to develop training materials, to improve laboratory facilities and to move the regional drug store from Nairobi to H~are. Dissemination An intercountry meeting on dysentery epidemics in the southern Africa region was held in October 1995. Over 50 participants from Francophone and Anglophone countries met to share information and experiences on the control of epidemics and the correct case management of dysentery due to Shigella dysenteriae type 1. An intercountry meeting of laboratory specialists was held in November 1995. The meeting drew together 17laboratory specialists from Malawi, Mozambique, Tanzania, Swaziland, Zambia, and Zimbabwe, with facilitators from WHO, CDC, and Liverpool School of Tropical Medicine. The meeting focused on sharing experiences and techniques related to the confirmation of cholera and dysentery at both central and peripheral laboratories. A number of Crisis Prevention and Mitigation recommendations were made to be followed up by both WHO and participants when they returned to their countries, including regular sharing of information between laboratories and establishing a regional reference laboratory for cholera/dysentery. 4 The first bulletin of epidemic diarrhoeal diseases in southern Africa was produced at the end of 1995. The bulletin was to be produced quarterly in 1996. The bulletin has been published three times as of April 1997. The bulletin has targeted mainly individuals who have participated in the intercountry meetings on epidemic preparedness and control. A number of copies are sent to WHO country offices for further distribution. What were the outcon1es of this activity? The research completed within this activity provided specific examples and evidence for WHO/AFRO staff to use in training with national health staff. The fmdings of the research were less important than hov.·· they were applied to strengthen national programs. Table 1: Fulfillment of Objccti\'cs Objective Met, Not Met, Exceeded Comments/Sources Reduce case fatality through Surveillance data improved case management Met of epidemic diarrhoeal diseases Increase ability of front-line Met Training reports; evidence health workers to respond to from surveillance data epidemics Identify and quantify the Met research reports long-term developmental needs for reducing epidemic diarrhoea Products • Training and reference materials • Training courses • The project has invested considerable resources in developing a number of materials related to preparedness and response to diarrheal disease epidemics, including laboratory up-grades. • Operations research on aspects of dysentery in four southern Africa countries. • • • Crisis Prevention and Mitigation 5 What complementary efforts have contributed to the results of this activity? Efforts by ministries of health and other involved national government sectors, international agencies (such as the UNHCR, UNICEF and DHA), bilateral foreign assistance programs, and non-governmental organizations in areas such as water and sanitation, environment management, and public education may have contributed to the results of this activities. Also, the states of southern Africa has been moving toward regional responses to a variety of issues through the Southern Africa Development Community (SADC). This activity readily fit within that regional context. What results have been achieved to date? The activity has increased the ability of national programs to plan for and respond more quickly and effectively to diahorreal epidemics which is seen in reduced fatality rates across the sub￾region. By working through African institutions, building local capacity, and assuring that treatment guidelines and supplies are in place, the activity has strengthened the regional perspective of crises prevention. Understanding the problem While recurrent diahorreal epidemics were recognized as a problem in most East and southern African countries. the activity focused on specific aspects of the problem Understanding the Problem Changes in Policies and Programs lbe process of policy and program change involves the interaction of describing problems, identifying solutions, and advocacy. which were then incorporated into both national and regional programs or responses. For example, the absence of a sub-regional warehouse for rapid drug and equipment disbursement was seen as a problem which was addressed in the activity. Extensive training and skill transfer occurred as a way to improve management of epidemics. Also, the activity affirmed the importance of regional responses to epidemics; national responses had been the norm, but the activity worked from a sub-regional perspective which reflected disease realities. Identification of Alternative Solutions In itself, the activity represented an alternative to individual country responses to epidemics. Regional training, networking and emergency stores all represented a new way of approaching common problems. The WHO emergency stores were transferred from Nairobi, Kenya to Harare, Zimbabwe in 1994 in support of the implementation of this activity. The logistics of storage and movement of stocks are organized through an agreement with the Government of Zimbabwe Medical Stores to ensure smooth running of the stores. By the end of 1994 supplies for diarrhoea epidemic Crisis Prevention and Mitigation 6 response such as ORS sachets, IV fluids- Ringers Lactate, WHO emergency health kits, • chloramphenicol injectable, nalidixic acid had been received. The nalidixic acid was immediately transported to Rwanda where it was urgently needed for the dysentery epidemic. Several countries were sent emergency supplies of drugs on request. Advocacy This activity provided an opportunity to implement the recommendations endorsed by a intercountry meetings of ministers of health and ministers of interior in 1992 to develop an aggressive approach to the control of cholera and dysentery in Southern African countries. Changes in policies and programs National and regional preparedness and response for outbreaks of Shigella dysenteriae type 1 (SD1) improved considerably. Training, resource materials and disease management guidelines for understanding and responding to epidemic dysentery all contributed to improvements in national programs. Guidelines for control of epidemics caused by SD1 are in place in all affected countries The subregional emergency stores have been appropriately maintained and replenished with supplies to respond to diarrheal disease outbreaks and other emergencies (e.g., floods in • Madagascar). Emergency supplies have been dispatched in a timely manner with WHO/AFRO clearance. The project has facilitated the expansion of the role of the emergency stocks to cover all health emergencies ~ All of the countries involved in the initiative have developed plans of action for the control of epidemic diarrheal diseases, or have updated the plans that already existed. Also, WHO/ AFRO is better able to offer technical assistance with the establishment of an Intercountry team at the WHO office in Harare. As a follow up to the recomn1cndation of the intercountry laboratory meeting, countries are now participating in external quality control which ensures the reliability of laboratory data, especially for monitoring drug resistance. The quality control program also is a mechanism to provide continuing education to laboratory staff. A review of this activity was conducted in April 1997. The review team found that the trends in case fatality rate (CFR) decreased both for cholera and dysentery over the three to four years for which data are available. The decrease in case fatality rate reflects the changes which have produced better case management for cholera and dysentery. The group interpreted this as an impact of the training efforts of the WHO/ AFRO intercountry team, but acknowledged that other factors also may have affected the CFR. Capacity building Crisis Prevention and Mitigation 7 Capacity building occurred in several areas: • District level training materials on cholera and dysentery were developed and two field workshops for the field testing of these materials were conducted for countries in Southern Africa. The following courses are illustrative of training efforts under this activity: .. Epidemic preparedness training in Malawi (field test), Zambia, and Swaziland; .. Development of guidelines, including dysentery case management and laboratory diagnosis in Malawi, Swaziland, Zambia, and Zimbabwe; .. Training in participatory methods for environmental hygiene in Malawi and Zambia-- Zambia has since replicated the course a number of times for district level health workers; .. A diarrhoea training unit (DTU) course was offered to increase the capacity of trained personnel in Zambia in case management of diarrhea diseases. The course was for trainers of trainers (TOT) and included participants from Burundi, Malawi, Zimbabwe. Zambia. and Swiss Disaster Relief (SDR) consultants. The impact of the activity has spread beyond the sub-region. Materials on cholera and dysentery developed in Southern Africa were used to develop integrated epidemic preparedness and response training materials and workshops were held in West Africa and in Ethiopia, Eritrea and Kenya. Laboratory capacity is being developed and inter-country networks established through country technical visits Malawi. Swaziland. Zambia, and Zimbabwe. What lessons have we learned from this activity? • Strong national commitment of the participating countries to the project, arising from the identified need of addressing cholera and dysentery epidemics, facilitated the implementation of the regional program. • The designation of a WHO focal point in each country (medical officer, APO or national officer) provides continuity and a means to assure follow-up of the intercountry team support. The adn1inistrative support of the WHO country office is paramount to the success of the project. • Integrating project activities with other relevant activities in the countries can help maximize efficiency and effectiveness of the program (e.g., add on to disease surveillance already in place, rather than create a parallel system). • The development of new training materials or guidelines was more resource intensive (involving manpower, finances, adequate time, etc.) than had been anticipated. • Although capacity building efforts were admirable, they could be improved in two respects: .. Research activities need to be designed to strengthen national research and analytical Crisis Prevention and Mitigation 8 skills in addition to generating findings; Afri • .. Laboratory and epidemiological improvements should more fully use can experts in the implementation and evaluation of project activities. • Coordination between agencies and the personnel invoJved in such projects can be improved by clarifying roles and responsibilities from the beginning of the project. What are the next steps to capitalize on the activity? Considering the overall findings of the review conducted in April 1997, it was proposed that the following critical activities in the region be supported to ensure the continuity and sustainability of the initial effort investment: • Complete the laboratory training and institutionalize surveillance for antibiotic resistance; • Complete the development, publication. and dissemination of the basic training materials; • Continue epidemiologic surveillance, assessment, and complete related research; • Fallow up on emergency preparedness training; • Continue intercountry meetings and maximize transferability of lessons learned to other subregions: • Needs assessments conducted in Swaziland, Malawi, Zambia, and Mozambique have found that IEC activities for diarrhoea disease prevention and control are weak. This area should be strengthened to increase the impact of this activity. • In addition, it still needs to be verified at which level the action plans have been implemented in each country. Given these recommendations, it is reasonable to suggest that US AID/ AFR continue its support to WHO/AFRO for an additional two to three years. During that period, transition planning with WHO/AFRO can help smooth the withdrawal ofUSAID funding. It may be feasible to include the Southern Africa Developn1ent Community (SADC) in that planning. SADC's regional mandate provides a possible mechanism to transfer this public health initiative to African control. Sources Consulted Written Informants Prepared by SARA: Duale Sambe Latest Revision: August 31, 1998 Crisis Prevention and Mitigation 9 Research and Analysis • Needs and priority assessments for ·response to epidemic diarrheal diseases in five southern Africa countries. • Operations research on aspects of dysentery in four southern Africa countries. • Social/environment • Treatment of dysentery in health centers in Mozambique. • Dysentery modes of transmission in Kwazulu-Natal Province, South Africa. • Clinical trial of ciprojloxacin for the treatment of dysentery due to SDJ in children: Durban o .. r/ Building Capacity for Improved Epidemic Preparedness and Response to Diarrheal Disease Epidemics in Southern Africa What happened Dissemination • Intercountry meeting on dysentery epidemics in the southern Africa region held with over 50 regional participants. in southern Africa produced to share information. Advocacy Capacity Building Training of lab specialists and progam nwnngers. TA and Other Activities • Full-time CDC technical advisor placed in \\'11 0//\FRO Itarare . • USAILJ evaluntion team helped develop strategies. What changed Changes in Policies and Programs • National and regional preparedness ami response for outbreaks of Shil{ella dysenteriae type I (SO I) improved considerably. • A review of the activity in April 1997 found a fatality rate (CFR) decreased both for cholera and dysentery over the three to four years for which data are available. The decrease in case fatality rate reflects the changes which have produced better case management for cholera and dysentery. 'onal emergency drug warehouse transferred to Harare and improved, providing quicker response to epidemic outbreaks. • All of the countries involved in the initiative have developed plans of action for the control of epidemic diarrheal diseases. Capacity Building • WHO/ AFRO strengthened and able to strengthen national epidemic response programs. • WHO/ AFRO better able to offer technical assistance with the establishment of an Intercountry team at the WHO office in Harare. • Crisis Prevention and Mitigation Building Capacity for Improved Epidemic Preparedness and Response in Africa Main results and significance of the activity • As a result of advocacy by US AID/ AFR/SD and WHO/ AFRO with governments, West African ministers of health and ministers of interior signed in October 1996 a protocol of agreement on a collaborative and integrated approach to addressing the epidemics affecting the sub-region. • Institutional capacity at WHO/ AFRO to respond to country needs has been strengthened by the recruitment and placement of one epidemiologist and one lab specialist in Abidjan, one epidemiologist at the WHO/ AFRO headquarters, and in FY98 one advisor for the Great Lakes region of Africa. • Laboratory capacity is being developed and inter-country networks established through country technical visits to Niger, Mali, Burkina Faso, Chad and Nigeria and training of laboratory technicians in Nigeria and Mali. • With improvements in laboratory functioning, epidemiologic reporting is improving and leading to more rapid and coordinated responses by countries and regional personnel to outbreaks of common diseases. • In Ghana, the 1997 meningitis epidemic triggered the reactivation of the national crisis committee and the mobilization of funds for purchasing millions of doses of vaccine by the Ministry of Health. • Additional resources have been leveraged from the following partners: European commission, Swiss Disaster Relief, Norwegian AID, and selected governments of African participating countries Dates of activity: Locations: Implementing Agency : Total HHRAA funding: Leveraged funds : 1996 - ongoing Sub-Saharan Africa in general, and Burkina Faso, Chad, Mali, Ghana, Togo, Niger, and Nigeria in particular. WHO, CDC, Epicentre, SARA, African Institutions $3,215,000 European Union: 500,000 ECU; Swiss Disaster Relief: ? NORAD:? Crisis Prevention and Mitigation 2 What was the problem or gap being addressed ? For several years, the monitoring and reporting of and response to epidemics of cholera (especially in Eastern and Southern Africa), yellow fever, meningitis and measles in Africa (particularly in West Africa) has been ad hoc and crisis-driven nature. The absence of systemic tracking and reporting to governments and international agencies contributed to delayed responses and high levels of fatalities during epidemics of cholera in 1992 and 1993 and of meningitis in West Africa in 1995 and 1996. The out-breaks of epidemics of meningitis, cholera, dysentery, malaria, measles and hemorrhagic fevers--including Ebola, Lassa, and yellow fever--in the past few years in Africa indicated the urgent need to strengthen the capacity of African countries to prevent epidemics outbreaks and to rapidly and effectively manage them when they occurred. WHO/ AFRO was unable to adequately respond to country requests for assistance in dealing with these recurrent epidemics. In response to countries' needs, WHO/ AFRO--with USAID/AFR/SD's support--initiated, in collaboration with a number of partners, selected programs to assist African countries to deal with the problem of recurrent epidemics. What was the purpose of the activity? The activity was carried out as a component of Strategic Objective 10 which deals with policies, strategies, and programs to improve the prevention, mitigation, and· transiting out of crisis. More specifically, it addresses IR 1 0.2.2--strengthen capacity to implement and coordinate responses to epidemics. The increasing number of epidemics has threatened to overwhelm already heavily constrained health systems. The purpose of the activity has been to strengthen the capacity of WHO/ AFRO to assist national governments to develop and implement effective responses to epidemics of common diseases in order to lower case fatality rates during disease outbreaks. Through its funding, USAID/ AFR/SD sought to encourage both WHO/ AFRO and sub-regional governments to move beyond single disease approaches and to adopt comprehensive epidemic response systems. What were the specific objectives of the activity? The objectives of the activity were to : • Support the recruitment of technical staff to strengthen institutional capacity of WHO/ AFRO to assist countries to prevent and respond to epidemics; • Strengthen WHO/AFRO's capacity to assist countries up-grade national laboratories and training for front-line health staff; and • Reinforce regional communications systems. • • • Crisis Prevention and Mitigation 3 What took place during the implementation of the activity? WHO/AFRO organized an October 1996 meeting of West African ministers of health and ministers of interior to focus on the threat of meningitis to the sub-region. African governments agreed to increased the level of regional cooperation. In order to support those efforts, WHO/ AFRO recruited three epidemiologists, one at the regional headquarters whose primary tasks are to develop training materials and support countries in the training of frontline district health teams. The other two epidemiologists were based in Abidjan and supported initiatives in West Africa. WHO/AFRO worked to strengthen national surveillance systems in order to generate systematic data over time and monitor disease outbreaks. As disease outbreaks occurred, the surveillance systems have collected and analyzed the data, thus accumulating a database from which trends and patterns can be observed. The surveillance systems depended on improvements in national laboratories. Thus, several national laboratories received (and others can request) basic diagnostic equipment and reagents. Training materials for use by district-level health authorities were produced and disseminated to all 46 sub-Saharan African countries. Actual training activities occurred in over half of African countries by early 1998. Also, materials on cholera and dysentery which had been developed with HHRAA support in Southern Africa were used to develop integrated epidemic preparedness and response training materials for distribution across Africa. Workshops using these materials were held in West Africa and in Ethiopia, Eritrea and Kenya. A follow up West Africa sub-regional ministerial meeting on the progress made in the implementation of the protocol of cooperation and the plan of action on epidemic prevention and control was organized in Abidjan in February 1998. The meeting concluded that although good progress has been made, much more has to be achieved in order to ensure that countries are well prepared and fully equipped to cope with epidemics. What were the outcomes of this activity? Assessments of national laboratory capacities at different levels were under taken in 18 countries (13 Western African countries and 5 countries from the Great Lakes region). Four national laboratories (Burkina Faso, Mali, Niger and Chad) had received basic equipment and reagents, according to individual country request. Ghana, Togo and Benin have received latex reagents for meningococal meningitis rapid diagnosis. Crisis Prevention and Mitigation 4 Table 1: Fulfillment of Objectives Obje·ctives Met, Not Met, Exceeded Comments/Sources Support the recruitment of Met and on-going Project reports technical staff to strengthen WHO/ AFRO capacity to assist national response programs. Strengthen WHO/AFRO's Met and on-going Project reports capacity to up-grade national laboratories and training. Reinforce regional Beginning Informants communications systems Products • Training modules on "Epidemiological Surveillance" and "Epidemics Management'' for use at the district level were produced and disseminated to all 46 African countries; • • As of March 1998, 33 countries had carried out training activities in at least I district with some 4600 health workers and 52 facilitators have been briefed on the use of the training modules; • • Training of laboratory technicians has been accomplished in 9 West African countries. What complementary efforts have contributed to the results of this activity? This grant complemented work funded by USAID in 1994 on cholera and dysentery in the southern Africa region. Materials on cholera and dysentery developed in southern Africa with AFR/SD support were used to develop integrated training materials for workshops held in West Africa. What results have been achieved to date? WHO/ AFRO has been strengthened with added staff and new training materials to better assist national programs to control epidemics of yellow fever, measles, meningitis and cholera. With a strengthened regional health body, governments are in a stronger position to support a regional strategy of epidemic control. The strategy is backed by WHO/AFRO's support for improved surveillance, diagnosis and reporting of epidemic outbreaks. Understanding the problem West African countries have recognized that disease outbreaks readily cross national boundaries, and that a regional response often is the only way to readily control the spread of a disease. • Similarly, WHO/AFRO and participating countries formally endorsed an integrated approach to major epidemic diseases affecting the region. West African health and interior ministers signed a protocol of cooperation and adopted a plan of action for the prevention and control of epidemics in the sub-region. Identification of Alternative Solutions The activity itself supports individual country responses to epidemics within a regional context. Advocacy Crisis Prevention and Mitigation 5 lbt! process of policy and progr.un change involves lhe interaction of describing problems, identifying solutions. and advocacy. In October 1996, USAID/AFRISD participated in a meeting with West African ministers of health and ministers of interior. The meeting had been organized by WHO/ AFRO with the intent to focus on the threat of meningitis to the sub-region. USAID's technical and financial support to WHO/ AFRO enabled the former to advocate for a broader focus for the meeting so delegates could address an integrated approach to major epidemic diseases affecting this region. As noted above, USAID was successful as WHO/AFRO and member countries in West Africa formally endorsed the approach. Changes in policies and programs • Several countries in West Africa have created a budget line item to set up national and sub-regional security stocks of vaccines and other medical supplies and are sustaining the cost of the first interventions. • In Ghana, a recent meningitis epidemic triggered the reactivation of the national crisis committee and the mobilization of funds for purchasing millions of doses of vaccine by the Ministry of Health. • A regional meeting on strengthening laboratory capacity for disease surveillance and epidemic control in Africa held in January 1998, adopted guiding principles for establishing laboratory services and set objectives for laboratory support for disease surveillance and epidemic control. • The WHO/ AFRO Regional Programme on Emerging and other Communicable Diseases Control (EMC) leveraged additional support from several other donor agencies, including the European Union which committed to strengthen the sub-regional team for the West Africa epidemiological block based in Abidjan. The Norway Cooperation Agency (NORAD) contributed to the strengthening of the regional level by providing financial support for an epidemiologist and a technical officer. The Swiss Disaster Relief is funding an inter-country epidemiologist. Capacity building Crisis Prevention and Mitigation 6 • Epidemiological surveillance systems and response capacity have been strengthened • through: ... recruitment of an epidemiologist; ... development and dissemination to all 46 African member countries of an integrated training module for use with district-level staff on basic epidemiology with case studies for four priority diseases (meningitis, cholera, measles, yellow fever); ... organization of workshops and refresher courses for at least 4600 district health workers on basic epidemiology, disease surveillance and epidemiology control; ... review of epidemiological surveillance system in Niger, with recommendations for strengthening the system; ... field support visits to Niger, Togo, and Ghana. • Laboratory capacity is being developed and inter-country networks established through WHO/ AFRO technical assistance to Niger, Mali, Burkina Faso, Chad and Nigeria and training of laboratory technicians in Nigeria and Mali. • Training of laboratory technicians has been accomplished in 9 West African countries; • The institutional capacity at WHO/ AFRO to respond to country needs has been strengthened by the recruitment and placement of two epidemiologists in Abidjan and one at the WHO/ AFRO Headquarters. • A subregional (inter-country) technical team of two epidemiologists and a laboratory • specialist have been set up in Abidjan, Cote d'Ivoire, to train country medical staff and to coordinate epidemic preparedness and responses in the subregion; What lessons have we learned from this activity? • A relatively small grant to a regional organization can make a major difference in country responses to health problems. Thus, the hiring of staff by WHO/AFRO was a cost￾efficient input. • The activity generated tremendous leveraging power in bringing on other donors to support regional and sub-regional interventions and additional strengthening of WHO/AFRO. • Concerted efforts by governments and donors are key to building capacity for epidemic preparedness and response in Africa. • Well-timed advocacy around clearly identified issues can result in policy changes. What are the next steps to capitalize on the activity? In order to sustain the changes occurring in the region, then: is a need to accelerate training • activities, supervise trained persons and improve communication systems. WHO/AFRO will continue to need support to do that. Crisis Prevention and Mitigation 7 Consideration by US AID/ AFR/SD of continued support to WHO/ AFRO to use the experiences in West Africa in developing protocols of cooperation and plans of action for the other epidemiological blocks (i.e., Hom of Africa, Southern Africa, Great Lakes, and Central Africa). Based on the West African model, other inter-country technical teams will be established in each epidemiological blocks to support individual countries in developing national plan and implementing the integrated disease surveillance strategy with more emphasis on early detection and rapid response to epidemic prone diseases. Resources Consulted Written AFR/SD SOWs relevant to the WHO/AFRO grants. WHO/AFRO progress reports Crisis Prevention and Mitigation 8 Report of the Informal Consultative Meeting on Epidemic Preparedness and Response in Africa. Informants Mary Harvey, USAID/AFRO/SD Duale Sam be, SARA/ AED Andre Ndikuyeze, WHO/AFRO Bradley Perkins, CDC Deo Barakanyfitiye, WHO/ AFRO Mamadou L. Kone, WHO/Abidjan Prepared by SARA: Sambe Duale Latest Revision: August 31,1998 • • • Building Capacity for Improved Ep, Research and I Analysis • Not specifically a research activity, but survei I lance systems are generating epi data including laboratory findings. What Dissemination • Training materials for use by district￾level health authorities produced and disseminated to all 46 sub-Saharan African countries. Africa and in Ethiopia, Eritrea and Kenya. happened -- I Advocacy • USAID/AFR advocated with WHO/ AFRO and West African health and interior ministers to view epidemic prevention and .aic Preparedness and Response in Africa Capacity Building • Training of laboratory technicians has been accomplished in 9 West African countries. • Training activities in over half of TA and Other Activities • WHO/AFRO TA to national programs for surveillance, labs, and prevention systems and mobilization. • AFR/SD and What changed Changes in Policies and Programs • Several countries in West Africa created budget I ine items to have supplies for rapid responses. • Ghana mobilized funds to purchase millions of doses of vaccine during a recent meningitis outbreak. • Several donors added support for epidemic control. • West African countries recognize that most epidemic diseases are transnational and need to be approached on a regional basis. • A new approach of merging inter￾country and individual country responses to epidemics is being implemented. Capacity Building • WHO/ AFRO abi I ity to provide T A increased with new staff. • Epidemiological surveillance systems and response capacity strenthened with staff and training materials. • Laboratory capacity is being developed and inter-country lab networks established. (") :::0 0 C/) C/) I (") c:::: H H H z 0 z ()"Tl ('Tl0 z:::o -l:S::: ('Tl)> :::0--l (J)-0 z Cross Cutting Issues Sharing Research Findings: Information Dissemination Centres in East and Southern Africa Main results and significance of activities • Seven country-level African information institutions have adopted new working methods and are identifying, re-packaging, and distl-ibuting public health research in formats designed to inform and motivate policy and program changes. • Four Dissemination Centers have formed task forces to promote advocacy on priority issues. • The Dissemination Center in Zimbabwe funded a play on unsafe abortions. The play has drawn large audiences. including regional policymakers, and has attracted the attention of other projects and donors. • Five national policy seminars on unsafe abortions and maternal mortality and one on nutrition were organized by lDCs to inform and stimulate policy makers and program managers. 1 • Research findings--including findings from "grey" literature--on several maternal mortality, unsafe abortion, and nutrition were summarized in easily comprehensible formats for use by policy makers. - • The dissemination centers ensured that the important HHRAA/SARA-funded monograph and policy brochure on the consequences of unsafe abortion were distributed widely in the region. • Dissemination systems (including mailing lists) now exist for distributing documents of regional relevance, including those produced by HHRAA/SARA. 1 • Researchers, service providers. program managers, policy makers, donors, and others in Africa now have significantly greater access to reproductive health and nutrition research. Dates of activity: Locations: Implementing Agencies: Total HHRAA funding: Leveraged funds: 1995 - present Kenya, Malawi, Namibia, Tanzania Uganda, Zambia, and Zimbabwe SARA (initially through CRHCS, and eight national information centers) c.$540,000 $5000 (Policy Project), $50C') (PCS) Cross Cutting Issues 2 What was the problem or gap being addressed by this activity? • Promotion of health policy and programmatic changes requires access to current research findings, especially prepared in formats which facilitate understanding and use. As HHRAA￾funded research evolved. it became clear that: ... Policy makers in the region often lacked appropriate evidence-based information to shape options for decisions about health care delivery and the allocation of human and financial resources. Where research results did exist, they tended to be presented in academic or highly technical formats which were not easily used by policy-makers for timely and effective decision-making. ... Program managers and service providers, too, lacked information on latest technologies, strategies. and experiences from existing projects, upon which to model more successful activities. ... Researchers in the region were scientifically isolated from each other and lacked knowledge about and access to literature which could guide either the determination of research priorities or the development of their research. Bibliographies of completed research from the region were lacking. ... Important and useful "grey" literature 1 was often unavailable to researchers, program • managers and donors. The capacity did not exist in east and southern African countries to share research findings effectively or expeditiously with those who needed them. CRHCS/ECSA and the SARA project had prepared numerous regional health-related publications, but no mechanisms existed to systematically disseminate them within countries in the region. CRHCS/ECSA and SARA staff recognized that the key to effective health information dissemination for advocacy was the involvement of national-level African institutions, however most of those institutions lacked the resources to play a pro-active role in dissemination or had not been charged with the task. What was the purpose of this activity? The purpose of the activity--in line with the mandate of the HHRAA/SARA project to increase the utilization of research, analysis, and information in support of improved health, nutrition, education, and family planning strategies, policies, and programs in Africa--has been to strengthen the capacity of African institutions to distribute relevant information in a timely manner and increase its use by policy makers and program managers. Both national 1 Grey literature is defined as literature that is not nonnally accessed through sources such as Index Medicus. It includes dissertations, papers presented at conferences, country reports, annual • reports, project reports, newspaper articles, radio and TV broadcasts, leaflets, and archival records. ' Cross Cutting Issues 3 dissemination centers and a regional network of centers have been the focus of the activity. What was the specific objective of the activity? Objectives of the activity included: ... Identification of institutions in seven countries willing and able to collect and disseminate for advocacy research findings on reproductive health and nutrition issues; ... Strengthen the national institutions to collect, compile, and disseminate for advocacy research literature; ... Increase the skills of information centers to repackage CHRCS and SARA research reports for use by policy makers and program managers; ... Re-orient dissemination centers to focus their information dissemination and advocacy work on priority health issues and to use new methods (such as task forces) to assure that information is used rather than just distributed. What took place in in1plementing the activity? Ground-breaking research had already been undertaken by the Commonwealth Regional Health Community Secretariat/East, Central and Southern Africa (CRHCS/ECSA, henceforth CRHCS) in the area of reproductive health. CRHCS had written a proposal for support for dissemination of its research reports. Also, CRHCS's nutrition unit was ready to take on a much-needed regional networking role. Thus, CRHCS had the institutional interest and experience to take on a much-needed regional networking role for disseminating research findings and increase the use of research for policy advocacy and programmatic change. A CRHCS/SARA assessment led to the identification of Information Dissemination Centers (IDCs) at existing institutions in eight sites in seven countries2• SARA provided financial and technical support to CRHCS to hire a dissemination and coordination professional for two years after which CRHCS would assume the cost. Each center formed an advisory task force to provide technical -input and direction and leadership for advocacy. These task forces were comprised of well-respected professionals from NGOs, government, associations of health professionals, the media, and women's groups with an interest in health information and its use in advocacy. Five of the centers organized a policy seminar, using the CRHCS-produced booklet, Addressing complications of unsafe abortion in sub-Saharan Africa as a reference point. However, advocacy is a relatively new concept and re-packaging information into formats to inform and 2 Kenya (Kenya Medical Research Institute)~ Malawi (Ministry of Health); Namibia (University of Namibia Library); Tanzania (Tanzania Food and Nutrition Centre and Tanzania Centre for Development and Health Activities); Uganda (Child Health and Development Centre); Zambia (University of Zambia Medical Library); and Zimbabwe (University of Zimbabwe Medical Library). Cross Cutting Issues 4 influence policymaking has required more skill-building than anticipated. • Reproductive health and nutrition were identified as priority health areas for CRHCS, so the dissemination centers were tasked to work on these issues. A training seminar was held for each IDC in re-packaging information for advocacy. Annotated bibliographies of existing country￾level research were compiled in Botswana, Kenya, Malawi and Namibia. In Malawi, the project￾supported nutrition bibliography is hoped to become the electronic Nutrition Database for Malawi. In Zimbabwe, support was provided through the IDC to a popular theater troupe to develop and perform a play on unsafe abortion to sensitize the general public and to keep the issue on the policy agenda. The play has been performed numerous times, including before regional policy makers. Electronic networking was established with the intent of allowing the eight centers to communicate by email with one another and with CRHCS and SARA. Electronic communication has been important for communication with CRHCS and SARA, for monitoring the activities of the IDCs~ and encouraging links between the IDCs themselves, although those links have yet to fully thrive. Most of the IDCs were connected to HealthNet, an international information sharing network on health issues. Analyses of media coverage of reproductive health issues were undertaken in Kenya and Malawi. The purpose of these analyses was to provide feedback to the media on the pattern of its coverage of reproductive health issues, and to open communication for improved coverage. Some centers • tried to develop relationships with the print and broadcast media to increase coverage and quality of health issues. These relationships have had varying degrees of success, depending upon individual interests and skills on each side. A newsletter, "Dissemination Centres Update", published by CRHCS, helped inform IDCs about successful dissemination strategies on a regular basis. Targeted mailing lists were developed in all IDCs. These lists facilitated the dissemination of documents produced by CRHCS and local researchers. In Kenya, the IDC distributed publications down to the district level. The Uganda center has achieved recognition by other organizations such as UNICEF, UNFPA, government departments, and NGOs, which regularly request information and publications from the center. Partner institutions (including, for example, family planning associations, government agencies, women's advocacy groups, special interest groups, etc.) gradually are being identified to create a multiplier effect for disseminating materials. A change in leadership in CRHCS caused some difficulties for this activity. The head of the research department who had been the main champion of this activity resigned in February 1996 and the dissemination coordinator relocated to Nairobi. A permanent post has been approved by CRHCS ministers but had not been filled as of mid-1998. · • Cross Cutting Issues S What were the outcomes of these activities? For the most part, the dissemination centers have demonstrated their importance in making available information to key constituencies. • 7 of the 8 IDCs have demonstrated their effectiveness, in disseminating research information and promoting advocacy. • The Uganda and Zimbabwe IDCs have been very active and effective. • One of the centers (Namibia) remained generally inactive. Table 1: Fulfillment of Objectives Objective Met, Not Met, Exceeded Comments/Sources Identify institutions in seven Met SARA annual reports; Bery trip countries willing and able to reports collect and disseminate for advocacy research findings Strengthen the national Met and on-going reports from IDCs and CRHCS institutions to collect, compile, and disseminate research literature Increase the ski lis of Partially met reports; synthesizing research information centers to findings has required more time repackage research reports for and work than expected use by policy makers Re-orient dissemination centers Met Bery trip reports; CRHCS to focus on priority health reports issues and to use new methods to assure that information is used Products What the IDCs have done: • 5 IDC Coordinators designated by their institutions; • 8 advisory task forces formed; • 6 dissemination/advocacy events held; • over 12,000 SARA-funded publications disseminated (including bibliographies) through the IDCs; • over 10,000 other publications disseminated through the IDCs (via CRHCS); • 5 presentations made by IDC coordinators based on content of the technical materials Cross Cutting Issues 6 within the IDCs. • What CRHCS and SARA have done: • Conducted 2 skills building activities for 25-30 people from 13 ECSA countries; • Published 3 issues of dissemination center newsletter; • Linked the 8 centers to e-mail (not all SARA funded); What SARA has done since coordinator relocated to Nairobi: • 7 presentations made by regional advisor on technical materials within the IDCs; • 20 technical assistance visits to 8 centers; • Provided workshops on sustainability for all centers. What complenzentary efforts have contributed to the results of this activity? The reproductive health program at CRHCS had done several multi-site studies and had findings reading for dissemination and advocacy. The HHRAA/SARA funded research on the consequences of unsafe abortion had been carried out by CRHCS and SARA/JHPIEGO and this material was ready for distribution. A Reproductive Health Research Network had been established with support from the Rockefeller Foundation and the Nutrition Network had attracted the attention of several USAID projects as well as the Geneva-based Nutrition • Coordinating Committee. What results have been achieved to date? The ECSA dissemination centers have begun to fill an identified gap in health information and advocacy for the sub-region. As a result of the activity, information specialists in seven of the eight IDCs have begun to re￾define the role of information dissemination. What largely had been untargeted and passive (or re-active) distribution of materials, changed as the dissemination centers assumed an activist role: a conscious re-packaging of Changes in Policies and Programs lternative Solutions 1be process of policy and program change involves lhe interaction of describing problems, identifying solutions. and advocacy. research findings to fit specific audiences, an active dissemination of that information, and the application of information to promote changes on specific public health issues. Understanding the problem There ·has been an appreciation and acceptance of responsibility for dissemination of health information and its use in advocacy efforts by regional and Ylational policy makers. The • ministerial council of CRHCS agreed to assume funding for a position of dissemination '. coordinator after the start-up grant from USAID ends. Positions have been created for over half Cross Cutting Issues 7 of the national coordinators by their home institutions. Alternative solutions By compiling information (i.e., bibliographies), re·packaging research results (unsafe abortion) and/or organizing events to sensitize policy and program authorities (maternal mortality and reproductive health workshops), the centers have contributed to definitions of problems and debates on approaches and options to address public health problems. Advocacy Advisory Task Forces were established through each IDC. These Task Forces were able to advocate for the collection and use ofhealth·related research in ways that the IDC staff alone could not because they did not have the necessary influence or contacts. The Task Forces also helped identify and n1eet the information needs of various audiences, established links with community groups and facilitated contacts with the media and senior policy makers. One of the reproductive health topics of greatest interest across the region was unsafe abortion. The IDCs were instrumental in disseminating, and creating venues for discussing the monograph and policy booklet on consequences of unsafe abortion funded by SARA. Like the other IDCs, the Uganda IDC (i.e., the Child Health and Development Center) coordinated media coverage of the policy seminar on maternal n1ortality. This both raised the profile of maternal mortality￾related issues, and generated substantial public debate through editorials and letters to the editor. In Zimbabwe, a theater group developed and performed a play dealing with unsafe abortion. Changes in policies and programs There are several notable changes arising from this activity: • The CRHCS council of ministers of health of the 13 member countries created and agreed to support a post of dissemination coordinator. • In Tanzania, materials collected through the activity provided the basis for the development of a health manual on adolescent reproductive health for use in program interventions in schools. This was undertaken in conjunction with CRHCS and the Ministry of Education. • In Malawi, the dissemination seminar on reproductive health, undertaken in collaboration with the College of Medicine, featured a study on HIV I AIDS. Discussion of this study resulted in greater recognition by USAID and the Ministry of Health of the magnitude of the epidemic and the need for increased efforts to change sexual behavior rather than just provide information about modes of transmission. • In Zimbabwe, action plans were formed to address the social and medical consequences Cross Cutting Issues 8 of abortion following the policy seminar sponsored by the project. After the seminar, to • keep the issue in the spotlight, the IDC commissioned a well-known theater group to develop a play based on the policy booklet on unsafe abortion. The play has been performed at least three times and has attracted the support of the POLICY Project. • The Kenya IDC (i.e., Kenya Medical Research Institute) determined that provincial and district policy discussions would be more effective than national ones, and held its first maternal mortality seminar with district policy makers in Kilifi district. Other specific country-level changes arising from activities of the dissemination centers are more difficult to assess because: • it took longer than originally anticipated to produce tangible outputs by the centers, such as the completion of bibliographies; • policy and program change are often slow to occur as a result of such efforts; • it is difficult to attribute such change to any one project or intervention. Capacity building Two dissemination methods training workshops were held for IDC staff from 13 ECSA countries--Botswana. Kenya, Lesotho, Malawi, Mauritius, Namibia, Seychelles, South Africa, Swaziland, Tanzania. Uganda, Zambia and Zimbabwe. These were followed by technical • assistance from CRHCS and SARA staff to strengthen the capacity of national-level dissemination project staff in the following skill areas: • application of new information/communication technologies such as use of e-mail and CO-ROMs to improve dissemination of information and networking within countries and the region~ • strategies for accessing grey and other unpublished literature (including how to establish contacts with potential sources; keeping profiles of partners and institutions which generate grey literature ~ the need to track reports from United Nations, World Bank and USAID missions, etc); • management of information and development and maintenance of appropriately-targeted mailing lists~ • techniques to identify partner institutions~ • development of advocacy, communication, and overall action plans; • assessment of health information activities and developing plans to increase information access at the policy and program level; and • analyzing and updating health profiles of individual countries. A mid-1998 field visit by SARA staff confirmed that capacity among IDC has been enhanced, especially in their appreciation and application of elements of the overall information-change process. It was noted that IDC staff now: • work collaboratively with technical experts to develop activity plans; • Cross Cutting Issues 9 • better understand the dissemination process and the value of disseminating pro-actively; • appreciate the necessity of distributing information in a format which engages a particular audience; and • think more carefully about targeted dissemination. At the level of the IDC staff themselves, several have reported that the skills and visibility they have gained as dissemination center coordinators have been recognized, and have afforded them new opportunities--such as the Uganda IDC coordinator being invited to advise the National AIDS Documentation Centre. What lessons have we learned from this activity? A number of lessons have been learned from this activity. • Institutional and task force support and control are key ingredients for success and effectiveness: • IDCs which had strong support from their institutions (such as Uganda and Zimbabwe) and which achieved good visibility had greater impact than others. • Establishing task forces at country level can significantly increase the visibility and clout of the centers. stretch their reach, and help ensure that policy makers receive and act on their materials. • Building a sense of ownership of the IDCs was hampered by the fact that the centers could not select their own priority topics for dissemination, but rather had to follow the priorities of the CRHCS. • Achieving sustainability of the a portion of the IDCs is possible. Several IDCs have already engaged in dissemination activities without SARA funds by attracting new contributors and new activities. For example, the IDC in Kenya has signed a contract with JHU to distribute POPLINE. Zimbabwe has attracted funds from USAID's Post-abortion Care Initiative. • Support of the task forces is very critical, but takes time to establish: • convening a task force involves bringing together disparate groups of people who normally do not work together, the progress can be slow and laborious, requiring determination. patience and persistence. • many Task Force men1bers were over committed and did not have enough time to give to the IDC. • small task forces are often more efficient and effective than large ones. • having a "champion" on the task force (who has vision and commitment) leads to greater output of the task force. • Task force members are good resources but need to be given direction, guidance and appropriate credit for their contributions. • Creation and mobilization of an active task force is a key factor for IDCs to assume an advocacy role: Cross Cutting Issues 10 ... IDCs are not advocacy organizations but can organize a task force to play that role • provided the IDCs provide appropriate and timely information for use~ advocacy. · ... Carefully-selected task force members often are better placed to act as advocates than are the IDC staff then1selves who often do not have the skills or organizational position to take on the task of advocacy. ... Establishing ongoing relationships with journalists was not feasible for most IDCs. Establishing effective and useful relationship takes considerable effort, and may not be appropriate for IDCs alone. An effectively-functioning Task Force can help in this regard. • Repackaging and synthesizing academic and technical research materials into shorter, simpler. policy-relevant documents is a major constraint for the IDCs. The task requires skills which are difficult to find. In addition, issues of copyright and ownership of repackaged information may slow the process. • Networking between IDCs did not prove to be as useful or necessary as originally envisioned. Activities at national level remain their primary focus. IDCs were interested in the work of counterparts in other countries and like exchanges and face-to-face experiences provided at the workshops. • Sustaining Internet service is costly in many countries in the region. • Collection of "grey" literature is not easy. Researchers are. sometimes uncooperative or unwilling to share information, and facilities and funds to copy the information are not always available. However, the compilation of bibliographies and production of issue summaries may stimulate researchers to contribute their works. What are the next steps to capitalize on the activity? • New priority areas identified by the IDCs themselves, such as the expressed interest in HIV I AIDS, should be considered by HHRAA/SARA, as long as they are consistent with HHRAA/SARA areas of activity. An assessment of other existing resource or dissemination centers will help clarify areas of need. • SARA needs to: ... Plan follow-on activities with the four most dynamic centers (e.g., those in Kenya, Malawi, Uganda, Zimbabwe) and explore co-funding opportunities with those centers. ... monitor the work of the other IDCs until funds have been spent. ... hand-off the activity to a regional coordinating body before the end of the project., The relationship with CRHCS has already expired and was not renewed by SARA. However, recent developments at CRHCS may offer new opportunities to collaborate. ... explore the possibility of starting an electronic dialogue on experience related to · information dissemination and advocacy in order to strengthen networking among the IDCs. • • Cross Cutting Issues 11 • Provide training to at least the most active IDCs in the synthesis of research findings for use by non-academic and non-technical audiences and in the methods to present the synthesized findings to various audiences for policy development. Abbreviations CHRCS ECSA HHRAA IDC JHU NGO SARA UNFPA UNICEF Commonwealth Regional Health Community Secretariat East, Central and Southern Africa Health and Human Resources Analysis for Africa Information Dissemination Centers Johns Hopkins University N on-governn1ental organization Support for Analysis and Research in Africa United Nations Population Fund United Nations Children's Fund Sources Consulted Written Judy Brace, "Trip Report: Regional Health Information Dissemination Workshop of the Commonwealth Regional Health Community Secretariat," SARA: 1995. Stephen N. Kinoti, "Information retrieval documentation and dissemination in East, Central and Southern Africa for better research and health care." July 1993. "Information dissemination and communication in ECSA. Report of a pre-implementation assessment for reproductive health and nutrition." July I 994. L .. Gikaru, et al., "Proceedings of the regional workshop on information dissemination for better health," I 995. L. Gikaru, "CRHCS information dissemination programme. Progress report," 1996. Informants Renu Bery, SARA/ AED Suzanne Prysor-Jones, SARA/ AED Prepared by SARA: Beth Preble Latest Revision: June 17, 1998 Sharing Research Findings: Information Dissemination Centres (IDCs) in East and Southern Africa Analysis/Resource Collection • JDCs in Kenya and Malawi analyzed local media coverage of reproductive health issues. • Published and "grey" literature collected. What happened Dissemination Advocacy Capacity Building TA and Other Activities • > 12000 copies of • IDCs formed task In 2 inter-country skill- • CRIICS full-time What changed SARA-funded pubs forces for technical building workshops for dissemination • Credible infonnation regularly made disseminated (eg, input and advocacy. c. 25-30 staff of the coordinator funded available to researchers, advocates and CRIICS monograph • Task force members I DCs received tmining for 2 years. policy makers on nutrition and and policy book let were important in the: reproductive health issues. on unsafe abortion contributors to issues • application of ne\v • Ench of 8 IDCs • Role of information dissemination and CERPOD advocacy. informntion/communi visited twice. shifted from untargeted and passive (or booklet on adolescent • 6 IDCs organized c<1tion technologies re-active) distribution of materials, to RH . advocacy events or • development of • SARA assessment/ re-packaging of research findings to fit • Bibliographies seminars for advocacy and specific audiences, active dissemination compiled on nutrition • >I 0000 non-SARA discussion of of that infonnation, and the use of and RH in Kenya, maternal mortality, information to promote change. . . . . . . Information made available through the ~< eal~)!lf9 i•; ,! J~~- ~;~ · .. li.f: Afric~"? PR)l -~d ~>~·; :- ~habq~i~n i~sues ~-. ~-·.f. .. : . s contributed to debates and :_:-_: ~~pa,.~~Ci~H··~/:. ~~¥_ .•. :: ~i: s: __ :~ _ .FS_ .. pu~lis_.~ti~p~>.~i ;~_- ~ i :~imba~we qrg~~~t; !~·;. co~i e · n of options to deal with '-'·· ;'"':;;9r:\ · ·:l':f ·~~ ,.~J.I~~t b-.f:O.. . .J.., ,J ·.:'"" .. ·>':: tli."J.''~ r#T:l'~'"f e\ biii. ;· rr. ,:;. ,\': · ,t:it P:~'i ."~1;·;: f. J-..:>~·~ l~ ~-] ~: .,• .. a voeacy ev~n oQ. .: 1on an repro uctlve health tssues. :;.;t.~jtf'' · !: ;: ~ ... ·: ~! ~ "'~~ J-': .. ·:· ~· -· . ·· •. :: .• ··:.; 1' ,..· •• • · .,. ~~ , · • ·.: ·!;;, .. ,. J;; ·~ · · · · ,...,.j.:· ·: ..... :· ~r~ ·1~.·;~ .. ~~~ ~'~ : Nutrition newsletter published. breastfeeding. information; and Changes in Policies, and Programs Commission • Most staff of IDCs • analyzing health • In Tanzania, materials collected were repackaged DHS • Targeted mailing lists not comfortable with profiles of countries. C 1 t used to develop a manual in KiSwahili omp emen ary nutrition info. developed in all 8 advocacy roles. Activities on adolescent RH for use in 3chools. • Zambia IDC repackaged CRHCS material on unsafe abortion. centers. • In Malawi, a dissemination seminar on • • Theater group organized play on unsafe abortion; presented several times, including at two international fora onRH. • REDSOIESA and Policy Project promoting Zimbabwe theater group's play. reproductive health resulted in greater recognition by USAID and the MoH of the magnitude of the AIDS epidemic. It convinced the MoH to focus more on sexual behavior change interventions. • In Zimbabwe, seminars opened and stimulated public debate on sensitive issues (i.e., unsafeabortion, HIV and breastfeeding). The seminars led to drafting of action plans to address the consequences of unsafe abortion. • The Kenya IDC held its first maternal mortality seminar for district officials . • Building Capacity for Advocacy: An Introduction to Advocacy Training Guide Cross-Cutting Issues Main results and significance of the activity • The first major resource targeted to African public health activists and specialists to increase and improve advocacy efforts for policy and program changes. • Three training organizations in Africa have used the An Introduction to Advocacy to develop their skills for the training of others. • With the An Introduction to Advocacy as a model and resource, at least four regional training events have been held. Over 500 reproductive health professionals in Africa have been trained in advocacy methods and process in order to use research to influence policy in their own institutions and at higher levels. • An Introduction to Advocacy has enabled advocacy specialists in Africa to train clients with a consistent, adaptable guide. Dates of Activity: Location: Implementing Agencies: Total HHRAA Funding: Leveraged Funding: 1995-1997 Senegal, Mali SARA, ACI, Goree Institute, Porter/Novelli $45,000 POLICY Project supported translation into Spanish and Arabic Cross-Cutting Issues 2 What was the problem or gap being addressed? Many African institutions and researchers have had little experience in the processes of moving research findings into policy and program arenas. It was fairly common that research reports were presented in whole, with little consideration to transforming the findings for easy use by appropriate authorities. SARA recognized a need to increase the capacity of African researchers, research institutions, public health specialists and program managers to effectively translate research into action/policy. The first step was to develop an knowledge-based rationale for advocacy. A SARA-supported study, Knowledge, Utilization and the Process of Policy Formation, reviewed the use of research findings in policy development. It concluded that the process of policy change was a result of three converging factors: defining the nature of the problem, identifying alternative approaches to solving the problem; and advocacy for adoption of the priority alternative(s ). While defining problems and exploring alternative solutions have long been used to promote change, the need for systematic and iterative advocacy in the process has been less well understood. Researchers, managers, NGO personnel and other concerned groups and individuals seeking policy or program changes often had too little knowledge of, experience or training in advocating for those changes. What was the purpose of the activity? The An Introduction to Advocacy is a tool for people to better understand the advocacy process. It is designed to: • inform potential advocates about advocacy and its methods; • build basic skills in advocacy; . • increase the use of available data to inform the advocacy process; • give confidence to those who are embarking on advocacy efforts; and • encourage the democratic process by providing people with the skills needed to make their voices heard. What were the specific objectives of the activity? The specific objectives of the activity were: • To quickly collect materials, experiences, and lessons learned from advocacy organizations and projects; • To design and produce a training manual on advocacy based on findings gathered from • • • Cross-Cutting Issues 3 other organizations; • To field test the manual at two advocacy training workshops in Africa; • To produce a trained cadre of reproductive health professionals in Africa alert to the linkages between research and policy. What took place in implementing the activity? Information gathering SARA co11ected information on advocacy during a one-day workshop it hosted in Washington, DC. An "expert panel" from CEDPA, InterAction, PATH, the Advocacy Institute, George Washington University and Georgetown University discussed advocacy materials from their organizations and lessons learned from using the materials in the field. In the process, SARA discovered that there was no advocacy guide to readily distribute to public health specialists. The An Introduction to Advocacy was subsequently developed and prepared for testing at two workshops in Africa, one in Mali and the other in Senegal. Revisions to the guide were made following feedback received at both workshops. The final version was divided into 10 distinct modules, each containing an introduction, learning objectives, key points, case studies, and exercises. The guide was translated into French, Spanish, Portuguese, and Arabic. Dissemination Approximately 850 copies of An Introduction to Advocacy have been sent to a variety of individuals and organizations worldwide. A brochure advertising the guide was produced and is disseminated widely. In addition, the An Introduction to Advocacy has been bought, at a cost of$10 each, by NGOs, PVOs, foundations, individuals and resource centers. So far, 415 copies have been bought, resulting in a cost recovery of $4,150. What were the outcomes of the activity? Methodology Drafting of the text of the guide was based upon existing materials, experiences, and lessons learned of numerous advocacy experts and organizations involved in advocacy efforts in Africa. Cross-Cutting Issues 4 Table 1: Fulfillment of Objectives Objectives Met, Not Met, Exceeded Comments/Sources I Collect materials, experiences, I Workshop Report and lessons on advocacy in Met African and elsewhere for the purpose of influencing pol icy ,, Produce a training manual on advocacy Met An Introduction to Advocacy Field test the manual at two I advocacy training workshops in Met Trip Reports Africa Train a cadre of reproductive Met Trip reports health professionals alert to the linkages between research and policy Products -A 130-page manual, An Introduction to Advocacy: Training Guide, was produced by SARA. What complementary efforts have contributed to the results of this activity? The An Introduction to Advocacy has been translated into Spanish and Arabic by the Policy Project, supported by the Futures Group, CEDPA and RTI. What results have been achieved to date? The Guide filled a gap felt by many public health groups in Africa. There is wide recognition of the importance of advocacy to promote policy and programmatic changes, but misconceptions about the advocacy process and lack of experience in organizing and conducting advocacy efforts have constrained organizations from promoting their agendas. The response to the Guide has been positive. Several African organizations have adapted it to meet a demand for training in advocacy. Also, the process described in the Guide has been adopted by NGOs for their application. Understanding the problem An Introduction to Advocacy provides a step-by-step guide, with numerous examples and I I • • • practical exercises, for developing and implementing an advocacy campaign around one or more public health issues. The guide seeks to demystify advocacy and present effective advocacy as a problem-solving exercise (or set of exercises). Alternative solutions An Introduction to Advocacy is one of the Cross-Cutting Issues 5 Changes in Policies and Programs ·1be process of policy and progr.un change involves the interaction of describing problems, identifying solutions. and advocacy. very few practical guides that explains the advocacy process within the context of policy change. By breaking do·wn the process into planning steps, the guide makes the process familiar and less intimidating to users who often have an image of policy advocacy as something that occurs only with senior decision makers. Advocacy The guide has been used in several advocacy training workshops to develop the expertise of health research professionals to the linkages between research and policy. Feedback from participants. many of whom were project managers in governmental or quasi-governmental organizations, indicated that they would use the material to promote new program ideas or program directions within their organizations or through a government agency. As yet, however, there has been no clear advocacy connected with or arising from use of An Introduction to Advocacy and the process outlined. Changes in Policies and Programs CERPOD has changed its approach to research presentations as a result of the guide. Capacity Building Informal use of the guide in the field has been reported by a number of people. Unfortunately, the extent of its use is impossible to track. In May 1996, an eight-week long workshop on the male role in fertility, family planning and reproduction was held in Dakar, Senegal. Thirty-six participants attended the workshop from Burkina Faso, Cameroon, Cote d'Ivoire, Central African Republic, Ghana, Haiti, Kenya, and Senegal. The participants represented African government agencies, such as Ministries of Health, and quasi-governmental health organizations. Two trainers from ACI and one trainer from the Goree Institute were trained in using the advocacy guide and they, in tum, used the guide to train participants in the workshop during a three-day training of trainers session. Cross-Cutting Issues 6 In October 1996, a five-day regional advocacy-training workshop was held in Bamako, Mali. • The workshop was initiated by SARA and attended by CERPOD staff and members ofthe Reproductive Health Research Network from Burkina Faso, Cameroon, Cote d'Ivoire, Guinea, Mali, Niger, and Senegal. SARA used the meeting to train CERPOD staff while testing the An Introduction to Advocacy. What lessons have we learned from this activity? • Preparation of a practical training guide without extensive field research is feasible if previous experiences and materials are reviewed and if a clear target audience is defined before writing. • While the guide can be used as a stand-alone tool, training in the advocacy methods outlined in the guide significantly adds to its value. In addition, the provision of resources for national or local groups to organize advocacy efforts and follow up TA are essential to sustainability. • Need for the guide is great in Africa. However, it needs to made adaptable to cross￾cultural and cross sectoral situations. • There needs to be a follow-up questionnaire distributed in the field in order to better track • use of the guide. What are the next steps to capitalize on the activity? • A guide for trainers to complement the An Introduction to Advocacy is in development. This guide will be designed to enable trainers to present a consistent, complete progression through each of the An Introduction to Advocacy's modules. • SARA consider preparation of a complementary tool on the process of adapting and synthesizing research findings for use in policy advocacy efforts. • SARA consider assessing in greater depth than this assessment the outcomes of the training activities conducted with An Introduction to Advocacy. • Cross-Cutting Issues 7 Resources Consulted Written An Introduction to Advocacy: Training Guide. SARA: Washington, DC, 1995. Report: SARA Advocacy Workshop (Washington, DC: August 3, 1995). "Trip Report: SARA Advocacy Training at the DHS/Macro!WHO-Sponsored Workshop on 'The Male Role in Fertility, Family Planning, and Reproductive Health."' (Dakar, Senegal: May 21-31 , 1996). "Trip Report: SARA Advocacy Training Workshop on Adolescent Reproductive Health." (Bamako, Mali: October 14-18, 1996). Informants Renu Bary, AED/SARA Ritu Sharma Lalla Toure, AED/Morehouse Taly Valenzuela, The Futures Group Prepared by SARA: Arin Farrington Latest Revisions: July 1, 1998 . . , • •