USAID/BRAZIL
Mid-Term Evaluation of IMPACT/FHI, IMPACT/MSH,
Pathfinder do Brasil, and DKT do Brasil
Prepared by:
The Synergy Project
TvT Associates, Inc.
James Sitrick, Jr.
Ann Lion Coleman
John Novak
May 2001
Acknowledgments
The USAID/Brazil Mid-Term Evaluation Team wishes to thank the staff of the Coordenação
Nacional DST/AIDS, as well as the staff of the STD/AIDS programs in the states of São Paulo,
Rio de Janeiro, Bahia and Ceará and the Municipalities of São Paulo, Rio de Janeiro, Salvador
and Fortaleza for having been helpful, generous with their time, and receptive to the idea of this
midterm assessment. In addition, we wish to thank the staff of the Coordenação Nacional de
DST/AIDS in Brasilia for sharing their opinions regarding where and how assistance from
USAID Cooperating Agencies is most needed. In every interview, staff answered all questions
with enthusiasm and candor. Without their collaboration, the effort would have been less rich
and valuable.
The team thanks Family Health International, Management Sciences for Health, and Pathfinder
do Brasil managers and staff for the significant efforts they put into preparing for our visit.
Documents were prepared in advance and others were made available as soon as they were
requested. Staff also helped with preparations for the visit, organized the schedule of meetings
with their partners, and could not have been more open to discuss any and all aspects of their
programs. They were very professional and cooperative in sharing information on their
programs with team members.
We thank the entire staff of DKT do Brasil in São Paulo, who dedicated an enormous amount of
time providing information and preparing more materials about DKT and its social marketing
programs in Brazil than one would ever hope to read. In addition, we thank the staff of the
Coordenação Nacional de DST/AIDS in Brasilia, as well as those who work in the STD/AIDS
program in the municipality of São Paulo, all of whom were generous with their time and open to
speaking both about DKT do Brasil and how social marketing fits in with their programs.
We thank all of Pathfinder’s partners from the municipal and state health posts and HIV/AIDS
prevention programs in Bahia and Ceará who took time from their duties to speak with us about
their jobs, their work with Pathfinder do Brasil, and the problems they face daily dealing with
STI/HIV/AIDS in their communities. Staff members of several NGOs that received support from
Pathfinder in the past were also helpful. We also thank staff of the NGOs that receive support
through DKT do Brasil, in particular: Murilo Mota of GAPAAR in Rio de Janeiro for arranging
for the team to attend a performance of the youth-run street theatre troupe he has organized in the
favela of Rocinha; Daisuke Onuki of JICA; and Márcia Martins of Aliança Luz in Ceará.
We thank USAID staff in Washington and Brazil; they were available to verify facts, arrange
appointments, and shed light on all questions posed to them throughout this assignment. Finally
we thank the Synergy/TvT staff, particularly Lori Salins, who tirelessly responded to all
technical, administrative and logistics needs during this evaluation, and did a tremendous amount
of work to make the trip a great deal easier than it otherwise might have been.
Additional copies of this report may be obtained by writing to:
1101 Vermont Avenue, NW Suite 900
Washington, DC 20005
(202) 842-2939
(202) 842-7646 (Fax)
e-mail at tvt@tvtassociates.com
web site: www.synergyaids.com
TABLE OF CONTENTS
Page
EXECUTIVE SUMMARY ..................................................................................................... i
I. INTRODUCTION
1.1 Purpose of Evaluation...................................................................................... 1
1.2 Methodology ................................................................................................... 1
II. BACKGROUND....................................................................................................... 2
III. IMPACT (FHI/MSH) ................................................................................................ 5
3.1 Background ..................................................................................................... 5
3.2 Management and Technical Assistance............................................................ 6
3.3 Key Findings and Recommendations............................................................... 11
IV. PATHFINDER DO BRASIL ....................................................................................... 17
4.1 Background ..................................................................................................... 17
4.2 Management and Technical Assistance............................................................ 18
4.3 Key Findings and Recommendations............................................................... 19
V. DKT DO BRASIL.................................................................................................. 22
5.1 Background ..................................................................................................... 22
5.2 Management and Technical Assistance............................................................ 22
5.3 Key Findings and Recommendations............................................................... 23
VI. FUTURE DIRECTIONS ............................................................................................27
APPENDICES
A. LIST OF CONTACTS
B. DOCUMENTS REVIEWED
C. SCOPE OF WORK
ACRONYMS
AIDS I First World Bank loan to Brazil for HIV/AIDS prevention
AIDS II Second World Bank loan to Brazil for HIV/AIDS prevention
APROGE Auto-Avaliação dos Processos Gerenciais (Self Assessment of
Program Management)
ASPLAV Assessoria de Planejamento e Avaliação (Planning and Evaluation Unit,
Brazilian Ministry of Health)
BCC behavior change communication
BCI behavior change intervention
CA cooperating agency
CETAD Centro de Estudos e Terapia do Abuso de Drogas (Center for the Study
and Treatment of Drug Abuse)
CN DST/AIDS Coordenação Nacional da Doenças Sexualmente Transmissíveis e AIDS
(Brazilian Ministry of Health’s STD/AIDS Coordinating Committee)
CSM condom social marketing
DKT do Brasil Brazilian affiliate of DKT International, an international social marketing
firm
FACT Ferramenta de Auto-avaliação de Capacidade Técnica" (Program
Technical Self-Assessment Tool)
FHI/IMPACT Family Health International/Implementing AIDS Prevention and Care
FSN foreign service national; local employee of USAID in overseas Mission
FY fiscal year
GRAPAAR Rocinha Youth Project, Rio de Janeiro
IBRD International Bank for Reconstruction and Development
IC Intervenção Comportamental (Behavioural Change Intervention)
IEC information, education and communication
IR Intermediate Result; a term used by USAID for elements of SO (see
below) that contribute to achievement of an SO
JICA Japan International Cooperation Agency
MOH Ministry of Health
MOST Management Organization Sustainability Tool
MSH Management Sciences for Health
MTCT mother-to-child transmission of HIV; also known as vertical transmission
NACP National AIDS Control Program (see also CN DST/AIDS)
NGO nongovernmental organization
OSC Organizações da Sociedade Civil (civil society organizations, or
nongovernmental organizations)
PACS Programa de Agente Comunitário de Saúde (Community Health Agents
Program)
PEDEP Planejamento Estratégico Decentralizado e Participativo (Decentralized
and Participatory Strategic Planning)
POA Plano Operacional Anual (Annual Operational Plan required by World
Bank for operating units that seek funding from the World Bank’s AIDS II
loan to Brazil)
PSF Programa Saúde da Família (Family Health Program)
RH reproductive health
SO Strategic Objective, a USAID term to describe the overarching goal in a
specific technical area
STD sexually transmitted disease
STI sexually transmitted infection
TOT training of trainers
UNAIDS Joint United Nations Programme on HIV/AIDS
UNESCO United Nations Educational, Scientific and Cultural Organization
USAID United States Agency for International Development
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EXECUTIVE SUMMARY
The team finds that overall, the current USAID/Brazil Strategic Objective 3 (SO3) for HIV/AIDS
prevention remains relevant and useful. Under the mandate of Intermediate Result 1, Family
Health International (FHI) and Management Sciences for Health (MSH), through the
Implementing AIDS Prevention and Care (IMPACT) Project, have successfully strengthened
managerial and technical skills among HIV/sexually transmitted disease (STD) programs at the
state and municipal levels. Under the mandate of Intermediate Result 2, Pathfinder do Brasil has
established excellent working partnerships with municipal and state officials in integrating and
improving HIV/AIDS/STD services in 20 state and municipal health posts in Bahia and Ceará,
two northeastern states of Brazil, to prevent the spread of HIV and other STDs. Under the
mandate of Intermediate Result 3, DKT do Brasil has accomplished its goal of increasing access
to high quality, affordably priced male condoms among target groups and has also been
successful in introducing the female condom to Brazil.
This summary highlights the evaluation’s principal findings and contains some recommendations
regarding future activities.
Overall Findings for Intermediate Result 1:
· For a number of historic and situational reasons, USAID cooperating agencies (CAs) to date
have not undertaken any strategic or concerted efforts to strengthen Brazil’s HIV/AIDS
programs at the national level. At present, the timing is ripe to redirect the exclusive focus
thus far on state and municipal programs and to begin to work more closely with the Ministry
of Health’s National AIDS Coordinating Committee (Coordenacao Nacional da Doencas
Sexualmente Transmissiveis e AIDS - CN DST/AIDS).
· As a result of decentralization efforts, funded in part first by the World Bank AIDS I and
subsequent AIDS II loans, the roles of each of these three levels (national, state, municipal)
of the national program are now being questioned and changed. Consequently, CN
DST/AIDS recognizes a need for improved managerial and strategic thinking. The timing
for implementing the Self-Assessment of Program Management Tool, APROGE (Auto￾Avaliacao dos Processos Gerenciais), developed by IMPACT/MSH therefore has been ideal.
The APROGE management tool has been accepted and used at the 10 sites, and is being
requested at the national level as well.
· IMPACT/FHI has labored industriously to strengthen the technical skills at the same four
state and six municipal HIV/AIDS programs targeted under MSH's program. All sites have
used the Program Technical Self-Assessment Tool, FACT (Ferrmamenta de Auto-avaliacao
de Capacidade Tecnica). The results of these assessments determined the content of seven
technical courses offered thus far to staff at all 10 sites. These efforts, however, have
received mixed reviews. Several sites questioned the need for FACT. The follow-on
technical courses, which apparently have been well received, are performed outside the
parameters of the national training system. Both of these FHI efforts are therefore unlikely to
be sustainable over the long term. Also noteworthy was the inability of CN DST/AIDS to
describe the concepts or purpose behind FACT. Without their support, these efforts are not
sustainable, even if they were designed to be so.
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· Representatives of the national program identified as yet unmet, yet vitally important
technical national needs. Specifically, they mentioned the lack of a functional national
HIV/ STD surveillance system and requested technical assistance in this extremely vital area.
Overall Findings for Intermediate Result 2:
· Pathfinder do Brasil's activities meet existing needs and successfully address both
USAID/Brazil’s Strategic Objective 3 and Intermediate Result 2.
· Pathfinder do Brasil’s activities to integrate STD/HIV service delivery have been
implemented well; all sources, both anecdotal and written, show both an increase in the
demand for and an improvement in the quality of the STD/HIV services delivered by
Pathfinder-trained health post staff.
· Pathfinder do Brasil has been unusually successful in its efforts to establish excellent
relations with its Brazilian partners at both municipal and state levels.
· State and municipal authorities and health post staff trained by Pathfinder do Brasil
understand and agree on goals and future priorities for Pathfinder do Brasil. There was
surprising unanimity shown for not only continuing but expanding this program further.
· USAID/Brazil’s support for training and improving the quality of service delivery at state
and municipal levels by Pathfinder do Brasil dovetails extremely well with the current
decentralization process underway by the Ministry of Health, which is devolving
responsibility for providing health care, including STD/HIV/AIDS, to local authorities.
· The indicators currently used to report on its progress in many cases do not reflect either the
magnitude or the success of Pathfinder do Brasil’s activities.
· USAID/Brazil’s direct funding of Pathfinder do Brasil during the past year has reduced
operational difficulties inherent in funding Pathfinder do Brasil though USAID/Washington
centrally funded programs.
Overall Findings for Intermediate Result 3:
· DKT carries out condom social marketing (CSM)–marketing and selling male condoms
priced and distributed in ways that make them accessible and affordable to low income
consumers. DKT also promotes and sells the female condom at cost, and has exceeded its
sales targets for this product.
· DKT has contributed to the recent growth of the condom market in Brazil, and has worked
to lower the cost of condoms to consumers by supporting activities that reduce taxes on
condoms and condom sales.
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· Between 1991 and 2000, condom sales in Brazil grew from 50 million units per year to more
than 300 million. During this time, DKT's share of this market increased from 0.8% to more
than 17%, while the average cost of a condom in Brazil has decreased by 40% in real terms.
· DKT works closely with local nongovernmental organizations (NGOs) and USAID CAs to
prevent AIDS in Brazil. Its collaborative activities include providing condoms, supporting
NGO activities that target hard-to-reach populations, advising public sector HIV/AIDS
programs about CSM and working to increase awareness of the importance of condom use in
preventing HIV transmission.
· DKT has achieved greater financial sustainability in less time than was anticipated. USAID
support of DKT therefore has represented an extraordinarily successful leveraging of funds.
Overall Recommendations for Intermediate Result 1:
· Shift CAs to a role of “system strengtheners” that build replicable skills. CAs currently are
viewed more as program implementers than providers of technical assistance.
· Refocus CAs to view CN DST/AIDS as their primary partner, and better coordinate their
efforts with those of the national program.
· FHI should make FACT II and all further FACT applications optional and do not link them
to APROGE.
· FHI should work with both CN DST/AIDS and the state training commissions to assure that
technical knowledge and skill deficits are addressed by existing systems, rather than develop
new courses.
· FHI should work closely with CN DST/AIDS to shift the overall emphasis away from FACT,
offer technical courses that improve national HIV/STD surveillance, and provide technical
assistance to strengthen STD diagnosis and treatment.
· MSH should continue local efforts with emphasis on leaving the operating units more self￾sufficient and able to replicate efforts elsewhere.
· MSH should work more closely with CN DST/AIDS to address local operating unit needs
and work on making CN DST/AIDS the real leader and provider of technical assistance.
· USAID should work closely with CN DST/AIDS to assist it with the transition prior to the
phasing out of World Bank resources and to plan for sustainability thereafter.
· USAID should reevaluate funding MSH through IMPACT.
· USAID should hire an STD/HIV/AIDS coordinator to oversee and coordinate the Mission’s
expanding role in HIV/AIDS prevention in Brazil. In addition, USAID could facilitate its
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relations with Brazilian government agencies by hiring a Brazilian Foreign Service National
to work on HIV/AIDS-related issues.
Overall Recommendations for Intermediate Result 2:
· USAID should continue to support Pathfinder do Brasil’s programs in Brazil and expand
their scale by broadening their geographic focus.
· USAID/Brazil should provide financial resources and technical assistance to identify and put
into place indicators that would capture better the impact of Pathfinder do Brasil’s activities.
· Pathfinder do Brasil should work with USAID/Brazil and the other SO3 CAs to establish a
closer working relationship with CN DST/AIDS in Brasilia.
· USAID should review CN DST/AIDS statement of interest in replicating Pathfinder do
Brasil's activities nationally and in incorporating such activities under its system of provider
training.
· Pathfinder do Brasil’s training activities in Northeastern Brazil have contributed significantly
to improving the quality of STI/HIV/AIDS service delivery in two states and should be
expanded to additional municipalities and other states.
· The Mission should request technical assistance to improve its indicators for Pathfinder do
Brasil and for its other HIV/AIDS indicators so that they demonstrate clearly the impact
USAID programs have on HIV incidence in Brazil.
Overall Recommendations for Intermediate Result 3:
· USAID should continue to support DKT do Brasil’s CSM programs in Brazil and fund DKT
to expand its geographic scope to cover additional states.
· USAID should continue funding DKT do Brasil to work with NGOs in condom promotion
and to provide additional technical assistance in CSM to NGOs and the public sector.
· DKT do Brasil should establish a closer working relationship with CN DST/AIDS in
Brasilia, which has shown interest in learning more about CSM and how it works.
· Additional USAID resources are needed to assist DKT do Brasil’s work with its partners to
support further and permanent reductions in taxes on condoms in Brazil.
· The Mission should explore alternative mechanisms to fund DKT do Brasil that do not make
it necessary to pay interest on borrowed funds while awaiting the annual USAID funds.
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I. INTRODUCTION
1.1 Purpose of the Evaluation
The overall objective of this mid-term evaluation was to assess the mid-term progress achieved
toward expected results for the Intermediate Results (IR) under Strategic Objective 3,
 "Increased sustainable and effective programs to prevent sexual transmission of HIV
among major target groups", viz:
IR1: Strengthened institutional capacity to plan, implement and evaluate sexually transmitted
disease (STD)/HIV programs
IR2: Strengthened institutional capacity to conduct in-service training to implement quality
integrated reproductive health (RH) and STD/HIV services in Bahia and Ceará
IR3: Sustainable condom social marketing (CSM)
The evaluation assessed the overall accomplishment of the U.S. Agency for International
Development (USAID) Strategic Objective 3 (SO3/HIV/AIDS) program in Brazil to date and the
appropriateness of the project strategy in order to make recommendations for improvements,
expansions to and/or new activities in the HIV/AIDS prevention arena for implementation during
the next few years. The evaluation also examined the adequacy of the current indicators, the data
collection and monitoring systems, the tools and methods used to provide technical assistance to
achieve SO3 goals. Finally, the evaluation examined the technical assistance and training
provided by USAID/Brazil's implementing partners to SO3 customers (i.e., State and Municipal
Health Secretariat, Brazil Ministry of Health (MOH) AIDS National Coordination,
nongovernmental organizations (NGOs) involved in AIDS prevention).
1.2 Methodology
The evaluation team was composed of three members: an HIV/AIDS program evaluation
specialist/team leader, a program management and evaluation specialist, and a program
monitoring and implementation specialist. Field work was carried out in two phases, with the
DKT do Brasil and Pathfinder do Brasil assessments conducted over 3 weeks in September and
October 2000, and the Family Health International (FHI) and Management Sciences for Health
(MSH) assessments conducted over 3 weeks in October and November 2000. Steps included:
a) A review of the enhanced scope of work, project documents, project papers and reports, and
studies and research papers related to the HIV/AIDS situation in Brazil was carried out prior
to the beginning of the evaluation and throughout the evaluation process.
b) Group and individual meetings and interviews were conducted with the following: Synergy
Project staff, USAID Latin America/Caribbean (LAC) Bureau and HIV-AIDS Division staff
in Washington, DC; USAID/Brazil staff in Brasilia; senior officials from the MOH and
National AIDS Committee in Brasilia; Joint United Nations Programme on HIV/AIDS
(UNAIDS) and United Nations Educational, Scientific and Cultural Organization (UNESCO)
officials in Brasilia; State Health Secretariat and Municipal Health Secretariat officials in São
Paulo, Rio de Janeiro, Ceará and Bahia; and the implementing agency staff in all four states
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and Brasilia.
These meetings and interviews focused on project performance to assess whether
interventions were effectively applying strategies, whether the approach and strategies used
were effective in integrating HIV/STD components into various levels of RH care and related
health sectors, whether efforts were being made to create effective partnerships, and if
capacity building was taking place.
c) Debriefings were conducted at the presentation of the draft reports to USAID/Brazil.
d) Debriefings were also conducted at Synergy, with regular coordination on follow-up redrafts
submitted to USAID for review and comment and distribution to the implementing partners
for review and comment. Final revisions incorporated all comments.
A list of contacted individuals and institutions is included in Appendix A of this report.
II. BACKGROUND
The evaluation of the first International Bank for Reconstruction and Development (IBRD) loan
to the Government of Brazil for HIV/AIDS prevention (AIDS I) found that most STD/AIDS
prevention programs in Brazil had developed good techniques, either through adapting other
countries' experiences or creating new approaches according to Brazil's standards. However, the
same evaluation also detected management weaknesses in state and municipal STD/AIDS
programs and recommended that these programs need to improve their autonomy and
institutional sustainability, in addition to learning how to make best use of available resources.
During the development phase of the second IBRD loan (AIDS II), in-depth discussions took
place on ways to address the above issues, as well as on the monitoring and evaluation of these
activities. As a result of active participation in those discussions, USAID/Brazil developed a
5-year AIDS prevention strategy (SO3) for "Increased sustainable and effective programs to
prevent sexual transmission of HIV among major target groups."
The proposed strategy for AIDS programming is consistent with the overall USAID Goal 4,
"World population stabilized and human health protected" and the USAID Strategic Support
Objective for HIV/AIDS (SSO4), "Prevent HIV transmission and mitigate the impact of the
HIV/AIDS pandemic." USAID/Brazil's strategy specifically relates to four of the six
Intermediate Results under SSO4:
ß Increased quality, availability, and demand for information and services to change sexual
risk behaviors and cultural norms in order to reduce transmission of HIV;
ß Enhanced quality, availability, and demand for sexually transmitted infection (STI)
prevention and management services;
ß Improved knowledge about, and capacity to address key policy, cultural, financial and
other contextual constraints to preventing and mitigating the impacts of HIV/AIDS; and
ß Strengthened and expanded private sector organizations' responses in delivering
HIV/AIDS information and services.
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Brazil's AIDS prevention programming is dominated by the national program, which was
supported initially by a $160 million World Bank loan and $90 million counterpart funding from
1993 to 1997 and is currently supported by a second 4-year World Bank loan for a total of $300
million, with $165 million in World Bank funds and $135 million in federal and state funding.
USAID's comparative advantage in this situation is to provide access to technical assistance,
which can be applied in the large national/state/municipal programs. The Government of
Brazil's strategy for controlling HIV/STI lists three goals:
1. Reduce the incidence of HIV/AIDS among vulnerable populations and those at high risk
of infection, with priority on women, low-income populations, adolescents, indigenous
populations, and drug users.
2. Improve the quality of services offered to persons living with HIV/AIDS.
3. Strengthen public and private institutions dedicated to STI/HIV/AIDS prevention
activities.
USAID/Brazil's strategy contributes to the first and third objectives of the Government of Brazil
program.
Initially, four strategic objective-level indicators were selected:
· Number of target states with greater than a 5% increase in expenditures of HIV prevention;
· Number of effective interventions adopted by USAID-funded and non USAID-funded
programs;
· Percentage financial sustainability of condom social marketing programs; and
· HIV incidence among military draft registrants.
These were subsequently revised in FY1999 and currently include four new indicators:
· Number of programs/organizations demonstrating low, medium and high levels of
effectiveness in planning and implementation;
· Number of programs/organizations demonstrating low, medium and high levels of
effectiveness in evaluation;
· Number of target programs achieving or maintaining low, medium and high levels of
expenditure of allocated funds from the loan for HIV/AIDS; and,
· Percentage of financial sustainability achieved by DKT of Brazil CSM.
Currently the Mission supports four cooperating agencies (CAs): FHI, MSH, DKT do Brasil and
Pathfinder do Brasil. Previously, from 1992 through 1997, support for HIV/AIDS prevention
was channeled through a single umbrella project, AIDSCAP, which carried out a wide variety of
activities in prevention; information, education and communication (IEC); social marketing; and
policy change in the four states (São Paulo, Rio de Janeiro, Seara and Bahia) that the Mission
designated as high priority for HIV/AIDS prevention program interventions.
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The present country strategy calls for each CA to implement its HIV/AIDS activities
independently, with responsibilities for reporting results assigned for each of the Intermediate
Results (IRs), as follows:
IR 1: "Strengthened institutional capacity to plan, implement and evaluate STI/HIV
programs" - FHI and MSH
The IR indicators selected were:
1. Number of programs demonstrating low, medium, and high levels of technical capacity in
planning, implementing, monitoring and evaluation;
2. Number of organizations showing increased capacity to manage STI/HIV/AIDS
programs;
3. Proportion of consultants providing technical assistance through the USAID strategy who
are Brazilians.
IR 2: "Strengthened institutional capacity to conduct in-service training to implement
quality integrated RH and STI/HIV services in Bahia and Ceará" - Pathfinder do
Brasil
The indicators selected were:
1. Number of central-level institutions with capacity to conduct in-service training to implement
quality integrated STI/HIV prevention and RH services;
2. Number of central-level institutions with capacity for monitoring quality, integrated
STD/HIV prevention and RH services;
3. Number of program health units with capacity to provide quality, integrated STI/HIV
prevention and RH services;
4. Percentage of the program health units implementing monitoring and evaluation tools for
quality, integrated STI/HIV prevention and RH services.
IR 3: "Sustainable condom social marketing" - DKT do Brasil
The indicators selected were:
1. Percentage of sales of DKT do Brasil male condoms;
2. Percentage growth of DKT do Brasil female condom sales
Intermediate Results 1 and 2 under the new strategy have focused on providing technical
assistance and training to different public sector entities, and some nongovernmental
organizations (NGOs). This strategy was presented formally to, and accepted by, the MOH
National AIDS Coordinating Committee, CN DST/AIDS (Coordenacao Nacional da Doencas
Sexualmente Transmissiveis e AIDS) in mid-1998. 
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III. IMPACT PROGRAM (Family Health International/Management Sciences for
Health)
3.1 Background
The Synergy Evaluation Team spent the better part of 3 weeks in Brazil and interviewed staff
from eight of the ten state and municipal STD/AIDS programs that currently receive USAID￾funded technical assistance through IMPACT. In addition, the team met with USAID/Brazil
personnel who oversee the implementation of SO3, as well as with most of the principal actors
from the two CAs that work with resources from USAID/Brazil through the IMPACT project.
Finally, the team spent almost an entire day with Ministry of Health CN DST/AIDS officials to
determine their knowledge of IMPACT and their interest in continuing to work with FHI and
MSH. The team met with several key officials whose opinions matter greatly with regard to the
implementation of USAID’s Intermediate Result 1, and whose support is essential if such
activities are to continue in the future.
Since the end of AIDSCAP in 1997, USAID/Brazil has funded IMPACT, whose prime
contractor is FHI, with MSH as a subcontractor. Under the IMPACT Program, FHI and MSH
together have the responsibility for achieving the Mission’s Intermediate Result 1:
“Strengthened institutional capacity to plan, implement and evaluate STI/HIV programs.”
The current strategy was drafted in mid-1997 and approved in December 1997 by USAID's
Bureau for Latin America and the Caribbean. As originally approved, the strategy directed
IMPACT, under Intermediate Result 1, to provide technical assistance to the Brazil Mission –
and to the Ministry of Health – in identifying and disseminating the most effective HIV/AIDS
program interventions in Brazil. This IR also included funding for technical assistance to the
Ministry to improve its capacity to monitor and evaluate programs and to improve information,
education and communication (IEC) activities, both of which the World Bank identified in its
evaluation of AIDS I as areas requiring significant improvement.
The new USAID/Brazil strategy was presented formally and accepted by the Ministry of
Health’s National AIDS Coordination Committee (CN DST/AIDS) in mid-1998. At the
beginning of IMPACT, FHI executed a subagreement with its former AIDSCAP Country Office,
by then an independent NGO, Associação Saúde da Familia (ASF), for the implementation and
management of the IMPACT program in Brazil. This arrangement was discontinued in late 1998.
However, FHI continues to collaborate with ASF on other non-USAID activities. Subsequently,
FHI decided to establish representation in Brazil and at that point a Resident Advisor was
recruited and an office opened. FHI do Brasil was legally registered and incorporated as a local
NGO in Brazil in late 1999.
In late 1998 and early 1999, FHI recruited a country representative in Brazil, opened a new
country office and changed the direction of its activities from disseminating lessons learned to
strengthening technical capacity. This meant that FHI initiated its programmed activities almost
a year later than originally planned. MSH, which had signed a subcontract with IMPACT/FHI in
early 1998, began to implement its activities in June 1998.
MSH’s expertise and extensive experience in improving managerial capacity make it a natural
6
partner for FHI in Brazil for strengthening management capability in priority states and selected
municipalities. MSH’s role under IMPACT is to provide tools and technical assistance to the
selected target areas to improve management of the operating units in HIV/AIDS prevention. By
improving the management of these programs and their staffs, MSH hopes to increase program
effectiveness and sustainability, and therefore, improve overall program impact. This approach
complements FHI’s work, which emphasizes updating and expanding technical knowledge at the
operational level to improve the technical capability of the same operating units.
USAID selected the states of Rio de Janeiro, São Paulo, Bahia and Ceará as priority areas for its
HIV/AIDS prevention programs, and included four municipalities in these states’ capitals. Two
other municipalities in São Paulo state were added, one of which, Santos, is Brazil’s principal
port city–the site of one of AIDSCAP’s most successful interventions. Thus, a total of 10
STD/AIDS programs in four states and six municipalities were selected under the IMPACT
program.
When FHI/IMPACT opened its offices in Brasilia in 1999, USAID anticipated that IMPACT’s
role would be enhanced as the primary coordinator of USAID-funded activities in Brazil with
CN DST/AIDS. The coordinating role was extremely important to USAID, and was one of the
reasons IMPACT chose to base its operations in Brasilia. As the lead CA, it was also expected
that IMPACT would maintain a close working relationship with the Mission. This became even
more important as staff changes at CN DST/AIDS, FHI and USAID/Brazil made it essential to
ensure continuity among the working partners.
As the lead CA and recipient of the greatest level of Mission HIV/AIDS funding, FHI is also
charged with reviewing the workplans and semiannual reports of the other CAs in Brazil and
preparing a consolidated workplan and semiannual report for submission to USAID/Brazil for
review and approval.
MSH/IMPACT was subcontracted to improve the management of the 10 selected municipal and
state STD/HIV/AIDS programs. In addition, MSH was asked to work on management issues
with CN DST/AIDS. For this purpose, FHI issued a task order for MSH to carry out a series of
activities. The initial task order was for one year, from June 1998 through May 1999, with a
budget of US$ 200,000. It was subsequently extended until September 2000, and funding
increased by US$ 250,000. Since October 2000, MSH has been working with a new task order,
funded at US$ 450,000, which is scheduled to end in September 2001.
3.2 Management and Technical Assistance
Family Health International (FHI)
FHI has played a significant role in Brazil's HIV/AIDS prevention activities for over a decade
and was seen as the agency to provide a leading, proactive technical role in the Mission’s
STD/HIV prevention efforts. Under AIDSCAP, FHI’s role included disseminating best practices
as well as technical assistance to CN DST/AIDS in monitoring, evaluation and strategic
planning. Following the subsequent negotiations between USAID/Brazil, CN DST/AIDS and the
other CAs, FHI shifted its emphasis from the dissemination of best practices to coordinating the
program monitoring and evaluation and strategic planning efforts in partnership with MSH. In
7
addition, FHI seeks to strengthen the technical capacity in the nine sites in which it is currently
working. A tenth state, Rio de Janeiro, will be added in the current fiscal year. FHI’s Annual
Workplan (FY 2001) also includes efforts to strengthen the sustainability of NGOs working in
AIDS.
Ideally, other CAs would look to FHI as the source for leading edge technical expertise in
HIV/AIDS activities. In the year and a half that the new FHI representative has been in place, a
significant amount of work has been accomplished. He has adapted/developed the Program
Technical Self-Assessment Tool, or FACT (Ferrmamenta de Auto-avaliacao de Capacidade
Technical), applied it in nine locations and contracted for seven weeklong workshops. He has
been highly productive, is extremely organized and is highly knowledgeable and able to present
FHI’s work.
FHI should be viewed as an important technical resource to the national HIV/AIDS program.
Some USAID CAs see FHI as doing a fine job of sharing technical reports and other technical
information as it becomes available. However, the nine sites have not benefited equally from
FHI as a sharer of technical resources. CN DST/AIDS is not particularly clear on what FHI’s
role is or what its technical strengths are. CN DST/AIDS staff identified several areas in which
they could use technical assistance, but were not clear as to what assistance they could obtain
from FHI.
Many technical areas for which FHI is world-renowned, and from which Brazil could benefit, do
not appear to be emphasized by FHI under IMPACT in Brazil. Among them are STD reporting
systems and HIV surveillance and reporting systems, which were mentioned numerous times in
the various interviews carried out by the evaluation team. These are significant areas of
weakness in the AIDS program, and they are areas in which FHI has led the way technically in
other countries.
Development and Use of FACT (FHI)
FHI has developed a program technical self-assessment tool known as FACT. This tool is based
on a technical tool developed by FHI/Arlington and the self-assessment of program management
methodology of the MSH-developed APROGE (Auto-Avaliacao dos Processos Gerenciais)
instrument. FACT measures capacity in the following eight technical areas:
· Behavioral change and prevention of sexual transmission
· STD control and prevention
· Barrier methods and prevention of sexual transmission
· Intravenous drug use harm reduction
· Prevention of vertical transmission
· Voluntary testing and counseling
· Support referral
· Epidemiology and supervision
8
FACT has been implemented in nine sites, and the tenth was scheduled for implementation in
December 2000. The second round of FACT assessments was scheduled to begin in February
2001.
As each site finishes its initial diagnostic effort (FACT I), it develops an action plan to
strengthen the areas identified by FACT as in need of improvement. As FHI completed the first
phase of FACT efforts, several common needs appeared at several sites. To address the areas
identified, FHI developed a number of weeklong training courses. FHI staff subcontracted local
technical experts to design and carry out eight workshops. Seven courses have been completed,
and the timing and emphasis of the last course, on Epidemiological Surveillance, is still under
discussion with CN DST/AIDS.
The seven workshops completed to date have addressed the following topics:
1. Design, Implementation and Evaluation of STD/AIDS programs
2. Harm Reduction and Intravenous Drug Use
3. Supervision and Monitoring of AIDS Prevention Activities
4. Counseling and Testing
5. Condom Social Marketing
6. Evaluation of IEC Programs
7. Evaluation of Behavior Change Initiatives.
For each course, participant selection criteria are left to the program managers at each of the
sites. The trainers are consultants hired both to design and conduct the course, with a consultant
hired exclusively for course follow-up. All sites are invited to send a limited number of
participants to each course.
Training Courses
The choice of courses was based on the technical needs most often identified from the nine
FACT assessment efforts carried out. FHI contracted consultants to develop and conduct the
courses and is now hiring a consultant to oversee the implementation of the resulting workplans.
The majority of participants interviewed enjoyed attending the courses, felt that the topics were
relevant and that the facilitators were very good. Most interviewed stated that the 2 days set
aside to focus on workplans was helpful and that they benefited from the group approach to
working on workplans. Participants noted that if workplans were produced in every course, as
well as from both FACT and APROGE, each site could produce a total of nine different action
plans as a consequence of its work with IMPACT (one from each of the seven courses, one each
from APROGE and FACT). This seemed overwhelming to some participants, but to others it
was welcome. The latter group included, more often than not, staff from smaller, less mature
programs in which the STD/AIDS coordinator could attend most of the activities and coordinate
plans as they were developed.
Several participants stated that they were not able to attend any or most of the courses owing
primarily to their length. Additionally, virtually all staff working in the public health sector have
at least two, if not three, jobs, thus making attendance at a weeklong course difficult. The cost
was also prohibitive for most participants. It appears that the courses may not have been
designed with the needs of participants in mind. This may account in part for FHI's obligation to
fund participant costs beyond what had been originally contemplated.
9
CN DST/AIDS has signed contracts with hundreds of training centers throughout Brazil to
support STD/AIDS technical training needs At the state level, an STD/AIDS training
commission has been established to identify training priorities for the year. These priorities are
built into annual operational plans. In 1999, more than 3,500 people were trained in more than
150 workshops. It seems clear that the national program has mechanisms through which to
provide large-scale training. While participants were appreciative of the specialized effort put
forth by FHI in the design and implementation of the courses, the question of whether the
courses represent effective use of scarce USAID funds remains open, particularly while the
larger national effort is underway.
Development and Use of APROGE - Management Sciences for Health
To address the need for improved program planning, management and implementation, MSH
adapted an existing management tool it had developed previously for reproductive health
programs. This instrument, the Management and Organizational Sustainability Tool (MOST),
was modified so that it focused specifically on HIV/AIDS programs and the unique set of
challenges they represent for program managers and their staffs. Furthermore, it was revised for
use in Brazil, taking into account the ongoing decentralization process that is devolving
responsibility for day-today management of health care provision to municipal authorities, the
idiosyncrasies of the Brazilian Unified Health System (SUS), and the Portuguese language. This
new instrument is known as APROGE.
MSH developed APROGE, using MOST as a model, in conjunction with a working group that
included staff from CN DST/AIDS, state STD/AIDS program staff from both São Paulo and
Ceará, and municipal STD/AIDS staff from Rio de Janeiro. This group first met in May 1998
and over the course of nine months developed APROGE as an instrument acceptable to all. To
validate APROGE, MSH carried out APROGE on a trial basis with the staffs of the municipal
STD/AIDS program in Campinas (São Paulo) in March 1999 and shortly thereafter with the
Ceará state STD/AIDS program in April 1999.
APROGE assists the program staff, through a highly active and participatory process, to identify
and classify their existing management systems, clarify where the program’s management stands
versus where they would like it to stand, and formulate both indicators of progress and an Action
Plan that will help them to achieve their goals. Among the themes addressed by APROGE were
elaborating or clarifying an agreed mission statement, setting out specific objectives, formulating
a strategy to achieve these objectives, and agreeing upon a program's managerial structure. The
structure of various management systems and their effectiveness was also addressed.
These systems included:
· Strategic planning
· Program monitoring and evaluation
· Requesting sufficient financial resources
· Human Resource Management
· Supply procurement and management
· Financial administration
The initial diagnosis and development of an Action Plan using APROGE I was carried out using
facilitators trained in the use of APROGE. As of October 2000, all 10 target HIV/AIDS
10
programs (six municipalities and four states) have conducted APROGE I and thus have
developed Action Plans that lay out which management improvements they intend to accomplish
during the next year.
Following up on APROGHE I, MSH provided technical assistance to the 10 programs using
Brazilian consultants. The extent of technical assistance required for each location was
determined during the APROGE I exercise, and was viewed as falling into one of three
categories:
· Category I – Program requires no external technical assistance to implement Action Plan.
· Category II – Program requires technical assistance, but no financial resources to achieve
Action Plan goals.
· Category III – Requires both technical assistance and financial resources to achieve Action
Plan goals.
The consultants focused, for the most part, on the systems identified most frequently as needing
improvement. Principal among them were Strategic Planning and Human Resource
Development. Strategic Planning was addressed in coordination with CN DST/AIDS, which has
been working to define and finalize an STD/AIDS strategic planning model applicable to all
STD/AIDS programs in Brazil at the municipal, state, and national levels. Technical assistance
in Human Resource Development was given to the STD/AIDS programs in Fortaleza and
Salvador municipalities and to the state STD/AIDS programs in Ceará, and Bahia. This
assistance included team building exercises as well exercises to better define specific roles and
responsibilities for individuals whose programs contribute to formulating the most effective
response to STD/AIDS. These programs include maternal and child health, and adolescent
health.
One year after APROGE I, MSH facilitators returned to carry out APROGE II. This allowed
program staff to assess progress in terms of management improvement after 1 year of Action
Plan implementation and number of goals met. To date, eight of the ten sites have completed the
APROGE II exercise. Findings included achieving approximately 50% of the goals laid out a
year earlier, which was considered a success for the activity's first year.
NGO Sustainability Study
In Brazil, the NGO movement has played a significant role in the fight against HIV/AIDS and is
viewed by the World Bank as a key contributor to the country's successes in curbing the
epidemic. As such, the NGO sector is vital to the long-term sustainability and effectiveness of
the national HIV/AIDS program. An estimated 500 NGOs are presently working in HIV/AIDS
prevention and mitigation, many of which receive funding from the World Bank via CN
DST/AIDS. As the World Bank’s support through AIDS II winds down over the next 2 years, it
will be increasingly important to focus on improving the managerial and financial sustainability
of key NGOs that work in HIV/AIDS prevention and control. To address this need, CN
DST/AIDS placed considerable importance on assessing the levels of NGO sustainability.
FHI worked with CN DST/AIDS to review proposals to carry out the assessment, and JSI do
Brasil Insituto Promundo was subsequently contracted by FHI to perform the assessment. FHI’s
role in the study was not a technical one. They participated in carrying out the procurement, and
hired another CA to carry out the study. From the evaluation team's perspective, the premises
11
and the methodology were faulty, and the results were not particularly helpful.
3.3 Key Findings and Recommendations
USAID-funded activities are strengthening management systems within the target sites. Sites
with stronger management systems are able to write more effective Annual Operational Plans
(POA - Plano Operacional Annual) for submission to CN DST/AIDS and thus access CN
DST/AIDS/World Bank funding. However, it should not be assumed that an STD/AIDS
program with better management and greater funding will reach target populations with
HIV/AIDS prevention activities better than one that lacks these elements.
Since the profile of HIV/AIDS in Brazil continues to change, the Synergy Evaluation Team
concludes that USAID needs to revisit its current strategy, with en eye toward defining new or
emerging targets of opportunity, in the event that additional HIV/AIDS funding becomes
available. An overview of the trends indicates that the epidemic is “municipalizing,” or
spreading to new interior areas. In the June 2000 MOH Epidemiology Bulletin, the Ministry
reports that 59% of Brazil’s 5,507 municipalities have reported at least one AIDS case. The
Brazilian Northeast is the area experiencing the fastest growth of AIDS cases, and is recognized
as the region whose health infrastructure is least prepared to address this trend. In addition,
HIV/AIDS is found increasingly among both women and heterosexual men, with more than 70%
of new cases being diagnosed among 20-39 year olds.
Prevention programs under the current USAID strategy take place outside of the formal, existing
public health care system. Specifically, working with adolescents on correct and consistent
condom use is a key area that may be best addressed either in schools or through peer
counseling. Adolescent girls in particular run a high risk of contracting HIV, owing to their
biologic vulnerability, lower societal status, and reduced power in relationships. The complexity
of interwoven gender, biological, cultural and economic factors places adolescents at high risk
for HIV infection. The team suggests that USAID look for opportunities to integrate activities
between CN DST/AIDS and the Ministry of Education.
By working nationally with the MOH through CN DST/AIDS, the poorest and most rural
populations, particularly those in the Northeast, will theoretically gain increased access to
improved preventative health care services through USAID-supported management
strengthening efforts. This effort highlights the need for better epidemiological surveillance and
the training of primary health care providers in counselling and testing in STI/HIV/AIDS.
Strengthening Management Systems
MSH had been successful in its Family Planning Management and Development projects using a
managerial assessment tool, APROGE. Participants unanimously applauded the 3-day
workshops and agreed that the timing for carrying out an exercise such as APROGE was
excellent, the time spent was appropriate, the facilitators skilled, and the action plans feasible.
Participants also reported that APROGE results were useful in the development of POAs,
required by the World Bank for operating units that seek funding from the World Bank AIDS II
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loan. CN DST/AIDS also reported that POAs coming from sites that had adopted APROGE were
superior.
Recommendation: MSH should intensify its efforts with CN DST/AIDS, as well as with its
state and municipal counterparts, to adapt the APROGE instrument for use at all three program
levels (national, state and municipal) to complement the UNAIDS strategic planning
methodology, which has been adopted and is being implemented by CN DST/AIDS.
Recommendation: MSH’s objective should be to transfer to CN DST/AIDS the ability to
conduct APROGE and help create a team of trained APROGE facilitators at CN DST/AIDS.
Technical assistance provided by MSH is considered to be of excellent quality and is timely to
site needs and schedules.
Participants at all sites mentioned that technical assistance should continue and be made
available with their institutions. Several participants mentioned that the legal and bureaucratic
limitations imposed by the public sector make hiring a consultant virtually impossible. MSH fills
an important niche for the sites, which they would like to see expanded. For example, it would
be helpful for the sites to know they have a certain number of days of consultant services that
they can use in specific areas, and that they have the right of refusal (even though, so far, all
consultants have been excellent). Some sites recommended a technical resource databank in
which they could pool resources to ease dependence on technical assistance from MSH.
Recommendation: MSH should continue local site efforts with an emphasis on making the
sites self-sufficient and enhancing their ability to replicate these efforts elsewhere.
Recommendation: MSH should work more closely as a partner with CN DST/AIDS to
address local site needs and to make CN DST/AIDS the lead provider of technical assistance.
Recommendation: Materials for using the APROGE tool should be developed and made
available to all 27 States and 150 Municipalities that currently have agreements (convenios) with
CN DST/AIDS to implement activities using resources from the World Bank AIDS II loan.
Recommendation: MSH should respond to technical assistance requests from the 177 sites
and coordinate with CN DST/AIDS to avoid duplication of effort.
FACT has had a mixed experience in its first year. Staff at almost all of the sites visited felt that
their experience with FACT was more complicated than it had been with APROGE. Some of the
more frequently stated reasons included lack of clarity as to FACT’s purpose and how it related
to APROGE. Another factor often mentioned, especially by the more mature STD/AIDS
programs, was that they already had identified their technical weaknesses, and did not need
another tool to identify them. Some less developed programs, however, felt that FACT was
useful in helping them identify their technical needs.
FHI's approach to carrying out technical workshops or courses encountered some difficulty.
Apparent rigidity regarding scheduling dates by FHI made several sites unhappy because they
were unable to send their "best people." They also felt that FACT was "mandated from above"
13
rather than resulting from dialogue and partnership. The word "rigidity" came up in almost all
interviews when discussing FHI. Several sites used the word “cumbersome” (pesado) when
describing their experience with FACT. Many sites objected to FHI's insistence that FACT be
used where APROGE was carried out. When asked what this meant, some sites said that the
instrument itself was tiring and overly lengthy while others said the self-reflection necessary to
go through FACT was difficult.
Recommendation: If FHI seeks to obtain support for FACT in the future, it needs to work to
ensure that CN DST/AIDS understands the purpose of and supports the use of this instrument,
and to counter the view that FACT is peripheral and of little relevance to HIV/AIDS prevention.
Recommendation: FHI should make FACT II and all further FACT applications optional and
not link them to APROGE applications.
Recommendation: FHI should work with both CN DST/AIDS and the state training
commissions to assure that technical knowledge and skill deficits are addressed by existing
systems, rather than developing more courses.
Creation of Effective Partnerships
USAID has undergone significant staff changes since the program was designed in 1997. There
was a change in both direct hire positions, a loss of health expertise within the direct hire staff,
and three FSN staff changes during a 2-year period. This lack of continuity among
USAID/Brazil staff overseeing the HIV/AIDS portfolio has affected priorities, direction, levels
of involvement and effectiveness in dealing with CN DST/AIDS. FHI would prefer to have
more contact and technical direction from USAID, and USAID states they would like more and
better contact with FHI. MSH and USAID seem to communicate better and work more
effectively even though MSH is not based in Brasilia.
Recommendation: Each CA should view CN DST/AIDS as their primary partner, thereby
improving coordination of efforts with those of the national program.
There have been few concerted efforts to institutionalize or strengthen partnerships between the
CAs. The only significant effort has occurred via the semi-annual CA meeting attended by all
CAs. However, the purpose of these meetings appears to be more to inform USAID of activities
and plans than to strengthen coordination efforts. Other less formal efforts take place on a
frequent basis, through phone calls, ad hoc meetings and e-mail communications. The
partnership however, could be stronger and more effective.
The earlier ProQuali effort implemented through a consortium formed by MSH, JHPIEGO and
Johns Hopkins university Center for Communication Programs (JHU/PCC), was considered
successful for many reasons, one of which is that it helped create a lasting partnership. Together,
each partner developed a set of tools to be used by the public sector to improve quality of
services. Each CA contributed in its own areas: management, clinical expertise, and
communications, respectively. The application of these tools has proved difficult since USAID
funding ceased, however.
When asked why the ProQuali partnership worked, MSH gave the following reasons:
14
· Each CA left their organizational identities “at the door.”
· All felt they were equal partners.
· Frequent meetings were held for coordination purposes (every three months).
· A rotating leadership for meetings was instituted.
· All partners were concerned that each receive equal credit for successes.
· Each partner brought its own clear technical advantage to the table.
Virtually none of these factors are present in the existing FHI-MSH partnership under IMPACT.
On the positive side, a healthy partnership was demonstrated when FHI negotiated for Pathfinder
do Brasil to design and give one of the FHI courses in exchange for an MSH workshop for
Pathfinder staff. Overall, however, the partnership as it now stands between FHI and MSH
requires strengthening.
FHI has had mixed results in the lead CA role. FHI identified reporting requirements as a
particularly problematic area. In part, this difficulty is a consequence of changing USAID
reporting formats or requirements, thus requiring that FHI prepare multiple versions of the same
report to satisfy the Mission. This process has been difficult both for FHI and the other CAs
from which it receives reports to pass on to USAID.
MSH is seen as an important technical resource in the field of management. Both FHI and
Pathfinder do Brasil see MSH as leaders in this area and call on them when necessary. CN
DST/AIDS also sees MSH as a technical leader in the management field, and has requested that
APROGE be adapted for its national strategic planning efforts. Several persons interviewed
spontaneously mentioned how well the experts from MSH experts worked as partners.
While MSH feels very positive about the autonomy given to them by FHI in the managerial areas
and recognizes the importance of the management and technical complementarities, the Synergy
Evaluation Team feels that in its present configuration this relationship may contain
irreconcilable differences.
MSH feels that it differs with FHI in its philosophical approach to working in development. This
view manifests itself in a number of small but significant ways. FHI has paid for the airfare and
per diem for many of the participants who have attended the FHI courses, since it became aware
that participants would not have attended without this assistance. This was confirmed by many
of the participants, who stated that the POA had not taken into account the need to cover travel
and attendance at these courses. MSH feels strongly that all participants of courses, workshops or
similar events should have their sponsoring institution cover participant costs. This view has
lead to confusion among the partners as to what guidelines USAID uses in implementing such
activities. Apparently MSH and FHI determine consultant daily rates differently as well, which
leads to further confusion among potential and actual consultants.
Regarding FHI’s perception of its role as the lead CA, it is extremely satisfied with MSH’s
technical work and feel the managerial-technical "marriage" is a sound one. However, MSH feels
that it spends an inordinate amount of time ensuring that it receives equal representation in the
IMPACT partnership.
15
The NGO sustainability study is an example of one activity that would have fallen within MSH’s
scope of work. MSH was interested in working on it, but was requested not to work or bid on
the activity, which was subsequently awarded to JSI do Brasil Instituto Promundo. As FHI is
well known for its leading edge technical expertise in STD/AIDS, MSH is acknowledged to have
significant expertise in NGO sustainability, so this particular instance stands out as an example
of confusion regarding appropriate roles for both the lead and subcontractor on IMPACT.
Recommendation: Reevaluate funding MSH through IMPACT.
Pathfinder do Brasil has a collegial relationship with FHI, and occasionally asks FHI for contact
information at the Federal level. FHI has been responsive and helpful with this information.
Overall, FHI is pleased with its lead CA role, but also feels the need for a stronger technical
partnership with USAID.
Capacity Building
FHI appears not to have transferred its technical skills effectively to the Federal level, as CN
DST/AIDS was unable to articulate what FACT was or what it entailed. In its 2001 Work Plan,
however, FHI plans to address this. At the nine sites where the FACT tool has been applied
there was little evidence of any intent to transfer the ability to implement FACT to the
counterparts. The follow-up courses were designed with minimal counterpart input and
implemented by outside technical experts. The objective of these courses was to improve the
knowledge and skills of each participant. Presumably, knowledge levels increased, but skill
levels were not measured. It is too early to determine whether these courses will have a
measurable impact in the workplace. Overall, FHI may not see its role as one of strengthening
capacity, but of improving knowledge.
MSH’s efforts to work with CN DST/AIDS at the national level are more successful. CN
DTS/AIDS has been more enthusiastic about APROGE tool, as well as the technical expertise
provided by MSH. While skill transfer has not yet begun, capacity building has begun, as
demonstrated by CN DST/AIDS request for APROGE to be adapted and integrated into the
national strategic planning efforts for all 27 states and 150 municipalities programmed to receive
funding from AIDS II.
Locally, several sites felt that they will be able to carry out APROGE III on their own, although
they hoped that outside facilitation technical assistance might be available from MSH. Across
the board, all sites visited have adopted APROGE as their own, and feel a sense of ownership.
MSH successfully carried out the capacity building necessary for this ownership to take place.
Technical assistance activities, which will address the weaknesses identified by APROGE, are
divided by participants into three areas related to transfer of ownership of the strengthening
process to the site: (1) those that the site can address on its own; (2) those that require outside
technical assistance; and, (3) those that require both technical and financial assistance. The role
of MSH then becomes responsive rather than directive. Overall, while more needs to be done in
capacity building at CN DST/AIDS level, it is clear that the lines of communication are open,
and MSH has been successful in capacity building.
16
Recommendation: FHI should provide technical assistance to all sites to ensure that the
variety of workplans generated by FACT workshops and courses are folded into a single,
practical and easy-to-implement plan. MSH should be included in this effort to ensure that the
workplans developed through APROGE also are integrated
Recommendation: FHI should work closely with CN DST/AIDS to shift the overall emphasis
away from FACT and offer technical courses to develop an improved system of national
HIV/STD surveillance, and to provide technical assistance to strengthen STI diagnosis and
treatment.
Indicators for Performance Measurement
The three indicators for IR 1 are:
1.1 Number of programs demonstrating low, medium and high levels of technical capacity in
planning, implementing, monitoring and evaluation.
1.2 Number of organizations showing increased capacity to manage STI/HIV/AIDS
programs.
1.3 Proportion of consultants providing technical assistance through the USAID strategy who
are Brazilian.
While the areas addressed by the indicators are important, progress reported using these
indicators may not always reflect the kinds or degree of effort that the two CAs have made.
Furthermore, there may be significant overlap between IR 1.1 and IR 1.2; if a program has the
capacity to manage, it must have the capacity to implement, monitor and evaluate.
Recommendation: USAID/Brazil should seek the services of an organization with specific
expertise in developing and testing indicators for HIV/AIDS prevention programs, to work in
conjunction with CN DST/AIDS and state and municipal programs.
Recommendation: Add an indicator showing the number of POAs that have received support
from the CAs or their partners, that CN DST/AIDS rates as successful.
Recommendation: USAID should hire an STD/HIV/AIDS Coordinator to oversee and
coordinate the Mission’s expanding role in HIV/AIDS prevention in Brazil, and should further
enhance its relationship with Brazilian government agencies by hiring a Brazilian Foreign
Service National
The World Bank
World Bank staff interviewed said that they viewed USAID’s comparative advantage as being
capacity building at CN DST/AIDS, State and Municipal levels. The World Bank provides little
in the way of direct technical assistance in the areas of management strengthening or training in
specific HIV/AIDS technical areas. The team concluded that the World Bank hoped USAID
activities would strengthen local managerial abilities so that, at the operational level,
implementing agencies would be better prepared to assume greater authority for their new
responsibilities following decentralization.
The team agreed that this is an excellent role for USAID. The strong recommendation that all
17
USAID activities be carried out in close partnership with CN DST/AIDS is shared by the team.
Because CN DST/AIDS does not appear to be to adequately preparing for the phasing out of
World Bank loan funds, and because USAID has significant experience in assisting agencies to
prepare for the cessation of funding, this is another area in which USAID technical assistance
might be of value to Brazil.
IV. PATHFINDER DO BRASIL
4.1 Background
Pathfinder do Brasil carries out training and related activities to integrate STI/HIV service
delivery in 20 municipal and state-run health posts in the two northeastern Brazilian states of
Bahia and Ceará. Activities are implemented both by Pathfinder do Brasil staff and by four local
consultants hired in Ceará. In the past, Pathfinder do Brasil also provided support to four local
NGOs. However, owing to funding restrictions, this support ended in late 2000. Pathfinder do
Brasil collaborates with other USAID CAs and works closely with public sector HIV/AIDS
programs in the states and municipalities in the two northeastern states.
Pathfinder do Brasil focuses on achieving the Mission's Intermediate Result 2:“Strengthened
Institutional Capacity to Provide Integrated STI/HIV Services in Bahia and Ceará”.
Pathfinder do Brasil, which is based in Salvador, the capital of the northeastern state of Bahia,
worked extensively for a number of years with USAID/Brazil in family planning and was
already well known in both states. It was determined that Pathfinder do Brasil should build on
its existing relationships and reputation and continue to work in these two states, but with a new
focus on integrating STI/HIV care into what had previously been purely family planning
activities.
Pathfinder do Brasil's mandate is to work as closely as possible with the local state and
municipal authorities to strengthen management and institutional capacity. Its role has changed a
number of times, as have its indicators. This has made it difficult for Pathfinder to be consistent
over time with regard to its activities or the indicators it needs to report on to USAID/Brazil.
During the period from August 1997 to August 1998, Pathfinder do Brasil was given $700,000 in
funding by the Mission for specified technical assistance activities. During this same period,
Pathfinder, in conjunction with the Mission and the other CAs, developed a proposal to integrate
STI/HIV into family planning programs at several of the same locations where it had been
working previously. This new series of activities began in July 1998, along with additional
activities supporting four NGOs in Bahia and Ceará, each of which received grants between
$20,000 and $40,000. In October 2000, Pathfinder do Brasil and the Mission agreed upon a new
bilateral funding mechanism. This new agreement, however, did not allocate sufficient resources
for it to continue to support the four NGOs. These transition phases have now ended and there is
more clarity at both Pathfinder do Brasil and USAID/Brazil on its roles and scope of technical
assistance.
Due largely to its longstanding collaboration with previous USAID-funded programs, Pathfinder
do Brasil entered into its new role with a favorable reputation throughout northeastern Brazil.
18
However, this also meant that it had to clarify its new mandate with its partners, many of which
viewed them as primarily a family planning organization. Pathfinder do Brasil has been highly
successful in conveying that its role has changed, and in laying out what its new role entails.
4.2 Management and Technical Assistance
Pathfinder do Brasil's programs in Bahia and Ceará have made the successful transition from
working primarily in, and being associated exclusively with, family planning, to its current
management and technical assistance role of integrating family planning services with STI/HIV
services. Health posts whose staff have received training through Pathfinder do Brasil see more
clients for HIV/STIs, request, receive, and distribute more condoms, and disseminate more
information about HIV/STIs than before.
Pathfinder do Brasil’s programs are designed to increase the capacity of health care providers to
provide information and treatment for STI/HIV/AIDS in conjunction with existing family
planning services at 20 municipal and state health posts in Bahia and Ceará. The health posts
and trainees were selected on the basis of interest expressed by local officials and the health post
director, and the capacity of the health post to incorporate new and expanded services. Providers
were trained in the basics of counseling for and diagnosing of STIs and HIV, according to their
specialties (e.g. nurse, social worker, physician) and were trained in how to integrate these
STI/HIV services with what, in most cases, had been a focus on providing family planning
services. The training was both theoretical and practical, with the trainers following up on each
trainee with periodic visits to the health posts. All participants interviewed saw these follow-up
visits as key to the success of the overall effort. In particular, they said this follow-up and the
assistance that Pathfinder do Brasil staff and consultants provided after the formal training period
made the training better than any previous training they had received.
Pathfinder do Brasil’s interventions fit well with the MOH’s ongoing decentralization effort, in
which it seeks to place the responsibility for providing health care services, including those for
STI/HIV, in the hands of municipal authorities. Pathfinder do Brasil's current approach requires
no modification, except for perhaps better clarifying and defining the respective roles for
Pathfinder do Brasil and other USAID CAs in strategic planning by states and municipalities.
The quality of the training and the value placed on Pathfinder do Brasil activities by its local
partners have contributed significantly toward improving the quality and increasing the volume
of STI/HIV services in several communities. Annually in Bahia and Ceara, approximately
$60,000 of funds received from CN DST/AIDS are dedicated to activities that complement or
further the activities initiated under Pathfinder do Brasil.
The goodwill that has been created make this model program easily replicable elsewhere in these
two states and, possibly in other states. This places Pathfinder do Brasil in a strong position to
work with CN DST/AIDS to apply this program or something similar at the national level. At
present, CN DST/AIDS claims that it supports approximately 3,500 training programs
nationwide. The incorporation of Pathfinder do Brasil programs in some of the national training
activities has the potential for making an even more significant impact vis-à-vis USAID-funded
program efforts.
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4.3 Key Findings and Recommendations
USAID has been working to limit the overall impact of the HIV/AIDS epidemic for more than a
decade, and through activities carried out by Pathfinder do Brasil and its other CAs, has been
successful. This success can be even greater if it continues to expand its work to additional
municipalities in the four selected states and, eventually, to additional states.
Pathfinder at present conducts training for only the staff of 20 health posts in two states, Bahia
and Ceará in northeastern Brazil. Bahia alone has 417 municipalities with at least one health
post. To date, 80 of these 417 municipalities have reported at least one case of AIDS. This
figure does not include those infected with HIV. In the state capital, Salvador, requests for HIV
tests in 2000 rose 63% over the number requested in 1999. State health officials have begun to
note a shift toward more AIDS cases in rural areas than was true earlier in the epidemic–a trend
that has been observed in other Brazilian states. Ceará has a population of more than 7.5 million
living in 184 municipalities, with 32 municipalities of more than 50,000 inhabitants. The training
needs in these two states alone could occupy Pathfinder do Brasil for years.
Strengthening Management Systems
While it is hard to capture completely and effectively the impact that these efforts have had,
Pathfinder do Brasil has achieved impressive results in improving the knowledge and motivation
of health posts staff, meeting the increasing demand for STI/HIV services, and attracting
favorable interest by all program participants. Pathfinder activities have contributed to improved
knowledge of STI HIV/AIDS and improved access to condoms. The involvement of the health
post director in trainee selection and the use of trainers for periodic follow-up with the trainees
have contributed significantly to the smooth integration of STI/HIV services in the family
planning/reproductive health (FP/RH) services delivery system. In addition to providing training,
Pathfinder do Brasil has updated protocols and tools to facilitate the inclusion of HIV/AIDS in
FP/RH service delivery.
Through support to local NGOs in Bahia (GAPA - Groupo de Apoio e Prevencao a AIDS and
CETAD - Centro de Estudis e Terapia do Abuso de Drogas) and Ceará (ISDS - Instituto de
Saude e Desenvolvimento Social and Communicacao e Cultura), Pathfinder has also introduced
HIV/AIDS awareness campaigns, ranging from supporting school newspapers reporting on
RH/HIV/AIDS issues to training of radio disc jockeys to community-based activities reaching
women and high-risk populations.
The strengthening of health posts together with the support of local officials has led to increased
demand, including among men who seek services from within and outside the catchment area,
and among women who attend what had been traditionally viewed as family planning centers.
Staff who received training and the directors of the health posts where Pathfinder do Brasil
worked also told of receiving an increasing number of calls from local community organizations
and schools asking for additional information on HIV/STIs, and invitations to give talks in the
community on HIV/STI prevention and control issues.
Recommendation: USAID should continue to support Pathfinder do Brasil's programs in
Brazil, and expand their scale by broadening the geographic focus of these activities.
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Recommendation: Pathfinder do Brasil’s training activities in Northeastern Brazil have
contributed significantly to improving the quality of STI/HIV/AIDS service delivery in two
states and should be expanded to additional municipalities and other states.
Recommendation: USAID should review CN DST/AIDS statement of interest in replicating
Pathfinder do Brasil’s activities nationally and in incorporating such activities under its system
of provider training.
Creation of Effective Partnerships
Pathfinder do Brasil has created highly effective working partnerships with the staff of the heath
posts where it has trained providers and has extended its efforts beyond the health posts to the
municipal and state authorities responsible for health care in those communities. Most staff cited
an increase in the number of men and adolescents coming to inquire about HIV and other STIs.
Both state and municipal authorities, when asked what their priorities were, stated simply “to
expand the training to other health posts.” In the few health posts where for financial reasons
Pathfinder do Brasil had limited training to only certain members of the post’s staff, provision of
training to all staff was identified as a priority. Expanding Pathfinder training program, in
conjunction with municipal, state and CN DST/AIDS authorities, has the potential to have a
significant impact on addressing the overwhelming demand for more and better training for
health care providers.
Pathfinder do Brasil's work with municipal and state health authorities and health care providers
makes for a good case study in how to establish and operate partnerships. Pathfinder do Brasil
has been asked to participate in strategic planning exercises to plan for future state HIV/AIDS
programs in both Bahia and Ceará. Pathfinder do Brasil is viewed not as an outside agency, but
as a local partner that is willing to provide assistance whenever and wherever it can. It would be
difficult to find a better example of partnerships than the ones that Pathfinder do Brasil has
established in the communities where it works.
Pathfinder do Brasil collaborates with other CAs as well when opportunities arise. When it was
no longer able to continue funding for the CETAD program that uses a mobile van in Salvador to
educate street children, injecting drug users and underserved communities about HIV and
provides both health education as well as male and female condoms, DKT do Brasil, at
Pathfinder do Brasil's request, agreed to renovate the vehicle, cover operating costs, and supply
its own brands of male and female condoms for distribution. Funding for this activity is fully
covered by DKT do Brasil. In another instance, when Pathfinder do Brasil expressed an interest
in learning more about voluntary counseling and testing for HIV, IMPACT designed and
conducted a course on this topic.
Recommendation: Pathfinder do Brasil should work with USAID/Brazil and the other SO3
CAs to establish a closer working relationship with CN DST/AIDS in Brasilia; CN DST/AIDS
expressed an interest in replicating Pathfinder do Brasil’s activities nationally and in
incorporating such activities under its system of provider training.
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Capacity Building
Clearly, the health posts whose staff have received Pathfinder training have benefited. It is
evident from the materials reviewed and the information gathered from interviews that there is
considerable improvement in both capacity and morale among trained health post staff.
However, this improvement is difficult to measure quantitatively. The indicators for
IR 2 have changed, along with Pathfinder do Brasil’s role, and at present do not capture
effectively the degree of capacity building that is taking place.
Staff turnover at the Mission since the country strategy was adopted in 1997 has made it difficult
to fully stay abreast of Pathfinder do Brasil's activities. A lack of long-term continuity among
Mission staff and changes in priorities, directions, levels of involvement in dealing with CN
DST/AIDS as well as with the CAs has also had some effect. Relations remain good and the
Mission feels that Pathfinder do Brasil does an excellent job of reporting on its activities.
Recommendation: Pathfinder do Brasil should work with USAID/Brazil and the other SO3
CAs to establish a closer working relationship with CN DST/AIDS in Brasilia
Indicators for Performance Measurement
Pathfinder do Brasil and USAID have struggled with the IR 2 indicators since AIDSCAP ended
and the present Country Strategy began in mid-1998. The existing indicator for Pathfinder do
Brasil is " Percentage of health units with capacity to provide quality integrated STI/HIV/AIDS
prevention and family planning services." Measuring institutional capacity is difficult at best
and hard to quantify. This makes it hard to capture the extent of Pathfinder do Brasil’s efforts,
and therefore its results. Furthermore, much of the effort that it devotes to following up on
initial didactic training is not measured at all, being merely a recording of the number of
supervisory visits. Pathfinder do Brasil is as frustrated as the Mission with this situation, and has
asked for technical assistance to determine indicators that could better capture the full range and
scope of its efforts.
USAID/Brazil will require technical assistance to develop a set of indicators that can measure
changes in institutional capacity, and will thus be able to better assess Pathfinder do Brasil’s
progress. Indicators should link Pathfinder do Brasil’s activities to awareness of how STI/HIV
may be prevented and eventually to a decline in prevalence in communities where Pathfinder
trained health care providers.
Developing indicators also relates to the efforts of CN DST/AIDS, which is aware that current
epidemiological surveillance statistics do not reflect the most accurate and up-to-date picture of
the HIV/AIDS epidemic in Brazil. At present, surveillance captures only those diagnosed with
AIDS who seek out medical assistance in the public sector. The World Bank is also urging
Brazil to establish better systems for the collection and reporting of more up-to date HIV/AIDS
statistics.
Recommendation: The Mission should request technical assistance to improve its indicators
for Pathfinder do Brasil and for its other HIV/AIDS indicators so that they demonstrate clearly
the impact USAID programs have on HIV incidence in Brazil.
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Recommendation: USAID/Brazil should provide financial resources and technical assistance
to identify and put into place indicators that would capture more accurately the impact of
Pathfinder do Brasil’s activities.
V. DKT DO BRASIL
5.1 Background
DKT do Brasil focuses on Intermediate Result 3 (IR 3):“Sustainable Condom Social
Marketing” under the Mission’s current SO3. While DKT do Brasil carries out its own condom
marketing and distribution programs, it also supports local NGOs and public sector HIV/AIDS
programs, and collaborates with other USAID CAs in CSM activities.
Under SO 3, IR 1 and IR 2 focused on how USAID and its CAs might best support the MOH and
CN DST/AIDS to maximize the impact of the AIDS II-funded activities. It is worth pointing out
that while the first two intermediate results under the new strategy concentrated on providing
technical assistance and training, IR 3 specified that DKT do Brasil continue to carry out CSM
activities similar to ones it had implemented under AIDSCAP. This continuity has given DKT
do Brasil relatively more autonomy than either IMPACT or Pathfinder. The new USAID/Brazil
HIV/AIDS strategy was presented formally and accepted by CN DST/AIDS in mid-1998. Since
then, both IR 1 and IR 2 and their indicators have been modified somewhat. IR 3, however, has
remained unchanged.
While USAID/Brazil defined Rio de Janeiro, São Paulo, Ceará and Bahia as priority states for its
HIV/AIDS programs, DKT do Brasil has established CSM programs in other states as well. This
was a result both of DKT do Brasil’s need to sell enough condoms to maintain its operations and
because DKT do Brasil’s principal competitors in Brazil’s condom market are large-scale
commercial firms with national coverage. DKT do Brasil needed therefore to demonstrate that
its products were reliable, widely available, and better priced than competing brands; this in turn
meant that its products needed to be known nationwide. Even as it expanded, however, DKT do
Brasil continued to focus primarily on addressing the needs of marginalized or underserved
target groups by providing reliable information about condoms and how to use them, as well as
providing a well-regarded product at an affordable price for those of more limited means.
CSM has come to be viewed during the 1990s as a vital weapon in the battle against the spread
of HIV/AIDS. In the 1996 book Confronting AIDS, published by the World Bank, Brazil was
cited as an example of how CSM could have an impact on the AIDS epidemic. UNAIDS also
highlights the growth in Brazil’s condom market as well as the high overall awareness of
condom use. In its June 2000 Report on the Global HIV/AIDS Epidemic, UNAIDS cites Brazil
as having the lowest proportion of girls and boys aged 15-19 who do not know how to protect
themselves from HIV among 17 African and 4 Latin American countries surveyed. In a 1999
survey of 3,500 Brazilians, 50% of young men reported using a condom the first time they had
sex–a significant increase from the 5% use rate reported in a 1986 survey.
5.2 Management and Technical Assistance
DKT do Brasil, an affiliate of the USA-based DKT International, is an independent entity
incorporated in Brazil. For legal reasons it had to incorporate as a commercial firm in Brazil,
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which means that DKT do Brasil must pay the same corporate taxes as other commercial firms in
Brazil. While this required different financial management procedures, it has not kept DKT do
Brasil from responding to the needs of local NGOs for condoms, information about their use and
the role of condoms in preventing disease. They also recommend people who can speak about
CSM issues to NGOs and public sector HIV/AIDS program staff. DKT do Brasil also
collaborates with the other USAID CAs, by supplying commodities and offering technical
assistance on CSM issues.
DKT do Brasil differs from IMPACT and Pathfinder do Brasil as well in its indicators, which are
more specific and relatively easy to measure. Through the monitoring of its sales, market share,
the extent of its distribution network and people’s attitudes towards condoms, particularly DKT
do Brasil's own condom brands, it is well placed to demonstrate its progress towards achieving
USAID/Brazil’s goals. Sales figures are captured by the salespeople, who receive commissions
based on the condoms they sell to retail outlets or points of sale. In addition, DKT do Brasil
periodically commissions extremely detailed Nielsen surveys that show the market share
achieved by different condom brands in different parts of Brazil. DKT do Brasil thus is able to
assess not only how many condoms it sells, but also how it is doing versus the competition in
different locations.
While it is relatively easy for DKT do Brasil to demonstrate its success to USAID, as a
commercial firm it also faces stiff competition from other condom manufacturers and
distributors, most of which are owned or operated by multinational firms with access to
extensive resources. Since its targets for condom sales emphasize reaching those populations
with limited means or little access to formal health care, DKT do Brasil must price its products
as low as it can, while at the same time generating sufficient revenue to pay not only its own
operating costs, but also incentives and commissions to its salespeople and distributors. This
sometimes leads competitors to view DKT do Brasil as a threat to their profits.
DKT do Brasil needs to prepare progress reports both for Population Services International
(PSI)/AIDSMark in Washington, which in turn reports to the USAID Global Bureau, as well as
for USAID/Brazil, which uses this information to prepare its annual R4 submission to the
Program and Policy Coordination Bureau in Washington. The result is the preparation of two
parallel but not identical sets of reports. This also means if USAID/Brazil wants to negotiate
programmatic changes or shift the focus of its activities, DKT do Brasil needs to discuss these
changes with both the Mission and with PSI, which in turn must consult with the Global Bureau.
While this situation is by no means unique to DKT do Brasil or USAID/Brazil, it complicates
matters for an independent firm such as DKT do Brasil, which is not set up to prepare the
number of different reports sometimes required by this situation.
5.3 Key Findings and Recommendations
DKT do Brasil began CSM activities in Brazil in 1991, shortly before AIDSCAP began in 1992.
Since then, it has achieved or exceeded every goal set forth by USAID. DKT do Brasil is well
on track in implementing its CSM programs. Currently, USAID support constitutes
approximately 8% of its operating costs, with the remainder generated primarily from sales
revenue. DKT do Brasil has surpassed its own sales targets and exceeded it goals for market
share with an average of US$ 344,000 in annual funding from USAID over 4 years. If its current
support for NGOs were terminated, DKT do Brasil would be financially self-sustaining.
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Decreasing Sexual Transmission of HIV/AIDS in Target Groups
DKT do Brasil’s programs provide affordable and high-quality condoms, and focus on reaching
communities in need. While CSM is almost always included on the list of effective interventions
to limit the impact of the HIV/AIDS epidemic, it is difficult to assess the impact of even DKT do
Brasils’s highly successful CSM program on the sexual transmission of HIV/AIDS in Brazil.
What can be measured, however, are DKT do Brasil’s condom sales in the four USAID priority
states, along with partnerships that DKT do Brasil has established to help those who lack
resources, confidence, or access to other sources of condoms.
Between 1999 and 2000, according to Nielsen, DKT do Brasil’s share of the total condom
market in Brazil increased from 13% to over 17%. In 2000, DKT do Brasil sold more than
50 million male condoms and 600,000 female condoms. Of these, 52% of the male condoms, or
26.25 million units, were sold in the four USAID priority states. The female condom, marketed
under the brand name “Reality,” achieved sales of more than 368,000 in the same four priority
states, or 60% of DKT’s total female condom sales in 2000. Thus, sales figures show that the
majority of DKT do Brasil’s CSM activities are reaching people in these selected target areas.
Through its own condom distribution network, DKT do Brasil distributes its "Prudence"
condoms not only to pharmacies, but also to general stores, bars, convenience stores, and gas
stations. Collaborating with NGO partners, DKT distributes condoms in both traditional and non￾traditional outlets, or wherever people come together socially. DKT do Brasil also relies on its
NGO partners to reach communities in which people have limited access to formal public health
care or the means to purchase commercially priced condoms. Specifically, DKT do Brasil
supplies informational material and condoms to NGOs in all four USAID priority states:
BARONG in São Paulo; GRAPAAR in Rio de Janeiro; CETAD in Bahia; and, Aliança Luz in
Ceará. This last NGO also receives support from the Japan International Cooperation Agency
(JICA), and through this relationship with JICA, DKT do Brasil has begun to sell its condoms in
“Pague Menos,” one of the largest pharmacy chains in Northeastern Brazil. Significantly,
Aliança Luz has through the efforts of its own staff, as well as through support received from
DKT/USAID and JICA, become practically self-sustaining.
Free condoms are available at municipal and state-run health posts. From direct observation and
conversations with heath care providers in a variety of locales, however, it is evident that the
supply is insufficient to meet the demand in most cases. To obtain these free condoms, people
must go to the health posts, where condoms may or may not be still available. Most health posts
are given separate quotas of condoms for family planning or disease prevention, and providers
are not supposed to substitute condoms from the family planning quota for use in disease
prevention or vice versa. Most of these providers lack sufficient training in inventory control,
thereby making it difficult for them to monitor trends in the demand for condoms, and assess
their future commodity needs.
Recommendation: USAID should continue to support DKT do Brasil’s CSM programs in
Brazil to expand its geographic scope to cover additional states (i.e., Minas Gerais and
Pernambuc) and along major transit routes and in border areas.
25
Recommendation: USAID should provide DKT do Brasil with additional resources to
implement CSM–including both its standard Prudence condom as well as newer products–in
new states while continuing ongoing efforts.
Creation of Effective Partnerships
DKT do Brasil has worked to create partnerships with a variety of other actors in HIV/AIDS
prevention in Brazil. In addition to its work with NGOs, as described above, the USAID CAs
also collaborate with each other. They attend semiannual CA meetings with CA and Mission
staff, where they strengthen coordination and inform USAID and other CAs of ongoing
activities, problems and remedies, future plans, and ways to avoid duplication of efforts. Other,
less formal communication between the CAs and USAID takes place on a more frequent basis,
including through phone calls, individual meetings and via e-mail. Overall, the partnership could
be a stronger and healthier one, although once again, DKT do Brasil’s role is different than those
of the other CAs.
Cooperation between Pathfinder do Brasil and DKT do Brasil occurred when the former lacked
funding to continue its support for CETAD, a local NGO in Salvador, Bahia, to reach street
children, particularly intravenous drug users, with health messages and condoms. DKT do Brasil
currently provides commodities and informational materials to CETAD’s van, which was
renovated with DKT do Brasil funds and travels daily to the favelas (slums) around Salvador.
The benefits from this arrangement are mutual, since CETAD promotes and educates hard-to￾reach populations with health messages and information about HIV/AIDS, and distributes DKT
do Brasil's condoms.
On a larger scale, DKT do Brasil has sought out and established extremely good working
relationships with several NGOs. Assistance has been provided in the form of financial support,
commodities or technical advice to more than 70 NGOs throughout Brazil. In 2001,
approximately $500,000 will be provided to these NGO partners, either in condoms or in direct
financial support. Among the NGOs that DKT do Brasil currently supports are:
ß BARONG, which operates a mobile van in different locations in São Paulo that sells
condoms at a discounted price while also providing information about HIV/AIDS;
ß Centro Corsini Consumer Hotline, which responds to calls for information about
Prudence, condom use and HIV/AIDS; and
ß Rocinha Youth Project (GRAPAAR ), which works with young people in Rocinha, Rio de
Janeiro’s largest slum.
The last project produces and performs street theatre to teach youth about HIV/AIDS and
reproductive health. GRAPAAR has enjoyed considerable success, and its troupe of teenage
actors recently appeared on a television broadcast at the invitation of one of Brazil’s leading
television stations. The project is about to inaugurate a new youth center that has been
rehabilitated with funds from DKT do Brasil.
While it focuses on assistance to NGOs in the four USAID target states, DKT do Brasil also
works with others, such as Arco Iris, which operates a mobile van that promotes condom use and
distributes condoms around Brasilia.
26
DKT has had relatively little interaction with IMPACT, although when opportunities to
collaborate arise, the two projects do work together. At IMPACT's request, DKT made materials
available and provided personnel to conduct a 3-day CSM training course for the staff of several
municipal and state HIV/AIDS prevention programs.
Recommendation: USAID should continue funding DKT do Brasil to work with NGOs in
condom promotion and to provide additional technical assistance in CSM to NGOs and the
public sector.
Recommendation: DKT do Brasil should establish a closer working relationship with CN
DST/AIDS in Brasilia, which has shown interest in learning more about CSM and how it works.
Capacity Building
DKT do Brasil has contributed significantly to improving CSM capacity in Brazil, although often
in unexpected ways. The best example is from approximately 4 years ago, when BEMFAM, the
Brazilian IPPF affiliate, began to sell its own condom brand, Prosex, using DKT do Brasil's
CSM methodology and techniques. DKT do Brasil’s reputation in Brazil for CSM is also
illustrated by IMPACT’s request for assistance when it wished to conduct a course about CSM
for the prevention of HIV. Also significant is increasing interest by CN DST/AIDS in Brasilia,
which coordinates Brazil’s overall response to HIV/AIDS, in learning how CSM works and
possibly in carrying out its own version of CSM, either in partnership with DKT do Brasil or
using it to provide technical assistance in CSM. While DKT do Brasil’s operations to date have
taken place for the most part in the private sector, this increasing interest on the part of the public
sector represents a tremendous potential for expanding CSM dramatically throughout Brazil. It
thus appears that CSM has proven itself in Brazil, and that there is significant capacity building
occurring with respect to CSM, although not always in the most coordinated fashion.
Capacity building is also taking place within DKT do Brasil, as it has since the Mission
established its 1997 HIV/AIDS strategy. DKT do Brasil is intent on achieving complete
sustainability by 2002. This goal will be achieved more rapidly once an alternative funding
mechanism, to avoid interest charges on borrowed funds, is identified. The Mission is aware of
the cost of the delayed obligation of funds. At this writing, DKT do Brasil has paid
approximately $100,000 in interest on funds it has had to borrow to cover expenses while
awaiting the annual USAID/Brazil obligations.
When the current country strategy began and DKT do Brasil initiated CSM activities with
funding through AIDSMark in 1998, DKT do Brasil covered 78% of its operating costs with
revenues generated by sales of Prudence, its basic condom. For 1998, the planned goal was to
achieve 82% financial self-sustainability; DKT do Brasil covered 90% of its costs. The
following year was a difficult one, as Brazil unexpectedly devalued its currency by 52%. DKT
do Brasil raised the price of Prudence by only 20%, yet thanks to a variety of cost-cutting
measures, it still achieved its goal of 86% financial self-sustainability. In 2000, its workplan
called for DKT do Brasil to meet 90% of its own costs; the actual figure was 92%. These figures
show that USAID support over the past 3 years has been effective in leveraging funds. DKT do
Brasil reduced its dependence on USAID funding from 22% to 8%, while at the same time
increasing its overall condom sales volume and expanding the scale of its CSM activities. DKT
27
do Brasil enhances USAID-funded projects by providing commodities to its AIDSMark
activities. This represents a good return on USAID’s investment and speaks directly to DKT do
Brasil’s ability to expand its CSM capacity while at the same time reducing its dependence on
external funding.
It is unlikely that DKT do Brasil has reached anything near the absorptive capacity for CSM
activities in Brazil. Its sales show no sign of slowing and it continues to introduce innovative
products. With the growing interest on the part of the public sector in pursing CSM and the
existence of a rival social marketing firm affiliated with BEMFAM, there is great potential for
expansion and further growth of DKT do Brasil’s CSM activities.
Recommendation: Additional USAID resources are needed to assist DKT do Brasil’s work
with its partners to support further and permanent reductions in taxes on condoms in Brazil.
Recommendation: The Mission should explore alternative mechanisms to fund DKT do
Brasil that would preclude payment of interest on borrowed funds while awaiting annual USAID
funds.
Indicators for Performance Measurement
The existing indicators are useful in measuring the performance of DKT do Brasil vis-à-vis the
impact of the USAID strategy. They capture performance in terms of sales and market share, but
given the low percentage of costs covered by USAID, it is difficult to assess what proportion of
DKT do Brasil’s achievements should be attributed to USAID or accurately fall within the
Mission’s manageable interest. Similarly, the indicators that USAID currently requests do not
sufficiently measure the effectiveness of DKT do Brasil’s CSM efforts in reducing the spread of
HIV.
Recommendation: USAID/Brazil should contract with an organization with expertise in
developing indicators for HIV/AIDS prevention programs, including CSM, and establish
indicators that measure how success in implementing CSM programs affects the sexual
transmission of HIV/AIDS.
VI. FUTURE DIRECTIONS
Implementation of SO3 is progressing very well and the key CAs responsible for activities under
Intermediate Results 1, 2 and 3 have made significant contributions to the strengthening of
institutional capacity for integration of STI/HIV services in traditional FP/RH service delivery
programs, and expansion of sustainable condom social marketing activities. The approaches
taken by IMPACT, Pathfinder do Brasil and DKT do Brasil have been well received and have
generated enormous goodwill.
However, the country strategy introduced under AIDSCAP and continued to the present–i.e.,
concentrating resources in four priority states and six municipalities–needs to be revisited. The
time is right to initiate discussions with CN DST/AIDS to expand activities within the four
priority states and, second, to increase collaboration for greater impact on the epidemic while at
the same time complementing donor efforts. In light of DKT do Brasil's projection that it will
28
become completely self-sufficient by 2002, FHI, MSH and Pathfinder should be encouraged to
view CN DST/AIDS as their primary development partner and focus on strengthening systems
and transferring technical and managerial skills within that partnership.
CN DST/AIDS recognizes that under AIDS II its primary role is to coordinate national resources
and facilitate decentralization of planning, implementation and evaluation of STD/AIDS
programs to the states and municipalities. CN DST/AIDS request that USAID assist with its
national strategic planning process represents a significant opportunity for USAID/Brazil and the
CAs to become more widely involved at the municipal, state and national levels. With the
introduction of the Management and Leadership Development Project, managed by MSH, an
additional resource will be available for improving leadership skills at the national level, which
in turn could be harnessed to assist CN DST/AIDS in strengthening leadership in the
decentralized STI/HIV/AIDS programs. Such a capacity building effort would help CN
DST/AIDS prepare for its transition to the next phase of World Bank funding, which is expected
to be more limited in scope than that of AIDS II.
USAID/Brazil should enhance its comparative advantage over the World Bank project, which
provides little in the way of direct technical assistance in management strengthening or training
in specific areas related to HIV/AIDS. While future contributions to the strengthening of
management and institutional capacity under the new MSH project could be significant, the CAs
should focus on strengthening of current, and development of new, technical capacities. In
particular, FHI should take advantage of its institutional strengths and internal technical expertise
to help put in place a functioning sentinel surveillance system to measure and assess the spread
of HIV. In addition, FHI should collaborate with CN DST/AIDS to establish STI diagnosis and
reporting systems throughout Brazil. Similarly, Pathfinder do Brasil, in expanding its training
programs in municipalities, states and at the national level, has the potential to have a significant
impact on addressing the overwhelming demand for more and better training for health care
providers in the area of HIV/AIDS.
Coordination between the CAs remains an important facet of future programming. Semi-formal
and informal mechanisms currently in place are not based on a common vision, as was hoped
during the life of ProQuali. Defining clear roles for all actors is critical. The current overlap in
technical areas such as strategic planing, organizational restructuring, and service quality
improvement should be eliminated through better planning and clearer definition of technical
responsibilities and roles based on the mandates and capabilities of each CA. Guidance should be
provided by USAID/Brazil, both on consistency in the preparation of annual workplans and on
presentation of program information and data quality in annual and semi-annual reports.
The April 2000 agreement among UNAIDS, the World Health Organization, USAID and the
U.S. Department of Health and Human Services to introduce standardized indicators and
instruments for the monitoring and evaluation of HIV/AIDS/STI programs at all levels paves the
way for USAID/Brazil to take advantage of the initiatives under the USAID's Expanded
Response to revise, adapt, and develop indicators to monitor, measure and report on progress. As
noted earlier in this report, several of the IR indicators are not adequate for reporting on the full
extent of the interventions carried out under the institutional capacity strengthening and condom
social marketing programs of Pathfinder do Brasil and DKT do Brasil, or under the institutional
29
capacity strengthening capacity programs of FHI and MSH under IMPACT. In some instances, a
similar situation exists in CN DST/AIDS system, in that surveillance statistics do not reflect the
most accurate and up-to-date status of the HIV/AIDS epidemic in Brazil.
NGOs receive 10 percent of the AIDS II funds, and the nearly 500 NGOs working on HIV/AIDS
activities with these funds are in need of considerable assistance if they are to become
sustainable. While USAID will not be able to provide the needed level of assistance, a strategic
approach to assisting selective NGOs by strengthening management and leadership skills, and
possibly, resource planning and income diversification, should be considered.
APPENDICES
A. List of Contacts
CETAD, Salvador, Bahia, Brazil
· Dr. Tarcísio Matos de Andrade, Coordinator, Program on Reduction of Drug-Related
Harm
DKT do Brasil, São Paulo, Brazil
· Carlos Ferreros, Country Manager
· Daniel Marun, Controller
· Márcio Rodovalho Clemente, Marketing Manager
· Simone Martins, Institutional Relations Manager
· Wilson Rodregues, Supervisor for Financial Planning
Family Health International do Brasil, Brasília, Brazil
· Paulo Roberto Proto de Souza, MD. , Director
· Valmir Costa, Project Manager
GRAPAAR, Rio de Janeiro, Brazil
· Murilo Peixoto de Mota, Director
JICA/Aliança Luz, Fortaleza, Ceará, Brazil
· Daisuke Onuki, Expert in Health Education and Social Assistance
· Márcia Costa Martins
Management Sciences for Health/IMPACT
· Roberto Brant Campos, Coordenador de Projeto, DST/AIDS
· Karen Johnson Lassner, Representante para o Brasil
· Lia Junqueira Kropsch
Ministerio de Saúde, Coordenação Nacional de DST e AIDS, Brasilia, Brazil
· Ivo Brito, Unidade de Prevenção
· Cláudia de Paulo, SCDH
· Maria Alice Diparoni
· Jane Galvão, Assesora, Cooperação Externa
· Alexandre Grangeiro, Coodinador Adjunto
· Paulo Meireles, COOPEX
· Cristina Raposo, Assesor en ONGS
· Mário Angelo Silva, Unidade de Treinamento
· Mauro Teixeira de Figueiredo, Assessor – Cooperação Externa
· Dr. Paulo R. Teixeira, Director
· Maria Alice Tironi, Planejamento e Avaliação
Ceará, Brazil
· Dr. Anastasio, Secretario da Saúde
· Francisca Marie Andrade
· Silvia Bastos de Paula, Consultora ao Estado de Ceará
· Virginia Maria Costa de Oliveira
· Dr. Luís Eduardo de Menezes Lima, Subsecretario da Saúde
· Dr. Francisco Holanda Júnior, Chefe, Celuala de Saúde Reproductiva
· Telma Martins, Coordendora, DST/AIDS
Município
· Rose Mary Freitas Maciel, Secretaria da Saúde
· Sheila Maria Santiago Borges, Chefe de NUVECDA
· Fatima Verónica, Coordendora de Programa DST/AIDS, Secretaria Muncipal de de
Desenvolvimento Social
Rio de Janeiro
Estado
· Valdiléa Veloso, Coordenadora, Programa Estadual DST/AIDS – RJ
Município
· Rita Mendes Ferreira, Assistente - Coordenação de Doenças Transmissíveis
· Lilian de Mello Lauria, Assistente – Coordenação de Doenças Transmissíveis
São Paulo/SP
Estado
· Renato Barboza, Assistente Técnico de Diretoria – Divisão de Prevenção
· Maria Clara Gianna, Coordenadora Adjunta
· Artur Olhovetchi Kalichman, Diretor / Coordenador
· Leda Jamão, Vice-Coordenadora da Vigilância
Município
· Cássio Figueiredo, Coordenador, Programa Municipal de DST/AIDS de São Paulo
· José Cláudio Domínguez, Coordenador Programa Municipal de DST/AIDS de São Paulo
Bahia Estado
· Alicina Andrade, Coordenadora Sit. Saúde Programa Estadual DST/AIDS
· Dra. Marlene T. Barros de Carvalho, Gerente/DIVEP
· Márcia Sampaio, Coordenadora, Programa Estadual DST/AIDS
· Míriam Sepúlveda, Diretora do Centro de DST/CTA
Município de Salvador
· Maria do Socorro Farias Chaves, Secretaria Municipal de Saúde
· Dulcelina Anjos do Carmo, Secretaria Muncipal de Saúde
Pathfinder do Brasil, Salvador, Brazil
· Christina Barrros Kramer, Country Representative
· Ilka Rondinelli, Senior Manager for Project Development
· Carmen Pereira, Program Officer
Pathfinder do Brasil, Fortaleza, Brazil
· Claudia Jatahy, Consultant
· Raimunda Hermelinda, Consultant
· Danila Paula Careiro de Oliveira, Consultant
· Marionescu Purcaru, Consultant
Prefeitura Municipal de Fortaleza, Secretaria Municipal de Desenvolvimento Social,
Fortaleza, Brazil
· Rose Mary Freitas Maciel, Secretaria
· Fátima Verónica Teixeira de Lima, STD/AIDS Coordinator
· Sheila Maria Santiago Borges, Chefe de NUVECDA
· Marilia Marquez Carvalho
TvT Associates/Synergy Project, Washington D.C.
· Barbara de Zalduondo, Project Director
· Saha AmaraSingham, Monitoring and Evaluation Specialist
· Martha Lindauer, Communications Specialist
· Denise Lionetti, Deputy Director
· Lori Salins, M&E Program Manager
UNAIDS/UNESCO, Brasília, Brazil
· Telva Barros, Country Program Advisor, Brazil
· Dr. Jorge Werthein, UNESCO Country Representative in Brazil
· Matias Spektor, Assistant to the Representative
USAID/Brazil, Brasília, Brazil
· Lawrence Odle, Deputy Country Representative
· Janice Weber, Country Representative
USAID/Washington, Washington, D.C.
· John Coury, G/PHN/OPFS
· Carol Dabbs, LAC/RSD/PHN
· Maggie Farrell, LAC/RSD/PHN
· John Novak, G/PHN/HIV-AIDS
World Bank, Brasilia
· John W. Garrison II
B. Documents Reviewed
ABIA Relumé-Damará, Jonathan Mann, AIDS no Brasil, Rio de Janeiro, 1994.
CN-DST/AIDS, Carmen Dhalia, Draurio Barreira e Euclides de Castilho, SPS-MS AIDS no
Brasil – Situação Atual e Tendências.
Coordenacão DST/AIDS, Carmen Dhalia, Draurio Barreira e Euclides de Castilho, SPS-MS
AIDS no Brasil – Situação Atual e Tendências.
Correio da Bahia, “Parceria Viabiliza Projecto de Prevenção,” terça-feira, 05 de setembro de
2000.
De Souza, Maria Madalena, Cartilha de Higienização Hospitalar, Prefeitura Municipal de
Fortaleza, Secretaria Municipal de Desenvolvimento Social, Fortaleza, 2000.
De Souza, Maria Madalena, Higienização Hospitalar: Manual de Normas e Rotinas, Prefeitura
Municipal de Fortaleza, Secretaria Municipal de Desenvolvimento Social, Fortaleza, 2000.
Distribução de Casos de AIDS, Segundo Ocorrência na capital e interior deo estado. Ceará,
1995-2000. Undated handout given to evaluator during site visit.
Distribução de Casos de AIDS, Segundo Sexo e Idade. Ceará, 1995-2000. Undated handout
given to evaluator during site visit.
Distribução de Casos de DST, Sífilis Congêtica, AIDS, Segundo Ano de Diagnóstico. Ceará,
1995-2000. Undated handout given to evaluator during site visit.
Estado do Ceará, Secetaria da Saúde , Célulaa da SaúdeSexual e Reproductiva, “Projecto de
Fortalecimento da Açõs Integradas de DST/AIDS e Saúde Reproductiva,
Estado do Ceará, Secretaria Estadual da Saúde, Secretarias Municipais de Saúde, “Sistema
Microrregional de Serviços de Baturité. Undated handout given to evaluator during site visit.
FHI – Family Health International, BRAZIL – “Semi-Annual Report # 5,” Impact –
Implementing AIDS Prevention and Care Project, April to September 30, 2000.
FHI – Family Health International – FACT, Ferramenta de Auto-avaliação de Capacidade
Técnica, Janeiro 2000.
FHI – Family Health International, Consolidação de Baselines – Monitoramento USAID,
Fevereiro 2000.
FHI, Relatório da Oficina de Aplicação do FACT, São Paulo, 04 a 06 de outubro de 1999.
FHI, Relatório da Oficina de Aplicação do FACT, Salvador, 20 a 22 de Setembro de 1999.
FHI/IMPACT, Plano de Trabalho Ano I – Revisado, Outubro 98 a Setembro 99.
FHI/IMPACT – Relatório Final das Oficinas de Auto-avaliação da Capacidade Técnica – FACT,
Fevereiro 2000.
FHI/IMPACT, Consolidado do Plano de Trabalho Ano II (CA’s), Outubro 1999 – Setembro
2000.
FHI/IMPACT, FY01 Workplan and estimated budget, October 2000 – September 2001.
FHI/IMPACT, Semi-Annual Report 6, Cooperative Agreement HRN-A-00- 97-00017-00, April
to September 30, 2000.
FHI/IMPACT, APROGE & FACT, Auto-avaliação de Processos Gerenciais e da Capacidade
Técnica de Programas e Organizações que Atuam no Controle, Prevenção e Assistência às DST e
à AIDS.
FHI/IMPACT, “Consolidado do Plano de Trabalho Ano II (CA’s), Outubro 1999 – Setembro
2000.”
FHI/IMPACT, “Plano de Trabalho Ano I – Revisado, Outubro 98 a Setembro 99.”
FHI/IMPACT, “Semi-Annual Report 6, Cooperative Agreement HRN-A-00-97-00017-00,” April
to September 30, 2000.
FORTALEZA, PREFEITURA MUNICIPAL, Secretaria Municipal de Desenvolvimento Social,
Boletim de Saúde de Fortaleza, PACS – Programa Agentes Comunitários de Saúde, Fortaleza,
CE, ano III, nº 4 – Outubro a Dezembro 1999.
Governo do Estado de Ceará, Secretaria Estadual da Saúde, “Microrregiões de Saúde, Uma
Opção do Ceará. Undated handout given to evaluator during site visit.
“Instrumento para Avaliação da Qualidade da Assistência Integrata DST/AIDS/SR;” Undated
handout from Pathfinder.
“Instrumentos para o Diagnóstico de Necessidades para o Fortalecimento da Qualidade da
Atenção Integrada DST/AIDS/SR;” Various reports of site visits to Pathfinder-trained health post
staff dated from October 6 1998 through March 23 1999.
Ministerio da Saúde, Secretaria de Políticas de Saúde, Coordenação Nacional de DST e AIDS,
“AIDS II: Relatorio de Implementação,” Brasília –DF, 22 de Septembro de 2000.
MSH – Management Sciences for Health, Management needs assessments and management
training/Brazil – Final Report, Impact Project, June 1,1998 through September 30, 2000.
MSH – Management Sciences for Health, APROGE DST/AIDS, Auto-Avaliação dos Processos
Gerenciais.
MSH/BRASIL, Relatório Parcial, Ano I, 01 a 31/07/1999.
NEPAIDS, Programa Estadual DST/AIDS-SP, CRT DST/AIDS-SP, Tá Difícil de Engolir? –
Experiências de adesão ao tratamento anti-Retrovial em São Paulo, São Paulo, 2000.
Pathfinder/SESA/SMDS; Activdades de Maio 2000, Junho 2000, Julho 2000, Agosto 2000,
Cronograma de Visitas de Avaliação.
Pathfinder do Brasil, “Integrated Performance Improvement Checklist,” Handout during
Evaluation Visit to Pathfinder do Brasil offices, October 2000.
Pathfinder do Brasil, “Needs Assessment Checklist,” Handout during Evaluation Visit to
Pathfinder do Brasil offices, October 2000.
Pathfinder do Brasil, “Project Overview: Challenges, Strategies, Progress to Date and Lessons
Learned,” Handout during Evaluation Visit to Pathfinder do Brasil offices, October 2000.
Pathfinder do Brasil, “Public Sector Financial Counterpart,” Handout during Evaluation Visit to
Pathfinder do Brasil offices, October 2000.
Pathfinder do Brasil, “Workplan Sample, Health Unit,” Handout during Evaluation Visit to
Pathfinder do Brasil offices, October 2000.
Pathfinder do Brasil, “Workplan Year III,” Handout during Evaluation Visit to Pathfinder do
Brasil offices, October 2000.
Pathfinder International, GAPA Bahia Article, Pathpapers, Vol. 1, No. 1, Spring 2000.
Prefeitura Municipal de Fortaleza, Secretaria Municipal de Desenvolvimento Social,
“Boletim de Saúde de Fortaleza: Doenças de Notificação,” Ano III No. 1/1999.
Prefeitura Municipal de Fortaleza, Secretarias Executivos Regionais, Map of Munipality given to
Evaluator During Site Visit, October 2000.
Projecto HIV/DST Ceará, Boletim Informativo, Agosto/Setembro 2000, No. 2.
Projeto “Fortalecimento das Ações Integradas DST/AIDS e Saúde Reproductiva,” SESAB/SMS￾SESA/SMDS-Pathfinder do Brasil, “Instrumento de Melhoría do Desempenho da Equipe da
Saúde – Assistência en DST/Prevenção À AIDS; Various undated handouts given evaluator while
making site visits in Bahia.
Revista do Farmacêutico, nº 49, São Paulo.
RIO, PREFEITURA, Secretaria Municipal de Saúde, Saúde em Foco, DST/AIDS 2000, Boletim
Epidemiológico, Ano IX, nº 20, Rio de Janeiro, Novembro, 2000.
RIO, PREFEITURA DO, Secretaria Municipal de Saúde, Saúde em Foco, Sífilis na Gravidez,
Ano IX, nº 24, Rio de Janeiro, Maio 2000.
SÃO PAULO, GOVERNO DO ESTADO, Secretaria de Estado da Saúde de São Paulo, Programa
Estadual DST/AIDS, Boletim Epidemiológico, Sífilis Congênita e Doenças Sexualmente
Transmissíveis – Dois desafios para a Saúde Pública, Ano II, nº 1 – São Paulo, Janeiro de 1998.
SÃO PAULO, GOVERNO DO ESTADO, Secretaria de Estado da Saúde de São Paulo, Programa
Estadual DST/AIDS, Boletim Epidemiológico, AIDS – Humanização de Paciente HIV/AIDS,
Ano XVIII, nº 1 – São Paulo, Abril de 2000.
SÃO PAULO, GOVERNO DE, Programa DST/AIDS, Secretaria de Estado Da Saúde de São
Paulo, Boletim Epidemiológico, CRT – DST/AIDS, AIDS – Imunização de Pacientes HIV/AIDS,
Ano XVIII, nº 1, São Paulo, Abril 2000.
São Paulo, prefeitura do município de, Secretaria Municipal da Saúde, Programa de DST/AIDS,
Boletim Epidemiológico de AIDS do Município de São Paulo, “A Mortalidade por AIDS,” Ano I,
nº 1, São Paulo 1997
São Paulo, prefeitura do município de, Secretaria Municipal da Saúde, Programa de DST/AIDS,
Boletim Epidemiológico de AIDS do Município de São Paulo, “A Mortalidade por AIDS,” Ano I,
nº 2, São Paulo 1997.
São Paulo, prefeitura do município de, Secretaria Municipal da Saúde, Programa de DST/AIDS,
Boletim Epidemiológico de AIDS do Município de São Paulo, Subsídio para um Estudo
Regional, Ano II, nº 4, São Paulo 1998.
São Paulo, prefeitura do município de, Secretaria Municipal da Saúde, Programa de DST/AIDS,
Boletim Epidemiológico de AIDS do Município de São Paulo,”Distribuição Espacial dos Casos
Notificados De AIDS no Município de São Paulo,” Ano II, nº 3, São Paulo 1998
Saúde, Ministério da, Secretaria de Políticas de Saúde, Coordenação Nacional de DST e AIDS,
“Política Nacional de DST/AIDS, Princípios, Diretrizes e Estratégias,” Brasília, 1999.
Saúde, Ministério da, Secretaria de Políticas de Saúde, Coordenação Nacional DST/AIDS,
Controle do HIV/AIDS: A experiência brasileira, Brasília, 1994 – 1998.
Saúde, Ministério da, Secretaria de Políticas de Saúde, Coordenação Nacional DST e AIDS,
“AIDS no Brasil – Um esforço conjunto Governo-Sociedade,” Brasília, Julho 1998
SAÚDE, MINISTÉRIO DA, Secretaria de Políticas de Saúde, Coordenação Nacional DST/AIDS,
Controle do HIV/AIDS: A experiência brasileira, Brasília, 1994 – 1998.
SAÚDE, MINISTÉRIO DA, Secretaria de Políticas de Saúde, Coordenação Nacional DST e
AIDS, AIDS no Brasil – Um esforço conjunto Governo-Sociedade, Brasília, Julho 1998
SAÚDE, MINISTÉRIO DA, Secretaria de Políticas de Saúde, Coordenação Nacional de DST e
AIDS, Política Nacional de DST/AIDS, Princípios, Diretrizes e Estratégias, Brasília, 1999.
SAÚDE, MINISTÉRIO DA, AIDS II – Relatório de Implementação, Acordo de Empréstimo
BIRD 4392/BR, Brasília, 22 de setembro de 2000.
Secretaria de Saúde do Estado de São Paulo - APROGE DST/AIDS Brasil, Plano de Ações–
CRT/DST AIDS, 04/07/00.
Servicio Social do Comércio Rio Grande do Sul (SESC), “Relatorio de Evento/Activitades, April
19 1999.
Sitrick, James B., Jr. “Summary Points from Evaluation of DKT and Pathfinder Components of
USAID/Brazil Strategic Objective 3,” October 20 2000.
SO3, Increase sustainable and effective programs to prevent sexual Transmission of HIV/AIDS
among major target groups.
Social Development Notes, NGO Participation in HIV/AIDS Control Project in Brazil Achieves
Results, May 1999.
UNAIDS, Epidemiological Fact Sheet on HIV/AIDS and sexually transmitted Infections, 2000
update.
UNAIDS, Report on the Global HIV/AIDS Epidemic – June 2000.
UNAIDS, Epidemiological Fact Sheet on HIV/AIDS and sexually transmitted Infections, 2000
update.
UNAIDS, Report on the Global HIV/AIDS Epidemic – June 2000.
Undated Organigram of Ceará State Health system.
UNESCO – Pesquisa Nacional, Violência, AIDS e Drogas nas Escolas, Brasília, Maio de 2000.
UNITED NATIONS DEVELOPMENT PROGRAM, Final Evaluation – Prevention and Control
of Sexually Transmitted Diseases and AIDS, BRA/92/001, May 1998.
USAID/Brazil, “SO 3 Performance Data Tables,” dated April 27, 2000.
USAID/Brazil, “Strategic Objective 3 Results Framework and Performance Monitoring Plan,”
undated.
USAID/Brazil, R4 – FY 2001, March 1999.
USAID/Brazil, R4, April 2000.
USAID/Brazil, Strategic Objective 3, “Increase sustainable and effective programs to prevent
sexual transmission of HIV/AIDS among major target groups.”
USAID/Brazil, Strategic Plan for HIV/AIDS Prevention and Control,FY 1998-2002.
USAID – Development Experience Clearinghouse, USAID/BRAZIL R-4 –FY 2001.
USAID, G/PHN/POP, Ellen Starbird, PHN Team Review of Brazil R4, May 18, 2000.
World Bank, “Project Appraisal Document on a Proposed Loan in the Amount of U$ 165 million
equivalent to the Federative Republic of Brazil for a second AIDS and STD Control Project,”
July 31, 1998.
THE WASHINGTON POST, Brazil Becomes Model in Fight Against AIDS, Sunday, September
17, 2000.
THE WASHINGTON POST, Manufacture Provision of Drugs Reverse AIDS Epidemic in Brazil,
Sunday, September 17, 2000.
WORLD BANK, Project Appraisal Document on a Proposed Loan in the Amount of US$
165 million equivalent to the Federative Republic of Brazil for a second AIDS and STD Control
Project, July 31, 1998.
WORLD BANK, Civil Society – Government – World Bank Relation in Brazil, John Garrison,
From Confrontation to Collaboration, June 2000 Washington, DC.
WORLD BANK, Segundo Projeto de Controle de DST e AIDS, Missão De Supervisão, Brasília,
18 a 22 de setembro de 2000.
C. Scope of Work
BACKGROUND:
The evaluation of the first IBRD loan to the Government of Brazil for HIV/AIDS
prevention (AIDS I) found that most STD/AIDS prevention programs in Brazil have
developed good prevention techniques, either through adapting other countries'
experiences or creating new approaches according to Brazil's peculiarities. However, the
same evaluation also detected management weaknesses in state and municipal STD/AIDS
programs and recommended that these programs need to improve their autonomy and
institutional sustainability, in addition to learning how to make best use of the resources
available.
During the development phase of the second IBRD loan (AIDS II), in-depth discussions
took place on ways to address the above issues, as well as on the monitoring and
evaluation of these activities. As a result of active participation in those discussions,
USAID/Brazil developed a five-year AIDS prevention strategy (Strategic Objective #3)
for "Increased sustainable and effective programs to prevent sexual transmission of HIV
among major target groups".
The four original SO level indicators (1) Number of 4 target states with greater that 5%
increase in expenditures of HIV prevention; (2) Number of effective interventions
adopted by USAID-funded and non-USAID funded programs;,(3) Percent financial
sustainability of condom social marketing programs (DKT and BEMFAM); and (4) HIV
incidence among military draft registrants) were revised in FY 1999 and currently include
four new indicators: (1) Number of programs/organizations demonstrating low, medium
and high levels of effectiveness in planning and implementation; (2) Number of
programs/organizations demonstrating low, medium and high levels of effectiveness in
evaluation; (3) Number of target programs achieving or maintaining low medium and
high levels of expenditure of allocated funds from the loan for HIV/AIDS; and, (4)
percent of financial sustainability achieved by DKT of Brazil (dropping BEMFAM)
condom social marketing).
Currently USAID/Brazil is financing three implementing partners: FHI (located in
Brasilia) with subcontractor MSH (located in Rio), PSI/DKT (located in Sao Paulo) and
Pathfinder (located in Salvador, Bahia). At the SO level FHI/MSH report on results for
indicators #1 and #2. The Ministry of Health in Brasilia reports of indicator #3 and DKT
reports on indicator #4.
At the intermediate Results (IR) level FHI/MSH is responsible for implementing and
reporting results on activities under IR#1"Strengthen institutional capacity to plan,
implement and evaluate STI/HIV programs" - the nine programs include the three state
secretariats of Health in Sao Paulo, Bahi and Ceara, and the six municipality health
secretariats of Rio, Sao Paulo, Campines, Santos, Salvador and Fortaleza). Pathfinder is
responsible of implementing and reporting results on IR#2 (Strengthen institutional
capacity to conduct in-service training to implement quality integrated Reproductive
Health (RH) and STI/HIV/AIDS services (in Bahia and Ceara only). DKT implements
and reports results on IR#3 (Sustainable condom social marketing).
PURPOSE OF THE EVALUATION:
The purpose of this mid-term evaluation is to assess the overall accomplishment of
USAID's Strategic Objective #3 (HIV/AIDS) program in Brazil to date and the
appropriateness of the project strategy as well as to make recommendations for
improvements, expansions to and/or new activities in the HIV/AIDS prevention arena for
implementation during the next few years. The evaluation will examine the adequacy of
the current indicators, the data collection and monitoring systems, the tools and methods
used to provide technical assistance to achieve SO#3 goals. Finally, the evaluation will
examine the technical assistance and training provided by USAID/Brazil's implementing
partners to SO#3 customers (State and Municipal Health Secretariat, GOB Ministry of
Health AIDS national Coordination, Non-Governmental Organizations involved in AIDS
prevention).
STATEMENT OF WORK:
The grantee shall conduct an evaluation and submit a report, which provides clear and
concise findings, conclusions and recommendations. The evaluation reports shall also
provide a statement of lessons learned and future directions that may emerge from the
exercise.
The key aspects of the project to be addressed are listed below:
1. Approach:
USAID interventions focus on promoting behavior change to reduce high-risk sexual
behaviors. In addition, the SO#3 aims at promoting the use of condoms, and improving
the management capacity, and improving the quality of STD/HIV/AIDS services
provided by NGOs and State and Municipal Secretariats.
Questions that should be addressed are:
· Are the interventions effectively achieving the SO#3 goals?
· Does the approach need to be revised or reinforced?
· How effective has the SO#3 strategy been at integrating its IR activities into Brazil's
health care systems at various levels?
· Is there any duplication of effort between the initiatives of State and Municipal
Secretariats and the activities under SO#3?
· Is there room for expansion without duplicating other programs or has the area been
saturated?
Primary Responsibility -- Team Leader
2. Capacity Building/Partnership Development/Sustainability:
USAID/Brazil's SO#3 AIDS prevention program works with several organizations to
accomplish the objectives of the program. Inherent in the strategy is strengthening the
capacity of various organizations, to effect behavioral change among high-risk groups in
the four target states. (Note: USAID/Brazil's US NGO implementing partners and their
customers are considered as USAID's partners for the achievement of SO#3 goals.)
The Team should consider:
· What have been the efforts so far to create effective partnerships and what needs to be
done to further these efforts?
· Is capacity building taking place? What further efforts need to be taken?
· Are the results of SO#3 activities sustainable? If not, what further efforts are needed?
Primary Responsibility – Program Monitoring & Evaluation Expert
3. Implementation:
To contribute to achieving the Strategic Objective three intermediate results were
selected; (IR# 1- Strengthen institutional capacity to plan, implement and evaluate
STI/HIV programs, IR#2 - Strengthen institutional capacity to conduct in-service training
to implement quality integrated Reproductive Health (RH) and STI/HIV/AIDS services
(in Bahia and Ceara, and IR#3 - Sustainable condom social marketing).
Issues to consider include:
· Is implementation on track and achieving satisfactory progress towards stated
objectives?
· How effective have USAID/Brazil's implementing partners been in implementing SO
activities (FHI/MSH, PSI/DKT, Pathfinder and to a lesser degree Population Council)
and how effective have customers(state and municipal secretariats of health, the CN
and AIDS NGOs) been in adopting the TA and training they have received to their
HIV/AIDS programs?
· Are the indicators, data collection and monitoring systems adequate for measuring
impact of current and future activities?
· Are the results of the SO#3 AIDS prevention program being produced at an
acceptable cost?
· Is the financial and person-months input level adequate or too high/low for the
intended outputs?
· Has the absorptive capacity of implementers been reached?
· What has been the impact to date of Technical Assistance provided by
USAID/Brazil's implementing partners?
Primary Responsibility – PM&E Expert
4. Social Marketing & Communications
Sustainable social marketing was to contribute to the effectiveness of Brazilian efforts in
preventing sexual transmission of HIV by making affordable condoms more accessible to
lower middle class consumers. Free condoms for the lowest income groups were to be
provided to public health facilities by the Ministry of Health.
Issue to consider include:
· Do the percentage changes of DKT do Brazil male and female condoms reflect that
need is being met?
· What degree of financial sustainability has been achieved by the DKT do Brazil
social marketing program?
· What are the identified effective interventions which have been disseminated?
· Are the interventions sufficient to meet SO#3 goals of preventing sexual transmission
of HIV among the target groups?
Primary Responsibility -- Social Marketing/Communications Expert
5. Attribution:
While USAID/Brazil works directly with US NGO implementing partners, USAID/Brazil
also works directly or indirectly with the Ministry of Health and other international
donors through the UNAIDS Thematic Group to achieve the results under the Strategic
Objective. During the implementation period of the World Bank-funded AIDS II Project,
USAID/Brazil SO#3 will provide technical assistance to the Ministry of Health to ensure
that the best practices developed under the existing government and donor programs are
disseminated, thus spreading knowledge of effective use of resources already invested in
pilot programs.
Issues to consider include:
· Is the host country (which includes central/state/municipal governments, private
sector) and/or other donors providing support to any of USAID/Brazil's SO#3
activities?
· What is the nature of their intervention and what is the amount of the resources
involved?
· Does the USAID/Brazil SO#3 project significantly influence the direction of the host
country and/or other donor resources; i.e. did the USAID activities help to leverage
new or additional funds? If yes, how did SO#3 activities accomplish this?
· Are interventions under SO#3 leading to replication of similar activities by the host
country and/or other donors, i.e. did it have a demonstration effect?
· Based on these do the indicators accurately reflect the manageable interest of
USAID/Brazil's SO#3?
Primary Responsibility – Team Leader / PM&E Expert
6. Future Direction:
Based on the progress to date the Team is requested make recommendations regarding
the initiation of new activities which would complement or strengthen SO#3.
Primary Responsibility – Team Leader and Team Members
METHODOLOGY
In order to examine the above issues, the following methodology should be considered:
· Review of documents such as USAID/Brazil's 1998-2002 Strategy Document, Result
Review and Resources Request (R4) and semi-annual reports from implementing
partners
· Meetings and discussions with appropriate officers at USAID and three implementing
partners and their subcontractors, GOB's ministry of Health National AIDS Control
Program (CN) other donors including UNAIDS and PAHO
· Review USAID/Brazil's of monitoring and evaluation reports
· Site visits to SO#3 funded activities in the field and other agencies
· Interaction with target groups
· Other information such as case studies, observational and anecdotal data may also be
used as appropriate.
REPORTING REQUIREMENTS:
The grantee's consultant(s) undertaking the evaluation/assessment phase (Evaluation
Team) of this Scope of Work (SOW) will conduct an initial briefing with appropriate
USAID/Brazil officials to present a schedule of activities to carry-out the evaluation
including a timeline for USAID/Brazil approval.
The grantee's evaluation team will submit a draft evaluation report (1 hard copy and a
computer version - either in the form of floppy disk or as an email attachment) to
USAID/Brazil for its review no later than two days prior to the final briefing in Brasilia
USAID/Brasilia will have 2 weeks to provide comments to the draft after which the
grantee will have 2 weeks to incorporate these comments and 1 week to edit, proof and
print the final evaluation report (to be submitted to USAID/Brazil electronically).
The appendices will include at a minimum the following:
· bibliography of documents consulted
· list of institutions and individuals consulted
· list identifying other documents relevant to this evaluation.
PERFORMANCE PERIOD
The evaluation team will accomplish the field work in Brazil in two phases. In the first
phase of approximately three weeks duration, Social Marketing Specialist will cover the
DKT and Pathfinder programs. Depending on the availability of qualified and acceptable
consultants, the Team Leader and Program Monitoring & Evaluation Specialist will
return to Brazil for two to three weeks to cover the FHI and MSH programs)
The expected period of performance for the first phase will be September 25 through on
or about October 12, 2000.
The schedule will be as follows:
Week 1: (Brasilia only)
· Initial briefing in Brasilia with USAID/B staff
· Meet in Brasilia with MOH AIDS Coordinacao National (CN) staff
· Meet in Brasilia with donors - World Bank, WHO/PAHO, UNAIDS, UNESCO
· Meet in Brasilia with USAID/Brazil's implementing partner for IR#1 (FHI)/MSH)
End of Week 1 plus Weeks 2 and 3:
· Field visits in the state of Sao Paulo to USAID/Brazil's implementing partner for
IR#3 (DKT) and some of its local NGO subgrantees
· Field visits in the states of Ceara and Bahia to meet with USAID/Brazil's
implementing partner for IR#2 (Pathfinder) as well as meet Pathfinders FHI/MHS
and DKT's public sector (state and municipal secretariats of health) and private sector
(local AIDS NGOs), and customers of USAID/Brazil's At Risk Youth programs
which involve the dissemination of AIDS prevention information.
· Field visits to Rio de Janeiro to meet with the State secretariat of Health, visit DKT
subgrantee customers, as well as potential implementing partner, BEMFAM. Also,
meet with PAHO AIDS official., and the head of the National AIDS Committee in
Brasilia.