April 2008 This publication was produced for review by the U.S. Agency for International Development (USAID). It was jointly prepared by Mr. Chris Ward, Dr. John Ross, Ms. Anne Jorgensen, and Ms. Nadia Carvalho of the Health Policy Initiative, Task Order 1; and Mr. David Wilkinson, independent consultant. An Evaluation: Implementing the A-Squared Project in Bangladesh, China, Thailand, and Vietnam The USAID | Health Policy Initiative, Task Order 1, is funded by the U.S. Agency for International Development under Contract No. GPO-I-01-05-00040-00, beginning September 30, 2005. Task Order 1 is implemented by Futures Group, in collaboration with the Centre for Development and Population Activities (CEDPA), White Ribbon Alliance for Safe Motherhood (WRA), Futures Institute, and Religions for Peace. A2 is a joint project implemented by Family Health International (FHI), the East-West Center (EWC), and the USAID | Health Policy Initiative, Task Order 1, in collaboration with a number local organizations. The A2 Project aims to promote effective advocacy for evidence-based responses to HIV in Asian countries. An Evaluation: Implementing the A-Squared Project in Bangladesh, China, Thailand, and Vietnam April 2008 The views expressed in this publication do not necessarily reflect the views of the U.S. Agency for International Development or the U.S. Government. TABLE OF CONTENTS Abbreviations...............................................................................................................................................iv Introduction...................................................................................................................................................1 Regional A² Interviews .................................................................................................................................3 Bangladesh....................................................................................................................................................5 China.............................................................................................................................................................8 Thailand ......................................................................................................................................................12 Vietnam.......................................................................................................................................................15 Annex 1: List of Interviews ........................................................................................................................21 Annex 2: A² Meetings, Workshops, and Events .........................................................................................23 Resources ....................................................................................................................................................26 iii iv ABBREVIATIONS A2 Analysis and Advocacy (Project) AEM Asian Epidemic Model AIDS acquired immune deficiency syndrome ASIC AIDS Strategic Information Center CDC Centers for Disease Control (Chinese version) CEDPA Centre for Development and Population Activities DFID United Kingdom Department for International Development EWC East-West Center FHI Family Health International HCMC Ho Chi Minh City HIV human immunodeficiency virus ICDDR,B International Center for Diarrheal Disease Research, Bangladesh IDU injecting drug user MARP most-at-risk population MOPH Ministry of Public Health MOU memorandum of understanding MSM men who have sex with men NASP National AIDS and STD Program (Bangladesh) NGO nongovernmental organization NIHE National Institute of Hygiene and Epidemiology (Vietnam) PAC Provincial AIDS Committee (Thailand, Vietnam) PEPFAR U.S. President’s Emergency Plan for AIDS Relief PLHIV people living with HIV PRI Policy Research Development Institution Foundation RDM/A Regional Development Mission in Asia RNM Resource Needs Model RTI Research Triangle Institute STD sexually transmitted disease STI sexually transmitted infection TB tuberculosis TWG Technical Working Group UNAIDS Joint United Nations Program on HIV/AIDS USAID United States Agency for International Development VAAC Vietnam Administration for AIDS Control INTRODUCTION The Analysis and Advocacy (A²) Project is funded by the United States Agency for International Development (USAID) and jointly implemented by Family Health International (FHI), the East-West Center (EWC), and Futures Group. The overall goal of the project is to enhance the effectiveness of HIV and AIDS responses by promoting the use of evidence-based data to direct interventions and resources toward factors driving the HIV epidemic. The project works with numerous in-country organizations at the national and provincial levels, including AIDS control committees, departments of health, and research and epidemiology centers that track the course of the HIV epidemic. The A² approach builds on the integrated analysis work pioneered by the EWC. Integrated analysis includes the collection and analysis of all available biological, behavioral, programmatic, and economic data to provide a complete picture of an HIV epidemic in a particular country. The EWC led the data analysis in Asia and characterized the region’s HIV epidemics as follows:  Asian epidemics follow a similar pattern but vary in how quickly they grow and the level of HIV prevalence reached among different populations.  Prevalence is first found among injecting drug users (IDUs) and men who have sex with men (MSM) and then starts to spread among sex workers and their clients.  Male IDUs, MSM, and clients of sex workers transmit HIV to their wives, who, in turn, transmit HIV to their children. Despite this information and the availability of some country data, a gap was identified between lessons learned and the programs and policies being implemented. Governments, donors, and civil society are not appropriately targeting their interventions in reflection of the above factors. Data collected are peripheral to the decionmaking process, and data systems are not evolving strategically to fill gaps and help direct effective and appropriate responses. Finally, there is often insufficient political commitment to support effective responses for the stigmatized populations affected by the epidemic. Thus, prevention efforts targeting most-at-risk populations (MARPs) remain extremely limited. The A² Project: Integrated Analysis and Advocacy The A² Project moves the integrated analysis process one step further by incorporating advocacy at all stages of the analysis of and response to the epidemic. A² provides a practical approach to gathering, analyzing, and using information; extracting from this information relevant evidence-based recommendations for policies and programs; and proactively advocating for these recommendations to be translated into more effective policies and programs. The A² Project builds capacity at the national and provincial levels to collect and analyze local epidemiological, behavioral, response, and program-costing data with state-of-the-art modeling tools. This information is used to determine the responses and resources needed for achieving maximum impact, which are then shared with policymakers, program managers, and donors to promote evidence-based decisionmaking. To guide the advocacy process, the Health Policy Initiative designed the A² Advocacy Training Manual. Adapted from the Networking for Policy Change: An Advocacy Training Manual, developed by the POLICY Project in 1999, it draws from numerous HIV and advocacy resources and materials from the Asia-Pacific region, as well as from the experiences of practitioners working on advocacy and policy improvements in the region, particularly China, Thailand, and Vietnam. 1 Linking the Asian Epidemic Model and the Goals Model The A² Project makes strategic use of two models: the Asian Epidemic Model (AEM) developed by the EWC and the Goals Model developed by Futures Group. The successful linkage of these key modeling tools was a significant contribution to the establishment and credibility of the A² Project. AEM calculates expected trends in HIV infection based on observed patterns of the spread of HIV in the region. It uses behavior and STI trends, along with transmission probabilities and other relevant co￾factors, to determine the observed HIV trends among different MARPs. Once these baseline scenarios are available, the AEM can be used to explore the impact of differences in risk behavior, STI prevalence, and other relevant co-factors. Thus, AEM can be used to accurately model HIV prevalence trends based on measured behavioral trends. The Goals Model supports effective strategic planning by linking program goals to the level of resources necessary to achieve those goals. The model helps planners to understand the effects of funding levels and allocation patterns on program impact. It can also be used to set priorities for research allocation within HIV programming and to translate program coverage into infections averted. The AEM and Goals Model applications have produced high-quality data about the current epidemic and response, as well as alternative scenarios of the epidemic’s course based on changes in risk behavior and resource allocation. The data have provided compelling material for use in advocacy activities to promote more effective responses to the epidemic. The linked models create major opportunities to influence policymakers’ decisions about resource allocation and to estimate infections averted and costs for different combinations of interventions. Evaluating the A² Project The A² Project was launched at an inaugural project meeting in Bangkok in November 2004. The project is guided by a Regional Management Team, which includes representatives from FHI, EWC, and Futures Group. A Regional Technical Support Team provides support to the A² country teams. The project is implemented in Bangladesh, China, Thailand, and Vietnam. In late 2007, the Regional Development Mission in Asia (RDM/A) requested that an evaluation of the project be carried out in the four countries. The evaluation included a review of A² project-related documents, in-country interviews, and interviews with members of the A² regional management team (see Annex 1 for a list of the interviewees). The choice of evaluation consultants was vetted by FHI, Futures Group, and EWC; and the following were selected as part of the evaluation: John Ross of Futures Group (Bangladesh, China, and the region overall); a consultant, David Wilkinson (Thailand); and Anne Jorgensen of CEDPA (Vietnam). This report highlights the identified project successes, challenges, and recommendations for the future in each country. 2 REGIONAL A² INTERVIEWS Telephone interviews were conducted with several members of the A² regional management team, including those who had provided technical assistance to the project. These interviews provided information on the regional implementation of the project, including the provision of technical assistance. The major findings are described below. Funding During the time between the project’s initiation and the end of 2007 when these interviews were conducted, FHI faced two budget cuts that had an impact on the project’s implementation. In addition, some of the Futures Group work was under-funded, contributing to the challenges it faced in Bangladesh and elsewhere. Nevertheless, one respondent felt that the funding was generally adequate and continuous and that with more money, both FHI and Futures Group would have encountered other constraints. However, another respondent said that the limited funding reduced his time traveling in-country. Several respondents commented that the level of funding should be tied to the level of demand, which was already high at the project’s inception. Staffing Regional staff were highly qualified, but their time and availability were limited, so sometimes assistance to the countries was not as timely as it might have been. Regional support for the models was intensive, including working with local staff to apply the models with country data. Within countries, some local staff were distracted by other duties. Advocacy Work Respondents felt that the advocacy work needed to be more methodical and that more resources were needed to establish stronger supporting structures, especially for forming functioning technical advisory groups or advocacy networks. Skills building and other advocacy-related activities were limited. However, in China, project participants quickly grasped the models and advocacy concepts, taking messages to higher levels to increase budgets and so on. The limited support in Bangladesh partly stemmed from the lack of a Futures Group country office, staff turnover, and possibly a budget constraint affecting who could be recruited. Models AEM is a complex tool, and the EWC has been working to simplify it for the user. Over the last couple of years, the EWC has entered all the inputs and outputs (charts, tables, etc.) into Excel spreadsheets, which helps the user. The calculations are done separately from the data input and production of outputs, as intermediate calculations. However, AEM requires further work to add automatic consistency checks among data inputs, more built-in error checks, and more flags to catch improbable data inputs or results. User guidelines are being drafted. Interviewees felt that the Goals Model should follow the same approach, as one page on the screen may combine inputs and calculations. The Goals Model was adapted in the field, so it should now be revised for greater clarity and consistency in appearance. Respondents believed that in the future, the two models should be completely linked in one package. Also, the training load should be lightened, with decisions on the minimum required data, to permit more to be done at the national level. 3 Without question, local applications of the two models were hampered by poor data and uncertain assumptions, as well as by the complexity of the application. Therefore, more regional assistance was needed and will continue to be needed for training and fresh examinations of the available information. During the project, the availability and timing of regional support was constrained due to funding limits and the scheduling of experts’ visits. Summary Overall, the A² Project was ambitious from the start—not just because of the technical models but also because of the expectation of important policy changes. These changes take time, and it is difficult to tie project activities to particular changes given the complexity of the larger context. One can identify many factors affecting both the project and the environment: three international partners, multiple funding sources, diverse country situations, the regional focus, the mixture of highly technical analysis and advocacy work, and the political agenda. Nevertheless, it is clear that the project built local partnerships; increased local capacity; and applied and linked two useful models, fostering a better understanding of the HIV epidemic through the generation and use of new data and analyses. The project influenced policymaking, program planning, and resource allocation; and was successful in advocating for new national prevention goals in Thailand and for more funding for HIV efforts and an expansion of the data analysis process in China. One respondent expressed satisfaction about what has been achieved in only two years. Policy changes take time, but in several cases, the A² Project had a direct impact on government policies. This is evidence that the project successfully responded to a gap in assistance in these countries. 4 BANGLADESH Background and Project Structure With numerous donors and nongovernmental organizations (NGOs) implementing programs, HIV/AIDS activities are receiving significant support. The A² Project is one of many programs influencing the HIV environment. In Bangladesh, the USAID Mission funds A2 Project activities through a large bilateral agreement with FHI. FHI, in turn, subcontracts with Futures Group on specific activities, which recently included using AEM to project future HIV/AIDS trends for MARPs and conducting advocacy training. The model was applied first in Dhaka City and was then expanded to the whole country. The Goals Model was used to compare resource allocations for alternative action programs to gauge their impact and cost-effectiveness. The Bangladesh project, housed in FHI’s country office, employs both local and international staff, including long-term staff members, Amala Reddy (FHI Analyst) and Robert Kelly (FHI Country Director). Futures Group funds a part-time local advocacy position. International staff inputs from the East-West Center (Tim Brown) and Futures Group (Christopher Ward, Sarah Alkenbrack, Gayle Martin, and Nalinee Sangrujee) have been extensive. Timeline FHI, as part of the IMPACT Project, began implementing the “Integrated Analysis and Advocacy” approach and established the first set of size estimates for MARPs, including IDUs, sex workers, MSM, and others. Begun in September 2003, the estimation work was extensive, with staff visiting NGOs that work with each population group. A government working group was engaged to determine and approve the estimates, and the government officially adopted the findings at the end of 2005.1 In 2006, USAID/Bangladesh provided FHI’s bilateral project with funding to support the Goals Model application and advocacy activities through a subcontract with Futures Group. The AEM and Goals Model Early training on the AEM occurred in April 2004 during a workshop in Bangkok with Tim Brown and during the EWC’s 35th Summer Seminar on Population; both workshops were for country staff who would be directly involved in implementing the AEM in their respective countries. The A² Project in Bangladesh was fortunate to be able to use these size estimates of the various MARPs in the AEM and Goals Model applications. A series of additional workshops in Hawaii and Bangkok followed (see Annex 2), including one in April 2005 and another in April 2008 just for Bangladesh. By mid-2005, the A2 Project completed the first AEM application for Dhaka City; and in October, Amala Reddy (FHI) and Tim Brown (EWC) presented the results to the National AIDS and STD Program (NASP), associated NGOs, the AIDS Task Force (a network of USAID-supported NGOs and partners), the USAID Mission, and the International Center for Diarrheal Disease Research, Bangladesh (ICDDR,B) research groups. In December 2005, a draft report on the AEM data inputs was prepared; and in 2006, project staff presented the Dhaka Baseline Scenario to local groups, a World Bank review mission for HIV/AIDS, and a Bangladesh Review Mission of the United Kingdom’s Department for International Development (DFID). Subsequently, project staff prepared various draft reports on the national context of HIV in Bangladesh and sent them for review to the A² Regional Support Team.2 Two final reports 1 A second round of size estimates is under development between FHI and a subcommittee of the Technical Committee of the National AIDS Committee. 2 The A² Regional Support Team comprises representatives of the EWC, FHI, and Futures Group. 5 completed in 2007 include Bangladesh: An Epidemic in Transition: A Synthesis of the HIV Situation in Bangladesh and The Consequences of Current Risk: The Asian Epidemic Model for Dhaka City 2006. Futures Group has made progress in linking the AEM and Goals Model for use in Bangladesh. On May 20, 2007, Futures Group and FHI held a one-day workshop to introduce the Goals Model to high-level decisionmakers from the government, donors, and NGOs; and to update them on FHI’s work using AEM. Subsequently, Futures Group held a three-day workshop (May 21–23) to introduce the Goals Model to stakeholders likely to be “users” of the model (some already had experience using AEM). Following this workshop, the participants expressed interest in additional training and informally became the “modeling group.” In August 2007, the EWC conducted training on AEM for the modeling group in Dhaka to strengthen its capacity to link AEM and the Goals Model. The Advocacy Work Advocacy occurred during the numerous meetings to present the AEM results. Most presentations contained substantive advocacy messages with implications for action. Project staff emphasized that although national HIV prevalence is low, prevalence rates among MARPs (especially IDUs in central Dhaka) are rapidly rising; and thus, early action is needed to prevent further transmission among IDUs, male and female sex workers and their clients, and MSM. The presenters went on to say that Bangladesh has the opportunity to control the spread of HIV but that it will be lost if targeted interventions for MARPs are delayed. In March 2007, Futures Group held an advocacy training to build the modeling group’s capacity to identify key HIV issues. Scenarios deemed useful to policymakers and program managers in Bangladesh were identified and modeled to look at the impact of alternate patterns of resource allocations on risk behavior. From April 14–16, 2008, in collaboration with the Joint United Nations Program on HIV/AIDS (UNAIDS), Futures Group supported an advocacy workshop to train advocates using the A2 Advocacy Training Manual and to devise strategies for addressing the issues identified during the modeling exercises. Advocacy activities were to be implemented following the workshop, but because Futures Group only had a part-time advocacy consultant and turnover in this position was high, the activities were limited. Achievements To date, the A² Project in Bangladesh has used available data from surveys, the surveillance system, and other sources to apply AEM and produce extensive projections on the HIV epidemic and to draft technical reports on the national context of HIV, the funding picture, and the urgent need for immediate steps to slow the spread of HIV among MARPs. During the course of the project, data on unit costs, coverage, population size, and behavioral data have been collected and used to develop scenarios using the Goals Model, enabling policymakers to estimate the impacts of various resource allocation decisions on behavior change and ultimately on the HIV epidemic. With technical assistance from Futures Group and FHI, the scenarios developed by the modeling group and modeled using Goals were linked to AEM. Further capacity building to link the models will be done in the final Goals workshop planned for June 2008. The linked models allow the modeling group to explore the impact of different scenarios on the epidemic. For example, by linking behavior change resulting from funding allocations (Goals) to the epidemiological profile of the epidemic (AEM), it is possible to explore how alternative actions could change the course of the epidemic. Finally, relationships have been established and strengthened among key stakeholders (e.g., government agencies, donors, and NGOs)—to whom implications of the projections and scenarios are being presented. The comparative advantage of the A² Project in Bangladesh has been its leadership in estimating the size of MARPs, its capacity to provide in-depth information on the HIV epidemic, and the use of data and 6 information in AEM and Goals Model applications. No other project has been able to provide such an in￾depth understanding of the country’s HIV epidemic, which has given the project a strong influence on the orientation of policies and programs toward targeted interventions for MARPs. This decision to focus on MARPs emerged primarily from the AEM application. The government accepted the AEM results and made public statements about the value of the modeling process. The acceptance of AEM provided a solid platform on which to initiate the Goals application. The Goals Model complements AEM by identifying how funding allocation patterns can affect the epidemic, thereby encouraging funding to be directed where it is needed most. Challenges and the Future Momentum needs to be maintained to build on these achievements. Work to establish an advocacy network in Bangladesh has moved forward. However, given that the A2 Project is near completion, Futures Group has partnered with UNAIDS to conduct an initial advocacy workshop to ensure continuity after Futures Group’ work ends. Technical work to improve the AEM-Goals Model projections will continue, and in June 2008, results will be presented to the organizations constituting the modeling group. The final deliverable will be a technical report describing the various scenarios and results of the advocacy process. The FHI bilateral agreement terminates in July 2008 and will not be renewed. Whether other in-country sources can be tapped is unclear at this time. Continued advocacy efforts are needed to address resource allocation issues, as well as policy and program barriers to the implementation of HIV activities. To pursue the objective of modifying policies and practices, more advocacy is needed to build and maintain relationships and to exploit opportunities as they arise. There is great interest in strengthening advocacy efforts. However, with the subcontract between FHI and Futures Group ending in May 2008, other resources will need to be identified to maintain the advocacy efforts. Although the advocacy network might still be formed—with explicit membership and assigned tasks per the conclusions of the March 2007 workshop—its organizational development will require long-term assistance. UNAIDS might be able to sustain the momentum garnered from the advocacy workshop, but the likelihood of success would increase if Futures Group were to support the process using funding outside of the A2 Project. Overall, there is concern surrounding the continuity of the project’s work and its institutionalization. The project has a very small staff, and its overall funding is not assured beyond September 2008. Futures Group staff (Nalinee Sangrujee and Sarah Alkenbrack) further updated the information and scenarios using the linked AEM and Goals Model in early 2008, but once the Futures Group subcontract ends in May 2008, FHI staff will have to do these updates. Future assistance might come from the EWC, but it would be ad hoc and would require funding for their involvement. Furthermore, significant obstacles exist to establishing deep expertise on the modeling in Bangladesh. While many agencies in Dhaka were trained on the models and received numerous presentations on application results, much still needs to be done to institutionalize modeling in the NASP, the National AIDS Commission, or prominent NGOs. However, the small number of staff in these agencies, compounded by considerable turnover and the burden of bureaucratic demands on their time, is a big challenge. If further institutionalization does not occur and more funding is not assured to continue activities, the project’s contributions of the last several years might not be sustainable. 7 CHINA Background and Project Structure FHI and Futures Group implement the A² Project in the Yunnan and Guangxi provinces. The project’s activities are driven by targets that have both national support and oversight, adding to their validity and effectiveness. Moreover, provincial and national government counterparts, to a large extent, consider the activities their own. Project assistance has focused on the applications of AEM (FHI) and the Goals Model (Futures Group), as well as advocacy. To build local ownership, both companies established provincial offices and hired resident staff. In addition, FHI directly funded the participation of government personnel from the Chinese Centers for Disease Control (CDC) in the modeling exercises. FHI will continue this direct assistance in the next fiscal year, ensuring the continuity of the work during its transition to the Research Triangle Institute. Timeline September 2004 marked the beginning of the A² Project in Yunnan Province, when FHI, with support from the EWC, initiated the AEM application. In April 2005, Constella Future’s POLICY Project (predecessor to the Health Policy Initiative) introduced the Goals Model and signed a memorandum of understanding (MOU) in May 2005 with the Yunnan AIDS Office and Yunnan CDC. Also in May 2005, a similar MOU was signed in Guangxi. These MOUs served to enhance the capacity of the CDC to use the Goals Model and Resource Needs Model (RNM); facilitate the data collection required to implement the Goals Model; and facilitate forums for discussions regarding implications of the modeling. By September 2007, the linkage between the Goals Model and AEM had been completed. The AEM and Goals Model In December 2005, FHI and Futures Group provided technical assistance and financial support for a major national meeting in Beijing, which kicked off and fostered support for the A² Project in China. A² Project activities progressed rapidly, starting with basic training for CDC staff in Yunnan and Guangxi on the AEM and Goals Model (July 2005) and various key stakeholder workshops to develop the early scenarios. Subsequently, the relatively intense series of training sessions, consultant visits, and regional meetings began. In late 2007, Futures Group began implementing the Capacity Module of the Goals Model to ascertain the human capacity challenges and issues in Yunnan and Guangxi. This implementation included training five staff from the two counties in Guangxi and Yunnan, where intensive data collection occurred. The Advocacy Work Advocacy in China takes a somewhat different form from a more familiar Western model, whereby civil society advocates seek to inform and persuade decisionmakers within government to take action in support of an issue. From the outset, the workshops and training on the models necessarily engaged key government officials (e.g., from the provincial CDCs and AIDS offices); and this was a successful advocacy approach. As users of the models with a clear vision of the value of the projections, these government officials subsequently became effective advocates. Being highly placed within the provincial government, they were able to garner attention at even higher levels. According to one interview respondent, as a result of the officials’ advocacy, the governor’s office requested assistance with inserting the A² modeling projections into the governor’s speeches. Those speeches were then heard by all concerned agencies and presumably have helped to reinforce favorable policies. Other respondents gave examples of their own contacts with even higher officials in Beijing. 8 The project made substantial efforts to engage civil society groups in advocacy efforts. In 2006 and 2007, in Yunnan and Guangxi, Futures Group supported numerous advocacy workshops for government officials, international NGOs, and people living with HIV (PLHIV). However, the government was wary of this work, viewing it as pressure from “outside.” For instance, at a 2007 advocacy workshop, the trainers sought to assist workshop participants with using the data generated by the linked models to identify advocacy issues, goals, and objectives. This is the standard methodology whereby the A2 Project builds capacity for conducting evidence-based advocacy efforts in response to the epidemic. However, the provincial AIDS office did not permit the trainers to use the data—even though the data had been published at a Senior Policy Symposium in September 2006, where the results of AEM and Goals projections and policy implications were presented to senior provincial-level policymakers. Enabling civil society groups, and in particular PLHIV, to work in partnership with each other and with government authorities was also a challenge. Following the initial advocacy training, the project’s intent was to help establish a network for members to discuss and agree on priority HIV advocacy issues and to develop coordinated workplans based on these priorities. Network members were to include local and international NGOs, as well as representatives of government departments and academic institutions. However, on the closing day of the same 2007 workshop above, the AIDS office signaled that it would not permit the formation of such a network, notwithstanding the participation of government staff in the workshop and the proposed inclusion of various government departments and institutions (such as the provincial CDC) in the network. Thus, engaging civil society in advocacy efforts has been the biggest challenge faced by the project and has had the least obvious payoff. Achievements During application of the AEM and Goals Model in the Yunnan and Guangxi provinces, the central Beijing government—including the State Council HIV/AIDS Working Committee Office as the head of all provincial AIDS offices—developed a five-year HIV/AIDS Action Plan (2006–2011). This presented an opportunity for the A² Project to share its work at the national level. As a result of the presentation of data and scenarios developed under the project, the central government decided to replicate the models, inclusive of training on the models and their applications, in 12 provinces. By the end of October 2007, the government had completed the training in five provinces in coordination with the DFID-funded CHARTS Project; and training in the remaining provinces was to be completed by the end of December 2007. The central government is requiring that each province apply the adapted Chinese version of the Goals Model. Provincial officials interviewed for this evaluation maintained that the models were instrumental in the development of their respective action plans and provincial budgets. The major findings and recommendations, including policy scenarios developed in Yunnan and Guangxi are listed as resources at the end of this report. Thus, the overriding achievement of the project in China has been the Chinese government’s adoption of the AEM and Goals Model—not only in the two originally targeted provinces but also in 12 other provinces. Furthermore, the model results have been used for national-level planning. Another remarkable accomplishment is the extent to which the government, particularly the provincial CDCs, have made the models their own. Three staff in the Yunnan CDC are familiar with both AEM and the Goals Model and can manipulate assumptions and scenarios independently without technical assistance. This is equally true in Guangxi. This expertise was gained over time through participation in the EWC Hawaii summer seminars in 2005 and 2006 and through various workshops and technical assistance from in-country and overseas A² technical staff. As a result of this capacity building, Yunnan and Guangxi CDC officials serve as resources for stakeholders in Beijing; the officials have already provided some training and shared experiences about the A² Project. 9 Two interviews in particular highlighted some specific noteworthy outcomes of the A² Project. The former Director of the Yunnan AIDS Office, Dr Zhang Chang’an, listed several outcomes based on his experience; these outcomes were reinforced by Dr. Chen Jie, Director of the Guangxi AIDS Office:  Generation of data, helping the AIDS offices produce quantitative as well as qualitative reports  Support of the offices’ transition from using a rather passive approach to using an active one  Assistance with the allocation of resources to improve strategy  Provision of a decision tool to replace some necessary guesswork  Improved staff expertise  Promotion of policy changes and strategic change in the governor’s plans. For example, AEM and the Goals Model were vital in helping the Yunnan AIDS Office to cost the goals in its HIV/AIDS Action Plan (2007–2010). It was estimated that a budget of 1.85 billion RMB was needed to achieve the goals described in the plan, and the provincial government agreed to the estimated budget. Professor Yuan Jianhua of the Beijing Institute for Information and Control—who adapted the Goals Model for the Chinese environment and was instrumental in advocating to the central government for its application in the 12 provinces—listed the following A² Project contributions:  As a result of AEM and the Goals Model, the 2010 target for HIV prevalence in Yunnan’s “Five￾Year HIV/AIDS Action Plan” was reduced from 200,000 to 150,000 to make it more realistic.  The AEM projections indicated that the MSM group is larger than originally thought, so strategies targeted toward MSM were given a greater emphasis in the plan.  The RNM gave a clearer picture of the required resources needed to implement the plan, leading to funding revisions.  In October 2007, the Yunnan HIV/AIDS Technical Expert Committee incorporated the A2 results in an evaluation of Yunnan’s HIV response, which was submitted to Beijing. The committee used particular estimates of infections averted obtained through the linked AEM-Goals Model, and this was the first time that such reliable estimates were made available in the province. When asked who has been influenced as a result of the project, the respondents named three particular groups:  Directors and top staff of the AIDS offices, the CDC offices, and the provincial health bureaus  Local HIV experts, such as members of the A² Technical Working Group  Technical staff involved in collecting data and manipulating the models The respondents recognized that the pathways for reaching these audiences are often difficult—in terms of how data are interpreted to foster policy changes. Nevertheless, respondents believed that the thinking of these groups was affected; and in general, the A² Project is appreciated for providing a new, more scientific way to make decisions on complex problems. Challenges and the Future At the time of the interviews, immediate needs in China included completing the Capacity Module application and Capacity Module Technical Report and also preparing for the Senior Policy Symposium in Guangxi on the county-level application. These tasks were completed in December 2007, at which time Futures Group’s involvement in the A² Project under the Health Policy Initiative, Task Order 1, ended. Longer term needs include periodic model updates and repeated applications as new data are collected. The RNM has already been adapted, and some respondents feel that the other models should be simplified to remove demands for data types that are either too detailed or rarely available and for which guesswork is too unreliable. To produce reliable information for policymaking, close attention must be given in each 10 province to data quality and the full grasp of the assumptions in the models. Routine follow-up technical visits are recommended to reinforce the earlier training on the models and advocacy. Ideally, local personnel, in collaboration with the designers of the two models, would make the updates. Some turnover of technical staff at the CDC and AIDS offices is inevitable, so ongoing training activities must be provided. However, given that the work will be government-driven rather than project-driven and the Goals Model is in Chinese, the demand for support and training will be lower than at project inception. 11 THAILAND Background and Project Structure Thailand was acknowledged as the first country in Asia to reverse the trend of its HIV epidemic. However, there are indications that Thailand’s early successes have led to complacency. With competing priorities and a significant decrease in HIV prevalence, government perspectives have shifted and the government no longer considers HIV to be a priority issue. The Ministry of Public Health (MOPH) has failed to maintain its previous high-quality surveillance, while patterns of HIV transmission from husband to wife and among MSM pose challenges that the MOPH has been ill-equipped to address. The A2 Project focuses on the development of a strategic management model for HIV prevention by a network of stakeholders in Chonburi Province. The province was selected for the pilot initiative not only because of its large number of populations exhibiting high-risk behavior (in particular sex workers primarily in Pattaya) but also because of its well-established university and networks of collaboration. The goals of the project in Chonburi are to translate and integrate national HIV prevention strategies into evidence-based policies and implementation at the provincial level. A further objective is to provide evidence for the effectiveness of a bottom-up approach to analysis and advocacy. Burapha University was selected as the key provincial partner because of its academic capacity, independence and neutrality, and potential to mediate among the Provincial Governor, provincial authorities, and civil society. Two key university staff work on the project: the Vice-Chair of the university and a senior researcher with experience in community mobilization and public health. The Thai Working Group on HIV/AIDS, of which EWC is a member, has been using AEM to make projections in Thailand for more than a decade, but there are indications that the MOPH has not been effectively using the data, largely a reflection of advocacy gaps. In 2004, when the A² Project was launched in Thailand, project staff began work to establish a local foundation, the Policy Research Development Institution Foundation (PRI). Officially established in 2006, this foundation is consistent with the A2 philosophy of giving local government and/or government agencies and institutions a sense of ownership. Thailand is undergoing decentralization, with significant administrative and financial authority being transferred from the central government to local authorities. However, local authorities generally have limited capacity to plan health interventions and limited awareness of the need to address both the impact of AIDS and the prevention of new HIV infections. In the context of decentralization and public sector reforms, PRI focuses on the promotion of evidence-based HIV prevention policies, programming, and implementation at the provincial level. The strategy to work at the provincial level stemmed from the need to improve evidence-based decisionmaking at this level and the political and institutional constraints as part of decentralization and public sector reforms. Working at the provincial level also provides a geographical focus for data collection and analysis and supports a localized response—both of which are appropriate for the concentrated nature of the Thai epidemic. Timeline Using combined analyses from the AEM and Goals Model, training on the development of policy scenarios was held in Bangkok from February 15–24, 2006. At this time, the project team held additional AEM training on new modules (ART, children, migration), followed by an updated AEM training on new features of these modules in June 2007. 12 In May 2005, Thailand’s A² team attended a regional advocacy training in Bangkok to pilot the A² advocacy manual and, more important, to build advocacy capacity among A2 partners. The workshop provided the team with tools for mapping the decisionmaking process and identifying key decisionmakers. As the team felt that this training gave the participants sufficient advocacy capacity, this was the only major advocacy training provided to them; several participants did attend a smaller, follow￾on advocacy workshop in September 2007. The local HIV epidemic was modeled in December 2005, resulting in key AEM projections and recommendations for prevention goals. The team presented results of the modeling to the Director General of the MOPH in January 2006. In February 2006, alternative policy scenarios were developed, using analyses generated by linking AEM and the Goals Model. These plans were submitted to the local administration office as part of the budget request. In June 2006, at a meeting for the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) in South Africa, Futures Group collaborated with the Thai project team to give a presentation titled “Setting and Achieving a Prevention Goal in Asia: Combining Epidemiology, Effectiveness Analysis, and Advocacy in Thailand.” In August 2006, the PRI was formally established to support the A2 process and to ensure the continuation of activities initiated under the project, such as promoting evidence-based, HIV prevention policies and programming. The AEM and Goals Model In 2005, the MOPH asked the project to provide data and analysis to inform the drafting of the 10th National AIDS Strategic Plan. AEM was used to assess the current HIV situation and future projections, while AEM and the Goals Model were linked and used to develop and cost alternative response scenarios. The costing information—total estimated cost of interventions to reduce new infections by half within three years—was presented to the Director General of the MOPH. The costs of different intervention sets were also discussed in preparation for a meeting with key stakeholders. Based on the results from the AEM and Goals Model, a group of key stakeholders was brought together to prepare the new National AIDS Plan. The prevention goal of reducing new infections by half within three years (by 2010) was developed, along with key strategies to target five target populations: IDUs, MSM, sex workers and their clients, discordant couples, and youth. Specific behavior change targets were established for each population [e.g., maintain condom use among direct sex workers (between 82 and 95%), indirect sex workers (between 70 and 90%), and male sex workers (between 82 and 90%); and increase condom use among MSM (between 70 and 80%)]. Both AEM and the Goals Model incorporated the effects of ART provision to help refine epidemiological and financial planning. The Advocacy Work National level From the outset, the A2 Project sought to involve the MOPH, primarily through the Director of the Bureau of AIDS, TB, and STIs and the Department of Disease Control—both from which the MOPH had initially assigned technical staff to the project. In late 2005, the project approached the Director of the Bureau of AIDS, TB, and STIs about presenting results of the AEM and Goals Model applications to the MOPH. The Director General of the MOPH attended a presentation in January 2006, and as a result of the projections, advocated to other senior government officials and the Prime Minister on the importance of refocusing HIV efforts on prevention and particularly on the five target populations identified through the modeling. 13 A2 worked to build a close relationship with the MOPH to advocate with other partners in the government, NGOs, and UNAIDS. However, it appears that this close relationship was not sustained— although the MOPH continues to contact A2 team members on an informal basis. Provincial level The Chonburi Provincial Health Department has been one of the main contributors in the A² Project in Thailand. Burapha University was selected as the starting point for the project, in part because of its neutrality and capacity to broker relationships and mediate among PRI, the Provincial Health Department, and the Provincial Governor; and because of its technical position and availability to coordinate. In 2006, an MOU was signed by five partners: Burapha University, the Provincial Thai Red Cross, the Provincial Authority, the Provincial Governor, and PRI. Each Thai province has a Provincial AIDS Committee (PAC) with the mandate to coordinate HIV activities at the provincial level. However, PACs are generally under-resourced and institutionally weak. Therefore, in April 2007, to help coordinate the management of provincial-level HIV prevention efforts, the AIDS Strategic Information Center (ASIC) was established through an MOU signed by the five partners. PRI led the process of its formation. The ASIC established 10 working groups to focus on developing HIV prevention strategies and activities for the five key target populations in selected locations. The working groups were set up to work on interventions for each target population or setting (e.g., MSM and transgenders, male and female sex workers and their clients, youth in educational settings, youth in dormitories, street children, youth in custody, non-Thai migrant laborers, antenatal care, health services, the workplace, and drug rehabilitation centers and prisons). The plan to develop and implement the interventions for each target population will be submitted to the local administration office as part of the budget request. Each working group has a Burapha University Faculty Advisor, who convenes meetings that include local government authorities and NGO representatives (e.g., from the Pattaya Association of Entertainment Workers). The ASIC Steering Committee—chaired by the Vice-President of the faculty and co-chaired by an A2 project team member and the Provincial Governor—manages the groups. Each group is tasked with determining evidence for effective programs for each target group or setting. The groups’ progress has varied, depending on the extent to which they are self-directed (i.e., leadership within the group) and whether local NGOs are actively working with the target populations in the selected locations. Challenges and the Future As a next step, the process in Chonburi continues, and the project will advocate for and find resources for expanding this process/approach to other provinces. Challenges identified by the team include sustaining the partnerships/network/groups established at the province, maintaining joint focus/objectives on an initiative that involves multiple partners, and addressing capacities/understanding of provincial partners on what is required to achieve behavior change. The funding uncertainty for the project also remains a challenge, as well as the fact that local partners are busy with their main jobs and responsibilities. 14 VIETNAM Background and Project Structure The A² Project’s Technical Working Group (TWG) in Vietnam selected Ho Chi Minh City (HCMC) as the location for its activities for several reasons: (1) HIV prevalence in HCMC accounts for a quarter of the estimated number of HIV infections in the country; (2) more comprehensive data on the HIV epidemic existed for HCMC in comparison with other areas; (3) the city had a multisectoral PAC, with dynamic local political leadership interested in the A² methodology; and (4) local partners had already established relationships with the country offices of A² international partner organizations. USAID/Vietnam funded FHI and Futures Group’ project activities; and the RDM/A funded the EWC to support the AEM application. Timeline Interest in the A² Project in Vietnam began as early as December 2002, when a group of stakeholders participated in Futures Group’s pilot goals and advocacy training in Bangkok. By 2003, FHI, the EWC, the National Institute of Hygiene and Epidemiology (NIHE), as well as other partners such as UNAIDS and the World Health Organization, had initiated data collection and epidemiological modeling work. In early 2004, following the promulgation of the Vietnam National Strategy on HIV/AIDS Prevention and Control, Futures Group in Vietnam negotiated with the HCMC PAC to assist the committee with developing nine action plans to support implementation of the nine intervention components outlined in the national strategy. Thus, although there was not a formal “launch” of the A² Project in Vietnam, the November 2004 project kick-off meeting—and the resulting focused financial and technical assistance in Vietnam—led to swift formation of a country team, including relevant local and international organizations, to coordinate the work and uptake of the A² process. The EWC and FHI provided technical assistance to the NIHE and others to apply AEM and prepare the synthesis report; the final application was ready by mid-2006. In 2005, Futures Group began working with the HCMC PAC on Goals Model training and the preparation of cost estimates for the RNM. Throughout this process, members of Vietnam’s TWG and various individuals from the partner organizations participated in periodic regional meetings to receive technical updates and share experiences. Technical assistance and the application of the linked AEM and Goals Model led to the development of four alternate scenarios for resource allocation among the nine HCMC action plans. Presentation of the data to decisionmakers at the pivotal Senior Policy Symposium meeting in HCMC in October 2006 has already led to changes in the direction of and funding for HIV programs in HCMC. The AEM and Goals Model In 2004, the first application of AEM was completed in conjunction with EWC’s annual summer training in Hawaii. However, those actively engaged in applying the model deemed the projections as largely inaccurate and thought that more data were needed, particularly on MARPs. The next two years marked what all key respondents would describe as an arduous and time-consuming process of identifying and reviewing hundreds of reports—both published and grey literature—to close the data gaps in the estimates of the population sizes and behaviors of MARPs, especially sex workers and their clients, sex workers who are IDUs, and MSM. The team scoured through the reports to ascertain those reliable for use in the model estimates, avoiding the double-counting of studies reported in multiple journals and agreeing on the assumptions when the search did not result in relevant data. The extensive data search paid off. In April 2006, the team was ready with a revised AEM application, which the partners agreed was fairly accurate in reflecting the dynamics of HIV epidemics in HCMC and could be used to predict future epidemiological trends. In July 2006, FHI, in partnership with the NIHE, 15 completed the full synthesis report on the application; the NIHE alone was originally tasked with completing the report, but the institute’s human resources were stretched among many competing priorities. The full report remains unpublished, as it contains politically sensitive issues. However, because the findings are important for gaining overall support for HIV interventions, a more consolidated, accessible version—The HIV Epidemic in Ho Chi Minh City: Where is it going?—was published and disseminated widely in Vietnam. Changes to the full report included shifting emphasis away from the 06 centers in the report, notwithstanding their significant role in the response to the epidemic in HCMC. Futures Group conducted the first training on the Goals Model in HCMC in June 2005. This was followed by a series of intensive trainings and working sessions with the local Futures Group staff member and PAC representatives in HCMC to complete the Goals Model and start the alternate scenario modeling through the linked models in the summer of 2006. One respondent mentioned that at first, the Goals Model confused PAC members, but over time and with practice, it became clearer. Another noted that the Goals Model was easy to understand and use. As commonly experienced in the application of the model, much of the financial data required for the RNM were not readily available in the format that was required to be inputted into the RNM spreadsheet; and the team had to devise strategies to gather the information and reach consensus on inputs and assumptions. Nevertheless, the data inputs were considered sufficiently accurate by local authorities for use in developing the four alternative scenarios of resource allocation, which ultimately informed the nine action plans prepared for HCMC. Looking back, the local partners were exceedingly grateful for the technical assistance provided on the AEM and Goals Model; however, some partners questioned whether more than two or three people in HCMC could manipulate the models. While several individuals within the PAC, NIHE, and the Medical University in Hanoi might be familiar with one or the other model, they lack the technical depth and experience to work independently with them. One stakeholder thought that the institutionalization of the Goals Model might be more feasible than that of AEM. For example, at a meeting called by the Chair of the HCMC AIDS Control and Prevention Committee in July 2006, Dr. Lan Thao (Deputy Head of the HCMC AIDS Standing Office) presented the modeling done through the Goals Model and RNM application in HCMC and an analysis of the findings and recommendations; while at this same meeting, it was EWC’s Tim Brown who presented the projections from the AEM application in HCMC. The PAC is aware of the need to build a cadre of technical staff; and both Futures Group and FHI recognize the need to further institutionalize the models, possibly working through national and provincial universities. The Advocacy Work Those interviewed for this evaluation agree that the Senior Policy Symposium on October 27, 2006— attended by representatives of the HCMC administration, the People’s Committee, the PAC, media, and other stakeholders—was the single most important and effective advocacy forum in the country. In sharing projections of the funding gaps and possible courses of the epidemic (based on various resource allocations across components of the nine HCMC actions plans), clear and urgent recommendations were presented to HCMC authorities. All stakeholders agreed that this was the most evidence-based decisionmaking process undertaken in HCMC to date. A report, Combining Epidemiology and Economic Analysis to Inform the Response to the HIV Epidemic in Ho Chi Minh City, includes a full description of the process. Respondents point to Dr. Le Truong Giang, Vice-Chairman of the HCMC PAC, as the lead policy champion and liaison with other senior HCMC authorities. However, the interviews clearly indicated that those directly involved in the modeling work were informed and committed advocates within the city as well as with external donors. For instance, Dr. Thao spoke of the “hundreds of presentations to various audiences” stored in her computer files, which cite data from the A² Project. Other stakeholders spoke about their own increased effectiveness in making informed program decisions within their departments. 16 This is clearly an area where the multisectoral nature of the PAC fostered benefits, particularly in the leadership of various departments; for example, the Ministry of Labor, Invalids, and Social Affairs— through its participation in the process—recognized the need to re-orient its programs toward preventing HIV among MARPs and, thus, did not need to be targeted for advocacy. One respondent stated that many other good initiatives, (e.g., the HIV law, the national strategy, and other directives from central committees) have dovetailed with the A² Project outcomes; and collectively, the messages have persuaded HCMC authorities to increase their focus on HIV. Initially, civil society representatives (e.g., lawyers associations, PLHIV, and faith-based organizations) were peripherally involved in A²-related activities. For example, PLHIV provided advice on some of the data inputs for the RNM application and other project activities in HCMC. Futures Group conducted the first formal advocacy workshops for civil society groups under the rubric of the A² Project in Hanoi and HCMC in November 2007. With the future expansion of knowledge and technical approaches to other locations in mind, the project invited stakeholders from the neighboring Can Tho and An Giang provinces to the workshop in HCMC and stakeholders from the Quang Ninh, Hai Phong, and Nghe An provinces to the workshop in Hanoi. Participants acknowledged the powerful potential effect of using Goals Model results in their advocacy work. While no plans exist to create formal advocacy networks (for both programmatic and financial reasons), a Futures Group Program Officer3 working on the A² Project had hoped to foster “networking” opportunities among the stakeholders from each participating province. Specific follow-up to the advocacy workshops is likely still in process, as decisions are being made on the best use of remaining project resources. The advocacy work has not been limited to HCMC. When asked about ripple effects from the activities in HCMC at the national level or whether the HCMC process has been recognized as a model for other provinces, most respondents reported some direct or indirect recognition at the national level. However, most also noted that replicating the HCMC process nationally or in other provinces will be a challenge due to data gaps. Still, others cited opportunities for positive communication nationally about the A² Project. For example, project partners shared the HCMC process at a national-level monitoring and evaluation conference in Hanoi in January 2007, which generated demand among other provinces for more information about the A² Project. Achievements The A² Project activities in Vietnam have led to several notable achievements: Policy, planning, and funding changes. In HCMC, the most significant result was the redesign and reallocation of funding for the nine action plans (2006–2010). Although the plans have not been officially approved, all the key respondents confirmed that the plans have been changed and that the reorientation of resources and programming is underway. One respondent surmised that the official approval has been delayed due to political sensitivities; however, this person did not believe this would negatively impact the operationalization of the overall redesign. Another respondent cited the possible sensitivity surrounding the harm-reduction approach, which some view as incongruent with the 05/06 compulsory residential rehabilitation programs (for sex workers and drug users, respectively) and Vietnam’s Three Reductions Plan. Whereas respondents were certain about the shift in funding, they were less certain about the extent of a concomitant increase in funding from the city’s coffers to the action plans. There was an implicit assumption that there were increases; one respondent reported that the People’s Committee had increased its own funding for prevention of mother-to-child transmission. Determining the level of funding 3 This Program Officer resigned in early January 2008 to pursue further studies in Australia. 17 increases attributable to the A² Project alone will require additional inquiry with other respondents. The funding streams from a variety of donors are increasing rapidly; thus, PAC members and others are operating in an environment of overall increased funding availability. One PAC member said that the challenge is convincing donors (e.g., World Bank, DFID, U.S. government) of the most important areas for directing their increased levels of funding. This respondent also mentioned that the projections from the models have helped the PAC make the case for increased funding toward prevention efforts—relative to the increases that donors are directing toward treatment. Data collection efforts in HCMC have received a boost from the A² Project. One respondent in HCMC stated that participating in the project and recognizing the planning power of the models helped the PAC chart a direction for future studies and research. Another HCMC respondent noted that the NIHE was able to convince an international donor to support a department’s household surveys to obtain necessary quantitative data for future AEM applications. At the national level, the impact of having implemented the project in HCMC is still evolving. Due to scheduling conflicts, the evaluation process did not include interviewing representatives of the Vietnam Administration of AIDS Control (VAAC) or NIHE; however, interviews with the other stakeholders indicated that the VAAC is interested in pursuing aspects of the project both nationally and in other provinces. For example, the VAAC has incorporated the A² process as an example of using data effectively in its national M&E training curriculum. The VAAC has also asked the TWG to explore using the A² approach in other provinces. Furthermore, at least two respondents mentioned that the project played a role in the VAAC’s recognition of the need for additional and uniform national data collection, particularly for MARPs. One respondent is actively working with the VAAC to develop new indicators, design new reporting forms, and explore changes in the next iteration of the nationally representative Integrated Biological and Behavioral Surveillance. Institutional change and human capacity development. The HCMC PAC has clearly adopted the modeling tools for evidence-based decisionmaking. Not withstanding the concern expressed above—that a limited number of senior technical people are comfortable with the models—the PAC has taken up the models as indispensable tools for making funding and programmatic choices and looks forward to an updated application of the model in 2008. Several respondents credited the A² Project for a fundamental recognition of the need for more reliable, longitudinal, and comprehensive data collection. Having learned lessons from the A² data collection process, the HCMC PAC has created and staffed a monitoring and evaluation center and is building a more sustainable data collection process to be able to use the models in the future. Those who actively participated in the A² Project effort clearly view it as an intensive learning experience—in terms of new technical skills or new levels of awareness about the urgent actions needed to affect the direction of the epidemic. As noted above, most local partners indicated increased confidence in doing their work as a result of participating in the process. One respondent credits the project for her increased effectiveness as a member of the M&E Technical Working Group. The effects of the recent, formal inclusion of more PLHIV and civil society groups into the advocacy process are currently unknown; however, if enthusiastic participation, creative ideas, and good multisectoral collaboration during the workshop in HCMC are any indication, their participation will surely lead to positive results. Challenges The structure of the A² Project in Vietnam is complex, involving government and technical institutions at the provincial and national levels, as well as both in-country and regional or global offices of international partners. In reflecting on the project to date, respondents recognized that either more financial resources were needed for human resources (in the case of Futures Group); or more financial resources should have 18 been redirected to support the necessary human resources for coordinating among partners (in the case of FHI), implementing activities in accordance with the workplans, and monitoring project activities. Futures Group and FHI staff responsible for the A2 Project activities in Vietnam had several other responsibilities, which likely affected coordination among the key partners and the speed of activity implementation. For example, while there were significant advocacy achievements in Vietnam, most of them were achieved through learning-by-doing and recognizing the power of presenting data-based evidence to officials. The project might have benefited from additional human and financial resources for implementing its specific advocacy component. For example, the original project design included establishing an advocacy and data use group, but this did not occur due to time constraints experienced by the project partners. The project’s advocacy capacity-building component was not initiated in-county until late 2007. The Futures Group Program Officer in HCMC, in addition to other project responsibilities, necessarily focused first on working with local partners on the models, as well as training partners to use the models (particularly the Goals Model and RNM). The same level of attention could not be paid to building, early on, the capacity of a local team member to take a leadership role in the advocacy trainings; adequate capacity building will be needed to pursue an advocacy strategy. According to respondents, although envisaged as a forum for both technical guidance and coordination, the TWG has met infrequently; and the group’s membership, terms of reference, and roles and responsibilities are unclear. As noted below, with additional clarity and commitment, there could be an important role for this type of group at the national level in the future. The Future For FY08 (i.e., with COP 07 funds), Futures Group and FHI will focus their efforts in Hai Phong Province. Although data collection for AEM in Hai Phong has already started and a draft report on the data is available, several respondents questioned whether AEM would need to be simplified before moving forward with the application in the province. Remaining Futures Group funding (through September 2008) will not support the same level of training and technical assistance provided in HCMC for the Goals Model in Hai Phong. In addition, the Futures Group A² Program Officer in HCMC, who was most familiar with the models, recently departed for further studies, leaving the project with reduced in-country capacity to train partners on the use the Goals Model and on advocacy. Certainly, respondents struggle with how to expand the process beyond HCMC and Hai Phong. Lack of data for the models is cited as the biggest hurdle; the data demands of the models will make it difficult to apply them at provincial levels and gain an acceptable degree of confidence in the projections. If the models are simplified for use in less data-rich settings and multiple applications are done in succession or simultaneously, the demand for technical assistance will significantly increase. Although lessons learned will increase the efficiency of future applications, funding will need to increase above the past levels. Given the diversity of the epidemic across provinces, it will be difficult to use the linked models for an application at the national level. However, the Ministry of Health has expressed interest in Futures Group’s support to apply the RNM to Vietnam’s national strategy. At the same time, several respondents in HCMC expressed that there is a need to repeat the application of both models in 2008, given the dynamic nature of the HIV epidemic. In addition, the re-focusing of the prevention programs across the nine action plans will inevitably require an assessment of the human resources needed to implement the programs—both in terms of the number of people and the skill sets required for different levels of coverage. Dr. Lan Thao of the PAC is particularly interested in exploring the use of Futures Group’s Human Capacity Model for this type of assessment. 19 20 The A² Project team in Vietnam was uniformly grateful for the regional meetings and acknowledged that they served an important service—particularly as the project was starting up and the learning curves were steepest. However, most respondents recommended that these regional workshops be scaled back significantly in the future, with more funds being directed to national forums and sustainable, local capacity-building efforts. To strengthen and sustain use of the models, respondents recognize the need to partner with additional local institutions of higher education at the national and provincial levels. The models will have routine updates, new modules will be added, and there will be demand for new model applications as new data become available. Keeping up with these developments locally will require a stable and renewable cast of trained users; and, thus, institutionalizing the models in graduate schools would be beneficial. Most respondents did not think that translating the models into Vietnamese was critical for working at the provincial level. Finally, the overall A² process could benefit from clarification on the TWG’s purpose and its members’ roles and responsibilities in the oversight and coordination of future efforts. The respondents mentioned opportunities for increasing the visibility and utility of the A² Project among country-wide donor assistance working groups and other forums. In addition to coordinating the technical arms of the A² Project, there are other national advocacy, communications, and development objectives that the TWG could consider and other opportunities for bringing donors and technical assistance projects on board. One respondent recommends that the A² approach be incorporated into national Three Ones planning. At least two respondents thought that the same general process could be applied in responding to other diseases in Vietnam. ANNEX 1. LIST OF INTERVIEWS Bangladesh China Thailand Vietnam Washington, D.C. Dr. Robert Kelly Dr. Hu Bin Mr. Chris Ward Dr. Le Thuy Lan Thao Ms. Sarah Alkenbrack, Country Director Country Director Advocacy and Policy Deputy Director Senior Scientist FHI/Bangladesh Futures Group, China Advisor Futures Group AIDS Committee Standing Bureau Ho Chi Minh City Futures Group Washington, D.C. Dr. Amala Reedy Prof. Shi Tian Ming Dr. Jeremy Ross Dr. Tran Thinh Ms. Nadia Carvalho Data Synthesis Specialist Development Research A2 Program Manager Deputy Director Senior Scientist FHI/Bangladesh Center, Yunnan FHI, Bangkok AIDS Committee Standing Bureau, Ho Chi Minh City Futures Group Washington, D.C. Ms. Areba Panni Alam Chen Yaohong Mr. Ganrawi Winitdhama; Dr. Cai Phuc Thang, Dr. Gayle Martin Consultant, A² Project Program Officer/A² Associate Technical Senior Officer Sr. Economist Futures Group Country Coordinator FHI/Kunming Officer FHI, Bangkok Committee on Culture and Ideology Communist Party, Vietnam Futures Group Washington, D.C. Dr. Nadia Rahman Tony Bennett Mr. Philippe Girault Mr. Le Van Nhan Dr. Nalinee Sangrujee Program Officer FHI/Kunming Sr. Technical Officer Ministry of Labor, Invalids, Sr. Economist FHI/Bangladesh FHI, Bangkok and Social Affairs Ho Chi Minh City Futures Group Washington, D.C. Dr. Mozzamel Hoque Prof. Yuan Jianhua Dr. Wiwat Dr. Ngo Tri Tue HIV Advisor Beijing Institute of Peerapatanapokin, Program Officer UNODC/Bangladesh Information and Control Epidemiology Expert PRI, Bangkok Futures Group, Vietnam Dr. Lazeena Muna￾McQuay Social Mobilization and Partnerships Advisor UNAIDS/Bangladesh Dr. Zhang Chang’an Former Director, Yunnan AIDS Office Provincial Health Bureau, Yunnan Prof. Somsak Pantuwatana Vice President for Research Affairs Burapha University, Chonburi Dr. Nguyen Dac Tho Deputy Director Preventive Medicine Center, Ho Chi Minh City Mr. Mahboob Aminur Rahman M&E Adviser UNAIDS/Bangladesh Dr. Zhou Hongmei Deputy Director CDC, Yunnan Dr. Sunantha Osiri Associate Professor Burapha University, Chonburi Dr. Thu Anh Nguyen Faculty of Public Health Medical University, Hanoi 21 22 Dr. Sukumar Sarker Project Management Specialist, PHN USAID/Dhaka Dr. Ma Yanling Deputy Director AIDS Prevention Division CDC, Yunnan Dr. Wiput Phoolcharoen Director PRI, Bangkok Dr. Stephen Mills Country Director FHI, Vietnam Dr. Shahana Hayat Country Director Voluntary Services Overseas Ms. Chen Hehe Former Vice Director of AIDS Prevention Division, CDC, Yunnan Dr. Sombat Thanprasertsuk Director, Bureau of AIDS, TB and STIs, MOPH Bangkok Mr. Tran Tien Duc Country Director Futures Group, Vietnam Ms. Habiba Akter Executive Director Ashar Alo Society Mr. Jiaxiong Liang Project Officer Futures Group, China Dr. David Stephens Resident Advisor Futures Group, Vietnam Ms. Asma Parveen Program Manager Ashar Alo Society Ms. Shi Yuhua Formerly at Public Health Dept, Guangxi Dr. Munir Ahmed Team Leader – HAPP, HIV CARE Bangladesh Dr. Chen Jie Director AIDS Office, Guangxi Mr. Shakawat Alam TC-HIV CARE, Bangladesh Zhu Qiuying Deputy Director, AIDS Dept CDC, Guangxi Mr. Abu Taher Program Officer, HIV CARE, Bangladesh Prof. Lu Zhuoping Guangxi Medical University Dr. Peter Kim Streatfield Head (Public Health Sciences Division and Head, Population Program) ICDDR,B Ms. Liu Min Former POLICY Project staff Shanghai ANNEX 2. A² MEETINGS, WORKSHOPS, AND EVENTS November 17–19, 2004—Launch of the A² Project at regional meeting in Bangkok, Thailand November 2004—Part-time A2 Coordinator employed by FHI ARO March 2005—Full-time A² Advocacy Specialist employed by Futures Group January 2006 – Full-time A2 Project Manager employed by FHI ARO May 2006—Full-time A2 Country Coordinator employed by FHI China Regional A² Team Meetings  January 2005  April 2005  August 2005  February 2006  September 2006  June 2007 Formation of Country Technical Working Groups  Bangladesh: March 2004 (for implementation of Asian Epidemic Model, the application of which began prior to the commencement of the A2 Project)  Vietnam: November 2004  Thailand: December 2004  Yunnan: March 2005  Guangxi: August 2005 AEM Modeling  Yunnan: June 2004  Bangladesh: April 2005  Thailand: December 2005  Guangxi: February 2006  Vietnam: April 2006 AEM Technical Reports  Vietnam: September 2006  Guangxi: June 2007  Bangladesh: August 2007  Yunnan: Date to be determined  Thailand: Date to be determined Goals Technical Reports  Bangladesh: Expected June 2008  Guangxi: July 2006  Yunnan: August 2006  Thailand: February 2006  Vietnam: February 2007 23 AEM and Goals Training  Training workshop for synthesis specialists, Integrated Analysis and Advocacy Project, EWC/Thai Red Cross Society Collaboration on HIV Modeling, Analysis and Policy, Bangkok. Coordinator: Dr. Tim Brown, EWC (April 2004)  AEM training for synthesis specialists at 35th Summer Session on Population, Workshop 2: Integrated Analysis to Improve HIV Responses in Asia and the Pacific, EWC, Honolulu. Coordinators: Dr. Tim Brown and Dr. Wiwat Peerapatanapokin, EWC; and Dr. Tobi Saidel, FHI (June 2004)  Data Management and Analysis Workshop (using Stata), Family Health International (FHI) Asia Pacific Division, Bangkok. Coordinator: Ms. Elizabeth Pisani, FHI/Indonesia (March–April 2005)  Practical training in using AEM to model the HIV epidemic for Bangladesh, Bangkok, Thailand. Trainer: Dr. Tim Brown, EWC (April 2005)  Workshop on HIV modeling for Yunnan and Guangxi, Honolulu (January 2006)  Policy Scenario Training Workshop using the new version of AEM, the linked Goals Model, and various advocacy tools, Bangkok. Coordinators: Dr. Tim Brown, EWC; and Dr. Gayle Martin and Dr. Chris Ward, Futures Group (February 2006)  Modeling for policy analysis and effective responses to Asian epidemics (April 2006)  Training in AEM at the 37th Summer Seminar on Population, Workshop 1, From Analysis to Action: Advocating for Effective HIV Responses, Honolulu. Coordinators: Dr. Tim Brown, EWC; and Dr. Dimitri Prybylski, FHI APRO Bangkok. Resource Person: Dr. Amala Reddy, FHI (June 2006)  A2 Project AEM Update Training on new features of AEM, Honolulu. Coordinator: Dr. Tim Brown, EWC (June 2007) Advocacy and Associated Training  Regional (multi-country) advocacy training to pilot A² advocacy training curriculum, Bangkok. Trainers: Anne Eckman, Chris Ward, and Nadia Carvalho (May 2005)  Yunnan and Guangxi advocacy training workshop, Kunming. Trainers: Anne Eckman, Chris Ward, and Shetal Datta, Futures Group (September 2005)  Yunnan and Guangxi advocacy training-of-trainers, Kunming. Trainers: Anne Eckman, Chris Ward, and Nadia Carvalho, Futures Group; and Nancy Tian (CEDPA) (December 2005)  Guangxi advocacy training workshop, Nanning. Trainers: Anne Eckman, Chris Ward, and Shicun Cui, Futures Group (December 2005)  Yunnan advocacy training workshop, Kunming. Trainers: Chris Ward and Shicun Cui, Futures Group (February 2007)  Bangladesh advocacy training workshop, Dhaka. Trainer: Chris Ward, Futures Group (March 2007)  Guangxi and Yunnan advocacy training-of-trainers, Kunming. Trainer: Chris Ward, Futures Group (June 2007)  Yunnan advocacy training workshop for PLHIV networks, Kunming. Trainers: Chris Ward, Hu Bin, and Shicun Cui, Futures Group (June 2007)  Guangxi advocacy training workshop for PLHIV networks, Nanning. Trainers: Chris Ward, Hu Bin, Shicun Cui, and Liang Jiaxiong, Futures Group (August 2007)  Regional (multi-country) advocacy training, Bangkok. Trainers: Chris Ward and Shetal Datta, Futures Group (September 2007)  Hanoi and HCMC advocacy training workshops. Trainers: Chris Ward, Nalinee Sangrujee, and Ngo Tri Tue, Futures Group (November 2007)  Bangladesh advocacy training workshop, Dhaka. Trainer: Sumi Devkota, Futures Group (April 2008) 24 25 Synthesis Reports  Vietnam: July 2006  Guangxi: August 2006  Bangladesh: May 2007  Yunnan: December 2007  Thailand: incomplete (expected date unknown) Modeling Alternative Scenarios  Bangladesh: April 2005  Thailand: February 2006  Vietnam: July 2006  Guangxi: August 2006  Yunnan: August 2006 Advocacy and Dissemination Meetings  Bangladesh AEM Baseline Intervention Scenario presentation to stakeholders (Dhaka, October 2005)  Yunnan Senior Policy Symposium (Kunming, September 2006)  Guangxi Senior Policy Symposium (Nanning, September 2006)  Vietnam Senior Policy Symposium (HCMC, October 2006) Policy Briefing Papers  Guangxi: September 2006  Yunnan: September 2006  Vietnam: October 2006 Policy Mapping  Yunnan: June 2007  Dhaka: August 2007 Other Key Dates/Events  Seminar on A2 Project at Kobe ICAAP meeting (June 2005)  Presentation of key AEM findings and recommendation for development of prevention goal to Thai MOPH (December 2005)  Presentation at PEPFAR meeting in South Africa on A2 Project: “Setting and achieving a prevention goal in Asia: Combining epidemiology, effectiveness analysis, and advocacy in Thailand” (June 2006)  Thailand team registered as an independent local NGO (September 2006)  Presentation on A2 Project and methods, meeting of China National CDC (September 2006)  AEM projections and Goals resource needs analyses presented at Yunnan Provincial HIV/AIDS Annual Working Meeting (February 2007)  Formation of and advocacy training for Yunnan advocacy network (Kunming, March 2007)  Formation of and advocacy training for Guangxi advocacy network (Nanning, March 2007)  Presentation on A2 epidemiological and economic analysis for the adoption of a new HIV prevention goal in Thailand at 7th ICAAP, Colombo (August 2007)  A² Advocacy Training Manual developed by Futures Group (October 2007) RESOURCES A2 Project. A2 Advocacy Training Manual. Washington, DC: Futures Group/Health Policy Initiative. A2 Project. 2007. A² Advocacy Training Report, Dhaka. A2 Project. 2007. Guangxi Zhuang Autonomous Region Goals Model Technical Report. Guangxi: Futures Group/Health Policy Initiative. A2 Project. 2006. “Combining Epidemiology and Economic Analysis to Inform the Response to the HIV Epidemic in Ho Chi Minh City.” Paper prepared for an October 2006 meeting in HCMC. A2 Project. No Date. The HIV Epidemic in Ho Chi Minh City: Where is it Going? (In Vietnamese). Hanoi: FHI and Futures Group/Health Policy Initiative. A2 Project. No Date. The HIV Epidemic in Ho Chi Minh City: Costs of Things to Come—Resource Implications of the HCMC HIV/AIDS Action Plans. A2 Project. 2006. “The Epidemic of HIV/AIDS in Yunnan Province: Epidemiological and Economic Analyses.” POLICY Project Briefing Paper. A2 Project. 2006. Goals Model Technical Report, Yunnan Province, China. Author unknown. 2005. “A² Strategic Planning Exercise for Yunnan: Review of Day 1.” PowerPoint Presentation. A2 Project. 2006. “The Epidemic of HIV/AIDS in Guangzi Zhang Autonomous Region: Epidemiological and Economic Analyses.” POLICY Project Briefing Paper. A² Project. 2006. Policy Brief for Guangxi Province. Brown, Tim, and W. Peeropatanapokin. 2004. “The Asian Epidemic Model: A Process Model for Exploring HIV Policy and Programme Alternatives in Asia.” Sex Transm Infect 2004:80(Suppl 1): i19– i24. doi: 10.1136/sti.2004.010165. EWC, FHI, POLICY Project, and USAID. 2004. A²: Collectively Doing Things Differently to Make a Difference.” Paper prepared for the First Regional Integrated Analysis and Advocacy (A²) Meeting. November 17–19, 2004, Bangkok, Thailand. FHI. 2006. Synthesis Report on the HIV and STD Epidemics, Behaviors, and the Response in Guangxi Province, China. Version 1.0. Guangxi: FHI. FHI. 2007. Technical Report on the Guangxi AEM Baseline Scenario. Version 1.0. Guangxi: FHI. Guangxi Centers for Disease Control and Prevention. 2005. “Progress of A2 Project in Guangxi.” PowerPoint Presentation. Peerapatanapokin, W., et al. 2002. “Projections for HIV/AIDS in Thailand 2000–2020: An Application of the Asian Epidemic Model.” Int Conf AIDS (July 7–12): 14: Abstract no. ThPeC7448. 26 27 Reddy, Amala. 2007. An Epidemic in Transition: A Synthesis of the HIV Situation in Bangladesh. Dhaka: FHI. Reddy, Amala, and Tim Brown. 2006. “The Future of HIV in Bangladesh: The Dangers of Slowly Scaling-up Prevention.” PowerPoint presentation. Reddy, Amala, and Tim Brown. 2007. Technical Report on the Asian Epidemic Model, Dhaka Baseline Scenario, 2006. Dhaka: FHI. Reddy, Amala, Robert Kelly, and Tim Brown. 2007. The Consequences of Current Risk: The Asian Epidemic Model for Dhaka City 2006. Dhaka: FHI. Sanders, Rachel. 2007. “Goals Capacity Module in Yunnan and Guangxi.” PowerPoint Presentation. Washington, DC: Futures Group/Health Policy Initiative. Sangrujee, Nalinee, and Rachel Sanders. 2007. “Update on Goals Model Applications in Asia: China and Indonesia.” PowerPoint Presentation. Schwartlander, B., et al. 2001. “Resource Needs for HIV/AIDS.” Sciencexpress June 21, 2001: 1–10. Shi, Tian Ming. 2007. HIV/AIDS: Policy Issues of China and Yunnan Province. China: Futures Group/Health Policy Initiative. Statement by H.E. Prof. Dr. Suchai Chareonratanakul, Deputy Prime Minister of Thailand. High-Level Meeting on HIV/AIDS of the 60th Session of the UN General Assembly, New York, June 2, 2006. Ward, Christopher. 2007. HIV/AIDS Policy Audit, Bangladesh. Dhaka: Futures Group/Health Policy Initiative. Stover, J., et al. 2002.”Can We Reverse the HIV/AIDS Pandemic with an Expanded Response?” The Lancet 360: 73–77. Agence France Presse (AFP). 2006. “Thailand Aims to Halve HIV Infections within Three Years: Official.” Available at http://www.aegis.com/news/ads/2006/AD060278.html. Health Policy Initiative, Task Order 1 Futures Group One Thomas Circle, NW, Suite 200 Washington, DC 20005 USA Tel: (202) 775-9680 Fax: (202) 775-9694 Email: policyinfo@futuresgroup.com http://ghiqc.usaid.gov http://www.healthpolicyinitiative.com