|Guide to Strategic Planning Process for a National Response to HIV/AIDS: Strategic Plan Formulation (UNAIDS, 1998, 32 p.)|
|III. Formulating a strategic plan|
|III.8 Plan flexible management and funding to ensure support for emerging strategies|
This example of strategy formulation for a single priority area builds on the scenarios described in Modules 1 and 2, which describe the situation of young people in a fictional country, and the existing response.
1. Re-examine guiding principles
The national constitution guarantees equality of treatment for men and women and the Seven Principles of State espouse access to education and basic health care for all as national goals. Respect for elders is a basic cultural premise. The legal age of majority is 21, and until then young people have no independent legal rights.
2. Confirm priority areas for a national response
The situation analysis has clearly demonstrated that young people are behaving in ways that put them at risk of HIV infection. The response analysis has pointed to several gaps in the response in this situation.
The needs are:
· a better understanding among policy-makers of how, when, and why young people have sex;
· a better understanding among young people about the risks involved in sex and how to avoid them;
· condoms that young people want to use and can easily buy; and
· services that will help young people minimize their risk of HIV infection and that of their partners.
In all of these areas, the strategies will have to take into account potential parental opposition and the fact that many young people, especially young women, cannot be reached through the school system.
3. Set objectives in priority areas
Zero HIV infection among young people. Young women and men know how to avoid HIV infection and have the power, means, and desire to act on that knowledge.
Specific objectives for all key elements that need to be covered by a strategy in priority areas.
(Specific targets for the end of the planning period in parentheses)
· Planners know which young men and women are vulnerable to HIV and why (national and regional studies describe sexual behaviour and attitudes of young men and women).
· Young people are actively involved protecting themselves and their peers from HIV infection, and in coping with its impact (all young people are exposed to at least one informal responsible behaviour educational contact from someone of their own age group).
· Young people have access to condoms they want and can afford to use (condoms used by young men in all commercial sex encounters, by young women in all sex with older partners).
· Young people have access to teen-friendly STD services and HIV testing and counselling (counselling services established for young people established in five largest cities)
4. Identify strategies to achieve the objectives
· What can be used or adapted from the current response?
· What opportunities can be used?
· What obstacles must be avoided?
Objective: Planners know which young men and women are vulnerable to HIV and why
The planned household survey should be continued, but must be supplemented with more in-depth studies of adolescent attitudes and behaviours. Skills in social research on sensitive subjects are limited. A partnership between the Social Research Institute of the Global South and the National University could build domestic skills while conducting the research to international standards. Focus group interviews could be conducted with a subset of adolescents in the age range of interest, with separate sessions for young men, young women, students, young workers and those who neither work nor go to school. Some focus groups would need also to explore differences in sexual behaviour and attitudes between young men and women in cities and in rural areas. Although young people are among the most sexually active, very little is known about the epidemiology of infection in this group.
Suggested strategy for key element 1:
· To build up a picture of changing trends in reported behaviour:
- support plans for repeat of household survey.
- supplement with focus group series carefully designed to give information that explains which young people are vulnerable and why.
· To build up a picture of changing trends in infection:
- increase sample size of women in the youngest age groups during routine sero-surveillance at ante-natal clinics, and analyse data in one- or two-year age bands.
- screen blood samples taken from military recruits for HIV as well as STDs through unlinked anonymous testing.
Objective: Young people are actively involved in protecting themselves and their peers from HIV infection, and in coping with its impact
Because of culturally dictated distance between generations, parents cannot be relied upon to communicate with their children about intimate issues such as sexual behaviour. What is more, many adults follow religious leaders in refusing to countenance sexual behaviour among unmarried young women. Although they recognize young men are sexually active, they cannot openly acknowledge this. Some children will get information from school - the head of the teachers union supports more HIV education in schools but parents continue to oppose it, especially where there are girls in the class. Many adolescents do not go to school - the source of information about AIDS for most of them is ill-designed government spots and well-designed comic books whose reach is very limited. The most obvious common ground for young men is the football club. Young women have no universal leisure activity, but they do usually go to market once a day to shop for their elders.
Suggested strategy for key element 2:
· To erode parental opposition:
- work with regional religious conference to create support among religious leaders for more communication with young people about responsible behaviour.
· To maximize potential of in-school sexual education:
- with the help of the Teachers Union, develop curriculum for healthy lifestyle education, including responsible sexual behaviour.
· To reach young people who are both in and out of school:
- in partnership with private advertising agency and private media, develop healthy lifestyle spots aimed at young people to be aired during prime time such as football matches.
- invite football stars and pop stars (both male and female) to join in the national response by visiting youth clubs, making videos, giving interviews, etc., concentrating their messages on responsible sexual behaviour.
- expand the comic book initiative, developing separate issues for girls and boys and distributing the former at markets and the latter at football clubs and youth clubs. Cover the cost with a small cover price.
These initiatives should help form a critical mass of young people with some knowledge of HIV and an interest in helping reduce its spread.
· To take advantage of the communication skills and situation-specific knowledge of young people:
- involve a TV station in a true stories video series. Young people can enter a competition to tell HIV-related stories on air. Those with the best ideas will attend a three-day video-production workshop with a leading national film director. They will be lent a video-camera for a week to make their mini-documentaries, which will be aired on national TV. Approach Regent Enterprises (local distributors for Sony cameras and Fuji film) for donation of cameras and film. Approach New York-based film industry charity Screen Cares for cash funding.
- ask teenagers in church groups to develop plays with an HIV theme, and to perform them at street festivals, in schools, at markets, and in food distribution centers.
- train a group of young women to be market sisters, telling young women who visit the market about responsible sex, employment opportunities, and teen-friendly services for HIV advice and contraception.
Objective: Young people have access to condoms they want and can afford to use (see example Multi-initiative strategy for increasing condom use, III)
Objective: Young people have access to teen-friendly STD services and HIV testing and counselling
The Red Cross runs a testing and counselling service but it is rarely used by young people. Staff feel they lack the time and skill to deal with young people. Young people think they will be lectured and patronized, and worry about cost. STD clinics are already stigmatized and confidentiality is almost non-existent. Although quite a high proportion of men suffering from STDs do seek treatment, they prefer to go for cures promoted by street vendors. For young people, and especially for unmarried women, visits to an STD clinic would be impossible.
Suggested strategy for key element 3:
· To build on the services already offered and make them more accessible:
- increase training for counsellors and involve them in open discussions with young people to increase their awareness of and capacity to cater for the needs of adolescents.
- close counselling centres one day a week to allow counsellors to visit youth clubs, church groups, and schools for general talks about HIV and responsible behaviour, about services on offer, costs and confidentiality. Provide specially designed material with contact points for further information.
- designate monthly teen health days at primary health centres. Offer a range of services that might attract young people and neutralize parental opposition, perhaps providing free vitamins and advice about a range of health and lifestyle issues as well as STD services and referral for HIV testing and counselling.
- train providers of street medicine for STDs to refer clients to health centres.
5. Examine strengths and weaknesses of proposed strategies
· Are there interest groups that will oppose the initiatives in the strategy?
· Does the technology for the initiatives in the strategy already exist?
· Does the country have the means to implement the initiatives in the strategy?
· Are the initiatives in the proposed strategy in line with the nations guiding principles?
Key element 1: If the basic rules of research are followed, and the populations involved carefully informed of the reason for the study and the importance of their contribution, there is unlikely to be any major opposition to most of the research initiatives. Researchers should, however, ensure that parents as well as participating adolescents are fully informed and consenting. It may also be difficult ethically to do focus group interviews with a subset of young people from the household survey, since it may compromise anonymity guaranteed by the survey. Researchers should find a different sampling frame for their focus groups.
Reliable methods for tracking both behaviour and sero-status exist and are being constantly improved: the country has already successfully conducted one household survey in this sensitive area. There is no clash with the nations guiding principles. Focusing on young pregnant women in sero-surveillance may be difficult in areas where population density is low since it may take too long to reach a sample size large enough to give stable results by single year of age. More tests also means more cost. Strategy should concentrate resources for this activity in a handful of high-volume sites.
Key element 2: Although the teachers union may be supportive, individual teachers may resist the added workload or the difficult subject matter of a healthy lifestyle curriculum. If resources were available, teachers might be given a bonus to compensate for the training and work involved. Could a large personal-care firm be approached to sponsor the cost?
It might be difficult to persuade private TV stations to give up advertising revenue during their prime time slots. If the ministry of information increased their licence to broadcast until 2330 (from the current limit of 2300) they could more than compensate for lost revenue.
The market sisters initiative will require a great deal of training in the initial phases since the information to be imparted must be accurate and comprehensive and many of the young women who might act as sisters cannot read. To succeed, the initiative must be preceded by one that builds up training capacity. Suggestion: female university students could act as big sisters, passing on skills and information to teenage little sisters to use with their peers. The initial training would then be reduced to training university students - a much less resource-intensive task.
Key element 3: Counsellors are already overworked and underpaid, and many are demoralized by their work. Previous attempts to increase funds for this area have failed. Even if they could find the time to train to deal with young people, it is not clear that they would want to. Existing clients are likely to complain loudly if existing services are shut down once a week. The outreach work does not need to be done by trained counsellors - it can be done by a team of motivators developed by an organization of families living with HIV.
Street medicine sellers will not be enthusiastic about referring clients to health centres, since they will lose their revenue. Negotiations with the Association of Traditional Healers could lead to a cross-referral service where clients are seen at clinics for diagnosis and advice but charged a premium for drugs. They would still, then, have the incentive to buy their medicine on the street but would be more likely to properly diagnosed and to have access to information on safer sexual behaviour.
6. Revise strategies and objectives where necessary, choosing those most likely to succeed with the greatest impact on the epidemic at an acceptable social, financial, and political cost
If strategies are revised to include concerns raised in the analysis of the strengths and weaknesses, most of them have a high likelihood of successful implementation. For many of the strategies, major resources have already been identified. Providing counselling remains problematic - even the modest objective of services in five major cities may not be met. In any case, the initiatives designed to involve young people in the response, increase awareness of risk behaviour and how to avoid it, and ensure that people choose and can afford to use condoms are likely at this stage to have the greatest impact on the epidemic. Providing STD and basic health services are considered more important that testing and counselling at this stage. If other priority areas are considered, programmes for young people have to be scaled back. Specialized testing and counselling services for teenagers should be considered the lowest of the important priorities for this population in this country.