Establishing an HIV/AIDS programme in developing countries: the Ethiopian experience

Abstract

Introduction There is global consensus on speeding up action against HIV/AIDS to mitigate the impact of the epidemic as rapidly as possible. However, there are no common blueprints on how to organize and manage accelerated HIV/AIDS prevention, care and support programmes to be followed by countries. Countries have tried to develop their intervention measures on the basis of local realities and international experiences available to them. The Ethiopia HIV/AIDS programme implementation process involves a high degree of the learning-by-doing approach, which capitalizes on positive lessons learned further to speed up action against HIV/AIDS. This article is a modest contribution and an example of what can be done in Africa in response to the epidemic in terms of project preparation and implementation (Table 1). It is hoped that some of these experiences can provide useful lessons for the preparation and implementation of HIV/AIDS prevention and control programmes in other countries.Table 1: Landmarks in the history of HIV/AIDS interventions in Ethiopia. Brief history of HIV/AIDS in Ethiopia and rationale for intensified action AIDS is now the leading killer in sub-Saharan Africa. Globally, Ethiopia has the sixteenth highest prevalence of HIV/AIDS and the third largest number of people living with HIV/AIDS (PLWHA), after South Africa and India. The primary modes of transmission in Ethiopia are sexual contact (heterosexual) and perinatal/mother-to-child transmission. Although the magnitude of the problem has yet to be sufficiently assessed, harmful indigenous practices and unsafe needle injection may be considered to be mechanisms for the spread of the virus in view of the wide practice in Ethiopia. The first evidence of HIV in Ethiopia was noted in 1984, and the first two AIDS cases were reported in 1986. HIV prevalence remained low in the 1980s, but has increased rapidly since the early 1990s. HIV prevalence increased from 3.2% in 1993 to 7.3% in 2000 (Fig. 1) [1]. During the same period, increasing trends were noted among women attending antenatal clinics in sentinel surveillance sites with notable regional variations. Estimated adult HIV prevalence according to the Ministry of Health in November 2000 was 16.8, 13.4 and 5% for Addis Ababa (capital city), other urban areas and rural areas, respectively.Fig. 1.: Ethiopia – adult HIV/AIDS prevalence.Initial HIV/AIDS-related activities in Ethiopia A National Task Force for HIV/AIDS was established in 1985. Two medium-term HIV/AIDS prevention and control plans were designed and implemented between 1987 and 1996, with the emphasis on information, education and communication, condom promotion, surveillance, patient care and the expansion of HIV screening laboratories in different health institutions. However, the interventions were limited in scope and there was little involvement of communities, sector ministries, non-governmental organizations (NGOs) including religious organizations and private organizations. The extent of interventions did not correspond to the fast spreading nature of the infection. Factors leading to organizational changes in the management of HIV/AIDS programme Global evidence of the adverse effects of unchecked HIV/AIDS epidemics on the socioeconomic situation of countries and the international movement to scale up action against HIV/AIDS have in no small way influenced the Ethiopian government to take accelerated action against the HIV/AIDS epidemic. Also, the First International Conference on AIDS in Ethiopia held in Addis Ababa on 7–10 November 1999 provided an additional forum for generating the support and commitment of high government officials to enhance HIV/AIDS interventions in Ethiopia. The government of Ethiopia became conscious of: (i) the devastating effects of the increasing infection rate that had reached epidemic proportions; (ii) the devastating impact of HIV/AIDS with the huge number of deaths severely straining the traditional social coping mechanism (the EDIR, a social organization created by communities to support families during funerals); (iii) the weaknesses of the existing organizational set-up to handle the rapid progress of the infection; and (iv) the common understanding that if the epidemic is left unchecked, it will alter the trajectory of the country's development by retarding growth, weakening human capital, discouraging investment, exacerbating poverty and increasing inequality. Ethiopia, therefore, in August 1998 approved a comprehensive HIV/AIDS policy to provide guidance and direction to the preparation of a multi-sectoral and multi-partner HIV/AIDS prevention and control programme. A National HIV/AIDS Council composed of ministers, regional heads of state, civil society, religious leaders, NGOs and PLWHA was established under the chairmanship of the President of the Federal Democratic Republic of Ethiopia in April 2000. The National Council has appointed the National Advisory Board, which meets monthly to provide direction and guidance to the implementation of the multi-sectoral HIV/AIDS control and prevention programme through the National HIV/AIDS Secretariat and its Project Coordinating Unit (PCU). Regional and local coordinating bodies were also established to facilitate the implementation of HIV/AIDS interventions at the community level. Influence of global HIV/AIDS movements on HIV/AIDS programmes in Ethiopia Globally, HIV/AIDS is now treated as an economic crisis and not merely a health problem. Successful HIV/AIDS interventions under such circumstances require actions as broad as the epidemic itself and intense enough to respond effectively to the level reached by the epidemic. The resource needs of such massive interventions are too enormous to be sufficiently addressed by many developing countries. A number of international agencies have expressed readiness to increase their commitment substantially in the fight against HIV. In order to realize this commitment, an International Partnership Against HIV/AIDS in Africa was formed, and UNAIDS was established co-sponsored initially by UNICEF, UNFPA, UNDP, UNESCO, WHO and the World Bank. The number of co-sponsors has since increased. The co-sponsors and UNAIDS secretariat met in Annapolis, Maryland, USA, on 19–20 January 1999, and agreed to work together to slow the spread of HIV in Africa drastically, and enhance a sustainable political and social mobilization at an unprecedented scale in order to reduced HIV transmission and suffering and to mitigate the impact of HIV/AIDS. The World Bank, conscious of the crisis created by the epidemic and the consequences of inaction, and convinced that it could play a greater role in HIV/AIDS prevention and control, prepared a strategic document in May 1999 [2] entitled ‘Intensifying action against HIV/AIDS: responding to a development crisis'. The Bank's new strategic plan placed HIV/AIDS at the centre of its development agenda to combat the epidemic, in partnership with African governments and UNAIDS. To stimulate and support the implementation of the strategy, the World Bank took three major actions: (i) established a multi-sectoral AIDS Campaign Team for Africa (ACTAfrica); (ii) directed all bank projects to include an HIV/AIDS component; and (iii) made available an initial US$500 million fund to be drawn by African countries to scale-up their HIV/AIDS interventions. A second amount of US$500 million was recently approved by the board of the World Bank. The global mobilization efforts have to a great extent encouraged the government of Ethiopia to intensify the action against HIV/AIDS to reverse the tragic situation. Enabling environments (internal and external) created to scale-up HIV/AIDS interventions in Ethiopia The global movement to accelerate and expand action against HIV/AIDS has created a potential for the increased availability of essential resources to developing countries. In Ethiopia a number of international and bilateral donors (e.g. WHO, UNICEF, UNDP, UNFPA, UNAIDS, ILO, USAID, DFID, GZT, DANIDA, Irish Aid, Norway, the Netherlands, Italy, the World Bank) have either provided support or are finalizing their project support. The government of Ethiopia approved a multi-sectoral and comprehensive HIV/AIDS policy that created an enabling environment for a wide range of HIV/AIDS prevention and control activities. The establishment of the National HIV/AIDS Council, the Advisory Board, National and Regional HIV/AIDS Secretariats, and their decentralized bodies have established potentially appropriate organization and management structures to lead expanded and intensified HIV/AIDS interventions throughout the country (Fig. 2).Fig. 2.: Organizational structure for HIV/AIDS management programme. NGOs, Non-governmental organizations.The World Bank has made funds available to countries including Ethiopia to draw from its initial allocated fund for HIV/AIDS. The Ethiopia Multi-sectoral HIV/AIDS Project (EMSAP) finances a 3-year (2000–2003) government HIV/AIDS strategic plan that is estimated initially to cost US$63.4 million [3,4]. The World Bank has approved US$59.7 million to help pay for the project, of which more than US$28 million is earmarked to support civil societies and community-driven HIV/AIDS initiatives. The process undertaken during the preparation of the Ethiopia Multi-Sectoral HIV/AIDS Project After formulating the national HIV/AIDS policy and preparing the National HIV/AIDS Strategic Framework [5], the Government of the Federal Democratic Republic of Ethiopia requested the World Bank to support its efforts to accelerate and expand action against the epidemic of HIV/AIDS in the country. As the request was in line with the global commitment and strategic plan of the Bank, the Bank agreed to the Government's request as long as there were institutional arrangements in place, such as the formation of a National AIDS Council, the establishment of the National Secretariat and the appointment of a National Task Force to lead the process of project formulation and development. The National HIV/AIDS Council was inaugurated in April 2000, and the appointment of the head of the National Secretariat was announced in the same forum. The preparation of EMSAP started in July 2000. Again at the request of the Government of Ethiopia, a multi-donor HIV/AIDS identification and preparation mission was undertaken to facilitate the preparation of a fundable project for an HIV/AIDS prevention and control programme in Ethiopia. A preliminary consultation workshop was held early in July 2000 to assess the prevailing HIV/AIDS situation in the country, and suggest the scope and actions to be undertaken to address the epidemic. The participants included members of the newly formed National HIV/AIDS Council, representatives of major sector ministries, regional state representatives, NGOs, and members of the civil society (women, youth, PLWHA, religious organizations, academic institutions) and donors. On the basis of the briefing on the status of HIV/AIDS and discussions that followed, the meeting agreed on actions that needed to be taken to mitigate the effects of the epidemic rapidly. The meeting stressed the following points during its deliberations: That HIV/AIDS activities should be guided and directed by the highest authority in the Government and the National HIV/AIDS Secretariat should be directly under such an authority that commands respect for its directives by all concerned. HIV/AIDS activities should be community based and driven. A special emergency grant fund should be created to support civil society and community-based initiatives. The fund should flow directly to communities, circumventing the normally bureaucratic financial system of the Government. The establishment of such a financial system would help ensure a fast flow of funds to support communities to engage rapidly in scaled-up HIV/AIDS interventions. NGOs, private organizations, community-based organizations and PLWHA should be actively involved and supported to expand their HIV/AIDS interventions by directly providing grant funding to support their activities. The project should be designed in a way that provides flexibility. The participants of the meeting outlined the objectives, components and logical framework for EMSAP. On the basis of the strategic plan and the logical framework, the National AIDS Secretariat Task Force, with technical support from World Bank staff and other donors, developed a draft multi-Sectoral HIV/AIDS Programme. The main objective of EMSAP is to help reduce the spread of the HIV/AIDS epidemic, alleviate its impact, and increase access to treatment, care and support for those infected and affected by HIV/AIDS. The components of the project were identified as including: (i) capacity building of public and private institutions; (ii) the Government multi-sectoral (iii) the response of communities, NGOs and the private sector to mitigate the and (iv) project and A draft project document was prepared and to a second The draft document was also for to of the during the initial meeting and an international mission composed of UNAIDS and bilateral institutions. The draft document was on the basis of the and provided by and a document was which the Government for funding to donors. Brief of components and activities The project components the scope of activities that have to meeting the agreed The country has a limited public capacity to the newly HIV/AIDS programme. It was to the institutional capacity of Government civil society and the private sector at and to accelerate the implementation of the HIV/AIDS programme. in this include the of human and other to the national and regional and and HIV/AIDS bodies in the were on EMSAP and were to the Project and other and the multi-sectoral implementation response of government agencies The of this is to support the multi-sectoral response of government organizations to scale up their interventions in the fight against the expansion of HIV/AIDS. The initial interventions prevention condom and and and care and support for those infected and affected of financial and support to PLWHA and in this government organizations at the level have established HIV/AIDS and their work plans and for and by the National Advisory the work plans and were approved and funds have to of (Table approved and for projects by non-governmental organizations, private organizations and people living with HIV/AIDS by the National HIV/AIDS The Ministry of has held and and HIV/AIDS for and and is the formation and of The Ministry of has up condom availability and the and of The authority has not the of HIV/AIDS interventions as and condom infection and as of the with but also is in the process of HIV/AIDS interventions among its and work regional sector have developed and their work plans and to the regional HIV/AIDS fund The emergency HIV/AIDS fund is an of EMSAP. A number of NGOs and community-based organizations in the country are to potential that could be by providing additional and including The is designed to support NGOs, the private religious organizations and community-based organizations to scale up their HIV/AIDS prevention and control activities in order to reduce the of the epidemic as fast as possible. The has two for and and the other for NGOs, private organizations, PLWHA and civil societies for all two with and NGOs religious and private organizations have from the of the fund (Table programmes and care and support to those infected and affected has increased in scale and scope in of the and communities supported by of funds by the Project Coordinating Unit to ministries, regional and HIV/AIDS Although there are in the country, International support for community-based programmes will be in for the There have to increase the number of support. The is not the of funds but the capacity to provide the support to The process of implementation also involves that require of the experiences the of an is to what has and what needs to be or The process involves a high degree of learning-by-doing a of experiences Project and management The main of this is to help develop a and management system that is of coordinating and the the National Secretariat is the management and is to a under the direction of the National HIV/AIDS Secretariat The is with structures that include programme and and The of funds to International Government of of NGOs, non-governmental National Project Coordinating people living with Regional The has established with the essential and The provides support to the establishment of the regional The has more than for funding at a national and has the of some funds to the appropriate A and has established and a and has appointed in an to a and system for HIV/AIDS in the country. process and impact have identified to help the and of the an HIV/AIDS system has developed with the of The Ethiopian and with support from the is actively involved in HIV/AIDS the support of USAID, Health International is a on HIV/AIDS. of these are to to and the effects of the interventions. of the Ethiopian project EMSAP is by communities, NGOs and donors. the US$63.4 the is US$59.7 million The is to be by donors, NGOs and The financial management system two of the funds is provided through the government fund flow and the other is directly to that have established and financial control the of the preparation of many expressed a to support the project, but the created an that in a After the of in the a number of donors have to support the Government's HIV/AIDS programme. became on January this the World Bank is the major to the The major and experiences in the implementation of the project National and regional and have established and The and have formed in the first of and were appointed and are in and coordinating community-based activities. have funds from the centre and have started up HIV/AIDS interventions. activities have is as by the increase in the number of HIV/AIDS is with by private and public in a of in the for HIV/AIDS is through the UNAIDS In briefing are by the to on the status of implementation of the The financial and system and organization and have prepared to the management of the project at and other have provided to the and the regional to facilitate and activities. have placed for the of and to and the of by health institutions. for have prepared and In view of the by the of the epidemic, the management of the national and regional had to be rapidly and in a There was little for the and to and the implementation process of the project In the project has a a number of and which made In view of these the progress in implementation is not as fast as for an emergency The project is implemented by many and decentralized and were prepared and to coordinating and bodies to the implementation of the project the have useful in the implementation However, there is a to ensure to facilitate the of the to different The project by massive involvement of NGOs, the private sector and community-based organizations to scale up HIV/AIDS prevention and control interventions to mitigate the impact of the epidemic rapidly. This epidemic a coordinating mechanism at all as the government would to facilitate the of these in the and management capacity of the and regional have the of all those to be actively The of government is an of EMSAP. Although it is to that some sector have expanded their HIV/AIDS a number of require and support to increase the scope of their HIV/AIDS interventions. The development of the and system was special from the of the composed of national and international organizations in and was established to and provide for and development. A national and was and in and held in South Africa. action is needed to the and system a in the of an appropriate and system will the process of project actions are taken by all to enhance the establishment of a and learned The Ethiopia HIV/AIDS project was prepared a fast project preparation a fast preparation process was by the to resources for an emergency situation that had started economic and a on the existing social coping The of the project has not increased but has also the establishment of management structures essential for intervention international partnership was in and generating government to take action against HIV/AIDS. The Government of Ethiopia established a comprehensive HIV/AIDS a HIV/AIDS strategic and a multi-sectoral HIV/AIDS National Council, under the of the President of the Federal Democratic Republic of Ethiopia. In the government established a National HIV/AIDS Secretariat under the a under the National and a policy that the of all of which are essential for up HIV/AIDS interventions in the country. The government has that of activities in limited areas are to slow the rapidly increasing epidemic, and has up regional and that are now leading a against HIV/AIDS It is that in the epidemic an expansion of community-based interventions. The Government of Ethiopia has taken unprecedented measures to interventions at a community level by a to funds to flow directly to communities, and public funds available to support NGOs and private organizations. This action has made the rapid of to communities to help the rapid implementation of community-based which would have slow if the flow of funds had followed government As a of such a rapid progress has noted in some of the communities as by the increase in activities and support to those affected and infected the to all the during the first was The to the number of to has created a forum for what a learning-by-doing an to assess the in the and to the and of the intervention measures during the first learned during the first of implementation were to some of the in the of The level of and capacity of communities is in terms of their to The that communities are provided with and is not should be supported by community-based NGOs or other development to in the The the government has an implementation in has encouraged many donors to in HIV/AIDS interventions in the country. than donors are now a new commitment to provide additional technical and financial support. EMSAP is of the first two HIV/AIDS programme projects by the World Bank in sub-Saharan Africa. The of project preparation and of implementation have for many other HIV/AIDS projects in with of the scope and of the epidemic, and the readiness of many of the to fast action at the project level is and However, rapid project preparation and implementation and that to be addressed as early as possible. EMSAP the of the of the implementation process in order to and early measures to the project to its the adverse consequences of and conscious of the limited capacity of the existing the World Bank has taken special measures to support the national and regional and to accelerate the implementation of EMSAP. In to the support provided by the and the at the country a bank was to support the and the regional This has substantially to project implementation at all The National Secretariat and have with regional to assess progress and on actions to be taken during the following such have and the discussions and taken in these have created common understanding on project implementation and common to during The and the taken to an HIV/AIDS programme in Ethiopia can provide and for other developing countries on this public health A of the major the actions taken and are in The fast preparation process undertaken by this project in Ethiopia was in funds available to scale up intervention activities by communities, NGOs, private organizations and the public sector rapidly. The project a learning-by-doing than to programme in during which would have by of major action taken and the process project funds were directly to NGOs, community-based organizations, and communities to scale up rapid HIV/AIDS interventions at the local the are the of the project and the of of the the during the first are not the HIV/AIDS project in Ethiopia, a number of national and international organizations have now developed a partnership with the government by providing financial and support to the project to be in Ethiopia, trends have in and the expansion of care and support at the community level. A number of World Bank staff and international organizations have to the preparation and implementation of the project, and it is to all and organizations. The to the special contribution of the following in the and implementation of and The would also to their of the and support by the national and regional the Project and the international and bilateral organizations. the special support and to the by World Bank President for and the have support and guidance to the preparation and implementation of the