Process evaluation of the AIDS technical support project (ATSP) (project no. 936-5972)

Process evaluation covers the period 1992-2/96 vs. a PACD of 8/97. The Phase II design was novel and even audacious: (1) in a departure from Phase I, a single major implementing entity, the AIDS Control and Prevention Program (AIDSCAP), was created; (2) Phase II integrated three "proven" technical interventions: increased condom access and use, behavioral change communication, and treatment of sexually transmitted diseases (STDs). The project's umbrella-like structure gave USAID the opportunity to respond flexibly to the growing body of information and experience about HIV/AIDS, while the concentration of USAID's HIV/AIDS resources in the Global Bureau's HIV-AIDS Division allowed that unit to influence USAID Missions and provide global leadership. On the other hand, the Phase II structure centered the management of this large and complex project on AIDSCAP which was larger than its mother institution, Family Health International (FHI). FHI and its subcontractors have struggled with this management burden. AIDSCAP has done best in health and family planning, areas where FHI had experience, less well with behavior change and policy activities. The complexity of its task may have discouraged AIDSCAP's managers from being flexible to Mission demands or open to new intervention paradigms. Also, AIDSCAP tended to focus more on interventions and operations, and less on learning activities, such as behavioral research, pilot contextual approaches to HIV/AIDS, and programmatic collaboration. The management efficiencies that were realized from transforming Phase I's bimodal management structure into Phase II's single large project have been lost in recent years due to the mid-stream conversion of AIDSCAP from a cooperative agreement to a contract (which reduced risk-taking and flexibility, and greatly increased the documentation workload of USAID staff) and the introduction of field support budgeting (which, combined with major budget cuts in FY96, is threatening to undermine the project's viability). Although 85% of project resources have been devoted to AIDSCAP, USAID has funded valuable complementary activities implemented by other cooperating agencies (Cas), including behavioral research and pilot tests of alternative AIDS prevention models. However, most Missions are unaware of these other activities and USAID has not provided resources to enable the two subprograms to learn from each other. Considerable friction was initially created by what Missions perceived as the "Washington-only" design of the project and its rather set approach. However, Missions now feel that AIDSCAP has become more responsive to their needs and more decentralized in decisionmaking. Only seven Missions have established bilateral HIV/AIDS projects that do not use AIDSCAP as the primary implementing agency. Since no single evaluation system has been created for the project, USAID will not be able to evaluate the project's overall impact. Evaluating the impact of HIV/AIDS interventions is a complex and difficult task in any case, and USAID should not promise results to Congress or to advocacy groups. The project's 5-year time frame is extremely tight -- even with a 1-year extension, a major commitment of financial resources and staff time will be needed to analyze and disseminate the rich data potentially available. As to technical focus, most observers believe that the project's three core strategies are still appropriate, but should be expanded to include: contextual interventions; a more community-centered approach; reaching beyond traditional "at risk groups" to reduce women's and girls' vulnerability to HIV/AIDS; research and testing of vaginal microbicides; and linking prevention and care. Phase II is likely to achieve the target of 10-15 full-scale HIV prevention and control programs leading to documented changes -- an extraordinary accomplishment -- although structural problems may prevent the sustainability of some subprojects. On the other hand, the target of applying behavioral research findings to communication strategies in priority countries is not likely to be achieved; at best, the findings of a limited number of medium-term research activities will be available. The target to establish a global PVO/NGO federation -- the International HIV/AIDS Alliance -- was achieved. The Alliance is off to a good start, but its financial sustainability is doubtful. Finally, prospects for achieving the target of improved policies, especially for condom distribution and mass media communications relating to AIDS prevention, appear positive, although this outcome will be difficult to measure. A new strategy is needed for Phase III of the project, because a much wider population is now known to be vulnerable and the societal and economic impacts are deeper and more systemic than was realized when Phase II was designed in 1990. As both a chronic and an infectious disease, HIV/AIDS is an extraordinarily difficult public health problem, which has not been and is not being prevented on any significant scale and for which there is no simple solution. Various combinations of biomedical, behavioral, and policy changes may be effective, but need to be tailored to specific countries and contexts. Since HIV/AIDS is here to stay, increased attention to capacity building and sustainability is required. Also, HIV/AIDS is now recognized as a significant development problem, not simply a public health problem. At the same time, USAID's financial and staff resources are diminishing, and USAID is likely to be less dominant among HIV/AIDS donors in the future; carefully coordinated donor strategies and country strategies will be needed. Overall donor resources available for HIV/AIDS have reached a plateau and may decrease during Phase III. New funding sources (local government, NGO, private sector, philanthropic) and an increased focus on low-cost and sustainable actions will be needed. Detailed recommendations for designing Phase III are included.