Briefing
“We believe the community has the power to tackle HIV if they are recognised and supported to do so.�
Our theory of change: For sustaining community action on health, HIV and rights
p2 Our theory of change
About the International HIV/AIDS Alliance We are an innovative alliance of nationally based, independent, civil society organisations united by our vision of a world without AIDS. We are committed to joint action, working with communities through local, national and global action on HIV, health and human rights. Our actions are guided by our values: the lives of all human beings are of equal value, and everyone has the right to access the HIV information and services they need for a healthy life.
Published: December 2013. Š International HIV/AIDS Alliance Information contained in this publication may be freely reproduced, published or otherwise used for non-profit purposes without permission from the International HIV/AIDS Alliance. However, the International HIV/AIDS Alliance requests that it be cited as the source of the information. Designed by Progression / progressiondesign.co.uk
Unless otherwise stated, the appearance of individuals in this publication gives no indication of either sexuality or HIV status. Sharmim, a part time teacher and peer leader of an MSM group in Bangladesh. He takes pride in his teaching job, and also in providing SRHR info to young people via the youth group. Copyright International HIV/AIDS Alliance, Community health volunteers in Burkina Faso capturing real-time data on the health of households. Š Olivier Girard for IPC, Burkina Faso.
International HIV/AIDS Alliance 91-101 Davigdor Road Hove, East Sussex BN3 1RE United Kingdom Tel: +44 1273 718 900 Fax: +44 1273 718 901 Email: mail@aidsalliance.org Registered charity number 1038860
www.aidsalliance.org
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Introduction Our strategy, HIV, health and rights: sustaining community action 2013-20201, provides high-level direction and sets ambitious but measurable goals for the whole of the International HIV/AIDS Alliance (the Alliance). Our theory of change clearly sets out the difference we want to see in the world, and defines the outcomes that are implicit in our HIV programming. It describes how we go about effecting this change and the assumptions and evidence behind our chosen strategies. This theory of change is designed to help us better describe what we do, develop our HIV programming and advocacy, and prove the value of our efforts.
Making use of the Theory of Change Our theory of change serves as a programming tool - informing the design, implementation and quality review of more specific interventions (e.g. for a particular region, community and/or thematic area), a positioning tool - by introducing a common way of describing what we do and a monitoring and evaluation tool – helping us to monitor and evaluate how we are progressing towards the goals outlined in our global strategy. We also have a Results Framework1 which sets a small number of research questions and indicators to be prioritised in our future research, evaluation and routine monitoring. For more information about the Theory of Change and/or the Results Framework for Sustaining Community Action, contact: Jill Russell, Associate Director (jrussell@aidsalliance.org) Farai Matsika, Manager: Institutional Effectiveness (fmatsika@aidsalliance.org) 1. The Results Framework was developed in partnership with Programme and Monitoring and Evaluation directors from seven Linking Organisations (KHANA in Cambodia, Alliance India, Alliance Ukraine, Alliance Uganda, KANCO in Kenya, ANCS in Senegal and POZ in Haiti).
1. http://www.aidsalliance.org/publicationsdetails.aspx?id=90626
Our theory of change clearly sets out the difference we want to see in the world.
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20 years of community action As an alliance of national, civil society organisations (known as linking organisations), we have supported community mobilisation in response to the HIV epidemic for 20 years. We work in the knowledge that communities are critical to the success of the HIV response. We work alongside communities, community-based organisations and networks to ensure there is equitable access to effective HIV prevention, treatment and care for all those who need it. We work through the realisation of human rights; the empowerment of people living with HIV and other affected populations; by demanding political accountability; and strengthening community and health systems.
Evidence: the challenge of proving it works The benefits of our approach are evident on a daily basis. However, our challenge has been to provide a clear definition of community mobilisation and to gather evidence for its impact on health and social-political outcomes. Randomised controlled trials to test the efficacy of medical interventions have taken precedence and community action has remained difficult to quantify and measure. In June 2011, the Investment Framework for HIV and AIDS2 was published in The Lancet which recognised community mobilisation as one of 11 ‘critical social enablers’ in the response to HIV. The critical role of communities was not news to us, or to many other community actors or local government institutions, but it had rarely been described so prominently as a ‘critical’ ingredient for effective health programming. The Investment Framework provided a catalyst for the need to better understand the concepts of critical enablers and community mobilisation. It also underlined the fact that it is vital for those involved in the HIV response to better articulate the role and added value that civil society plays in improving health outcomes. As such, it gave us the impetus needed to be much clearer about the Alliance’s own theory of change. That is the logical sequence of changes that are required to achieve the desired outcomes of our work, and our assumptions about how and why that sequence of change might come about.
2. Schwartlander et al, (2011) ‘Towards an Improved Investment Approach for an Effective Response to HIV AND AIDS’ The Lancet, 377, 2031-2041
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Building the evidence • In early 2012, UNAIDS commissioned us to carry out a qualitative review3 of the Alliance approach to community mobilisation and provide some examples and costings from our programming. This review would also communicate to other civil society organisations and international organisations how our commitment and approach to community mobilisation matched against the Investment Framework for HIV and AIDS. • As a follow on to this work, in late 2012 the Alliance engaged the London School of Economics and Political Science (LSE) to examine and document4 the role of community mobilisation across Alliance HIV programming. The research team interviewed 39 people from Alliance linking organisations, implementing partners, networks, the international secretariat in the UK and regional offices. In the words of the lead researcher “what is emerging is a rich and fascinating record of community action and empowerment at a grassroots level”. • Finally, in 2013 the World Bank concluded a three year evaluation of the impact of the community response to HIV and AIDS5. This large scale research included country studies in Burkina Faso, India, Kenya, Lesotho, Nigeria, Senegal, South Africa and Zimbabwe and provides strong evidence in support of our theory of change.
What did the research tell us? Firstly, we learnt that the premise on which the Alliance was founded 20 years ago - that community mobilisation is an essential means to end AIDS - is more relevant today than ever. Both the LSE and World Bank research revealed that community mobilisation is vitally important in the achievement of long term HIV and health outcomes, in particular reaching people at higher risk of HIV and changing social norms and practices. Specifically, the LSE research found that the greatest resources of the Alliance are the community activists and community workers who are often members and groups affected by HIV and AIDS. The research also recognised that the Alliance, while being focused on tackling HIV, does not consider HIV in a vacuum, “Community mobilisation is both aimed at reaching the goal of HIV/ health and it is viewed as an achievement in its own right.” The World Bank research highlighted that investments in communities have produced significant results including improved knowledge and behaviour, and increased use of health services, and even decreased HIV incidence. 3. Drew, R., Mclean, S., and Teltschik, A. (2012) ‘Discussion paper: community mobilisation and HIV/AIDS’ (unpublished) – Alliance (2012) ‘Discussion paper ‘Invest in Communities to Stop AIDS: Don’t Stop Now’ 4. Cornish, F., Dashtipour, P., Mannell, J., and Montenegro, C. (2012). Towards a theory of change: Report on an interview study of the International HIV/AIDS Alliance. Health, Community, Development Group, London School of Economics and Political Science 5. Rosala Rodriguez-Garca, David Wilson, Nick York, Corinne Low, N’Della N’Jie & Rene Bonnel (2013) Evaluation of the community response to HIV and AIDS: Learning from a portfolio approach, AIDS Care: Psychological and Sociomedical Aspects of AIDS/HIV, 25:sup1, S7-S19, DOI: 10.1080/09540121.2013.764395
The research revealed that community mobilisation is vitally important in the achievement of long term HIV and health outcomes.
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Our response
Expected outcomes
High-level strategies
Short term outcomes
Commitment to community strength & agency
The Alliance • Increase access to HIV & health programmes • Support community-based organisations to be effective & connected elements of health systems • Advocate for HIV, health and human rights.
Community action • Peers engaged to deliver services • Community members taking leading roles in programmes • Programmes responding to community priorities • Community & social capital enhanced • Communities socially and politically mobilised
• Build a stronger Alliance
KEY:
Programme interventions
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Our results Medium term outcomes
• People at higher risk reached • Communities most affected by HIV meaningfully engaged • Quality assured, nondiscriminatory services delivered • More sustainable community based organisations and systems built
National and global environments enabled • Policy makers receptive to effective & integrated HIV programmes • Access to funding increased • Violence against people most affected recognised and addressed • Key populations decriminalised
Goal
Healthy people • People actively reducing their own risk • Health needs being met • Key populations, women and girls benefitting
Empowered communities •Communities exercise collective voice and active citizenship •Civil society strengthened to secure greater accountability
To work with communities through local, national and global action on HIV, health & rights to end AIDS (see our Results Framework)
HIV & health services accessed & utilised
Long term outcomes
p8 Our theory of change
Secondly, the Alliance holds a deeply-rooted commitment to community strength and agency and it is from this commitment that the Alliance forms a global ‘community of communities,’ animating their interrelations, allowing them to learn from each other and fostering its security and sustainability. The LSE research acknowledged our role in creating and bolstering communities of people living with HIV, and those most affected by HIV, by amplifying their voices, giving credibility to their needs and demands, and representing their voices within higher-level decision-making spaces, such as the board of The Global Fund to Fight AIDS, TB and Malaria or within technical groups led by the World Health Organisation. The credibility and reputation of the Alliance were deemed to be very important resources. The LSE research stated “They provide the symbolic capital needed to establish the legitimacy of marginalised and stigmatised groups. Being a member of the Alliance offers such groups status and results in enhanced levels of influence. Being part of the Alliance therefore allows and supports affected groups to make the links between ‘voice and ears’, stating their needs, and having those needs heard by people with power to make significant changes”. Finally, while the LSE research acknowledged that the strength of the Alliance comes from its diverse approach, it also identified five common short-term outcomes which are recognisable across our work: 1. Peers engaged to deliver services: this approach typically involves training community members to deliver community based services. For example, people living with HIV were trained as Network Support Agents in Uganda, to increase demand for a variety of HIV services. 2. Community members taking leading roles in programmes: this approach goes beyond a common peer approach to include supporting participation in decision making and in more ambitious roles in the planning and implementation of programming. For example, employing people who use drugs and training them as peer outreach counsellors. 3. Programmes responding to community priorities: this includes targeting people and interventions that will have the greatest impact on the state of the HIV epidemic. An HIV programme focused on treatment adherence, for example, can fail if an individual’s poverty needs are ignored. As a result this strategy includes activities that fall outside typical HIV activities, for example, offering job-seeking services to increase people’s chances of obtaining employment.
The Alliance holds a deeply-rooted commitment to community strength and agency
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4. Community & social capital enhanced: this includes bringing people together and creating a community in environments where people living with HIV and those most affected by HIV may previously have been isolated. Many activities depend on individuals gathering in the same physical space (e.g. self help groups), and the office of a community-based organisation is often used for this purpose. 5. Communities socially and politically mobilised: this includes both collaborative and adversarial approaches to political mobilisation, but the aim of both is to tackle stigma, discrimination and criminalisation in order to improve access to health services.
Gaps in the evidence base Whilst the LSE and World Bank research was mostly positive, it was clear that in some areas the evidence remains weak. The World Bank study, for example, showed that evidence of the impact of community responses to HIV on social transformation6 (the change of society’s systemic characteristics) was more mixed, with community groups found to be effective only in some settings. A separate literature review7 conducted by LSE disappointingly revealed that much of the research and evaluation of community mobilisation has been qualitative and focused on process rather than outcome evaluation. The review concluded that “Such an appraisal is difficult... given the diversity of definitions and operationalisation of community mobilisation, and the challenges of properly evaluating complex interventions. The authors therefore argue that the problem is not that community mobilisation is ineffective, but that it is poorly defined and evaluated.”
6. http://www.unesco.org/new/en/social-and-human-sciences/themes/international-migration/glossary/social-transformation/ 7. Cornish, F., Campbell, C., Priego Hernández, J. (2012). The impact of community mobilisation: a systematic and scoping literature review. Health, Community, Development Group, London School of Economics and Political Science
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Putting the evidence into action Informed by the evidence we had, we developed a theory of change (see diagram on pages 6-7) to support our new global strategy HIV, health and human rights: sustaining community action 2013-2020. This Theory of Change broadly defines the series of outcomes that are implicit in our HIV programming. It highlights the sequence of actions which ultimately lead to our impact on health and social-political outcomes, and informs the results we should expect to see if our new strategy is implemented as planned. The assumptions which underlie our theory of change (drawn from the LSE research) explain the connections between the short, medium and long term outcomes and the expectations about how and why proposed interventions will bring them about. Overall, our assumptions are based on the belief that communities have the power to tackle HIV if recognised and supported to do so and that some civil society capacity and resources exist at both local (community) and national levels. Specifically in relation to the short and medium outcomes, our assumptions are as follows: For community action: • Community-based activities are rooted in a diagnosis of context and the drivers of HIV and poverty. • Marginalised groups have some freedom of assembly. • Communities (and the community-based organisations working with them) have greater knowledge about their HIV and AIDS related needs. • Community-based organisations are able to fund skilled staff. • Community groups actively and frequently discuss HIV and AIDS related issues. • There is strong interpersonal communication about HIV and AIDS related experiences (including deaths) within community groups. • The protective effects of group members equally protect women and men (e.g. some research shows women benefit more).
We believe that communities have the power to tackle HIV if recognised and supported to do so
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For HIV and health services accessed & utilised: • Health facilities are accepting of all HIV-affected communities. • Government and service providers are willing and empowered to improve capacity and shift attitudes to provide quality assured, non-discriminatory services • Community-based organisations are committed to building capacity to manage and lead their own projects, and resources/leadership exist to support this. • Community-based organisation funding is sufficiently available and utilised in a way that is responsive to local priorities, needs and context. • Strong community-based organisation presence increases knowledge (e.g. knowledge of correct condom use). • Organised groups that bridge facility-based care and communities (e.g. such as home-based care alliances and caregiver networks) are recognised and resourced. For national and global environments enabled: • National policies protect women and key populations (e.g. legislation protecting women and/or key populations from violence is adopted). • There is greater awareness and social consequences for the perpetrators of violence & discrimination. • The greater awareness of HIV and TB does not lead to further exclusion. • Dialogue with police and community leaders around issues facing the most vulnerable and excluded communities is possible. • Key global figures, institutions and donors continue to advocate for and fund global health initiatives.
Community Animator, Clare Foster, in front of the Carnival Bus with an armful of Pouches. [Source: The Loop Sep 08] © Alliance
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“Our theory of change clearly sets out the difference we want to see in the world.�