COMMUNITY MOBILIZATION IN AVAHAN Mexico IAS Conference – NACO Satellite Session August 3, 2008 NOTES FOR USAGE Help for presentation creation and template usage can be found in FND_TemplateAddendum.ppt. Be sure to first Save As this file with another name. (By renaming the file, you preserve the template for the next person.) TITLE SLIDE: Background photo can be deleted or replaced. For additional photos, see PHOTO LIBRARY.
AVAHAN – A VERY LARGE SCALE HIV PREVENTION PROGRAM Dec 03 Jun-04 Dec-04 Jun-05 Dec-05 Jun-06 Dec-06 Jun-07 Dec-07 578 598 604 605 531 465 376 408 Towns covered 7200 7100 7500 6200 5000 4000 2300 240 Peer educators 280 250 171 135 104 79 49 22 High risk groups covered (figure in thousands) 15 13 States (6) 10 Districts (83) 7 Intervention sites 5 6 2 1 Condoms distributed and sold per month (figure in millions) Source: Avahan routine monitoring data
SETTING CONTEXT – OUR COMMUNITIES ARE MARGINALIZED AND FACE HIGH RISK Female sex workers Men who have sex with men Injecting drug users
SETTING CONTEXT – OUR DEFINITION OF COMMUNITY MOBILIZATION FOR HIV PREVENTION Community mobilization is the coming together of persons from a community to utilize their intimate knowledge of vulnerability to overcome the barriers they face and realize reduced HIV risk and greater self reliance through their collective action. Community Mobilization is the creation of an active and informed consumer of health services –aware of her rights, and driving improvements across the supply chain, in demanding better service Persons from a marginalized community come together Knowledge of vulnerability factors used to overcome barriers Collective action leads to reduced HIV risk and greater self reliance
OUR VISION ENVISAGES INCREASING COMMUNITY INFLUENCE AND OWNERSHIP OVER PROGRAM… led Action BY the Community Community Driven Community tackles own priorities Networked from sites, districts, state Broader vulnerability reduction Action WITH the Community Peer Driven Safe spaces are hubs for community activities Peers understand risk profile of every sex worker she serves Action FOR the Community NGO Driven Peers do outreach Peers trained in communications techniques Externally led
THESE COMMUNITIES ARE THE FOUNDATION OF THE AVAHAN SERVICE DELIVERY ORGANIZATION
Service delivery channels Subject matter experts OUR DESIGN ENVISAGES COMMUNITIES IN MANY CRITICAL ROLES IN PROGRAM DESIGN AND DELIVERY Service delivery channels Microplan-based peer outreach Crisis response Consumers Service uptake and feedback Norm setting around risks Accountability from service providers Subject matter experts Mapping and size estimation Vulnerability reduction Governance Program monitoring District and local advocacy
MICROPLANNING - UNLOCKING THE POTENTIAL OF COMMUNITIES Micro-planning uses specially designed tools that allow peers —including those who have low literacy—to record and analyze data on the specific personal and social factors that make each individual vulnerable to high-risk behavior, and to track their outreach at daily, weekly, and monthly intervals. Adopted to improve outreach targeting and efficiency by unlocking community knowledge
MICRO-PLANNING FORMATS – DAILY TRACKING
MICRO-PLANNING FORMATS – MONTHLY TRACKING
MICRO-PLANNING RESULTS 40 percent increase in contacts per peer Source: Avahan program monitoring data
CORRELATION BETWEEN VIOLENCE AND HARASSMENT AND HIV RISK Source: Karnataka Health Promotion Trust (KHPT), Bangalore, Integrated Biological and Behavioral Assessments among FSWs and MSM-T in selected districts of Karnataka, 2006
CRISIS HOTLINE CARD
VIOLENCE AGAINST FEMALE SEX WORKERS IN 11 DISTRICTS OF TAMIL NADU Level of police and client violence experienced by female sex workers have decreased over three years but reports of partner violence are going up; this may be attributed to backlash violence or increased reporting. Note: Out of 1,023 total cases, cases for 2008 are only recorded through May Source: TAI program monitoring data
VIOLENCE AGAINST HIGH-RISK MEN WHO HAVE SEX WITH MEN Family violence is a problem for high-risk men who have sex with men, as well as violence from police and partners. All appear to be going down as their are being addressed by crisis response systems. Note: Out of 261 total cases, cases for 2008 are only recorded through May Source: TAI program monitoring data
TYPICAL GOVERNANCE STRUCTURES ON THE GROUND State Federations District Community Based Organization Representation by peers capped at 40% and community members 60% Elected offices; deals with HIV service deliver and advocacy at high level Committees for Clinics, DIC, Outreach, Advocacy, Crisis Management Block Group (at the sub-district level) 10-20 members total with 2 representatives Brings organized approach to advocacy and service influence down and priorities up from 10-20 site level groups. Depending on the # blocks, the numbers will change District CBO also mention - Distinctions are made to ensure community leaders for advocacy work separately and financial resources for advocacy work are mobilized separately from programme related activities to ensure autonomy Hot-spot/Site Level Groups 5-10 Site level groups, usually informal, with 10-30 members Determines needs; acquires training and brings in support to address
in sex workers and clients …LEADING TO RISK AND VULNERABILITY REDUCTION FOR SUSTAINABLE PREVENTION Activities Outputs Intermediate outcomes Long-term outcomes Impact Vulnerability Reduction 24 hour violence response Savings / insurance schemes Strong service engagement Community projects tackle local KP problems Linkages with entitlement schemes Functional community based organizations Networked community groups Enabling Environment Coalitions built in wider community Police endorse peer outreach Media outreach to reduce stigma Sex workers empowered, stigma reduced Strengthen Collective Agency Crisis Response Advocacy Planning Community Savings Community Groups (CG) CG Network Safe spaces Community members represented in district and state-level structures Strong community structures are sustained Social Impact beyond HIV Sex workers have increased financial independence Community voice Influences supportive policy decisions Reduced HIV incidence in sex workers and clients Violence reduced Condom use with clients becomes normative Police harassment reduced Background: Avahan works from the theory that service driven solutions alone cannot tackle HIV vulnerability and community mobilization is essential to bridge the gap between the needs on the ground and what the programme can deliver on its own. “In addition to individual risk, HIV transmission dynamics are also a function of vulnerability, which stems from social, economic, or legal circumstances that increase susceptibility to infection, deter individuals from seeking essential prevention services, or enhance the likelihood of engaging in unsafe behaviour.” (Global HIV Prevention Working Group, 2007) Avahan’s field experience to date and global best practices reveal that communities should be at the center of the program to reduce risk and vulnerability to HIV Communities are one of the two natural owners during the transition phase. Empowered key population members, strong networks and community capacity are critical not only to consolidate the work to date but also to sustain the results of the Avahan program National AIDS Control program III is ambitious and places communities at the center and in fact plans to hand over the program to communities in many places Avahan is well positioned to influence and inform the national program’s community approaches given the invaluable experience and lessons from the past few years of implementation in multiple contexts Priorities for the next phase of the program are informed by progress and evidence to date, implementation and capacity gaps and the community aspirations and the national program directions It is critical for Avahan to document and fully establish the science of community mobilization as it can inform large scale HIV programs around the world Reduced HIV incidence in larger community Better condom negotiation and efficacy Strengthen Individual Agency Peer led DIC Violence Reporting Program Committee BCC / IPC New HIV and STI infections prevented Quality HIV Services Health clinics established and accessible On going peer outreach and behavior change communication Commodities provided Counseling for risk, care & treatment Condoms normalized Improved health-seeking behavior
TENETS OF MICROPLANNING Give peers an in-depth understanding of the risk and vulnerability factors for each high-risk individual they serve, and helps them to track these over time Allow peers to manage and plan their own work Enable peers and their supervisors to track each high-risk group member's progress over a period and to prioritize and monitor outreach Improve the quality and scale of outreach by individual peers Improve program service delivery levels Provide ways for peers to participate in program planning, determining priorities and devising improvements
MEASURABLE CHANGES DUE TO COMMUNITY MOBILIZATION Early impact of community mobilization from a district survey in coastal Andhra Pradesh Program-wide behavioral surveys initiated in 2008 to assess key measures of community mobilization including violence, stigma and collective action Source: Yale Parivartan RDS Survey round one and two (Rajahmundry)