Learning by Doing: Uganda's AIDS Control Project Empowers Local Managers

In this "Development Outreach" article published by the World Bank, the authors assert that the "learning by doing" approach to the management of HIV/AIDS programmes empowers local managers to guide their own programmes, so that solutions can be tailored to specific local conditions.

According to surveillance systems in Uganda, HIV prevalence declined from 21.1 percent in 1991 to 6.4 percent in 2001. National HIV/AIDS Committees are responsible for both covering their populations with the highest quality prevention, care, support, and treatment programmes possible, and for improving them constantly. Unfortunately, "the process that managers can use to continually enhance programs is not well understood. What contributes to this challenge is that program quality can vary substantially from one area of a nation to another. Diverse geographical, cultural or logistical conditions contribute to this variation. Also, some areas may have had HIV/AIDS programs for several years, while in other areas programs are recently established."

Based on this, the authors advocate for a "community learning" approach to HIV/AIDS education programmes. They believe that local managers are in a better position to make decisions about how to make tactical changes to their programs than administrators stationed in a national capital. "The people who are responsible on a daily basis for providing services are in the best position to analyze the challenges in their areas and to decide on the tactical changes."

"During 2003 the Global HIV/AIDS Monitoring and Evaluation Support Team (GAMET)—a unit of the World Bank’s Global HIV/AIDS Program—launched its Community Learning activities to equip local managers with tools to rapidly assess their program interventions and identify priority areas for improvement. GAMET offered training in tools that are suitable to be used at the local level by service providers, require a small amount of time to collect data, and produce information that is reliable and easy to interpret. GAMET promotes a 'Learning By Doing' approach to program management."

The Ugandan experience

"During September 2003 the Ugandan AIDS Control Project (UACP) on behalf of the Uganda AIDS Commission (UAC), with support from GAMET, was implemented to assess the current status of its programs. By September 30 districts were identified for assistance. For the initial assessment, UACP identified 19 of these districts to participate.

By mid-October all the District HIV/AIDS Committees (DHACs) had been contacted and agreed to participate. They recruited Civil Society Organizations in each county who identified at least 2 people to be trained in LQAS [Lot Quality Assurance Sampling]. The DHACs used the national census to identify villages targeted for HIV/AIDS program support. The UACP developed a set of six short questionnaires to collect information useful to program management, and translated them into six local languages. The six questionnaires were developed to survey small samples of: orphans, mothers of infants, youths, sexually active men and women, and people living with HIV/AIDS. The surveys were intended to provide information for key categories of HIV/AIDS Programs including: Prevention of Mother to Child Transmission, Voluntary Testing and Counseling, Home-Care, Prevention, Behavior Change, Care and Support of people affected and or infected with HIV.

The data collection in most cases took 5-days. A few locations required an additional day due to problems of rain and difficult roads. After that, the teams returned to the training venue in Mukono District to hand tabulate their data. One week later they presented preliminary findings to their own DHACs in their home districts. Soon after, the UACP organized three more workshops. The “Learning By Doing” approach was being successful and teams were becoming increasingly empowered to use Community Learning approaches."

An example of the "Learning by Doing" approach concerns people living with HIV/AIDS (PLWHA). Aggregated at a national level, the LQAS data showed that 78.3 percent of PLWA were ill during the last month and 94.5 percent of those who were ill sought medical care. The authors feel this is positive evidence that the treatment component of the Home Care program is functioning as PLWHA are counseled to see medical support whenever they are ill. "Despite this positive sign the data also reveal portions of the program that need improvement. The data show that 41 percent of PLWHA are sexually active. However, as the figure reveals only 51 percent of men and 48 percent of women always used a condom. Twenty-four percent of men and 22 percent of women reported they never used a condom. These data show that not only are some PLWHA placing others at risk but they are also exposing themselves to re-infection."

The authors conclude that although this approach needs more research and time to determine its efficacy, it has nonetheless received some positive results in Uganda in the short term.

"The more managers are empowered... the greater the likelihood that we will be able to gather a set of lessons that can be built upon. Lessons are derived from local people working together to solve their own problems while being provided with the support they need. If local managers can do this, we consider the program to be on the road to success."

Joseph J. Valadez, PhD, MPH, ScD, Senior Monitoring and Evaluation Specialist, Global HIV/AIDS Monitoring and Evaluation Support Team in the Global HIV/AIDS Program, The World Bank; and Peter Nsubuga, MD, Project Coordinator, Uganda AIDS Control Project, Kampala, Uganda.

"Development Outreach" is a magazine in the field of global knowledge for development which reflects the learning programmes of the World Bank and aim to present a range of viewpoints by renowned authors and specialists worldwide. It is published three times a year and is designed to occupy a middle ground between the scholarly journal and the general interest magazine.