1

SOCIAL ANALYSIS

OF MULTISECTORAL HIV/AIDS PROJECTS

IN AFRICA

A Guidance Note

Africa Region Social Development Team

October 31, 2002

TABLE OF CONTENTS

Page

Introduction 1

  1. Social Development Objectives in MAP Projects 4

Relationship to the Regional Development Strategy 4

Changing Perspectives on HIV/AIDS 6

  1. HIV/AIDS in the African Social Context 9

Poverty 9

Gender relations 9

Age differences10

Ethnic diversity10

Conflict and violence11

Weak institutions11

Poor governance12

Africa’s assets13

  1. Social Analysis for MAP Projects in Africa14

Country strategy14

Project identification15

Project preparation16

Project appraisal19

Social diversity and gender19

Social institutions, rules, and behavior20

Stakeholder analysis22

Participation28

Social risks31

Institutional arrangements and sustainability32

Social analysis after appraisal34

Monitoring and evaluation35

Conclusion38

Page

Best Practice Boxes

1. Findings Relevant to HIV/STI Projects from OED Reviews 8

  1. Building Local Capacity through Social Assessment18
  1. Identifying and Addressing Gender Issues21
  1. Involving Service Providers in Community Response Programs24
  1. Promoting Partnerships with Traditional Authorities26
  1. Involving NGOs in Program Implementation27
  1. Sharing Knowledge about Local Responses to HIV/AIDS28
  1. Incorporating Traditional Healers and Indigenous Knowledge30
  1. Assessing the Needs of Indigenous Minorities32
  1. Using Beneficiary Assessment Techniques37

Annexes

Annex A. Generic Terms of Reference for Social Assessment of MAP Projects39

Annex B. Social Development Indicators for MAP Projects42

Annex C. Social Analysis Matrix for MAP Projects43

Annex D. Bibliography50

1

SOCIAL ANALYSIS OF MULTISECTORAL HIV/AIDS PROJECTS IN AFRICA[1]

Introduction

HIV/AIDS poses a tremendous development challenge in Africa – a challenge that comes on top of already difficult circumstances. Africa contains a growing share of the world’s absolute poor. Africa’s role in the world economy has eroded, with declining export shares in primary products, little diversification into new lines of business, and massive flight of financial and human capital to other regions. Women provide much of the region’s labor, and their productivity is hampered by a culture that perpetuates the isolation of women from knowledge and other assets.[2] Armed conflict and other forms of violence are increasingly used to appropriate political power and redistribute resources. The failure of post-colonial states to provide a level of living commensurate with, if not better than, that experienced during the colonial and pre-colonial past evokes in many Africans the diffuse rage that derives from rising and unsatisfied expectations. All of these factors are closely linked to the fact that Africa is the most vulnerable of all regions in the world to the rapid spread of HIV/AIDS.

In response to this challenge, the Africa Region of the World Bank has developed a strategy to stimulate awareness of the epidemic and its potential consequences for development among high level decision makers, and to provide financial resources and technical support for actions to address HIV/AIDS across all sectors of its operations. It works in partnership with other donors through the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the International Partnership Against AIDS in Africa (IPAA). These programs assist African countries to develop and implement national strategies to combat the spread of HIV/AIDS and to provide care, support, and treatment for Persons Living with HIV/AIDS (PLWHA). As part of this strategy, the Region has developed a new lending instrument, the Multi-Country AIDS Program (MAP), which permits the rapid processing of country projects meeting the following criteria.[3]

  • Satisfactory evidence of a strategic approach to HIV/AIDS. In principle, this should be demonstrated through a coherent, national, multi-sectoral strategy and action plan that has been developed through a participatory approach using social assessment techniques. In practice, however, the urgency of making resources available to fight HIV/AIDS has led to some projects being designed and approved while the strategic planning process is still ongoing.
  • A high-level HIV/AIDS coordination body has been established, including broad representation of key stakeholders from all sectors, including PLWHA. This criterion aims to ensure continuing stakeholder involvement throughout project implementation.
  • Government has agreed to use appropriate implementation arrangements to accelerate project implementation. This criterion is aimed at facilitating rapid disbursements while ensuring transparency and accountability. Often, it requires Government officials to implement procurement practices which they do not fully support.
  • Government has agreed to use and fund multiple implementation agencies, including community-based and non-governmental organizations. This criterion is intended to ensure the full mobilization of all available resources to design and carry out HIV/AIDS programs.

Twenty-four (out of 45) African countries have received support through MAP projects through FY 02, and many more are in the pipeline.

The purpose of the present Guidance Note is to assist MAP project task team leaders and the social scientists on their teams in assessing the social dimensions of HIV/AIDS in African countries, and in developing, together with borrowers and other donors, an ongoing process of social analysis to be implemented from project identification through post-project evaluation. This process should, hopefully, continue under the leadership of the borrowing country after the project is completed.

It is important to note that MAP projects are multi-sectoral and focused on minimizing and mitigating the impacts of HIV/AIDS on a country’s entire economy and society. This Note does not address the social analysis requirements of projects in other sectors that may have an impact, positive or negative, on the spread of HIV/AIDS. Specific sectoral guidelines are already being developed within Africa Region for sectors such as transport and rural development. In the absence of a separate social analysis, project impacts on HIV/AIDS, and appropriate mitigating measures, should be identified as part of the agenda for project social and environmental assessment.[4]

This Guidance Note discusses the social development objectives of MAP projects in the context of the Bank’s Africa Region development strategy, describes some aspects of African societies and cultures which contribute to make the Region more or less vulnerable to the spread of HIV/AIDS, and presents a proposed approach to the social analysis of MAP projects. This approach is summarized in the table on the following page. The Note is based on a review of the literature on HIV/AIDS in Africa and elsewhere, as well as a review of available project documents for ongoing MAP projects. Current “Best Practice” examples are described in Boxes found throughout the Social Analysis section of the Note.

Project Cycle
/
Social Analysis
Poverty Reduction Strategy/Country Assistance Strategy / Establish country social development objectives
Project Identification / Set project social development objectives
Assess work already done by the borrower, other donors, and the research community
Identify key stakeholders
Identify needs for further baseline social data collection and impact assessment
Draft TORs for social assessment
Project Preparation / Support borrower in carrying out social assessment, ensuring use of all available data, participation of stakeholders, and timely completion, including social impact mitigation plan
Project Appraisal / Evaluate adequacy of social assessment
Assess social risks and mitigation measures
Discuss key social conditions for success with borrower and other stakeholders
Identify social indicators and methods for monitoring and evaluation
Ensure that social impact mitigation plan, participation plan, and plans for monitoring and evaluation are included in the Project Implementation Manual
Project Negotiations / Assist project team in reviewing legal documents and Project Implementation Manual to ensure that social concerns are adequately addressed
Project Implementation / Support borrower by providing technical support for social development aspects
Monitor implementation of community based activities, participation plan, and social impact mitigation plan
Coordinate with social development specialists of client and other donors
Project Evaluation / Assess achievement of project social development objectives
Assess implementation of participation plan, social impact mitigation plan, and social impact monitoring system
Identify lessons learned for future projects

I. Social Development Objectives in MAP Projects

In the context of the World Bank’s primary commitment to poverty alleviation, its social development objectives can be expressed in terms of inclusion, empowerment, and security.[5] Achievement of these objectives is of course primarily the responsibility of the borrower. The Bank provides assistance through country policy dialogue, support for the participatory preparation of poverty reduction strategies and other national and sectoral strategies (for the fight against HIV/AIDS, for example), and lending operations (such as MAP projects). Country-specific objectives and targets are articulated through country ESW as well as through the national and sectoral strategy formulation process. However, it is often the case that these objectives and targets are not well defined at a national level when HIV/AIDS projects are in preparation. The process of social analysis undertaken by the Bank team in collaboration with country counterparts and other donors can help establish such objectives and increase the effectiveness of HIV/AIDS programs in promoting positive social outcomes.

Relationship to the Regional Development Strategy

The strategy for the new millenium set out for Africa and supported by the World Bank recognizes HIV/AIDS as “a new menace” threatening to undermine human health and welfare, reduce savings and investment, and stress the social fabric in many African countries.[6] However, the strategy does not focus on fighting HIV/AIDS. Rather, it focuses on the need to develop participatory approaches that facilitate consensus building (instead of conflict) and include marginalized groups, as well as to strengthen Africa’s institutions for decentralized service delivery. The strategy takes an optimistic view of the capacity of African communities to manage development programs, and of the ability of governments to provide the enabling environment that will become attractive to private investors. All of this is summed up in the need not only for economic growth but for simultaneous economic, political, and social development (or “nation-building”).

In this context, and in the context of Bankwide social development objectives, the Africa Region is preparing a Social Development Strategy to guide the social analysis of country programs and projects. This strategy proposes that the social development goals for Africa should include:

  • Development that promotes inclusive and equitable societies which recognize and protect human and civil rights, and support the dignity of all social groups and individuals;
  • Development that promotes eradication of poverty by first recognizing and scaling up local people’s own internal production structures, and then ensuring that the benefits of increased productivity are distributed equitably within society;
  • Development that promotes strong, effective, responsive, and transparent institutions, and good governance.[7]

The strategy recognizes Africa’s problems – poverty, inequality of access to resources (especially gender inequality), social exclusion, insecurity and conflict, environmental degradation, vulnerability to natural hazards, ineffective formal organizations, and poor governance. It also recognizes Africa’s assets in terms of underutilized productive capacity, local institutions, shared values of inclusion and solidarity, cultural diversity and indigenous knowledge. It calls for country programs that will promote accountability and institutional change through civic engagement, build cohesive and resilient societies that can prevent and manage conflict, and promote socially responsible development and investment. Again, this strategy does not explicitly address the HIV/AIDS dimension of Africa’s development challenge. One purpose of the present Note is to show how the goals of the regional development strategy, including its social development component, can be addressed through HIV/AIDS projects, which constitute a significant share of the regional lending program.

The goals of MAP projects in Africa are to intensify action against HIV/AIDS in order to avert future infections, alleviate human suffering, and help preserve national development prospects. Expressed in social development terms, the main expected project outcome is improved security (health and welfare), especially for vulnerable groups, among both the poor and the non-poor, but with a focus on ensuring equitable access of the poor to project benefits. Project activities often tackle issues of exclusion and stigmatization (i.e. aiming at inclusion and empowerment) with respect to these vulnerable groups. A major focus in most projects is capacity building (empowerment) at the community level, in government agencies, and in civil society. In a still broader sense, the projects aim at preserving prospects for economic growth, which is essential to future poverty alleviation.

Expressed in terms of the region’s strategic priorities, MAP projects contribute to regional social development in the following ways:

  • They aim to minimize the stress on core social structures (households, kin groups, communities, public agencies, and productive organizations) caused by illness, death, and the requirements of care for HIV/AIDS victims;
  • They promote inclusion of marginalized groups by reaching out to involve such groups in program planning, giving them “voice,” and bringing them within the sphere of public social responsibility;
  • They aim to increase the security of the poor (and the public in general) by providing adequate resources to support the delivery of needed information and services;
  • They aim to empower the poor (and the public in general) by involving them in the design and delivery of services and in monitoring and evaluating project activities;
  • They aim to build capacity insocial institutions at all levels, from local communities to the national government;
  • They confront the need for cultural changes in gender relations, in conflict resolution, in governance, and in recognition and respect for human rights, which are fundamental to achieve sustainable social development in Africa.

Changing Perspectives on HIV/AIDS

It must be recognized that action to address HIV/AIDS will be exceptionally difficult to initiate and sustain, in Africa and elsewhere, because of the deeply personal and private nature of behavior associated with the spread of HIV/AIDS, and strong social and cultural constraints on dealing with issues of sexuality, illness and death. These matters are not easily discussed or objectively analyzed in any culture. The social analyst must first overcome his or her own reluctance to deal with these issues on a personal level, and come to accept the limits on understanding imposed by his or her own sociocultural background and perspective.[8] It is tempting to “objectify” the issue by defining it as a medical problem or a problem of communication, rather than as a fundamental problem in human and social relations. Social analysts must expect to encounter resistance to this definition, both from other members of the project team and from borrower colleagues.

Knowledge and understanding of the HIV/AIDS epidemic, in Africa and elsewhere, is new and is constantly evolving. Initially, it was seen as primarily a health problem; indeed, given the initial focus on its prevalence among marginal populations (male homosexuals and drug users), it was not even a major concern for African health care professionals. Once recognized as a major challenge, however, African health care systems tended to respond in terms of a biomedical model, with programs to protect the quality of blood transfusions, improve diagnosis and treatment of STDs, and intervene to prevent mother-to-child transmission (MTCT) of HIV. Recognizing the limitations of these approaches, a public health approach was added that focused on providing more information to groups at risk and the general public, in the hope of inducing the broad behavioral changes needed to slow the spread of the epidemic.

It was at about this point that the Bank came on the scene with its interpretation of

HIV/AIDS as a key challenge for development in Africa. Its economic arguments and simulation models were effective in convincing national leaders to acknowledge the existence of HIV/AIDS and to devote a significant share of national resources to AIDS prevention and care programs. In other respects, however, the Bank needed to learn from colleagues in the donor community how best to tackle the problem. Its earliest interventions focused on IEC (information, education, communication) campaigns and “social” (i.e. subsidized) marketing of condoms in order to overcome the many “market imperfections” believed to explain “irrational” risky behavior. However, the Bank soon recognized that individual choice was also constrained by social, economic, and cultural factors, and recommended the introduction of measures to alter social norms, reduce the stigma attached to vulnerable groups, raise the status of women, and reduce poverty.[9]

During this time a great deal of sociological and anthropological research has been carried out, in Africa and elsewhere, leading to a greater understanding within the research community of the social and cultural context in which HIV/AIDS programs are situated. (A partial listing of relevant references is provided in Annex D, Bibliography). This is an area in which Bank teams have much to learn from other donors and from international NGOs. Some African research institutions have been actively involved in this work as well, and are in a position to provide leadership and guidance to project teams tackling the social assessment of HIV/AIDS. The emerging concept is that the structural and cultural context of a country or community constitutes the “enabling environment” for individual behavioral change.[10] This context can be modified through actions that can be incorporated in Bank-financed projects, such as legal and policy change, economic incentives, participatory approaches, and capacity building activities that capitalize on existing social and cultural assets.

A recent OED publication summarizes the findings relevant to HIV/AIDS projects arising from OED reviews (see Box 1). Several of these findings have implications for the institutional design of such projects, especially for components that expect to rely on NGOs or CBOs for implementation. However, these findings fail to reach deeply into the social and cultural context for an explanation of project success or failure. This is partly due to the inadequate design and even more inadequate implementation of project monitoring and evaluation systems, which generally do not take changes in the social and cultural context into account.