Joint Workshop on APIN Phase II:
Policy and Institutional Capacity Module

For officials from the University of Ibadan,
the Nigerian Institute for Social and Economic Research (NISER)
and HSPH Faculty

Harvard School of Public Health, Boston, USA
October 28-30, 2002

Workshop Summary Report

Also see photo gallery.

The AIDS Prevention Initiative in Nigeria (APIN) held a Joint Workshop on APIN Phase II - Policy and Institutional Capacity Module for officials of the University of Ibadan, NISER and Faculty at the Harvard School of Public Health (HSPH) in Boston, MA from October 28-30, 2002. The purpose of this workshop was to help participants to:

1. Achieve a common understanding of the goals and objectives of the Policy and Institutional Capacity Module
2. Specify the areas of collaboration among the University of Ibadan, NISER and HSPH faculty
3. Clarify expectations and responsibilities on all sides
4. Lay out a feasible work plan for collaboration.

The participants from Ibadan, 6 Nigerians, were made up of the Provost, Deans (Public Health, Postgraduate School) and the Head of the Department of Health Promotion and Education at the College of Medicine, University of Ibadan as well as the Director-General of NISER and a senior researcher from NISER. APIN is working with HSPH faculty, specifically from the Department of Population and International Health headed by Prof. Michael Reich, to develop and support the implementation of a Policy and Institutional Capacity Module, with emphasis on the economic and development implications of HIV/AIDS in Nigeria.

Day One, October 28

Welcome

Prof. Phyllis Kanki, APIN Director, welcomed the group and presented background information on the APIN project. Her major points were:

• APIN has completed 18 successful months of operation. Based on guidance from the APIN Advisory Council, this next phase will emphasize knowledge-intensive areas of work, including applied research and capacity building, in line with the comparative advantage of APIN and Harvard University.
  
  
• APIN Phase II focuses on capacity building, prevention and technical support based on evidence/research. (While APIN may provide high-level technical support to ensure that antiretroviral programs are of good quality, APIN will not engage in drug treatment programs. This is because the Gates Foundation does not focus on direct treatment programs)
  
  
• NGOs will be more and more involved in collaboration with universities and researchers. The important role of many NGOs in access to particular high-risk populations have already been demonstrated in APIN’s first 18 months of operation. For select NGO groups in each of the target states, APIN hopes to develop this role more fully. Selected NGOs will collaborate closely with APIN’s Surveillance/Intervention sites in support of the intervention programs

Objectives and Expectations
Soji Adeyi, Isaac Adewole, Olu Ajakiye, Michel Reich, and all participants

The major program goal was stated to be: To strengthen local capacity based on sound analysis, which can guide effective programs and provide input into effective advocacy.

Prof. Reich encouraged the group to comment on their expectations for the workshop as well as for the Policy and Institutional Capacity module in general.

Expectations in a broad sense of APIN II module

Expectations for APIN II Workshop

Achieve big difference with minimum mistakes and high sustainability Establish collaboration between Nigerian group and HSPH Identify key people on each side Identify areas of capacity building based on existing studies and research Understand how the project contributes to other national activities in order to avoid duplication Make results widely available (questions of dissemination)

Develop work plan including allocation of responsibilities, realistic budget, and two-three areas of collaborative work Discuss management of collaborative activities (traveling, exchanges, relations, working on the joint proposals) Understand various roles Exchange ideas Produce 1-2 page summary of three-day workshop as a concept paper, which might include: areas of collaboration, estimated number of visits, budget, etc. Make decisions Bring back work plan, high motivation and readiness to work

Possible Areas of Collaborative Work

Prof. Reich started the session by introducing the HSPH faculty who would be participating in the workshop:

1) National AIDS accounts	Ajay Mahal, Peter Berman
2) Socio-economic impact	David Canning, David Bloom, Peter Berman, Ajay Mahal
3) Policy impact and strategies	Soji Adeyi, Michael Reich
4) Capacity building for different groups	Marc Mitchell, Sofia Gruskin, Richard Cash
5) Behavioral interventions	Ted Green, Vinand Nantula, Alan Hill
6) AIDS control, implementation by states	Tom Bossert

As an added agenda item, Dr. Yaa P. A. Oppong presented her research on how the media impacts the HIV epidemic in Ghana. She has looked into what the media is saying and how that has an effect on society, i.e., the way HIV/AIDS is presented in the press can have an impact on key decision makers.

Prof. Reich then made a presentation on how policy making is a profoundly political process. He stated that against the political background, good data does not automatically result in good policy and sometimes good policies are made even in the presence of bad data. The political analysis governing policy decisions are important. He then went through a demonstration of the Policymaker software, introducing it as a tool for analyzing the politics surrounding a policy, helpful for strategies, identifying other influences and players. This tool could be helpful in analyzing how the AIDS policy in Nigeria could be put through when there are many players involved.

Dr. Soji Adeyi, APIN’s Associate Technical Director, opined that the problem in Nigeria was not solely the lack of policies, but the quality and implementation of those policies. Possible reasons given for this included: statements regarding HIV/AIDS being viewed as just rhetoric; the way the policy makers view agencies who provide evidence for the proposed policy and a lack of sense of ownership on the part of policy makers; and a lack of concreteness which is what usually appeals to politicians in most policy issues.

It was agreed that epidemiological and economic evidence were not enough in getting the issue of HIV/AIDS policy on the political agenda. Consideration should also be granted to the political aspects of the issue. The Policymaker software was seen as a useful tool that could be customized to the Nigerian context and help in politically analyzing the feasibility of getting the policy makers to accept evidence and respond with corresponding urgency. Copies of the software were distributed to the Nigerian participants.

AIDS Accounts
Peter Berman and Ajay Mahal

Prof. Peter Berman gave the background leading up to HSPH’s involvement with the AIDS account project during APIN Phase I and acknowledged all those involved. The goal was to lay out a concept for developing a National AIDS account for Nigeria, which was looked at from different angles, i.e., who delivers the service, type of service, and who benefits from the service. He predicted that households and the private sector would take a bigger hit than the Government from the HIV problem. It was therefore important to focus on how resources were allocated. With reference to Government budgets, Prof. Oladepo was quick to point out that there was a huge disparity between amount approved, amount allocated, and amount received, and this should be taken into account when preparing the estimates. The issue of double counting was also brought up and it was clarified that the National Health Account (NHA) framework could prevent this.

Prof. Ajay Mahal then raised an issue regarding the advantages of expanding the survey instrument to accommodate other issues that may be used to elicit more information that could be analyzed such as the impact of AIDS on other social parameters, i.e., nutrition. These issues may not be within the APIN area of interest, but could provide potentially useful information. It was also suggested by Prof. Isaac Adewole that the group working on this component should be given the latitude to generate a survey instrument that could capture all the other parameters of interest, and these may eventually be streamlined based on available funding.

It was agreed that the NHA was important in determining who actually bore what percentage of the burden of HIV. This was predicted to stem mostly from the private sector and households. The policy implications of such a result could change the way the policy makers view the Government’s financial contribution on the issue. Seeing that the NHA had a lot of potential for generating other data, it was suggested that a survey instrument be designed to accommodate more information on the impact of HIV/AIDS, which could be used for other analyses.

Assessing and Improving Performance in HIV/AIDS Program Development and Implementation

Dr. Tom Bossert presented the decentralization module and its implications to HIV/AIDS programs assessment and the capacity building at local levels. Decentralization is a useful tool to think about power distribution among defined geographical areas (center vs. states, smaller districts, municipalities). It is a complex block with variety of functions such as finance, source of local decisions, human resources, governance, etc. By looking at the degree of power distribution or capacity levels we can analyze and provide the ways to reorganize and to change the status quo.

Decentralization helps us to think about decision space and to answer the questions: How much choice people have at local levels? How much budget can they allocate without asking the center? What kind of capacities people have and what kind of capacities they need to improve in order to achieve desired criteria?

Map of Decision Space

Function	Narrow	Moderate	Wide
Finance
Source of local decisions
Human Resources
Governance

Dr. Bossert suggested that decision space has to be looked at in the Nigerian context. It is important to determine what the different levels of Government control, and then we determine what kind of capacities they need to make decisions and choices. It is important to identify the performance indicators we intend to use and then the adequate benchmark to compare it with. There may be some merit in using these sets of indicators to compare the different states in Nigeria and though it will likely be controversial, it will at least generate interest in the issue.

Day Two, October 29

Sexual Behavior – Research and Programs
Ted Green, Vinand Nantulya

The major points presented by Drs. Green and Nantulya included:

• Sexual behavior patterns meter
• Uganda’s population prevention approach with an emphasis on fidelity, abstinence, and delay of debut was a major factor in reducing new HIV cases
• Community perceptions of HIV risks need to be studied and addressed in order to reach risk avoidance behavior
• Participation of as many stakeholders as possible and strong leaderships at different levels are essential.

The discussion following the presentation included:

1. Monitoring is an important component in order to find out what contributes to transmission reduction.
2. Looking at existing NGOs, impact evaluation and effectiveness of intervention.
3. What is the right combination of research and programs interventions?
4. Picking the right balance between risk reduction (condoms, STI treatment) and risk avoidance approaches.
5. How to be sure that we send a consistent message to the public (message comes from numerous NGOs, media, religious leaders, etc.).
6. Understanding the economic situation and its impact on sexual behavior.
7. Understanding culture, norms, and values within the communities.
8. Thinking not only about proximal risks but also distant risks.
9. Providing a media survey to see how people talk about their sexual behavior.

Development of Local Capacity to Train Mid to Senior-Level Staff

Capacity Development
Marc Mitchell

Dr. Marc Mitchell discussed how effective organizations are needed to achieve results, whether in program implementation, research, or any other endeavor. The goal of this component, therefore, is to assess and improve the current organizational capacity of those institutions that have a major role in the design and delivery of HIV/AIDS interventions and research in Nigeria and to evaluate and document these changes so that the most effective approaches to capacity development can be replicated in other parts of Nigeria and potentially in other countries as well.

Prof. Reich asked the group what the training capacity is in Nigeria and what help is need from Harvard? What is it that the groups in Ibadan can provide with respect to training where it has knowledge? Which kinds of courses are necessary to produce what kinds of changes and who does it? How much can this project do with limited resources available?

Prof. Kanki informed the group on the Gates Foundation mandated HSPH to emphasize its comparative advantage as an academic and research institution. HSPH has a reputation for international HIV work and models used in collaborations are useful. She also stated that Gates is concerned with sustainability and the group should think about performance-based trainings and how they will be evaluated.

Ethics
Richard Cash

Dr. Cash provided an overview of the Ethics Workshop in Abuja last December, which covered bio medical and social research where a first rate dialog ensued emphasized by a good quality ethical review. Dr. Cash suggested the need for more workshops on ethics as well as help setting up review boards. Prof. Adewole thought there should be a 2-phase approach (impact assessment of the last workshop and a situation analysis) to identify the gaps that exist on the ground in order to design the curriculum for the next workshop. People who would be on the review board should be at the next workshop.

Human Rights
Sofia Gruskin

Prof. Gruskin discussed the differences between HIV related stigma and discrimination. Stigma is the process of devaluing people because of their real or perceived HIV status. Discrimination is the legal, institutional and procedural ways in which people are denied access to inter alia education, inheritance, employment, health and social services. She also highlighted the definitional precepts on human rights.

Prof. Gruskin’s areas of work include:

1. Studying interaction of HIV/AIDS and human rights.
2. Bringing tools and methods of human rights to HIV/AIDS work and vice versa
3. Building capacity of governments to fulfill their commitments to health and human rights.

She then explained that valid restrictions on rights provided for and carried out must be:

1. In accordance with the law;
2. In the interest of a legitimate objective of general interest;
3. Strictly necessary to achieve that objective;
4. No less intrusive and restrictive means is available to reach the same objective
5. The restriction cannot be unreasonable or otherwise discriminatory in the way that it is written as a law or policy, or in the way that it is applied.

Economic Effects of HIV/AIDS
David Canning, Peter Berman, Ajay Mahal, and all participants

Dr. Canning highlighted possible areas for investigating economic effects of HIV/AIDS:

1. HIV impact on the age distribution, dependency ratio, youth education
2. HIV impact on labor market, demand, competitiveness of the economy, and foreign investment
3. Need a combination of micro and macro analysis
4. Need reliable data for micro level analysis

Importance of showing policy makers consequences of "Not doing anything". To do this we need to first understand what are the interests of Nigerian policy makers today. (via focus groups among politicians, civil society groups, etc.) e.g., we can show the Ministry of Finance the impact of HIV on health sector expenditures, and to the Ministry of Health, what the caseload will be. We can show the gap between locally defined gold standard of HAART therapy and existing practices and how much money is needed to decrease this gap.

The three main areas of interest in economic investigations:

a. Economic-social impact (including family level: psychological, health, social benefits)
b. Health system financing and policies (AIDS accounts)
c. Cost-effectiveness analysis of existing interventions

Defined Areas Of Work

After hearing the Faculty presentations, the group narrowed the module components into the following areas. The Nigerian participants were asked to draft proposals in these areas to be presented to the group the next day.

Economic cluster

1. AIDS Accounts
2. Cost benefit analysis of AIDS intervention programs
3. Quality and resource requirements for large-scale ARV treatments
4. Socio-economic impact analysis of AIDS (households, sectors, macro)

Capacity Building

1. Capacity building in HIV/AIDS prevention and control
   - Gap analysis and indicator development
   - Short term training
   - Long term training
   
   
2. Ethical issues workshop
   
   
3. Outcome evaluation of HIV/AIDS
   - Media education
   - Stigma
   - Content analysis with software
   
   
4. Sexual behavior
   
   
5. Strategic management component (Situation analysis, strategies for policy change, influencing policy, action)

Day Three, October 30

Center for Research and Policy on AIDS & Development in Nigeria (CREPAD?)

The group used the workshop as an opportunity to discuss more concretely the idea of establishing a Center for Research and Policies on AIDS and Development in Nigeria. It was decided that for now, a Coordinating Committee will be developed which can subsequently be converted into the Center. Sustainability and funding were the main points in this argument. It was suggested that the Coordinating Committee will serve as virtual, network entity with a small budget (to be spent on meetings, seminars, publications, working papers, part time 20-25% coordinator, etc.) and will be working on accomplishments of the set objectives and coordinating activities.

Updating the Workplan

After reviewing the draft workplan proposals, the HSPH faculty commented on their content and made the following remarks:

Sexual behavior (Ted Green, Vinand Nantulya, Oladimeji Oladepo)

1. Add to the list of objectives #6 "How people interpret their sexual behavior (personal safety before, during and after a sex act)?"
2. Use data (when available) from Behavioral Surveillance Survey in analysis (will be provided by Pr. Kanki)
3. Provide in addition to quantitative research, qualitative research on sexual behavior. Ted Green will assist in instruments development

Media (Oladepo, Oppong)

1. Think about scale of research. 12,000 respondents, and 2,000 might be too much
2. Use an existent KAP data from one state (will be provided by Pr. Kanki)
3. Think about impact of Media Manual (e.g. pre- and post- evaluation)
4. Use of coding developed by Yaa Oppong in media analysis
5. Think about linkages with current APIN activities (data usage, media manual, etc.)

Administrative procedures: Key Persons for Defined Areas

Prof. Kanki asked the group to submit a 3 – 5 page proposal and to think about five-line budget (major categories, big items). The following individuals were assigned to co-lead each of the proposed module areas. The group was asked to submit all final proposals to Hope Bryer, APIN Assoc. Dir. for Educational Programs, for final distribution.

	Area	NPSG	HAPN
1a	AIDS Accounts/Socio-Economic Impact	Ajakaiye	Mahal
1b	Cost Benefit Analysis	Ajakaiye	Mahal
1c	ARV Tx, Resource requirements	Ajakaiye	Mahal
2a	Gap analysis	Adeniyi	Mitchell
2b	Training	Adeniyi	Mitchell
2c	Evaluation follow up	Adeniyi	Mitchell
3	Ethics	Adewole	Cash
4	Behavior Interventions	Oladepo	Green
5	Media	Oladepo	Oppong
6	Coordinating Committee	Ajakaiye	Reich