Learning about scale, measurement and community mobilisation: reflections on the implementation of the Avahan HIV/AIDS initiative in India

Abstract

Debates have raged in development for decades about the appropriateness of participatory approaches and the degree to which they can be managed, scaled and measured. The Avahan programme confronted these issues over the last 7 years and concludes that it is advantageous to manage scaled community mobilisation processes so that participation evolves and programming on the ground is shaped by what is learnt through implementation. The donor (Bill & Melinda Gates Foundation) and its partners determined a standard set of programme activities that were implemented programme-wide but evolved with input from communities on the ground. Difficulties faced in monitoring and measurement in Avahan may be characteristic of similar efforts to measure community mobilisation in a scaled programme, and ultimately these challenges informed methods that were useful. The approach the programme undertook for learning and changing, the activities it built into the HIV prevention programme, and its logic model and measurement tools, may be relevant in other public health settings seeking to integrate community mobilisation. BACKGROUND

Community mobilisation programme for female sex workers in coastal Andhra Pradesh, India: processes and their effects

“…Community mobilisation and structural intervention strategies have been an integral component of the Avahan initiative for HIV prevention efforts in four southern states of India 12. These initiatives have incorporated the main lessons from the Sonagachi experience, so that these programmes, including our project, can be looked on as further testing of the applicability of the Sonagachi model.…”

Rolling out new biomedical HIV prevention tools: what can be learned from Avahan, the India AIDS initiative?

“…17 From a community mobilisation perspective, India has an extensive history of successful participatory development approaches, ranging from longstanding production cooperatives to large self-help group movements. 22 The Sonagachi project in Kolkata, West Bengal, is a globally recognised model of a community-led FSW intervention resulting in both HIV risk reduction and improved social outcomes. 23 HIV prevention interventions among FSWs, MSM and TGs, however, were hampered by legal issues, pervasive stigma and discrimination, including from health providers and by social stratification.…”

“…First, to support community ownership and social norm change, a progressively participatory approach was implemented whereby KPs were encouraged and capacitated to shape, refine and implement the program. 22 Second, to support management and performance measurement, a common minimum program was developed to set minimum standards, which were periodically and iteratively improved and expanded. Routine data collection systems were established to aggregate and consolidate indicators at every level, from the frontline workers through to KP-program contact points to district, stage and central levels.…”

“…Microplanning tools were developed for their use, coupled with clear targets, and they were given authority and responsibility for meeting the targets, resulting in a marked increase in the number of KPs contacted monthly by KP peer outreach workers, a narrowing in the condom distribution gap (the difference between the estimated number of condoms needed by sex workers, based on reported client numbers, and the number of condoms distributed) and increased clinic utilisation. 22,[31][32][33][34] This indicator was used to gauge the extent to which KP peer outreach workers were acting as role models. Other efforts were undertaken to ensure that STI testing and treatment were not coercive, mandatory or incentivised in any way.…”

How The Avahan HIV Prevention Program Transitioned From The Gates Foundation To The Government Of India

“…The Avahan program's focus on building the organizational capacity of most-at-risk populations has been described elsewhere. 30 The prior experience of large donor-funded programs in India indicated that transition to country ownership also required strengthening the government's capacity to absorb and manage the new program. 14 Building on the work of Eric Goosby and colleagues 4 and of Adrienne Germain, 6 we identified four dimensions critical to the sustainability of donor programs through increased country ownership.…”