Documenting Best Practices: Advocacy on Integrating SRH HIV

"...when HIV/AIDS programs are linked with other initiatives {e.g. family planning, sexual health, ante- and post-natal care, gender-based violence (GBV) prevention and services, prevention and control of sexually transmitted infections (STIs), or youth empowerment} and vice-versa, they can demonstrate greater effectiveness and value for money than when implemented alone."

From the International Planned Parenthood Federation (IPPF) South Asia Region Office (SARO), this report captures the process and the achievements of Building Momentum for SRH HIV Integration, a programme advocating for the integration of sexual and reproductive health (SRH) and HIV in Afghanistan, Bangladesh, Iran, India, Maldives, Nepal, Pakistan, and Sri Lanka at policy, system, and service delivery levels through its Member Associations (MAs) in the respective countries. Based on the 3 pillars of strategic partnerships, capacity enhancement, and knowledge products, the document includes several case stories. These focus on the varied partnerships built during the process, scaling up of advocacy actions through capacity enhancement programmes, and creating and supporting multidimensional learning opportunities in support of integration. The methodology adopted for this documentation was based on the understanding that this document had to act as a practical tool that facilitates sharing within and between Member States as well as a larger audience and CSOs in order to assist stakeholders to scale up interventions based on learnings, challenges, and opportunities.

Carried out from 2011 to 2015, the project consisted of the following 4 components, which worked in tandem to increase the Country Coordinating Mechanisms (CCMs') commitment to SRHHIV integration and thereby increase the number of SRHHIV integration proposals submitted to and funded by the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) in the 8 project countries. It also included increase of the government stakeholders' commitment to providing integrated services: (i) a multi-sectoral team established to raise awareness and advocate for SRH HIV integration at the national level (especially within Global Fund processes); (ii) small grants to local civil society: to support advocacy with the stakeholders for SRH HIV integration in Global Fund proposals, positioning CSOs as Principle Recipients or Sub Recipients, advocacy and/or information work with media representatives to create greater coverage of issues; (iii) technical assistance (TA): a TA Hub established to support civil society organisations (CSOs) in making strong SRH HIV integration proposals to the CCMs and to support the CCMs in developing the technical capacity needed to commit to SRH HIV integration; and (iv) national advocacy to build support for SRH HIV Integration. Advocacy activities sought to reach CCM members, relevant government representatives, and stakeholders who are able to influence the CCMs. According to IPPF, the uniqueness of this project rests on its focus on facilitating enabling processes and cross-learning platforms for varied stakeholders, including the government, international NGOs, CSOs, community-based organisations (CBOs), and MAs for integrating SRH HIV at the policy, program and implementation levels. The 4-year-long engagement helped in gaining specific insights on the principles of advocacy actions that could yield promising results, increasing uptake of both HIV and SRH services, especially for women, young people, people living with HIV (PLHIV), and marginalised groups.

The report finds that "[p]artnership, engagement with a wider stakeholder base, involvement of opinion leaders, knowledge sharing and grass-root activism coupled with policy level actions are almost mandatory requirements to achieve results in advocacy actions." Some of the techniques of advocacy that were followed by IPPF–SARO and its MAs include: designing an advocacy and mobilisation plan to achieve greater results; creating and strengthening strategic alliances with key players within the United Nations (UN) system, CSOs and networks, governments, and the international development community; policy monitoring and policy dialogue; campaigns for policy change as well as effective implementation; building the advocacy capacity of stakeholder groups; preparation of knowledge products; and demonstrator projects.

Because IPPF-SARO believes that effective advocacy is possible through a regional advocacy partnership which is based on evidence and rooted in grassroots empowerment, IPPF-SARO and its MAs formed varied partnerships to involve and engage a wider group of stakeholders to promote the SRH HIV integration agenda. These partnerships were formed by convening various committees based on the skill sets and influencing capacities of the members of that particular group. It is noted that encouraging participation of a multi-sectoral, multi-stakeholder group to advocate for SRH HIV integration is a unique practice to facilitate an enabling environment for advocacy actions. This has served many purposes: They have provided a platform for different perspectives to be discussed; they have created awareness among varied groups; they have integrated SRH HIV in their own work; they have facilitated formation of an interest group that can act as a pressure group for CCMs to integrate SRH HIV in their next negotiation with the Global Fund; and, as the members are all considered reputed citizens of the country, they become silent advocates for the issues under discussion. This partnership brought in the benefit of "economy of scale", with sharing of expertise, funds, and human resources to advocate for the integration cause. The 4 pillars of building a sustainable, active, and strategic partnership are:

• Educate: Understand the knowledge gap and constantly feed into information in the network/ partnership to bridge the knowledge gap;
• Engage: The cornerstone of member engagement is relevancy - getting the right messages to the right audiences. The more you can segment your lists (active donors, volunteers, members, prospective members, etc.), the more you can tailor messages to the things these groups care about most;
• Mobilise: Have a mobilisation strategy and adapt it to conditions as they develop (as opposed to simply relying on nimbleness alone); and
• Measure: Extend measurement metrics beyond "we made our goal" or "we did not make our goal". Try to understand things like "What messages resonated most with our partners?", "What campaign yielded the most results and why?", "Where and how are people responding to your messages (email, print, social media), and how does that affect how we will spend our money next year?", and "What did we learn and how can we get better?".

Engaging with media was another important strategy of this project. IFFP contends that the uniqueness of this engagement was that it not only focused on responsible writing practices but also oriented journalists from the electronic, as well as print, media on the importance of issues related to SRH HIV integration. Besides this, CSOs were supported to continue with this engagement; CSOs were mentored by the MAs and the TA Hub experts to develop content for the radio sessions and also helping CSOs to reach out to media personnel at the grassroots level. Several examples are provided in the report; to cite only one: Radio Audio Pvt. Ltd. of Nepal trained media personnel as part of this project and broadcast several episodes on SRH HIV integration. To bridge the knowledge and information gap, Radio Audio produced and broadcast radio episodes of Khulduli.com addressing adolescent and youth in order to encourage them in safer sexual and reproductive behaviour. Sessions included experts answering their queries through an interactive radio programme on SRH HIV. The programme included interaction with former drug users and peer educators. "As the program has been receiving a number of SMSs [text messages] on HIV and STI [sexually transmitted infections], Radio Audio continued to produce and broadcast the episodes on HIV and STI. We found it essential because there are many who are still unaware about HIV and STI. Thus, it is essential to disseminate information regarding HIV and STI and live a healthy and stigma free life. For this, Khulduli.com production team has used pamphlets and reference books to answer the queries."

The report shows that the capacity development of CSOs, with support from the European Union (EU) and IPPF South Asia Region, has helped them to scale up and expand their actions, as well as facilitating a learning environment that promotes advocacy and ownership. For example, Aarju Foundation, a non-governmental organisation (NGO) in Mumbai, India working with the community of men who have sex with men (MSM), utilised lessons learned from a capacity building workshop run by the Family Planning Association (FPA) of India. Aarju field staff were trained to provide information on the importance of the diagnosis of SRH-related problems, and to encourage MSMs and their partners to visit the MSM clinic for treatment and diagnosis. After 3-4 months, a positive response was noted among married MSMs, who began to raise their SRH issues as well as their spouse's problems. There was also an increased interest in getting HIV tests for children. In addition to advocacy initiatives with clients and service providers, Aarju conducted an advocacy workshop with 11 NGOs and CBOs also working in HIV/AIDS prevention programmes.

In terms of specific communication approaches, the report shows that drama is one of the best ways to spread the message of the integrated SRH HIV intervention among different people and communities. An example is provided of using street drama to highlight the benefits of integration and support the rights of female sex workers (FSWs) in Sri Lanka. "Indrani along with two other women founded an organization called Praja Diriya Padanama in North Western Province of Sri Lanka. As part of the small grant facility, Praja Diriya Padanama got the opportunity to educate community on integrated services through street drama in two districts of Ampara and Batticoloa. This was an interesting challenge because the people in Ampara are mostly Sinhala and Muslim while in Batticoloa the greater majority is Tamil. In both districts, the drama was the medium to reach out to different types of people with support from the police, probation officer and the Medical Officer - STIs. A great achievement was that they were able to establish close links with sex workers in these two districts who contacted them by telephone after watching the performance. In Batticoloa, besides performing in the usual locations, they also linked up with the Suriya Development Foundation, a very well-known and established NGO that works on women issues. Fifty members of different CSOs/CBOs in Batticoloa watched the performance. Later, they were able to successfully engage in a dialogue with the audience who told them that they welcomed the drama because they had limited knowledge of SRH HIV issues." What makes this a best practice is: selecting public places for the performance so as to reach a wider audience; reaching out to different provinces irrespective of language and cultural differences; linking with local organisations to ensure wider dissemination of the integration messages; and galvanising support from the police department to stage performances on SRH issues of FSWs.

Key lessons that have been learned at various levels through the implementation of the project are as follows.

• Integration of SRH HIV is a strategic intervention that could bring in optimisation of health resources at all levels: policy, practice, and operation.
• Integration leads to client satisfaction: Tt ensures client satisfaction as it reduces the number of visits that clients make to health facilities. The integration interventions' thrust to collaborate with varied stakeholders and primarily traditional leaders and community opinion leaders has helped create linkages between the health facility and the community, enabling them to access services that are more structured in a way that responds to their needs and lifestyles.
• Building capacity of service providers ensures participation and ownership creation: The structured approach adopted by the programme to engage with the service providers has made practitioners more confident, which has resulted in greater ownership and appreciation of the services being provided by health care workers.
• Systematic capacity enhancement of strategic partners is the key to success for any advocacy action.
• Educating the community to promote demand-driven advocacy is linked to sustainability of the programme.

According to the report, the 8 foundation areas for stronger advocacy are: credibility, skills, intra-office coordination and leadership, capacity to generate and communicate relevant evidence, ability to assess risks, capacity to work with children and young people, long-term partnerships that can form a broad base for advocacy, and sufficient resources. Steps that one needs to know prior to starting work on an advocacy agenda include:

• Know your case and document your facts on the issue that you would like to advocate for.
• Whenever possible, ensure that you are familiar with current policies on the said issue.
• Know opposing cases and arguments and develop a strategy for countering them. You may find that role playing will help you to refine your strategies.
• Advocacy by coalition requires effective collaboration. Ensure that each person/organisation has a clearly defined role and that communication within your group is timely and effective.
• Know your resources and allies. Consult these people, inform them of your issues, and enlist their assistance.
• Take a positive approach. Assume good will on the part of the system and communicate this assumption to those within the system. Use positive documentation and give credit where it is due. Whenever possible, recruit those within the system to your cause as your ally/partner.
• Demonstrate to those in the system the ways in which the system interferes with or defeats its own goals and suggest alternative ways to optimise its outcomes.
• Never engage in an overt power struggle without the agreement of your planning group as well as government structures.
• Always be aware of the vulnerability of those within your group. The group must assess risks and weigh them carefully against possible gains before choosing confrontation.

A number of principles to be adopted are outlined, including: Participatory decision-making processes could help to ensure that everyone has a voice. IFFP also recommends defining the theory of change (be strategic in advocacy) and developing a clear (and evidence-based) message, tying your message to the stakeholders' concerns to remind your advocacy audience of how addressing the issue will help fulfill their responsibilities. Choosing the messenger strategically involves engaging popular, known people with experience, credibility, and a public image that complements advocacy goals; this can bring media attention to issues. Proposed recommendations should be validated with research and data analysis wherever possible.

This note on the importance of research is reflected in the report's conclusion: "In order to be successful in their efforts to influence policy, advocates will need to have a very deep understanding of the policy process and political landscape. In addition to the usual problem analysis, corresponding research (if needed), and stakeholder analysis, is critical. This means identifying and analyzing policy targets - down to the level of the target population - and clearly understanding the constraints under which they work (e.g. political obligations, election concerns, or budgetary constraints). Though there is growing understanding from all concerned stakeholders about integrating SRH HIV, there are still certain concerns, such as lack of facilities, stigma, discrimination and accessibility issues that need to be addressed. Capturing this data on a regular basis would provide a trend analysis that would help in understanding the momentum of the advocacy actions, to plan better and also to rate the involvement of various stakeholders to identify like-minded people at all three levels – policy, system and services to develop a targeted response for the issues under discussion."