Interview with Rick Olson, Project Officer, UNICEF Namibia, November 2001
Part I: Lessons about developing the training materials
Q. When creating the materials for My Future is My Choice (MFMC), how did you adapt materials like "Focus on Kids" and "Stepping Stones" to local circumstances in Namibia?
A. This was before my time, but this is what I understand of the story... UNICEF did a sub-contract with the University of Maryland (School of Medicine), in the USA, who had designed the Focus on Kids materials. With funds from Fogerty and the World AIDS Foundation, they, "as consultants", came over and drafted a version together with the Directorate of Special Education, under the Ministry of Basic Education. During this process, the Ministry of Basic Education, who had initiated the process of developing a life skills intervention under the Inter-sectoral School and Health Committee, helped establish "a life skills research and life skills curriculum sub- committees". Pre-testing of the initial draft was done with young people. This led to the name, etc., and a research phase was established to test the intervention.
Those who went through MFMC delayed sexual intercourse longer, and, when they became sexually active, more of them used condoms
The research was done in 1996 using control and intervention groups, with a 14 session (28 hour) version of the manual. This research showed that those who went through MFMC delayed sexual intercourse longer, and, when they became sexually active, more of them used condoms. When I arrived in mid-1998, the manual was down to 11 sessions (22 hours), and implementation had been underway since 1997, so the research findings must have led to further revisions of the manual.
When I arrived and started to get a sense of the intervention, I heard from some of the young people who were both training and using the manual, that there were still concerns about the level of English, and some of the activities and methodologies. From my own review, it was clear that there were some problems. For example, the background information on HIV and sexual health were not covered until Session 5, but, in Session 1, participants started using HIV concepts (assumes the participants would already have the knowledge). I organized a workshop with young people and trainers and we went through the manual. I then re-wrote it, and ran two further workshops with the young people who were trainers of trainers during the re-write period, to test out the sessions and activities and get their feedback on what was working or missing, etc. This lead to the current version, with a much more expanded monitoring and reporting system. The assumption we operate on is that, if the previous version was able to facilitate delayed sexual activity and increase condom use, this version - more focused, more participatory and more logical in processes - should be more effective. However, there is still room for improvement in this current version.
Q. What are some of the myths you had to overcome, and how did they vary across groups/regions, etc?
A. There are many. Some myths are linked to gender; like "a boy is only a man once he gets an STD," or, "forcing a girl to have sex is a normal part of a relationship." Some people still believe Traditional Healers can cure AIDS. Our pre- and post- tests ask about traditional healers being able to heal HIV. MFMC participants still score poorly on that question in both pre- and post- tests. We looked into it and realized it must be because we only have one line about traditional healers in the teaching materials.
Some myths are linked to gender; like "a boy is only a man once he gets an STD.
There is confusion about how easy is it to get pregnant: "you won't get pregnant standing up or the first time you have sex." There is confusion about the efficacy of the virus, about practices like coitus interuptus, and about the fact that we can't see HIV. There was some confusion about faithfulness to one partner as a prevention message; young people used this as an excuse to practice consistent safe sex by saying they are faithful in their current relationship, but, then that relationship ends after 3 months and they start another, saying they are being faithful in this relationship, and so on…
We also find that people are not clear on transmission. Young people are not personalising risk. We believe condom use is much lower than studies indicate. People are worried that there is a gap between knowledge and behaviour, but, I believe knowledge levels aren't as high as we think. They are high on only a few indicators. So, there is still a gap in our program. It is a shortcoming that, with 20 hours of training, 2 hours are spent on HIV/AIDS and 2 hours on sexual health. Facilitators must go quickly from the known to unknown, and they must be kept up to date.
Q. What lessons were learned from the adaptation process?
Part II: Lessons about involving stakeholders
Q. How did you gain the support and commitment of political leaders / senior officials, teachers, parents?
A. The Ministry of Basic Education had attended a regional UNICEF Workshop in Uganda in 1995 on Life Skills. The ministerial representative took the issue seriously and was able to convince her ministry to look at the issue. UNICEF put some funds behind it and this led to the development process, which was then written up under the 1997-2001 Programme of Cooperation as a project. In late 1998, I set up a National Steering Committee to bring the other ministries (Ministries of Youth and Health, as well as the National Youth Council) in as formal partners, to improve national ownership. We also set-up and formalized regional level multi-sectoral Youth Health & Development Committees, for the planning, management and monitoring of the intervention. We de-centralized funding for the implementation of MFMC to these committees to improve ownership. We put most of the funds through the regional Governors' offices, so they would be more aware of the intervention and take some ownership (e.g., financial accountability). Providing opportunities for senior government officials to see the intervention in action and talk with young people created support for the intervention from the Permanent Secretary for the Ministry of Health and the Ministry of Basic Education. It was also useful to provide good reporting to inform key government officials, and to use the representative to "brief" senior government officials on the interventions, so that these officials could talk effectively about it as "their" intervention.
Teachers could not get any cash incentives, while the Ministry of Youth insisted that young people get cash incentives. This ... led some teachers to drop out.
With teachers, we had mixed experiences. We first started to train them, as the original design called for one teacher and one young person to be co-facilitators, but, this did not work, for a few reasons. One was that many of the teachers had problems discussing sexual information and promoting condom use with their students, especially sexually active teenage students. Another reason was that the young people were also not at ease discussing their sexual history, substance use, etc, with one of their teachers. Another problem area was about incentives: a decision was made by the Ministry of Basic Education that teachers could not get any cash incentives, while the Ministry of Youth insisted that young people get cash incentives. This affected the motivation of the teachers, and led some teachers to drop out. These factors led to the phasing out of using teachers as co-facilitators.
But, teachers are still involved, and we plan to strengthen their role. We have created the "contact teacher" designation, to ensure that, at each school, the principal delegates supervision of AIDS activities to a teacher. That teacher helps with the continuity, record keeping, follow-up for advice, and provides some supervision by the school of MFMC. The Ministry of Basic Education wrote a "circular letter" for all levels of staff to inform them of the intervention, and highlight their responsibilities.
For parents, we developed in 1999, an information booklet on the intervention, which was widely distributed and every young person who "signed up" was given one to bring home to their parents. We also have two TV and radio adverts aimed at parents, to support condom use by young people, which is an aim of MFMC.
Q. How do you build ownership in each community where MFMC is active?
A. A number of methods were used… As mentioned, planning, managing, funding and monitoring are all decentralized through the Regional YHDP Committees, to create ownership at that level. Some of those Regional YHDP Committees ran "orientations" for traditional leaders and school committees on what MFMC was about. Others organized YHDP/MFMC Days, as an awareness raising event. Mass media was used, too, with young people from the regional committees being invited to speak on the radio about the program, and the press also covering the intervention on national and language radio services.
Q. How do you recruit young people to be peer educators?
A. It's important to get the incentives right. A large percentage of kids who joined in the early years, joined for the wrong reasons: the cash incentive of 500 Namibian dollars given to each MFMC facilitator for 20 hours of facilitation. This can be more than the monthly wage of a young person working as a shop clerk, or security guard. Next year, under the new program, we will bring the incentives in line with the national volunteer scheme - where the government will pay volunteers up to 250 Namibian dollars per month, for volunteer work. We have been discussing this with the volunteers, saying that we will support out-of-pocket expenses, but will do away with a “facilitation fee”. This may lead to some drop-outs, but we are confident that there are a core group of young people very committed to the intervention and volunteerism. With the reduction in the facilitation fee we are going to invest more money in on-going training to keep a core group of good facilitators active in the program over a longer period of time.
Regarding the selection of facilitators, the process was decentralized in 1998. The regional Youth Health & Development Committees do a mapping exercise to identify their needs and recruit based on that, through advertising within communities where the facilitator is needed. The regions also use the language services of the national radio system to advertise the application process. Those young people who apply are interviewed by the monitoring & evaluation YHDP sub-committee members.
The young people selected participate in a 10-day facilitators training (training is centralized for quality control), where they do a lot of role plays and mock facilitating, are ranked by their peers, and in some cases, are asked to withdraw from the program. The training is quite intense, as it an opportunity to establish the quality of the facilitation. Upon completing the training, they sign a volunteer service agreement which says they may get some allowances and that they can be de-selected from the program if they fail to follow their terms of reference. New facilitators are then assigned to a school/community.
Q. How do you reach young people to receive education (what methods, what settings)?
A. Students are self-selected. Facilitators place posters in schools and around communities, advertising when and where the training will be. One quarter of the students are supposed to be out-of-school youth. We have an average completion rate for all 10 sessions (20 hours) of about 80 percent. About 90 percent complete 6-8 sessions. HIV is covered in the first 2 sessions, to reach those that don't complete the entire training. There are incentives for students: a T-shirt and certificate when they complete all ten sessions. The facilitator usually provides small snacks and refreshments during the 2 hour sessions since they are done right after classes and some of the participants may be hungry. This was in the design, but in practice, the participants usually wait for they snacks and drinks until their graduation party, when they complete all 10 sessions.
So, there is a large supply component to the program, requiring a well-organized distribution and monitoring system. It includes the distribution of condoms (bought by UNFPA). Currently for the 25,000 participants each year, we need 22,000 t-shirts and certificates, 25,000 workbooks, notebooks, pens, hundreds of thousands of monitoring forms, etc …
Q. How do you maintain the commitment of young people?
A. Unfortunately, the best facilitators don't last very long. It seems in the past two years that the biggest employer of MFMC facilitators has been the army and police. When we train the facilitators we ask them to commit to doing at least 4 courses of 20 hours each (that means training 80-85 kids). As each course is run over 3-5 weeks (minimum one 2-hour session each week), so, we are asking for between a 3 to 5 month commitment.
We ask [the facilitators] to commit to doing at least 4 courses of 20 hours each ... between a 3 to 5 month commitment.
Some of our facilitators have been with the program since 1997. They do two courses in the first school term, and then do other volunteer or paid work. We had over 600 facilitators in 1999; we are now down to 330, but achieving close to the same number of courses. That means many facilitators are doing 7 or 8 courses in a year. Each of the 13 regional YHDP office has at least one Senior Master Trainer. This young person, who reports directly to the Chairperson of the regional committee, manages the office and materials and supervises a number of Master Trainers. Each of the Master Trainers are responsible for supervising a number of facilitators (maximum of 10), and are responsible for going out to the schools to monitor the facilitators and provide feedback and in-service training. They also consolidate facilitators reports and monitor the use of the supplies. They are an extra hands and legs to help manage the office. We provide them with monthly cash incentive and program partners see these incentives as being well spent.
Q. With all their obligations, how to you convince teachers to participate?
A. Some schools have had the same contact teacher for four years. Other schools can't easily identify who their contact teacher is. We want to look at the teacher commitment in the new program. The government is currently developing a national AIDS policy with school HIV/AIDS programs covered under the Regional AIDS plans (for basic and higher education). We would like to make MFMC an official extra-curricular activity in every school, to be in the school calendar and school program. We would like one teacher to be accountable for the school's HIV/AIDS program, with MFMC as just one component. School programs could also include an AIDS awards scheme, AIDS awareness club, and distribution of IEC materials. The AIDS committee in the Ministry is now briefing other donors about the intervention, and have taken over much of the ownership
Part III: Lessons learned about "going to scale"
Q. How did you expand the reach of your program each year?
A. It was important to get an operational committee in place at the regional level. It was also important to produce the project management working note, updated every year. There is a TOR for the committees, and sub-committees on monitoring, training, finance. We helped them set up offices, with financial accounts through regional Governors' offices. We provided training on how to set up committees, do budgets and accounts, and had an implementation structure in place. We revised the manual and retraining in 1999. It wasn't a smooth process: it stopped and started various times because of the limitation of resources - e.g., offices could not get new money until they accounted for old money.
My advice to other programs… You have to plan the program to scale. When you design it, design it to scale. Make sure the budget line is enough. Be serious about the money. Look at those issues - how many to train, how many schools to reach, how to do this in this time, what resources need to be in place. Spend more time on writing annual workplans rather than 5-year plans. Be flexible to adjust each year. Create realistic and planned targets. We had originally planned to reach 80 percent of 10-18 year olds, with different programs for 10-12, 13-14, 15-18 year olds. We had to limit those expectations and so we prioritized sexually active young people and managed to get a program running for the 15-18 age group. As much as possible, use existing structures and remember to involve young people from the beginning, as partners.
Q. What will be necessary to reach your target of 80 percent of 15-18 year olds by the end of this year?
Buying 25,000 t-shirts each year can be expensive, but that is now part of the norm for our activities.
A. The trouble with that figure is that, every year we add 25,000 kids to that cohort (14 year olds who turn 15), so national partners have agreed on a baseline figure of 100,000 as the 80 percent target. We have reached this number already, and may get close to 110,000 by the end of the year. The problem with the intervention is that it is resource-heavy. Each participant gets a workbook, a T-shirt, and a certificate; each facilitator gets a facilitation fee; there are multi-sectoral committees for each region to manage the intervention… So, if you start out as a “rich” intervention, it is more difficult to go backwards. Buying 25,000 t-shirts, etc., each year, can be expensive, but that is now part of the norm for our activities. We will have to look at using cheaper paper in the workbooks, and other measures, but a major expense is the facilitators' incentives, and we need to reduce them. We will have to agree on a new minimum incentive package and make it clear up front. For those performing way beyond the call of duty, we will introduce prizes like a bicycle or study tour. It's important to have incentives, but getting the mix between materials and out-of-pocket cash is important.
So, to continue the intervention, we need donor funds. Each year between 25-30,000 adolescents will turn 15 and will require the intervention. This is not like digging wells, it will only be “sustainable” when the government has the funds… but, as an intervention, it will have to happen each year if we want to make an impact on HIV infection. The challenge will be to reduce the costs over time.
From another angle, you might not have to reach such large numbers; 80 percent may not be necessary - it may not be the critical mass need to create change in social norms among young people. Currently we ask in the last session for each graduate of MFMC to create an Action Plan, and commit themselves to reaching 5 friends with the most important skills and information they have learned. If you have a good quality training program, and your graduates can reach 10 or 20 or 50 of their peers, this may be equally or even more effective… we are not sure what that critical peer education mass is.
Q. As you expand nationally, how do you meet the unique needs of each community/region?
A. We're going backwards now to do more with less. At first we had very large multi-sectoral committees at regional levels. Now we work with a core group of committed government people who manage the intervention at regional levels with very few incentives. The involvement of young people from the communities where MFMC is implemented, both as facilitators and as monitors, is an important component. They are known in the community and have access to the schools. In some regions, we have established more that one committee, to reflect both the large size of the region and the ethnic diversity.
We'd like to improve follow-up by the facilitators, through AIDS awards for schools and AIDS clubs.
We are now in the process of formalizing the YHDP Committees as Youth Health Committees, whose operations will be officially supported by one ministry which will act as a secretariat. The Youth Health Committees will be official sub-committees of the Regional AIDS Co-ordinating Committees. They will be able to manage more than the MFMC intervention. They will act as a platform for mobilizing, organizing and training young people for HIV prevention and care activities. They will broaden the role of young people as a resource for youth health issues. Any program, NGO, etc., who wants to mobilize young people as partners would be able to use these existing committees. Other agencies could put money into the committees to support their activities. This will move forward faster, once all of the UN partners agree to use this structure. Government needs our help to make the YHDP committees formal, fixed, and budgeted for Youth Health Committees. Once this happens we can have the same young people active in more than one activity, funded by a number of different partners.
Q. While continuing to grow, how do you envision MFMC changing?
A. We're glad MFMC is being recognized more widely - we just won the Commonwealth Prize for HIV/AIDS - but we still want to be honest about the problems. And we want to improve it. For example, we'd like to improve follow-up by the facilitators, through AIDS awards for schools and AIDS clubs. We would also like to see the program in all schools. We're focusing on schools with high pregnancy rates. We also want to improve the selection of facilitators. We envision building a cadre of AIDS activists, working in schools and communities.