When M&E falls short (and can even hinder): Scale-up dilutes impact of #HIV intervention among #sexworkers in India

Tuesday, June 2, 2015

My husband has taken an interest in ethnographic research after taking an Asian Ethnographies class last spring. As a data analyst and a quant-oriented person in general, I tend not to warm to qualitative research (particularly of the social sciences variety), but there are undoubtedly places where it is valuable. In some cases it can fill in the gaps that monitoring and evaluation cannot reach - and even highlight areas where standard M&E approaches fail and, sometimes, do more harm than good.

Last week, NAM aidsmap highlighted two such studies in India, one in Andhra Pradesh and one in Mumbai:
Two qualitative studies, investigating the implementation of a massive programme of HIV prevention through community mobilisation in India, have identified challenges to the rapid scale-up and roll-out of a programme in which grassroots action was meant to be central. While the programme was intended to empower sex workers to tackle the social conditions which made them more vulnerable to HIV, a more narrow focus on condoms and clinical services took over. This discouraged sex workers from getting involved in the programme.

Implemented in six Indian states with a high HIV burden, Avahan was one of the largest HIV prevention programmes ever delivered. It aimed to slow the transmission of HIV in the general population by raising the coverage of prevention interventions in high-risk groups such as female sex workers and men who have sex with men. Funded by the Bill & Melinda Gates Foundation, there was a strong emphasis on efficient delivery and scale-up of a defined package of interventions, in order to achieve saturation coverage. Monitoring and evaluation showed that this was achieved.
The Avahan programme aimed to replicate this success. But what happened in practice? Separate qualitative studies of the delivery of Avahan’s sex worker programmes in Andhra Pradesh and Mumbai have recently been published in Global Public Health and PLOS One respectively.
The original focus of the program was on community mobilization. Women who were well-connected and active in the community were engaged as peer workers who "not only distributed condoms, brought sex workers to clinics and provided sexual health information, but acted as community organisers to change conditions which produce HIV risk. They challenged police violence and harassment" and other conditions that contributed to HIV risk. They organized into community-based organizations and held rallies. However, when the program was transferred from the Gates Foundation to the Indian government and scaled up, these elements of the program were lost at the expense of more easily measured outcomes such as condoms distributed and clinic visits:
Less attention was given to community mobilisation, collectivisation and the formation of community-based organisations. While responding to incidents of police violence had been retained as a programme activity, the nature of the response changed. Rather than sex workers mounting a collective response, they were encouraged to approach existing public institutions such as the legal aid authority. In the end, sex workers faced with police or partner violence stopped involving the community-based organisations that Avahan had helped set up.

Whereas meetings had previously helped sex workers forge a sense of collective identity, there were now fewer structured opportunities for peer workers to meet with other sex workers or peer workers. Previously, sex workers had been interested in engaging with the community-based organisations, but the organisations’ new narrower health-focused remit felt less relevant.
These studies underscore why successful programs are holistic in nature. While "measurable" outcomes are important and necessary to demonstrate that a program is working (or not), a disproportionate emphasis on them can actually harm a program - in this case, implementers focused on them at the expense of the elements of the intervention that had real value to the target population. Qualitative and quantitative approaches must complement each other.

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