Decentralization in National AIDS Control and Prevention Programs Robert M. Hollister Senior Health Research Analyst Research Triangle Institute Center for International Development
Summary Decentralization has been recognized as a possible answer to some of the operational and coordination problems confronting AIDS control and prevention programs. Public health experts believe that a program of decentralization is needed to elicit a stronger multi-sectoral response to the epidemic and that it can accelerate the implementation of projects at all levels of society. Many of these efforts, however, may be proceeding with only limited understanding of why decentralization programs have failed in the past, or of the conditions necessary for them to succeed. A properly planned and supported system of decentralization has the potential for expanding not only the associated organizations’ resource base, but also the funding and managerial talent that can be brought to bear on the AIDS epidemic. For this to happen, however, careful analysis and planning is needed to develop the political support, the policies, the support systems, and the institutional context in which those programs can succeed.
Introduction Many national AIDS control programs (NACPs) are adopting policies intended to decentralize the planning and implementation of HIV/AIDS prevention and service programs to regional, district, and community levels. Decentralization is viewed as a means of mobilizing the skills, commitment, and resources of both governmental and nongovernmental organizations (NGOs) at the local level to deliver educational, counseling, medical, and support services to a variety of target groups. As families, businesses, and communities have begun to feel personally the consequences of AIDS, local organizations of all kinds have come to realize that they can and must play a role in the fight against the epidemic. They increasingly understand that like health care services, AIDS prevention and care services are by their very nature decentralized: their foundation and power is the direct face-to-face relationship between a caregiver and a client. Churches, clubs, school groups, employers, political parties, voluntary organizations, cooperatives, local leaders, and others are accepting their responsibility to become involved. They are asking what they can do, and how they can do it. And they are looking to NACPs for assistance. The move toward decentralized programs arises from the recognition that many NACPs are overburdened, understaffed, and underfunded. They cannot and should not be expected to plan, 1
finance, staff, and implement the broad array of service-delivery programs that is needed. However, they can and should be expected to mobilize and support a multisectoral response that supports other organizations in taking action. Faced with the need to encourage such a broad-based, multisectoral response to the threat of AIDS in their societies, government officials and NACP managers are turning to the concept of decentralization as a means of guiding and supporting the diverse activities of a large and increasing number of organizations and projects. International and bilateral donor agencies are also confronted with the questions of whether, when, and how to support efforts at decentralization. This article examines the promise and the problems of decentralization within national AIDS control and prevention efforts. After reviewing the potential benefits of decentralization, and the various forms that it can take, it sounds a warning: decentralization has rarely lived up to its expectations. Central offices may lack the ability and resources to effectively implement a program of decentralization. Moreover, there are severe constraints in most developing countries, such as inadequate resources and poorly trained personnel at lower levels, that must be overcome if decentralization is to succeed. NACPs will therefore require substantial support if they are to play a meaningful role in coordinating the efforts of other projects and organizations. This paper describes conditions associated with successful programs of decentralization, and suggests guidelines for designing and implementing such programs.
The Need for Decentralization The need for decentralization arises from the recognition that NACP central offices cannot possibly plan, fund, staff, implement, and manage the many programs and services that are needed at the intermediate and community levels. Central offices have critical and unique functions that they alone can fulfill, and they are correctly expected to concentrate on these core responsibilities. They must give priority to policy development, planning, resource generation, logistics, surveillance systems, laboratory services, donor coordination, liaison with international agencies, and the operation of national-level programs. This means that they have relatively less time and energy for other activities. One thing central offices are not designed to do, and are typically not good at, is providing direct services through community-level programs. Central offices often lack the time, personnel, transport, knowledge, and the inclination to sustain a presence at the local level. Responsibility for the planning, mobilization of resources, and management of local intervention programs is better left to subsidiary levels of the system through a policy and program of decentralization. Most NACPs do have, as an explicit program goal, the task of eliciting and coordinating a broadbased social response to the epidemic. That is, despite their program responsibilities at the central level, and their comparative disadvantage in operating direct service-delivery programs at the periphery, they are expected to mobilize a social, political, ethical, and programmatic response that involves all segments of society. They are asked to fashion a system that allows for the participation and involvement of diverse and dissimilar groups and organizations, many of which operate outside 2
of direct government funding or control. In many instances, these collaborating organizations participate on the basis of voluntary self-interest, and provide services to a narrowly defined target group. How should such efforts be managed and organized? Should governments even try to coordinate them? How are the many and diverse interests and needs of these groups to be supported through a system that, of necessity, must be flexible, voluntary, and collaborative, and must strive to maintain the independence, autonomy, and free participation of the collaborating organizations?
The Potential Benefits of Decentralization A properly planned program of decentralization can serve as a mechanism for mobilizing the type of broad-based, multisectoral response that is needed for the HIV/AIDS epidemic. Such an approach can reduce overload and congestion in central offices, and use the complementary strengths that exist at other levels in the service-delivery system. More specifically, a program of decentralization can help to: # Involve other ministries, the private sector, volunteer organizations, churches, clubs, political parties, employers, unions, communities, and other groups in responding to the crisis; # Expand the resource base of organizations, as well as the funding, personnel, and managerial talent that can be brought to bear on the epidemic; # Define, develop, and better use the comparative advantages (differential strengths and capabilities) that exist in organizations at different levels of society and within the delivery system; # Increase the responsiveness of programs to local needs and to the local epidemiological situation by involving local groups and the community in program planning and implementation; # Enhance the self-reliance and sustainability of programs that are genuinely “owned and operated” by local organizations; # Increase administrative and managerial effectiveness by placing increased authority and responsibility at operational levels; # Decrease dependence on the NACP and the ministry of health to provide a large percentage of the funding, personnel, management, and other resources needed for project implementation; and # Increase the quantity, quality, and equitable distribution of services to those in need. The concept of decentralization is built upon the principles of role specialization, differentiation of functions within complex systems, interdependence among levels and units within the system, and the 3
exploitation of the special strengths and capabilities (the comparative advantage) that exist, or can be developed, at different positions in the system. Decentralization can be seen as a natural managerial response to systems that are growing and evolving, and that are becoming increasingly complex, differentiated, specialized, and interdependent. Decentralization accepts that the levels and components within the system must play increasingly unique and different roles, and that they will interact as much on the basis of interdependency and commonality of interest as on direct hierarchical relationships. It accepts that control and power will be exercised in different ways, which has implications for management styles and approaches. It recognizes that as size, scope, and complexity of programs grow, managers must adapt by distributing responsibility, authority, and maneuvering room to their component parts. Within the context of HIV/AIDS control programs, decentralization is congruent with the types of interventions and approaches needed to slow and halt the spread of HIV. In the absence of effective vaccines or affordable treatments, HIV/AIDS prevention requires a decentralized system able to deliver interventions that are appropriately targeted, are personalized, and use face-to-face relationships to effect changes in the sexual decision-making and behavior of individuals. Every person whose behavior places himself/herself at risk must be reached with information, skill training, support, reinforcement, encouragement, and choices. Within each person must be built the motivation, the skill, the means, and the commitment to choose behaviors that will eliminate or reduce their risk of infection. This objective is often best met through the mobilization of social support networks and interpersonal relationships that are valued and trusted, and that can serve as a bridge across which influence can be exerted. These social networks and relationships are by definition local and personal, or, in a word, decentralized.
The Forms of Decentralization There are four generally recognized forms of decentralization,1 each of which has its own features and characteristics. They are: # With deconcentration, administrative authority and responsibility are handed over to lower levels within central-government agencies or ministries. This arrangement shifts parts of the workload and some decision-making authority from the central administration to intermediate levels and the periphery, and gives discretion to local managers to adapt central directives to local conditions. The key feature of deconcentration, however, is that responsibility for program implementation remains within the jurisdiction of the central office or program. Deconcentration is the most frequently applied form of decentralization. NACPs usually accomplish deconcentration by giving increased managerial authority and responsibility to provincial- and district-level managers for planning, allocating resources, and
Dennis Rondinelli, John R. Nellis, and G. Shabbir Cheema, Decentralization in Developing Countries, World Bank Staff Working Paper No. 581, ISBN 0-8213-0235-3 (Washington, DC: World Bank), p. 13. 4
initiating and implementing projects. As project interventions become more standardized, and as experience is gained, projects can be increasingly managed by personnel at lower levels in the system. The distinguishing characteristic of deconcentration is that responsibility for the planning, funding, and implementation of these activities remains within the jurisdiction of the central government, usually the NACP. They are centrally funded and managed programs, usually staffed by regular civil-service personnel. # Delegation, a second form of decentralization, transfers responsibility and authority for program operation to organizations or institutions that are outside the regular bureaucratic structure of the government. These organization are usually established as semi-independent or parastatal entities such as regional development authorities, marketing boards, water or electric utilities, agricultural development projects, and social service organizations. These are often “mixed enterprises” that combine government and private resources. The characteristic feature of delegation is that responsibility for the enterprise or activity remains with the quasi-independent organization or authority, which is usually outside of the regular government bureaucracy. # Some health care services, particularly those related to family planning, have been established through semi-independent “family health associations” that operate outside of the ministry of health, although with funding from the ministry and with the ministry’s active participation on the governing council. Many AIDS prevention and service organizations have been set up along similar lines. # Devolution is a third form of decentralization, whereby independent authority and responsibility for certain functions or programs is constitutionally or legally transferred to subnational units of government that are substantially independent from the central government. Examples of devolution are found in the federal or provincial structures of the United States, Nigeria, or Canada, where states or provinces carry independent responsibility for education, health care, and social welfare programs, for example. The subnational unit of government normally possesses independent constitutional authority to collect taxes and raise revenue to support the services. Devolution has not been a widely used form of decentralization in developing nations. # Privatization can be a fourth form of decentralization, whereby authority and responsibility for the provision of certain services is transferred or sold to the private sector. Governments can divest themselves of certain areas of involvement by selling assets, such as utility systems, or by granting authority to professional organizations (accountants, medical societies, trade unions, lawyers) to set standards, grant licenses, or regulate professional conduct. An important form of privatization is the use of private voluntary organizations (PVOs) and NGOs that provide a broad range of health care, educational, and social services. There can be a role for each form of decentralization in AIDS prevention and service programs. Each has strengths, weaknesses, and unique characteristics that can be matched to various objectives of the AIDS control program and the needs of the organizations that contribute to its efforts. Careful analysis is required, however, to determine the form or forms that decentralization should take in any given national setting. A “mixed” pattern will usually be chosen which combines deconcentration of 5
the government system; delegation of certain programs to outside, semi-independent organizations; the support of PVOs and NGOs to work on AIDS activities; and sometimes the devolution of responsibilities to subnational levels of government. To be successful, programs of decentralization need to be carefully planned, phased, and implemented. The approach needs to be incremental, flexible, and experimental, and should contain strong elements of participation, debate, and joint planning. Decentralization must be viewed as a management tool. Like any other management approach, its success depends upon judicious application, careful planning, preparation, communication, collaboration, and follow-through. Donors, planners, and managers of AIDS control programs need to understand the conditions that are associated with successful decentralization, and to devise strategies to cope with the many constraints that must be overcome. Decentralization by decree does not work. It requires incremental, step-by-step planning, as well as the development of support systems, linkages, and appropriate structural relationships.
A Warning Despite the attractive potential benefits of decentralization within AIDS control and prevention programs, the question must be raised as to whether central governments should, through the agency of their NACPs, attempt to guide and coordinate the efforts of essentially independent, private, voluntary, self-financed, and autonomous community-level projects. Given the serious resource constraints experienced by NACP central offices, should they be given the additional burden and responsibility of trying to mobilize and coordinate efforts of nongovernmental programs? Might it not be more practical or realistic to adopt a laissez-faire approach that relies on the independent evolution of these programs and activities? Each government will answer these questions for itself as it determines the nature and extent of the interrelationships between the public and private sector AIDS control activities. At a minimum, central governments will play a strong role as: provider of surveillance data needed for targeting and priority setting; dominant provider of clinical care services; standard-setting body; supplier of drugs and commodities; conduit of multi-and bilateral aid; and originator of national policies on blood supply, testing, confidentiality, and human rights. As clinical facilities become overwhelmed with AIDS patients, and as the crisis deepens, some governments will decide that a broader response is required, and mechanisms will be sought to expand prevention and care efforts beyond the public sector. If political and program leaders, including donors, determine that a broad coordination role is desirable, and that the public sector should provide it, then some form of decentralized planning and administrative system will probably be considered. Just as form follows function in architecture, so will a decentralized, collaborative, supportive system be needed to strengthen the efforts of an increasingly diverse, complex, loosely organized but interrelated network of HIV/AIDS organizations and service providers. 6
Problems in Implementation The presumed benefits of decentralization have attracted development planners for decades, and decentralization has become an integral component of many national development plans. The seductive prospect of accelerated implementation, improved quality, increased participation, and expanded service delivery is a powerful inducement. While many of these benefits do, in fact, result from successful programs of decentralization, it must be understood that in most cases the reality of decentralization has not lived up to the promise. Despite notable successes in some countries, decentralization has not been a panacea that dramatically solves program and service delivery problems. In fact, programs of decentralization have run into serious difficulty, or failed, in more places than they have succeeded. It is important, therefore, that policy makers, donor agencies, and managers of AIDS control programs understand why and how decentralization efforts have succeeded or failed. Managers need to understand the variety of forms that decentralization can take, and to design programs that are appropriate to the unique political, bureaucratic, and organizational situations that exist in each country. They need to be familiar with factors and conditions associated with successful efforts.
Constraints to Decentralization There are forces at work in most developing countries that make effective decentralization difficult to achieve. These may include strong centralist political ideologies and traditions, authoritarian patterns of leadership, confusing or overlapping layers of bureaucracy, unclear patterns of authority and responsibility, arbitrary decision making, inadequate transfers of resources to lower levels, poorly trained personnel at lower levels, the inability of local governments and organizations to generate revenue, lack of managerial and administrative expertise, logistical and communications problems, political interference, rapid staff turnover, and other problems. These problems are not trivial, and are often beyond the control of managers attempting to decentralize their programs. Because of these conditions, an effective program of decentralization must be based upon careful analysis and planning. Some forms of decentralization can cope with certain of these constraints better than others. Critical to success is the development of support systems and linkages that allow the various levels in the system to interact, resolve problems, transfer resources, and complement each other.
Effectively Functioning Systems Decentralization programs that are functioning well use strengths at one level of a system to compensate for weaknesses at other levels. Central offices, as previously noted, often do a poor job at operating service-delivery programs at the periphery. They find it difficult to achieve local participation, to adapt programs to local conditions, to build local capacity, and to achieve sustainability of local programs.
The key strengths of local organizations, on the other hand, are precisely in the areas where central programs are weak: local presence, legitimacy, an established role in the community, low-cost or voluntary manpower, knowledge of the local situation, and motivation to serve their membership and the immediate community. It is this “embeddedness” in the community which central and regional programs lack, and which can be provided only by local organizations. In situations where “government” is suspect, these local organizations can provide a crucial interface between central programs and the general population. For AIDS prevention efforts, the ties that local organizations have to their members and to the community are the medium for exerting influence to change the sexual behavior of individuals. But local organizations often lack technical, financial, and managerial expertise and resources, which instead can often be provided from central and intermediate levels. Training, materials, resource sharing, and other forms of support can build competence and capabilities in these local organizations without necessarily compromising their independence and autonomy. The desired goal is a situation in which each level in the system possesses strengths, resources, and capabilities that can be shared with other levels to create an effective delivery system. In this way, weaknesses that affect the scope and effectiveness of a particular level or program may be overcome. The goal of any attempt at decentralization, therefore, is to create the conditions whereby each level can do what it does best, and can get help from other levels for what it does poorly. It is a linked system that seeks to maximize the comparative advantage of each level or component in the system, while relying on assistance from other levels to cope with areas of weakness.
Conditions Associated with Successful Decentralization Available analyses of decentralization efforts indicate that success depends on the careful and systematic creation of political, organizational, behavioral and other conditions that encourage the uptake of initiative, and build capacity at the local level. The previously cited World Bank study of decentralization in developing countries2 identified four factors that affected the success of these programs: The degree to which — # central political leaders and bureaucracies support decentralization and the organizations to which responsibilities are transferred; # the dominant behavior, attitudes, and culture are conducive to decentralized decision-making and administration; # policies and programs are appropriately designed and organized to promote decentralized decision-making and management; and
Rondinelli, Nellis, and Cheema, pp. 46-47. 8
# adequate financial, human, and physical resources are made available to the organizations to which responsibilities are transferred.
Implementation Steps for Decentralization Within AIDS Control Programs The ability of governments and NACPs to successfully implement programs of decentralization will depend on their ability to promote an understanding of the aims of decentralization, and to create political will, appropriate structural relationships, operational procedures, new management behaviors, and resource-sharing systems needed to support intermediate- and local-level programs. The following steps are suggested for implementing a system of decentralization. Ø Build Political Support and Understanding of Decentralization Policies and Objectives Managers and political leaders who are responsible for designing and supporting AIDS programs need to understand the implications of decentralization in terms of its benefits, liabilities, and administrative requirements. Policies need to be based on a careful assessment of the specific political and bureaucratic context in which those programs will operate. The involvement of other ministries, NGOs, and the private sector will require that new policies be developed and that joint planning, communications, and coordination mechanisms be established. A key characteristic of decentralization is that management control, coordination, and collaboration are achieved through different mechanisms. These mechanisms include careful attention to the policy framework, the collaborative setting of priorities for programs and funding, the creation of coordinating councils, and the establishment of communication patterns and decision-making procedures that are based on equity, respect, transparency, and participation. In addition, extraordinary investments are needed in the support, supervisory, training, and resource-sharing systems to build capacity at various levels and among an increasing number of projects, most of which operate outside of the direct control of the ministry of health. An unfortunate misunderstanding about decentralization is the belief that responsibility and power are shifted from central ministries to the periphery. Program managers and civil servants fear the loss of control over programs, personnel, and funds. In fact, an effective program of decentralization must strengthen both the periphery and the center. Effective implementation depends upon a strong, committed, and properly supported central staff that understands and genuinely supports the goals of the decentralization program. An important early step is the indepth involvement of central personnel in an analysis of decentralization policies and procedures, and the development of different styles of leadership and interaction.
Ù Develop Organizational Structures and Procedures Research on public sector decentralization programs in developing countries indicates that simplicity and clarity are important to success. Procedures and interorganizational relationships need to be clear, and as simple as possible, yet complete enough to communicate the responsibilities, authority, and roles to be taken up by each unit or level of the system. People at each level need to know how much authority and discretion they have, and they need to be rewarded for taking initiative and responsibility. Distinct plans and guidelines are usually needed for those program components that use different forms of decentralization. Deconcentration of responsibility within a ministry of health or within an NACP, for example, will require a specific set of management actions, including guidelines, personnel actions, new operating procedures, role reorientation, training, and the transfer of specific types of authority to intermediate and lower levels. Programs of delegation, including the authorization and support of independent or semi-autonomous PVOs and NGOs, often will require a distinct program approach with its own enabling legislation, grant-making mechanisms, monitoring procedures, and coordinating councils. A similar situation holds with privatization and devolution: planners and managers need to think through and design specific structures, guidelines, legislation, regulatory approaches and monitoring procedures that are tailored to each strategy. Ú Create an Effective Grants Management System A grant-making system that enjoys the support of donors, and that possesses the needed mechanisms for proposal solicitation, review, 10
Points to Consider 1. Do not be seduced by the superficial attraction of decentralization. There are serious constraints at work that render decentralization difficult to achieve. It is not a panacea that can magically or rapidly produce successful local level programs. 2. Successful efforts at decentralization require careful and systematic analysis and planning. Although there are general guidelines to be followed, there are no cookbook solutions. Successful decentralization has proven to be more of an art than a science. 3. Some analysts suggest that there are minimum levels of development that must be present before local governments and organizations can successfully assume increased responsibilities. There are undoubtedly situations and conditions in which certain forms of decentralization should not be attempted. 4. Most attempts at rapid decentralization (decentralization by decree) have failed to live up to initial promises or expectations. Successful efforts are characterized by the careful and gradual building of the political, administrative, procedural, and behavioral conditions that facilitate the shift of initiative, responsibility, and activity to the periphery. 5. Effective implementation depends upon a strong, committed, and properly supported core or central staff. An unfortunate misunderstanding about decentralization is that responsibility and power are shifted away from the center. In fact, an effective program strengthens both the periphery and the center. The central staff play a critical role in building and supporting the system.
approval, monitoring, and evaluation can be a key component of any decentralization program. Grants can be considered as a mechanism for the implementation of a program of delegation. Grants, contracts, and cooperative agreements can be used within ministries, across ministries, and with nongovernmental and private organizations. They serve to focus activities toward the goals and priorities established by the funding agency, and to provide a structured framework for project planning, review, and supervision. Grants management systems are used to coordinate the support coming from multilateral and bilateral donors, and to ensure that implementing organizations receive the resources they need. The goal-setting, planning, reporting, and evaluation functions of a well-designed grants management system are important tools for motivating and guiding program implementation. At the same time, grants can help to maintain the autonomy and independence of the collaborating organizations if the monitoring and evaluation functions are properly structured. Û Provide Implementation Planning Support for the Organizations Brought into the HIV/AIDS Service Delivery and Prevention Effort Because AIDS is a new and lethal disease, and because education is the primary means of prevention, the epidemic is placing unprecedented demands on community organizations that may have little prior experience in delivering health-related educational activities and care projects. These groups need help with planning, proposal writing, training, and other areas. Implementation planning is the process whereby these organizations can acquire the resources they need to provide a product or service—resources such as management capacity, technical expertise, funding, training, equipment, work procedures, supervision, etc. The planning encompasses the steps the organization goes through from the decision to act, the selection of strategy, and the setting of objectives to the point where services are being delivered in a sustained manner. In addition, carefully structured participatory training programs will be needed to assist in project planning and implementation. Ü Strengthen the Managerial and Administrative Systems Within the NACP Whether a decentralized HIV/AIDS service delivery and prevention system can be created that involves the collaborative efforts of many organizations will depend, to a considerable degree, on the functional adequacy of managerial, administrative, and support systems at the central level. These systems include: (1) budgeting, accounting, and financial control; (2) training, to provide trained manpower to both governmental and nongovernmental programs; (3) supervisory systems, to provide sustained contact, support, and problem-solving assistance to projects; (4) management information systems, to provide information for monitoring and for identifying problems; (5) personnel management; (6) logistics, including procurement, inventory control, and distribution; and (7) vehicle control, to ensure effective use of available transport. When these systems are not operating properly, effective decentralization will be difficult to achieve or sustain. Technical assistance may be required to ensure the development and adequate functioning of these systems.
Ý Create Linkages Among Organizational Levels and Implementing Agencies Linkages are the channels of communication and reciprocal influence that are needed so that program capacity is developed, problems are identified, and appropriate coordination and control mechanisms are created. Many countries lack effective linkages between local organizations and the national and international agencies that can provide support. Particularly lacking are the middle-level managerial personnel and programs that can provide consistent support and assistance to local projects. This problem is made worse where “vertical” programs must be integrated with other programs at the service delivery level. Extraordinary effort and investment of time and energy may be required to overcome some of these difficulties.
The Role of International Donor Organizations Multilateral, bilateral, and international nongovernmental organizations are supporting an expanding array of HIV/AIDS prevention and care programs. There is enormous variety among the groups’ capabilities, the objectives of their programs, the services they provide, their scopes of operation, and the target audiences being served. NACPs are increasingly confronted with the dilemma of whether and how to coordinate a more coherent national response to the epidemic. At the same time, many NACPs are so weak or so preoccupied with other priorities that they lack the capacity to guide, support, or even interact with the many organizations and groups that are spontaneously becoming active. What role should donor organizations play in advocating and promoting programs of decentralization? Where decentralization is not seen as a feasible or needed response, or where conditions favorable for decentralization do not exist, there is little that international donors can or should do to promote it. Each country and each donor must judge the merits and potential benefits of decentralization for itself and embark on a program only after careful analysis and free informed choice. There are few carefully done studies of the costs of decentralization but substantial anecdotal speculation that it is not cheap. Where interest and potential exists, there is a great deal that international agencies can do to increase the likelihood that decentralization programs will be conceived and implemented with a higher probability of success. These include: (1) activities to build commitment and understanding at the national level of the potential, the limits, and the requirements of decentralization; (2) the provision of technical assistance for the development of decentralization policies and procedures; (3) assistance programs to build managerial and technical capacity at central, intermediate, and local levels; (4) operations research and information dissemination to better characterize the alternative forms of decentralization and to share success stories; (5) use of their grant making and monitoring powers to “model” decentralization practices and procedures; and (6) coordination among donors to promote decentralization at national and local levels.
But a major dilemma remains: What can be done where the need, interest, and will exist, but where NACPs are so weak, overburdened, or otherwise constrained that they are incapable of managing a program of decentralization? One answer can be found in the alternative forms of decentralization, specifically in programs of delegation and privatization. A model can be seen in the various family health associations, as mentioned earlier, that exist in many countries as independent or semiautonomous organizations to promote and manage family planning and related programs. These constitute “parallel organizations” whose independent status allows them to acquire and retain managerial expertise, generate resources, and develop other capabilities that may not be available within government sectors. These organizations often manage large service delivery programs in situations where government programs, for one reason or another, are constrained. It is likely that HIV/AIDS service and support programs can be established along similar lines. One option, therefore is to support these types of organizations and look to them to provide the training, funding, and technical assistance needed to promote a broader response to the epidemic.