Moving Toward a Long-Term Mechanism for HIV/AIDS Prevention and Control in Yunnan Province, China July 2009 Background Yunnan Province, located in southwest China, borders Myanmar, Laos, and Vietnam. It also borders the so-called Golden Triangle, notorious for being one of the world’s largest opium-based drug production and trafficking bases. Yunnan has a total of 25 border cities and more than 90 border crossings that provide easy access to these Southeast Asian countries. Yunnan first identified its HIV epidemic in 1989 when 146 injecting drug users were found to be HIV positive. Since then, HIV infections have been detected in other at-risk groups, such as men who have sex with men, sex workers and their clients, and workers returning from overseas. Needle sharing remained the primary transmission mode for new HIV infections until 2008 when it was overtaken by sexual transmission, which now accounts for more than 50 percent of new infections. Yunnan is one of China’s worst affected provinces in terms of HIV prevalence. Epidemiological projections made by the Advocacy and Analysis (A2) project 1 indicate an increasing number of HIV infections in Yunnan until at least 2010. Yunnan was quick to respond to the HIV threat. In 1990, the province established a multisectoral HIV and AIDS prevention and control group. In 2005, it launched its first three-year “people’s war” aimed at preventing, and controlling HIV and drugs. This government campaign mobilized all sectors to work toward HIV prevention and control and had reasonable success, although it was unable to halt the epidemic. As a result, in 2008 the provincial government resolved to conduct a second round of this people’s war to curb the spread of HIV by 2010. At the June 5, 2008, review of Yunnan’s first people’s war, the Standing Committee of Yunnan’s Provincial Communist Party acknowledged that fighting the epidemic required more than ad hoc, short-term measures and called for a long-term 1
A2 Project; Policy Briefing Paper on Yunnan’s HIV/AIDS Epidemic: Epidemiological and Economic Analysis (September 2006).
The map indicates the hotspots in Yunnan and Guangxi provinces where the U.S. Agency for International Development (USAID) and the Chinese Government cooperate to provide HIV prevention services.
mechanism for HIV and AIDS prevention and control. In response to this call for action, the Yunnan Provincial AIDS Bureau, in partnership with USAID | Health Policy Initiative in the Greater Mekong Region and China project, undertook this study to recommend how to build a long-term working mechanism.
Approach Three sources were consulted to better understand the long-term mechanism and develop recommendations. First, Yunnan’s relevant policy papers; laws and regulations; administrative procedures; work plans; and reports, including the Evaluation Report on the People’s War Against HIV/AIDS in Yunnan (2005–2007), were collected, reviewed, and analyzed. Second, interviews and seminars were held with 192 representatives from government agencies, social organizations, and affected populations involved in HIV prevention, care, and treatment from eight Yunnan prefectures or municipalities and four counties. Third, five provincial experts reviewed the draft report’s findings and conclusions.
Moving Toward a Long-Term Mechanism for HIV/AIDS Prevention and Control in Yunnan Province, China
What is a Long-Term Mechanism? Most respondents interviewed during the development of this policy brief understood that “HIV prevention and control has only a beginning but no end,” 2 would take a long time to implement, and hence could not be expected to be completed within the three-year deadline set by the first people’s war. But few could comprehensively define the elements of a long-term mechanism. The United Nations Joint Programme on HIV/AIDS (UNAIDS) “Three Ones” principle provides a solid foundation for developing a definition for a longterm mechanism. This principle exhorts nations to develop one agreed HIV/AIDS Action Framework, providing direction to the work of all stakeholders; one National Coordinating Authority with a broad-based mandate to cover all stakeholders; and one agreed country-level Monitoring and Evaluation (M&E) system. Building on this, an effective long-term mechanism clearly needs to be • Led by Government, but inclusive of not only different government departments, but all stakeholders whether they be businesses, nongovernmental organizations (NGOs), other civil sector organizations, or, most importantly, people affected and infected by HIV; • Standardized in its approach to HIV prevention and control and regulated according to acceptable standards of treatment, care, and prevention, as laid down by laws at the macro level and technical protocols at the micro level; • Regularized or institutionalized so that it does not become subject to the whims of leaders or rotations in staff; and • Sustainable both financially and in its evolution so that, for example, funds are allocated, approaches adapted to new trends, and new staff trained. “The long-term mechanism means achieving systematic and scientific prevention and control.” –Director, Dali AIDS Prevention Committee Office
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Quote from a Deputy County Mayor interviewed during the development of this policy brief, November 2008.
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Based on all these criteria, a long-term mechanism can be defined as: A government-led, evidence-based (or “scientific”) HIV prevention and control system involving all sectors of society that continually develops and improves on policies, regulations and procedures, physical infrastructure, and staff in accordance with rational, securely funded plans all measured through effective M&E systems, incorporating functioning feedback loops which enable evidence to drive plans and maximize resource utilization.
Recommendations for Improving Yunnan’s Long-Term Mechanism Yunnan has already developed a firm foundation for an effective long-term mechanism. Laws have been promulgated, regulations compiled in Yunnan’s Provincial-Level Regulations for HIV/AIDS Prevention and Control, master plans made, protocols developed, and staff trained. In addition, the coordinating body of the Provincial Bureau of HIV/AIDS Prevention and Control (with 41 agencies as members), along with its associated subordinate prefecture and county-level Working Committees, has been established and staffed and meets regularly. However, challenges remain. There is a need for greater political commitment especially at the local level, increased involvement from non-Public Health Bureau departments, more civil society mobilization, improved harmonization of laws and strategies, and improved use of quality data to inform decision making. Therefore, to assist in fully realizing the long-term mechanism’s potential over the next three years, the following are recommended: Improve the Quality of information to Better Inform Decision Making •
The likely epidemiological evolution of Yunnan’s HIV epidemic is hotly debated. Over the past two decades, Yunnan has collected much data and, based on this, developed many effective approaches for HIV prevention and control. These approaches now need to be analyzed and synthesized to enable scale-up within the province. But, because of limited staff and organizational capacity at subprovincial levels, collection, analysis, and use of data are insufficient. To overcome this, Yunnan authorities should solicit more national-level support, conduct more training, and encourage cross-departmental cooperation.
Moving Toward a Long-Term Mechanism for HIV/AIDS Prevention and Control in Yunnan Province, China
Plug Policy Gaps, Resolve Policy Inconsistencies, and Implement Existing Policies •
National and provincial governments have established a solid legal and policy framework for HIV prevention and control. However, implementation of these policies requires joint effort at all levels and across all departments. For example, Yunnan’s Provincial-Level Regulations for HIV/AIDS Prevention and Control requires that all prefectures use their own legal powers to develop appropriate essential local regulations, yet many have not done this. Similarly, interpretation on when, during the voluntary counseling and testing (VCT) process, patient identification should be required varies widely from prefecture to prefecture and this inconsistency needs clarification because it limits the effectiveness of the VCT process. • Laws, policies, and regulations are not always followed, even by local government and government department heads, because of a lack of knowledge about these requirements caused by the department head or by turnover of political leadership. Furthermore, the Party Schools and Administration Colleges that government officials and leaders are required to attend should incorporate the available HIV prevention and control laws and regulations into their curricula. • Implementing the policies that already exist should also be a priority. For example, the continuing existence of stigma and discrimination toward people living with HIV means that they are reluctant to receive testing or take advantage of services offered by the government, thereby limiting the effectiveness of the Four Frees and One Care Policy. 3 Activating this policy requires relevant government departments to develop detailed, cost-effective strategies to combat stigma and discrimination and ensure sufficient funding for its implementation. Fully Exert Coordination, Supervision, and Monitoring Functions of the Provincial AIDS Bureau, Working Committees, and Offices •
AIDS Working Committees and their Offices at the provincial, prefecture, and county levels were set-up by the government to cater to the needs of HIV prevention and control with specific requirements for their functions and
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The Four Frees and One Care Policy is a national policy entitling Chinese to free HIV testing, antiretroviral drugs for HIV positive people, medication for HIV positive pregnant women, and education for HIV orphans. This is combined with financial assistance (care) for low-income households with family members who have HIV.
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responsibilities in mind. Unfortunately, in reality, the AIDS Working Committees and Offices have not fully fulfilled their roles. As a result, it is essential to further clarify their roles, appropriately staff the Offices, and improve their work with regulations in order to strengthen their role in coordinating, supervising, and monitoring in accordance with the requirements of the Provincial Chinese Communist Party (CCP) and the provincial government. • While administratively, the Working Offices have been established under the Public Health Bureau, it is important to recognize that they are subordinate to the Working Committee rather than the Public Health Bureau. As a result, the Offices should have the authority to deal with other Bureaus as a representative of the Working Committee rather than as a lower-level subordinate of the Health Bureau. China’s HIV/AIDS regulations mandate that Working Committees and their Offices are the preeminent coordinators for HIV/AIDS work. As a result, all other Working Committee member departments, such as Public Security and Public Health, should actively fulfill their responsibilities and participate in the HIV/AIDS prevention and control work proposed by the Working Committees and Offices. • At the same time, the AIDS Offices themselves should strengthen communication with other departments to achieve mutual understanding and support and to create a collaborative environment to fight HIV/AIDS. “The long-term mechanism means that institutional arrangements, human resource allocation, and policy development should meet the demands of long-term work.” –Section Chief, Provincial Bureau of Science and Technology
Continually Train Staff and Improve Personnel Management Procedures •
Yunnan has thousands of government staff working on HIV and AIDS prevention and control, yet their capacity does not always match the demands placed upon them. As a result, continual and intensive training needs to be provided in every department and agency to improve services and control quality. • Similarly, while technical protocols exist to serve both people infected and affected by HIV, professional health staff need more training to ensure that these procedures are uniformly applied and followed according to established standards.
Moving Toward a Long-Term Mechanism for HIV/AIDS Prevention and Control in Yunnan Province, China
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The 2008 Health Reform report makes many recommendations regarding personnel management that should be implemented to improve the capacity and reduce the turnover of professional health staff. Included are recommendations regarding, for example, regulating special salary top-up payments to staff undertaking certain functions, underusing staff, and limited capacity building, that in the past may have led to rapid staff turnover.
Harmonize HIV Plans and Integrate HIV Prevention into Socioeconomic Plans •
Since the 1990s, Yunnan has had a plethora of HIV and AIDS prevention and control plans, including medium- and long-term action plans, three-year implementation plans, and the six- and 10-year project plans. These plans have served the Province well, but unfortunately, they have not all been consistent with each other or with the reality of the epidemic in Yunnan. Yunnan should adopt a five-year master planning cycle concurrent to the National HIV/AIDS Prevention and Control Plan and the national public health plan. Shorter-term annual and localized plans can then be developed that will synchronize and are consistent with this long-term plan, thereby avoiding less relevant projects. • HIV and AIDS prevention and control needs to be integrated into wider socioeconomic development plans if HIV is to be prevented and controlled at its source. Thus, HIV education needs to be integrated into public reproductive health education plans; care, social assistance, and income generation activities for people living with HIV need to be integrated into social welfare plans; a long-term assistance mechanism for HIV affected children should be established; and initiatives to generate employment and measures to alleviate poverty need to be incorporated into the Provincial Poverty Alleviation Plan. Once integrated, these plans will guide other government departments not directly involved in health to seamlessly fulfill their responsibilities to HIV prevention and control.
Provincial CCP and government leaders above the city level meet to discuss HIV/AIDS and antidrug measures.
Secure, Expand, and Improve User Efficiency of the Funding Base •
An effective long-term mechanism obviously requires long-term, secure funding. Since 2004, funding for HIV prevention and control from all levels of government has increased yearly. But given scarce resources and competing demands, government and international aid budgets cannot grow indefinitely. As a result, the government should explore leveraging resources from the civil sector to expand the funding base. To mobilize these resources—which might consist of time and goods in kind, as well as monetary contributions from businesses, individuals, or social groups— relevant departments will need to develop appropriate regulations and policies. For example, tax deductions could be allowed for charitable donations, while civil agencies providing support or income generation activities to people living with HIV might be given tax breaks or financial support. • Defending and securing long-term government funding requires a needs-based funding plan supported by hard evidence. Past HIV budgets should be critically analyzed and upcoming needs budgeted and reviewed by appropriate experts. These HIV budgets need to be integrated into each department’s overall budget rather than being freestanding, separate budgets. For example, the infrastructure budget for HIV prevention and control should be integrated into the wider public health development plan to avoid any wasteful overlap. • Once budgets have been developed and assigned to the relevant upper-level supervising government body, funds must be transferred to the implementing agencies on time and in the agreed amount.
Moving Toward a Long-Term Mechanism for HIV/AIDS Prevention and Control in Yunnan Province, China
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Given limited resources, AIDS Working Committees and their Offices should maximize the output from resources used and allocate them to what works.
Promote Community and Well-Integrated Civil Sector Involvement •
To maximize social participation in HIV prevention, care, and treatment, the Provincial AIDS Bureau should develop a Community-Based HIV Prevention and Control model led by community or village committees and tested in selected communities for eventual province-wide scale up if successful. In rural areas, this would include tapping local leaders and designating staff to disseminate information, as well as gradually improving the wages of village doctors and village HIV prevention, care, and treatment educators. In urban areas, it should incorporate community health centers, family planning service centers, and community-based organizations. However, building the capacity of these grassroots government agencies is a prerequisite for this to succeed. • Civil society, government NGOs (GONGOs), NGOs, and community-based organizations should be encouraged and funded by the government to provide HIV prevention, care, and treatment interventions, especially in educating the public. These groups should unite to conduct joint projects and mobilize greater society participation to create a social force to respond to HIV. Businesses should be encouraged to provide HIV education and workplace programs for their employees and surrounding communities in accordance with existing HIV laws. Competitive government tenders (e.g., for condoms) will also secure greater business involvement. “Besides government input, [any long-term mechanism] must encourage enterprises to provide financial input to HIV/AIDS prevention and control.” –Section Chief, Provincial Bureau of Finance
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Given the relatively unregulated rapid growth in the number of international NGOs working in HIV and to avoid wasteful resource overlap, the Provincial AIDS Bureau should better communicate its priorities and develop guiding principles and management strategies for international NGOs. Furthermore, management staff and work of international NGOs need to be better integrated into the Province’s master plan for HIV prevention and control.
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Regularize and Effectively Implement Administrative Supervision, Monitoring, and Evaluation •
Yunnan already has well-developed administrative procedures to monitor and supervise lower-level units within both administrative government and line departments based on a management-byobjectives approach. Annual HIV prevention and control targets are set at the provincial level and form the basis for “contracts” signed with prefecture governments at the county level and so on down the reporting line to the level of each hospital, VCT clinic, etc. Subsequent enforcement of these contracts is facilitated by three mechanisms: “top leader responsible” (meaning the highest person in that department is held accountable for the targets on which she/he signs off), “veto by one ballot” (meaning rewards—such as bonuses and promotions—are dependent on meeting all targets and will not be given if staff fail in any one area), and “accountability investigations” (meaning the provincial-level government annually inspects the work of countylevel governments). However, these mechanisms are not always carried out thoroughly; the targets often emphasize quantity over quality; and, especially for non-Public Health Bureaus, HIV prevention and control targets are insufficiently prioritized. Departments must abide by the Yunnan Provincial Government’s Measures for Accountability Investigation of Administrative Leaders. Issues identified during the annual subordinate-level inspection should not only be reported to the upper-level inspection group, but also to the local (e.g., county) government so that the administration, their departments, and the inspection group can develop appropriate solutions. • To sustain constant long-term mechanism improvements, more frequent and regular impact evaluations with wider coverage are needed. To date, the only province-wide evaluation done has been the evaluation of the first people’s war. Regular evaluations across all counties at the same time and using the same methodology do not exist. Evaluation indicators need to be refined and broadened, supervision and evaluation must be linked to those indicators, and supervision visits and evaluations need to become regular institutional requirements.
Moving Toward a Long-Term Mechanism for HIV/AIDS Prevention and Control in Yunnan Province, China
“Evaluation [of prevention and control] should be regularized, the official assessment should be combined with the technical assessment, and attention paid to using financial inputs efficiently.” –Deputy Director, Provincial Center for Disease Control
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AIDS Committee Offices and third parties, such as the Audit and Inspection departments, 4 People’s Congress, and the China People’s Political Coordination Committee should be employed to ensure that HIV prevention and control funds are used as efficiently as possible, in accordance with best national and international practice and linked to effective programs.
Next Steps: Promoting Adoption of the Recommendations In its leadership role, the Yunnan Provincial AIDS Bureau will advocate for action on the above recommendations. It plans to publish an advisory report to distribute to relevant government departments and submit papers on the long-term mechanism to the government’s Development Forum. Additionally, in 2009, curricula used by the Party School of Yunnan, responsible for training government leaders, will include training on the long-term mechanism for HIV prevention and control, thereby advocating for real change at every level of leadership.
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These two departments do not fall under any specific implementing agency (such as the Public Health or Security Bureaus) and therefore, can conduct independent investigations on how agencies work and use funds.
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This brief was produced for review by the USAID. It was prepared by staff of the USAID | Health Policy Initiative in the Greater Mekong Region and China (HPI/GMR-C). The authors’ views do not necessarily represent those of USAID or the U.S. Government. HPI/GMR-C is funded by USAID under Contract No. GPO-I-00-05-00035-00, beginning September 28, 2007. It is implemented by RTI International, in collaboration with the Burnet Institute for Medical Research and Public Health. For more information, please visit: http://ghiqc.usaid.gov/hpi.
