Engaging Key Stakeholders: Ensuring the Right to HIV/AIDS Education and Health Care Services

Published as part of the New Tactics in Human Rights Tactical Notebook Series, this 16-page document evaluates a communication strategy for addressing HIV/AIDS undertaken by CARE-Bangladesh, through its NGO Service Delivery Program. Following a background on the HIV/AIDS situation in Bangladesh, the authors detail how they engaged key stakeholders, developed advantageous partnerships with unions, and implemented the programme. They then share results, lessons learned, and strategies for transferring the tactic to other settings/issues.

As explained here, organisers recognised that a critical means of combating the spread of HIV/AIDS in Bangladesh relies on the engagement of key stakeholders - in particular, transport workers, their unions, and trucking companies that employ them. The participatory intervention for social change is outlined in detail here (excerpts provided below from various sections of the report are meant to illustrate and analyse how this strategy worked):

In short, drawing on the strategies outlined below, as of this writing the programme had 45 Drop-In Centres (DICs) nationwide, each called 'Traveller,' about 300 paid peer outreach workers, and 25,000 volunteer peer educators (recruited from the transport workers themselves). Approximately 4,000 transport workers receive health services from the DICs each month. The project has also established a system for the social marketing of condoms through peer outreach workers and more than 200 local depot holders.

An excerpt from the document follows:

"...Because we planned to give the project over to its participants - namely the transport union...the primary stakeholders...have been actively involved in program development and activities. By holding the union accountable and responsible, CARE-Bangladesh has facilitated a process whereby the workers' union has become an implementer of health care services, including prevention services, related to sexually transmitted infections (STIs) and HIV....Its participation and sense of ownership have been essential in sustaining the program and making it socially acceptable. Union involvement was also instrumental in the scaling up of project activities and the ability to quickly create a nationwide service network....

Due to bad experiences in the past with non-government organizations (NGOs), the union initially had reservations about collaborating with CARE. It resented the implication that truckers were responsible for HIV transmission, and even resisted the insinuation that truckers were sexually active outside marriage. Open discussions of sexual activity and public displays of condom use...were novel and suspect.

...[CARE-Bangladesh] staff devoted a great deal of time to developing a trusting relationship with union leaders, one ultimately formed through discussion, advocacy, careful building of reputations, and the sharing of information. With persistence, CARE staff shed their image as outsiders and became friendly collaborators and, eventually, equal partners...

Another key element of our relationship building during this period was the transparency of our goal and objectives. We wanted our counterparts to be certain that we had no hidden agenda for starting this project. We were also careful to share information, an act crucial in motivating someone to join your side.

During the period of our discussions and negotiations with the union leaders, we were conducting a factfinding baseline survey to identify actual behaviour patterns of transport workers in Dhaka city. The findings of this survey helped us gain the support of union leaders and the union as partners in this project. It allowed us to establish an understanding of risk, and to make clear that HIV would be a problem for union members in the near future...

Union leaders give time and moral support during the opening and graduation ceremonies of the Volunteer Peer Educator training course. Peer educators are motivated to participate more actively in the training process after they hear a union leader praise their role and contribution; receiving a certificate from their union leader also bestows a sense of prestige.

One of the most important activities of the union and its leaders is to bargain collectively with transport owners and broker agencies for their participation in the project activities, as their support is important in making the program sustainable...

Two key elements of our partnership with the union are the access to infrastructure and the commitment of personnel close to the education activities. Drop-In Centres [DICs] are located within union offices because transport workers feel that these office[s] are their own.....One central advantage of a union-run project is the solidity of its infrastructure. In our case, with the DICs managed by the union, the educational posters, pamphlets, and knowledge will remain, even if the outside funding ends....This provides tremendous social acceptance of the interventions, which grows when truckers see educational materials and messages while hanging around union offices, and medical care is available in the same place. The DIC, along with the union, is their own and it takes care of them...

...[P]artner management of STIs [sexually transmitted infections] is a crucial element of our approach. When a transport worker comes to a clinic with a[n] STI, the doctor also counsels him on the importance of partner management, including treatment for his wife and other traceable partners...

The project also depends on the community, with the active involvement of the transport union and members in decision-making and program activities. In particular, it relies on peer participation, which has been crucial in developing community engagement. Peers - who are transport workers themselves - help identify areas for outreach, ensure cultural appropriateness of the prevention message, and serve as outreach workers. They are most effective at persuading their peer transport workers to participate in project activities in a meaningful way, and to feel that the project belongs to them...

...To date, the program has trained more than 25,000 volunteer peer educators...[who] participate in two-day training sessions on STI/HIV prevention. After training they are given a certificate of completion and asked to provide informal education to their friends, family, and colleagues during their daily activities....As most have never completed schooling, they have no certificate related to education or any extracurricular activity. The certificate, then, means a great deal to them...

...[T]he peer educator model is valuable in a number of ways:

• It helps to disseminate the message about HIV through pre-existing, natural, and informal networks of neighbours and friends, rather than requiring other systems or authorities to supplant these networks.
• It supports the sustainability of HIV education work. The hope is that by taking the message from the hands of paid educators, the viability of the work will be ensured.
• Work as a peer educator is for some an initial step toward the development of skills (cognitive, motivational) needed as outreach workers, who are recruited from the more skilled peer educators. And all peers learn about the larger context of the international HIV/AIDS epidemic and the risk behaviours involved.
• This work empowers individual members of society to express care for their communities, and provides an avenue to help in the struggle against diseases affecting those communities.
• Rather than training an individual in order to promote him out of his working community, the peer volunteer model enriches the knowledge, skills, and leadership of that community without changing the individual's identity as a member.

...Many people are shy about attending a medical clinic and instead receive treatment from a variety of alternative practitioners....During outreach education activities, peer outreach workers encourage the transport workers to avail themselves instead of the services of the qualified medical personnel....Some practitioners are enlisted as educators....After the training we have seen that practitioners are providing the correct drugs so as to cure patients. We have also found that they refer complicated patients to the DICs...

It is essential to keep in mind that the interest level of various stakeholders involved in an issue will vary. As a result, the tactics you use to engage and involve them will need to be adapted..."