This section presents country level discussions for the advocacy context in which different participants deliver their programmes. Case studies from stakeholder interviews and core group interviews are presented to highlight contextual enablers and challenges.
It is easy, I participate at the Ministry of Health. I have been doing advocacy for many years, in the early years of development we used to use placards with signs, marching ‘’we want treatment’’ – this has really evolved. The level of engagement has changed now. We need to sit down with these people. Your target is your ally, advocacy has evolved. Things are changing.
As civil society we are catalysing the process of PrEP roll out in Botswana. We are represented at the Ministry of Health PrEP Technical Working Group, where we are trying to push the Ministry of Health to move faster and ensure we have roll out of PrEP by end 2018. We have a number of CSOs represented in the Technical Working Group, membership also includes representatives from FHI360 and USAID. There are only about four civil society representatives, but it used to be two and we recommended for two additional.
Botswana was named as a place where doing advocacy is easy. The respondent had a longer history of engagement with government. They cited existing platforms where civil society are able to engage and influence government policy and guidelines for HIV in general and PrEP roll-out in particular. They were also to provide an example of increasing civil society participation in government strategy platforms.
The respondent worked for a youth-based organisation that works with PLHIV, focused on provision of prevention and support services. Treatment advocacy toward improved access for people living in rural areas, mobile populations and certain populations of labourers was foregrounded.
It is not difficult in Zimbabwe, the response is evidence based. The government is operating within the systems with the available knowledge. There are opportunities to engage with government around different aspects of HIV policy. This is managed through the National AIDS Council of Zimbabwe. In my context it is easy in terms of policy, but it is difficult in terms of resources.
There is an acute lack of resources in Zimbabwe as a whole and even in HIV, the country received less funding than others. In this small funding pool, advocacy is last on the list of things that would be funded. Civil society have had to find informal ways of engaging to do the work.
We are supported to participate in regional and international platforms as civil society to contribute to advance global advocacy agendas. The challenge is support to take this information down to the ground and engage with affected communities. Money to do in-country work is not there. Even when it comes to policy meetings there is a challenge to bring members from outside of Harare into the city to offer their perspective and also to be engaged.
The respondent described the advocacy context as easy. They expressed a good working relationship with government and could name existing platforms where civil society can influence policy and guidelines. The greatest challenge was cited as a lack of resources for coordination, consequently consultation platforms for civil society often include nominal representation of non-urban stakeholders. The respondent felt that funding community advocacy was not a priority among donors.
The respondent was very involved in HIVPRx advocacy including policy advocacy for PrEP access for young women 24 years old and under; policy advocacy – directed at the government department and ministries. The respondent had also conducted training with health journalist to report timely, correctly and sensitively, ensuring that HIV reporting is HIV evidence based.
The participant response considers the overarching environment in which Biomedical HIV prevention research to roll-out advocacy is implemented, government engagement and resourcing for civil society.
Doing Advocacy in our context is very easy, our representatives are very reachable. Advocacy around specific prevention tools has been varied engagement with civil society. When there was talks for microbicides Kenya were preparing for roll out; sitting in different policy making platforms in the country. Discussions looked at how to raise community awareness around microbicides, who are the priority populations for roll out and facilitating multi-platform conversations, doing community awareness, access and availability. At the moment there is not really discussions around microbicides.
Recently there was research literacy for PrEP for communities living around the area where the research is happening, preparing them to be part of research to not only participate as specimens, to influence – share feedback. Kenya has also done well to engage key populations people who use drugs.
As a country we are not investing enough in research, with most funds going to treatment. The treatment lobby are well mobilised and can drive advocacy around ensuring that PLHIV have appropriate access to treatment
Kenya was described as providing an enabling environment for HIVPrX advocacy. The respondent could cite examples where government has worked alongside civil society in preparing for roll-out of NPTs, facilitating policy platforms, discussions on community engagement and priority populations for roll-out.
Organisational Context: The respondent works with adolescent girls and young women around access to SRH services with a human rights approach. Their focus is on appropriate access to quality services, effective linkage to care and adherence support.
It is very difficult and the main reason is we just don’t have the information. If you haven’t barged in, you’re left outside. We haven’t reached that point in Malawi where we are invited, still not being invited to sit around the table.
Civil Society are not deliberately involved in research studies. CABs are set up, was thought of as community members, rather than advocates. There is a gap in information, no source where you get regular updates from all the research happening nationally.
It’s not that there’s no engagement, most studies do involve community members and they do a lot of awareness raising at that level. These are community representatives not advocates. With civil society being engaged we play an additional role, we are empowered with information and are also hopefully linked up to other developments and so are aware about what is happening in other countries. As advocates we are able to critique more than community representatives.
The advocacy context in Malawi was described as difficult. The participant expressed that civil society are not actively engaged to meaningfully participate as stakeholders in research studies. To stay abreast of developments, the onus is on civil society to do follow-ups. There is not an engagement mechanism whereby interested civil society can become more involved in research studies.
The participant worked across different areas of health advocacy as part of a national network organisation; developing and supporting community systems for action in the prevention, treatment and care of HIV. The participant was also directly involved in policy advocacy and roll-out of PrEP.
Here the participant framed advocacy ease/or difficulty from the perspective of civil society proximity to research studies overall and the ease or difficulty experienced in gaining access.
For us, you are engaging stakeholders to buy into new ideas they have not yet seen and be found effective vis a vis the immediate needs of preventing new infections. We have tools that work, some pose the question as to why we don’t invest in the implementation of what works instead of doing advocacy for supporting research.
Over the years we have expanded the number of stakeholders engaged through the realisation that more tools are needed in order to end the epidemic. The funding channels around HIV PRx is very lean, as organisations we need to constantly find innovative ways to remain focused and committed.
The focus is on stakeholder engagement including communities and government to see how they buy into the research and demonstration projects for PrEP. We’ve effectively engaged with government in discussion around PrEP delivery and identifying the best models for service provision. Within that there is also advocacy for access for key populations. .
The participant described the advocacy environment in Nigeria as challenging. While there were no ongoing trials for NPTs, the government had concluded a PrEP demonstration project. The participant confirmed an ongoing engagement with government around PrEP policy and expanded access for key populations.
The participant is engaged in community mobilisation and policy advocacy for HIVPrx advocacy. Information resources on HIV Prx studies are made more accessible and distributed through their online platform and through face-to face engagements. ..
The respondent reflected on ease or difficulty in implementation and mobilisation of support for NPTs from their organisational experience as driving HIVPrx agendas at community and government levels.
Is it doable but I acknowledge that there is a lot of challenges as we do this kind advocacy. We do evidence based advocacy – generate enough evidence so we are able to influence decisions with the specific or respective ministries and sanction change in this area.
There are a number of challenges in this process – advocacy involves partnerships and collaborations and individuals who determine the focal points in the ministry or the government. Tanzania has a new regime since 2015, there has been a lot of ministerial reshuffles, and administration reshuffles. As a result the organisation has lost some of the politicians that were champions.
We try to ensure that government and ministries understand out advocacy ask, so we can present this at the parliamentary sittings. Lost 70% of champions, so you need to engage new people to share the advocacy messages.
The other thing would be direction and priority. Government has so many different priorities that by the time you get there it is difficult because there are so many agenda points, the things you are trying to explain are complex and government is too ambitious. So it is hard to get your agenda on the table.
The participant described advocacy as ‘’doable’’ pointing to a difficult operating context, but not one where government is entirely uncooperative. The success of any given advocacy programme was linked to the success of getting that particular advocacy issue on the government agenda and forging partnerships to achieve the desired outcome.
The participant works with communities and local government toward the delivery of people centred health systems. Their advocacy focus includes domestic resourcing for health and policy advocacy for improved access to services.
Here the respondent reflects on the impact of political environment for implementing advocacy and how work with state actors has to be navigated through shifting national priorities.
It is not that easy. If we look specifically at biomedical HIV prevention research advocacy it is something that the country was not ready for, not decision makers, policy implementers – not sure whether it is lack of information. Has been challenging to convince them to take up these new biomedical tools.
I was saying that the advocacy space has been shrinking, and given that some of these tools are for some key populations, the legal environment has been hostile and certain populations that need these tools are regarded illegal here, so it is a funny topic to talk about in some instances. Not a platform.
Frustrating that these trials are happening in the country, but as government they are not getting involved. It is important bridging that gap and having our government taking advantage of these trials happening in our backyard and rapidly scaling these up.
The participant described the advocacy environment in Uganda as challenging. They reflect on advocacy for the advancement of HIV prevention research in particular and express a lack of government engagement and leadership in research to roll-out studies.
The participant forms part of an advocacy organization focused on promoting youth-friendly policies in health. Their work around biomedical HIV prevention is around treatment as prevention (TasP) promoting access to PrEP, and VMMC, through community engagement and scale up activities.