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There is no question that the stigma and discrimination associated with HIV and AIDS can be reduced through intervention. The inclusion of stigma and discrimination reduction as a critical component of achieving an AIDS-free generation in recent UNAIDS, UN and PEPFAR political initiatives is promising. Yet national governments need evidence on effective interventions at the individual, community and societal levels in order to strategically incorporate stigma and discrimination reduction into national AIDS plans. Currently, the heterogeneity of stigma and discrimination reduction approaches and measurement makes it challenging to compare and contrast evaluated interventions. Moving forward, it is critical for the research community to: (1) clearly link intervention activities to the domains of stigma to be shifted; (2) assess the stigma domains in a consistent manner; and (3) link stigma and discrimination reduction with HIV prevention, care and treatment outcomes (e.g., uptake, adherence and retention of ART). These steps would further advance the scientific evidence base of stigma and discrimination reduction and allow for the identification of effective interventions that could be scaled up by national governments., Introduction Adherence to HIV antiretroviral therapy (ART) is a critical determinant of HIV-1 RNA viral suppression and health outcomes. It is generally accepted that HIV-related stigma is correlated with factors that may undermine ART adherence, but its relationship with ART adherence itself is not well established. We therefore undertook this review to systematically assess the relationship between HIV-related stigma and ART adherence. Methods We searched nine electronic databases for published and unpublished literature, with no language restrictions. First we screened the titles and abstracts for studies that potentially contained data on ART adherence. Then we reviewed the full text of these studies to identify articles that reported data on the relationship between ART adherence and either HIV-related stigma or serostatus disclosure. We used the method of meta-synthesis to summarize the findings from the qualitative studies. Results Our search protocol yielded 14,854 initial records. After eliminating duplicates and screening the titles and abstracts, we retrieved the full text of 960 journal articles, dissertations and unpublished conference abstracts for review. We included 75 studies conducted among 26,715 HIV-positive persons living in 32 countries worldwide, with less representation of work from Eastern Europe and Central Asia. Among the 34 qualitative studies, our meta-synthesis identified five distinct third-order labels through an inductive process that we categorized as themes and organized in a conceptual model spanning intrapersonal, interpersonal and structural levels. HIV-related stigma undermined ART adherence by compromising general psychological processes, such as adaptive coping and social support. We also identified psychological processes specific to HIV-positive persons driven by predominant stigmatizing attitudes and which undermined adherence, such as internalized stigma and concealment. Adaptive coping and social support were critical determinants of participants’ ability to overcome the structural and economic barriers associated with poverty in order to successfully adhere to ART. Among the 41 quantitative studies, 24 of 33 cross-sectional studies (71%) reported a positive finding between HIV stigma and ART non-adherence, while 6 of 7 longitudinal studies (86%) reported a null finding (Pearson's χ 2=7.7; p=0.005). Conclusions We found that HIV-related stigma compromised participants’ abilities to successfully adhere to ART. Interventions to reduce stigma should target multiple levels of influence (intrapersonal, interpersonal and structural) in order to have maximum effectiveness on improving ART adherence., Introduction HIV-related stigma and discrimination continue to hamper efforts to prevent new infections and engage people in HIV treatment, care and support programmes. The identification of effective interventions to reduce stigma and discrimination that can be integrated into national responses is crucial to the success of the global AIDS response. Methods We conducted a systematic review of studies and reports that assessed the effectiveness of interventions to reduce HIV stigma and discrimination between 1 January 2002 and 1 March 2013. Databases searched for peer-reviewed articles included PubMed, Scopus, EBSCO Host –CINAHL Plus, Psycinfo, Ovid, Sociofile and Popline. Reports were obtained from the www.HIVAIDSClearinghouse.eu, USAID Development Experience Clearinghouse, UNESCO HIV and AIDS Education Clearinghouse, Google, WHO and UNAIDS. Ancestry searches for articles included in the systematic review were also conducted. Studies of any design that sought to reduce stigma as a primary or secondary objective and included pre- and post-intervention measures of stigma were included. Results Of 2368 peer-reviewed articles and reports identified, 48 were included in our review representing 14 different target populations in 28 countries. The majority of interventions utilized two or more strategies to reduce stigma and discrimination, and ten included structural or biomedical components. However, most interventions targeted a single socio-ecological level and a single domain of stigma. Outcome measures lacked uniformity and validity, making both interpretation and comparison of study results difficult. While the majority of studies were effective at reducing the aspects of stigma they measured, none assessed the influence of stigma or discrimination reduction on HIV-related health outcomes. Conclusions Our review revealed considerable progress in the stigma-reduction field. However, critical challenges and gaps remain which are impeding the identification of effective stigma-reduction strategies that can be implemented by national governments on a larger scale. The development, validation, and consistent use of globally relevant scales of stigma and discrimination are a critical next step for advancing the field of research in this area. Studies comparing the effectiveness of different stigma-reduction strategies and studies assessing the influence of stigma reduction on key behavioural and biomedical outcomes are also needed to maximize biomedical prevention efforts., Introduction Global scale up of antiretroviral therapy is changing the context of HIV-related stigma. However, stigma remains an ongoing concern in many countries. Groups of people living with HIV can contribute to the reduction of stigma. However, the pathways through which they do so are not well understood. Methods This paper utilizes data from a qualitative study exploring the impact of networked groups of people living with HIV in Jinja and Mbale districts of Uganda. Participants were people living with HIV (n=40), members of their households (n=10) and their health service providers (n=15). Data were collected via interviews and focus group discussions in 2010, and analyzed inductively to extract key themes related to the approaches and outcomes of the groups’ anti-stigma activities. Results Study participants reported that HIV stigma in their communities had declined as a result of the collective activities of groups of people living with HIV. However, they believed that stigma remained an ongoing challenge. Gender, family relationships, social and economic factors emerged as important drivers of stigma. Challenging stigma collectively transcended individual experiences and united people living with HIV in a process of social renegotiation to achieve change. Groups of people living with HIV provided peer support and improved the confidence of their members, which ultimately reduced self-stigma and improved their ability to deal with external stigma when it was encountered. Conclusions Antiretroviral therapy and group-based approaches in the delivery of HIV services are opening up new avenues for the collective participation of people living with HIV to challenge HIV stigma and act as agents of social change. Interventions for reducing HIV stigma should be expanded beyond those that aim to increase the resilience and coping mechanisms of individuals, to those that build the capacity of groups to collectively cope with and challenge HIV stigma. Such interventions should be gender sensitive and should respond to contextual social, economic and structural factors that drive stigma., Introduction HIV stigma and discrimination are major issues affecting people living with HIV in their everyday lives. In Thailand, a project was implemented to address HIV stigma and discrimination within communities with four activities: (1) monthly banking days; (2) HIV campaigns; (3) information, education and communication (IEC) materials and (4) “Funfairs.” This study evaluates the effect of project interventions on reducing community-level HIV stigma. Methods A repeated cross-sectional design was developed to measure changes in HIV knowledge and HIV-related stigma domains among community members exposed to the project. Two cross-sectional surveys were implemented at baseline (respondent n=560) and endline (respondent n=560). T-tests were employed to assess changes on three stigma domains: fear of HIV infection through daily activity, shame associated with having HIV and blame towards people with HIV. Baseline scales were confirmed at endline, and each scale was regressed on demographic characteristics, HIV knowledge and exposure to intervention activities. Results No differences were observed in respondent characteristics at baseline and endline. Significant changes were observed in HIV transmission knowledge, fear of HIV infection and shame associated with having HIV from baseline to endline. Respondents exposed to three specific activities (monthly campaign, Funfair and IEC materials) were less likely to exhibit stigma along the dimensions of fear (3.8 points lower on average compared to respondents exposed to none or only one intervention; 95% CI: −7.3 to −0.3) and shame (4.1 points lower; 95% CI: −7.7 to −0.6), net of demographic controls and baseline levels of stigma. Personally knowing someone with HIV was associated with low fear and shame, and females were less likely to possess attitudes of shame compared to males. Conclusions The multivariate linear models suggest that a combination of three interventions was critical in shifting community-level stigma – monthly campaign, Funfair and IEC materials. This is especially important given Thailand's new national AIDS strategy to reduce HIV-related stigma and discrimination by half by 2016. Knowing which interventions to invest in for HIV stigma reduction is crucial for country-wide expansion and scale-up of intervention activities., Introduction Globally, HIV-related stigma is prevalent in healthcare settings and is a major barrier to HIV prevention and treatment adherence. Some intervention studies have showed encouraging outcomes, but a gap continues to exist between what is known and what is actually delivered in medical settings to reduce HIV-related stigma. Methods This article describes the process of implementing a stigma reduction intervention trial that involved 1760 service providers in 40 hospitals in China. Guided by Diffusion of Innovation theory, the intervention identified and trained about 15–20% providers as popular opinion leaders (POLs) to disseminate stigma reduction messages in each intervention hospital. The intervention also engaged governmental support in the provision of universal precaution supplies to all participating hospitals in the trial. The frequency of message diffusion and reception, perceived improvement in universal precaution practices and reduction in the level of stigma in hospitals were measured at 6- and 12-month follow-up assessments. Results Within the intervention hospitals, POL providers reported more frequent discussions with their co-workers regarding universal precaution principles, equal treatment of patients, provider-patient relationships and reducing HIV-related stigma. Service providers in the intervention hospitals reported more desirable intervention outcomes than providers in the control hospitals. Our evaluation revealed that the POL model is compatible with the target population, and that the unique intervention entry point of enhancing universal precaution and occupational safety was the key to improved acceptance by service providers. The involvement of health authorities in supporting occupational safety was an important element for sustainability. Conclusions This report focuses on explaining the elements of our intervention rather than its outcomes. Lessons learned from the intervention implementation will enrich the development of future programs that integrate this or other intervention models into routine medical practice, with the aim of reducing HIV-related stigma and improving HIV testing, treatment and care in medical settings., Introduction Stigma associated with HIV has been documented as a barrier for accessing quality health-related services. When the stigma manifests in the healthcare setting, people living with HIV receive substandard services or even be denied care altogether. Although the consequences of HIV stigma have been documented extensively, efforts to reduce these negative attitudes have been scarce. Interventions to reduce HIV stigma should be implemented as part of the formal training of future healthcare professionals. The interventions that have been tested with healthcare professionals and published have several limitations that must be surpassed (i.e., lack of comparison groups in research designs and longitudinal follow-up data). Furthermore, Latino healthcare professionals have been absent from these intervention efforts even though the epidemic has affected this population disproportionately. Methods In this article, we describe an intervention developed to reduce HIV stigma among medical students in Puerto Rico. A total of 507 medical students were randomly introduced into our intervention and control conditions. Results The results show statistically significant differences between the intervention and control groups; intervention group participants had lower HIV stigma levels than control participants after the intervention. In addition, differences in HIV stigma levels between the groups were sustained for a 12-month period. Conclusions The results of our study demonstrate the efficacy of the modes of intervention developed by us and serve as a new training tool for future healthcare professionals with regard to stigma reduction., Introduction Within healthcare settings, HIV-related stigma is a recognized barrier to access of HIV prevention and treatment services and yet, few efforts have been made to scale-up stigma reduction programs in service delivery. This is in part due to the lack of a brief, simple, standardized tool for measuring stigma among all levels of health facility staff that works across diverse HIV prevalence, language and healthcare settings. In response, an international consortium led by the Health Policy Project, has developed and field tested a stigma measurement tool for use with health facility staff. Methods Experts participated in a content-development workshop to review an item pool of existing measures, identify gaps and prioritize questions. The resulting questionnaire was field tested in six diverse sites (China, Dominica, Egypt, Kenya, Puerto Rico and St. Christopher & Nevis). Respondents included clinical and non-clinical staff. Questionnaires were self- or interviewer-administered. Analysis of item performance across sites examined both psychometric properties and contextual issues. Results The key outcome of the process was a substantially reduced questionnaire. Eighteen core questions measure three programmatically actionable drivers of stigma within health facilities (worry about HIV transmission, attitudes towards people living with HIV (PLHIV), and health facility environment, including policies), and enacted stigma. The questionnaire also includes one short scale for attitudes towards PLHIV (5-item scale, α = 0.78). Conclusions Stigma-reduction programmes in healthcare facilities are urgently needed to improve the quality of care provided, uphold the human right to healthcare, increase access to health services, and maximize investments in HIV prevention and treatment. This brief, standardized tool will facilitate inclusion of stigma measurement in research studies and in routine facility data collection, allowing for the monitoring of stigma within healthcare facilities and evaluation of stigma-reduction programmes. There is potential for wide use of the tool either as a stand-alone survey or integrated within other studies of health facility staff., Introduction In Kenya, human rights violations have a marked impact on the health of people living with HIV. Integrating legal literacy and legal services into healthcare appears to be an effective strategy to empower vulnerable groups and address underlying determinants of health. Methods We carried out an evaluation to collect evidence about the impact of legal empowerment programmes on health and human rights. The evaluation focused on Open Society Foundation-supported legal integration activities at four sites: the Academic Model of Providing Access to Healthcare (AMPATH) facility, where the Legal Aid Centre of Eldoret (LACE) operates, in Eldoret; Kenyatta National Hospital's Gender-based Violence Recovery Centre, which hosts the COVAW legal integration program; and Christian Health Association of Kenya (CHAK) facilities in Mombasa and Naivasha. In consultation with the organizations implementing the programs, we designed a conceptual logic model grounded in human rights principles, identified relevant indicators and then coded structure, process and outcome indicators for the rights-related principles they reflect. The evaluation included a resource assessment questionnaire, a review of program records and routine data, and semi-structured interviews and focus group discussions with clients and service providers. Data were collected in May–August 2010 and April–June 2011. Results Clients showed a notable increase in practical knowledge and awareness about how to access legal aid and claim their rights, as well as an enhanced ability to communicate with healthcare providers and to improve their access to healthcare and justice. In turn, providers became more adept at identifying human rights violations and other legal difficulties, which enabled them to give clients basic information about their rights, refer them to legal aid and assist them in accessing needed support. Methodological challenges in evaluating such activities point to the need to strengthen rights-oriented evaluation methods. Conclusions Legal empowerment programmes have the potential to promote accountability, reduce stigma and discrimination and contribute to altering unjust structures and systems. Given their apparent value as a health and human rights intervention, particularly for marginalized populations, further rigorous evaluations are called for to support the scale-up of such programmes., Introduction HIV stigma inflicts hardship and suffering on people living with HIV (PLHIV) and interferes with both prevention and treatment efforts. Health professionals are often named by PLHIV as an important source of stigma. This study was designed to examine rates and drivers of stigma and discrimination among doctors, nurses and ward staff in different urban healthcare settings in high HIV prevalence states in India. Methods This cross-sectional study enrolled 305 doctors, 369 nurses and 346 ward staff in both governmental and non-governmental healthcare settings in Mumbai and Bengaluru, India. The approximately one-hour long interviews focused on knowledge related to HIV transmission, personal and professional experiences with PLHIV, instrumental and symbolic stigma, endorsement of coercive policies, and intent to discriminate in professional and personal situations that involve high and low risk of fluid exposure. Results High levels of stigma were reported by all groups. This included a willingness to prohibit female PLHIV from having children (55 to 80%), endorsement of mandatory testing for female sex workers (94 to 97%) and surgery patients (90 to 99%), and stating that people who acquired HIV through sex or drugs “got what they deserved” (50 to 83%). In addition, 89% of doctors, 88% of nurses and 73% of ward staff stated that they would discriminate against PLHIV in professional situations that involved high likelihood of fluid exposure, and 57% doctors, 40% nurses and 71% ward staff stated that they would do so in low-risk situations as well. Significant and modifiable drivers of stigma and discrimination included having less frequent contact with PLHIV, and a greater number of transmission misconceptions, blame, instrumental and symbolic stigma. Participants in all three groups reported high rates of endorsement of coercive measures and intent to discriminate against PLHIV. Stigma and discrimination were associated with multiple modifiable drivers, which are consistent with previous research, and which need to be targeted in future interventions. Conclusions Stigma reduction intervention programmes targeting healthcare providers in urban India need to address fear of transmission, improve universal precaution skills, and involve PLHIV at all stages of the intervention to reduce symbolic stigma and ensure that relevant patient interaction skills are taught., Introduction The African American church is a highly influential institution with the potential to greatly increase the reach of HIV prevention interventions and address HIV-related stigma in US African American communities. However, there are few studies on HIV-related stigma and African American church populations. This study explored HIV-related stigma among church and community members participating in an HIV education and testing intervention pilot study in African American churches, named Taking It to the Pews. Methods Four African American churches located in Kansas City, MO and KS, were randomized to either intervention or comparison groups. Churches assigned to the intervention group received religiously tailored HIV education, testing and compassion messages/activities (e.g., sermons, brochures/church bulletins, testimonials) via the Taking It to the Pews HIV Tool Kit. Comparison churches received non-religiously tailored HIV information. HIV-related stigma was assessed with 543 church members and with community members served through church outreach services (e.g., food/clothing pantries, social services) in the four churches. Participants completed surveys at baseline, 6 months and 12 months to assess their HIV-related stigma beliefs, exposure to intervention components and satisfaction with the study. Results At baseline, HIV-related stigma beliefs were similar across experimental groups and were quite low. Mean HIV-related stigma scores were not significantly different between experimental groups at 6 months (p=0.92) or at 12 months (p=0.70). However, mean HIV-related stigma scores within both groups showed decreasing trends at six months, which approached significance. Analysis of previously studied HIV-related stigma factors (e.g., age, gender, income, HIV knowledge, religiosity) did not yield changes in the null findings. Intervention group participants were highly exposed to several intervention components (sermons, HIV resource tables, posters, brochures/church bulletins). Overall, participants were highly satisfied with the intervention pilot study. Conclusions African American churches may be well positioned to increase the reach of HIV prevention interventions to church and community members and could serve an important role in addressing HIV-related stigma in their church communities. Future research is needed on measuring HIV-related stigma beliefs and on testing intensive, scalable, religiously tailored HIV interventions to impact HIV-related stigma in African American churches., Introduction Men who have sex with men (MSM) often face socially sanctioned disapproval of sexual deviance from the heterosexual “normal.” Such sexual stigma can be internalized producing a painful affective state (i.e., shame). Although shame (e.g., addiction) can predict risk-taking (e.g., alcohol abuse), sexual shame's link to sexual risk-taking is unclear. Socially Optimized Learning in Virtual Environments (SOLVE) was designed to reduce MSM's sexual shame, but whether it does so, and if that reduction predicts HIV risk reduction, is unclear. To test if at baseline, MSM's reported past unprotected anal intercourse (UAI) is related to shame; MSM's exposure to SOLVE compared to a wait-list control (WLC) condition reduces MSM's shame; and shame-reduction mediates the link between WLC condition and UAI risk reduction. Methods HIV-negative, self-identified African American, Latino or White MSM, aged 18–24 years, who had had UAI with a non-primary/casual partner in the past three months were recruited for a national online study. Eligible MSM were computer randomized to either WLC or a web-delivered SOLVE. Retained MSM completed baseline measures (e.g., UAI in the past three months; current level of shame) and, in the SOLVE group, viewed at least one level of the game. At the end of the first session, shame was measured again. MSM completed follow-up UAI measures three months later. All data from 921 retained MSM (WLC condition, 484; SOLVE condition, 437) were analyzed, with missing data multiply imputed. Results At baseline, MSM reporting more risky sexual behaviour reported more shame (r s=0.21; p, Introduction Same-sex practices and orientation are both stigmatized and criminalized in many countries across sub-Saharan Africa. This study aimed to assess the relationship of fear of seeking healthcare and disclosure of same-sex practices among a sample of men who have sex with men (MSM) in Swaziland with demographic, socio-economic and behavioural determinants. Methods Three hundred and twenty-three men who reported having had anal sex with a man in the past year were recruited using respondent-driven sampling and administered a structured survey instrument. Asymptotically unbiased estimates of prevalence of stigma and human rights abuses generated using the RDSII estimator are reported with bootstrapped confidence intervals (CIs). Weighted simple and multiple logistic regressions of fear of seeking healthcare and disclosure of same-sex practices to a healthcare provider with demographic, social and behavioural variables are reported. Results Stigma was common, including 61.7% (95% CI=54.0–69.0%) reporting fear of seeking healthcare, 44.1% (95% CI=36.2–51.3%) any enacted stigma and 73.9% (95% CI=67.7–80.1%) any perceived social stigma (family, friends). Ever disclosing sexual practices with other men to healthcare providers was low (25.6%, 95% CI=19.2–32.1%). In multiple logistic regression, fear of seeking healthcare was significantly associated with: having experienced legal discrimination as a result of sexual orientation or practice (aOR=1.9, 95% CI=1.1–3.4), having felt like you wanted to end your life (aOR=2.0, 95% CI=1.2–3.4), having been raped (aOR=11.0, 95% CI=1.4–84.4), finding it very difficult to insist on condom use when a male partner does not want to use a condom (aOR=2.1, 95% CI=1.0–4.1) and having a non-Swazi nationality at birth (aOR=0.18, 95% CI=0.05–0.68). In multiple logistic regression, disclosure of same-sex practices to a healthcare provider was significantly associated with: having completed secondary education or more (aOR=5.1, 95% CI=2.5–10.3), having used a condom with last casual male sexual partner (aOR=2.4, 95% CI=1.0–5.7) and having felt like you wanted to end your life (aOR=2.1, 95% CI=1.2–3.8). Conclusions MSM in Swaziland report high levels of stigma and discrimination. The observed associations can inform structural interventions to increase healthcare seeking and disclosure of sexual practices to healthcare workers, facilitating enhanced behavioural and biomedical HIV-prevention approaches among MSM in Swaziland., Introduction HIV infection may be affected by multiple complex socioeconomic status (SES) factors, especially individual socioeconomic disadvantage and community-level inequality. At the same time, stigma towards HIV and marginalized groups has exacerbated persistent concentrated epidemics among key populations, such as persons who inject drugs (PWID) in Vietnam. Stigma researchers argue that stigma fundamentally depends on the existence of economic power differences in a community. In rapidly growing economies like Vietnam, the increasing gap in income and education levels, as well as an individual's absolute income and education, may create social conditions that facilitate stigma related to injecting drug use and HIV. Methods A cross-sectional baseline survey assessing different types of stigma and key socioeconomic characteristics was administered to 1674 PWID and 1349 community members living in physical proximity throughout the 32 communes in Thai Nguyen province, Vietnam. We created four stigma scales, including HIV-related and drug-related stigma reported by both PWID and community members. We then used ecologic Spearman's correlation, ordinary least-squares regression and multi-level generalized estimating equations to examine community-level inequality associations, individual-level SES associations and multi-level SES associations with different types of stigma, respectively. Results There was little urban–rural difference in stigma among communes. Higher income inequality was marginally associated with drug-related stigma reported by community members (p=0.087), and higher education inequality was significantly associated with higher HIV-related stigma reported by both PWID and community members (p

The lord’s resistance army (LRA) has inflicted enormous suffering on millions of civilians in several countries of the Great Lakes and Central African regions since it began operating in the 1990s in Northern Uganda. In March 2008, after months of intensive efforts by regional and international stakeholders to bring the conflict to an end, representatives of the Government of Uganda and the LRA finalized the final peace agreement. The military operations have significantly reduced the strength and operational capacity of the LRA over the past three years. Despite the relative success of the joint military operations, the group continues to pose a serious security threat to civilians due to the limited capacity of the national security forces in the affected countries. The LRA’s indiscriminate attacks on civilians constitute serious violations of international humanitarian and human rights laws and have caused a serious humanitarian crisis in the affected countries. The main purpose of this paper is to outline the context and rationale for interventions in LRA affected areas, to briefly describe the pilot with its regional dimension, and to present lessons learned as well as recommendations for strengthening design and implementation of support to socio-economic associations in LRA affected areas.

For the 2014-2020 programming period, the Government of Romania (GoR) is considering a new approach presented by the European Commission (EC) - community-led local development (CLLD). Through CLLD, empowered communities have the opportunity to directly shape and own the process of local development, during all stages of EU - funded interventions, from concept design through implementation. If Romania ultimately pursues CLLD, the critical task facing the government is to design an optimal implementation framework for the new approach - this is precisely the focus and scope of the current integrated intervention tool (IIT). The preparation of this IIT entailed a number of steps, including extensive field work to define relevant subtypes of urban marginalized communities and to review past experiences with urban integration in Romania. This summary covers multiple sections, in line with the key chapters of the main IIT report. It first reviews CLLD's main features and best practice principles at the EU level. It focuses on Romania, making some recommendations for where CLLD can apply and what it will require in terms of coordinating different sources of funding. It also covers the main six stages of operationalizing CLLD in Romania, as follows: launch: preparations through capacity building and information campaigns; call for expressions of interest regarding the potential submission of local integration strategies (LISs); mobilization of the community for the establishment of local action groups (LAG) and development of LIS by each LAG; selection of strategies to be financed; implementation of LISs approved for financing, including selection and implementation of individual projects under these strategies; and phase-out activities and evaluation.

Ownership of development goals and priorities by local stakeholders is widely viewed as a critical factor impacting development effectiveness and achievement of the Millennium Development Goals (MDGs). The 2008 Accra Agenda for Action identifies the concept as one of inclusive ownership, involving parliaments, local authorities and civil society organizations (CSOs), as well as governments. The importance and challenges of building such broad-based ownership across society were a key discussion topic at the Fourth High Level Forum on Aid Effectiveness in November 2011 at Busan. This study aims to generate deeper operational knowledge on what can be done to foster inclusive ownership; its initial findings were presented at Busan. This study involves a retrospective review of a small sample of cases. From these cases it is possible to demonstrate that inclusive ownership, when considered in terms of the operational dimensions examined in the study, can improve as a result of strategic capacity development efforts. It also shows how using an analytic lens such as the CDRF, in particular for the assessment of intermediate results of capacity development, helps to deconstruct the change process in a given case and suggest some operational lessons. Further learning is warranted on how inclusive ownership can be fostered through the design and delivery of capacity development initiatives. Collaboration among and across global communities concerned with ownership and capacity development would enable this work to draw on wider development experiences and generate deeper knowledge on how capacity development can support transformative change.

This evaluation assesses the performance of the Community Officer (CO) project, a trial community policing mechanism initiated by the Royal Solomon Islands Police Force (RSIPF) in late 2009, with assistance from the Participating Police Force (PPF) of the Regional Assistance to Solomon Islands (RAMSI). Current interest in community policing in Solomon Islands is occurring in the larger context of the rebuilding and reform of the RSIPF that has been taking place with the assistance of RAMSI. The Solomon Islands Government (SIG) and RSIPF are committed to introducing a viable form of community policing across the country.

Direct cash transfers for vulnerable elderly and disabled populations have been provided by the Ministry of Social Welfare (Kementerian Sosial, Kemensos) since 2006; a similar cash transfer for at-risk youth was inaugurated in 2009. The Government of Indonesia's (GoI) pro-poor development initiatives, international agreements and domestic laws and regulations, and considerable experience delivering more general social assistance programs led to the creation of cash transfers for these historically neglected and difficult-to-reach groups. These programs Jaminan Sosial Lanjut Usia (JSLU), Jaminan Sosial Paca Berat (JSPACA), and program Kesejahteraan Sosial Anak (PKSA) for the elderly, disabled, and youth respectively transfer cash directly to beneficiaries. They account for increasing shares of the Kemensos overall budget, but subsidies directed to care and rehabilitation facilities as well as direct provision of institutional care still account for a noticeable portion of the Kemensos budget for these groups. Program support operations socialization and outreach; allocation, targeting and prioritization; monitoring and evaluation; and complaints and grievances have very small budgets and depend crucially on cooperation and enthusiasm from local governments and facilitators. A full range of safeguarding activities is spelled out in program guidelines but these have not been institutionalized at the local implementation level. There is variation in the content, methods, frequency, completion rates, and outcomes in all safeguarding activities, and no easy-to-use reporting process that would ensure information from implementation level reaches the central funding and policy agency, Kemensos. The note summarizes quantitative and qualitative evidence in order to build a sound foundation for evaluating the cash transfer programs JSLU, JSPACA, and PKSA provided by Kemensos. The evidence on which the evaluation is based here is composed primarily of first-hand observation of the programs in operation. Where possible information collected from administrative records, including monitoring and evaluation reports, and from Kemensos itself, is summarized. Design features, efficiency and effectiveness of program implementation and operation, and impacts (intended or not) the program produces for beneficiaries are all analyzed in as much detail as possible. Current policy planning within Kemensos assumes expansion of these programs in the coming years, so an evaluation of the programs' features is relevant for Indonesian policymakers and stakeholders.

Analizuojant daugiavaikių šeimų socialinės situacijos ypatumus buvo panaudota aprašomoji matematinė statistika (vidurkiai, procentiniai dažniai) ir neparametrinis Kruskal-Wallis kriterijus. Tyrimo duomenys rodo, kad šių šeimų socialinė situacija kebli ne tik dėl materialinių išteklių ribotumo (darbo, pajamų, būsto), bet ir dėl menkų edukacinių, laisvalaikio galimybių. Straipsnyje analizuojama daugiavaikių šeimų socialinė situacija, jos ypatumai dabartiniame socialiniame ekonominiame kontekste. Remiantis bendruomenės narių požiūriu, nagrinėjama šios grupės žmonių socialinė situacija, atskleidžiamas esamų problemų spektras, pateikiami jų ypatumai. In analysing the experiences of the social situations of large families, descriptive mathematical statistics (means, percent age frequencies) and non-parametric Kruskal-Wallis criterion were used. Research data demonstrate that the social situation of these families is difficult not only because of limited material resources (work, income, accommodation) but also due to poor education and the lack of leisure possibilities. The article deals with the social situations of large families and their specifics in the current social-economical context. The social situation of this group of people is analysed, based on the community members’ attitude, the spectrum of existing problems is disclosed and their specifics are presented.

Bangladesh is one of the world's poorest and most densely populated countries, and subject to annual cyclones and flooding. Despite these challenges, it benefits from strong economic growth, good performance on health and education, and poverty reduction, alongside weak governance and pervasive corruption. The reasons include strong macroeconomic policy, pro-poor spending, credible elections, export growth and remittances, improved capacity for managing natural disasters, and a stronger civil society than comparable countries. After over a decade of intense engagement with the Bank on governance, Bangladesh adopted in 2006 a governance-oriented Country Assistance Strategy (CAS) with four main objectives: to improve implementation capacity; to 'tackle corruption' by fully operationalizing the Anti-Corruption Commission; to lay the foundation for comprehensive legal and judicial reform; and to strengthen 'voice, empowerment and participation.' The choice of a wide range of instruments and areas of intervention was appropriate, given the political instability at the time of 2006 CAS preparation. The Bank signaled it was ready to engage in all areas, and could scale up or pull back depending on emerging political and bureaucratic commitment. The 2006 CAS yielded mixed results, and the subsequent Country Partnership Strategy (CPS) has been more selective on GAC issues. At the project level, governance has been a key priority, in line with the South Asia region's heavy emphasis on GAC-in-Projects. Investments in GAC-in-primary education, a local government project, anti-corruption efforts in the power sector, and projects strengthening the investment climate have yielded positive results. Investments in GAC-in-roads projects have had mixed results in terms of effectiveness. GAC activities were mainly adopted prior to the 2007 GAC strategy. Although Bangladesh was a Country Governance and Anticorruption (CGAC) country, the country team chose not to use CGAC funds because the country had already been intensively using GAC approaches well before the GAC strategy was adopted.

Moldova has suffered over the last two decades from rising poverty, territorial secession, armed conflict, and the spillover effects of a regional financial crisis, with declining population size and life expectancy, and an economy approximately one-half of what it was in 1990. The return of the Moldovan Communist Party (PCRM), which won two major elections after 2001, contributed to increasing centralization of governmental authority along with a reform agenda that emphasized greater state control over the economy, fiscal support to state enterprises and collective farms, land consolidation, economic protectionism, and the tolerance of monopolies in industry and energy. At the same time, the government has increased social expenditures, and taken major steps to improve public financial management. Bank engagement was moderately effective at the country and project levels, and substantially effective at the sector level. There was progress in several aspects of public financial management (PFM). Regulatory streamlining has reduced costs to business, although resistance to civil service reform has left much work to be done. The Bank has also helped achieve progress on Governance and Anticorruption (GAC) issues in primary education, roads, and private sector development. Education progress is highly uneven across regions, for example, overweight trucks continue to tear up roads, and private investment is not enough to make a dent in high unemployment. A graduated approach to country systems and road sector technical audits help address GAC issues at the project level. The overall impact of GAC strategy implementation was moderate. The GAC committees set up at the regional and sectoral Bank department levels are particularly useful mechanisms for disseminating practices from the GAC Council. Staff has been proactive in using Country Governance and Anticorruption (CGAC) resources. However, three applications for window one funding were not approved, reducing the ability of this small program to seize opportunities.

What happens when the state's vision and expanding reach bring it into contact with traditional value systems and governance structures? In what circumstances can the distribution of resources in a fragile society prevent-or exacerbate-conflict within and between communities? How do state expansion and public spending impact upon societal expectations of the state and state legitimacy? This report examines these questions through the lens of access, claiming, and decision making in government-sponsored community development programs. The findings illustrate the hurdles faced by government and development actors operating in pluralistic societies, and provide input on how local governance and decision making might be incorporated to enrich programming. This report aims to provide the government of Timor-Leste, particularly those responsible for decentralization, community development, and local governance planning, with information to inform their determination of an appropriate mix of models for local development. The relative priority the government will ultimately give to these different models, partly a trade-off between speed and depth, will impact on the way in which development and local governance are understood and taken on board by rural communities. This report finds that the achievement of the dual goals of state legitimacy and sustainable, effective local development hinges in large part on the willingness of state officials (and the donors that support them) to engage productively with communities and locally legitimate customary systems of authority.

The objectives of the Costing Adaptation through Local Institutions (CALI) study were (a) to identify the costs of adaptation through local institutions, and (b) to investigate which institutions help households adapt to climate variability, which efforts and costs are needed to realize the adaptation options, and how they facilitate adaptation to climate variability. The study was carried out in Ethiopia, Mali, and Yemen. This report discusses the results for Yemen. In Yemen, village surveys were conducted in six villages and two expert workshops were organized to discuss the main framework of the study and to evaluate the draft results. The study assessed household vulnerability, analyzed the strategies households adopt to reduce the impacts of climate hazards, and evaluated the assistance households receive from different institutions. The analysis was based on household surveys, focus group discussions, and institutional stakeholder interviews. Vulnerability profiles, developed on the basis of field survey results, show that household vulnerability differs substantially between and within villages. The results show that the vulnerability and agro ecological potential in Yemen are related to rainfall, which is related to altitude. This study is a reflection of the insights that (a) poor, rural households are facing most of the climate variability- related hazards; (b) adaptation also has socioeconomic aspects; (c) understanding local adaptation processes is important for informing macro-policies; and (d) for prioritizing future adaptation, it is crucial to analyze historical adaptation strategies. The study involves an assessment of the adaptation options rural household pursue. The study also considers the differential access of various vulnerability groups, as well as the drivers for adopting particular strategies or constraints for not adopting other strategies. For this, households and institutional stakeholders were interviewed in six villages in Yemen, focus group discussions were organized, and experts were consulted.

Mines have the potential to impact communities and such impacts can be both positive and negative. Historically, mines have played an important role in impacted communities but that role usually ended with the closure of the mine. More recently, there is a strong interest by governments, communities and mining companies in the sustained development of mine impacted communities. The World Bank Group (WBG) has a role to play in mining-led development at both the national and community level. The purpose of this report is to provide draft model community development agreement regulations suitable for adoption into legislation or which can be modified for use as guidelines. It is not the intent of this report to suggest that every nation should adopt the model legislation, rather the model legislation is simply another tool that governments can consider as part, or not, of their development strategy. In many nations, the promulgation of regulations is easier than introducing a new or amended mining law, and thus, model regulations were drafted rather than model mining law provisions. This report is the product of a phased project approach. Phase one was designed to prepare a draft set of Community Development Agreement (CDA) regulations in consultation with and benefiting from technical experts. Phase two, of which this report is a part, was intended to obtain feedback from a broad spectrum of stakeholders including governments, private sector, non-governmental organizations, civil society and development experts.

The economic value of the Upper Tuul ecosystem in Mongolia reports on a study carried out under the auspices of the World Bank and the Government of Mongolia. The goal of the study was to improve understanding about the economic value of the Upper Tuul ecosystem for Ulaanbaatar's water supplies and how this might be affected by different land and resource management options in the future. The study also aims to develop and apply ecosystem valuation methods that can be used more widely in the country, to generate information about the contribution of the environment to the Mongolian economy, and to make the case for improved budget allocations for the conservation of the Upper Tuul. Integrating eco-hydrological and economic valuation techniques, the study traces through the biophysical effects and socioeconomic impacts of future land and resource degradation, and ecosystem conservation, in the upper watershed.

Local and Community Driven Development (LCDD) is an approach that gives control of development decisions and resources to community groups and representative local governments. Poor communities receive funds, decide on their use, plan and execute the chosen local projects, and monitor the provision of services that result from it. It improves not just incomes but people's empowerment and governance capacity, the lack of which is a form of poverty as well. LCDD operations have demonstrated effectiveness at delivering results and have received substantial support from the World Bank. Since the start of this decade, our lending for LCDD has averaged around US$2 billion per year. Through its support to local and community-driven programs, the Bank has financed services such as water supply and sanitation, health services, schools that are tailored to community needs and likely to be maintained and sustainable, nutrition programs for mothers and infants, the building of rural access roads, and support for livelihoods and micro enterprise. This eBook brings together the thoughts and experiences of many of the leading proponents and practitioners of LCDD, a phrase that evolved from Community-Driven Development, and most clearly describes the process of empowering communities and their local governments so they drive economic and social development upwards and outwards. This, too many, appears as a new paradigm, though it has actually evolved over the decades, since it emerged from India in the 1950s. While many LCDD projects have taken root, the key challenge now is how such islands of success, that is, the discrete LCDD projects, can be scaled up into sustainable national programs that build skills in decision-making, management, and governance.

This report examines the theoretical and practical synergies between three intervention models that are currently being employed to improve local governance in developing countries: 1) democratic decentralization or devolution; 2) community participatory approaches, and; 3) rights-based approaches. The aim is to identify the possibilities and challenges of an 'integrative approach' to local governance that combines the strengths of each of the three intervention models. It is assumed that an integrative approach can help enhance efforts to improve the downward accountability of local governments, enhance equity in the distribution of services and in various citizens' access to influence, and increase citizen participation in local governance processes. This is supported by a number of empirical cases from Africa, Latin America, Asia and Bosnia-Herzegovina, which are presented in the report. Each case also highlights a number of context-specific challenges to using an integrative approach, such as available financial resources, national policy environments and local conflicts. The report fills this gap by both identifying theoretical synergies and by drawing on the few empirical cases that exist.

The devolution of procurement responsibilities to local levels of government is increasingly occurring across South Asia. This trend is significant because increasingly localized decision-making better enables communities to hold government authorities accountable for the effectiveness of public spending, which can lead to various improved development outcomes, such as improvements in quality of service delivery; greater empowerment and understanding by end-users services supplied through public procurement processes; and improved oversight and accountability of service delivery agencies. The objective of this report is to set out an overview of the strategic approach developed by World Bank Institute (WBI) as a component of the Norwegian governance trust fund (NTF) program `procurement and service delivery: establishing effective collaboration between government and beneficiaries on monitoring procurement outcomes`. WBI received funds under the NTF to facilitate the development of context and audience-specific knowledge products by recognized practitioners and civil society organizations in South Asia as part of a broader effort to create a practical curriculum on social accountability in procurement.

This review focuses on the role of local institutions in adaptation to climate change. It does so under the belief that climate impacts will affect disadvantaged social groups more disproportionately, and that local institutions centrally influence how different social groups gain access to and are able to use assets and resources. It suggests that adaptation to climate change is inevitably local and that institutions influence adaptation and climate vulnerability in three critical ways: a) they structure impacts and vulnerability, b) they mediate between individual and collective responses to climate impacts and thereby shape outcomes of adaptation, and c) they act as the means of delivery of external resources to facilitate adaptation, and thus govern access to such resources. In focusing on local institutions, the review fills two glaring gaps in the existing understanding about institutions and climate change: the lack of middle-range theories of adaptation practices to help frame policy debates, and the absence of comparative empirical studies of adaptation to support policy interventions. To contribute to middle-range theoretical knowledge about climate change the review develops a conceptual framework to understand and classify the adaptation practices of the rural poor, view the institutional structuring of adaptation, and examine the types of external support interventions that local institutions inevitably channel. The review proposes a focus on different forms of mobility, storage, diversification, communal pooling, and market exchange in rural settings as the basic mechanisms through which households address riskiness of livelihoods. Using the familiar typology of public, private, and civil society institutions the review proposes an institutional linkages framework that highlights the role of institutional partnerships in facilitating adaptation and drawing from social network analysis it presents a conceptual toolkit to analyze institutional partnerships and their impacts on resource access of vulnerable social groups. In examining the role of institutions in channeling financial, information and technological, leadership, and policy interventions into rural areas, the review highlights that institutions are critical leverage points through which to determine the direction and magnitude of flows of resources to different social groups.

Debido al avance progresivo de la investigación clínica, nuevas exigencias y requerimientos se hacen necesarios, tales como: apertura de comités de ética, creación o adaptación de legislaciones, mayor entrenamiento de investigadores, entre otros. El objetivo del presente artículo es hacer una crónica de lo sucedido con Reglamento Peruano de Ensayos Clínicos y analizar si la regulación peruana incluye una efectiva participación de la comunidad en los comités de ética. Due to the progressive advance of clinical investigation, new demands and requirements are made necessary, such as: the formation of ethics committees, the creation or adaptation of legislation, and increased training for researchers, among others. The objective of this article is to report on what occurred with the Peruvian Regulation of Clinical Tests and to analyze if the Peruvian regulation includes an effective participation of the community in ethics committees. Devido ao avanço progressivo da pesquisa clínica, novas exigências e requerimentos se fazem necessários, tais como: criação de comitês de ética, criação ou adaptação de legislações, maior treinamento de pesquisadores, entre outros. O objetivo do presente artigo é fazer uma crônica do sucedido com o Regulamento Peruano de Ensaios Clínicos e analisar se a regulação peruana inclui uma efetiva participação da comunidade nos comitês de ética.

High levels of injection prescribing were reported in Mongolia. Understanding the factors influencing the injection prescribing is essential to reduce their inappropriate use. The study evaluated the views, experiences and attitudes of community members associated with the prescribing of injections in Mongolia. A structured questionnaire focusing on respondents' characteristics, experiences and views about injections was developed and administered face-to-face to community members in Ulaanbaatar, Mongolia. Standard descriptive statistics were used to summarize demographic data and responses to the questionnaires. Dependent variables were compared using Kruskal-Wallis Tests for independence. Statistical analyses were performed using SPSS Version 21.0. Six hundred participants were approached and the response rate was 79% (n = 474). Almost half of the respondents were aged between 31 and 50 (n = 228, 48.1%) and 40.9% of respondents were male (n = 194). Most respondents were from Ulaanbaatar city (n = 407, 85.7%). All respondents had received injections in the past and 268 (56.5%) had received injection in the past year. The most common reason for having an injection in the past year was reported as treatment of a disease (n = 163, 60.8%), or for administration of vitamins (n = 70, 26.1%). Injections were prescribed by a doctor (n = 353, 74.9%), dispensed by a pharmacist (n = 283, 59.7%) and administered by a nurse (n = 277, 54.9%). Only 16% of all respondents had the expectation of receiving injections when they visited a doctor (n = 77). An important perception regarding injections was that they hastened the recovery process (n = 269, 56.8%). When asked their opinion about therapeutic injections, 40% of all respondents agreed that injections were a better medicine (n = 190) than oral medications, with older respondents strongly agreeing (p

BACKGROUND: Conventional diagnosis of malaria has relied upon either clinical diagnosis or microscopic examination of peripheral blood smears. These methods, if not carried out exactly, easily result in the over- or under-diagnosis of malaria. The reliability and accuracy of malaria RDTs, even in extremely challenging health care settings, have made them a staple in malaria control programmes. Using the setting of a pilot introduction of malaria RDTs in Greater Garissa, North Eastern Province, Kenya, this study aims to identify and understand perceptions regarding malaria diagnosis, with a particular focus on RDTs, and treatment among community members and health care workers (HCWs). METHODS: The study was conducted in five districts of Garissa County. Focus group discussions (FGD) were performed with community members that were recruited from health facilities (HFs) supported by the MENTOR Initiative. In-depth interviews (IDIs) and FGDs with HCWs were also carried out. Interview transcripts were then coded and analysed for major themes. Two researchers reviewed all codes, first separately and then together, discussed the specific categories, and finally characterized, described, and agreed upon major important themes. RESULTS: Thirty-four FGDs were carried out with a range of two to eight participants (median of four). Of 157 community members, 103 (65.6%) were women. The majority of participants were illiterate and the highest level of education was secondary school. Some 76% of participants were of Somali ethnicity. Whilst community members and HCWs demonstrated knowledge of aspects of malaria transmission, prevention, diagnosis, and treatment, gaps and misconceptions were identified. Poor adherence to negative RDT results, unfamiliarity and distrust of RDTs, and an inconsistent RDT supply were the main challenges to become apparent in FGDs and IDIs. CONCLUSION: Gaps in knowledge or incorrect beliefs exist in Greater Garissa and have the potential to act as barriers to complete and correct malaria case management. Addressing these knowledge gaps requires comprehensive education campaigns and a reliable and constant RDT supply. The results of this study highlight education and supply chain as key factors to be addressed in order to make large scale roll out of RDTs as successful and effective as possible.