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Project Support Group (PSG)
   Last updated: 16.08.02
Implementers
The Project Support Group (PSG) is a regional non-profit organization founded in 1986 to provide training and support to community organizations. PSG works in eight Southern African countries: Zimbabwe, Zambia, South Africa, Malawi, Botswana, Swaziland, Lesotho and Mozambique. It has branches in Zimbabwe, Zambia, South Africa and Malawi and a strong academic collaboration with the Universities of Zimbabwe, Zambia and Pretoria. These partners share responsibility for project management, training and field support. PSG has national and regional governing structures.

PSG defines its mission as building bridges between knowledge and application, i.e. applying state-of-the-art knowledge to implementation and generating state-of- the-art knowledge that will improve practice. It integrates professionalism and voluntarism, adding value to altruism. It also develops approaches that link formal health systems to informal community-based AIDS prevention and mitigation initiatives.

PSG seeks to develop economical, effective methods that build partners' capacity to deliver economical, effective AIDS prevention and mitigation services. PSG's approach to capacity building is based on the conviction that effectiveness derives from partner ownership, a results orientation, continuous support, rather than one-off training, provision of tailored materials and emphasis on how to do rather than what to do.

Background
In 1987, the University of Zimbabwe began an ethnographic study of HIV-vulnerable, low-income women in Bulawayo, Zimbabwe’s second largest city.
The women who participated in the study requested STD/HIV/AIDS education and services, which the Bulawayo City Council agreed to provide, initiating STD/HIV/AIDS project for HIV-vulnerable communities of women and men in 1989. With the University of Zimbabwe’s support, other health authorities and community organizations in Zimbabwe followed the Bulawayo City Council’s lead, developing projects for HIV-vulnerable communities of women and men PSG evolved from the University of Zimbabwe, as a service delivery arm, to complement research activities. As the number of partners seeking its assistance grew, PSG became increasingly formalized and structured. To manage its increased responsibilities, in consultation with partners and stakeholders, PSG became a regional non-profit organization in Zimbabwe, Zambia, South Africa, and Malawi, strengthened its institutional governance structures in each country and developed an overall regional governance framework, with equal representation from South African, Zimbabwean, Zambian and Malawian partners.

PSG recruited additional staff and formed an associate group of 20 experienced field coordinators to provide training and support to regional partners.

In order to support its growing network of partners, PSG developed a structured training program, based on horizontal training approaches. Partners complete a structured training cycle. New partners first attend a skills building workshop, which provided an overall conceptual and skills-based framework. This is followed by a practical internship, in which new coordinators visit experienced coordinators for a practical, field-based orientation. Thereafter, field support visits take place, in which experienced coordinators visit new coordinators to provide on-site practical assistance. Through these reciprocal visits and interactions, coaching and mentoring partnerships evolve, in which new and experienced partners form ongoing "parenting" or coaching relationships.

As its number of partnerships has grown, PSG has sought to make its training approaches as structured as possible. It has two training suites, a management training suite with 10 modules and a coordinators’ training suite with six modules. PSG and partners have also developed five core training courses: a project managers' course; a prevention coordinators' course; a mitigation coordinators' course; a peer educators' course; and a care supporters' course. Thus, the organization has significantly increased its structure and capacity in order to manage its increase.

PSG also needed highly structured standardized approaches. We did these through modules, manuals and structured participatory approaches. The World Bank and the World Health Organization have commended the PSG approach.

Objectives and main activities
PSG’s overall goal statement is: “To assist Southern African government, municipal, non-profit and church partners to develop, manage and sustain optimally efficient, effective, evidence-based HIV/AIDS prevention and mitigation projects”. Its unifying theme is community-based HIV/AIDS prevention and mitigation approaches, utilizing carefully trained and supported community volunteers to deliver services.

The organization does not support institutional approaches to HIV/AIDS prevention and mitigation, which invest in physical plant or institutional facilities.
The regional project believes that the scope of HIV/AIDS prevention and mitigation needs is too great for formal, institutional approaches and that only through the fullest possible involvement of community members can services of sufficient scope be introduced.

The Project Support Group has two project areas: STI/HIV prevention and HIV/AIDS impact mitigation. PSG’s prevention and mitigation activities share a common approach. They both work with community volunteers to deliver large-scale, economical, locally relevant services that increase community response capacity.

PSG develop systems to train and support community volunteers effectively. In prevention, volunteers serve as peer educators, providing training, behavior change communication and condoms to their communities particularly low income, HIV-vulnerable communities. In mitigation, volunteers work as care supporters, training and supporting community members to care effectively for family members with HIV and orphans.

Concerning an illustrative example of prevention, in Mutare, Zimbabwe, community peer educators, organize thousands of community meetings, reaching men in workplaces, bars and nightclubs and women in homes and markets. They use participatory approaches to stimulate community debate and to shape safer sexual norms. They also distribute condoms through their social networks and at hundreds of fixed distribution points throughout Mutare. They give low-income women STI treatment cards, to enable them to secure free, high-quality treatment. Through participatory dialogue to foster safer sexual norms, large-scale condom promotion and distribution, and improved STI care, the project has sharply reduced STIs, and by implication, HIV.

An example of PSG’s work in mitigation can be seen in Masoyi, South Africa, where church members have volunteered to serve as care supporters. They are trained provide home care and to train family members to offer palliative care. Once trained, they visit their neighborhoods to identify families with terminally ill patients. They assist the family to gather firewood, sweep their yards and clean their houses, bring food and simple medicines, assist the family to care for the patient and above all, train the families to provide high quality palliative care. The care supporters have trained, equipped and supported hundreds of families in Masoyi to care for terminally ill patients.

PSG has three major activities: implementation research, project training and field support, and on-grant management. The first stream is implementation research, to identify, refine effective prevention and mitigation strategies. PSG is currently involved in five studies in three countries; Zimbabwe, Zambia and South Africa. Two studies are evaluating alternative approaches to reduce STI/HIV transmission among HIV-vulnerable adults. Two studies are evaluating school STI/HIV prevention approaches. One study is evaluating the coverage, economy and quality of community AIDS care.

The second stream is project training and field support. Through national and regional grants, PSG provides training and field support to approximately 130 projects, including 60 in South Africa, 40 projects in Zimbabwe, 22 in Zambia, 4 in Malawi, 1 in Botswana, 1 in Lesotho, 1 in Swaziland and 1 in Mozambique. An estimated 60% are prevention projects and 40% are mitigation projects, but the percentage of mitigation projects is growing fast. Project training and support involves site visits, to foster interest, and regular skills building workshops, to learn and reinforce concepts. Each year, PSG co-facilitates 10 skills building workshops in South Africa, 6 in Zimbabwe and 4 in Zambia. It also involves internships, with experienced projects, to learn practical skills, mentoring partnerships, in which experienced projects coach emerging ones.

The third stream is on-grant management. PSG currently contributes national and regional on-grant funds to 60 partners, including 40 in South Africa, 10 in Zimbabwe, 4 in Zambia, 3 in Malawi, 1 in Lesotho, 1 Swaziland, and 1 in Mozambique. PSG and its partners have developed comprehensive on-grant management systems, including project application packages, review forms and financial and progress reporting manuals and forms.

Resources and timeframe
PSG try to have at least five sources of funding in each program for diversity and sustainability. These include private sector contributions in cash or in kind, particularly in South Africa, with its large, cash-rich corporations. It also includes community contributions, such a community and household training and meeting facilities and community members’ volunteer time. It includes government contributions, such as personnel, grants, medical supplies and services, condoms and IEC materials. It also includes multilateral/bilateral contributors, who provide funds. Finally, foundations play an increasingly important role.

The organization’s regional programs have a current time frame of five years.

PSG has adequate resources and staggers its expansions in relation to resources available, on a phased, country-by-country approach. It keeps its per project costs low and its administration particularly low, by having a very small management nucleus. PSG passes on in direct grants fully 90 to 92.5% of all resources received. It believes that the proportion of resources disbursed to those retained is the only meaningful measure of administrative costs. All other indicators can be embellished, usually by re-profiling administration as capacity building or implementation support services.

The efficiency and economy of the PSG is evidenced by the fact that despite this sustained growth in activity, full-time program staff now number only five persons, supported by a finance manager. They are assisted by 10 part-time associate members (primarily partner project managers and coordinators of excellence), who assist in the training and mentoring of new coordinators. PSG believed in the principle of co-funding for sustainability and most funders accepted the notion.

The costs of scaling-up during the initial period in new countries are relatively high. They also varied from country to country, in keeping with cost of country operations and economies of scale in respective countries. For example, operations in Zambia and Mozambique are significantly more expensive and project costs in Zimbabwe have grown and infrastructure and productivity have declined.

Donors agreed with the organization’s timeframe because they were familiar with its budgets. PSG also identified donors with a long-term focus and those who were willing to work regionally. PSG then complemented its core donors with additional funds from donors with a shorter-term perspective. However, it was careful not to position funds from shorter-term donors at the core of any program activity. PSG kept administration both monetary and office staff costs low.

The organization developed project management systems to support its work. In particular, project application, management, monitoring and reporting packages were developed, to assist projects to prepare applications, monitor progress and provide progress reports.

Outputs/outcomes
All 20 Zimbabwean projects held 750,000 meetings, reached 24 million people (including repeat attenders) and distributed 100 million condoms. These outputs have been delivered within exacting cost targets. Bulawayo's unit costs (excluding opportunity costs and donated condoms) average US$1.2 per outreach meeting, US$0.02 per person reached and US$0,01 per donated condom distributed. In Lusaka, Zambia, unit costs average US$7.48 per outreach meeting, US$0.38 per person reached and US$0,05 per condom distributed. These unit costs far surpass economies achieved in other health promotion projects.

Through large-scale activities, high coverage has been achieved. Nine projects have conducted community coverage surveys. In Bulawayo, 80% of 705 sex workers have attended peer education meetings and 91% of these had received condoms during meetings. In Mutare, 98% of 204 sex workers and 92% of 508 clients had attended peer education meetings and 93% of sex workers and 84% of clients had received condoms during meetings. In Mutare, a survey showed that peer educators were the primary source of condoms compared to bars, health centers family planning clinic and friends.

High coverage has provided a basis for behavior change. In Bulawayo, condom use in sex work rose from 18% at the outset to 72% within two years. Condom use was closely related to intervention coverage and exposure. Condom use in the last commercial sex act was reported by 27% of those who had attended no meetings, 46% of those who had attended one meeting and 77% of those who had attended two or more meetings.

Behavior change appears to have contributed to reduced STD/RPR rates [RPR is a blood test which provides an indication of active syphilis prevalence]. In Zimbabwe project sites, STD/RPR rates fell by 48% in Bulawayo, 52% in Mutare, 63% in Kariba, 71% in Chitungwiza and 74% in Masvingo. In Zambia project sites, RPR rates fell by 77% in George, 78% in Kanyama and 47% in Matero.

The projects’ impact have been independently evaluated by international universities, including the London School of Tropical Medicine, Johns Hopkins University, University of Michigan, University of North Carolina and Amsterdam University.

The most challenging aspect of scaling up was trying not to dilute quality and building country support mechanisms in each country. It was also a challenge to preserving research quality in many sites more than half of the sites had no research expertise.

 
Internal organizational implications
The core organization has become more involved in management. It has increasingly delegated training and support to downstream partners, particularly associate group members.

Expansion improved morale, because staff and volunteers felt part of a growing, expanding, evolving organization. In addition, the organization has become more skilled and focused, greater breadth, capacity and overall professionalism.

Evaluation
PSG has powerful project impact data from Zimbabwe, Zambia and South Africa, which gives confidence that the approach works.

The organization has made significant progress towards the development of a project monitoring and evaluation framework.

The prevention and mitigation components have both developed monitoring forms, for peer educators/care supporters, coordinators and project managers. These forms are included in the project information packages. The prevention component has developed baseline and follow-up behavioral surveillance surveys for priority groups. These surveys have been translated into Shona, Ndebele, Zulu, Sotho and Nyanja. Community coping and quality of care surveys have been developed, to assess baseline and follow-up coping capacity and quality of support.

PSG has developed a comprehensive framework for evaluating projects. The framework encompasses inputs, outputs, unit costs, coverage, behavioral outcomes and STD/RPR trends.

The framework has a detailed, logical results chain. The results chain is as follows: Inputs lead to outputs. These outputs are achieved within specified costs. Through large-scale outputs, high coverage is achieved. Coverage is imperative for change: a project cannot modify behavior unless it actually reaches communities. Through high coverage, important behavioral outcomes especially increased condom use and improved STD symptoms knowledge, suspicion, recognition and care seeking behavior, occur. These behavioral outcomes lead to reduced STD/RPR rates, which are the best measure of the projects’ “real world impact”.

Evaluation component » Results chain

Inputs Outputs » Inputs lead to outputs

Unit costs » Outputs are achieved within specified costs

Coverage » Through large-scale outputs, high coverage, a prerequisite for change is achieved

Behavioral outcome » Through high coverage, behaviour change outcomes, especially increased condom use and improved STD care utilization occur

STD/RPR declines » Through behaviour change, STD/RPR rates decline, showing “real world results” have been achieved.

PSG's inputs include: a suite of 10 program management modules, available in English and Portuguese, a suite of six peer educator training manuals, over 100 participatory outreach activities, an average of 10 training courses annually and over 500 person days field support annually. These inputs have contributed to significant outputs. Since 1987, the oldest project, in Bulawayo (population 900,000) recruited 80 peer educators, held 250,000 outreach meetings, reached 10 million people (including repeat attenders) and distributed 32 million condoms.

Lessons learned
PSG has managed to build in-country training and support mechanisms. It expanded without run-away administration costs. This was because it was able to develop a structured, standardized approach that could be replicated in each of its focal countries. Each country is unique and there are slight differences and challenges during implementation of the projects.

One of the major drawbacks that the PSG encountered was the failure to access sufficient STI care, home care medicines and food and condoms as needs grow. Current need and /or use of condoms are about 100 million annually. Many partner countries are experiencing drug and condom stock outs. Home care programs are critically short of food.

To have a successful program one needs a structured, standardized approach, with supporting modules and packages. In short, an organization needs to build its systems as rapidly as the growth of the organization. There is need to develop horizontal training approaches, through site visits, internships, mentoring partnerships as projects are being implemented.

If PSG were to go through the process of scaling up again, it would try to develop fully standardized materials more rapidly. It would also establish the horizontal training school earlier.

In all its projects there has been no major resistance. However, early partnerships resent the loss of attention and uniqueness as scaling-up proceeds. Before replication of any projects in any country, PSG consulted with beneficiaries on expansion plans in each region. Their expertise was used to identify sites and approaches that were appropriate in the relevant countries.

The larger impact of scaling up was expanded coverage and scope of services. This led to truly district (Zambia), provincial (SA) and national (Zimbabwe) coverage.

Above all, projects must have a commitment to structured, methodical approaches and to a rigorous results orientation. Process cannot be a substitute for structure or results.

Source: A Question of Scale
This is an extract from A Question of Scale: The challenge of expanding the impact of non-governmental organisations’ HIV/AIDS efforts in developing countries,
by Jocelyn DeJong, published by the Horizons Project of the Population Council with the International HIV/AIDS Alliance in 2001. To view the whole report follow this link.

To download, complete with graphics, in pdf format (which requires Adobe Acrobat software to read it) follow this link (file size 1.43 Mbytes).