October 2014 ANALYSIS OF THE SOCIAL FEASIBILITY OF HIV AND AIDS PROGRAMS IN KENYA Sociocultural Barriers and Facilitators and the Impact of Devolution This publication was prepared by Allan Korongo, Daniel Mwai, Annie Chen, Nicole Judice, and Tom Oneko for the Health Policy Project. HEALTH POLICY PROJECT Suggested citation: Korongo, A., D. Mwai, A. Chen, N. Judice, and T. Oneko. 2014. Analysis of the Social Feasibility of HIV and AIDS Programs in Kenya: Sociocultural Barriers and Facilitators and the Impact of Devolution. Washington, DC: Health Policy Project, Futures Group. ISBN: 978-1-59560-084-4 The Health Policy Project is a five-year cooperative agreement funded by the U.S. Agency for International Development under Agreement No. AID-OAA-A-10-00067, beginning September 30, 2010. The project’s HIV activities are supported by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). The project is implemented by Futures Group, in collaboration with Plan International USA, Avenir Health (formerly Futures Institute), Partners in Population and Development, Africa Regional Office (PPD ARO), Population Reference Bureau (PRB), RTI International, and the White Ribbon Alliance for Safe Motherhood (WRA). Analysis of the Social Feasibility of HIV and AIDS Programs in Kenya Sociocultural Barriers and Facilitators and the Impact of Devolution OCTOBER 2014 This publication was prepared by Allan Korongo,1 Daniel Mwai,2 Annie Chen,2 Nicole Judice,2 and Tom Oneko.2 1 University of Nairobi, 2 Health Policy Project The information provided in this document is not official U.S. Government information and does not necessarily represent the views or positions of the U.S. Agency for International Development. CONTENTS Acknowledgments ............................................................................................................ iv Executive Summary ............................................................................................................ v Overview ................................................................................................................................................. v Findings .................................................................................................................................................. v KNASP III’s achievements .............................................................................................................. vi Challenges going forward .............................................................................................................. vii Conclusion ............................................................................................................................................ vii Abbreviations ..................................................................................................................... ix 1. Introduction ..................................................................................................................... 1 1.1. Methodology .................................................................................................................................... 1 1.1.1 Sample size and sampling procedures ..................................................................................... 1 1.1.2 The assessment process ........................................................................................................... 2 1.1.3 Ethical considerations ............................................................................................................. 2 1.1.4 The study’s limitations ............................................................................................................. 2 1.2. Background ...................................................................................................................................... 3 2. Field Study Findings ........................................................................................................ 5 2.1 Perspectives on HIV and AIDS Policy Development and Implementation ...................................... 5 2.1.1 Perspectives on policy goals, objectives, and targets ............................................................. 5 2.2 Perceived Achievement of KNASP III Goals and Objectives .......................................................... 6 2.2.1 HIV prevention ........................................................................................................................ 6 2.2.2 HIV treatment, care, and support .......................................................................................... 11 2.2.3 Community response to HIV within the local context ........................................................... 11 2.2.4 Stakeholder participation in policy development and implementation ................................. 12 2.2.5 Effectiveness of coordination agencies in the local HIV response ........................................ 13 2.2.6 Unintended consequences of KNASP III ............................................................................... 14 2.3 The Political Context of HIV Policy Implementation..................................................................... 16 2.3.1 Devolution and HIV policy implementation .......................................................................... 16 2.3.2 Status of county-specific HIV strategies ................................................................................ 17 2.3.3 Capacity of county governments to implement the national HIV strategy ............................ 18 2.3.4 Political factors that facilitate or hinder implementation of the national HIV strategy ....... 19 2.3.5 Political barriers ................................................................................................................... 20 2.3.6 Support for KNASP III’s implementation .............................................................................. 21 2.3.7 Opposition to KNASP III’s implementation .......................................................................... 22 2.4 The Sociocultural Environment of HIV Strategy Implementation ................................................. 23 2.4.1 HIV needs in the counties in relation to services .................................................................. 23 2.5 Social and Cultural Factors ............................................................................................................. 25 2.5.1. Sociocultural factors that facilitate HIV interventions ......................................................... 25 2.5.2 Sociocultural factors that create barriers to HIV interventions ............................................ 26 2.5.3 Institutional capacity for policy development and implementation at national and county levels ......................................................................................................................... 29 2.5.4 Resource mobilization and use by policy-implementing institutions ..................................... 30 3. Conclusion .................................................................................................................... 31 References ........................................................................................................................ 33 iii ACKNOWLEDGMENTS We are grateful for the technical support provided by Stephen Muchiri, Thomas Maina, and David Mbote in the Kenya office of the USAID- and PEPFAR-funded Health Policy Project (HPP). We thank the consultant social scientists—Bibi Mbete, Tom Nyangau, Rahma Hassan, and Claudette Jollebo—who served on our fieldwork team. We also thank the research assistants—Diana Wendo, Margaret Mundia, Carol Gakii, Maryanne Mwangi, and Bernard Musyoka—who collected and analyzed the data; and Alice Wanjuu of HPP’s Kenya office for making logistical arrangements to facilitate this assessment. We appreciate the support of the National AIDS Control Council (NACC) for this assignment. Special thanks go to Regina Ombam and Bryan Okiya for organizing interviews through NACC’s regional offices. We also thank all of the NACC regional officers in the study sites for supporting our fieldwork in their counties: Busia, Garissa, Homa Bay, Kiambu, Kwale, Makueni, Mombasa, Nairobi, Nandi, Narok, Tharaka-Nthi, and Turkana. Finally, we thank all of our respondents—national and county policymakers, community leaders, religious leaders, representatives of civil society organizations, and service providers—for their contributions to this report. iv EXECUTIVE SUMMARY Overview The Government of Kenya, through the National AIDS Control Council, is developing the Kenya AIDS Strategic Framework 2014/2015 to 2018/2019 to provide guidance on the country’s priorities in HIV programming and increase the effectiveness of the national response. The framework will build on and succeed the Kenya National AIDS Strategic Plan 2010–2013 (KNASP III). To inform work on the new framework, from April to October 2014, the council collaborated on a study with the Health Policy Project (funded by the U.S. Agency for International Development and the U.S. President’s Emergency Plan for AIDS Relief). The study team examined the social, cultural, and political barriers to and facilitators of policies intended to support the four pillars in HIV programming: HIV prevention, treatment, and care and multisectoral mainstreaming. The team also considered how these barriers and facilitators, in turn, affect clients’ experience of HIV programs under previous HIV strategic plans.