Western Mindanao State University College of Public Administration and Development Studies Zamboanga City

GOOD GOVERNANCE IN HIV/AIDS MITIGATION IN ZAMBOANGA CITY

by

MARK ANTHONY A. SIASON

GOOD GOVERNANCE IN HIV/AIDS MITIGATION IN ZAMBOANGA CITY Mark Anthony Siason1 Abstract The Millennium Declaration of 2000 2specifically outlines HIV/AIDS as among the fiercest challenges that the world would have to face in the 21st Century. Consequently, stopping the spread of the infection has to be made integral to any development endeavor aimed at improving the lives and wellbeing of citizens of the world. The United Nations acknowledges good governance to be the means to achieving the targets set forth in the Declaration, and that, principles of good governance has to be integrated as well to the creation and management of institutions, processes, and programs aimed at beating the targets to achieving the Millennium Development Goals (MDGs). This paper reviews the context that would paint the present and future scenario of HIV/AIDS prevention and mitigation in the Philippines and analyzes the same to identify some elements of intervention needed to operationalize strategy for effectively responding to the challenge in a way that integrates principles of good governance. Particular case in point for analysis is that of the HIV/AIDS program of Zamboanga city, which won the Galing Pook Special Citation Award in 2006 and recipient of various foreign funding programs on HIV/AIDS. The paper thus, looks into the program to identify some elements which have made it successful and which may be of replication to other localities. And, based on discussions on the context and background of HIV/AIDS in the country, it hopes to identify some specific points to be the focus of strategy, and into contributing to program improvement. The paper argues that any such approach to good governance in the area of HIV/AIDS, also has to be contextualized into the cultural-moral realities of the locality, and that for it to be truly participatory, it has to find engagement and integration with the existing reinforcing cultural norms. I. INTRODUCTION The Millennium Development Goals (MDGs) was first developed by the United Nations and has since been adopted by governments throughout the world as a guide for development planning, as well as to monitor and evaluate a countrys progress. Number 6 of those 8 goals is the reversal of spread of dreaded diseases and infections particularly HIV/AIDS. The Philippine government, for its part, recognizes the importance of HIV and AIDS prevention
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Doctoral student of Public Administration at the College of Public Administration and Development Studies, Western Mindanao State University, Zamboanga City/ 2 The MDGs are a set of targets on certain human development variables adopted by the Millennium Declaration of the UN General Assembly in 2000 (UNDESA, 2007).

and care as a development issue, with HIV and AIDS prevalence as one of the key indicators for measuring progress in attaining the MDGs as reflected in its Medium Term Philippine Development Plan (MTPDP) for 2005-2010. In the world context, UNAIDS estimated that at the end of 2004, 38 million adults and children worldwide are living with HIV. Moreover, in 2003, 4.8 million new infections were recorded and an estimated 2.9 million adults and children died. And since 1981, 20 million people have already died of aids. The UN has thus, recognized the far-reaching economic and social impacts of AIDS in the world (UNESCO, UNAIDS; 2001). HIV and AIDS prevalence in the Philippines, on the other hand, has been described as low and slow with a prevalence rate of just less than one percent of the countrys population. However, there is a growing consensus that the countrys HIV and AIDS situation is rather hidden and growing. The Philippine National AIDS Council (PNAC) reports that HIV infection in the country has been significantly picking up pace since 2000. It is also estimated that 20 people get infected every month on an average and the current rate of new case reports is at least twice that observed in the 1990s. The second trimester of 2005 saw 2,354 documented HIV infections, 30 percent of which are AIDS cases (HIV/AIDS Country Profile 2005). Nonetheless, local and international experts have been baffled by the low prevalence and slow growth of HIV/AIDS in the Philippines because the conditions that can make the situation explosive are existing. In its 2002 report, the DOHs National HIV/AIDS Sentinel Surveillance System (NHSSS) attempted to offer some possible explanations: (a) the network of sex workers is not as extensive as those found in countries with high HIV prevalence; (b) the rate of injecting drug use is low, although other types of drug use might be more prevalent; (c) the number of clients seen by sex workers per night is lower than in Thailand and Africa; (d) social hygiene clinics are available to regularly examine and treat infected establishment-based female sex workers; and (e) there have been early and accelerated multi-sectoral responses mounted against the threat of HIV/AIDS. The report says that the low rate of prevalence may also mean that the virus has not yet reached the critical level in the population to promote a rapid spread, and it is believed that the disease is concentrated in vulnerable groups (Mateo et al. 2005). This is not a reason to be complacent though as figures presented may just merely be tip of the iceberg considering that surveillance and detection is mostly made on those vulnerable groups like sex workers and clients or their partners infected with other sexually transmitted infections (STIs). Given these facts and figures, it comes to be apparent that the issue of HIV/AIDS is a challenge which some (Avert, 2002; Walker, 2002; Dirmie, 2002) have argued to have very serious economic and social implications, and thus, interventions necessitate multi-faceted approaches involving targeted responses like behavioral change, increased government capacities and resources, and 2

harnessing existing social institutions. With the seriousness and complexity of the problem at hand, the United Nations advocates good governance principles and practices towards formulation, and implementation of effective strategies and responses for combating spread of HIV/AIDS. This paper thus, examines the context of HIV/AIDS prevention and mitigation, including various issues and considerations to arrive at some areas of focus for interventions. It also provides as an initial discussion the importance of good governance principles of participation, transparency and accountability, rule of law and human rights, and pro-poor policies and capacity improvements in public administration and civil service, in providing for an effective framework for action on a multi-level platform in local, national, and international spheres. This interaction is however viewed and analyzed from a local standpoint, specifically from experiences on the Zamboanga City HIV/AIDS program. From this, specific lessons are drawn that shall inform other existing programs on HIV/AIDS. Specific focus is also given on discussing the importance of participation in integrating a cultural-moral perspective to program formulation and implementation in HIV/AIDS. II. CONCEPTUAL FRAMEWORK Discussions that follow ground HIV/AIDS initiatives from a development perspective. The issue is viewed as both means and ends within a wider development agenda and framework of the Millennium Development Goals (MDGs). Hence, it cannot be extricated from the treatment of good governance as mechanism toward its achievement. A 2000 study conducted by the Health Action Information Network (HAIN) reveals that HIV and AIDS have significant implications on development in the Philippines. It argued that there is a dynamic interaction between HIV and AIDS n one hand, and development, on the other, in a two-way process: lack of development increases susceptibility and vulnerability to HIV and AIDS; and conversely, an unmonitored spread of the infection and disease places significant stress on the countrys resources and cripple its poverty reduction strategies (HIV and AIDS Country Profile, Philippines, 2005) In response to HIV/AIDS as a major development concern, the United Nations advocates for good governance towards the achievement of the millennium development goals. It argued that Governance and MDGs are linked in two ways: indirectly, via the growth of the economy of a country, and directly through certain elements of governance that affect the attainment of MDGs. This stems from the fact that almost every dimension of governance is correlated with income, which is required to finance both public and private investments and recurring outlays to achieve the MDGs. On the other hand, the achievement of MDGs can potentially lead to high growth and better governance through improved human capital 3

accumulation. These underscore the importance of a broad-based strategy to meet the MDGs, directly through good governance practices and indirectly through investments in human capital and infrastructure (UNDESA 2007). The same goes therefore to HIV/AIDS, prevention mitigation, and care. The United Nation adds that the direct linkage between achieving MDGs and economic and political governance is established via the following critical dimensions of good governance: a pro-poor policy framework, public administration and civil services, decentralization and delivery of services. The cross-cutting dimensions include accountability and transparency, rule of law, human rights and the role of civil society. Thus, it becomes apparent that for achievement of MDGs, principal areas needing reform and strengthening are economic institutions, either through effective decentralization and/or sector specific improvements in service delivery. Thus, a local response coordinated within a national strategy and international support is particularly essential. Improved transparency and accountability in particular, combating corruption along with an appropriate framework for propoor policies, and one that considers the wider socio-economic implications of the problem, as well as improved public administration and civil services are necessities. Strengthening of cross-cutting dimensions (for example, human rights and rule of law) is also of importance, as is the supporting role of civil society institutions to provide quite meaningful participation. III. RELATED LITERATURE Kaufmann and Kraay (2003), while exploring the causality of the positive relationship between governance and growth, discover a negative feedback from higher per capita income to governance. This implies that good governance leads to higher growth but not vice versa. This has apparently significant implications. The strategy then of waiting for income to increase significantly to have corresponding increased capacity for governance is not likely to succeed. Similarly, it is unlikely to observe a virtuous circle of better governance improving incomes and this in turn leading to further automatic improvement of positive and sustained interventions to improve governance in countries where these are lacking. Indeed the fact the good governance is not a luxury good that a country automatically acquires when it becomes wealthier means in practical terms that leaders, policy-makers and civil society need to work hard and continuously at improving governance within their countries and most importantly at their locality (UN 2007). In the main, while good governance can contribute to economic growth and, conversely, bad governance can impede it, governance itself can be improved by investing in factors (like education and health) that support economic growth and human capital accumulation. As such, achievement of MDGs can potentially lead 4

to high growth and improved governance through improved human capital accumulation. This, places efforts on combating dreadful diseases like HIV/AIDS which can potentially adversely impact human capital accumulation to be at the fore of development strategies. Good governance, underscores the importance then, of a broad-based strategy to meet the MDGs, directly through good governance practices and indirectly through investments in human capital, improved public sector management, and infrastructure. Consequently, achieving the development goal for HIV/AIDS requires promoting growthin particular pro-poor growthand accountability and transparency. These are the prime objectives of economic governance3. Political governance4, besides improving accountability and transparency, aims at empowerment of the people, particularly the vulnerable, their participation in decisions of the state and enhanced access particularly of the marginalized. Pro-poor policy framework. According to the United Nations, a critical requisite for achieving the MDGs is a conducive and coherent policy framework. This involves first, the contextualization of the goals by each country, and down to identifying sectoral concerns and on to effective local responses. Responses and interventions to HIVAIDS entails a national policy framework that provides for effective decentralization of action and one that effectively coordinate implementation and resource mobilization as well as achieve a critical mass of support from the public in a much cost effective way. The policy framework to be pro-poor means, that it recognizes the social and economic implications of HIV/AIDS and seeks to integrate social and economic interventions to mitigate the spread of the infection and disease. Public Administration and Civil Services. The achievement of MDGs requires properly trained and skilled civil services and properly managed public administration systems to: develop and formulate specific strategies and policies; coordinate debate and dialogue with development partners and civil society; ensure participation from all sections of the population; organize databases and the information and analysis necessary for decision making; deliver services efficiently and cost effectively; forge partnerships; improve coordination; develop a regulatory framework for development partners; design incentives to improve motivation and performance of staff members; and organize training/capacity enhancement programs (UNDESA 2007). Decentralization and Delivery of Services. Ultimately, most services can be delivered locally under the subsidiarity principle and should work best if they are under democratic local control. One way of achieving this is to decentralize authority of service provision to the lowest possible level of government. Some
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Economic governance involves the entire gamut of institutions, processes, and their interrelationship involved in bringing about economic growth through increased GDP. 4 Political governance corresponds to the institutions, processes, and mechanisms for interest articulation, people empowerment, and public participation in governmental decision-making and action.

elements of good governance in the area of decentralization and delivery of services include: increasing awareness and creating political will; mobilizing local communities; localizing national goals, strategies and policies so that they are need-based and responsive; enhancing local participation and inclusion (particularly of the marginalized sections of local communities) in policy making, monitoring and evaluation and impact assessment; empowering people and giving them voice. Simultaneously, there is a need to increase the flow of information and ensure openness of decision-making and transparency to check both corruption and capture by elites (UNDESA 2007). The increased involvement of civil-society and the private sector as viable development partners is particularly encouraged at the local level especially in resource mobilization and public conscientization. Accountability and Transparency. Promoting accountability and transparency is another dimension of sound governance. Raising awareness of rights and obligations at the public level through dissemination of information and analysis is an essential component of the strategy to achieve MDGs. This, of course, requires political and bureaucratic will to open access to and a flow of information. Strong civil society institutions like the media and think tanks, and other development non-governmental organizations (NGOs) are required to facilitate this. Since MDGs principally target the poor and the marginalized, effective improvement will not be achieved until and unless these groups are meaningfully involved in the debate, dialogue, policy making, implementation and monitoring (UNDESA 2007). Situations and Context of HIV/AIDS in the Philippines To be able to contextualize the problem of HIV/AIDS in the Philippines and understand, and even draw some strategies that may be effective in curbing the low and slow yet entirely hiddenly increasing infection of HIV/AIDS, it is necessary to consider some epidemiological data. A 2005 report published by the National Epidemiology Center of the DOH (2005) summarizes the current state of the epidemic. From January 1984 to March 2005, there were 2,250 HIV Ab seropositive (i.e., HIV-positive) cases reported, of which 1,570 (70%) were asymptomatic and 680 (30%) were AIDS cases. Roughly 69 percent (1,504) of those testing positive were between the ages of 20 and 39, while 63 percent (1,416) were male. Sexual intercourse (84%) remained the primary mode of transmission. At the time of the report, a total of 266 individuals had already died due to AIDS-related complications. In the month of March 2005 alone, when the report was issued, there were 19 new HIVpositive cases reported (although no cases of AIDS), and those cases demonstrated similar patterns in terms of gender, age, and transmission modes, and a slight rise from the previous years average monthly number of cases.

This situation is further exacerbated by the complex problem of Family planning in the Philippines as some groups and sectors are aggressive in opposing family planning services especially the church. The 2003 NDHS found that the total fertility rate (TFR)the average number of children a woman has in her lifetimeminutely decreased from 3.7 in 1996-1998 to 3.5 in 2001-2003. Significantly, this is 30times the rate in Thailand. It is increasingly being advocated that access to reproductive health services should not be limited to family planning; in particular, young people also need access to sex education, family planning and other reproductive health services. In fact from existing data (PNAC 2005), there is an alarming vulnerability of young people as the proportion of young people engaging in premarital sex increased from 17.8 percent in 1994 to 23.1 percent in 2002. Actually, the health risk is not so much of PMS per se than of unprotected sexual activity that could lead to early pregnancies and marriages, or sexually transmitted infections including HIV.

Report below by the DOH in 2005 singles out heterosexual contact as most prevalent mode of transmission of HIV, followed by homosexual and bisexual contact respectively. These give an essential basis for a targeted response on particular groups and sectors especially on the entertainment sector. However, it increasingly becomes apparent as well, that solutions to the problem can be mitigated by cultural and social approaches taking stock of the much more conservative attitudes of Filipinos.

Sexually transmitted infections (STIs) As earlier cited, the predominant mode of transmission of both HIV and other STIs is sexual intercourse. Measures for preventing sexual transmission of HIV 7

and STIs are the same, as are the target audiences for interventions. In addition, strong evidence supports several biological mechanisms through which STIs facilitate HIV transmission by increasing both HIV infectiousness and HIV susceptibility. Thus, detection and treatment of individuals with STIs is an important part of an HIV control strategy (EFS 2006). If the incidence/prevalence of STIs is high in a country, then there is the possibility of high rates of sexual transmission of HIV. Monitoring trends in STIs provides valuable insight into the likelihood of the importance of sexual transmission of HIV within a country, and is part of effective surveillance. These trends also assist in assessing the impact of behavioral interventions, such as delaying sexual debut, reducing the number of sex partners and promoting condom use. These, interventions, like use of condoms and artificial contraceptives, however, have to be implemented with caution as they may be counter-cultural to existing patterns of behavior and custom in a given locality, thus, building distrust to programs even before making considerable progress. Clinical services offering STI care are an important access point for people at high risk for both STIs and HIV. Identifying people with STIs allows for not only the benefit of treating the STI, but for prevention education, HIV testing, identifying HIV-infected persons in need of care, and partner notification for STIs or HIV infection. Consequently, monitoring different components of STI prevention and control can also provide information on HIV prevention and control activities within a country including possible economic intervention, like education, counseling, and skills training and entrepreneurship to provide a way out of prostitution for those engaging in the industry. Socio-Economic Impact of HIV Aids Earlier discussion put forward some initial implications of HIV/AIDS to the social and economic development of a country. Specific studies reveal actual figures on the effect of HIV/AIDS infection and disease to the population. Especially hard hit are countries in Sub-Saharan Africa where infection would reach to as much as 20 percent of population (UNDP 1999). According to a study by Avert (2002), effect on GDP would be modest in countries with a less than five percent infection rate among adults; or could result in GDP losses of up to two percent per year, where prevalence is 20 percent or more. Another study estimates a decline of between 48 and 78 percent income when a household member dies from HIV/AIDS, excluding the costs of funerals (Walker 2002, in Drimie 2002). This burden in turn impacts the macro-economy and national development of individual countries (Drimie 2002). Others show that the AIDS crisis impacts not only child mortality but also the working-age population (Drimie 2002; cf. Haacker 2002).

The International Labor Organisation (ILO) found excessive numbers of juveniles from 10 to 19 filling jobs in the Tanzanian labor force as productive-age adults die; and project that the number of workers not earning at least a dollar a day is falling to 1998 levels (Menda 2003). Hence, the Philippine, figure of less than 1 percent infection rate from population may not be that alarming as yet, but if rates continue to increase, it is apparent that similar pressures on income and subsequent government expenditures on treatment and care, may far outweigh any preventive efforts cost that the government and the public may currently need to spare. Participatory approach The middle years of the HIV/AIDS epidemic were characterized by the increasing development of HIV prevention programs aimed at the level of community (Aggleton, 1996). These programs shared a common acknowledgement that decisions about behavior, including sexual decisionmaking, are made in the context of shared social experiences. In particular, peer education programs have attempted to address the social processes, which influence the gender and sexual norms of young people. Several studies have demonstrated that peers are important in shaping gender identity and roles and attitudes towards sexual behavior among young people (Svenson, Hanson & Johnsson, 1995). This facts point to the essentials then of participatory approaches at the community level to curb out the spread of HIV/AIDS as the same has seen to be a moral-cultural issue stemming primarily on sexually promiscuous behaviors of a sector of the population inasmuch as it has also economic dimension. Programs which attempt to work at the level of community, go some way towards a recognition of the social construction of gender roles and sexual attitudes and behavior approach with the wider social and cultural context for much more meaningful participation and a non-disruptive approachthereby utilizing the conservative norm of society to put a check to deviant sexual practices. Participation within the present context entail a wire non-governmental participation as a catalytic force to achieving critical mass of support for much more sustainable results and attitudinal change in society. This apparently becomes the case as an active civil society contributes to strengthening and deepening good governance in several ways: by undertaking policy analysis and advocacy; monitoring state performance and the action and behavior of public officials; building social capital through community organization and enabling citizens to identify and articulate their values, beliefs and norms; mobilizing particular constituencies, particularly the vulnerable and marginalized sections of society to participate more fully in public affairs; and finally, 9

undertaking development works to improve the well-being of their own and other communities. On the other hand, it is also acknowledged that civil societys potential impact is constrained by challenges such as a lack of financial sustainability, the absence of a conducive legal and regulatory framework, inadequate internal accountability and government suspicions about their roles (UN 2006). Cultural and Moral Dimensions Anent to the participatory approach to HIV/AIDS is an underlying cultural and moral dimensions. Following a proposal made by UNESCOs Culture Sector to the UNAIDS Program, on taking a cultural approach to HIV/AIDS prevention and treatment for sustainable development, a joint project A Cultural Approach to HIV/AIDS: Prevention and Care was launched in May 1998. The goals were to stimulate thinking and discussion and reconsider existing tools so as to capture and mainstream into the strategy some idiosyncratic characteristic of a particular society ad utilizing existing social and cultural instruments to mitigate efforts on prevention and care arising from the HIV/AIDS issues. According to UNESCO, taking a cultural approach means considering a populations characteristics including lifestyles and beliefs- as essential references to the creation of action plans. This is indispensable if behavior patterns are to be changed on a long-term basis, a vital condition for slowing down or for stopping the expansion of the epidemic. Generally speaking, a cultural approach to development must meet two conditions, derived from the UNESCO Mexico definition of culture, and which can be summarized as follows: Grounding development on mentalities, traditions, beliefs and value systems, for practical and ethical reasons, in so far as they may enhance needed changes, or hamper them, if they are not correctly identified, and will necessarily interfere in the action taken; Mobilizing the cultural resources of the given populations, in order to benefit from their support, when bringing about, through the joint identification of needs and action, the necessary changes in thinking and behavior for endogenous sustainable human development. For a rather, traditionally conservative Filipino society which is predominantly Catholic, the advocacy for the use of protective devises like condoms would be a significant challenge, but potential strategy would be tackling the root cause of infection, such as promiscuous sexual behavior; and utilizing the cultural-moral approach, solidarity and participation from the church and other civil groups may be made on a larger-scale with such campaigns as moral regeneration. If good governance principle of participation would have to be meaningful and 10

successful, it has to put into perspective such cultural and religious norm of society even in such issues as HIV/AIDS. Key Lessons in Good Governance from the United Nations Finally, key lessons emanating from UNs Good Governance for the MDGs (2007), show that it is crucial for policies to be: (1) nationally owned and primarily home-grown; (2) sustained financially (with adequate resources, timely released), politically (with continued political support, irrespective of change in government) and administratively (with bureaucratic commitment supported by champions of reform); (3) tailored to local socio-economic and political contexts and demonstrating pragmatic improvisation and perhaps incrementalism to make services work, particularly in weak institutional environments like those in conflict or post-conflict countries, LDCs or crisis situations; (4) based on a bottom-up approach involving all stakeholders at all levels of development and implementation, preceded by social mobilization and change in mindset; (5) properly managed, coordinated and monitored with realistic and well-defined targets and goals; (6) evolutionary in nature, learning from their own and others experiences; and (7) to the extent required supported, financially and technically, by donors and the international community with efficient, harmonized and predictable aid. IV. CASE IN POINT: ZAMBOANGA CITY HIV/AIDS PROGRAM By taking on the challenge posed by the Millennium Development Goals (MDGs), Zamboanga City has risen as a prime sentinel against the dreaded AIDS/HIV (acquired immune deficiency syndrome/human immunodeficiency virus) pandemic as well as a staunch implementer of programs that address poverty, health, education problems, womens reproductive health issues, education and gender inequality (Galing Pook 2007). Zamboanga City was originally chosen as one of the sentinel sites by the Department of Healths (DOH) National HIV Sentinel Surveillance System in the battle against the spread of AIDS/HIV because of its strategic location in the south and its proximity and interaction with various Southeast Asian Countries. As the countrys backdoor, Zamboanga City has been a main trading center, shipping and entry point to the Philippines neighboring countries. Its ports are busy and its booming entertainment industry attracts thousands of visitors from countries including those with high incidence of HIV/AIDS like Brunei and Malaysia. Thus, while the city attracts potential investors and tourists who could enhance the citys income, it also becomes doubly vulnerable to the outbreak of AIDS/HIV and other sexually transmitted diseases and infections (STDs/STIs) (Ibid.).

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To date, the City health office reported 14 cases of HIV infections, 7 coming from the city, and 7 are merely transcients. Of these, there were 5 reported deaths. Thirteen of these cases are reportedly, overseas Filipino workers, confirming strong cross-boundary infection. With this looming threat in mind, the Citys local government officials came up with potent solution by implementing a multi-dimensional approach involving stronger civil-society participation, legislative action, resource mobilization, economic development initiatives, and consensus-building and collaboration among diverse local champions for the cause against HIV/AIDS. The Program, primarily involved monitoring, control, and prevention efforts. These efforts enabled the city to be among those to receive the Galing Pook Special Citation Award in 2007 for outstanding local government program. There are various elements that made the program successful and which may be of replication to other localities: public-civil society partnership, communityoriented/based policy formulation and implementation, committed local champions, effective local IEC campaigns, including innovative infrastructure support. Public-Civil Society Partnership The project initially started as a partnership between the city government and the Human Development and Empowerment Services (HDES), a nongovernment organization working towards an AIDS-free Zamboanga City. However as IEC campaigns escalated, other groups within the city have adopted the project as well. Hence, a network of partnerships has been forged between local officials and civil society organizations, national government agencies, business and the private sector, which provided the force and momentum for the success of the campaign within and even outside the city. At present, Zamboanga City is one of the nine local government units (LGUs) in the country that have developed a reliable system to monitor and counter the spread of HIV/AIDS and other sexually transmitted diseases and infections (STDs/STIs). However, this did not come easily, and based on earlier discussions by the United Nations, there has to be commitment from local leaders towards arriving at a coherent policy framework for implementation of program and its sustainability safety nets and integrating to it good governance principles. The government civil society partnership between the city government and HSDES provided the seed initiative for the wide-scale program implementation and IEC (Information, education, and communication) campaigns needed to raise consciousness and mobilize other sectors. It also meant creating the platform for gaining national and international support through convincing program results and local commitment to include the conceptualization of the viable framework and working for its institutionalization through local ordinance and budgets.

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Figure below presents this platform including various components for implementation of the program. It involved the creation of the Reproductive Health and Wellness Center co-managed by the City Health Office and partner NGO. The core components involved case finding and surveillance, education, counseling, referral, monitoring and treatment of cases of not just HIV/AIDS but other STIsit has earlier shown the complementary nature on HIV/AIDS and STIs, such that prevention and treatment of STIs would have significant impact on HIV/AIDS prevention efforts. Organization and Management

Moreover, significant action on the part of the city government has been the institutionalization of the policy against HIV/AIDS with the enactment of the Zamboanga City AIDS Prevention and Control Ordinance No. 234. Among the highlights of the ordinance are the creation of the Zamboanga City Multi-sectoral AIDS Council, the compulsory HIV prevention education among local public schools, the 100% condom use program policy, regular medical examination of entertainment workers in establishments in the city, access to quality reproductive health care in local city-supported hospitals and clinics. The succeeding figure shows how participation is institutionalized with the creation of the AIDS Council. Membership is diverse involving various NGOs and other civil society organization, educational institutions, the media, the youth sector, the religious, as well as the private sector and to include a separate sectoral representation among gays.

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Community-Oriented/ Community Based The Zamboanga City Multi-Sectoral AIDS Council (ZCMSAC) established primarily for the implementation of the program was responsible for ensuring that the comprehensive plan would be carried out. The plan included upgrading of medical facilities in all barangays; increasing public awareness through massive education and information campaigns; upgrading the knowledge, attitude and skills of its health personnel and community health outreach workers and peer educators at HDES; setting up a systematic and organized behavioral serologic surveillance system; conducting disease detection efforts through case finding, contact tracing and reinstating treatment and counseling; maintaining its own data bank on STIs/STDs and HIV/AIDS; strengthening linkages with other government agencies, NGOs and other sectors; and ensuring that adequate funding would be available for the program (Galing Pook 2007). These local responses to the HIV/AIDS pandemic in Zamboanga City have, according to Galing Pook Foundation, impacted on the health and well-being of the vulnerable sectors and has transformed LGUs health providers and volunteers into effective health service providers. More importantly, this program has been implemented side-by-side with other programs that are aimed at accomplishing the other MDGs. Innovative optimized use of infrastructure support Due to limited budgetary resource, the City had to innovate on its infrastructure support to make means meet ends with its other health programs using an integrated multi-pronged strategy to facility utilization. Fifteen main health centers and 84 sub-centers were made functional and provide variety of services from AIDS/HIV and STD/STI prevention to family planning counseling, to assisting the other health needs of the general populace. In among these 14

health centers are also the venue for immunization of children against tuberculosis (TB), diptheria, pertusis, and tetanus (DPT), measles and hepatitis B. Aside from these, the skills of health officers and workers down to the barangay levels are undergoing regular upgrading through orientations and trainings in areas such as maternal care, family planning, and childbirth. Trainings and orientations on new medical procedures and development are also given. For example, two medical officers and three nurses were trained and oriented on how to conduct newborn screening, a relatively new procedure previously available only in some private hospitals and in the Medical Center. Moreover, the main health centers have been converted into lying-in clinics that provide regular prenatal services to mothers, vitamin A supplementation (both for pregnant mothers and children) and even post-partum care. These centers also cater to mens reproductive health problems and provide adolescent fertility management orientation to adolescent and youth leaders in the community (Galing Pook 2007). The health centers also serve as centers for the anti-AIDS/HIV and STDs/STIs program. This is where intensive STD/STI prevention services are made available from counseling to information dissemination about HIV/AIDS and STDs/STIs. This is also where the behavioral and serologic surveillance are done with the help of barangay officials who reports to the City Mayor the presence of transients or new comers to the city. These barangay officials were also trained on migration and urbanization to help them effectively monitor migration trends and influence population movements (Ibid.). Livelihood Assistance Cognizant that HIV/AIDS spread is strongly linked to prevalence prostitution and in turn linked to poverty and economic deprivation of some which pressure them to enter into prostitution, the Citys program on HIV/AIDS has a livelihood and social component which seeks to increase capabilities of families and individuals to live decent lives. It implemented special livelihood and housing and shelter projects aimed at vulnerable and special groups like indigenous peoples, displaced workers, students and youth. It also established livelihood infrastructure support by building post-harvest facilities, multi-purpose drying pavements, rice mills and farm equipment like threshers, corn shellers, backpack sprayers and even farm inputs like seeds and organic and inorganic fertilizers. Credit has also been provided to provide capital. All these may seem distant from actual focus of prevention, but these efforts tackle the very root cause of prostitution, which is economic and social deprivation from essential government support to livelihood and means of living much decent lives. 15

Financial Resources Essential to any successful program is the support made available in terms of financial resources. The HIV/AIDS program of Zamboanga city has been effective to the extent of recognition significantly because of its capability to attract funding and support not just from the city coffers but even from national and international agencies. Below is the break down of sources of financing from the years 1999 through 2007. Quite noticeable is the withdrawal of funding from DOH, which has traditionally been channel of international funding. From the years 2004 through 2007, funding for the program came primarily from the city government and HDES. The funding for the HDES however comes from several foreign components: the USAID-LEAD for Health, UNICEF, and Global Fund for Tropical Diseases Foundation.

V. LESSONS FROM HIV/PROGRAM IMPLEMENTATION Significant lessons can be derived from HIV/AIDS program implementation of Zamboanga City. For one, it validates the necessity of good governance principles in HIV/AIDS program implementation and perhaps in the achievement of the other MDGs. Participation has seen to be sine qua non to effectively reaching out to the consciousness of the public and gathering support for the program. Within the participatory framework, utilizing the cultural approach proves effective by hinging the program around IEC campaigns that appeal to the moral and cultural norms of the conservative Zamboangeno societycomposed predominantly of devout Muslims and Catholicsand mainstreaming such campaigns to local events and traditions such us prayer rallies and candle

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lighting on the streets during AIDS day celebration including the production of IEC materials in local dialects. Viable platform for public-civil society partnership on a wide-scale multipronged program has been shown to be effective at the local level both in initiating the seed effort and groundwork in mobilizing support and most especially in sustaining the program in a way that is owned and borne not just be the local government but by a variety of key players. Within this partnership is seen a stronger capacity buildup in the management and technical levels resulting to improved public administration and civil service in the local public heath sector. In this setting, there is inherently an increase in transparency and accountability due to presence of many actors and even international supporters who get to evaluate the programs as requisites for refunding. Pro-poor policy framework integrated into an institutionalized local development agenda for HIV/AIDS with an enlarged socio-economic component and with national and international funding has also shown to promising results. While it has been observed that socio-economic impact of HIV and AIDS may seem minimal because of the low prevalence rate of HIV in the country, there is a looming threat however that poses serious impediments to poverty reduction and economic development. As it is, even without the heavy burden of HIV, government funds for social services and health care are already very limited Hence the need for multi-level collaboration among, local governments, national government agencies and international donors and aid agencies. As seen in the case of Zamboanga City, the impact of HIV and AIDS in the Philippines is more pressing at the micro-level than at the national level. Poor households are affected most due to inadequate access to basic social services, medical care and expensive HIV and AIDS medication. Results from the 2003 National Demographic and Health Survey (NDHS) suggest that poorer and less educated people are at a greater risk for reproductive health problems. They have less access to health care and reproductive services, have less knowledge on HIV and AIDS prevention methods, and are more likely to engage in unprotected sexual activity at an early age. Hence, efforts towards combating HIV/AIDS has to have a strong component that directly addresses socioeconomic concerns like education, livelihood and skills development, and provision of other social safety nets. On the sustainability and strategic vision components of good governance, the HIV/AIDS programs of Zamboanga City has shown that best practices and fruitful experiences across the years can, and have to be institutionalized into a coherent policy as in the adoption of local ordinance and providing the needed support through budgets and actual programs to be implemented by the city government. This then provides the framework that guides present and future action as well as lay down necessary authority structures that shall enforce implementation of the law. And, by allowing for greater public participation in the 17

policy formulation process, wider acceptance and adherence to the rule of law is achievedhence, greater and more faithful participation and adherence to regulations, for instance, by entertainment workers and establishments in the testing and surveillance as well as treatment for STIs and HIV/AIDS. And finally, although the City has exhibited considerable success in its participatory endeavor of enjoining civil society and other sectors support into a collaborative agenda and action towards HIV/AIDS prevention, care and control, it has not fully integrated the cultural and moral approach into utilizing the inherent influence of the church and the muslin sector toward mainstreaming moral regeneration and commitment towards human development and human rights, as ultimate long-term and sustainable solution. This coincides with UNESCOs cultural approach strategies of fully integrating and utilizing cultural components of societies that would help mitigate development efforts and in the case of HIV/AIDS, its control and prevention. And as in current strategies, this one would not be that easy. It requires local champions commitment ad competence to build-consensus on a set of agenda and programs for implementation. VI. CONCLUSION The issue on HIV/AIDS is a complex problem that require a multidimensional approach. However, as in other issues in the millennium development goals (MDGs), there is found conceptual and practical relevance to instituting good governance principles and practices built around improved capacities for public administration and civil service, decentralization in delivery of services, transparency and accountability, expanded role of civil-society, and the centrality of participation grounded on the rule of law and human rights. Meaningful participation does happen when the people themselves initiate and take part in the crafting of laws most especially at the local level, which also ensures their adherence to these laws and rules, and that their rights in the participation effort and in the eventual implementation of these policies are recognized even in their wider social and economic implications. With a viable institutional platform for wider and more meaningful participation and public-civil society partnership, increased capacity for innovation in program management and implementation is achieved including capacities for resource mobilization due to shared ownership and responsibility of the program. Along this is a marked improvement in transparency and accountability especially with the presence of civil society and external actors in reviewing or evaluating progress as requisites for sustained support. Ultimately, the issue on HIV/AIDS has a moral-cultural dimension that development planners and practitioners have to capitalize efforts and strategies 18

on in dealing with a given society. Most societies and religion perceives promiscuous and deviant sexual behaviors, linked to rapid spread of HIV/AIDS, as taboos and socially unacceptable and therefore effectively engaging the civil society, church and religious groups towards education and moral regeneration strategies can promise a longer-term and much sustainable strategies and action that would be built strongly into the culture of societies and makes them ever more conscious and concerned on dimensions, such as human dignity, human rights and security, and the greater human development. REFERENCES Ann May, 2003, Social and Economic Impacts of HIV/AIDS in Sub-Saharan Africa, with Specific Reference to Aging, INSTITUTE OF BEHAVIORAL SCIENCE POPULATION AGING CENTER, University of Colorado at Boulder Boulder CO 80309-0483 Avert. 2002. HIV & AIDS in Africa. On-line publication: http://www.avert.org/aafrica.htm; accessed 4/26/02. Drimie, Scott. 2002. The Impact of HIV/AIDS on Rural Households and Land Issues in Southern and Eastern Africa. A Background paper for the Food and Agricultural Organisation, Sub- Regional Office for Southern and Eastern Africa, August. Haacker, M. 2002. The economic consequences of HIV/AIDS in Southern Africa. IMF Working paper. Menda, Aloyce. 2003. HIV/Aids Playing Havoc with Tanzanian Labour Force. Business Times. Dar es Salaam, May 2. Mateo, Ricardo, Jesus N. Sarol, and Roderick Poblete. 2005. HIV/AIDS in the Philippines. Unpublished report presented at a consultative workshop conducted by the Remedios AIDS Foundation in Manila (2728 April). HIV Prevention and Care: A Cultural Approach, UNESCO; UNAIDS, 2001 HAIN (Health Action Information Network); Philippine National AIDS Council; UNAIDS Philippines, HIV/AIDS Country Profile, Philippines, 2002. Caccam, Eugenio M. Jr., Current State and Future Projections of the Spread of HIV/AIDS, 2006.

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