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MPANGO WA ELIMU YA UKIMWI SHULENI

MKOA WA TANGA

MID-TERM EVALUATION REPORT

July 1999

Report submitted by:

Rehema L. Mwateba

Babette Pfander

Margaret Kilembe

This report is the result of four weeks' fieldwork in all districts of Tanga Region followed by a feedback workshop. The compilation of data was done in Tanga itself, the final version of the report has been produced in Dar es Salaam. The team of consultants is grateful for the assistance and support received during the survey and the compilation of data.

In the first place the team of consultants would like to thank all MEUSTA staff for their kind cooperation during the entire time of the external evaluation. Persons we are most grateful to include Mr. R.S. Kakunya (Project Coordinator), Mr. J. Mchome (Education Officer), Ms. L. Mwingira (Public Health Nurse), Ms. F. Lwanda (Secretary), Ms. C. Mzoo (Community Mobilization Officer), Ms. E. Swai (Accountant), Mr. R. Daudi (Driver) and Mr. H. Rashidi (Officer Helper).

The team of consultants was accompanied by two Standard VI or VII students (one male, one female) during the visits to the schools. In each district, including Same two young people volunteered to assist their peers while filling the questionnaire. The team of consultants is very grateful for the facilitation work these 14 young people accomplished.

The same amount of gratitude goes out to all members of the Regional Resource Team, the Regional Steering Committee, the District Resource Teams, the District Steering Teams and the Ward Resource Teams.

Furthermore, all government staff at regional, district and ward level, who provided the team of consultants with valuable data and insights. Special thanks go to Mr. Msanga (RPLO), Mr. Mwengee (REO) and Ms. Kalalu (RCDO) at regional level, as well as Mr. Y. Tessua (DED), Mr. H. Mhina (DEO) and Dr. J.S. Kimey (DMO) in Korogwe, to Mr. O.K. Mwasho (DED), Mr. H. Njama (DEO) and Dr. J. Mahona (Act. DMO) in Muheza, to Mr. Msoffe (DED), Mrs. H. Mayombola (DEO) and Dr. Mbwana (DMO) in Pangani, to Mrs. J.T. Malange (Act. DED), Mr. Kalinga (DEO) and Dr. Hussna (DACC) in Tanga, to Mr. R.K. Komoleta (DED), Mr. A. Waziri (DEO) and Dr. S. Mshana (DMO) in Handeni, as well as to Mr. W.H. Sabuni (DPLO), Mr. J. Mushi (AEO), Mr. A. Ngoda (SLO) and Dr. S. Mgema (DMO) in Lushoto.

At the level of schools visited the team of consultants is very grateful for the readiness of teachers, EDU teachers, head teachers, school committee members, students, their parents and the members of the community, who came to spend some of their valuable time for the evaluation.

A special thank you shall be sent out to the project coordinator of CCBRT Aids Programme in Dar es Salaam for sharing information about the latest developments with regard to the national HIV/AIDS/STDs policy.

AEO Adult Education Officer

CBG Community Based Group

DACC District Aids Control Officer

DED District Executive Director

DEO District Education Officer

DMO District Medical Officer

DPHC District Primary Health Care

DRT District Resource Team

DSI District School Inpector

DST District Steering Team

EDU Education against AIDS (Elimu dhidi ya Ukimwi)

FGD Focus Group Discussion

HQ Headquarters

IEC Information Education Communication

KAP Knowledge Attitude Practise

LEPSA Learner centered Problem Posing, Self Discovery and Action Oriented

MEUSTA Mpango wa Elimu ya Ukimwi Shuleni Mkoa wa Tanga

MISC More Intelligent and Sensitive Child

MP Member of Parliament

NACP National Aids Control Programme

NGO Non Government Organization

NNA Norwegian Nurses' Association

PHC Primary Health Care

RCDO Regional Community Development Officer

REO Regional Education Officer

RPLO Regional Planning Officer

SDP Service Delivery Point

SHP School Health Project

MCH Mother and Child Health

MOEC Ministry of Education and Culture

MOH Ministry of Health

RRT Regional Resource Team

RSC Regional Steering Committee

STDs Sexually Transmitted Diseases

WRT Ward Resource Team

Introduction: MEUSTA can be translated into English as: "Programme for school-based provision of HIV/AIDS education in Tanga Region". MEUSTA’s long term goals are: Firstly, to contribute to permanent control and limitation of HIV/AIDS infection among youth and adolescents in the region. Secondly, to strengthen the Existing School Health Programme, as well as the Cooperation between Education and Health Sectors. Thirdly, MEUSTA had foreseen networking activities with NGOs and influential people, as well as exchange visits of MEUSTA staff.

HIV/AIDS Situation in Tanzania: The spread of HIV/AIDS epidemic in Africa had appeared in the early 1980. By December 1997 the number cumulative reported AIDS cases reached 103'185 (NACP, 1997). As a response to the threat HIV/AIDS is posing to the nation, a National Aids Control Programme (NACP) was established under the MOH. The major task of the MOEC lies in the formulation of guidelines for HIV/AIDS/STDs preventive education in schools, in the design of appropriate curriculums and in the production/ dissemination of teaching materials.

Rationale for mid-term evaluation: MEUSTA has given much support to HIV/AIDS education in primary schools and the community of Tanga Region in general for the past three years. In order to see whether the approach chosen is still appropriate, MEUSTA decided to conduct an external mid-term evaluation. A team of three consultants was given the task to assess the achievements of the first phase of the project and to give recommendations for future modifications and improvements. These recommendations were to be valid for the second phase of MEUSTA activities (until 2001), as well as for the continuation of the programme after phasing out of donor support. In particular the specific objectives of the mission were:

• Assessment of implementation in accordance to MEUSTA yearly activity plan
• Conduct a survey on AIDS, AIDS knowledge, attitude and behavioral change among the target group and their surrounding
• Assess achievements with regard to capacity building
• Conduct a SWOT analysis of functioning of "the MEUSTA approach"
• Assess the perception of MEUSTA by the target group, the community and political leaders
• Asses participation and contribution of the community and political leaders
• Assess the availability of resources and the potential of takeover of activities by Local Government after 2001 (sustainability)

The MEUSTA approach: The programme's approach is based on a collaboration between different line ministries, such as the health, education, community development and planning sectors at regional, district and ward level. Besides having strong ties with the Government Sector, MEUSTA invests much into a close collaboration with other projects and NGOs targeting youths with respect to HIV/AIDS issues.

The top authority over MEUSTA activities is at the Regional Administrative Secretary (RAS). The Regional Resource Team (RRT) consists of the members of MEUSTA Office, an Education Officer (EO), the Regional AIDS Control Coordinator (RACC), one Community Development Officer (CDO) and a representative of the RAS' office. In an initial phase, the health specialists were held responsible to teach the members with other qualifications about the health aspects of HIV/AIDS. The same was done with regard to education, community development and planning issues. The RRT designed a training manual for Resource Teams at lower administrative levels (districts and wards) and subsequently for training teachers in EDU.

The District Steering Team (DST) is the top decision-maker at district level. It consists of the District Education Officer (DEO), the District Medical Officer (DMO), the District Planning Officer (DPLO), District Community Development Officer (DCDO), as well as the District School Inspector (DSI). The District Resource Team (DRT) consists of a Public Health Nurse (PHN), a School Health Programme Coordinator (SHPC), a school inspector, the District AIDS Control Coordinator (DACC) and a Community Development Officer (CDO).

The Ward Resource Team consist of the Ward Councilor, the Ward Executive Officer (WEO), the Ward Education Coordinator (WEdO), the In-charge of health facilities (HO), head teachers of all primary schools in the ward (HTs) and the Ward Community Development Officer (WCDO).

Besides teaching the students at school, MEUSTA is also involved in activities of community mobilization.

Ownership of MEUSTA Activities: The consultants perceive ownership of MEUSTA as being diffused. Ownership of the respective Local Governments is demonstrated by ownership of district infrastructure (schools, government offices, conference and training facilities), transport facilities and the human resources (government officials at district and ward level, teachers), which are at MEUSTA's disposal for its activities. The actual target group of MEUSTA, the school children of Tanga Region, show high levels of satisfaction with MEUSTA. Ownership by the general community within which MEUSTA operates can be measured by the overall acceptance of MEUSTA activities. An overwhelming majority of interviewed community suggested that MEUSTA activities should be sustained by a collaboration between the community and the government after external funding comes to an end.

To further increase ownership within the community, it is recommended that religious leaders should be more involved in the planning of MEUSTA activities. This may even enhance the development of community mobilization plans for specific religious denominations through the religious leaders, who had been involved in MEUSTA planning.

Assessment of Goal 1 (Contribute to Permanent Control and Limitation of HIV Infection among Youth and Adolescents in Tanga Region). For the achievement of goal 1, MEUSTA had foreseen three major activities. These are training, production of training and publicity materials, as well as community mobilization. The number of training session conducted for different target groups (DRTs, WRTs, EDU teachers, different segments of community, etc.) and the number of trained individuals is very large and MEUSTA has fully achieved the goal it had set. For its achievements with regard to training, MEUSTA definitely deserves compliments (also see chapter 6.5.1).

Assessment of Goal 2 (Strengthen the existing School Health Programme, as well as the Cooperatoin between Education and Health Sectors). For the achievement of goal 2, MEUSTA had foreseen support to the Primary Health Care (PHC) system and to the School Health Programme (SHP), as well as parents' education and MEUSTA Club activities. Although MEUSTA has invested much energy, the outcome was not as expected, since not all people involved took up initiative to support the MEUSTA idea.

Assessment of Goal 3 (Ensure close collaboration with all sectors within the PHC sector, other NGOs, CBGs and other interest groups in Tanga Region targeting youth). For the achievement of goal 3, MEUSTA had foreseen institutional development through the multi-sectoral approach, networking activities with NGOs and influential people, as well as exchange visits of MEUSTA staff. MEUSTA has successfully managed to bring representatives of different line ministries into the different teams/committes. This approach enhanced the exchange of information and know-how, as well as a democratization within the respective entities. Networking seems to fulfill the purpose of efficient exchange of information and ideas, as well as coordination of activities. With regard to the information MEUSTA generates, the potential is not fully exhausted. MEUSTA has a lot of valuable information, which could be used more efficiently in community mobilization work.

Education Sector: The MOEC is given the main responsibility for implementing and coordinating HIV/AIDS/STDS education in school.

Guidelines on HIV/AIDS/STDs Education in Schools: According to the Guidelines for HIV/AIDS/STDs Preventive Education for Schools (1996), HIV/AIDS education should started at primary school level. Education on HIV/AIDS and STDs, including information about sexuality is to be accessible to all students in the country. The Ministry is held responsible for guiding the design of curricula and instructional materials for HIV/AIDS/STDs education suitable for different age groups and different educational levels/institutions. Overall responsibility for integrating HIV/AIDS/STDs information into the core curriculum through carrier subjects is given to the Tanzania Institute of Education. It is stated in the guidelines that the information packages should contain the following information: Detailed and correct information about transmission and prevention of HIV/AIDS/STDs, as well as potential sources of information and counseling with regard to HIV/AIDS/STDs issues. Encouragement to abstain from sexual activities at young age.Information about safer sex, including condom information (however, condom services shall not be provided by schools). In order to ensure quality education, special training on HIV/AIDS/STDs and counseling skills will be provided in the pre- and in-service teachers courses.

The students should be taught, how to access HIV/AIDS/STDs related services, which can not be provided through schools, such as e.g. specific health services. NGOs and other agencies running such support services (e.g. counseling, HIV testing, STD treatment) should invite young people to access their respective services.

Unfortunately, the access to HIV/AIDS/STD information is limited to Standard V to VII students, leaving the young individuals below Standard V aside. The old curriculum includes HIV/AIDS related issues in Kiswahili and social science lessons only, where poems or short-stories are used to raise awareness about the existence of HIV/AIDS. This means that students do not have access to HIV/AIDS/STDs information through curricular activities.

Health Sector: The Health Policy (1990) states that the Ministry of Health (MOH) is responsible for developing and overseeing implementation of the national health policy.

National District Health Planning Guidelines: The Ministry developed guidelines for district health planning to guide primary health care service and delivery for which the local Government is responsible over dispensaries and health centres. Although the guidelines have improved district planning, adolescent health has not yet been accorded the weight it has with respect to the HIV/AIDS situation. The guidelines recommend data collection for three different social segments only, namely pre-school children, school children, women age 15 to 45.

The Family Planning Policy and Services Standards Guidelines (1992): Adolescents shall be provided with information, education and counseling on family planning. "Family planning information and services will be provided through Government, non-government and private health facilities, including Maternal and Child Health (MCH) and family planning clinic (urban and rural), and through community based and commercial social marketing programme outlets. Future information campaigns against HIV/AIDS need to recognize that HIV/AIDS is a part of an overall entity of reproductive health and that HIV/AIDS cannot be addressed without the basics of reproductive health. The Family Planning Policy and Services Standards Guidelines document is currently being reviewed to incorporate shift towards Reproductive Health and Child Health. Hopefully, this MOH programme will be supportive of current efforts within the school-based AIDS education programme to channel down crucial information down to the grass roots.

National Policy on HIV/AIDS/STDs: The objectives of the National Policy on HIV/AIDS/STDs is to make all individuals knowledgeable about transmission and prevention of HIV/AIDS, as well as to ensure adequate treatment of those already infected. With regard to MEUSTA activities is important to see that the policy lays the foundation of providing information to society as a whole, but also specifically for young people in schools. The policy is explicit about all ways of HIV/AIDS transmission, however, focusing strongly on sexual transmission of the disease. Appropriate information on reproductive health matters related to HIV/AIDS/STDs has to be included in the school curricula:

• Instruction and counseling on condom use should be made available to school children
• Information/treatment of other STDs must be given more attention, as there STD infected individuals are more prone to be infected with HIV/AIDS
• Female condoms are to be promoted and provided, in order to reduce women's vulnerability to HIV/AIDS infection

MEUSTA between MOEC and MOH: According to the MOEC guidelines for HIV/AIDS/STDs education the following activities are given a legal basis:

• Giving out information about contraception and condom use to adolescents
• Providing detailed information about the transmission and prevention of HIV/AIDS/STDS
• Involving the community into HIV/AIDS prevention activities, if in accordance with the MOEC criteria

According to the National Policy on HIV/AIDS/STDs the following activities are given a legal background:

• Providing detailed information about the sexual transmission of HIV/AIDS/STDs
• Providing students with information about condom use
• Providing young people with basic information about reproductive health

MEUSTA already has established functional channels for the dissemination of HIV/AIDS related information, DRT and WRT members and teachers are already trained and MEUSTA is accepted within society. In view of this situation, the next step for MEUSTA to take is the design and dissemination of age specific information packages, which include all the information young people need to protect themselves from being infected, including issues of sexuality, reproductive health and condom use.

Gender Perspective on HIV/AIDS: All statistics obtained at district level indicated a higher HIV prevalence among women than among males. To keep track of MEUSTA's long term impact, it is suggested that district officials keep records of the HIV/AIDS trend for districts and even wards, where possible. The information could for instance be strategically disseminated during special events like the MEUSTA week and the World AIDS Day. Existing channels of information dissemination can be utilized. For lobbying activities with regard to Local Government contribution to in-school and out-of-school EDU each district needs to have annually updated records on agreed indicators, such as for example prevalence of HIV infection, AIDS cases, STD cases and early pregnancy/childbearing (under 18).

Education Sector: The compilation of district education figures posed several problems. In all districts and therefore as well on the regional level, more boys than girls drop out of school. The fact that many children are outside the school system (either never enrolled or dropped out) poses a serious challenge to the dissemination of HIV/AIDS information. It points to the reality, that school-based dissemination of information can not suffice the purpose of safeguarding the young generation from being infected with HIV/AIDS. There is a need for further quantification and characterization of this out-of-school youth, in order to design an appropriate way of providing them with HIV/AIDS information.

Training of Trainers in EDU through MOEC: In an effort to combat the spread of HIV/AIDS and STDs the Ministry of Education and Culture (MOEC) organized training sessions for school inspectors, teachers and education officers at regional, district and school level. As a consequence, little was implemented and if had there not been MEUSTA to take the initiative, the students of Tanga Region would still be denied access to valuable information about HIV/AIDS. It was MEUSTA staff who went to MOEC headquarters to collect EDU textbooks, posters and reference and distribute it to all school in Tanga Region.

The Views of Students: In every school the consultants conducted a focus group discussion with a group of young boys and girls separately. In all cases, the adolescents express satisfaction about the fact of being taught about issues of HIV/AIDS. Students as part of EDU demanded information about reproductive health (process of becoming mature, menstruation, sexual intercourse, pregnancy, abortion, STDs) and HIV/AIDS origin, transmission, being HIV positive, cure.

Knowledge about transmission of HIV/AIDS: As in the 1997 KAP study, the vast majority of students (93.8%) is aware that anyone can be infected by HIV/AIDS, regardless of age or sex.

Responses to the question, whether HIV/AIDS really dangerous show that children and adolescents are very much aware about the danger of HIV/AIDS. In focus group discussions with students the consultants realized that the fear of being infected is very widespread among children, and many of them mention that they need more detailed information about reproductive health and HIV/AIDS in order to feel safer.

It is scientifically proven that 9 out of 10 HIV/AIDS positive persons are infected through sexual intercourse. It is scientifically proven that 9 out of 10 HIV/AIDS positive persons are infected through sexual intercourse. It thus recommended that EDU in subsequent MEUSTA phases becomes more explicit about sexual intercourse being the most frequent way of HIV transmission, as well as about issues of reproductive health in general.

Although the guidelines for teaching about HIV/AIDS/STDs in principle allow the dissemination of condom related information (not services), no word is mentioned in any of the textbooks or teaching materials. Also, there is no word that your only sexual partner may already be infected with HIV/AIDS.

Sexual Practice: Roughly 40% deny having had sexual intercourse. The majority of boys had sexual intercourse with persons of the same age or younger ones. Study findings show that among those who had planned sexual intercourse, boys comprise 80.7%. The fact that sexually active adolescents are a reality, has an important consequence for the education strategy and the dissemination of information with respect to HIV/AIDS and STDs. Also, it is scientifically proven that 90% of all HIV infections in Tanzania occur through sexual intercourse.

Condom information: There is need for more information among young people about condoms, as different institutions disseminate contradictory information (especially fundamentalist church organizations are very prone to distort information according to their needs).

Sources of HIV/AIDS/STDs Information: As the above table shows, the impact of school based information has very significantly risen since the 1997 KAP study, which is definitely a MEUSTA achievement (44.8% to 79.8%). Many of the students are not able do define the link between HIV/AIDS and STDs.

Parents as a source of information deserve ample attention, as 63.7% of the entire sample of students indicate that they talk to parents about issues of HIV/AIDS. For the dissemination of HIV/AIDS information the relatively high level of literacy among parents is an advantages. At the same time, the development of an adequate methodology for informing and communicating with illiterate parents on the HIV/AIDS epidemic must be designed, as HIV/AIDS information is crucial for any citizen, regardless of academic achievements. The desire of being better informed about HIV/AIDS issues was expressed by parents in all places, where focus group discussions with parents were held. Many parents judge their own knowledge about reproductive health and HIV/AIDS as to limited for teaching their own children well. Since HIV/AIDS is a reality, the question whether to teach children about reproductive health and HIV/AIDS or not is not any more only a question of cultural values and beliefs, but as much a question of life and death.

With regard to the above insights, MEUSTA's approach of reaching parents has to be modified during MEUSTA phase II. Thirdly, the information packages recommended for children need to be age and gender specific. It is suggested to develop information packages for girls and boys, from pre-school age to marriage age. Lastly, WRTs should cooperate with village leaders to disseminate HIV/AIDS information in villages. The fact of Muslim predominance must be taken into account when planning the future of MEUSTA's community mobilization approach, as religious leaders may play an important role in disseminating HIV/AIDS information.

Service Delivery: Parallel to investigations about health service delivery from the demand side (i.e. community/ students) the point of view of the supply side (i.e. Service Delivery Points (SDPs) and School Health Programme (SHP)) was assessed. In addition to the above mentioned health facility staff orientation on STD health talks (group guidance) to young boys and girls, the provision of adolescent sexuality training and the inclusion of STDs into school health might fall under their responsibilities.

MEUSTA Phase II (1999-2001) and beyond: The Evaluation mission observed diffused ownership of MEUSTA. The respective local governments own the district infrastructure including schools and teachers. On the same accord, all district councils accorded office space to MEUSTA. In all districts, MEUSTA is very well accepted. In recognition for susceptibilities and vulnerabilities that primary school children are exposed to MEUSTA tried to involve the different community segments of particular importance are parents, school committees, religious leaders political leaders of various levels.

For II phase MEUSTA should animate the three institutions so that the respective institutions begin to implement HIV/AIDS information and services campaigns to their followers. Here the major objective for MEUSTA should be to penetrate and influence institutions take on HIV/AIDS of the development issues. District Specific data and if possible Health facility information might be very useful in put for animation.

MEUSTA is an abbreviation for the Kiswahili phrase: "Mpango wa Elimu ya Ukimwi Shuleni Mkoa wa Tanga". The above phrase can be translated into English as: "Programme for school-based provision of HIV/AIDS education in Tanga Region". MEUSTA’s long term goals are:

• Firstly, to contribute to permanent control and limitation of HIV/AIDS infection among youth and adolescents in the region.
• Secondly, to strengthen the social, cultural, economic and health welfare of youth in Tanga Region.
• Thirdly, to ensure close collaboration with all sectors within the PHC Sector, other Non Governmental Organisations (NGOs), Community Based Groups (CBGs) and other interest groups in Tanga Region targeting youth.

In order to accomplish these goals, MEUSTA uses a multi-sectoral approach, which is commonly called "the MEUSTA approach". The approach is based on a strong link to the existing government structures at all administrative levels (Region, District, Wards). The government of Tanzania contributes to the project costs in terms of personnel emoluments and the provision of infrastructure. The majority of the running costs are covered by a cash grant originating from the Norwegian Nurses Association (NNA) and the Norwegian Agency for International Development (NORAD), whereby NNA and NORAD contribute 20% and 80% respectively.

Tanga is situated at the extreme north-eastern corner of Tanzania, and has a size of 27'348 km². The projected population reaches 1'644'849 people for the year 2000, out of which more than 50% are women.

Tanga Region is divided into six districts, namely Lushoto, Muheza, Handeni, Korogwe, Pangani and Tanga Municipality. The Indian Ocean coastal areas are warm and wet while the western plateau of Handeni district a hot and dry climate dominates. Those parts of the region lying in the Usambara mountains have a wet and moderate climate.

As far as the economy is concerned, the region depends on subsistence agriculture, livestock keeping and fishing. The food crops include maize,, bananas, rice and beans, while cash crops include sisal, cotton, coffee, tea, cardamom, coconut, tobacco and cashewnuts. Tanga region contains some natural resources such as mineral deposits, forestry, game reserves, fisheries and bee-keeping. Tourist attraction sides include the Mkomazi game reserve, Amboni caves, Totten Island, Tongoni ruins, Pangani beach and hot water baths in Amboni and Amani natural reserve.

The spread of HIV/AIDS epidemic in Africa had appeared in the early 1980. In Tanzania the first cases were reported in Kagera region in 1983. Since then the incidence of the epidemic has increased steadily. By December 1997 the number cumulative reported AIDS cases reached 103'185 (NACP, 1997). It is estimated that one out of 4 – 6 cases are reported to official sources in Tanzania. This gives the overall estimate of approximately 520,000 cumulative cases by December 1997. When comparing the different regions of Tanzania, Mbeya ranks first with case rate of 858.3 per 100'000, followed by Dar es Salaam, Kilimanjaro and Coast regions in descending order.

To date the HIV/AIDS pandemic has spread all over the world. The Government of Tanzania has been working towards improving the situation since the outbreak of the disease in 1983. In the beginning these efforts have been limited to the Ministry of Health (MOH). At a later stage, the Government has started to collaborate with the public sector, NGOs and CBOs to join forces in the fight against the disease. As a response to the threat HIV/AIDS is posing to the nation, a National Aids Control Programme (NACP) was established under the MOH. Unfortunately, NACP has not accomplished the formulation of a national policy on HIV/AIDS/STDs. Up do date only a draft has been published (1995). The consultants have been informed by NACP that there is a board of 10 specialists, who are given the responsibility to finalize the policy formulation process. However, there is no indication as to how much longer the Tanzanians have to wait for the document.

It soon became obvious, that HIV/AIDS is a phenomenon, which can not be restricted to the health sector alone. An important complementary role in prevention is given to the Ministry of Education and Culture (MOEC). The major task of the MOEC lies in the formulation of guidelines for HIV/AIDS/STDs preventive education in schools, in the design of appropriate curriculums and in the production/ dissemination of teaching materials. MOEC has made major efforts to respond to the urgent need of guidelines, teaching materials, students' textbooks and leaflets.

Adolescents constitute the largest group of the Tanzanian population. They are a very crucial group for a nation's development, as they are both tomorrow's productive force and the parents of the next generation. Therefore it is very crucial to safeguard their development and wellbeing, as an investment into the future of the Nation.

Research findings show that sexual indulgence of young people begins as early as the age 9 to 12 (Monadic et al. 1996). These young people practise unprotected sexual intercourse, which is often resulting in unplanned/unwanted pregnancies, abortions and/or abandoning of babies.

STDs is another very big problem among the adolescents. NACP report (1997) shows that among 30'189 people who consulted available STD services there were 4'205 individuals below age 20. Out of those, 1'459 were male and 2'746 were female. These figures do not indicate the real extent of STD prevalence among adolescents, because many others do not report to STD service delivery points, as they are unaware of the accessibility of such services.

Again, women are more affected than men. Information available from education authorities show that nearly a quarter of girls who drop out of primary and secondary schools, do so due to pregnancy (Mpangile et al. 1992).

The above stated information proves that adolescent sexuality is an undeniable reality in Tanzania, as much as in many other countries. With regard to the widespread prevalence of HIV/AIDS in the country, the refusal to accept this reality poses a major threat to the young women and men of Tanzania. The time for closing eyes at unwanted realities is over.

MEUSTA has given much support to HIV/AIDS education in primary schools and the community of Tanga Region in general for the past three years. In order to see whether the approach chosen is still appropriate, MEUSTA decided to conduct an external mid-term evaluation. A team of three consultants was given the task to assess the achievements of the first phase of the project and to give recommendations for future modifications and improvements. These recommendations were to be valid for the second phase of MEUSTA activities (until 2001), as well as for the continuation of the programme after phasing out of donor support.

In particular the specific objectives of the mission were:

• Assessment of implementation in accordance to MEUSTA yearly activity plan
• Conduct a survey on AIDS, AIDS knowledge, attitude and behavioral change among the target group and their surrounding
• Assess achievements with regard to capacity building
• Conduct a SWOT analysis of functioning of "the MEUSTA approach"
• Assess the perception of MEUSTA by the target group, the community and political leaders
• Asses participation and contribution of the community and political leaders
• Assess the availability of resources and the potential of takeover of activities by Local Government after 2001 (sustainability)

The evaluation was carried out by an interdisciplinary team of three female consultants, in order to guarantee a comprehensive appraisal of the project (for terms of reference, see annex 2). The three consultants were:

During data collection each of the team members was given specific responsibilities within the team, according to her professional background and experience. At the end of each day, information was exchanged and advice was sought from within the team. The final report is the product of joint efforts of all three consultants.

The external evaluation of MEUSTA has lasted almost two months. The following table shows the main phases:

During the first two weeks of May the most important administrative steps have been taken, in order to smoothen the way for the evaluation after June 23^rd. For each district two rural and two urban wards were randomly chosen and informed to kindly cooperate in the evaluation activities. In addition the questionnaire for the KAP study was pre-tested in one urban school in Tanga and thereafter refined to fit the students understanding and the computer software EPI Info.

The team of consultants also introduced itself to the most important government officials in the health, education and community development sectors.

After one week the team returned to Tanga Region for the phase of data collection in both urban and rural areas of all districts. It was decided that the consultants should involve all 6 districts into their evaluation activities, in order to get a clear picture about the question of sustainability issues after phasing out of donor support in 2001. Also, it seemed important for ownership of information by the respective Local Governments in the districts.

For each district the team met with the following interlocutors:

• District Executive Director, the District Medical Officer and the District Education Officer, if available
• District Resource Teams, the District Steering Team and selected Ward Resource Teams
• Teachers, including head teachers and EDU teachers
• Religious and political leaders, influential people
• School children
• Parents, if available
• School committee members

The multitude of partners in discussion gave the team a comprehensive insight into the present situation with regard to HIV/AIDS education in schools. In addition to these focus group discussions and individual interviews, in each school a random sample of 40 Standard VI&VII students (male/female 50% each) to fill a questionnaire for the KAP study (Knowledge, Attitude; Practice). The students were supported in filling the questionnaire by two peers (MEUSTA Club members).

In addition to touring in all district of Tanga Region, the team of consultants spent an additional two days in Same District (Kilimanjaro Region) in order to assess the situation (reference group).

After returning to Tanga the team of consultants focused on the compilation of data collected. Also, the existing data were complemented with additional information and recurrent cross-checking with MEUSTA headquarters took place, in order to produce adequate recommendation for MEUSTA.

On June 29^th a feed-back workshop was held in Tanga, where the representative of the Norwegian Nurses' Association (Mrs. Ruth Nesje) was present. Among the workshop participants there were members of DRTs and eventually DSTs, representatives of MOEC, MOH and MCD, representatives of NGOs and other organizations working in the AIDS sector.

The Government has put great effort in trying to control the spread of HIV and STDs through the Ministry of Health, Ministry of Education and Culture (MOEC), as well as NGOs. The MOEC is given the main responsibility for implementing and coordinating HIV/AIDS/STDs education in school. As an increasing number of actors showed interest to be involved in educational efforts, the need for the formulation of general guidelines become urgent. Therefore the MOEC formulated guidelines for school-based education programmes with regard to the prevention of HIV/AIDS and STDs in 1996. This was done on the basis of the existing Law of Education (1978). The Law of Education provided a solid framework for the design of the Education and Training Policy, as well as for the design of HIV/AIDS education guidelines in 1996.

4.1.1 Policy on Education and Training (1995)

The Policy on Education and Training includes explanations and guidelines for all levels of formal and non-formal education (pre-primary to university education). The main responsibility is thereby given to the Ministry of Education and Culture (MOEC), as well as to the Ministry of Science, Technology and Higher Education (MOSTHE). In addition, other line ministries are responsible for providing, coordinating and monitoring sector specific education.

Primary education is to be universal and compulsory to all children from the age of 7 years until they complete this cycle of education. The major objective is to enable every child to acquire basic learning tools of literacy, communication, numeracy and problem solving, as well as basic education of integrated knowledge, skills and attitudes needed for survival and development to the full capacity. The basic primary education should lay a strong foundation in scientific and technological literacy and capacity and thus guarantee self-reliant personal and national development.

During the curriculum revision in 1992, the number of compulsory subjects for primary education was reduced from thirteen to seven. The remaining subjects were Kiswahili, English, mathematics, social studies, life skills, religious instructions and science. In 1992 still HIV/AIDS education coupled with education on issues of reproductive health were not yet included into the curriculum. It is only lately that efforts have been undertaken to change this situation.

4.1.2 Guidelines on HIV/AIDS/STDs Education in Schools

According to the Guidelines for HIV/AIDS/STDs Preventive Education for Schools (1996), HIV/AIDS education should be provided at the following educational levels:

• Primary Schools Std. V to VII
• Secondary Schools Form I to IV, as well as Advanced Level Form V and VI
• Teacher trainees at certificate and diploma levels of education

For the implementation of such activities, a School AIDS Control Education Programme was established by the MOEC. It was foreseen that the students should be provided with preventive education and counseling in all HIV/AIDS and STDs related issues, with a major thrust on prevention skills, attitudinal change and on creating responsible individuals with regard to decisions and actions in life.

The overall responsibility for implementation and coordination is accorded to the MOEC. However, other line ministries (e.g. MOH), communities, NGOs, local and international agencies, religious bodies and individuals are encouraged to collaborate with the MOEC in the implementation of the School AIDS Education Programme.

As schools alone can not be expected to alter the lifestyles of young people unless the school-based programmes are part of a community wide approach. It was therefore foreseen to involve community representatives and school committee members into the AIDS Control Committee at all levels.

Education on HIV/AIDS and STDs, including information about sexuality is to be accessible to all students in the country. It is explicitly mentioned that related traditional taboos, should not be allowed to hinder the transmission of information. The Ministry is held responsible for guiding the design of curricula and instructional materials for HIV/AIDS/STDs education suitable for different age groups and different educational levels/institutions. The overall responsibility for integrating HIV/AIDS/STDs information into the core curriculum through carrier subjects is given to the Tanzania Institute of Education. Effective preventive social and moral education for appropriate ages and levels shall be ensured in order to solve the whole range of problems of youths such as drug abuse, early sex, teenage pregnancies and induced abortions.

It is stated in the guidelines that the information packages should contain the following information:

• Detailed and correct information about transmission and prevention of HIV/AIDS/STDs, as well as potential sources of information and counseling with regard to HIV/AIDS/STDs issues.
• Understanding of sex and sexuality, puberty, contraception, as well as safe and responsible behaviour (however, contraception services shall not be provided by schools)
• Encouragement to abstain from sexual activities at young age
• Information about safer sex, including condom information (however, condom services shall not be provided by schools)

In order to ensure quality education, special training on HIV/AIDS/STDs and counseling skills will be provided in the pre- and in-service teachers' courses.

The students should be taught, how to access HIV/AIDS/STDs related services, which can not be provided through schools, such as e.g. specific health services. NGOs and other agencies running such support services (e.g. counseling, HIV testing, STD treatment) should invite young people to access their respective services.

The MOEC guidelines are quite comprehensive, acknowledge that a proportion of primary school children are already sexually active and even allow the much disputed dissemination of information about the condoms. Unfortunately, the access to HIV/AIDS/STD information is limited to Standard V to VII students, leaving the young individuals below Standard V aside. This is a contradiction to the window of hope concept, which defines the individuals of age 5 to 14 as those who bear the hope of the survival of the Nation, if properly cared for. In accordance with the window of hope concept, it should be finally acknowledged that the young people need to be entirely informed about HIV/AIDS/STDs and fully aware about the occurrence of physical, psychological, emotional and social changes during puberty before they reach puberty, in order to be prepared. This is most important in view of the fact that HIV infected individuals can not easily be identified before the outbreak of the first AIDS related symptoms.

4.1.3 Translation of Guidelines into Curricula

At the level of curricula the situation is much less encouraging, as the old curriculum is still in use for educational levels above Standard III. The old curriculum includes HIV/AIDS related issues in Kiswahili and social science lessons only, where poems or short-stories are used to raise awareness about the existence of HIV/AIDS. There is, however, these items are rather of narrative or descriptive character, than being informative.

Within the new curriculum HIV/AIDS/STDs education is included into the science syllabus and is to be taught in Standard IV and V only. However, up to now the new curriculum is used only by a few schools and only up to Standard III (1999). This means that students do not have access to HIV/AIDS/STDs information through curricular activities. The only information they have access to, is the one provided through MEUSTA intervention, which is based on a set of textbooks issued by the MOEC. It is however not clear, how the teaching materials of the new curriculum and the textbook and teaching materials used by EDU teachers trained by MEUSTA are supposed to be fit together in the future.

It is encouraging to note the MOEC guidelines have given much space for preventive education to adolescents. The above described drawbacks of the way HIV/AIDS/STDs guidelines has been translated into syllabi and curricula of different subjects for different classes is serious. If EDU will not modified soon toward incorporating in-depth information one should not be astonished if many of the ex-EDU students will get wiped out by the epidemic.

An additional problem is the fact that many teachers do no comprehend the dimensions of adolescent sexuality and that many of them still feel reluctant to address issues of sexuality. Although MEUSTA has done a first step of enhancing teachers' confidence with respect to teaching HIV/AIDS, a lot remains to be done.

The Ministry of Health (MOH) is responsible for developing and overseeing implementation of the national health policy. The policy focuses on the delivery system for Primary Health Care (PHC) and the necessary collaboration with other sectors (e.g. education and community development) and actors (politicians, charitable organizations) at the implementation stage. Although the health policy is a rather old document with regard to the HIV/AIDS scourge, it nevertheless provides room for interested organizations and individuals to undertake initiatives such as MEUSTA.

The concept of PHC as such includes many aspects, such as:

• Education regarding preventive and curative health care
• Household level food security
• Assured supply of water and basic sanitation
• MCH and family planning services
• Vaccinations and epidemic control
• Appropriate treatment and provision of drugs

The existing health policy can be criticized for its lack of gender sensitivity. For example, only women and mothers are targeted for family planning services, leaving male and female adolescents in reproductive age aside. In the same line, other issues, which affect women's health are not mentioned at all (e.g. abortion practices). Furthermore, patients do not have appropriate sanctioning mechanisms with regard to hospitals' disrespect of exemption from cost-sharing for MCH and chronic diseases. There is ample space for interpretation when identifying individuals suffering from chronic diseases, such as HIV/AIDS, and exemption practices are often not properly followed.

4.2.2 National District Health Planning Guidelines

The Ministry developed guidelines for district health planning to guide PHC service and delivery for which the local Government is responsible through dispensaries and health centres. Although the guidelines have improved district planning, adolescent health has not yet been accorded the weight it should have with respect to the HIV/AIDS situation. For example, the categories for record keeping are not specific enough to allow a clear analysis of the HIV/AIDS impact on different segments of the society. The guidelines recommend data collection for three different social segments only, namely pre-school children, school children, women age 15 to 45. During the evaluation it was impossible to obtain records of STD prevalence, an indicator which is important for assessing sexual health. With regard to HIV/AIDS/STDs the following changes are recommended:

• Records on STD prevalence must be kept for both sexes, women and men
• The broad category of adults of ages 15 to 45 must be further segregated into smaller units
• Adults above age 45 may have sexual health needs as well and must be included as a category
• The category of out-of-school children must e added

There is an overall need for the guidelines to become more sensitive to gender issues and differences with regard to the diagnosis and treatment of STDs, as well as with regard to HIV/AIDS.

4.2.3 The Family Planning Policy and Services Standards Guidelines (1992)

In recognition of adolescents being sexually active, the MOH has made provisions for service delivery to adolescents in the National Policy Guidelines and Standards for Family Planning Service Delivery and Training (1^st edition 1992). Section I (Art. 3-7) contains crucial information about the eligibility for FP-services and the delivery procedures:

Language barriers may be partly responsible for the fact that some service providers and many teenagers themselves are not aware of the policy guidelines. While the guidelines are only published in English, the basic health care providers communicate in Kiswahili and not in English. In spite of this shortcoming, some health care providers reported that the document had given them valuable back-stopping during advocacy work with community leaders who were initially strongly opposing against the provision of reproductive health information and services to adolescents. The examples show that the improved dissemination of the guidelines might support advocacy work at all levels.

Future information campaigns against HIV/AIDS need to recognize that HIV/AIDS is a part of an overall entity of reproductive health and that HIV/AIDS cannot be addressed without the basics of reproductive health. The Family Planning Policy and Services Standards Guidelines document is currently being reviewed to incorporate shift towards Reproductive Health and Child Health. Hopefully, this MOH programme will be supportive of current efforts within the school-based AIDS education programme to channel crucial information down to the grass roots.

4.2.4 National Policy on HIV/AIDS/STDs

The objectives of the National Policy on HIV/AIDS/STDs are to make all individuals knowledgeable about transmission and prevention of HIV/AIDS, as well as to ensure adequate treatment of those already infected.

With regard to MEUSTA activities it is important to see that the policy lays the foundation of providing information to society as a whole, but also specifically for young people in schools. The policy is explicit about all ways of HIV/AIDS transmission, however, focusing strongly on sexual transmission of the disease. For the prevention of sexual transmission of the disease, the policy gives the following guidelines with regard to school children:

• Appropriate information on reproductive health matters related to HIV/AIDS/STDs has to be included in the school curricula
• Any government and non-government institution can participate in prevention and control activities, if they are in accordance with the overall guidelines
• Instruction and counseling on condom use should be made available to school children
• Information/treatment of other STDs must be given more attention, as STD infected individuals are more prone to be infected with HIV/AIDS
• Female condoms are to be promoted and provided, in order to reduce women's vulnerability to HIV/AIDS infection

In view of the fact that many adolescents are practicing sexual intercourse, adolescent sexuality needs to be pointed out as a separate policy issue within the national policy. Adolescents and adults can not be treated under the same umbrella with regard to preventing sexual transmission of HIV/AIDS. As it is now, the policy is not specific enough about how young people should be informed and treated and therefore there is ample room for individuals and organizations to interpret the policy according to their respective understanding/perception of the situation. This leads in many cases to a denial of access to information and services for adolescents in need. It would be very helpful, if the policy was more explicit for example about the logistics of condom information and service delivery through existing service infrastructure.

According to the MOEC guidelines for HIV/AIDS/STDs education the following activities are given a legal basis:

• Being open about adolescent sexuality and puberty related issues
• Giving out information about contraception and condom use to adolescents
• Providing detailed information about the transmission and prevention of HIV/AIDS/STDS
• Involving the community into HIV/AIDS prevention activities, if in accordance with the MOEC criteria

According to the National Policy on HIV/AIDS/STDs the following activities are given a legal background:

• Providing detailed information about the sexual transmission of HIV/AIDS/STDs
• Providing students with information about condom use
• Providing young people with basic information about reproductive health

Taking these government guidelines and policies as a basis, MEUSTA has great potential to become an even more important institution for the population of Tanga Region. MEUSTA already has established functional channels for the dissemination of HIV/AIDS related information, DRT and WRT members and teachers are already trained and MEUSTA is accepted within society.

In view of this situation, the next step for MEUSTA to take is the design and dissemination of age specific information packages, which include all the information young people need to protect themselves from being infected, including issues of sexuality, reproductive health and condom use. Suggested age categories are a) below 10, b) ages 10 to 14 and c) 15 and above. This task can be accomplished in collaboration with Local Governments, which have the disposition for delivering information packages designed for different age groups.

As a parallel activity for phase II, MEUSTA is advised to publish policy and programme implications of their experiences and insights.

The first AIDS case reported in Tanga Municipality was in 1987 at Bombo hospital. During the same year, another case was reported at Teule Hospital in Muheza. A decade later the disease had spread all over the region. By December 1997 the region had registered 4'278 cumulative cases.

The above table shows that the average infection rate is higher for young females than for young males. This might firstly be due to the fact that more and more men seek young partners for sexual intercourse, as they assume there are fewer young people being infected than older ones, who already had more exposure to sexual activities. Secondly, it might be a consequence of female submissiveness, economic dependence, lack of trust in marital relationships and the difficulties of refusing to have sexual intercourse without condoms. In addition, there might be other reasons not mentioned here.

As a background for understanding the necessity and impact of the MEUSTA intervention, it is interesting to get an insight into the HIV/AIDS situation in the districts of Tanga Region. Consultations with DMOs proved the existence of government efforts towards creating a district data base with regard to HIV/AIDS.

The team of consultants was specifically interested to obtain data, which shows the distribution of HIV/AIDS prevalence for different age groups of male and female sex separately. The effort of DMOs of teasing out information and the subsequent submission of data for the sake of the MEUSTA evaluation are very much appreciated. However, the formats used showed a great variation, which made it almost impossible to condense it into a meaningful statistical table. The evaluators gained the impression that data at district level is not generated for district level use, but rather for reporting to the headquarters in Dar es Salaam. It is recommended that MEUSTA encourages each DRT/DST to collaborate in laying a sound foundation for meaningful generation of data sets with regard to HIV/AIDS in their district. It is anticipated that this data, if updated annually, has a big potential of becoming an important benchmark for assessing MEUSTA impact. Furthermore, it can be useful for lobbying and advocacy work, as well as for consensus building for financial support for in and out of school EDU.

HIV infection among blood donors is commonly used as an indicator for assessing the percentage of persons affected by HIV/AIDS. For several reasons the indicator is not a very good one. Firstly, the sample is biased, as many more men than women donate blood and secondly, adolescents are not included, as they are not among the target group for blood donations. However, although it is not possible to assess the entire dimensions of the HIV/AIDS epidemic by analyzing this indicator, it produces at least approximate values and shows trends.

Data about the prevalence of HIV infection among blood donors between 1995 to 1998 shows that the proportion of female blood donors being HIV positive is higher than the proportion of male blood donors. Also, one can discern a clear upward trend in all districts. As an example, the table below shows the data submitted by two wards of Tanga Region and the same data for Same district.

The reality depicted in the above table should be reason enough for Local Governments, political and religious leaders and all other community members to take immediate action. Otherwise, there might soon be no community anymore to reign on or to lead.

Many sick people; impaired with AIDS remain at home or attend nearby health care facilities. Therefore, the presented figures do not show the entire dimensions of the HIV/AIDS phenomenon. To improve data collection on AIDS prevalence, DMOs suggested the syndrome approach should be used for diagnosing AIDS patients, whereby two major signs and two minor signs are indication enough to diagnose AIDS. Where possible, the diagnosis should be confirmed by Elisa testing after professional counseling (detection of HIV presence in human blood through test). It is furthermore suggested that health care at all levels (dispensaries, health centres, etc.) are included for broadening the basis for estimating AIDS prevalence within each district. Currently, efforts in this direction are in a preparatory stage at district level. It is planned to conduct Training of Trainers sessions for clinical diagnosis, in order to multiply initial training inputs (source: DMO Lushoto). It is anticipated the MOH and NACP will prepare ground for this by issuing circulars through the RMO.

The data in the above table also show that women make up approximately two thirds of all patients admitted to hospitals for care. It is unclear, whether this is a representation of a larger proportion of all AIDS patients being women, or whether women are more prone to seek care at the hospital, as there is no one at home to take care of them (women traditionally being the caretakers at home).

Data on distribution of AIDS patients by age indicate that patients within the age group of 16 to 19 years, some of which are at primary school going age, had been diagnosed with AIDS (creation of age categories decided upon by DMOs when extracting the data from hospital records). Considering the time span it takes for HIV infection to break out into the AIDS, the infection could have occurred during the period which is commonly called the "Window of Hope". It must therefore be concluded, that the real window of hope for Tanga Region is probably much narrower than what is generally assumed at national level.

All statistics obtained at district level indicated a higher HIV prevalence among women than among males. Up to now, there has been no serious investigation, in order to find out whether the statistics are biased by the sample or whether they represent the real picture. The bias in statistics may be caused by:

• Gender differentiated home care. While women provide home care to sick men, sick women are referred to hospitals for public supported care
• Lower economic status of women, which forces them to attend public supported health care

If women really make up the majority of HIV/AIDS cases, reasons for this trend must be assessed and intervention strategies to change the situation must be implemented immediately. The following are assumed reasons for finding more women falling prey to HIV/AIDS:

• Elderly men may look for young girls with the intention to have sexual intercourse with girls who are not yet infected.
• Female submissiveness and economic dependence to men make it difficult for females to insist on mutual fidelity or condom use.
• Women are biologically more vulnerable to HIV infection than men and
• As sexual partners, women are confronted by gender inequalities in various forms of commercial sex, matrimonial relations imposed by dowry and other traditions that confer less negotiating power in aspects of safe sex and sexual intercourse itself.

All in all, the conceptual framework of the disease needs to be synthesized and future interventions should take the gender perspective of HIV/AIDS sufficiently into account. It is recommended that during phase II the RRT, RSC, DSTs and DRTs undergo sharpen their awareness on the gender specific implications of the epidemic, in order to enhance the implementation of a gender sensitive HIV/AIDS intervention strategy in the long term.

In order to allow the implementation of such intervention strategies, more baseline data and understanding about the nature of the disease with respect to gender issues is necessary. For that purpose it will be necessary to conduct precisely focused studies. The more comprehensive the concept of HIV/AIDS phenomenon in Tanzania becomes, the better the affliction of the disease to human populations can be minimized.

To keep track of MEUSTA's long term impact, it is suggested that district officials keep records of the HIV/AIDS trend for districts and even wards, where possible. It is proposed that with RSC approval, the RRT collaborates with district teams in order to project the situation at current infection rates.

It is strongly recommended that the MEUSTA network agrees on the variables to be recorded (e.g. HIV prevalence among different samples, AIDS cases admitted to hospitals, etc.), on the recording frequency (annually, semi-annually, etc.) and on the recording format (dissagregated data for sex, age, etc.) in phase II of project implementation.

Packaging information in popular format will ensure its reallocation to the grassroots communities, who are the primarily affected ones. The information could for instance be strategically disseminated during special events like the MEUSTA week and the World AIDS Day.

Another simple technique for the dissemination of information is printing leaflets. With a shared computer, a photocopier and paper, one page leaflets containing crucial information can be easily be made. Existing channels of information dissemination can be utilized. It is proposed that in phase II DST/DRT of each district compile the existing information and mold it into a reader friendly and informative format. Frugality should be exercised to enable local governments sustain this type of record collection and compilation for their own use at the district level after NNA funding comes to an end.

It is strongly recommended that the districts come to a consensus about data to be collected. For lobbying activities with regard to Local Government contribution to in-school and out-of-school EDU each district needs to have annually updated records on agreed indicators, such as for example prevalence of HIV infection, AIDS cases, STD cases and early pregnancy/childbearing (under 18). Only by supporting lobbying arguments with statistical facts about the real state of affairs with regard to adolescent sexuality and HIV/AIDS councillors will be willing to allocate funds for prevention.

MEUSTA was established on the initiative of Ms Ruth Nesje, who was working for the National AIDS Control Programme (NACP) from 1988 to1991. She was given the task to design Information, Education and Communication (IEC) strategies within the Regional AIDS Control Coordinator's office. Touched by the state of affairs with regard to adolescents' access to information about HIV/AIDS, she took the initiative to communicate with the regional government administration in Tanga, in order to discuss about potential interventions or support to the government efforts. In 1995 an agreement was reached between the Norwegian Nurses Association (NNA) and the Government of Tanzania, which allowed NNA to cooperate in the establishment of the school-based AIDS education programme in Tanga Region. This is when MEUSTA as an institutional structure was created. The programme' approach collaborates with different line ministries, such as the health, education, community development and planning sectors at regional and district level.

From its first days, MEUSTA was designed with a strong tie to the existing government structure in order to ensure sustainability and an adequate institutional set-up. The idea was to create resource teams at all administrative levels (region, district, ward), which included representatives from different line ministries. These resources teams were to be in close contact with the government structures at the respective levels. To reinforce the ties, at regional and district levels a steering team/committee was created, which is essentially a congregation of relevant government officials (Education Officer, Medical Officer, Community Development Officer and Planning Officer). Bringing different sectors together within the institutional set-up was designed as to initiate organizational development in the sense of democratization (everybody is given space for participation, for contributing ideas and different perceptions.

Besides having strong ties with the Government Sector, MEUSTA invests much into a close collaboration with other projects and NGOs targeting youths with respect to HIV/AIDS issues. This is done in the view of the fact that MEUSTA alone can not take responsibility for all HIV/AIDS related interventions in Tanga Region (reproductive health, HIV/AIDS information, health service delivery, etc). For improving the situation in a comprehensive way, complementary efforts are necessary.

Feedback on Planning M&E, Supervision

Planning, M&E, Supervision

Feedback on Planning M&E, Supervision

Community

M&E, Supervision Training Training

Advise

Training

Membership

Source: own design

6.3.2 RSC and RRT

Historically MEUSTA has grown through a trickle-down process. The first step was the creation of a Regional Steering Committee (RSC), which elected the members of the Regional Resource Team (RRT), according to set criteria. Those developed, in collaboration with the project coordinator, the intervention strategy and the materials necessary for extending the intervention into the different districts of the Region.

The top authority over MEUSTA activities is at the Regional Administrative Secretary (RAS). On a next lower level there is the RSC, which consists of five government representatives from different line ministries, namely the Regional Medical Officer (RMO), the Regional Education Officer (REO), the Regional Community Development Officer (RCDO) and the Regional Planning Officer (RPLO) and a secondary school headmaster. The RSC is the top decision-maker within the organizational structure of MEUSTA.

The RRT consists of the members of MEUSTA Office, an Education Officer (EO), the Regional AIDS Control Coordinator (RACC), one Community Development Officer (CDO) and a representative of the RAS' office. The RRT, together with the Project Coordinator are responsible for the smooth implementation of the project in its everyday reality. The RRT is divided in three teams, which are responsible for two districts each.

In the initial phase, RRT trained itself through a process of horizontal exchange of knowledge. For example, the health specialists were held responsible to teach the members with other qualifications about the health aspects of HIV/AIDS. The same was done with regard to education, community development and planning issues. Using this method, all members of the RRT were both teachers and students.

The RRT designed a training manual for Resource Teams at lower administrative levels (districts and wards) and subsequently for training teachers in EDU. Overtime, the responsibilities of the RRT have changed. While it was mainly occupied with training and support to District Resource Teams (DRTs) in the beginning, the present focus of its work lies in supervision, as well as monitoring and evaluation.

The RSC meets quarterly, together with the Project Coordinator. Other members of the RRT may be invited, if their expertise is needed. The RRT meets twice weekly, in order to exchange information and to decide on urgent issues.

In addition, there are semi-annual "Cooperation in Future" meetings (June/January), where RSC members meet with the RRT, as well as with Chairpersons from all DSTs and DRTs. During these meetings implementation reports are discussed and new plans are decided upon.

6.3.3 DST and DRT

The District Steering Team (DST) is the top decision-maker at district level. It consists of the District Education Officer (DEO), the District Medical Officer (DMO), the District Planning Officer (DPLO), District Community Development Officer (DCDO), as well as the District School Inspector (DSI). Its main tasks are to facilitate the link to the Local Government and to supervise the Ward Resource Teams (WRT).

The District Resource Team (DRT) consists of a Public Health Nurse (PHN), a School Health Programme Coordinator (SHPC), a school inspector, the District AIDS Control Coordinator (DACC) and a Community Development Officer (CDO). The DRTs have been trained through the RRT, in order to enable the DRTs in a next step to channel down the information to the ward level (WRTs).

The main responsibilities of the DRT are to supervise the activities of the WRTs and the implementation at school level and to facilitate community mobilization through meetings and training.

The DST meets quarterly, together with the DRT chairperson and the DRT secretary. The DRT follows the same pattern as the RRT, which is meeting twice a week for the exchange of information and for planning.

In addition there is a quarterly district meeting where the Chairpersons from each WRT, all DRT members and two representatives of the RRT meet. These meetings are held in each district separately.

6.3.4 WRT and EDU teachers

The Ward Resource Team consist of the Ward Councilor, the Ward Executive Officer (WEO), the Ward Education Coordinator (WEdO), the Incharge of health facilities (HO), head teachers of all primary schools in the ward (HTs) and the Ward Community Development Officer (WCDO). WRTs are given the overall responsibility of channeling the training and information they had received from the DSTs further down to the EDU teachers. The EDU teachers then are those, who are in direct contact with the target population, namely the primary school students of Standard V to VII. EDU teachers are chosen on the grounds of their professional qualification and willingness to contribute.

The WRTs meet monthly to discuss issues of interest, in order to exchange information and in order to coordinate efforts.

6.3.5 MEUSTA Clubs

The MEUSTA Clubs were established in the school in order to supplement the EDU within curricular activities with extra-curricular activities. The Clubs are open to Standard III to VII students, the majority of students however are in Standard V to VII. Up to now it was possible to establish a MEUSTA Club in all primary schools of Tanga Region (with the exception of very small schools not having upper Standards). The following table illustrates the number of primary schools, students, MEUSTA Clubs and club members:

The above table shows that the coverage of MEUSTA Clubs has reached a very advanced stage. Almost all schools have their Club and roughly 30% of all Standard V to VII students are members of the respective Club. For further recording, it might be interesting to separately record the number of students below Standard V, in order to be able to calculate the exact percentage of Standard V to VII. Also, it might be important to record data by sex and eventually even by age, as a basis for targeting the activities to the specific needs of the individuals involved.

MEUSTA Clubs, being extra-curricular, were perceived as a powerful instrument for becoming an additional source of information for HIV/AIDS related issues, which are not foreseen within EDU in the school curriculum. As it is now, the most common activities of the clubs are singing in choirs, mini-drama, poems and role play "ngonjera", which is often used for community mobilization and in a few cases for fundraising (giving concerts). Other clubs are involved in agricultural activities or petty trade with pens, exercise books and sweets, as fundraising activities and in order to raise students' awareness of self-sustainability in life.

It soon became apparent that not only in-school children, but also those out of school should be given access to HIV/AIDS related information. Therefore, a strategy for opening up the clubs for out-of-school youth was sought for and found in the establishment of MEUSTA Clubs as a NGO. In September 1998, the registration procedures were successfully brought to an end. The long term perspective for MEUSTA Club is to establish multi-purpose youth centres improving the situation of adolescents with regard to their socio-economic, health and educational welfare. It is foreseen that the head office of MEUSTA should be in these youth centres.

6.3.6 Community Mobilization

Besides teaching the students at school, MEUSTA is also involved in activities of community mobilization. This is done through holding meetings with parents, organizing sessions of awareness raising among religious leaders, political leaders, health officials, traditional birth attendants, traditional healers and others.

By reaching out to the community itself, MEUSTA aims at contributing to an improved awareness, increased knowledge and changed behaviour within all layers of society. This is crucial for avoiding frictions between EDU students and their social environment, as well as for reaching out to those children and adolescents who are not enrolled in school. With respect to the insight, that many children/adolescents can not reached through school-based IEC, the efforts for out-of-school dissemination of information must be given more consideration than it is presently the case.

During the workshop, participants listed appropriate materials for future community mobilization:

• Mass media
• Ngoma, songs, "ngonjera", drama
• Posters and leaflets
• Seminars, meetings
• Minutes of MEUSTA meetings
• Teaching materials
• Recreational materials (football, netball, badminton, etc.)

The planning process is designed to follow a bottom-up approach, whereby the activity plans from the lower administrative levels are consolidated into a regional plan (according to the regional guidelines and the goals of MEUSTA). Planning procedures have been subject of much discussion. On the one hand, those at lower administrative levels complain about not having enough space to influence the planning, as the guidelines coming from the regional office and the revision process up to Norway do not allow much flexibility. On the other hand, those at regional level have witnessed that financial management at lower levels sometimes benefits the officials more than the target population, as large amount of the budget are spent on allowances for meetings.

Up to now, MEUSTA has managed to ensure that 75% of its overall budget directly reach the target population (through training, provision of information materials, MEUSTA weeks etc.) and there is a strong willingness to maintain that level. Therefore it is sometimes difficult in the Tanzanian context to follow a 100% bottom-up approach, if a big percentage of funds is to directly benefit the defined target population. It might be a viable solution to increase the financial responsibility of lower administrative under a well defined set of conditions. These must include parallel contribution from local funds, proper use of funds from the region according to the annual plans, comprehensive M&E/supervision according to set indicators measuring goal attainment. Some WRTs even suggest to increase the level of decision-making power at ward level by generating and reallocating funds for MEUSTA project activities themselves. They expect that locally generated funds would be spent more carefully than money coming "from above", because the accountability towards the citizens is immediate.

The three major goals of the project are the following ones:

1. Contribute to Permanent Control and Limitation of HIV Infection among Youth and Adolescents in Tanga Region
2. Strengthen the Social, Cultural, Economic and Health Welfare of Youth in Tanga Region (until 1997 formulated as: Strengthen the existing School Health Programme as well as the cooperation between Education and Health Sectors)
3. Ensure Close Collaboration with all Sectors within PHC, other NGOs, CBGs and Interest Groups in all Districts in Tanga Region

The following boxes show MEUSTA's overall achievements and activities according to the above goals between 1995 and 1999:

The above tables are a brief illustration of MEUSTA's high degree of goal attainment. The geographical coverage of project activities is enormous (reaching out to all schools in all wards) and the MEUSTA training sessions have reached a huge amount of people in different categories (DRT, DST and WRT members, teachers, students, parents, community leaders, health related staff). At the same time, there were many meetings held, in each of which representatives from different line ministries were present. With every meeting therefore, the people involved contributed a little bit to the organizational development by giving each other space in collaboration.

Following this brief overview over MEUSTA's achievements, each goal is discussed separately. The appraisal of goal attainment is based on the tables comparing planned activities with implementation (for more detail, see appendix 17). These tables have been compiled from MEUSTA activity plans for the years 1996-1998, from annual reports 1996-1998 and supplemented by information from the project coordinator.

For the achievement of goal 1, MEUSTA had foreseen three major activities. These are training, production of training and publicity materials, as well as community mobilization. The general level of achievement with respect to goal 1 is high. When looking at the implementation of activities, it becomes apparent that especially training is one of the major strengths of MEUSTA.

The number of training session conducted for different target groups (DRTs, WRTs, EDU teachers, etc.) and the number of trained individuals is very large. For its achievements with regard to training, MEUSTA definitely deserves compliments for building up a huge pool of valuable human resources in Tanga Region. MEUSTA has an outstanding record with regard to the geographical coverage. There has hardly ever been another project, which managed to reach out to so many institutions and inividuals within such a short time. MEUSTA has reached all schools in all districts with EDU since the beginning of the project, and it has trained a multitude of individuals from different segments of society in the whole region. With regard to training, MEUSTA has fully achieved the goals, which had been set (see tables 7 to 10 on previous page, as well as appendix 17). These impressive results notwithstanding, it is however recommended increasing the efforts of quality control, as the team of consultants has realized that some of the trained persons do not adequately channel down the training they received to the respective target populations. The efficiency of conducted training sessions must be judged by analyzing in what way the training reaches the intended end-receiver, i.e. the students. Students reported that many teachers still feel shy when teaching EDU. It is recommended that future training of EDU teachers includes an even stronger component for enhancing teachers' confidence when teaching issues of reproductive health.

The amount of materials produced is quite impressive, however, the consultants advice to be more careful with the design of materials. Any item should carry a specific message with regard to HIV/AIDS and MEUSTA activities. A calendar showing a group of adults says very little about MEUSTA's work. With the same amount of money spent, MEUSTA could increase its impact by more carefully designing the publicity material. Courses run by the Centre for African Family Studies (CAFS) in Nairobi might be a good source for selected MEUSTA staff to improve their skills in designing informative and effectively targeted publicity materials.

Community mobilization activities have been undertaken to a satisfactory extent. However, future community mobilization could become more efficient by targeting the sessions more specifically. The KAP study has shown that religious leaders and the parents' attitude and level of knowledge have a great influence on HIV/AIDS information dissemination. Therefore it might become very advantageous to invest more into the most influential groups, while leaving others a little bit more aside.

The title of this chapter indicates the initial formulation of goal 2, which was used 1995 to 1997. In 1998 the second MEUSTA goal was reformulated to include the MEUSTA Club approach, which could not be fit well into the initial definition of goal 2. The present day definition of goal 2 is: "Strengthen the Social, Cultural, Economic and Health Welfare of Youth in Tanga Region". It is foreseen to eventually go back to the initial definition of goal 2, once MEUSTA Club has become an independently functioning NGO.

For the achievement of goal 2 as initially defined, MEUSTA had foreseen support to the Primary Health Care (PHC) system and to the School Health Programme (SHP), as well as parents' education. MEUSTA's overall achievements for goal 2 are less impressive than those for goal 1.

MEUSTA has undertaken extensive efforts to link the different line ministries involved in HIV/AIDS related issues and has managed to smoothen the previously rigid borders between different sectors. MEUSTA has fully acknowledged the role the health sector can play with regard to school-based HIV/AIDS education. The MEUSTA approach managed to include the RMO and DMO as members of the respective steering committees. In addition a number of health personnel were trained, being members of either DRTs or WRT. As a consequence of health staff being part of the institutional set-up of MEUSTA, the health sector has been adequately involved in setting objectives, planning activities, implementation, monitoring and supervision. Contributions of medical expert were part and parcel of the training courses provided by MEUSTA at all levels. It is definitely an achievement that within the MEUSTA framework all institutional entities include representatives of the health, education and community development sectors. However, these interconnections are still at an institutional level and have not yet reached the level of MEUSTA's target population.

As shown by KAP findings, the linkage between different lines of service delivery are still very minimal, SHP and the related visits of PH Nurses are not executed as planned and accessibility of health facilities has not been improved to a satisfactory extent. Although MEUSTA put effort in encouraging health staff to reach out to all school in their area, remote schools are only rarely visited. If the school visit approach does not seem to be practical (financial and time constraints), other ways of connecting the students to available health services must be looked for (e.g. students' trips to the nearest functional service delivery point). In addition, planning committees at village and ward level might consider to support local health staff in their endeavour to visit their respective schools. Furthermore it is recommended that the health person being member of the WRT assists in the design of an annual schedule for school visits, which should be should be discussed and agreed upon by both the DMO and the DEO

The multi-sectoral approach of MEUSTA activities must remain an important characteristic of activities in the future. The need for medical back-stopping will arise again and again, for example when designing the information packages for children and adolescents at different ages.

During the feed-back workshop the success of the multi-sectoral approach was judged by participants. They judged it as successful, because sharing of experience, expertise and resources (transport, offices) takes place and because the community participation is increased. It was even suggested to involve NGOs in steering committees/team at levels where they exist.

Parents' training sessions have been conducted, however, it is difficult for the consultants to assess the extent to which these sessions on MISC have influenced the behaviour of parents as part of the society. As for other community development activities, it is mandatory to assess more carefully the actual impact in terms of attitudinal and behavioural change. Also, the methodology of community mobilization has to be reconsidered. The consultants have come to realize that society very often relates to cultural heritage, when justifying their own attitude and behaviour (e.g.: "it is culturally inadequate to talk about sexual intercourse to your children") or in terms of moral beliefs (e.g.: "it is bad to have sexual intercourse before marriage"). The arguments of the above mentioned types are therefore rarely of rational character. It is very difficult or rather impossible to influence such sets of beliefs by simply trying to convince the person of the contrary of what he/she feels and believes. For the sake of more efficient transmission of information, MEUSTA is advised to select its mobilization methodology more strategically. The consultants strongly recommend that the argumentative catalogue of MEUSTA for raising awareness and introducing attitudinal and behavioural change in the community, by arguing more from the points of view of quality of life and health. An example of "quality of life" arguments is: "If your child is not taught the detailed ABC of reproductive health, it may fall pray to the phenomenon of unwanted pregnancies at early age. As a consequence its education will be hampered, which also reduces its potential future income generating capacity and its value on the marriage market". An example of a health focused argument is: "If your children are not given information about STDs, they may not speak up and ask for timely treatment, because of ignorance and shyness. A possible consequence is the permanent damage of your child's reproductive organs to the extent of not being able to become mother/father". Such arguments can be scientifically and rationally proven and are therefore stronger than arguments on the irrational level, such as: "children have a right to accessible information about reproductive health issues".

For the achievement of goal 3, MEUSTA had foreseen a multi-sectoral approach for the institutional set-up, networking activities with NGOs and influential people, as well as exchange visits of MEUSTA staff.

With regard to collaboration within the PHC sector, MEUSTA has achieved to initiate organizational change, by strictly following a multi-sectoral approach. Much time has been invested in bringing representatives of different sectors together and in enhancing their communication and exchange of information. It is a novelty for Tanzania that multi-sectoral collaboration has been fortified by a shared work and activity plan, which describes the ways and goals of collaboration. The representatives of the different sectors are involved in MEUSTA activities two day per week, while they fulfill their usual ministerial duties during the other three days. The advantages of such an approach are that the representatives stay in touch with the latest developments in their sector, that they can channel new information into the MEUSTA network and then carry MEUSTA related insights back to their respective sectors of the government structure. In a long term perspective, such an approach will enhance organizational development and a democratization of organizational procedures, as every forum becomes a space, where representatives may freely contribute ideas, doubts and visions for discussion and implementation. Each of the meetings held by multi-sectoral teams can be considered as a small step, a practice session for more equal participation.

Concerning the exchange with other NGOs, CBGs and interest groups, the networking activities have taken a good momentum in terms of the organization of workshops and participation of MEUSTA in externally organized workshops. Networking is a very important activity for any project targeting the community, however, the cost of such networking must always be balanced against the impact with regard to general project goals. For the case of MEUSTA, networking seems to fulfill the purpose of efficient exchange of information and ideas, as well as coordination of activities.

With regard to the information MEUSTA generates, the potential is not fully exhausted. MEUSTA has a lot of valuable information, which could be used more efficiently in community mobilization work. The consultants thereby specifically refer to KAP findings (e.g. that a good percentage of Standard VI&VII students are sexually active, that their ignorance of reproductive health bears dangers, that religious leaders and parents are important interlocutors, etc.).

One general comment on the definition of goals, specific objectives and subsequently of activities must be stated here. There seems to be some confusion within the logical framework of MEUSTA planning and reporting. The team of consultants observed that there is not always a strict compliance of activities to a specific goal. In some instances the activities are interchangeably listed under different goals, in other instances activities are meaningful, but do not fit under any specific objective at all, etc. For improving donor attractivity it is recommended that MEUSTA staff go through their logical framework of planning and subsequent planning.

A more stringent planning framework would also enhance bottom-up planning and the cooperation with village governments, Ward Development Committees and District Councils could be smoothened.

The above table shows that number of children eligible for school enrollment, however, who have not enrolled in school as yet. It becomes apparent that there is a quite large number of young people who never get primary education, although the policy of MOEC prescribes Universal Primary Education. As these adolescent do not get access to EDU in school, there must be a complementary intervention to target out-of-school youth.

The compilation of district education figures posed several problems. Firstly, not all districts furnished the evaluators with the data of the same quality standard. For Handeni and Muheza drop-out rates had to be calculated by subtracting the number of students in a certain year from the number of students of one standard lower in the previous year (e.g. Std. I (1995) minus Std. II (1996)). In some cases, the number in the subsequent year exceeded the one in the previous year. In such cases the number of newly transferred students or repetitors must have overcompensated the number of drop-outs.

The data show that there are quite some students in the Region who drop out of school for different reasons. In all districts and therefore as well on the regional level, more boys than girls drop out of school. Reasons which are given by DEOs for drop outs are:

• Truancy (work on estates, petty business, IGAs, marriage (girls))
• Deaths
• Pregnancy (exact number difficult to assess, due to inaccurate reporting)
• Parents' economic and social problems (separation, unemployment, lack of land to cultivate)
• Disciplinary difficulties
• Transfers

The fact that many children are outside the school system (either never enrolled or dropped out) poses a serious challenge to the dissemination of HIV/AIDS information. It points to the reality, that school-based dissemination of information can not suffice the purpose of safeguarding the young generation from being infected with HIV/AIDS.

There is a need for further quantification and characterization of this out-of-school youth, in order to design an appropriate way of providing them with HIV/AIDS information. It is suggested that CDOs in collaboration with Ward Education Coordinators and Ward Executive Officer are made responsible for immediate action. It might fall into MEUSTA phase II activities to facilitate the set-up of a reliable data base on out-of-school youth, as a reference for future planning efforts (clear definition of categories to be recorded, format of recording).

In an effort to combat the spread of HIV/AIDS and STDs the Ministry of Education and Culture (MOEC) organized training sessions for school inspectors, teachers and education officers at regional, district and school level. A national training was conducted at Patandi Teachers' College in 1993. In order to multiply Government efforts, it was expected that the trained individuals would channel down the training to other teachers, education officers and other persons with potential for training youth in EDU in their respective environment. However, no funds were made available to facilitate the further transfer of knowledge and training to other persons. As a consequence, little was implemented and if had there not been MEUSTA to take the initiative, the students of Tanga Region would still be denied access to valuable information about HIV/AIDS. It was MEUSTA staff who went to MOEC headquarters to collect EDU textbooks, posters and reference and distribute it to all school in Tanga Region.

For each of the groups, the team of consultants used a specific questionnaire for exploring about views of different segments of society. In the following subchapters are a direct representation of the perceptions of EDU by representatives of different groups involved in the survey. Consultants' comments are declared as such.

Usefulness of training provided by MEUSTA:

• MEUSTA training was judged to be very useful by many interlocutors in the sense of providing vital information about HIV/AIDS to society. Some felt that MEUSTA training enabled them well to channel down the information to other members of society. Specifically, some mentioned the positive effect of overcoming the shyness of talking about issues of reproductive health and HIV/AIDS with their children.

Potential improvements with regard to MEUSTA training:

• Many interlocutors stressed the importance of an improved availability of teaching and publicity materials. Especially books, but also leaflets and posters have not reached their intended target population in sufficient amounts (It is not clear, whether there is really a shortage of materials, or whether they are hidden in store rooms, due to the reluctance of responsible persons to take action…consultant's comment).
• Influential political leaders, such as ten cell leaders, councillors, members of parliament should help to promote EDU diffusion by including supportive remarks on their agenda when giving public speeches.
• Religious congregations and health facilities (especially MCH) could be used as additional institutions for channeling EDU into society (religious leaders have been extensively trained and informed about the MEUSTA approach and a consensus for collaboration has been established…consultant's comment).
• Others recommended the increased use of radio broadcasts, video shows and Hamasa group performances in the villages.
• Some interlocutors suggested that the flow of information could be improved by educating youth to become peer educators for their fellow students (consultant's comment: MEUSTA has already undertaken efforts to train peer educators).
• Another key issue was the establishment of MEUSTA Clubs for out-of-school children and adolescents, for whom EDU is less accessible than for others.

Communication patterns within families with regard to HIV/AIDS issues:

• Communication about HIV/AIDS related issues is not very well practiced within the family. Many of those who have attended MEUSTA training reported an improvement with regard to their own readiness to talk about HIV/AIDS in general, but also with their children. However, shyness and reluctance to talk to children about HIV/AIDS still seems to be very prevalent. For most tribes, there is no tradition of exchanging information about issues of reproductive health between parents and children (rather between uncles/aunts/grandparents and children). Many individuals mention, that is very difficult for them to loosen these traditional rules.

Extent of HIV/AIDS information provided through EDU:

• The majority of the interlocutors state that the amount and quality of information provided through EDU is not enough to fully protect the youth from being infected with HIV/AIDS. The community members would like to see more EDU lessons per week and more in-depth information.
• Others suggest to start as early as Standard 1 with elementary information about reproductive health and HIV/AIDS, in order to create a sound foundation, once the students reach the age for being given in-depth information. This concern is also related to late enrollment (i.e. children are physically mature, before they reach Standard V to VII).
• Some interlocutors state that people of all age should have access to information of reproductive health and HIV/AIDS. Having a sound knowledge they can decide as responsible citizens. Ignorance bears too much danger with respect to a high HIV/AIDS prevalence.
• Some respondents indicate that the school-based EDU efforts must be complemented by dissemination of information through religious institutions.
• The information given should more directly lead to a changed behaviour in society. The respondents complain that students still circulate in risky environments and parents do not impose sufficient control over the environment their children live in.

Condom information and services to adolescents:

• Religious leaders totally reject the idea of providing young people with condom information, and even less with services, because it is against the will of God/Allah.
• Some religious leaders state that condoms are not safe (low quality, condoms having holes, the storage liquid for condoms contains HIV). Therefore condoms rather spread the disease than preventing it.
• Average members of the community, however, are not opposed to providing condom information and services, especially when confronted with preliminary KAP results of almost 50% of Standard VI&VII students being sexually active. On a whole, women show a higher readiness to put all shyness away, since they are often the ones who bear the negative impact of HIV/AIDS spread (caring for the sick, etc.).
• One community leader even went as far as distributing condoms to all households, in order to improve accessibility.

Preconditions for takeover of MEUSTA by Local Government Budget

• The members of the community asked for a continuation of EDU activities after phasing out of donor support. Local Government should start immediately to include MEUSTA activities in their plans and budget.
• Some focus on the existing human resources (trained EDU teachers, etc.) and changed curricula, which will continue to be operational, even if no additional funding can be found.
• Others suggest that the schools themselves could start income generating activities to support EDU activities. These funds should be collected reallocated at ward level.
• Another idea was to obtain a small percentage from tax revenues at ward level (e.g. business license fee). There was a strong plea for members of the village/ward development committees to make EDU a permanent agenda and budgetline.
• Some suggest investigations upon the possibility of Central Government subsidies.

7.3.2 The Views of EDU Teachers

Integration of EDU in primary school curriculum:

• In most of the schools visited by the evaluation mission, EDU has become an independent subject in the timetable (for Standard V to VII). The weekly session of EDU (40 min.) in most cases replaced music or "sanaa" lesson.
• In some schools the teachers were not very clear about the number of EDU lessons and about how they managed to fit EDU into the timetable (is EDU really being taught there… consultant's remark)

Feelings toward teaching EDU:

• Generally the teachers have gained confidence in teaching EDU. If any difficulties arise, they try to find a solution among themselves. EDU has become part and parcel of their teaching routine.

Students' response to the lessons:

• Students are reported to be eagerly listening in EDU sessions. Teachers acknowledge that there is a big demand for HIV/AIDS related information.

Adequacy and sufficiency of teaching and reference materials:

• In all schools visited, teachers report that there are not enough teaching and reference materials available. There is an additional need for posters, textbooks for students and especially a specified syllabus (It is unclear what happened to the material, which was initially distributed by MEUSTA. MEUSTA provided 4-5 teachers' manuals and enough books for two students sharing one book to each school. This is a ratio, which is reached in no other subject in Tanzanian schools …consultant's comment).

Usefulness of training provided by MEUSTA:

• Most EDU teachers said that the training was very useful and gave them a solid basis for teaching.

Suggestions for future improvements:

• Some suggested that the training should have been longer, in order to give them more time to digest the information and in order to include practical teaching trials.
• Others see the necessity of refresher courses for getting access to updated information about the development of HIV/AIDS developments and in order to further improve teaching methods. These courses could also be used as a forum for exchange of experiences and ideas among EDU teachers.
• Some teachers would like to invite specialists from outside the school environment (nurses, etc.) to teach about subject specific issues. For some teachers this was also judged to be a good way of disseminating issues of reproductive health (consultants' comment: what is hindering them to do so?).
• The use of audio/visual technology should be enhanced in future.

Extent of HIV/AIDS information provided through EDU:

• The vast majority of teachers acknowledges that the extent of information provided through EDU is not enough to fully protect the young people from being infected with HIV/AIDS. This is due to lack of time (one lesson per week is not enough).
• Reasons given for information not being sufficient:
• Students are confronted with many other sources of information, which disseminate partly contradictory statements. Adolescents need a source of information they can trust.
• Adolescents know that condoms exist. Giving them condom information responds to their needs.
• The school is an accepted place of knowledge transfer, more than the children's homes. Often the children are not taught at home because of traditional beliefs and shyness
• The existence of HIV/AIDS poses a risk to the youth and they need to know everything about it.
• Many adolescents are confused by the shallowness of information and their partial knowledge does not give them guidelines for safe behaviour.

Suggestions for future improvements:

• Society as a whole must be given more information, so that when pupils are coming back from school with HIV/AIDS information they can speak openly with knowledgeable interlocutors.
• EDU should start earlier (at least Standard IV, others even mention Standard I), because teachers realize that the students are sexually active.
• Condom information is included in the science curriculum for Standard VII, but there is a need for promotion of teaching condom related issues.
• Girls should be sensitized early about the danger of older men seducing them and social control over seductive men should be increased.
• Provision of more textbooks, reference books and teaching materials
• EDU should more specifically target at behavioural changes (Social control of adults seducing adolescents into sexual intercourse must be increased, increased control over students environment)

7.3.3 The Views of Students

In every school the consultants conducted a focus group discussion with a group of young boys and girls separately. In all cases, the adolescents express satisfaction about the fact of being taught about issues of HIV/AIDS. They are eager to know everything about HIV/AIDS, because they feel that knowledge can help them to protect themselves from being infected. In their critical appraisal, they formulated the following suggestions for future improvements of EDU:

• EDU teachers should be more open. Students feel that they are not given the entire information available to adults
• EDU should start earlier
• EDU should be taught even after Standard VII
• EDU should be spread in the whole community, to elders, to homes, everywhere
• EDU should be taught in separate classes for boys and girls, with male and female teachers respectively
• There should be more EDU textbooks

Towards the end of the focus group discussion the students were each given a piece of paper to note down further questions, they would like to be answered during EDU lessons. This was done, in order to investigate which information exactly the children would like to have access to. The team of consultants was overwhelmed by the amount of questions the students came up with. There are four broad categories of questions:

• Questions about adolescent life in general (drug abuse, accepted behaviour)
• Questions about reproductive health (process of becoming mature, menstruation, sexual intercourse, pregnancy, abortion, STDs)
• Questions about condom use (safety and purpose of condom use)
• Questions about HIV/AIDS in general (origin, transmission, being HIV positive, cure)

MEUSTA Clubs could be the appropriate forum for disseminating a small booklet containing these questions and appropriate answers in English and Kiswahili.

The KAP study showed that 23.9% of the students in the sample live in single-parent households and 7.0% live with foster parents (relatives or others). The remainder of 68.5% live with both parents. When investigating about the whereabouts of the parents, it showed that 18.4% of the students have either lost their mother or father and that 2.5% are orphans. The reason for parents' death has not been investigated upon within the questionnaire. In focus group discussions with teachers and members of the school committees the respective participants pointed out the difficulties to determine the reasons for parents' death, as medical diagnosis of HIV/AIDS as death cause is not commonly practiced. Many HIV/AIDS victims' death reason for dying is determined by the disease they finally surrender to (e.g. malaria, anemia, tuberculosis, etc.).

As it is now, it therefore remains unclear, whether the students in the sample lost their parents due to HIV/AIDS or any other reason. According to teachers' informal responses, however, it can be concluded that the phenomenon of orphans and half-orphans is at least partly caused by HIV/AIDS infection of their parents.

It is recommended that Local Governments look into this development by setting up a school-based data collection on parents' status. It has repeatedly been shown that HIV/AIDS infection of parents (prolonged care of the sick and eventual loss of parents) has serious negative effects on school attendance.

As in the 1997 KAP study, the vast majority of students (93.8%) is aware that anyone can be infected by HIV/AIDS, regardless of age or sex. Also, the three top ranking ways of being infected with HIV/AIDS were the same in the 1997 (see table below). One can however discern a general rise of the percentages of knowledge about specific ways of being infected (roughly 10% for each).

Precise knowledge about ways, in which HIV/AIDS is spread, is the very basis for an effective protection from being infected. Having a sound knowledge allows any individual to refrain from certain practices and to cope with dangerous situations, in order to stay healthy.

When comparing the results with the 1997 KAP study, the most outstanding change appears for the category of transmission by sharing sharp instruments, where the rise in percentages is enormous. This might be a reflection of teachers' and responsible persons' reluctance to talk about the number one cause of transmitting HIV/AIDS, which is sexual intercourse. It is scientifically proven that 9 out of 10 HIV/AIDS positive persons are infected through sexual intercourse. It may be a refuge for shy teachers and responsible persons to insist on the sharp instruments, as a way to avoid talking about issues of reproductive health. There must be put an end to EDU teachers emphasizing on easily spelled out dangers out of the fear of "kuonyesha utovu wa heshima" and the hope issues of sexuality will be clarified by themselves.

Furthermore, it has been noticed in focus group discussions with the children, that the nature of their knowledge is very partial and superficial. They know enough to tick the proper answer in a questionnaire, however, their knowledge does not seem to be profound enough to fully protect themselves from being infected (see chapter 7.3). The messages, which are given to the children, need to become more explicit in future.

Responses to the question, whether HIV/AIDS really dangerous show that children and adolescents are very much aware about the danger of HIV/AIDS. In focus group discussions with students the consultants realized that the fear of being infected is very widespread among children, and many of them mention that they need more detailed information about reproductive health and HIV/AIDS in order to feel safer.

It thus recommended that EDU in subsequent MEUSTA phases becomes more explicit about sexual intercourse being the most frequent way of HIV transmission, as well as about issues of reproductive health in general.

8.2.2 Means of Self-Protection

The vast majority of students 90.9% know that there are means of protecting oneself from being infected. However, this does not mean that they have access to these means or that they are using safe practices in their everyday life. Some means of protection, such as for example condoms, are not easily accessible or applicable for adolescents, especially in rural areas with high levels of social control in neighbourhoods.

The answers given, reflect many crucial issues, especially when data is compared with the findings of the 1997 KAP study. The percentage of "sexual abstinence" and "avoiding common use of sharp instruments" have significantly risen. On the other hand the percentage of "using condoms" and "having sex with only one partner" have significantly gone down. This can directly be linked to the messages as disseminated by MOEC through EDU.

Although the guidelines for teaching about HIV/AIDS/STDs in principle allow the dissemination of condom related information (not services), no word is mentioned in any of the textbooks or teaching materials. Action for the dissemination of condom information must be taken with reference to the KAP findings (roughly 50% of the sample are exposed to sexual practices) and can be taken with reference to the MOEC guidelines!

For the category of "having sex with only one partner" there seems to be a great confusion in society, as the definition of its meaning is not accurate enough. In fact in some places the evaluation mission observed that community members have misinterpreted advocacy efforts of one partner as being a push-factor for some adolescent "singles" to looking intensively for a partner, as according to the Government, everybody should have one. Furthermore the definition of having one partner does not explicitly state, whether it means having only one partner in your entire life or whether it may be synonymous with sequential monogamy (i.e. having one partner after another, but only one at the time). Also, there is no word that your only sexual partner may already be infected with HIV/AIDS. With reference to the 1999 KAP study, it becomes obvious that the category has become totally inadequate. Either it needs to be clearly redefined or entirely removed from the campaign's vocabulary.

The fact that an average of 13.3% of students fear of being infected with HIV/AIDS when giving blood, reflects the partial character of their knowledge. They know that the disease is transmitted through blood, but they were not taught intensively enough to distinguish different practices related to blood donation and transfusion. As mentioned above, EDU has to speak a clearer language in order to avoid confusion within children's and adolescents' heads.

8.2.3 Identification of HIV/AIDS Positive Individuals

Compared to the 1997 KAP findings, there is a slight decrease of the percentage of children, who are unaware about the fact that healthy looking persons can be infected with HIV/AIDS (from 29.5% in 1997 to 24.9% in 1999). However, very few students (18.3%) declare the difficulties of identifying the infected persons as being a danger, compared to 46.8% to 67% of students acknowledging other dangerous aspects of the disease (see table below).

As shown by the data, the danger of not being able to identify those who are infected but who do not yet show visible signs of being infected is widely underestimated. People need to be made more aware that the timespan between a HIV infection and the outbreak of firsts signs of being infected can be a long one (even years!). A major thrust to disseminate information in that sense is urgently needed and as the above table shows, there is still a long way to go. MEUSTA should be working more intensively to increase the percentage of students seeing a danger in HIV infection being difficult to identify, as lack of knowledge about this fact can be very dangerous.

The results with regard to top ranking symptoms are very similar in the 1997 KAP study. There are slight changes of illnesses associated with HIV/AIDS infection, which are due to HIV/AIDS as a disease changing its face.

For example, it is only recently that scientists have identified tuberculosis as a prevalent symptom of HIV/AIDS patients. Scientists are permanently working towards a deeper understanding of transmission mechanisms, symptoms and potential curative measures. All children and teenagers need to be informed that the phenomenon of AIDS develops, that illnesses related to HIV/AIDS infection may change over time, as scientists advance in their research. It is suggested that children are informed about signs and symptoms of HIV/AIDS within the ordinary lessons about the human immunity system. With respect to the fact that a good proportion of children and teenagers are not attending school, it is imperative that specific strategies for communication must be developed to reach out-of-school youth as much as in-school youth. For phase II, it is therefore recommended that MEUSTA intensifies its efforts of identifying and developing communication strategies that easily reach in- and out-of-school youth.

Th overall findings about whether the students are already sexually active are very similar to those of the 1997 KAP study. There are generally more boys who report to have had sexual intercourse (52.2% for boys vs. 17.2% for girls), and the girls are more often silent about their sexual practices (i.e. no answer).

It is an outstanding fact, that one third of all students openly declare to have had sexual intercourse. Roughly 40% deny having had sexual intercourse. The large proportion of students not indicating whether they already have had sexual intercourse or not leaves the picture a bit blurry. However, one can assume on good grounds that a good proportion of the silent ones was also involved in sexual activities.

The same data as table XY, but depicted in a different way, shows that the number of those who already had sexual intercourse is strongly dominated by boys. The imbalance between the two sexes raises important questions:

• Are girls less open about their sexual activities?
• Do girls who practice sexual intercourse sleep with several different young boys?
• Are boys satisfying their needs with other boys?

The answers to these questions must be explored upon more closely, as they have important implications for the young students involved.

The age groups between 5 and 9, as well as 10 and 14 are generally acknowledged to be the window of hope, which means the segment of society in which lies the hope for the future of the nation, if and only if properly cared for. The two tables above show that the children start very early with sexual intercourse and 46.2% of all the students included in the sample acknowledge to have had sexual intercourse during the window of hope period. If these children are really to become the productive force and the mothers and fathers of tomorrow, there is an urgent need to intervene with HIV/AIDS information at a very early stage. Otherwise the shutters of the window of hope will become a useless concept for the case of Tanzanian youth.

Upon being asked when they started to have sexual intercourse, 55.4% of the sexually active admitted to have started a year ago or more than one year ago and 46.9 % agreed to have a bodily lover at the time of the study. This should be information enough to open one's eyes to the reality of adolescent sexual activity in Tanzania.

The data shows that girls more often have sexual intercourse with men who are (significantly) older than they themselves. Very few girls have sex with younger partners. For boys the situation is quite different. The majority of boys had sexual intercourse with persons of the same age or younger ones.

Most of the sexually active had been in contact with their fellow students (40.1%), another 25.2% had sexual contact to family members and relatives and 9.5% with family friends. Sexual intercourse with family friends, relatives and family members could be in some cases be related to child abuse. Furthermore a connection might be established between the relatively high percentage of those having had sexual intercourse with the above mentioned categories and the number of girls who report to have had sexual intercourse with (significantly) older men.

Study findings show that among those who had planned sexual intercourse, boys comprise 80.7%. This is an indication that boys are the initiators for the majority of sexual acts at young age, while girls are more often pulled into it. Young people need to be informed on the potential negative consequence of sexual intercourse, such as pregnancies, and young girls especially need to be empowered on decision-making with regard to their own sexuality.

In response to the question why they had intercourse both boys and girls scored natural feelings and experimentation highest. This reveals a very important fact: the vast majority of young people do not have sex, because they are tempted or forced, but because their body develops and with this process of maturing the desire to have sexual intercourse and to experiment with the developing organs increases. These natural feeling are still very much denied in society, and it is time for things to change.

Any intervention on sexuality for adolescents needs to take the existing gender differences into account. Girls may need more reassurance to become the primary decision-makers about their own sexuality, boys may need more counseling on how to cope with the sexual feelings with arise in puberty without putting their lives at risk.

The fact that sexually active adolescents are a reality has an important consequence for the education strategy and the dissemination of information with respect to HIV/AIDS and STDs. The previous practice of relating any early sexual contact with "vishawishi" (temptations) and "uasherati" (prostitution or promiscuity), unless society is willing do declare at least 40% of their in school youth as little prostitutes. These terms are also very undesirable from a gender point of view, as they suggest that the main problem lies in young girls unable to resist. Sexual feeling come up in adolescents as they grow older, and it is nothing but natural that the youth starts to experiment. This is even more the case for adolescents, who are unaware of the dangers of early sexual intercourse for their physical health, because they had not been informed. Experience shows that sexual intercourse among adolescents can be delayed by acknowledging their sexual feelings and counseling them on how to deal with those feelings. In addition, such counseling has proven to induce overall behavioural change towards responsible reproductive practices.

Also, it is scientifically proven that 90% of all HIV infections in Tanzania occur through sexual intercourse. The sole emphasis on sharp instruments for piercing ears, injection needles and circumcision knifes has to give way to a stronger emphasis on sexual intercourse as being the most important means of HIV transmission.

8.3.2 Condom Use

HIV/AIDS being a widespread reality, it is scary to know that more than 61.9% of all young people being involved in early sexual practices have never been using condoms. The percentage of unprotected sexual intercourse might even be higher, taking into account that those who confessed having used a condom once, have not necessarily used it for all their episodes of sexual intercourse. There are obvious physical barriers to use of condoms by boys (size of penis), however, ingenious young people concerned with their own health and survival have found ways to overcome these limitations. In several schools young boys informed the mission that they tied oversize condoms with rubber bands to fit the size of the penis. Others reported to circumvent the inaccessibility of condoms by scavenging in the garbage deposits of guesthouses, yet others wash and keep a previously acquired condom for reusing it. These observations point to the need of explicit condom information and an accessible condom distribution service.

There is need for more information among young people about condoms, as different institutions disseminate contradictory information (especially fundamentalist church organizations are very prone to distort information according to their needs). Condoms should be introduced as a simple, cheap and efficient technology for preventing pregnancies and HIV/AIDS, as it is scientifically proven. Barriers to condom use should be gradually reduced, as they endanger the health of sexually active persons (young and old). It is crucial to disseminate more explanation about the proper use of condoms (how to check quality, how and when to put them, how and when to remove and throw them away).

Examples from success stories with regard to condom promotion need to be made more public (e.g. AIDS campaign in Uganda). Eventually, it might prove useful for few to conduct a study tour to Uganda for anti-condom-hardliners in phase II, where the Catholic Church courageously started to promote condoms and thereby managed to reverse the escalating trend of HIV/AIDS.

As the above table shows, the impact of school based information has very significantly risen since the 1997 KAP study, which is definitely a MEUSTA achievement (44.8% to 79.8%). Also, the extent to which parents have become sources of information have risen (14.3% to 17.8%). The importance of mass media on the other hand has significantly decreased since 1997 (60.0% to 32.1%). However, there is still ample space for improving the accessibility of information about HIV/AIDS. Some of the sources of information (e.g. parents, siblings, friends and religious institutions) could become more important in the future. When strengthening sources of information it is however crucial to also supervise the contents and accuracy of the information disseminated. The consultants were struck by finding a lot of wrong and inaccurate information circulating in society. Some of it was even strategically inserted into society in order to pursue institutional or personal interests (e.g. condoms being infected with the HIV/AIDS virus, condoms having holes etc.)

The findings of the KAP study show that students seem to know the term STDs. Many students were able to state the names of the most prevalent STDs in Tanzania. However, as with other subjects related to reproductive health their knowledge is very partial. Many of the students are not able do define the link between HIV/AIDS and STDs. In the questionnaires they either left the lines for explanations empty, they listed all the STDs they knew or they state that both is related to sexual intercourse. However, that there is an increased danger of being infected with HIV/AIDS when having STDs and vice versa was not mentioned by any student. Proper treatment of STDs should be propagated for all age groups, in order to reduce the probability rates of HIV/AIDS infection.

Since MEUSTA's capacity for becoming a strong provider for STD related information and for linking youth to service providers due to limited funds and human resources, it is suggested to mobilize other organizations within the existing network of related projects in Tanga (e.g. GTZ Family Health Project).

The relatively high percentage of students identifying prostitutes as a source of STDs points to the social perception of STDs being something "dirty and socially unacceptable". Advocacy in society with regard to STD prevalence and treatment should be undertaken, in order to promote a more balanced and neutral perception of the phenomenon.

The impact of such advocacy efforts can be controlled in a next KAP study, by assessing students' answers to possible means of avoiding STDs. If the percentages of students choosing the category of "using condoms" increases, while the percentage of "avoiding sexual intercourse with prostitutes" and "avoiding sexual intercourse with infected persons" decrease, the efforts can be declared as being successful. The category of avoiding sexual intercourse with infected persons should decrease, because not all STDs are discernible by laymen, they need to be medically diagnosed. The current perception of STDs being something "dirty and sinful" is a serious hurdle, preventing adolescents from seeking treatment for STDs.

Besides the above mentioned need for advocacy, it will be most crucial to improve the channeling of information to children and adolescents, especially with respect to sources of information within the social environment of the children (i.e. parents, religious institution, siblings and friends).

The consultants have been struck by the contradictions between data generated through the KAP questionnaire and data originating from focus group discussions (FGDs). In the questionnaire, many children indicate that they talk to parents of both sexes about reproductive health and HIV/AIDS. On the other hand, they firmly state in FGDs that they feel too shy to talk to parents and if they occasionally manage to overcome their shyness they strictly choose to address the parent of the same sex (i.e. girls to mothers, and boys to fathers).

As a basis for improving the flow of information within society, it may be necessary to conduct a small qualitative study about the transmission mechanisms of information in society. The term "talking to" must be more clearly defined. While students indicate in questionnaires that they "talk" to parents, they confess in FGDs that parents often just mention things without expecting feed-back. Children also complain about not getting the entire information they would like to get. An efficient strategy for the dissemination of information can only be designed on the basis of a sound knowledge about the actual practices with regard to communication within the families and society as a whole.

8.4.2 Of Parents, Imams, Sheikhs and Priests

Parents as a source of information deserve ample attention, as 63.7% of the entire sample of students indicate that they talk to parents about issues of HIV/AIDS. If children really talk as much to their parents as findings seem to suggest, more attention must be given to parents as a major source of information.

According to the KAP findings most of respondents indicated that they talk to parents of both sexes and one can only slightly discern that girls are more prone to talk with mothers alone and boys with fathers alone. However, as mentioned above, sexual segregation for discussions about issues of reproductive health and HIV/AIDS is still very much practiced. It is suggested that parents are encouraged to talk to children of the opposite sex through MISC training. Messages to girls from fathers about the male perspective of sexuality and male feelings/desires have been demonstrated to have an empowering effect on girls.

The KAP study reveals that the educational level of students' parents in the sample is relatively high (compared to national averages). There are slightly more mothers than fathers with no or incomplete complete primary education (17.6% vs. 9.4%). If analyzing the sample of parents with no or incomplete education, 65.1% are mothers. On the other hand, it is very encouraging to find 72.2% of mothers and 74.3% of fathers with complete primary education or above. Reasons for the relatively high level of literacy are unknown.

For the dissemination of HIV/AIDS information the relatively high level of literacy among parents is an advantage. Those literate parents can more easily be involved in the activities than others, as they are more capable of understanding and channeling information. At the same time, the existing methodology for informing and communicating with illiterate parents on the HIV/AIDS epidemic (role plays, etc.) must be contiued, as HIV/AIDS information is crucial for any citizen, regardless of academic achievements. These aspects must be integrated into the refinement procedures of the MEUSTA approach for parents.

The desire of being better informed about HIV/AIDS issues was expressed by parents in all places, where focus group discussions with parents were held. Many parents judge their own knowledge about reproductive health and HIV/AIDS as to limited for teaching their own children well. They fear being confronted with questions they may not be able to answer and they do not see any source of information, which is backing them up. Parents need to be supported in their willingness to transfer knowledge to their children through training and advocacy. Since HIV/AIDS is a reality, the question whether to teach children about reproductive health and HIV/AIDS or not is not any more only a question of cultural values and beliefs, but as much a question of life and death.

With regard to the above insights, MEUSTA's approach of reaching parents has to be modified during MEUSTA phase II. The following list shows a series of recommendations for transformation:

• Firstly, the category of parents needs to be widened by also including parents of out-of-school children
• Secondly, there is a need for adequate packages of information for parents of different educational levels
• Thirdly, the information packages recommended for children need to be age and gender specific. It is suggested to develop information packages for girls and boys, from pre-school age (e.g. anecdotes) to marriage age. There is no uniform pattern with regard to the need for information between girls and boys of different ages, as biological changes take place at different times. Girls and boys need to be informed about specific issues at the specific time, when the need for information arises.
• Fourthly, WRTs should cooperate with village leaders to disseminate HIV/AIDS information in villages. This should be done on the basis of a visit plan. The WRT members visiting the villages should consist of one man and one woman of the predominant tribe, who together relate the tribal concepts of sexuality the phenomenon of HIV/AIDS. The role of the DRT should be to prepare district specific information packages, while the RRT should be made responsible for the design of an overall information and animation pack for parents' information activities. The annual village visiting plan should be posted to walls of all public places in the ward.

With regard to religious affiliation, Islam is the far most prevalent religion in the KAP study sample (60.5% out of 878 individuals). The prevalence of Catholics 21.6% and Protestants 14.6 % is highly dependent on the historical roots of the villages chosen. Very often the villages were quite homogenous with regard to Christian religious affiliation. The fact of Muslim predominance must be taken into account when planning the future of MEUSTA's community mobilization approach, as religious leaders may play an important role in disseminating HIV/AIDS information. The existing MEUSTA approach of informing, training and involving them has shown to be adequate, as a change in the conviction of these people may be impossible for MEUSTA to achieve.

The above table shows data on the percentage of students talking about HIV/AIDS to religious leaders for the respective affiliation. The Catholic Church seems to be the most active one in disseminating information about HIV/AIDS in Tanga Region, as 31.1% of catholic students report to discuss with their religious leaders. The Catholic Church is followed by Islam (26.0%) and by the Protestant church (21.9%). For the design of future interventions within the network of social institutions it is crucial to take the absolute prevalence of a religious denomination, as well as the present intensity of respective denominations being involved in the dissemination of information into consideration. This is also an important insight with respect to replication of MEUSTA intervention in other regions of Tanzania.

For MEUSTA phase II it is recommended that the existing consensus on HIV/AIDS related issues is strengthened, in order to avoid religious leaders' obstruction against MEUSTA activities. If it seems to be within the capacity of MEUSTA to involve them in an even more proactive manner (religious leaders teach EDU according to the MEUSTA philosophy), it would enhance the sustainability of the project a lot.

Medical service delivery as such has not been defined as a planned MEUSTA activity. MEUSTA only aims at linking its target population, i.e. the students with the existing service delivery structure. There is no intention from the consultants side to suggest health service delivery by MEUSTA itself.

However, as certain aspects of service delivery have come up during the evaluation mission, the consultants decided to include the information into the report. This should allow other organizations (MOH, health related NGOs and bilateral projects) to get access to the information and to subsequently to take initiative for improving the situation.

8.5.1 Knowledge and Use of HIV/AIDS Testing Facilities

The KAP study shows that three quarters of the students seem to know where to seek assistance, in case someone wants to be tested. However, when looking specifically where students would want to seek assistance, it becomes apparent that their knowledge is quite limited. Roughly 30% of all students (urban and rural) mention dispensaries (27.7%) and health centres (32.8%) as potential testing facilities, although in reality testing is only possible at the level of district hospitals. A positive development from a health point of view is the fact that even in rural areas the traditional healers are not considered to be a major option for HIV/AIDS testing.

Another key issue is the fact that knowledge alone does not immediately and necessarily link with actual practices. Experience has shown, that the process from knowing where to go until an individual actually overcomes the fear of being tested is a very long one (Source: CCBRT Programme Manager, Dar es Salaam). There might also be social and financial barriers preventing young people to seek advice, counseling and testing services. The CCBRT Aids Programme widely disseminates simple small leaflets containing crucial information about where to go for a test without pressurizing on the reader to come immediately. Once a person is comes for testing he/she is intensively counseled before the testing is done. Counseling continues after testing, even if the person proves to be HIV negative, in order to assist the person in avoiding dangerous situation in the future.

To facilitate knowledge in society and more specifically among youth, MEUSTA could adopt a CCBRT like approach of disseminating leaflets as a powerful means of awareness raising within the community. For improving the actual access of young people to health facilities in general and specifically with regard to HIV/AIDS related services, guided visits to Service Delivery Points (SDP) might be a powerful instrument of raising awareness and improving accessibility. It is recommended that during MEUSTA phase II, DRTs and WRTs organize MEUSTA Club visits to the nearest SDP within the framework of a HIV/AIDS study tour. Since testing is carried out only at district hospitals, it is recommended that all staff at local SDP is instructed in counseling and guiding patients to HIV testing at district level.

If funds are available, it would be very helpful to bring HIV testing facilities closer to the community. As it is now only district hospitals offer HIV counseling and testing. An efficient and youth friendly counseling and HIV testing service delivery at reachable distance increases the percentage of HIV positive persons being identified and subsequently decreases the risk they pose to society. A properly counseled HIV positive person can not only better take care of him-/herself (health care, nutrition, etc.) but he/she may become more careful not to infect others.

8.5.2 Knowledge about Service Delivery Points for STDs

As presented in chapter 5.2.3 the, the policy guidelines define the range of clients welcomed for family planning as all persons in reproductive age, including adolescents male and female as much as men of all ages. In spite of this, it is common practice and understanding up to now, that those eligible for family planning are women, who have already been childbearing. The present-day interpretation and implementation of the government policy has several negative impacts on women:

• Women are more prone to pregnancy at a young age, extra-marital pregnancy, etc.
• Women alone are held responsible for reproductive control, leaving the men without responsibilities
• Women are more prone to HIV/AIDS/STDs due to a limited use of condoms
• Dissemination of crucial information is limited

The two tables below, however, show clearly that the guidelines set by the Ministry with regard to MCH service delivery have not yet taken momentum. It seems difficult to change the common perception of MCH Clinics being a service delivery point for pregnant women and mothers. As it is now, accessibility to reproductive health services is very restricted for young people.

8.5.3 Service Delivery from SDPs' Perspective

Parallel to investigations about health service delivery from the demand side (i.e. community/ students) the point of view of the supply side (i.e. Service Delivery Points (SDPs) and School Health Programme (SHP)) was assessed. The focus was on tracing WRT training and on analyzing division of responsibilities. It was observed that local health officers have a duty to serve schools within the catchment area of their respective SDPs, regardless of MEUSTA reinforcement. Some SDPs in Tanga Region are responsible for only one ward, while in other cases they are supposed to serve two to four wards.

Within the framework of the MOH School Health Programme, the illnesses listed in the box to the left are checked and treated, if necessary. Bearing in mind the high levels of early involvement in sexual intercourse by adolescents, the team of consultants suggests that the DMOs add STDs as an additional illness to be checked.

For assuring proper implementation of STD check-ups, it is proposed that all health staff undergo a brief orientation on the methodology of STD health care/ health talks with young boys and girls. This orientation could easily take place during the ordinary DMO-Health facility staff meetings.

Furthermore, it is recommended that the RHMT and DHMTs promote adolescent health care and services as a permanent agenda, in order to compliment MEUSTA efforts. In addition to the above mentioned health facility staff orientation on STD health talks (group guidance) to young boys and girls, the provision of adolescent sexuality training and the inclusion of STDs into school health might fall under their responsibilities.

In most cases a health staff, a clinical officer, a MCH aider or a PH nurse for health centres is also member of the WRT. At district level, the PH nurse and the In-charge of the SHP are members of the DRT. To consolidate the uptake of adolescent health issues in the existing MOH reporting structure it is suggested that all dispensary/health center staff, who are already doing outreach work, should be included as WRT members. They should specifically be given the responsibility of being the overall In-charge for adolescent reproductive health within the catchment area of the SDP.

8.5.4 Advocacy towards an Adequate Service Delivery

Denial of adolescents' involvement in sexual intercourse by some teachers, community leaders and parents could be observed in all wards visited during the evaluation. Ward specific data is needed for people to be convinced and decide on adolescent reproductive health services being accorded space at the nearest SDP. To minimize costs for such data collection, the questionnaire can be designed regionally and subsequently adapted to district conditions. It is suggested that at least one school from each ward should be included into the sample for data collection, firstly in order to guarantee ownership of information. Secondly, the locally generated data has an increased applicability for the respective location. It is anticipated that the study findings might help to create better understanding and guide efforts of accessing information and services to all those in need.

During the workshop, participants stressed that there is a need for guidelines for the provision of youth health services within the existing structures. They judged services for reproductive health, prevention and first aid, as well as an identification of youth health needs as the three most important fields for intervention and linkage. As further important services related to youth health, the participants mentioned: physical exercise, routine medical check-ups, advocacy and counseling, record keeping of youth health and fundraising for all of the above activities.

It is suggested that NNA in collaboration with other members of the AIDS NGO Cluster in Tanga thinks about supporting this study and a subsequent compilation of ward specific data (consolidated on district level) in leaflets.

The above mentioned information materials could for example contain the following information: ward specific information (compiled district-wise), age and sex disaggregated data on HIV/AIDS, antenatal care, delivery and child bearing by marital status, etc. In order to improve the support at ward level a clinical officer could be invited to give a speech about the ward STD profile based on his health facility records. Or, MCH staff could be invited to publicly explain about the dangers of early pregnancy.

Parallel to setting up a format for data collection and re-allocation/dissemination, health staff will need to be oriented about the procedures of keeping records by the DMO.

The consultants perceive ownership of MEUSTA as being diffused. To a large extent the MOEC owns the project through its control of EDU training guidelines, its responsibility for the interpretation of guidelines into curriculums and the design of training materials.

Ownership of the respective Local Governments is demonstrated by ownership of district infrastructure (schools, government offices, conference and training facilities), transport facilities and the human resources (government officials at district and ward level, teachers), which are at MEUSTA's disposal for its activities. In all districts DSTs willingly supplied transport to facilitate DRT mobility to rural areas.

The actual target group of MEUSTA, the school children of Tanga Region show high levels of satisfaction with MEUSTA. To reinforce the ownership of children, parallel interventions have been undertaken (community mobilization). This has been done in order to prevent social clashes between the EDU knowledgeable youth and the general community, which might not have had access to the same amount of information as the students. MEUSTA therefore chose to involve the most relevant segments of society, namely the parents, school committees, as well as religious and political leaders.

Ownership by the general community within which MEUSTA operates can be measured by the overall acceptance of MEUSTA activities. The MEUSTA intervention is very well accepted in all places visited during the evaluation and opposition to its activities, if at all existing, is limited to a few individuals who misconceive MEUSTA's mission. An overwhelming majority of interviewed community suggested that MEUSTA activities should be sustained by a collaboration between the community and the government after external funding comes to an end. Many individuals expressed gratitude for MEUSTA's comprehensive approach.

To increase ownership within the community, it is recommended that MEUSTA continues to involve religious leaders by informing them and respecting them and involving them into planning as much as common grounds are there. MEUSTA may consider to support religious leaders showing interest in the development of community mobilization plans for their specific religious denomination. This recommendation is valid for any other local organization with a potential for mass mobilization.

In the same line, sub-village and village government should be given accorded space within the MEUSTA planning process, in order to guarantee involvement and ownership at the lowest administrative level.

The consultants are not sure, whether the above mentioned institutions had been adequately animated, in order to enable them fully to include HIV/AIDS as a permanent agenda within their respective institutional set-ups. If the animation has been insufficient until now, there is a urgent need to change the situation immediately, as the sustainability of MEUSTA after NNA funding depends largely on the level of ownership by those institutions.

It could be one major activity of MEUSTA phase II to invest into the continued sensitization of those segments of the community. Thereby attention must be given to providing sound knowledge about HIV/AIDS issues, to furnish the them with a set of scientific argument for a chose intervention strategy (e.g. with regard to STDs or condoms) and to acquaint them with efficient forms of information dissemination. Many of these institutions run separate activities for women, children and adolescents, which could be used as a forum for age or sex specific sensitization. In addition, MEUSTA should be careful to assure sufficient male involvement within each institution, in order to avoid "veto situations".

For MEUSTA phase II, it is suggested that the RRT, the RST, DRTs and WRTs focus on positively influencing the development plans of CBOs as much as their position allows it. It is expected that the accessibility of quality information will be improved and that some CBOs with raised awareness and dedication would want to allocate funds for HIV/AIDS community work.

As mentioned before, the compilation of district specific data and eventually health facility information might be very useful for advocacy work. MEUSTA having the background knowledge for the compilation of such data already might consider supporting an initial round of data collection and presentation, with as little funds as necessary. The experience of the first round should be enough for Local Governments to take over financial and technical responsibility.

The main suggestions of participants during the feed-back workshop with regard to sustainability were:

• Councils should start to budget for MEUSTA activities
• Local Government should stipulate responsibilities for resources
• The right selection of appropriate people should take place for assigning them with clear MEUSTA duties
• MEUSTA is to be part and parcel of the District Health Team

In the course of evaluation, financial sustainability of MEUSTA beyond NNA funding was explored upon during the focus group discussions with the community. Community members repeatedly pointed out four specific sources, namely the District Council, Ward Development Committees (WDC), Village Governments and parents (via school fees). Each one of these sources will be discussed in the following sub-chapters, followed by a brief comment on the role of external donors.

On the whole, district officials who are currently serving as DST or DRT members are optimistic that the District Council will allocate a certain amount money, although certain doubts and fears persist. Likewise, ward leaders within the WRT indicate their willingness to contribute within their financial limits if they are shown a way to successfully raise and allocate money. The same response was given to the consultants by village leaders as well.

9.2.1 Council funds

The DED in Korogwe acknowledged that the district will have to set aside a recurrent budget for MEUSTA, for the project to be sustainable. For gaining sufficient support among influential persons, it is of paramount importance that MEUSTA activities are well understood and based within the community MEUSTA is operating in. The most important institutions with regard to decision making are the Full Council, the finance committee, the District Management Team, and on ward level the Ward Development Committee. The DED in Korogwe was of firm conviction that enough support can be found, if advocacy and lobbying start now. Nearly all DEDs asked for receiving a MEUSTA budget forecast as soon as possible, in order to be begin the projection of expenditure after the year 2001.

It is proposed that MEUSTA develops a budget that clearly indicates the baseline for Local Government and NNA funding. As a start, MEUSTA has to come up with a temptative budget forecast, which can be adopted by the Local Government after in-depth analysis, discussions and negotiations. This budget should be outcome of a collaboration between DRT and DST members, who design the budget during department meetings and subsequently submit it to the respective District Council.

As emphasized before, the HIV/AIDS phenomenon relates to several sectors (education, health, community development, deployment of human resources and finance). Therefore members of the respective council committees should adopt it as a subject within the sectoral agenda, in order to report in the Full Council, which subsequently has the final financial decision-making power over different budget lines. During this preparatory phase for take-over, it is very important for MEUSTA to keep the councillors informed about the developments, plans and decisions.

As potential sources within the council funds the 30% retention scheme on crop levy and the 20% retention on development levy were mentioned. A suggested example was to provide 3% of the income to each school and to set aside 5% for HIV/AIDS related activities benefiting adolescents in the district.

With regard to MEUSTA's sustainability, district officials were worried about the materials available at schools. They informed the consultants of repeated complaints about the lack of teaching and training materials, as well as reference materials. As mentioned in chapter 7.3.2 the initial provision of books and teaching aids to schools has been sufficient (two students per book, 4-5 teachers' manuals), but some of the materials seems to have gone lost.

For phase II, it is suggested to motivate the schools themselves, the village or ward government to work out a strategy (including budget) for replacing the lost material. Responsibility for teaching materials should lay at the level where it is most used. For reference material, MEUSTA could consider to select a few recent and informative books and make them accessible to primary schools or later on to MEUSTA Club libraries within the planned youth centres. It might be desirable that the DST/DRT collect views from teachers about which books to order as reference and additional reading materials for teachers. Organizations, which could be contacted for a list of available publications include UMATI, TGNP and EMAU. The budget for this should be shared between MEUSTA and respective local governments.

With concern, almost all district officials noted low overall cash collections from development levy. In recent years, for example Handeni District council could only raise 50% of the projected collections. In view of the low realizations, some District heads were skeptical on whether EDU could supersede personnel and transport costs as well as councillors’ allowances.

Probable constraints towards achieving desired tax include firstly a low preparedness of citizens to pay tax and secondly, weather fluctuations which in turn can influence crops harvested and related revenue (crop levy). Thirdly, the control of product marketing is difficult, especially for products having many channels of marketing. Fourthly, the fact that only men pay development tax is a further limiting factor. The implications of exempting women from paying development without careful analysis and consensus on gender contribution towards productive and reproductive activities could be holding up a lot of revenue that could otherwise be available for development work for the local government. As a strategy for increasing local government revenue it is recommended that district authorities conduct a study on productive and reproductive gender labour contribution using PRA methods, whereby community members themselves will be given a chance to make an input on how to solve the problem.

9.2.2 School fees

Another source of funds could be from school fees, either as a part of the existing school fees or by slightly rising the level of school fees. This suggestion was made by district officials, as well as by parents themselves. The fact that parents show a willingness to contribute from their pockets is a sign that they are very concerned about the risk HIV/AIDS poses to their children and that they are satisfied with MEUSTA.

The District Council on behalf of parents could collect contribution towards EDU activities as part of school fees. It has to be very clearly explained and justified to parents and students, how the money collection and reallocation system works, and in what ways their children benefit. It has been mentioned again and again that mutual transparency and accountability of the highest order is of paramount importance.

District top officials cautioned The district top officials however, cautioned that MEUSTA activities have to be really community based for obtaining general consensus over expenditure.

9.2.3 Ward Development Committee (WDC) Funds

20% of development levy collections are returned to respective wards they were collected in. As mentioned in chapter 9.2.1, the actual cash collection depends on several external and internal factors. Regardless of the ward's financial situation, it must be of first priority to mobilize the WDC to become involved in HIV/AIDS work and to create space for recurrent budget expenditure to the epidemic. During phase II, the role of MEUSTA should be to sensitize WDC to support the dissemination of EDU for youth irrespective of their schooling status, so that the wards will overtime take own initiative within the limits of the available resources.

9.2.4 Village Governments

Village governments were identified as another potential sources of funds. At the village level, crop levies, fines for crop destruction through livestock ("mihambulo"), crop licenses and other levies/fees contribute to the budget. The financial capacity of villages differs according to socio-economic characteristics of the village. The consultants were informed that some villages manage to raise enough money to put up classrooms, host meetings and pay allowances to leaders. Almost all interviewed village government officials sounded positive about contributing to the battle against HIV/AIDS.

The village government officials boasted about the influence they have on the mobilization of villagers. Many officials indicate willingness to use this capacity for activities with regard to HIV/AIDS, however, that they lack sufficient knowledge to properly inform their citizens. The interviewed leaders affirmed that village governments would like more information for further distribution to the households in their areas. People are thirsty for expert consultation about the disease. They hear on the radio about the disease but they cannot respond to the radio. Like for radio, they cannot respond and probe after reading newspapers and posters. They would like human contact, someone who can give them expert advice and guidance about the problem.

Therefore, it is recommended that in phase II MEUSTA attempts to support village governments to include HIV/AIDS as a development agenda, which deserves resource allocation (cash and infrastructure).

9.2.5 Donor assistance

In a few cases, DEDs mentioned that they might try to raise funds for continuation of MEUSTA from donors working in their district, as they assume local fundraising as impossible. It is suggested that, where chances arise, the RAS and DED should encourage technical staff to develop fundable project proposals to cover all young people below age 18 years with HIV/AIDS information and services, if necessary. In the same line, it is recommended that DRTs with assistance from RRTs develop project proposal concept papers to address both in school and out of school EDU.

For advocacy and lobbying work with regard to raising local funds for sustaining MEUSTA activities, it is necessary to set up a strong database, which can serve as a basis for negotiating about the necessity of an intervention. The following table shows an example of a set of indicators for with regard to adolescent reproductive health. For each indicator the responsible institution for keeping records is indicated in a separate column.

It is expected that data on the indicators mentioned below, serves as a sufficient justification of an intervention in the field of adolescent reproductive health and HIV/AIDS preventive education for in- and out-of-school youth.

Based on all observed strong points and opportunities at MEUSTA's disposal and taking into account the weaknesses and threats mentioned, the team of consultants suggests that MEUSTA should continue to work towards attaining its three goals. In addition, it is suggested to add a two more goals. A fourth goal, which covers the handover of MEUSTA activities to Local Government (transition and sustainability) and a fifth goal dealing with the future of project fixed assets and human resources.

9.4.4 Goal 4: To ensure MEUSTA sustainability

The following table shows a possible scenario of how present day MEUSTA activities could be continued after 2001 (second column). In the third column the reader may find indication about the changes necessary during MEUSTA phase II, in order to ensure a smooth take-over of funding through the Local Government.

For improving the situation, the responsible persons suggested that the DSTs/DRTs are given more autonomy over timing of MEUSTA activities, as they are closer to the ward level. In addition, WRTs suggest increasing the level of decision-making at ward level by generating and reallocating funds for MEUSTA project activities on ward level.

To increase ownership within the community, it is recommended that religious leader should be more involved in the planning of MEUSTA activities. This may even enhance the development of community mobilization plans for specific religious denominations through the religious leaders, who had been involved in MEUSTA planning. This recommendation is valid for any other local organization with a potential for mass mobilization. In the same line, sub-village and village government should be given accorded space within the MEUSTA planning process, in order to guarantee involvement and ownership at the lowest administrative level.

The consultants are not sure, whether the above mentioned institutions had been adequately animated, in order to enable them fully to include HIV/AIDS as a permanent agenda within their respective institutional set-ups. If the animation has been insufficient until now, there is a urgent need to change the situation immediately, as the sustainability of MEUSTA after NNA funding depends largely on the level of ownership by those institutions.

It could be one major activity of MEUSTA phase II to invest into the sensitization and training of those segments of the community. Thereby attention must be given to providing sound knowledge about HIV/AIDS issues, to furnish the trainees with a set of scientific argument for a chose intervention strategy (e.g. with regard to STDs or condoms) and to acquaint them with efficient forms of information dissemination. Many of these institutions run separate activities for women, children and adolescents, which could be used as a forum for age or sex specific sensitization. In addition, MEUSTA should be careful to assure sufficient male involvement within each institution, in order to avoid "veto situations".

For MEUSTA phase II, it is suggested that the RRT, the RST, DRTs and WRTs focus on positively influencing the development plans of CBOs as much as their position allows it. It is expected that the accessibility of quality information will be improved and that some CBOs with raised awareness and dedication would want to allocate funds for HIV/AIDS community work.

The number of training session conducted for different target groups (DRTs, WRTs, EDU teachers, etc.) and the number of trained individuals is very large. For its achievements with regard to training, MEUSTA definitely deserves compliments. It is however recommended to increase efforts of quality control, as the team of consultants have realized that some of the trained persons do not adequately channel down the training they received to the respective target populations.

The efficiency of conducted training sessions must be judged by analyzing in what way the training reaches the intended end-receiver, i.e. the students. Students reported that many teachers still feel shy when teaching EDU. It is recommended that future training of EDU teachers includes a component for enhancing teachers' confidence when teaching issues of reproductive health.

The amount of materials produced is quite impressive, however, the consultants advice to be more careful with the design of materials. Any item should carry a specific message with regard to HIV/AIDS and MEUSTA activities. A calendar showing a group of adults says very little about MEUSTA's work. With the same amount of money spent, MEUSTA could increase its impact by more carefully designing the publicity material. Courses run by the Centre for African Family Studies (CAFS) in Nairobi might be a good source for selected MEUSTA staff to improve their skills in designing informative and effectively targeted publicity materials.

Community mobilization activities have been undertaken to a satisfactory extent. However, future community mobilization could become more efficient by targeting the sessions more specifically. The KAP study has shown that religious leaders and the parents' attitude and level of knowledge have a great influence on HIV/AIDS information dissemination. Therefore it might become very advantageous to invest more into the most influential groups, while leaving others a little bit more aside.

KAP findings have shown that the SHP and the related visits of PH Nurses are not executed as planned. It must therefore be concluded that the accessibility to health facilities has not been improved to a satisfactory extent. If the school visit approach does not seem to be practical (financial and time constraints), other ways of connecting the students to available health services must be looked for. One potential alternative is to organize trips to the nearest functional service delivery point with the students, in order to acquaint them with the availability of health services.

For the sake of more efficient transmission of information, MEUSTA is advised to select its mobilization methodology more strategically. The consultants strongly recommend that the argumentative catalogue of MEUSTA for raising awareness and introducing attitudinal and behavioural change in the community, by arguing more from the points of view of quality of life and health.

With regard to the information MEUSTA generates, the potential is not fully exhausted. MEUSTA has a lot of valuable information, which could be used more efficiently in community mobilization work. The consultants thereby specifically refer to KAP findings (e.g. that a good percentage of Standard VI&VII students are sexually active, that their ignorance of reproductive health bears dangers, that religious leaders and parents are important interlocutors, etc.).

One general comment on the definition of goals, specific objectives and subsequently of activities must be stated here. There seems to be some confusion within the logical framework of MEUSTA planning and reporting. The team of consultants observed that there is not always a strict compliance of activities to a specific goal. In some instances the activities are interchangeably listed under different goals, in other instances activities are meaningful, but do not fit under any specific objective at all, etc. For improving donor attractivity it is recommended that MEUSTA staff go through their logical framework of planning and subsequent planning.

It is encouraging to note the MOEC guidelines have given much space for preventive education to adolescents. The above described drawbacks of the way HIV/AIDS/STDs guidelines has been translated into syllabi and curricula of different subjects for different classes is serious. If EDU will not modified soon toward incorporating in-depth information one should not be astonished if many of the ex-EDU students will get wiped out by the epidemic.

An additional problem is the fact that many teachers do no comprehend the dimensions of adolescent sexuality and that many of them still feel reluctant to address issues of sexuality. Although MEUSTA has done a first step of enhancing teachers' confidence with respect to teaching HIV/AIDS a lot remains to be done.

The existing health policy can be criticized for its lack of gender sensitivity. For example, only women and mothers are targeted for family planning services, leaving male and female adolescents in reproductive age aside. In the same line, other issues, which affect women's health are not mentioned at all (e.g. abortion practices). Furthermore, no sanctioning mechanisms with regard to hospitals' disrespect of exemption from cost-sharing for MCH and chronic diseases are accorded to patients. There is ample space for interpretation when identifying individuals suffering from chronic diseases, such as HIV/AIDS. It is recommended the existing policy be reviewed to incorporate gender issues and HIV/AIDS.

10.5.2 National District Health Planning Guidelines

The Ministry developed guidelines for district health planning to guide primary health care service and delivery for which the local Government is responsible over dispensaries and health centres. Although the guidelines have improved district planning, adolescent health has not yet been accorded the weight it has with respect to the HIV/AIDS situation. HIV/AIDS/STDs the following changes are recommended:

• Records on STD prevalence must be kept for both sexes, women and men
• The broad category of adults of ages 15 to 45 must be further segregated into smaller units
• Adults above age 45 may have sexual health needs as well and must be included as a category
• The category of out-of-school children must be added

There is an overall need for the guidelines to become more sensitive to gender issues and differences with regard to the diagnosis and treatment of STDs and in particular HIV/AIDS.

10.5.3 The Family Planning Policy and Services Standards Guidelines (1992)

Language barriers may be partly responsible for the fact that some service providers and many teenagers themselves are not aware of the policy guidelines. While the guidelines are only published in English, the basic health care providers communicate in Kiswahili and not in English. In spite of this shortcoming, some health care providers reported that the document had given them valuable back-stopping during advocacy work with community leaders who were initially strongly opposing against the provision of reproductive health information and services. The examples show, that the extended dissemination of the guidelines might support advocacy work at all levels.

Future information campaigns against HIV/AIDS need to recognize that HIV/AIDS is a part of an overall entity of reproductive health and that HIV/AIDS cannot be addressed without the basics of reproductive health. The Family Planning Policy and Services Standards Guidelines document is currently being reviewed to incorporate shift towards Reproductive Health and Child Health. Hopefully, this MOH programme will be supportive of current efforts within the school-based AIDS education programme to channel down crucial information down to the grass roots. It might be in the interest of NNA to sponsor some preparatory activities with regard to lobbying and advocacy, which could be important for the sustainability of MEUSTA.

10.5.4 National Policy on HIV/AIDS/STDs

In view of the fact that many adolescents are practicing sexual intercourse, adolescent sexuality needs to be pointed out as a separate policy issue within the national policy. Adolescents and adults can not be treated under the same umbrella with regard to preventing sexual transmission of HIV/AIDS. As it is now, the policy is not specific enough about how young people should be informed and treated and therefore there is ample room for individuals and organizations to interpret the policy according to their respective understanding/perception of the situation. This leads in many cases to a denial of access to information and services for adolescents in need. It would be very helpful, if the policy was more explicit for example about the logistics of condom information and service delivery through existing service infrastructure.

Taking these government guidelines and policies as a basis, MEUSTA has great potential to become an even more important institution for the population of Tanga Region. MEUSTA already has established functional channels for the dissemination of HIV/AIDS related information, DRT and WRT members and teachers are already trained and MEUSTA is accepted within society.

In view of this situation, the next step for MEUSTA to take is the design and dissemination of age specific information packages, which include all the information young people need to protect themselves from being infected, including issues of sexuality, reproductive health and condom use. Suggested age categories are a) below 10, b) ages 10 to 14 and c) 15 and above. This task can be accomplished in collaboration with Local Governments, which have the disposition for delivering information packages designed for different age groups.

As a parallel activity for phase II, MEUSTA is advised to publish policy and programme implications of their experiences and insights.

It is recommended that MEUSTA encourages each DRT/DST to collaborate in laying a sound foundation for meaningful generation of data sets with regard to HIV/AIDS in their district. It is anticipated that this data, if updated annually, has a big potential of becoming an important benchmark for assessing MEUSTA impact. Furthermore, it can be useful for lobbying and advocacy work, as well

To improve data collection on AIDS prevalence, DMOs suggested the syndromic approach should be used for diagnosing of AIDS patients, whereby two major signs and two minor signs are indication enough to diagnose AIDS. Where possible, the diagnosis should be confirmed by Elisa testing after professional counseling. It is furthermore suggested that health care at all levels (dispensaries, health centres, etc.) are included for broadening the basis for estimating AIDS prevalence within each district. Currently, efforts in this direction are in a preparatory stage at district level. It is planned to conduct Training of Trainers sessions for clinical diagnosis, in order to multiply initial training inputs (source: DMO Lushoto). It is anticipated the MOH and NACP will prepare ground for this by issuing circulars through the RMO.

All in all, the conceptual framework of the disease needs to be synthesized and future interventions should take the gender perspective of HIV/AIDS sufficiently into account. It is recommended that during phase II the RRT, RSC, DSTs and DRTs undergo sharpen their awareness on the gender specific implications of the epidemic, in order to enhance the implementation of a gender sensitive HIV/AIDS intervention strategy in the long term. In order to allow the implementation of such intervention strategies, more baseline data and understanding about the nature of the disease with respect to gender issues is necessary. For that purpose it will be necessary to conduct precisely focused studies. The more comprehensive the concept of HIV/AIDS phenomenon in Tanzania becomes, the better the affliction of the disease to human populations can be minimized. Future Perspectives

To keep track of MEUSTA's long term impact, it is suggested that district officials keep records of the HIV/AIDS trend for districts and even wards, where possible. It is proposed that with RSC approval, the RRT collaborates with district teams in order to project the situation at current infection rates.

It is strongly recommended that the MEUSTA network agrees on the variables to be recorded (e.g. HIV prevalence among different samples, AIDS cases admitted to hospitals, etc.), on the recording frequency (annually, semi-annually, etc.) and on the recording format (desegregated data for sex, age, etc.) in phase II of project implementation.

Packaging information in popular format will ensure its reallocation to the grassroots communities, who are the primarily affected ones. The information could for instance be strategically disseminated during special events like the MEUSTA week and the World AIDS Day.

Another simple technique for the dissemination of information is printing leaflets. With a shared computer, a photocopier and paper, one page leaflets containing crucial information can be easily be made. Existing channels of information dissemination can be utilized. It is proposed that in phase II DST/DRT of each district compile the existing information and mold it into a reader friendly and informative format. Frugality should be exercised to enable local governments sustain this type of record collection and compilation for their own use at the district level after NNA funding comes to an end.

It is strongly recommended that the districts come to a consensus about data to be collected. For lobbying activities with regard to Local Government contribution to in-school and out-of-school EDU each district needs to have annually updated records on agreed indicators, such as for example prevalence of HIV infection, AIDS cases, STD cases and early pregnancy/childbearing (under 18). Only by supporting lobbying arguments with statistical facts about the real state of affairs with regard to adolescent sexuality and HIV/AIDS councillors will be willing to allocate funds for prevention.

It becomes apparent that there is a quite large number of young people who never get primary education, although the policy of MOEC prescribes Universal Primary Education. As these adolescent do not get access to EDU in school, there must be a complementary intervention to target out-of-school youth.

The fact that many children are outside the school system (either never enrolled or dropped out) poses a serious challenge to the dissemination of HIV/AIDS information. It points to the reality, that school-based dissemination of information can not suffice the purpose of safeguarding the young generation from being infected with HIV/AIDS.

There is a need for further quantification and characterization of this out-of-school youth, in order to design an appropriate way of providing them with HIV/AIDS information. It is suggested that CDOs in collaboration with Ward Education Coordinators and Ward Executive Officer are made responsible for immediate action. It might fall into MEUSTA phase II activities to facilitate the set-up of a reliable data base on out-of-school youth, as a reference for future planning efforts (clear definition of categories to be recorded, format of recording).

It is recommended that Local Governments look into this development by setting up a school-based data collection on parents' status. It has repeatedly been shown that HIV/AIDS infection of parents (prolonged care of the sick and eventual loss of parents) has serious negative effects on school attendance.

There must be put an end to EDU teachers emphasizing on easily spelled out dangers out of the fear of "kuonyesha utovu wa heshima" and the hope issues of sexuality will be clarified by themselves. In focus group discussions with students the consultants realized that the fear of being infected is very widespread among children, and many of them mention that they need more detailed information about reproductive health and HIV/AIDS in order to feel safer. It thus recommended that EDU in subsequent MEUSTA phases becomes more explicit about sexual intercourse being the most frequent way of HIV transmission, as well as about issues of reproductive health in general. As mentioned above, EDU has to speak a clearer language in order to avoid confusion within children's and adolescents' heads.

As shown by the data, the danger of not being able to identify those who are infected but who do not yet show visible signs of being infected is widely underestimated. People need to be made more aware that the timespan between a HIV infection and the outbreak of firsts signs of being infected can be a long one (even years!). A major thrust to disseminate information in that sense is urgently needed and that , there is still a long way to go. MEUSTA should be working more intensively to increase the percentage of students seeing a danger in HIV infection being difficult to identify, as lack of knowledge about this fact can be very dangerous.

With respect to the fact that a good proportion of children and teenagers are not attending school, it is imperative that specific strategies for communication must be developed to reach out-of-school youth as much as in-school youth. For phase II, it is therefore recommended that MEUSTA intensifies its efforts of identifying and developing communication strategies that easily reach in- and out-of-school youth.

Study findings show that among those who had planned sexual intercourse, boys comprise 80.7%. This is an indication that boys are the initiators for the majority of sexual acts at young age, while girls are more often pulled into it. Young people need to be informed on the potential negative consequence of sexual intercourse, such as pregnancies, and young girls especially need to be empowered on decision-making with regard to their own sexuality.

In response to the question why they had intercourse both boys and girls scored natural feelings and experimentation highest. This reveals a very important fact: the vast majority of young people do not have sex, because they are tempted or forced, but because their body develops and with this process of maturing the desire to have sexual intercourse and to experiment with the developing organs increases. These natural feeling are still very much denied in society, and it is time for things to change.

HIV/AIDS being a widespread reality, it is scary to know that more than 61.9% of all young people being involved in early sexual practices have never been using condoms. The percentage of unprotected sexual intercourse might even be higher, taking into account that those who confessed having used a condom once, have not necessarily used it for all their episodes of sexual intercourse. There are obvious physical barriers to use of condoms by boys (size of penis), however, ingenious young people concerned with their own health and survival have found ways to overcome these limitations. In several schools young boys informed the mission that they tied oversize condoms with rubber bands to fit the size of the penis. Others reported to circumvent the inaccessibility of condoms by scavenging in the garbage deposits of guesthouses, yet others wash and keep a previously acquired condom for reusing it. These observations point to the need of explicit condom information and an accessible condom distribution service.

Any intervention on sexuality for adolescents needs to take the existing gender differences into account. Girls may need more reassurance to become the primary decision-makers about their own sexuality, boys may need more counseling on how to cope with the sexual feelings with arise in puberty without putting their lives at risk.

The fact that sexually active adolescents are a reality, has an important consequence for the education strategy and the dissemination of information with respect to HIV/AIDS and STDs. The previous practice of relating any early sexual contact with "vishawishi" (temptations) and "uasherati" (prostitution or promiscuity), unless society is willing do declare at least 40% of their in school youth as little prostitutes. These terms are also very undesirable from a gender point of view, as they suggest that the main problem lies in young girls unable to resist. Sexual feeling come up in adolescents as they grow older, and it is nothing but natural that the youth starts to experiment. Experience shows that sexual intercourse among adolescents can be delayed by acknowledging their sexual feelings and counseling them on how to deal with those feelings. In addition, such counseling has proven to induce overall behavioural change towards responsible reproductive practices.

Also, it is scientifically proven that 90% of all HIV infections in Tanzania occur through sexual intercourse. The sole emphasis on sharp instruments for piercing ears, injection needles and circumcision knifes has to give way to a stronger emphasis on sexual intercourse as being the most important means of HIV transmission.

Proper treatment of STDs should be propagated for all age groups, in order to reduce the probability rates of HIV/AIDS infection.

It is suggested that parents are encouraged to talk to children of the opposite sex through MISC training. Messages to girls from fathers about the male perspective of sexuality and male feelings/desires have been demonstrated to have an empowering effect on girls.

Parents need to be supported in their willingness to transfer knowledge to their children through training and advocacy. Since HIV/AIDS is a reality, the question whether to teach children about reproductive health and HIV/AIDS or not is not any more only a question of cultural values and beliefs, but as much a question of life and death.

With regard to the above insights, MEUSTA's approach of reaching parents has to be modified during MEUSTA phase II. The following list shows a series of recommendations for transformation:

• Firstly, the category of parents needs to be widened by also including parents of out-of-school children
• Secondly, there is a need for adequate packages of information for parents of different educational levels
• Thirdly, the information packages recommended for children need to be age and gender specific. It is suggested to develop information packages for girls and boys, from pre-school age (e.g. anecdotes) to marriage age. There is no uniform pattern with regard to the need for information between girls and boys of different ages, as biological changes take place at different times. Girls and boys need to be informed about specific issues at the specific time, when the need for information arises.
• Fourthly, WRTs should cooperate with village leaders to disseminate HIV/AIDS information in villages. This should be done on the basis of a visit plan. The WRT members visiting the villages should consist of one man and one woman of the predominant tribe, who together relate the tribal concepts of sexuality the phenomenon of HIV/AIDS. The role of the DRT should be to prepare district specific information packages, while the RRT should be made responsible for the design of an overall information and animation pack for activities with parents. The annual village visiting plan should be posted to walls of all public places in the ward.

For the design of future interventions within the network of social institutions it is crucial to take the absolute prevalence of a religious denomination, as well as the present intensity of respective denominations being involved in the dissemination of information into consideration.

For MEUSTA phase II it is recommended that religious leaders will be involved in a more proactive manner in order to finally convince them to include HIV/AIDS into the development agenda of their community, if they had not done so before. For the sake of MEUSTA sustainability it is mandatory to begin at the very onset of phase II with those activities of awareness raising.

There is need for more information among young people about condoms, as different institutions disseminate contradictory information (especially fundamentalist church organizations are very prone to distort information according to their needs). Condoms should be introduced as a simple, cheap and efficient technology for preventing pregnancies and HIV/AIDS, as it is scientifically proven. Barriers to condom use should be gradually reduced, as they endanger the health of sexually active persons (young and old). It is crucial to disseminate more explanation about the proper use of condoms (how to check quality, how and when to put them, how and when to remove and throw them away).

Examples from success stories with regard to condom promotion need to be made more public(e.g. AIDS campaign in Uganda). Eventually, it might prove useful for few to conduct a study tour to Uganda for anti-condom-hardliners in phase II, where the Catholic Church courageously started to promote condoms and thereby managed to reverse the escalating trend of HIV/AIDS.

As a consequence of health staff being part of the institutional set-up of MEUSTA, the health sector has been adequately involved in setting objectives, planning activities, implementation, monitoring and supervision. Contributions of medical expert were part and parcel of the training courses provided by MEUSTA at all levels. Their contributions included the facilitation of sessions requiring medical expertise (e.g. information about specific medical aspects of HIV/AIDS, etc.). For subsequent phases, it is recommended that the health aspects are increasingly included into training sessions, especially with regard to reproductive health. There is a need for medical back-stopping, when designing the information packages for children and adolescents at different ages, in order to include profound medical knowledge about adolescent sexuality and its medical limitations and dangers.

Health staff reported that they only manage to visit schools in walking distance from their homes and work places. Although MEUSTA put effort in encouraging health staff to reach out to all school in their area, remote schools are only rarely visited. The evaluation mission explored from students’ angle about their exposure to health care providers, who in most cases are nurses. Responses indicate that students do not have a clear concept of when the nurse is coming and what exactly she is coming for. There is an immense need for clarification about the PH nurses' issues.

Planning Committees at village and ward level might consider to support local health staff in their endeavour to visit their respective schools. It is proposed that, during phase II MEUSTA facilitates the mobility of health care officer to distant schools, an activity which is very likely to be sustained by the ward itself in the future. Furthermore it is recommended that the health person being member of the WRT assists in the design of an annual schedule for school visits, which should be should be discussed and agreed upon by both the DMO and the DEO

It is recommended that during MEUSTA phase II, DRTs and WRTs organize MEUSTA Club visits to the nearest SDP within the framework of a HIV/AIDS study tour. Since testing is carried out only at district hospitals, it is recommended that all staff at local SDP is instructed in counseling and guiding patients to HIV testing at district level.

As presented in chapter 5.2.3 the, the policy guidelines define the range of clients welcomed for family planning as all persons in reproductive age, including adolescents male and female as much as men of all ages. In spite of this, it is common practice and understanding up to now, that those eligible for family planning are women, who have already been childbearing. The present-day interpretation and implementation of the government policy has several negative impacts on women:

• Women are more prone to pregnancy at a young age, extra-marital pregnancy, etc.
• Women alone are held responsible for reproductive control and planning, leaving the men without responsibilities
• Women are more prone to HIV/AIDS/STDs due to a limited use of condoms
• Dissemination of crucial information is limited

The two tables below, however, show clearly that the guidelines set by the Ministry with regard to MCH service delivery have not yet taken momentum. It seems difficult to change the common perception of MCH Clinics being a service delivery point for pregnant women and mothers. As it is now, accessibility to reproductive health services is very restricted for young people.

Service Delivery from SDPs' Perspective: Bearing in mind the high levels of early involvement in sexual intercourse by adolescents, the team of consultants suggests that the DMOs add STDs as an additional illness to be checked.

For assuring proper implementation of STD check-ups, it is proposed that all health staff undergo a brief orientation on the methodology of STD health care/ health talks with young boys and girls. This orientation could easily take place during the ordinary DMO-Health facility staff meetings.

Furthermore, it is recommended that the RHMT and DHMTs promote adolescent health care and services as a permanent agenda, in order to compliment MEUSTA efforts. In addition to the above mentioned health facility staff orientation on STD health talks (group guidance) to young boys and girls, the provision of adolescent sexuality training and the inclusion of STDs into school health might fall under their responsibilities.

In most cases a health staff, a clinical officer, a MCH aider or a PH nurse for health centres is also member of the WRT. At district level, the PH nurse and the In-charge of the SHP are members of the DRT. To consolidate the uptake of adolescent health issues in the existing MOH reporting structure it is suggested that all dispensary/health center staff, who are already doing outreach work, should be included as WRT members. They should specifically be given the responsibility of being the overall In-charge for adolescent reproductive health within the catchment area of the SDP.

Advocacy towards an Adequate Service Delivery: Denial of adolescents' involvement in sexual intercourse by some teachers, community leaders and parents could be observed in all wards visited during the evaluation. Ward specific data is needed for people to be convinced and decide on adolescent reproductive health services being accorded space at the nearest SDP. To minimize costs for such data collection, the questionnaire can be designed regionally and subsequently adapted to district conditions. It is suggested that at least one school from each ward should be included into the sample for data collection, firstly in order to guarantee ownership of information. Secondly, the locally generated data has an increased applicability for the respective location. It is anticipated that the study findings might help to create better understanding and guide efforts of accessing information and services to all those in need.

It is suggested that NNA thinks about supporting this study as a major step for ensuring sustainability of MEUSTA. In addition, NNA could consider facilitating the production of information materials (leaflets) which contain the ward study finding in each district. MEUSTA might even try to seek assistance within the AIDS NGO Cluster in Tanga, in order to find a complementary source for funding.

The above mentioned information materials could for example contain the following information: ward specific information (compiled district-wise), age and sex desegregated data on HIV/AIDS, antenatal care, delivery and child bearing by marital status, etc. In order to improve the support at ward level a clinical officer could be invited to give a speech about the ward STD profile based on his health facility records. Or, MCH staff could be invited to publicly explain about the dangers of early pregnancy.

Parallel to setting up a format for data collection and re-allocation/dissemination, health staff will need to be oriented about the procedures of keeping records.

Institute of Education Tanzania, 1996

Mwongozo wa kundisha elimu ya kujikinga na Ukimwi. Shule ya Msingi

Dar es Salaam

MEUSTA, 1998:

The Meusta Training Manual, Vol. 1&2

Tanga

MOEC, 1990:

Elimu Dhidi ya Ukimwi. Kiongozi cha Mwalimu kwa Shule za Msingi/ Vyuo vya Ualimu Daraja "A" na "B".

Dar es Salaam

MOEC, 1996:

Guidelines for HIV/AIDS/STDs Preventive Education for Schools

Dar es Salaam

MOEC, 1998:

Kinga. Elimu ya Afya ya Kijikinga na Magonjwa ya Zinaa na Ukimwi

Dar es Salaam

MOH/ NACP, 1995:

National Policy on HIV/AIDS/STD. Draft

Dar es Salaam

MOH/NACP, 1997:

National AIDS Control Programme. HIV/AIDS/STDs Surveillance. Report No. 12.

Dar es Salaam

Mpangile G.S. and Mbunda W.M., 1992

Information on Adolescent Sexuality in Dar es Salaam.

Study on behalf of the Family Planning Association of Tanzania (Umati)

Dar es Salaam

URT, 1997:

Tanga Region Socio-Economic Profile

Dar es Salaam