CONCEPT NOTE
Strategic Impact Inquiry on Women’s Empowerment, Phase 3 (FY08)
Sex Workers, HIV and AIDS, and Women’s
Empowerment Component
Abstract: Impact research that looks at the intersection of women’s empowerment and HIV/AIDS
outcomes in CARE’s work with sex workers is one important component of Phase 3 of the
Strategic Impact Inquiry on women’s empowerment. This component of the global SII will help
CARE to: (1) generate empirical evidence of the impacts that CARE’s “empowerment approaches”
have on the empowerment of sex workers and on prevention of HIV/AIDS; (2) better understand
the diversity of sex workers’ experiences, circumstances and aspirations for empowerment, in order
to improve the effectiveness of our current and future programs; and (3) generate evidence that
enables us to advocate more effectively for policy change at various levels. More broadly, in the
context of the women’s empowerment SII, the particular case of women living and working on the
ragged margins of social acceptability – in this case sex workers – challenges conventional lenses
on “the deserving poor”. It offers a chance to address biases, and therefore to enrich our
understanding of the nature and assessment of change in women’s empowerment. Further, as part
of a focused inquiry on Women and HIV/AIDS, this component will demonstrate the extent to
which CARE’s interventions are leading to important power shifts between women engaged in sex
work and key social actors around them, and identify whether the resulting power shifts are
contributing to the prevention of HIV. The concept calls for intensive, in-depth research in
Bangladesh, Cambodia, India and Peru, and a range of supporting methods that may include: a) a
mapping and promising practices exercises of projects in other regions that have a focus on
HIV/AIDS and transactional sex; b) global literature survey; and c) evaluation synthesis. CARE’s
global project information database will also be mined to help fill out the global profile of CARE’s
empowerment efforts vis-à-vis HIV/AIDS and sex work.
I. Background
CARE’s Strategic Impact Inquiry (SII) into its programs’ impacts on women’s empowerment has been operating
since January 2005. Phase one research lasted from January-October 2005, comprising original field research in
Bangladesh, Ecuador, India, and Yemen, a randomized analysis of CARE project proposals, meta-analysis of a
convenience sample of CARE project evaluations, qualitative analysis of responses from some 400 projects to six
open-ended questions in the CARE International Project Information Network (CPIN) annual survey, and literature
reviews and synthesis. Phase two, launched late 2005 and recently concluded, entails original field research in 25
sites, in over 18 country offices in five regions, as well as CPIN analysis, a regional gender mapping exercise in
Asia, and a “promising practices inquiry” involving projects in eight country offices.
Within this broad sample, we seek to craft sub-studies to explore particular interactions of our sectoral work and its
impacts on women’s empowerment. This effort began with a four-site comparative study of the links between
women’s village savings and loans groups, household economic security, and women’s empowerment. Phase three
will build on these first two years, repeating key secondary data analyses, and focusing field research in these substudies on two principal themes:1:
1) women’s empowerment in the context of humanitarian crisis; and
2) women’s empowerment and HIV/AIDS prevention among sex workers.
This concept note is for the second of these themes, which ties the SII into a specific research program on the theme
of Women and HIV, led by CARE’s HIV/AIDS team and supported by the Ford Foundation. 2
CARE’s Programs with Sex Workers
CARE has been implementing HIV prevention programs with sex workers in India, Bangladesh, Cambodia, Peru
and Thailand, and there is deep interest in replicating this work in other countries. CARE’s SHAKTI project in
Bangladesh has been documented by UNAIDS and WHO as a best practice model in preventing HIV infection 3.
SHAKTI was based on learning from the Sonagachi project, a successful HIV program with sex workers in Kolkata,
India. The Sonagachi project has also been documented as a best practice model. 4 CARE India is currently
implementing SAKSHAM, a program supported by the Gates Foundation to document learning from the Sonagachi
project and translate those learning to scale up interventions with vulnerable populations including sex workers,
truck drivers and injecting drug users.
II. The Rationale and Stakes of this Research for CARE, our Clients and the Development
Community
CARE
As an organization committed to addressing the underlying causes of poverty and social injustice, CARE has made
the advancement of women’s empowerment a core principle and strategic thrust of all its work. Women’s
empowerment is valued both as an expression of CARE’s commitment to equal human rights for all, and as a
pathway for enduring impact on the deep structures that sustain poverty. However, in the context of CARE’s work
with sex workers and other highly stigmatized communities of women, this commitment to empowerment has drawn
a mix of skepticism and sharp criticism in a deeply polarized policy climate in the United States5.
1
The multi-country village savings and loan component will continue in Rwanda, Malawi, and Ghana.
“Carpe Momento! Women, HIV&AIDS, and Human Rights: From Evidence to Action” a proposal to the Ford Foundation. CARE USA, May
17, 2007. Researches CARE’s impact on women’s vulnerabilities to HIVAIDS in Burundi, India and Lesotho.
3
UNAIDS publication: Female sex worker HIV prevention project – lessons learnt from Papua New Guinea, India and Bangladesh, November
2000
4
Sustainability has been evaluated in the 12 year-old Sonagachi intervention and demonstrated reduced HIV infection and increased condom use.
Success is attributed to a package of approaches including peer outreach workers, addressing broad community concerns as an entry point,
leadership development of CSWs, support by health professionals; and ceding of leadership to a new sex worker association. CITE STUDY?
5
The resistance in the United States to a sex-worker empowerment agenda is a mere thread in two inter-related and much larger discussions. One
is on the call for more rigorous and robust evidence of impact in general, and in particular of rights-based approaches. The second is an almost
ideological battle, regarding possible links between exploitative prostitution and trafficking industries, and the empowerment of women and girls
who find themselves in this work.
2
Driven by its accountability and learning needs, and by the desire to engage constructively the current policy debate,
CARE’s HIV/AIDS Unit, Sexual & Reproductive Health team and Policy Advocacy Unit are keen to establish a
fuller and more empirically grounded narrative about the impacts on HIV prevention of CARE’s empowerment
approaches to working with sex workers. Meanwhile, in the context of the women’s empowerment SII, it is
important to use the particular case of women living and working on the ragged margins of social acceptability as a
way of testing and enriching our understanding of the nature of women’s empowerment, how to measure it and
CARE’s contribution to this process. And finally, HIV prevention is a goal that CARE shares with donors, and
although the debate with respect to prevention approaches has become increasingly politicized, generating evidence
about “what works” within an important high-risk group is of broad value.6
Our Clients
Unprotected commercial sex is one of the major drivers of the HIV epidemic in Asia, and sex workers are one of the
most marginalized and excluded groups worldwide. Sex workers are subject to levels of violence, discrimination
and rights denial that most other social groups are not, and are often one of the most vulnerable groups in the
contexts in which CARE works. Gender norms and ideologies are acute in the world of sex work, governing the
forces that bring women into the sex industry, the power relations between sex workers and the many stakeholders
in their lives, and the options available to them to claim their rights once they are identified as sex workers.
CARE’s empowerment approaches seek to address these power imbalances that underlie sex worker vulnerability –
to HIV/AIDS and a host of other harms. 7 Assessing how well our approaches support these women in their struggle
for a dignified life and future is an exercise of accountability of profound importance. The women we serve have a
right to describe their own aspirations, to learn how far they been able to reduce their vulnerability, and to assess the
value of CARE’s contributions.
There is a wealth of anecdotal evidence that our work is leading to important changes in the power of sex workers to
negotiate safer sex with clients, to engage with brothel owners and madams for fairer terms and to reduce their
exposure to violence. However, the outcomes of these changes – in terms of their impact on empowerment broadly
defined, or on vulnerabilities to HIV and its effects – have not yet been studied rigorously. This component of the
wider SII will demonstrate the extent to which CARE’s interventions are leading to raised perceptions by the sex
workers of their own self-worth, and hence to important power shifts between sex workers and key social actors
around them, and identify whether these power shifts are contributing to HIV prevention. If such links are
demonstrated, it could translate into improvements in uncountable women’s and men’s lives as such practices are
more broadly adopted in CARE and beyond. Compelling evidence on the effectiveness of empowerment
approaches would also help CARE advocate for changes to U.S. policies governing HIV and AIDS funding.
The Development Community
In the past few years, substantial efforts have been made to advance empowerment approaches to prevent HIV
transmission among sex workers, intravenous drug users, and men having sex with men. Many studies have been
conducted to demonstrate that empowering strategies (see footnote 2) that deliberately address gender inequities
have improved health status by increasing condom use and reducing HIV infection rates. 8 Studies have also revealed
positive correlations between such approaches and:
▪ community ownership and sustainability of such programs;
6
In 2003, for example, the U.S. Congress passed a law that requires organizations to adopt a policy explicitly opposing prostitution in order to be
eligible for U.S. HIV/AIDS funds. The law equates sex work with human trafficking, and the political climate surrounding the law is extremely
polarized, easily associating empowerment of sex workers with promotion of prostitution.
7
UNAIDS and WHO have recognized the empowerment approach as a key reason behind the success of the SHAKTI and Sonagachi projects.
This approach seeks to place sex workers at the center of the response, and to enable them to prioritize and own the interventions being
implemented. This approach differs from many public health responses to HIV (that target sex workers in Asia), which adopt a narrower medical
risk-reduction model. Most often these latter succeed in increasing rates of condom use at project level with little or no impact at country or
community level. None of these projects have made any perceptible impact in improving the quality of life of sex-workers and their children nor
do they address underlying causes of vulnerability within the sex trade.
8
Global HIV Prevention Working Group, “Bringing HIV Prevention to Scale: An Urgent Global Priority,” June 2007.
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▪
▪
psychological empowerment and social bonding which, in turn, can influence the social context of gender
relations;
improved child health and reduced fertility;9
But while such studies point to the effectiveness of empowerment approaches, they for the most part: a) conflate
“empowerment approaches” with women’s empowerment (as both a process and outcome), leaving us with a hazy
idea of what has changed vis-à-vis women’s lives and their ability to influence and make strategic life chances; and
so, b) fail to demonstrate connections between empowerment approaches, women’s empowerment outcomes, and
sustainable impacts on HIV prevention In essence, most studies leave us guessing about what, if any, permanent
changes have been affected in the gendered structures of power, the networks of relationships among social actors,
and the underlying causes of sex worker vulnerability to rights denial, violence, and HIV.
The sex workers component of Phase three of the SII will, therefore, make a contribution to the literature on the
relationships between empowerment approaches, empowerment outcomes and HIV prevention by defining what
empowerment of sex workers means in a practical sense, and demonstrating how empowerment approaches lead to
changes in capacity, behavior, vulnerability and citizenship - and, ultimately, contribute to HIV prevention. This
exploration will also provide a narrative that sheds light on “who does what” to facilitate empowerment, discussing
the evolving role of CARE vis-à-vis sex workers’ organizations as these efforts mature and seek sustainability.
At a more basic level, this phase of SII will explore the relationship between empowerment of sex workers and HIV
prevention outcomes in Bangladesh, Cambodia, India and Perú, and develop an evidence base that can inform
advocacy at national and global levels.
III.
Broad Research Design Considerations, Aims, and Key Research Questions
A. Conceptualizing Women’s Empowerment10
The proposed study falls within the broader institutional umbrella of CARE International’s Strategic Impact Inquiry
(SII) into women’s empowerment begun in late 2004. CARE chose to focus its first multi-year SII on this theme in
recognition of the wide literature that reveals the intimate links between gender inequality and poverty across the
communities we serve. Across the first two phases of the SII, CARE has implemented in-depth, participatory,
impact research on women’s empowerment in almost 30 countries; a global meta-evaluation of gender-focused
projects; an analysis of a random sample of project proposals; qualitative research using the organization’s global
project outputs database that contains data on around 900 current CARE projects; a “promising practices inquiry”
that seeks to identify useful strategies and approaches for advancing empowerment; desk reviews of selected
projects and programs; and an extensive review of the existing women’s empowerment literature.
Within the broad framework of this three-phased investigation into CARE’s impacts on women’s empowerment, the
proposed sex worker study is a critical test of the relationships between empowerment approaches, empowerment
outcomes, and more traditional human development outcomes.
CARE has already developed and widely tested a research protocol for its investigation into women’s
empowerment. The protocol conceptualizes women’s empowerment along three broad dimensions – agency,
structure, and relations – and within those dimensions 23 evidence categories.11 Specific indicators for evidence
categories are generated both via bottom-up, participatory conversations with women and men in specific locales
and through selection of national and international indicators generated through rigorous scholarship and taken up
See Nina Wallerstein, “What is the evidence on effectiveness of empowerment to improve health?” Health Evidence Network Report,
Copenhagen, WHO Regional Office for Europe, February 2006.
9
See Annex 1 for a capsule summary of the women’s empowerment research framework.
“Agency” refers to the aspirations, resources, and achievements of women themselves, to an individual’s ability to think for herself, take
action, and seek to influence others. The structural dimension of women’s empowerment indexes the broader social institutions that condition
women’s choices and chances offering both constraints and opportunities. The dimension we term “transactional relationships” points to the
social relationships through which women negotiate their needs and rights with other social actors.
10
11
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by institutions such as The World Bank, the Canadian Agency for International Development, the UN, and the
World Economic Forum. The research protocol and methods permit a focus on women’s empowerment that is
broad, inclusive, and able to be compared and connected with empowerment research by other actors. However, it
also permits specific sites and research locations to explore issues beyond those identified in the protocol – hence
mitigating the danger of ignoring local context – and so adapt the broadly comparative framework to more specific
local realities. For example, we remain open to the very real possibility that research participants may have a very
different vision of where they want their empowerment to take them. We encourage local teams to enable women to
define crucial concepts like “empowerment,” “equity” and “equality” themselves, before turning their attention to
whether CARE programs are having an impact on them.
3. Aims of the Study
At the broadest level, therefore, the aims of the sex worker and HIV/AIDS component to the global SII on women’s
empowerment are:
1.
2.
3.
to generate empirical evidence of the contributions that CARE’s “empowerment approaches”12 make
towards the empowerment of sex workers and on the prevention of HIV/AIDS;
to better understand the diversity of sex workers’13 experiences, circumstances and aspirations for
empowerment, in order to improve the effectiveness of our current and future programs;
to develop strong evidence-based arguments about “what works” with respect to HIV prevention with
marginalized, high-risk groups.
C. Specific Research Questions
Three broad research questions will frame this component of the global SII:
(1) What constitutes empowerment for the women these programs support, and are the programs resulting in
such empowerment? Here, we will seek to understand effects on individual and collective empowerment
through women’s own agency, changes in the wider structures and institutions of society, and shifts in the
power relations through which women negotiate their needs and rights. We hope to ascertain which
interventions or combination of interventions and at what levels (i.e. mobilizing sex workers into collectives,
building negotiation skills, training peer educators, advocating for policy change) are most important in
promoting empowerment.
(2) What impact do empowerment approaches and empowerment outcomes have on HIV prevention? Here, we
will explore how empowerment approaches and outcomes contribute in preventing HIV transmission and
increasing capacity to mitigate the impacts of AIDS. In most cases, we will have to use proxy measures
(condom use, STI prevalence, etc.) in place of HIV incidence.
D. Design Considerations
The primary research design challenge will occur at the intensive field sites, where full-fledged designs replete with
specific indicators, methods, analytical procedures, and rights-based, participatory research methods will eventually
need to be formalized. A number of design considerations will be pertinent in all sites, however, or are important at
the global level. These include:
1.
Operationalizing women’s empowerment in context. It will be important – as it has been in all SII research –
to not assume that we necessarily understand empowerment in context. The first step of the research will need
to be a dialogue with women about what empowerment means and how it might be measured in their specific
geographical and social contexts. Into these discussions of empowerment, CARE can and should also bring
“global” notions of agency/structure/ relational dimensions of important changes. While notions of
12
Empowerment approaches explicitly promote the empowerment of sex workers to claim their full human rights as citizens, and not simply to
treat them as disease vectors to be contained.
13
The first conceptual challenge is to recognize that the term sex worker labels a narrow identity group that excludes many involved in
transactional sex. For instance, the nature of transactional sex in Africa is very different to Asia, where sex workers occupy a stigmatized and
structured space in society. We need to decide whether to explore how our work affects empowerment outcomes for women where transactional
sex is less structured, and how our work affects men and transgender people involved in the sex trade (who are often the most marginalized).
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2.
3.
4.
5.
6.
7.
empowerment (ours or those of the women) may shift through this dialogue, retaining these distinct
perspectives, where they persist, is a critical part of telling the global story.
Living up to the CARE International program principles in the research process. CARE has specified a
number of ways that SII research should enact the Program Principles (see annex 2). Of note here is the aim of
including women themselves in the research process. Such inclusion needs to go beyond merely being
informants and an audience for draft findings – although certainly at a minimum this is necessary. It must seek
meaningful participation of sex workers themselves in research design, data gathering, data analysis and
identification of future action as a result of the research.
Ensuring CARE internal analysis as part of the impact research. All SII research on empowerment needs
to have a component of looking internally at CARE to try to understand the ways in which such internal factors
as our structure, funding, staffing, culture, and our programmatic and organizational GED policies and practices
help or hinder external impacts on empowerment. 14
The challenge of measuring HIV incidence and prevalence. It will likely be that we will only be able to
address this important question via proxies. Such proxies might include rates of condom use or STI prevalence,
access to services such as VCT, PMTCT etc. We also will likely want to look at the broad coverage of the
projects’ mobilization efforts and whether the project has had influence on government or donor policies related
to program design, ownership, building of the community etc.
The challenge of selecting the most critical dimensions of change to assess empowerment in the lives of
sex workers. Here we will have to be explicit and carefully focused regarding what changes we measure.
Potential indicators of interest here might include levels of violence faced by sex workers, rates of trafficking of
minors into the sex trade, increase in economic security, access to education for sex workers’ children, or
reduction of stigma. Still, we must recognize that the more variables we intend to look at, the more
relationships we are proposing need to be demonstrated and, as a result, the more resources that are needed in
order to make plausible claims of impact. Above all, our design must address what appear the most critical
relationships that we must understand at this point.
Data Completeness and Triangulation. Just a focus on women’s own empowerment narratives generates a
huge range of potential changes in their lives that need to be assessed – in agency, structure and relational
domains, spanning a gamut of resources, capabilities and aspirations. In addition, there are a host of important
questions that surround even the most narrowly-focused study. What are, for example, the unintended benefits
or harms that we need to register in these programs? Equally relevant might be metrics of change in the
behaviors of other actors and institutions, with respect to sex workers (partners, pimps, madams, children,
police, etc.). We need to craft a research design that leverages these types of informant and data triangulation,
many of which will only become clear through inductive learning about non-standard indicators and non-linear
impacts. Again, we must recognize that expanding informants and impacts will have resource implications, and
balance completeness and feasibility.
Organizational Learning. SII research is not to be delegated to external consultants although the use of an
external consultant as part of the team is recommended. Sites of intensive field research need to be able to
commit to the formation of an SII coordination team, a team that will be tasked with overseeing the
implementation of the field research engage deeply in data collection and analysis, draw conclusions, and
subsequently create and implement a diffusion strategy for the findings. The diffusion strategy needs to address
both internal diffusion – concrete mechanisms for lessons learned to be taken up and adopted by other programs
in the CO portfolio as well as communicating findings to regional management in ways that the RMU can then
share with other COs – and program- and policy-related dialogues about the findings with external stakeholders.
IV. Research Organization and Administration
A.)
Lead Research Consultant.
The proposed research requires the contracting of a lead impact research consultant. The lead consultant would be
expected to:
14
Existing reports (such as the unpublished Now They Look At Us As Normal based on CARE Bangladesh’s HIV and AIDS work) and initiatives
(such as ISOFI in CAREs India and Vietnam) should provide excellent insight into this aspect of the study.
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a)
Develop a global research framework, based on the concept contained in this note, through conversations with a
number of stakeholders in and out of CARE. A very important responsibility of the lead consultant will be to
ensure that this research is cognizant of and builds on other research into similar domains, and is responsive to
policy and advocacy needs of various levels organization;
b) Assist field research teams in Bangladesh, Cambodia, India and Perú to develop robust research designs;
c) Review synthesis of findings from prior studies, and from lighter inquiry exercises, to shape research questions.
d) Review and advise on development of TORs and selection of local lead researchers.
e) Review and advise on development of local research designs, including matching of questions, data
collection/management methods, sampling and ethical guidance, as well as development of data collection
instruments, indicator specification, analytic methods, and documentation strategies.
f) Provide quality review of sampled data, analytic output, and draft local research reports, and provide feedback
to improve validity of findings in a manner conducive to fostering learning and collaboration among sites; and
g) Produce a cogently-argued synthesis report of the findings and recommendations that is accessible to a nontechnical audience. This summary will integrate findings from the SII/sex worker sites and the additional two
African sites supported by the Ford Foundation grant.
B) Global Organization of the Research
CARE’s global coordination team for this research initiative is led by the HIV/AIDS unit, and includes the global
lead researchers, CARE’s SII Coordinator and the Senior Policy Analyst. The HIV/AIDS unit will act as the lead
contact for overall coordination, technical assistance, and product development.
Other key stakeholders who will be regularly engaged as members of the global SII team include the research site
team leaders and consultants, designated regional management staff, and the Director of CARE’s Sexual &
Reproductive Health Team. We will also seek to engage a team of external reviewers from entities such as the
London School of Economics, Overseas Development Institute, UNAIDS, WHO, the Population Council, the
Horizons Project and host governments.
C) Budget Overview
Funds for the research will need to be assembled from multiple sources. Our experience to date with SII research
indicates that it is quite difficult – assuming contracting a team of expert international and local research consultants
who can bring visibility and a sense of legitimacy – to do important primary impact research for less than $35,000
per site. The total budget of this component of the SII for phase three is, therefore, likely to be around $250,000
(assuming four in-depth field sites plus global support). Integration of the sex worker research with the closely
related “Women and HIV” research program enabled by a grant from the Ford Foundation will support field
research in India, and will help cover costs for the global consultant, global design and synthesis meetings, and
dissemination. The remainder will come from the SII budget, country offices, CARE International members, and
regional and technical units who are stakeholders in this inquiry – or from privately-raised funds.
D) Calendar
A possible calendar for the sex workers component (subject to revision) is as follows:
May-July: Identify field research sites, establish coordinating committee terms of reference and mechanisms.
July/August: Identify and contract lead research consultant(s), site research consultant(s).
September: Global and local research designs developed, with significant consultation and feedback
October: Research design meeting, including all sites and key external stakeholders.
October/November: Finalized research designs for the in-depth field sites
November-March: Field research completed and initial findings tested in local feedback and validation events.
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March/April: Synthesis workshop, including all sites and key external stakeholders
April/May: Synthesis report production, external/internal review for critical feedback, and finalization.
May - June: Preparation and finalization of specific knowledge products, presentation forums/panels, and advocacy
strategy for Global Aids Conference, Mexico City, and for internal and external presentation to multiple audiences.
August: Presentation of findings at International HIV, Mexico City.
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