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Pacific Regional HIV - AIDS Project: Project Monitoring and Evaluation Report.
Pacific Regional HIV/AIDS Project
November 2003 – June 2005.
EXECUTIVE SUMMARY
Strategic Approach
The Pacific Regional HIV/AIDS Project (PRHP) is actively working on the most effective ways in which sustainable and comprehensive response to HIV and AIDS can be managed and supported in the Pacific given the geographically dispersed and small populations and
unique contexts of the Pacific Island countries (PIC). The project is taking a strategic approach that is consistent with the current discussions on the analytical papers on Human
Immunodeficiency Virus Acquired Immune Deficiency Syndrome (HIV/AIDS) in the Asia Pacific Region1 and on Pacific Island Countries. Major challenges faced by the project include:
• addressing the vulnerability of small islands states to the threat of HIV and
developing responses in a way that is context specific;
• challenges to socio-cultural and religious norms and their impact on the threat of HIV;
• issues of governance accountability of leaders to the welfare and wellbeing of their populations;
• engaging government, religious and traditional leadership to acknowledge the threat of HIV and respond appropriately;
• building of appropriate sustainable national coordination mechanisms to ensure harmonization and coordination of responses to HIV and AIDS that is lead by local authorities;
• addressing cultural and gender issues that underlie the risks and vulnerability of people to the HIV epidemic in the Pacific;
• providing access to treatment and ensuring appropriate care and support to those already affected by HIV and AIDS; and
• ensuring harmonization and collaborative approaches with other bilateral and multilateral agencies in the region.
Situational Assessment
There have been significant changes in the Pacific region’s awareness, understanding and response to HIV since the project commenced in November 2003. In the past 18 months, there has been an increased sense of urgency observed about the need to respond to HIV
amongst many of the PICs. This sense of urgency may be driven by an overall increased awareness of the epidemic partially as a result of increases in the recording of the incidence
and prevalence of HIV and AIDS in the region. However, though the number of reported HIV infections in PICs, excluding Papua New Guinea (PNG), increased from 58 in 2003 to
71 in 20043, the greater focus on HIV cannot be attributed to these increases alone. The main factors affecting the level of concern about HIV and the response by many countries include:
• the rapidly expanding epidemic in PNG which has clearly demonstrated to leaders that the epidemic is no longer a distant prospect and that the Pacific is vulnerable;
• the increased reality of the epidemic through the reporting of more HIV positive cases amongst Pacific Islanders;
• the endorsement of the Regional Strategy by Pacific leaders which identifies HIV as an issue of serious concern in the region and has provided a mandate that it be given a higher priority and increased allocation of resources; and
• the resources being made available by a range of development agencies including Australian Agency for International Development (AusAID) and other multi laterals to support projects and development of country-level strategies and HIV responses.
As a result of the above the HIV agenda is increasingly finding its way into the public arena.
The project had increased its profile over the 2 years of implementation and has gained the respect and confidence of all the partners in the region. Significant engagement across a
broad range of government and non-government stakeholders in the consultation process indicates increased political commitment, ownership and participation in a regional response
to HIV and AIDS and a growing recognition of the need to respond as a matter of priority at country levels. HIV is now recognised for the first time in national budgets as a separate
line item in Fiji, Solomon Islands, Tuvalu and Kiribati.
It is clear that the Project is operating in a dynamic changing environment and needs to remain flexible and responsive to new and emerging needs This changing context will influence the implementation of the project in coming years so it is essential to continue to
monitor the context as well as the project in order to ensure that key issues of strategic importance are adequately addressed. The outcomes of this Monitoring and Evaluation process will be key inputs into the development of subsequent annual plans.
Development of a Regional Strategy and improved coordination
The 2nd Regional HIV/AIDS strategy has been developed and approved by the Pacific Islands Forum Leaders and the Secretariat of the Pacific Community’s Committee of Representatives of Governments and Administrations (CRGA), illustrating leadership support at the regional level. A Pacific Regional Strategy Implementation Plan Coordinating body made up of all the key stakeholders has been developed to oversee the implementation of the regional strategy.
The Regional Strategy is increasingly regarded as the central mechanism for cooperation and coordination in the HIV/AIDS response. All development partners participated in finalising
the Regional Strategy Implementation Plan (RSIP) in September 2005. For the first time, the RSIP brings together the plans of all regional partners, identifies gaps and overlaps in the
response and areas of collaboration between agencies. The implementation plan has also identified the gaps in resources required which will form the basis for resource mobilisation.
Monitoring and Evaluation
A key aspect of improved monitoring of the HIV/AIDS situation across the region is the presence of a robust surveillance system. In June 2004, members of the Coordinating Body of the Pacific Public Health Surveillance Network (PPHSN) agreed that HIV/AIDS is a major public health problem and included HIV/AIDS on the list of priority communicable
diseases for active surveillance. Until recently, reporting of HIV and AIDS by Pacific Island Countries and Territories (PICTs) to Secretariat of the Pacific Community (SPC) has been irregular. To date there has been little available data on HIV-related behaviours or
assessment of vulnerability in the region. With increased support for surveillance from PRHP, the Global Fund for AIDS, Tuberculosis and Malaria Global Fund Project (GFATM), and the World Health Organisation (WHO), the situation has improved markedly. In 2004, all Pacific Island Countries and Territories (PICTs) reported on HIV and
AIDS cases to SPC. However, only 30% of countries reported STI data. STI data is an important proxy for measuring risk and vulnerability in low HIV prevalent situations. Six countries have now completed HIV, STI and behaviour surveys in different population groups and surveys are currently underway in a further three countries. Low capacity in
many countries to conduct HIV and STI surveillance surveys has highlighted the need for further technical support. PRHP and SPC will collaborate with partners to undertake surveys and build capacity to strengthen country level surveillance systems. With further support it is
expected that by the end of 2006, the majority of PICTs will have completed HIV, STI and behaviour surveys.
The Behaviour Change Communication Specialist (BCCS) is supporting PICTs in planning and implementing behaviour change initiatives. The training provided, by the BCCS, in many
PICs over the past year has helped shift the focus from HIV education and awareness toward activities aimed at changing unsafe sexual behaviours. There is still reluctance in sections of the community in some countries for open and frank discussion about a range of
strategies for preventing sexual transmission of HIV, including the use of condoms. Capacity development efforts need to focus on supporting partners to use effective best practice processes which are culturally sensitive and cognisant of present cultural barriers which can constrain the production of informative and appropriate materials particularly for youth. There is also a need to introduce and adopt and adapt different behaviour change strategies
in PICs that have worked elsewhere, such as the Stepping Stones approach. In 2006, PRHP will collaborate closely with the Global Fund Project, the new ADB Project, UNICEF and the UNFPA-funded Adolescent Reproductive Health Project to introduce the Stepping Stones approach in the Pacific.
Country-level capacity to coordinate, manage and monitor HIV/AIDS responses
Thirteen of fourteen PICs included in Component 2 of PRHP have established a National AIDS Council / Committee (NAC) or equivalent to manage the national HIV response. In smaller PICs, such as Nauru, HIV-related activities are managed by the Health Promotion
Council which has a broader mandate than just HIV and AIDS. The NACs are currently at a fledgling stage of developing their mandate and capacity as the key coordinating agency. The
Solomon Islands’ NAC is functioning well and provides a useful model for other countries.
The key issues affecting NACs’ capacity to take up this mandate of coordinating activities and resources effectively are the presence of skilled individuals or drivers and access to and control over necessary resources. These issues are directly linked to both individual skills and knowledge, the political context and enabling institutional arrangements.
Coordination is required to ensure actors engage cooperatively at country level to support one coordination mechanism for planning and implementation of HIV and AIDS initiatives. Supporting and strengthening the country’s national coordination mechanism is important
for a comprehensive sustainable response in each country. PRHP is assisting NACs to achieve the active engagement of country partners’ and development organisations’ involvement in these processes, but this is not without its challenges. A key issue is the
Country Coordinating Mechanisms (CCMs) established by the GFATM which potentially duplicate the NACs. This has been addressed in some PICs, but it is critical that there is regional commitment to support one mechanism at country levels to avoid diluting a
country’s focus and resources.
Country planning and review mechanisms such as the updating of National Strategic Plans (NSP), development of annual action plans, and ongoing situational analyses are important
mechanisms to improve country level responses. PRHP actively engages in these activities as a part of the Project’s capacity building approach for strengthening national coordinating
mechanisms. A key indicator for successful planning and implementation is the degree to which a multi-sectoral response is achieved with the active engagement of different stakeholders. PRHP has assisted in ensuring that broad sectoral engagement has been achieved in the NSP reviews completed to date. That more sectors are currently involved in
planning and review than in implementation, reflects both the current level of implementation of NSPs and the capacity and resources of the different sectors that should ideally be involved. Annual action plans will hopefully facilitate more tangible
implementation of NSPs and greater sectoral and multi-sector involvement. Resources from PRHP and other donors/organisations can support this involvement through coordinated
and targeted programs.
The Capacity Development Organisation (CDO) model is emerging as a key catalyst for improved NAC coordination and management in its ability to provide critical support to stakeholders at national and community levels. This is both through its involvement in
national level planning, monitoring and review as well as its support to expand the HIV response by involving smaller, non-traditional organisations. The organisations established as CDOs initially had low levels of organisational and project management skills. However, after a year of support and training, we are now seeing evidence of change in three important ways:
1) CDOs being increasingly active in their role, 2) the development of skills and capacity through project training and support, and 3) evidence that CDOs are transferring skills through their own training and capacity building activities. In 2006, PRHP will review
CDO performance and assess and develop capacity development strategies. The review will consider the sustainability and replicability of the CDO concept to countries where it has not taken off as anticipated. Capacity building will also continue jointly with NACs, including
training such as in Monitoring and Evaluation (M&E), mentoring and country exchanges.
The grants programs are proving to be an important means to provide resources to meet country level priorities. NAC Grants are assisting NACs to resource NSP implementation, improving coordination between NAC and CDOs through the joint management arrangements, and facilitating the increased capacity and involvement of a broader range of organisations in the HIV response. The competitive grants program has attracted a significant number of proposals. However, while it is important that organisations can apply to undertake projects in areas in which they have experience and capacity, the need for fresh ideas and approaches has also been identified. As such, limited knowledge and capacity in
HIV/AIDS programs in most countries has constrained the degree of innovation in the proposals received. In response, PRHP proposes to expand the Rapid Response Grants guidelines to enable specific pilot initiatives to be trialled that have proven success in other regions, such as in Africa. PRHP will work with selected local organisations best placed to implement these pilot initiatives as part of its capacity building approach. The Rapid
Response pilot initiatives also provide and opportunity to address sensitive issues such as sex work and the vulnerability of men who have sex with men.
Key issues for 2006
A number of key issues have emerged and will be addressed in the 2006 annual plan. These include:
1. CDO Model for Capacity Building
In the partner countries where the CDO program is operating, the role of the CDO, in providing critical support to other stakeholders at national and community levels, indicates that the CDO model is appropriate. However, a performance review of CDOs will be conducted in 2006 to identify any weaknesses in individual CDOs and strategies for addressing these as well as reviewing the CDO Model itself with a view to developing strategies for its wider application or alternative models which may be more appropriate for
use in specific Pacific Island Countries.
2. Broader Sectoral Participation in Implementation
Involvement in planning does not guarantee involvement in implementation. The Project aims to enable a broader range of sectors to become more actively engaged in the national HIV responses. This is to be addresses through creating an increased level of awareness and
an improved understanding about appropriate sector responses for HIV and through the provision of Project assistance with the development of multi sector and sector specific responses within the country strategy. Extending joint training with regional partners across priority management and technical
areas will be pursued to promote a coordinated approach, maximise resources, and avoid duplication of effort.
3. National Strategic Plans
The Review of National Coordinating Mechanisms to be completed by the end of 2005 will inform strategies to improve NSP development. Country-specific strategies will be developed to ensure responses are appropriate to individual contexts. Processes and tools
for support planning processes will be refined, along with capacity development strategies to assist NAC’s achieve their mandates.
4. Capacity Development Model
Stronger collaboration between the NAC and CDO in the Solomon Islands has resulted in better awareness of capacity development needs in the country. The Solomon Islands’ model plan will be made available as a template for use by other countries.
5. Addressing the Needs of Vulnerable Groups
For the second round of the Competitive Grants Program submissions, organisations have been specifically asked to address the needs of vulnerable groups as a priority for funding.
6. Innovative Interventions
The Rapid Response Grants Program was initially developed to respond to projects with an immediate need for funding. In 2006 the Rapid Response guidelines will be revised to allow
PRHP to support innovative pilot projects and to be able to respond to these needs in a timely and flexible manner. Proposed innovative interventions include ‘Stepping Stones
Approach’; continuum of treatment, care and support models; and Anti-retroviral (ARV)treatment regimes.
7. Improved reporting
New reporting requirements were discussed and agreed at a meeting with AusAID Post in September. This included the introduction of SMT reporting and streamlining current reports to ensure timely provision of analytical information to AusAID and to avoid
duplication of information. The M&E framework has been revised to include the collection of more outcome level data.
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