Gender Mainstreaming Belize s HIV&AIDS National Strategic Plan

Transcription

1 Gender Mainstreaming Belize s HIV&AIDS National Strategic Plan

2 ACRONYMS AAA ARV FSW HCW HIV&AIDS IEC ILO KAPB M & E MCH MOH MSW NAC NAP NPESAP NSF NSP PLWHA PMTCT STI UNGASS UNICEF UNIBAM UNTG USAID VCT Alliance Against AIDS Antiretroviral Female Sex Worker Health care workers Human immunodeficiency virus/ Acquired Immune Deficiency Syndrome Information, education, and communication International Labor Organization Knowledge, Attitudes, Perceptions, and Behavior Monitoring and Evaluation Maternal and child health Ministry of Health Male Sex Workers National AIDS Commission National AIDS Program National Poverty Elimination Strategy and Action Plan National Strategic Framework National Strategic Plan Persons living with HIV / AIDS Prevention of mother-to-child transmission Sexually Transmitted Infection United Nations General Assembly Special Session United Nations Children Fund United Belize Advocacy Movement United Nations Theme Group on HIV / AIDS United States Agency for International Development Voluntary counseling and testing 2

3 1. INTRODUCTION The spread of HIV is not only a health issue. The HIV/AIDS epidemic has undermined development in continents and regions around the globe. The Caribbean is particularly affected, as the epidemic in the region is the worst in the Western Hemisphere and second in magnitude and prevalence only to that in Sub-Saharan Africa at an estimated 2.3 per cent adult HIV prevalence. Factors considered to be of particular importance in this context are: the wider socio-cultural context in which sexuality is expressed since this is linked to gender relations which influence the transmission of the virus; the extent of human rights violations to which persons living with HIV/AIDS (PLWHA) are subjected, and the gendered dimensions of these issues particularly in the delivery of health and related services. It has been noted by the United Nations Joint Program on HIV and AIDS (UNAIDS) that The effects of gender inequality leave women and girls more at risk of exposure to HIV. Less access to education and economic opportunity results in women being more dependent on men in their relationships, and many who have no means of support must resort to bartering or selling sex to support themselves and their children. 1 Furthermore gender inequality prevents the achievement of various development related international commitments, for example, the Convention to Eliminate All forms of Discrimination Against Women (CEDAW), the Millennium Development Goals (MDGs), Universal Access to HIV Prevention, Care and Treatment, and the Convention on the Rights of the Child (CRC). Belize is therefore challenged to develop practical gender-responsive strategies to halt and start to reverse the spread of the pandemic which as a result of gender inequality, is primarily spread through heterosexual sexual relations. Particularly concerning, are cultural norms around femininities and masculinities that increase risk and vulnerability, for example there is an expectation for women to be monogamous and have limited knowledge of sexual issues, while encouraging multiple relationships for men. Furthermore, promiscuity in men is much more acceptable. This exposes men to an increased risk of infection, and increases the possibility that they will transmit HIV/AIDS to their partners. In order to effectively address HIV issues, it is important that gender is a cross-cutting theme in the national HIV response. To this end, this study commissioned a review and assessment of the National Strategic Plan (NSP) for Belize. Based on this assessment, gender gaps were identified to allow the formulation of an action plan to be anchored within the priorities that are outlined in the NSP for HIV & AIDS. This incorporates gender and gender-related training, as well as program development

4 Generally, the analysis of the NSP revealed that gender is implicitly addressed; and there is a great need and opportunity to ensure that the NSP is more gender responsive; with a focus on infusing gender into HIV&AIDS services and programs in keeping with the unique realities of Belizean society and culture. The report below presents key findings, a comprehensive analysis of the NSP, a gender gap analysis and recommendations for strengthening of the NSP. BRIEF OVERVIEW OF HIV & AIDS SITUATION IN BELIZE (THE EPIDEMIC AND THE NATIONAL RESPONSE) 1.1 EPIDEMIOLOGICAL PROFILE HIV was first diagnosed in Belize in 1986 and since then there has been a steady increase in the rate of transmission. According to UNAIDS estimates for 2006, Belize has an adult prevalence of 2.4 per cent, ranking the country the highest in Central America and the third in the Caribbean Region. HIV & AIDS is among the top five leading causes of death in Belize s adult population alongside diseases such as diabetes, hypertension, road traffic injuries and heart diseases. Ministry of Health statistics indicate that during , it was the fourth leading cause of death in the years age group. In the same period, it was the second and first cause of death in the and age cohorts respectively. Since 2007 the National Surveillance Unit of the Ministry of Health revealed an accumulated total of 4,253 HIV cases reported. In 2007 there were 448 new infections, 850 AIDS cases, and 749 AIDS related deaths.. The number of women testing positive for HIV and acquiring the infection has steadily increased in the last 20 years. In the first 10 years of the epidemic, the male to female ratio was 2:1. In the last 10 years however, the gap has narrowed considerably between men and women; with a current male to female ratio of 1.1:1. In Belize the pandemic is progressively affecting all districts with the highest concentration of infected persons in the Belize district (which comprises 45% of the population: Belize NSP ). 1.2 RESPONSE TO HIV & AIDS IN BELIZE The National AIDS Response in Belize is guided by the National AIDS Commission (NAC). This multi-sectoral body has wide representation in key sectors that include both governmental and non-governmental agencies, civil society, faith-based organizations and Persons Living with HIV & AIDS. The day to day work of the commission is carried out through a secretariat which is managed by non-executive chair. 4

5 The priority areas identified for a targeted HIV response in the NSP are harmonization; which is intended to yield a stronger collaboration with national and international partners to strengthen the national response; prevention to reduce the prevalence and incidence of HIV and mitigation to improve the quality and extend the lives of PLWHAs. Together the activities in these priority areas are expected to halt and start to reduce the infection, as well as the impact of HIV & AIDS on the economic, social and cultural context in Belize. (NSP ) The NSP provides a guide on the direction of the response and recognizes the need for more informed planning and multi-sectoral, multi-stakeholder response. The focus therefore is on strengthening the need for relevant baseline information that will then guide the development of more detailed Operational Plans at macro and micro levels. 1.3 ROLE OF THE NATIONAL AIDS COMMISSION (NAC) AND SECRETARIAT The Commission is guided by the NSP and is responsible for the coordination of the national HIV response in the country. The role of the NAC Secretariat, the operational, arm of the Commission, is to facilitate the development of the National Operational Plan. To further strengthen the coordination functions of the NAC, the Secretariat recognized the following challenges in implementation of identified objectives and recommendations outlined in the NSP: There is a varied level of functionality among the various district committees. With greater ownership and involvement in the development of the operational plan, the NAC must advance a more inclusive way forward to mitigate these challenges. In the interest of inclusion and active participation of Commissioners, the NAC assessed the current structure of the NAC and the NSP, with the objective to build the ownership process and to ensure a more cohesive representation. The NAC is currently engaged in developing strategies to be detailed and costed in the operational plan. The costed operational plan will outline the current gaps, redefine priorities and identify strategies to mobilize additional resources and support for the successful implementation of the NSP. The NAC is also moving towards finalizing its National Monitoring and Evaluation Plan which includes gender responsive indicators The NAC recognized that many of the key stakeholders have developed and implemented their own institutional response to the HIV & AIDS epidemic, and that generally, these partners incorporated key areas of the NSP into their organization s strategic plan. However, additional work is needed to ensure that all partners are aligned to the NSP, and responding to the Three Ones (the UNAIDS guiding principles for coordinating a comprehensive country level response), of 5

6 One agreed HIV/AIDS Action Framework that provides the basis for coordinating the work of all partners. One National AIDS Coordinating Authority, with a broad-based multi-sectoral mandate. One agreed country-level Monitoring and Evaluation System. 2 The development of the operational plan therefore provides an additional opportunity for partners to not only align further their work with the NSP, but to also include more gender responsive programming. It has been recognized that integrating gender into the policies and programs of stakeholders will require training in gender mainstreaming, with a focus on preventionbased program that address reducing gender-based violence and stigma and discrimination. 2. BACKGROUND TO PROJECT Recognizing the gendered dimensions of the spread of HIV&AIDS in the Caribbean, the United National Development Fund for Women (UNIFEM), working in consultation with the Caribbean Inter-Agency Working Group on Gender and HIV, undertook a project aimed at deepening the understanding of the gendered causes and consequences of the HIV epidemic in the Caribbean. Components of this project included gender training of persons working in the HIV, reproductive health and gender equality areas, both from the state and non-governmental sector. In addition, UNIFEM has also been able to support the incorporation of gender analysis in the formulation of national strategic plans in a number of countries. In the case of Belize, where an NSP for had already been developed, UNIFEM s support focuses on a review of the current NSP with a view to identify the gaps in gender responsiveness and to propose gender indicators for monitoring and evaluating National HIV & AIDS policies and programs. This consultancy collaborated with the NAC and its social partners to support the integration of gender-responsive programs into the priority areas of the HIV& AIDS interventions outlined in the NSP

7 2.1. METHODOLOGY A mixed methodology was used in this study as both quantitative and qualitative approach was employed. The quantitative approach was two-fold using a comprehensive review of relevant literature including: the NSP for Belize, related literature on international guidelines and standards for mainstreaming gender in HIV & AIDS-related planning, as well as selected Caribbean literature on the subject. Replicating a model used in a recent study by Bruin et al., (2006), with some revisions, the NSP for Belize was assessed in two ways: 1. Through different ways of text analysis. 2. Through completion of a structured questionnaire/checklist produced for the study. Using the qualitative approach, the findings were buttressed by interviews with key stakeholders. The list of persons interviewed (Appendix) were selected based on their relationship with specific programs identified in the NSP and/or based on their direct input to the development and implementation of the NSP. Additionally, a checklist for gender-sensitivity of NSP for Belize was adapted from the UNAIDS Operational Guide on Gender and HIV & AIDS A Rights-based Approach and other researchers (Appendix 2). Members of the Monitoring and Evaluation Committee which fall under the NAC were given an electronic copy of the checklist and were asked to complete the checklist and return via . Through diverse methods of text analysis: This analysis was conducted in a three-prong approach where: 1. In a first analysis of the NSP, the researcher utilized keywords in context (KWIC): gender, female(s), male(s), woman/women, man, men, girl(s), and boy(s). 2. The second analysis, utilized open coding and whole text analysis (analyzing chunks of text). 3. In the final analysis, text was revisited in its entirety and final coding was applied. Through completing a structured questionnaire/checklist produced for this study: A comprehensive questionnaire/checklist for gender- sensitivity and integration in planning processes for HIV & AIDS was produced, drawn from UNAIDS Operational Guide on Gender and HIV & AIDS A Rights-based Approach, WHO (2003), Pargass (2005), and Kempadoo (2006) see appendix 2. 7

8 The questionnaire/checklist was distributed to members of the Monitoring and Evaluation Committee. Each member was asked to complete this checklist based on their knowledge and familiarity with the NSP. 2.2 LIMITATIONS There were some initial delays in formalizing the starting date due to availability of the consultant and the transition period that the Commission was undergoing as a result of recent elections. In addition, although the M&E Sub-committee of the NAC is functional, as the reformalization process continues, it presented some difficulties to access all members of this committee, as well as other stakeholders. Stakeholders were apprehensive in sharing information but were later able to understand the importance of the consultancy and provided detailed engagement in presenting the information. Based on the general response of the key persons interviewed, there was an atmosphere of consultancy fatigue. Some reports on the work of NAC (Annual Reports, M &E Operational Plan) were also unavailable at the time of the consultancy as they were in the process of being completed. GENDER AND HIV & AIDS Globally, heterosexual transmission of HIV largely accounts for its spread. Therefore, a key element in halting and reversing the spread of HIV is linked to impacting the way that women and men interact with each other in their sexual relations. Whereas sex refers to the biological or physiological characteristics of men and women which are given from birth; gender is socially constructed. Furthermore, gender roles are constantly changing in response to current social and economic conditions, whilst biological attributes can sometimes be altered, biological sex is essentially fixed. As a result of their sex and gender differences, women and men have differential needs and vulnerabilities to HIV. World Bank conducted research has shown that the greater the gender inequality in a country, the higher the prevalence of HIV. Because of the physiological and psychosocial impact on vulnerability to HIV; both a person s sex and gender are determinants of his or her vulnerability to HIV infection. For example, while gender norms related to sexual behavior increase men s vulnerability to HIV by promoting unprotected sex as an expression of masculinity, physiologically women are more susceptible to HIV infection than men and are almost twice as likely to become infected during sexual intercourse. 8

9 According to UNAIDS, women comprise half of all people living with HIV In parts of the Caribbean, young women aged years are up to six times more likely to be HIVinfected than young men in the same age group. As noted previously, a combination of socio-cultural and socio-economic factors add complexity to addressing the spread of HIV. In specific context, certain individuals may be more vulnerable or at risk to infection than others, depending on the level of their exposure to poverty and gender-based violence and their capacity to navigate towards healthy choices in problem solving around these i.e. their level of education, degree and quality of family and community support. As observed by Dunn, Bell and Perkins (2007), understanding the concept of gender helps stakeholders to address the specific vulnerabilities of males and females of different classes and cultures to HIV and AIDS. This is key in developing effective policy and program strategies for prevention, treatment, care and support services. Gender-sensitive policy and programming interventions take into account specific vulnerabilities of women and men by asking key questions such as: Who does what and with whom (gender division of labor)? Who has access to resources, benefits and opportunities? Who has control over these resources, benefits and opportunities? Who benefits from the use and distribution of these resources? Collection and analysis of data to answer these questions will ensure that women s, as well as men s concerns, needs and interests are integrated in the design implementation, monitoring and evaluation of HIV & AIDS policies and programs. The aim is to ensure that women and men benefit equally in all political, economic and societal spheres (Dunn et al., 2007). Prevention programs should address key differential risk factors for women and men. As a result of culturally perpetuated ideas of masculinities and femininities, men are often encouraged to engage in risky, sexual behavior increasing risks for both themselves and their partners. Additionally, as women are typically not accepted as equal partners in decision making about sex, their capacity to negotiate safe sex is greatly diminished, increasing their risk of infection. Therefore, prevention programs should directly target those cultural norms, in an effort to curb tendencies. According to UNAIDS, the promotion of gender equality in national HIV programs requires coordination, education and knowledge of countries about the epidemic in order to develop a comprehensive understanding of the role of gender inequality in driving the epidemic, as well as other social determinants, such as economic status, ethnicity, etc. UNAIDS also articulates the importance to achieve universal access to HIV prevention, 9

10 treatment, care and support, by paying attention to gender inequality, as well as the needs and interactions of men and women, girls and boys. Gender mainstreaming in national HIV responses is therefore based on the recognition that gender equality and equity are of pivotal importance to national development, and must include a rights-based approach to addressing social justice for women and men, contribute to good governance through people-oriented, participatory management and must incorporate poverty alleviation and the reduction of gender-based violence particularly in prevention programming. (Adapted from Commonwealth Secretariat 1999b) ANALYSIS OF NATIONAL STRATEGIC PLAN 4.1. FINDINGS The following observations are a result of using KWIC and analyzing chunks of text: Implicit level of gender consideration As mentioned previously, the Belize NSP while implicitly acknowledging gender as a pivotal area of focus in stemming the pandemic, it does not explicitly address the gendered dimensions that influence the spread of HIV in Belize. Additionally, it is not clearly stated that increase in HIV infection through heterosexual transmission and the increase in spread among women is a result of gender inequality. Indeed in many cases where the differential vulnerability of women and men, boys and girls is noted, the source of this differential risk and vulnerability is not. Additionally, the strategies identified in the priority areas of harmonization, prevention and mitigation are not gender responsive as they do not consistently incorporate the differential needs and vulnerabilities of women and men and boys and girls. Currently HIV health services are primarily delivered through the Ministry of Health (80%). This is representative of efforts to scale up the response through an increase in access to ARVs and services such as HIV counseling and testing. It has been noted in the current NSP, and rightly so, that a more expanded multi-sectoral response is required towards the achievement of universal access (UA) to prevention, treatment, care and support services. Greater attention must be paid to properly outlining and costing gender-responsive baseline studies as they are crucial to effective planning around prevention, treatment, care and support interventions. Therefore the areas where TBD was inserted must be revisited and required financial resources identified. 10 Explicit level of gender consideration

11 The Ministry of Health in collaboration with PAHO/WHO has begun collection of sex disaggregated and gender responsive health data, which has been instituted for some years. This data is currently being used to develop a gender-based analysis of priority health issues such as HIV, Non-Communicable Diseases (NCDs), domestic violence and road traffic injuries. This is being done in order to provide appropriate data and information which can affect the development of relevant gender-responsive policies, programs and services. However, based on the various individual interviews conducted, there is a general lack of understanding of how to mainstream gender into national programs despite numerous training completed by key stakeholders. This situation has resulted in national programs failing to be gender-responsive. Some effort has been made to incorporate gender in designing interventions and preventative measures as outlined in key outcomes of the NSP. The NSP lists many of the gender outcomes from UNGASS. To a great extent, most of the interviewees expressed knowledge by experience and training in defining gender and gender-sensitivity. However, this knowledge transferred into unbalanced focus on women as the main component of the employed gender analysis. Areas Inadequately/ Not Addressed Specific Cultural/Societal Norms that Contribute to Risk and Vulnerability among Women and Men and Boys and Girls The NSP fails to explicitly and clearly state the particular gender-based cultural norms that increase risk and vulnerability to women and men and boys and girls, although they are implicitly addressed throughout the NSP. Men who have Sex with Men (MSM) The NSP fails to effectively address the gendered dimensions of unprotected sex between men who have sex with men. It must be explicitly noted that systemically perpetuated stigma and discrimination associated with homosexuality and fixed concepts of masculinities fosters unhealthy patterns of behavior which have emerged as follows: Men who have sex with men are unlikely to get tested for HIV. Men have hetero-sexual relationships while engaging in unprotected sex with other men secretively; putting their female partners at increased risk. Sexual minorities such as MSMs In comparison to the NSP (2003), there has been a gradual improvement and incorporation of key stakeholders; the gender perspective is lacking. 11

12 Most of the performance indicators simply did not have any baseline. 67 of the 73 identified baselines were represented by TBD to be determined. The study also sought to identify the absence of gender considerations by checking if gender relevant issues were/were not covered by the text. As a result, the following observations were made: Poverty and lack of employment The Belize NSP recognizes poverty as a major factor to the prevalence of HIV and Aids. In an analytical and contextualized framework, the issue of poverty was treated in most instances as a gendered reality. Much effort was placed in ensuring that available data and statistics were analyzed and incorporated into the NSP for Belize. Primarily, under vulnerable population the gendered reality was made explicit and there was detailed separation of the groups: MSMs, MSWs, FSWs, persons living with STIs, persons living in poverty, incarcerated population. The NSP demonstrated recognition of the limitations of the ability to make safe choices as a result of poverty and it isolated MSWs and FSWs as an example. It also made reference to young women s vulnerability. Considerations were also given to poverty as part of the development of the NSP as it relates to its commitment to the National Poverty Reduction Strategy and Action Plan, Millennium Development Goals and UNGASS (2006). The NSP fails to demonstrate that there is a direct relationship between poverty, gender and HIV. Outcome 2.3 Reduced Prevalence among most at risk Population implicitly addresses poverty. However, the section on cultural and social norms is not detailed and written with clarity. It does not explicitly state that gender inequality is expressed through various cultural norms regarding sexuality. Gender-based violence both in and out of the home, including child abuse, coercion and rape of young girls and rape of women generally. There is minimal mention of this and these issues are primarily described in the context of the current situational analysis of the epidemic; not addressed on a policy and program level Gender inequality as illustrated through cross-generational relationships, specifically relationships between young/teenaged girls (minors) and older men. Reference is made to transactional sex between young women and older men and the risk involved as VCT data shows a prevalence rate of 12.5% in men 40 and older; however there is no evidenced-based data or recommended programs to address this Migrant workers Migrant workers (mobile populations) are isolated with clear distinction as forming part of the vulnerable and high risk group. Reference made to this group, as the group 12

13 responsible for the diseases prevalence based on their classification as CSWs. Outcome 2.3: Reduced prevalence among most-at-risk populations addresses this group in much detail. This group is not protected under the legal system and also, there is no indication of easy accessibility to same treatment and care in the health services. Multiple partnering and inconsistent or non-use of condoms Minimal mention but considerations were made to target this in the key areas of prevention and mitigation. Co-infection as it related to sexually transmitted infections There is much mention of this and the NSP addresses this in its outcome. However, whilst mentioned in the text, in its context, the language used to address this topic is not gender responsive or gender sensitive. Much of the language in the outcomes regarding this topic is not written in gender-responsive language. As an example, intermediate outcome Improved sexual behavior among men and women is not written as a gender-sensitive outcome. SUMMARY SECOND ANALYSIS Data collected from the M & E committee members was analyzed as per the table below. The information rates the four major components of the NSP. Component Maximu m Points Raw Scor e Comparative Value Ratio Vulnerability reduction and prevention of HIV infection Needs improvement 45% Provision of improved care and services 24 9 Needs improvement 38% Impact mitigation and support for coping capabilities Reasonable 53% Total Needs improvement 46% 13

14 Legend Ratio Comparative value 84% - 100% Very good 68% - 83% Good 51% - 67% Reasonable 34% - 50% Needs improvement 18% - 33% Needs drastic improvement 17% and less Unacceptable In analyzing the scores, impact mitigation and support for coping capabilities within the NSP is the most gender-sensitive module in the Belize Plan. Both Vulnerability Reduction and Prevention of HIV infection and Provision of Care and services are equally weak and needs improvement. Notwithstanding the significant progress in building gender sensitivity into the Belize NSP, there is still overall need for improvement in mainstreaming gender throughout. GENDER GAP ANALYSIS OF BELIZE S NSP (MATRIX) A gender gap analysis was conducted of Belize s NSP determined by the identification of best practices from various studies on gender in HIV & AIDS work. In particular, the majority of the best practices were extracted from the Caribbean Gender Checklist and Indicators for HIV and AIDS policies and programs by Dunn, Bell & Perkins (2007). The gap analysis matrix below provides some recommendations that the NAC may consider to increase the level of gender-sensitivity in the NSP. 14

15 NSP Gap Analysis Matrix/Action Plan This matrix is based on an analysis of the proposed outcomes and outputs identified in the Belize NSP re: the Three Priority Areas of Harmonization, Prevention and Mitigation Priority Area 1 Outcome Gap Analysis Recommendations/Actions Harmonization 1.1 Strengthen leadership of NAC and District Committees 1.2 Strengthen coordination role of NAC 1.3 Improve evidence-based program development 1.4 Creation of supportive environment to protect against stigma and discrimination (S & D) At the national level, there is minimal mention of gender mainstreaming into national HIV & AIDS programs and policies Reference made to gender equality as a cross-cutting theme in the NSP but transforming gender relations is not explicitly supported The NSP while acknowledging an increase in HIV infection among women does not explicitly state that this is occurring as a result of gender inequality Develop a Gender Management System at national and sectoral levels which is an integrated network of structures and mechanisms in order to guide, plan, monitor and evaluate the process of mainstreaming gender into national programs. Establish gender budgeting into the NSP. Develop and implement a training program on gender awareness, sensitization, and gender mainstreaming for key stakeholders. Develop a plan for building political will involving parliamentarians as well as key government ministries so as to secure resources and promote an expanded national response Strengthen HIV & AIDS data collection ensuring that data is collected based on gender responsive indicators including sex, age, ethnicity, income and geographical location in order to develop a gender analysis of the 15

16 The Belize NSP now has an M & E plan in draft form, soon to be finalized. However, the plan requires strengthening in order to be considered gender responsive epidemic. This report should be shared with key partners and stakeholders involved in the national response and should include information on why men and women are getting infected, and include attention to concurrent relationships, transactional sex, intergenerational sex, or sugar daddy syndrome as it is commonly referred to. Enhance the current M & E plan to fully incorporate gender analysis as a mandatory analytical category. This will require the presence of a gender specialist or gender specialist capabilities amongst the monitoring team and other important mechanisms such as the Secretariat and the Ministry of Health s National Aids Program Team. Prevention 2.1 Reduced transmission rates among recipients of blood and children born to infected mothers. 2.2 Reduced transmission rates in the general population with emphasis on youth (15-24). 2.3 Reduced prevalence among most-at-risk populations (MSM, CSW, prison population, None of the outcomes address prevention and protection against gender - based violence/violence against women and its intersection with HIV infection and access to HIV services Lack of gender focus on Ensure HIV testing for survivors of gender-based violence. Inclusion of baseline studies that focus on gender and the differential impact of key HIV prevention programs on women and men The need for targeted gender responsive health information promotion among specified vulnerable/at risk groups. Increasing access to prevention services 16

17 uniformed services). 2.4 Improved utilization of other related prevention services. HIV prevention. There is no acknowledgment of the role that stigma and discrimination, based on dominant gender norms and values;; increase risk and vulnerability of MSMs and CSWs. No mention of gender norms and values associated with sexual behavior among year olds Youth prevention programming is focused on STI prevention through knowledge distribution about the modes of HIV transmission and does not address the gender norms and values that contribute to risk and vulnerability among year olds by addressing issues of differential access among women and men. Assist key stakeholders in accelerating the implementation of gender responsive HIV programs and interventions Develop and implement gender responsive social communications campaigns focused on prevention/safe sex practices with messages that address gender inequality and target vulnerable groups Ensure that young men and women in and out of school have information about their own bodies and their differential vulnerability to HIV and other STIs. Ensure accessibility of female and male condoms in clinics and youth-friendly spaces (non-traditional places) Identify key companies cross-sectorally for the development of gender responsive health policies Encourage companies with existing health policies to ensure that they are gender responsive, including education on modes of transmission, prevention, factors driving the epidemic, the gender dimensions of HIV & AIDS and the implications of sexual behaviors and relations between men and women and 17

18 Mitigation 3.1 Improved effectiveness of integrated care, support and treatment services for people infected with and affected by HIV/AIDS. 3.2 Improved policies and programs addressing reduction of the socio-economic impact of infection for Persons Living with HIV/AIDS. Broad and generalized access as opposed to universal access to appropriate health care indentified in NSP. Health care is gender-specific, in favor of women and children year old males and female are targeted in the NSP to promote STI treatment. Promote gender responsive work place prevention and care programs in the private sector. Promote awareness programs and education regarding the universal access to appropriate treatment for all. Monitor programs to ensure gender-bias is minimized in areas related to health care. Design intervention programs from a gender/human rights perspective taking into account gender as a criterion. Develop innovative method of providing effective care to men, women, boys and girls infected and affected by HIV. Ensure that men, women, boys and girls have equal access to HIV& AIDS care, treatment and support services. 18

19 KEY RECOMMENDATIONS Consideration of gender as a social factor for inclusion in research and program development, implementation, monitoring and evaluation is a pivotal component of a successful national HIV response. As such, the national strategic response to HIV in Belize must actively mainstream gender analysis into its assessment of the epidemic; in defining areas of study for baseline research; in identifying key areas of focus for prevention, treatment, care and support programs and services and in determining monitoring and evaluation indicators. Also, the NSP should incorporate a strategy for mainstreaming gender incrementally, consistently and cross-sectorally to ensure a more stable base of applied knowledge and awareness of the gendered dimensions of the HIV pandemic in Belize. To maintain the viability of the approaches recommended in the NSP, an annual review should be conducted with leadership and participation of the NAC, its membership and other key stakeholders; to maintain inclusive and proactive incorporation of gender into the development, implementation, monitoring and evaluation of HIV prevention, treatment, care and support programs. Diverse groups of people from vulnerable populations, including but not limited to, people living with and affected by HIV and AIDS; youth, MSM, male and female commercial sex workers; national women s machineries, women s and men s NGOs, the business and faith-based communities and key persons in the HIV health and education service sectors should participate in annual reviews. Active and inclusive collaboration on annual revision of the NSP will accommodate emerging trends in the HIV pandemic; increase the effectiveness of approaches, identify and more easily prioritize, focus areas and determine what is working and what is not working. It will also promote resource and knowledge sharing for capacity building among those involved in the response. Additionally, efforts to strengthen reporting must be made in order to effectively assess monitoring and evaluation indicators for tracking annual progress in the three priority areas as outlined in the NSP. The developed operational plan should include a fully costed outline of gender responsive activities and strategies. It should also accommodate active and inclusive participation of key stakeholders including those affected and infected with HIV, in the priority areas of harmonization, prevention and mitigation. The operational plan must make special provision for the identification of data gaps and the conducting of corresponding baseline research that will provide data to inform gender responsive HIV programming, policy making and program reform. Baseline research 19

20 findings should be incorporated into an overall plan for developing and using strategic intelligence in the areas of harmonization, prevention and mitigation. The NAC Secretariat must also ensure that a fully costed gender responsive M & E operational plan is developed and implemented. Once the commission is reconstituted, it is imperative that the draft M & E plan gains approval. The NAC should maintain a sustained focus on strengthening the coordination of the national HIV response as outlined in the NSP. This can begin with the undertaking of a capacity assessment of key actors in the HIV response with assessment of both financial and human resources. Additionally, a gender analysis should be employed to identify how HIV and AIDS impact the work of each ministry and sector to build stakeholder and multi-sectoral participation. The following are summarized recommendations: 1. Ensure that the operational plan is fully costed and that activities are gender responsive. 2. Include the annual review of the NSP in the operational plan. 3. The operational plan must make provision for addressing gender-based violence and the development of policies that respect youth sexual reproductive health and rights. 4. The operational plan should include costing for implementation of an M&E plan. 5. Develop and implement a plan to strengthen data collection processes that accommodate gender responsive policy and program development including data disaggregation by sex; age, geographical location, ethnicity, employment, education, etc. 6. Employ a gender-based analysis of national HIV data and annually update the Belize epidemiological profile. The analysis process should be inclusive of other sectors such as: Education Department, Women s Department, BFLA, PASMO, etc. 7. Ensure recommendations are included in the gender-based analysis. 8. Disseminate information to key stakeholders for the development of appropriate interventions. 9. Mainstream gender into at least three key national HIV programs. 10. Engage and collaborate with national and international partners to strengthen the mainstreaming of gender into HIV programs and policies. 20

21 11. Utilize and share information produced by PAHO with the support of Pierrie Women s Center, which details guidelines on developing gender-based analysis, with other stakeholders and training conducted. 12. Build on the training conducted by PAHO/WHO country office for users and producers of information. 13. Integrate gender indicators in the national indicators. 14. Develop a clear action plan for the integration of gender into the HIV programs and policies. Plan should also identify training needs. 15. Include gender sensitive indicators in the M & E Plan of NAC. 16. Prevention strategies must focus on reducing gender-based violence and stigma and discrimination. Prevention should include consistent state-led social communications campaigns aimed at addressing Belize-specific concept of masculinities and femininities that promote behaviors which increase risk and vulnerability to HIV. 17. The activities identified in the priority areas of harmonization, prevention and mitigation in the operational plan must jointly focus on addressing concepts of masculinities and femininities that prevent access to HIV prevention, treatment, care and support services and increase vulnerability. GENDER RESPONSIVE INDICATORS TO BE INCLUDED IN BELIZE S M&E FRAMEWORK (MATRIX) The Strategic Plan for a Multi-Sectoral National Response to HIV & AIDS in Belize, includes a preliminary framework. The framework constitutes the basis for a detailed M & E plan for measuring progress in implementation of the strategic plan and in output/outcome target achievements. The M & E committee of the NAC was tasked with the further development of the framework. However, at the time of this consultancy, that framework has still not been finalized. Baselines at the time of writing the proposal had not been formulated. Data gathering for key impact indicators are in the process but a major limitation is the funding to cover the expense of carrying out these baseline studies. Nevertheless, the consultancy examined the extent to which gender-sensitive indicators existed in the framework. The framework includes several gender sensitive indicators especially in the priority areas for prevention and mitigation. However, there are still a significant number of generalized terms such as adults, children and cluster populations (i.e. migrant workers, mobile population and vulnerable groups). The matrix below provides a set of gender-sensitive indicators which can be utilized to further engender the 21

22 M & E framework. The indicators correspond to impact, outcomes and outputs of the three priority areas: harmonization, mitigation and prevention. It also provides possible data sources for these indicators. 22

23 Suggested Gender Sensitive Indicators Impact 1 Gender-Sensitive Indicators Data Source Improved effectiveness of the multi-sectoral coordination for implementation of the National HIV/AIDS Response A nationwide movement evolved reflecting participation and involvement of government (at state and local levels, and across sectors tourism, education, health, labor, economic development, social services, etc), nongovernment, private sector, civil society, community-based agencies, and vulnerable people s organizations in responding to the epidemic. NAC Reports, special studies/surveys Effective multi-sectoral coordination will also be reflected in a balanced (reasonable) mix of men and women participating and involved in the response. Level and extent to which a human rights and gender approach is centralized in the national response Outcome Gender-Sensitive Indicators Data Source 1.1 Improved leadership role of the NAC and District Committees to address HIVAIDS issues in Belize Level and extent to which system-wide processes are established horizontally and vertically to oversee program development, implementation, monitoring and evaluation, taking into account the situation as it pertains to women and men, boys and girls. Demonstrated commitment at highest levels to infuse a gender perspective in HIVAIDS issues in Belize: gender expertise lodged within the leadership of the NAC and capacities built at various levels to employ a gender perspective Outputs Gender-Sensitive Indicators Data Source Strengthened understanding of roles and responsibilities of various players involved in the National Response: NAC, NAC District Committees, NAC Secretariat, Ministry of Health, etc Improved involvement of NAC and District Committees for the effective implementation of the Strategic Plan Establishment of a system for Improved dissemination of information at the national, regional and international level to help in future planning and implementation Level and extent to which roles and responsibilities of different players, sectors, and committees reflect a gendered approach to their work Existence of operational plans at national, regional, sectoral levels that are developed from the national strategic plan that also reflect a gendered approach. Level and extent to which the system tailor-make the packaging of information to suit the diversity and needs of information users (making information user-friendly) NAC Reports, District Committee Reports, Reports from Sectors Annual Reports Information packages 23

24 1.1.4 Improved collaboration between various stakeholders (ministries, faith based groups, district health offices, CBOs and NGOs, private sector, media, donors and technical partners) involved in the national response Level and extent to which smart partnerships are formed and resources shared between various groups of stakeholders Number of cross-sectoral HIVAIDS programs offering comprehensive services to PLWHAs Annual Reports Outcome Gender-Sensitive Indicators Data Source 1.2 Strengthen the coordination role of the NAC Secretariat Level and extent to which the NAC commands the respect of the diversity of players as the leading authority in the national response Capacity and capability within the NAC Secretariat to utilize gender analysis in HIV and AIDS programming and implementation Evaluation reports Outputs Gender-Sensitive Indicators Data Source Improved ability of the NAC Secretariat to coordinate and mobilize resources in support of the multi-sectoral response Strengthen capacity of the NAC Secretariat and District Committees in planning, implementation, and monitoring of HIVAIDS programs at all levels Extent of training at the different levels in identifying gender issues and using gender analysis to aid the planning and monitoring processes. Reports Outcome Gender-Sensitive Indicators Data Source 1.3 Improved evidence based planning for the development and monitoring of national HIVAIDS programs and services Ability of planners at all levels to engender evidence-based planning and utilize gendered lens to monitor HIV program and services Outputs Gender-Sensitive Indicators Data Source Strengthened capacity of NAC Secretariat to establish and implement an M & E system to monitor the national response and guide future planning Improved ability of the relevant agencies to conduct necessary research and surveillance to inform the policy process as well as program development and implementation Level and extent to which gender indicators are integrated into the M&E framework Extent to which relevant agencies acquire the necessary skills to engender their research and surveillance methodology. Research and surveillance documents reflect gender perspective M&E framework Reports 24

25 Outcome Gender-Sensitive Indicators Data Source 1.4 Creation of a supportive environment to protect against stigma and discrimination of PLWHAs Percentage of the general population with accepting attitudes towards those living with HIVAIDS Percentage of PLWHAs and their families who perceive a change in respect for their rights by society Level and extent of training for duty-bearers, service providers in gender and human rights Surveys Outputs Gender-Sensitive Indicators Data Source Improved capacity of the NAC and partners to Number of relevant policies written or revised from a human rights and gender Policy documents apply gender and rights-based principles for perspective in support of the National HIVAIDS policy. HIV/AIDS program and policy development Strengthened capacity of the NAC Secretariat and District Committees to guide the policy process and to address HIVAIDS issues among NAC members and other key stakeholders, including the private and public sector, civil society, faith based organizations, and donors Improved number of sectoral policies addressing HIVAIDS issues in various sectors, such as reproductive health and family life policy, youth policy, public health policy, etc Develop programs and establish a legal framework in support of the National and Workplace HIVAIDS Policies Capacity building for various organizations and programs (media, uniformed services, health care providers, schools etc.) to present and address PLWHA without stigma and discrimination Change in participation level of various groups in policy dialogue and advocacy for HIVAIDS issues Number of policies developed by various sectors that address HIVAIDS issues from a gender perspective Number and types of gender sensitive program in existence to socialize information about HIVAIDS policies Existence of strong advocacy pressure group lobbying for and on behalf of PLWHAs for changes in policy and enforcement of anti-discrimination laws Dynamic mechanism in place to report and record experiences of stigma and discrimination by PLWHAs Policy documents Program reports Reports on advocacy initiatives 25

26 Impact 2 Gender-Sensitive Indicators Data Source Reduced prevalence of HIV in the adult population (15-49) of Belize Reduced prevalence of HIV for males and females in different age groups within the range. Reduced prevalence of HIV among females and males in different vulnerable groups : Sex workers, migrants and mobile population, tourism workers, incarcerated persons, etc. Strategies in place to promote shared responsibilities of men and women for safe sexual behavior Epidemiology surveillance reports Perception surveys Outcome Gender-Sensitive Indicators Data Source 2.1 Reduced transmission rates among recipients of percentage of infants born to HIV infected mothers that are infected Epidemiology surveillance reports blood, and children born to infected mothers (UNGASS) Outputs Gender-Sensitive Indicators Data Source Improved quality and access to safe and high quality blood products Improved delivery of and access to PMTCT services countrywide involving both private and public service providers Increased number of pregnant women from all age groups and geographical areas receiving a complete course of antiretroviral prophylaxis to reduce the risk of mother-to-child transmission. Increased number of pregnant women from all age groups and geographical areas attending at least one ANC visit who received an HIV test result and post-test counseling Epidemiology surveillance reports PMTCT Program reports Increased involvement of fathers in PMTCT program countrywide Outcome Gender-Sensitive Indicators Data Source 2.2 Reduced transmission rates in the general population with special emphasis on youth (15-24) Reduced percentages of young women and men aged who are HIV infected Reduced % of young women and men aged from different geographical areas and from different vulnerable groups Reduced percent of other age groups of women and men 26