EVALUATION REPORT OF THE ETHIOPIAN STRATEGIC PLAN FOR INTENSIFYING MULTI-SECTORAL HIV RESPONSE ( )

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1 EVALUATION REPORT OF THE ETHIOPIAN STRATEGIC PLAN FOR INTENSIFYING MULTI-SECTORAL HIV RESPONSE ( ) February 2009

2 ACKNOWLEDGMENTS The Evaluation Team gratefully acknowledge the superb leadership and technical support provided by the Evaluation Steering Committee. The Evaluation Team wishes to thankfully acknowledge the federal and regional agencies that participated in the evaluation process for sharing information and their views. The Federal HAPCO is specially thanked for facilitating the participation of the Evaluation Team members in its review meeting in Dire Dawa and for all rounded support during the evaluation process. The UNIADS and WHO country offices are acknowledged for financially supporting the activities of the Evaluation Team. The Team is very grateful to all informants involved during the process of the evaluation. The Evaluation Team Prof. Yemane Berhane (Principal) Prof. Ahmed Ali Dr. Alemayehu Worku Dr. Ayalew Gebre Wz. Haregwoin Cherinet Dr. Meaza Demissie Dr. Petros Olango Dr. Sirak Solomon 1

3 ACRONYMS/ABBRIVIATIONS AAU AIDS ANC ART BSS CC CSWs DHS HEW CBOs CSOs EDHS FMoH FBOs FGM FH FP GBV IGA HAPCO HCT HIV HRCI HTP KAP MAC MSM NGO OI OVC PLHIV PMTCT RAC RHAPCO RHB SNNPR SPM STI TB Addis Ababa University Acquired Immuno Deficiency Syndrome Ante Natal Care Anti Retroviral Treatment Behavioural Surveillance Survey Community Conversation Commercial Sex Workers Demographic Health Survey Health Extension Worker Community Based Organizations Civil Society Organizations Ethiopian Demographic and Health Survey Federal Ministry of Health Faith Based Organizations Female Genital Mutilation Family Health Family Planning Gender Based Violence Income Generating Activities HIV/AIDS Prevention and Control Office HIV Counselling and Testing Human Immuno Deficiency Virus High Risk Corridor Initiation Harmful Traditional Practices Knowledge, Attitude and Practice Millennium AIDS Campaign Men having Sex with Men Non Governmental Organization Opportunistic Infection Orphan and Vulnerable Children People Living with HIV Prevention of Mother to Child Transmission Regional AIDS Council Regional HIV/AIDS Prevention and Control Office Regional Health Bureau Southern Nations and Nationalities People Region Strategic Plan for Multi-sectoral response Sexually Transmitted Infection Tuberculosis 2

4 Table of Contents Executive Summary Introduction Objectives of the Evaluataion Methods of Evaluation Overview of the Findings of the Evaluation The Strategic Plan for Multisectoral Response ( ) Current Status of HIV Epidemic in Ethiopia HIV Service Utilization Findings by SPM Thematic areas Capacity Building Social Mobilization and Community Empowerment Integration of Health Programs Leadership and Mainstreaming Coordination and Networking Special Target Groups Annex 1: List of Persons Contacted and Consulted

5 Executive Summary The Ethiopian Government has been implementing the HIV Strategic Plan for Multi-Sectoral response (SPM) for the period The SPM was envisaged to enhance implementation capacity, coordination and networking, leadership and mainstreaming, social mobilization and community empowerment, integration of services and targeting responses in order to alleviate the health, social and economic impact of HIV. The SPM has been the lead document in organizing and implementing responses in Ethiopia. This evaluation was done with the aim of assessing the achievement and lessons Learnt during the implementation period, and based on the findings to forward recommendations for the next SPM. The summary of findings is presented below in various subsections; the findings are followed by recommendations specific to the respective subsections. Current HIV Epidemiology Efforts have been intensified to increase the evidence base for effective planning and implementation of HIV programs during the SPM implementation period; surveillance activities and special studies conducted systematically. Comprehensive knowledge about HIV prevention and transmission still low; knowledge is shallow. More importantly knowledge level about HIV prevention and transmission declined between 2004 and According to a recent study, knowledge was lowest among married, lowest wealth index, rural, uneducated, and in emerging regions. The prevalence of high risk sexual behaviour seems to have increased remarkably during the reporting period. In the global fund evaluation the young, rural, uneducated, and those from lowest wealth index reported higher risky sexual behaviour compared to what have been reported by earlier studies; notably the 2005 BSS. Risk groups identified by reviewing documents and key informants interview include students (from high school through university), migrant labourers, commercial sex workers, truck drivers, out-of-school youth, and indigenous populations in remote foreign tourist destinations that are involved in high risk commercial sex transactions. Gender based violence and substance abuse (alcohol and khat) exacerbate spread of HIV among higher learning institutions. Some emerging new risk groups have been hidden or denied; for instance, the presence of the gay community, especially men having sex with men (MSM). So far, the evidences suggest that the gay community is growing fast in number in Addis Ababa and other major foreign tourist destinations in the country. High risk sexual behaviours and high risk groups are increasing in number and type; college/university students and MSM are increasingly recognized as the most-at-risk population groups. The youth, women, and the poor remain vulnerable to HIV. There is a dire need for rapid expansion of prevention services among these population groups, otherwise, there still remains a huge, perhaps hidden for some, potential for a resurgence of the HIV epidemic threatening the past gains and the country s investment return in health, education and other developmental activities. Increased knowledge about HIV is not just enough to limit the spread of HIV. Preventive interventions must start at a younger age to be effective and reach the vulnerable. Schools must be used as media of communication to reach the surrounding communities, especially in the rural areas. Interventions must be 4

6 specific and targeted for youth, students, CSW, MSM, mobile workers, migrant labourers, rural population, and tourist destinations. The need for HIV incidence measures is clear with little value from prevalence studies in the era of ART. Current HIV Response Phenomenal achievements were made to expand access to HIV counselling and testing and ART services. Thus, the number of people benefiting from the services showed progressive increment. Efforts to reduce mother-to-child-transmission also showed progressive increment in coverage; though not as per the desired speed and volume. Responses are mainly focused on medical interventions. Social mobilization activities aim to increase the uptake of medical services. Condoms were not widely available for the purpose of HIV prevention except through social marketing schemes. Efforts directed at HIV prevention including abstinence, partner reduction, faithfulness and consistent use of condoms do not seem to have received the attention they deserve. While maintaining the current interventions to reduce morbidity and mortality for AIDS patients, more emphasis needs to be given for HIV prevention through a multi-sectoral approach. Emphasis need to be given to implement appropriate interventions targeting the most-at-risk populations in specific contexts; such as students, highly vulnerable women, migrant workers, and tourist destination populations. Involvement of the CBOs, CSOs and the private sector must be recognized and appropriate support need to be provided. Mechanisms to strengthen OVC and PLHIV care and support need to be intensified under a strong leadership of FHAPCO. Capacity Building A lot has been achieved in capacity building by expanding health infrastructure; for instance 350% achievement in the health post construction, 255% achievement in equipping health posts, and 20% increase in the number of hospitals. More importantly, availability and accessibility of services showed phenomenal increment. The Millennium AIDS Campaign and Universal Access to ART expanded free HCT and ART services to a very large number of eligible individuals. However, expansion of preventive services such as condom promotion and distribution and other core prevention interventions did not show marked improvement. The number of services providers increased, new categories of health workers was added at the grassroots level (Health extension workers), and task shifting was introduced, to overcome as well the staff turnover and attrition and expand the desired service. Short term trainings were provided to large number of services providers, mainly in the public sector. Due to high turnover of staff, nevertheless, capacity building remains to be a major challenge. The efforts to build human resource capacity have been focused only in the health sector. The potentials in the non-health sector and in non-public sector remained underdeveloped and underutilized. The shortcomings in the pre-service trainings not only in the health sector, but also in all other sectors are major concerns pertaining to the sustainability of certain interventions. 5

7 Guidelines and manuals were prepared and distributed to improve quality standards for services. Limited staff size in major implementing organizations, including in the federal and regional HAPCOs, is not compatible with the considerable resource mobilization efforts. HAPCO s structure among different regions is different; those under regional health bureaus are overwhelmed by the health interventions. At woreda level, the HIV coordinator s (HAPCO agent!) accountability is not consistent. However, irrespective of their accountability status, woreda level implementation capacities are limited in most regions. Limitation of budget, slow fund release and lack of prompt response for intervention proposals submitted for funding were reported to be deterrents for better responses. Disbursements of resources may not always reflect the magnitude of the problem and the implementation capacity in place at the regional and woreda levels. Lack of capacity for timely release and liquidation of fund was a chronic problem and a deterrent for timely implementation of activities according to plans. At the community level, the potentials of the already existing social structures such as Idirs (CBOs) and other cultural institutions have not been fully utilized for the fight against HIV. The need for drafting and enactment of HIV and human right laws is apparent and of urgency. Efforts need to be intensified to build strong and sustained capacity to handle the epidemic by increasing the capacity building horizon to non-public sectors (NGO, private...); establishing continuous training sessions with regular follow up; providing better incentive and on-job protection to services providers. Organizational structures for HAPCO need to be re-visited in line with its expectation to coordinate the multi-sectoral response. Accountability to multisectoral response can be imposed if HAPCO has the political and administrative power. Social Mobilization and Community Empowerment Social mobilization efforts, especially the Community Conversations (CCs), were very successful in reaching millions of people through kebeles and other grassroots level organizations and creating awareness about HIV and available services. Better involvement of communities and community based organizations in supporting orphans and PLHIV and mitigating the impact of HIV were observed. Stigma and discrimination were substantially reduced paving the road for better access to services. Awareness creation successes were not accompanied by behavioural changes. This may be related to the fact that messages were not specific to target groups and sustaining campaign activities was difficult. Specific interventions to reduce HIV vulnerability due to economic challenges were also limited. Lack of standards and inadequate resources to support orphans and vulnerable children (OVC) hampered reaching needy children and mitigating the impact of HIV. HAPCO also lacks the organizational structure to deal effectively with OVC. Social Mobilization efforts were not targeting people at leadership position and that had implication on the multi-sectoral response especially at regional levels. 6

8 Campaign activities must be followed by standard routine intervention packages in order to sustain the gains obtained through high price operations. Social mobilization interventions need to be specific to population groups and specifically address risk scenarios and should also target leaders at different level. Efforts to support OVC without displacing them from their familiar environment must get high attention. Organizational structures and mandates for HAPCO must include OVC. The role of CBOs in social mobilization and strengthening community level responses must be well recognized and interventions must have multi-sectoral approaches and be inclusive. Integration with Health Programs Many health facilities are well equipped to provide basic clinical services for HIV diagnosis and treatment. Provider initiated HIV counselling and testing services have been better integrated with the routine health services. Efforts to establish linkage between clinical care and support services are strengthened. In facilities where integration is achieved and to some extent functional referral link is established with primary health care units and health extension workers; responsibilities are shared, coordination is better, and resources are effectively and efficiently utilized resulting in better services for clients. The number of blood banks is expanding in the country; nevertheless, currently Gambella, Afar and Benshagul-Gumez regions have no functional blood banks. Compared to the number of hospitals in the country, the number of blood banks is grossly insufficient. High turnover of staff at all levels of care has hampered efficient implementation of interventions and ensuring standard quality of care. The involvement of non-public sector health facilities in providing comprehensive HIV services is very limited. To promote effective and better integration of HIV related services at facility level, further capacity building by providing training to providers and issuing practical guidelines/manuals is necessary. Standardizing the linkage between programs and strengthening it is needed to improve the HIV services. All stakeholders and funding partners need to understand the need for comprehensive and integrated HIV services and actively support its full implementation. Leadership and Mainstreaming Leadership: Better leadership commitments were achieved at national and regional levels; however, the level and effectiveness of leadership commitments significantly vary among regions. Sub-regional level and non-health sector leadership commitments remain much less than desired. High turnover of staff and lack of sustainable mechanism for provision of sustainable training as well as financial limitations limited effective leadership. 7

9 Effective leadership by HAPCO for the multi-sectoral response is limited by its organizational structure and accountability; except in the Amhara Region where HAPCO is accountable to the State Council. The functionality and effectiveness of many of the AIDS councils was not commensurate with the responsibility bestowed up on them. Meetings are not held regularly and the level of engagement is weak. Effective leadership obviously emanates from political power, thus the structural position of HAPCO must be re-examined in relation to its responsibility of providing leadership to the multi-sectoral responses and along the political organization of the country. AIDS Councils need to be strengthened to shoulder more responsibility for the multi-sectoral response. Adequate resources for operations and necessary incentives for the human resources need to be allocated based on objective criteria that consider the prevalence of HIV and population size among others. Making the National AIDS councils accountability to Prime Minister s Office would strengthen the multi-sectoral response. Mainstreaming: Increasingly sectoral public agencies have recognized HIV as one of their core activities and made necessary preparations including assigning a focal person or by establishing a coordination office. The education and social and labour affairs offices have better and exemplary accomplishments in mainstreaming. More and more sectoral public agencies are allocating up to 2% of their annual budget for HIV related activities within the agencies; and to some extent supporting external activities. Efforts and achievements in mainstreaming remain much less than desired in many sectors. Lack of conceptual understanding, unavailability of clear mainstreaming guidelines, and insufficient resources were among the major reasons for ineffective mainstreaming. Mainstreaming efforts in non-public sectors have not been recognized and supported enough; though CBOs such as Idirs have made substantial efforts to incorporate HIV impact mitigation activities in their routine work. Developing user friendly mainstreaming guideline and providing appropriate training with adequate supportive supervision is necessary to strengthen effective mainstreaming. Ensure accountability for HIV mainstreaming by making HIV part of the performance evaluation. Coordination and Networking One agreed national action framework developed and the principles of Three Ones adapted with HAPCO s leadership which lead to development of Plan of action for Universal Access to HIV Treatment, Care and Support ( ), and the Road Maps for Accelerated Access to HIV Prevention, Treatment, Care and Support ( & ). 8

10 Effective coordination and networking of activities were achieved through joint review meetings and joint integrated supportive supervisions. Consultative, taskforce force, and working groups meetings were better coordinated. Better coordination of resources was achieved by aligning and harmonizing donors and their programs. Several memorandums of understandings were signed to institutionalize efforts. Donors diverse interests and the desire to draw attention towards them have been significant challenge in implementing one multi-sectoral action plan. HAPCO s limited sphere of power has been a significant limitation in coordinating and networking activities; especially in the regional states. Strengthening and empowering HAPCO and NAC following the power/political structure of the nation is necessary to achieve better and effective coordination and networking of the multi-sectoral response. Special Target Groups The HIV responses over the last five years were generally targeting the whole population with some specific attention to certain groups like the urban population, military, youth, long distance track drivers, and commercial sex workers. CBOs and FBOs played major roles in intervention related to care and support of OVCs, and PLHIV. Although certain population groups are identified as risk groups, responses were targeting the general population and some either very vulnerable or high risk groups were not specifically targeted for appropriate interventions; the interventions targeting them were inadequate and coverage has been very low. Studies identifying at risk populations are scanty and not regularly conducted and thus, not adequate to guide responses. Situations that increase vulnerability are becoming more rampant because of urbanization, development activities, inter-border commercial activities, and refugee settlements and internal resettlements. In addition, in some areas with cash crops, traditional night market and tourist destination areas are reported to have increased vulnerability to HIV. Efforts directed to HIV prevention including abstinence, partner reduction, faithfulness and consistent use of condoms have not received the attention they deserve. There are emerging new risk groups such as college students and gay groups. Risk groups identified by reviewing documents and key informants interview include students (from high school through university), migrant labourers, commercial sex workers, truck drivers, out-of-school youth, and indigenous populations in remote foreign tourist destinations that are involved in high risk commercial sex transactions. Gender based violence and substance abuse (alcohol and khat) exacerbate spread of HIV among higher learning institutions. Urgent actions are required to reduce vulnerability of students in secondary schools and higher learning institutions. Strategies in the SPM should be specific to different target groups such as women, in- and out-of-school youth, migrant workers, and the general population. Regions must have specific intervention plans to give special attention to those risk groups in their respective regions. 9

11 Peri-urban and cash crop growing areas need to be given special attention. Special attention need to be given for major foreign tourist destinations. Major development initiatives and sectoral investments must seriously consider HIV in their planning with adequate resource allocation since none of the development efforts can succeed if populations are consumed by the devastating HIV epidemic. Monitoring and Evaluation Although the SPM has stated objectives and indicators, specific monitoring and evaluation plan was not developed. Some of the objectives were not SMART and some objectives lack connection to organizational structure of the expected implementing agencies, thus resulting in blurring of ownership and subsequent follow up of activities. Indicators of the SPM lack hierarchical presentation and some of the indicators in the SPM were incompatible or inappropriate or immeasurable. In some thematic areas there was incongruity between the objectives and strategies. No specific targets were set for some of the thematic area indicators and baseline has not been established for many of the indicators thus determining whether targets are achieved or not cannot be done easily. Indicators of the SPM lack hierarchical presentation (not prioritized by administrative level) and some of the indicators in the SPM were incompatible or inappropriate or immeasurable. In some thematic areas there was incongruity between the objectives and strategies. Data sources and empirical evidences for the program monitoring and evaluation are scattered, disorganized and not easily accessible; more so in the non-health sector. Efforts to streamline and strengthen the health information system need to be supported to ensure quality and timely data for programme monitoring and evaluation. Well planned and executed monitoring and evaluation system that is inclusive of all stakeholders and implementing agencies must be part of the HIV prevention and control effort. Programme objectives and indicators need to be well defined at the beginning of the SPM period and followed regularly. Establishing baseline and mid-term assessment to allow adjusting for emerging realities is necessary. Research and Surveillance Better attempts were done during the SPM period to gather relevant data/evidence; the DHS, BSS, ANC surveillance, large evaluation surveys (Global fund evaluation), and specific analytical studies (epidemiological review) were conducted during the implementation period. The need for more evidence has been well recognized; the demand for more evidence is clear at all levels there is high demand for evidence regarding the effectiveness of interventions (Are the interventions good enough to fight the epidemic?); trends in the prevalence and incidence; trends in sexual behaviours; emerging high risk groups...and willingness to cooperate in generating more evidence. The use of available information for planning purposes at all levels is very encouraging. 10

12 The timely use of evidences is limited by delayed release of surveillance information; for instance the 2005 BSS report was released in 2008 and the 2007 ANC surveillance report is not yet released. Surveillance of known and emerging high risk groups is non-existent; surveillance information on commercial sex workers is over a decade old. Research has not been an integral part of the SPM, thus no systematic approach was made to generate the necessary evidences for effective implementation of the prevention and control programmes. Hot spots were not well delineated and high risk behaviours and groups are not clearly known. Capacity for intensified surveillance and research activities remain to be developed at key coordinating and implementing agencies. Priorities for surveillance and research must be drawn and their implementation followed properly to make the fight against HIV evidence based and more effective. Evidence generation and utilization (demand and use) require both technical and systemic capacity strengthening at the key agencies. Meanwhile, outsourcing of technical activities to capable organizations should be explored. 11

13 Summary of Key Action Points Major emphasis must be given to the prevention component of the HIV program in order to significantly reduce the impact of HIV; reduce the incidence of HIV. Emphasis on treatment must be balanced in the interest of the country s overall goal of HIV impact reduction. Special emphasis must be given to known high risk and emerging risk groups as well as highly vulnerable populations such as students, disabled population, gay group, foreign tourist destinations, and pastoralist populations. HIV programs need to be tailored for special needs circumstances such as boarder areas, pastoralists communities, and traditional practices. Vulnerability reduction must be taken as one of the main HIV prevention strategies; poverty reduction must be intensified to ensure long lasting effects. The economic problems arising from studying away from home must be carefully evaluated and appropriate solution provided. Gender based and other forms of violence expose victims to HIV infection; prevention of such violence must be one component of the HIV prevention strategy. Efforts to reduce stigma and discrimination need to be intensified; disclosure of HIV status, behavioural changes, and proper utilization of HIV services is still hampered by these acts. Comprehensive HIV policy revision is necessary to protect and promote human rights of affected and infected groups as well as to protect the public from deliberate attempt to spread the virus by HIV positive individuals. Effective leadership by a well-organized and smoothly functioning governance structure in line with executive powers of the country is indispensable to ensure synergy of HIV programs, and the overall coordination of the multi-sectoral response. In that sense, HAPCO s structure and mandate must be revisited. HIV leadership and mainstreaming need to be related to accountability. HIV is a major development impediment and should be taken as one of the core functions of organizations. All economic and developmental activities must consider HIV as a major component of projects/programs; including road and building construction sites. Efforts must be intensified to fully strengthen the HIV programs in terms of structure, systems and human resource. Efforts should also include capacity building in all partners comprising of NGOs, CBOs, and CSOs to enhance their respective contributions for the prevention, control, care and support and impact mitigation of HIV. Continuous pre-service and in-service training opportunities are essential to build human resource necessary for HIV programs. Local training institutions must be actively engaged in human resource capacity building to ensure sustainability as well as produce the necessary human resource with speed, volume and relevance. Social mobilization and community involvement initiatives must focus on behavioural change rather than just creating demand and increasing service up take. Active involvement of community based organizations that are established through self-initiatives in HIV programs must be encouraged. The operational cost is minimal and sustainability is most probable. Health services must be further supported to strengthen the integrated delivery of services, and ensure full functionality with adequate human resource and uninterrupted supplies. Mechanisms for staff retention must be carefully designed. Greater emphasis need to be given to OVC activities. Minimum standards should be set for care and support activities and implemented. Special needs for OVC require better organizational support and intensified social mobilization to create more opportunities to obtain support locally. FHAPCO should take a more proactive leadership and establish the necessary organizational structure. Monitoring and evaluation as well as regular special studies need to be conducted in a systematic and continuous basis to gather relevant information for the program: to obtain up-to-date data on HIV prevalence/incidence, identify risk factors, identify sexual behaviour trends, identify hot spots, and determine the effectiveness of interventions. Promote greater involvement of PLHIV in all aspect of HIV/AIDS prevention and control efforts. 12

14 1. INTRODUCTION Ethiopia is among the least developed countries in the world, characterized with poverty and suffering from communicable and emerging non-communicable diseases, and nutritional problems. HIV and other sexually transmitted diseases are among the principal health threats. The impact of the health and related problems is exacerbated by the growing population, gender disparities, limited developmental infrastructure, and limited number of trained human power. It has been over two decades since the impact of HIV has been recognized and measures to counteract its devastating effects have been undertaken. There have been continuous and multi-dimensional responses to combat HIV since the National Task Force on HIV was established under the Federal Ministry of Health in HIV, however, remained to be not only a health threat, but also an overall developmental challenge in Ethiopia. Though the progression of the epidemic slowed since 2000, given the size of the infected and affected population, the chronic nature of the disease, and the impact of the long term devastation, it is evident that it will take time to witness a considerable decline in the overall negative and damaging impact of the disease. It is also important to note that the gains in slowing the progression of the epidemic can be reversed and an accelerated epidemic can be a reality if appropriate prevention activities are not in place. The Ethiopian SPM for the was developed and implemented with the ambition of achieving universal access to basic HIV services and intensifying prevention activities. Emphasis was given to planning, implementing and evaluating together with key stakeholders. New and better coordination mechanisms were introduced for the multi sectoral response. The SPM has taken into consideration the system weakness and placed major emphasis on capacity building. Those problems included: inadequate involvement of key stakeholders; insufficient institutional capacity, including poor resource absorption capacity, inefficient/ineffective management systems, shortage of qualified human resources; weak and unresponsive leadership; ineffective mainstreaming and multi-sectoral approach; high level of stigma and discrimination; inadequate information and research to guide policy and practice; insufficient/ineffective civil societies/ngos engagement; insufficient community involvement; inadequate targeting of risk/vulnerable populations; and inadequate emphasis on the selection of best practices. Among other capacity issues, the critical shortage of human resources that can skilfully and professionally handle the various aspects of HIV prevention initiatives was evident in all sectors in the country; including in the HAPCOs at the Federal and Regional levels. The high turnover of trained staff at all levels and internal/external brain drain have been posing serious challenges. To alleviate the human resource capacity crisis, innumerable efforts have been made to provide short term training. Efforts are still continuing to achieve sufficient diversification, improve the quality, and relevance of short term training programs. Effective multi-sectoral responses were also hampered due to lack of clarity on conceptual and operational matters among stakeholders. Many guidelines and manuals were prepared to clarify matters and standardize mode of operations. However, in the largely donor supported program establishing a common vision and 13

15 achieving effective coordination of responses has not been without major challenges. The need to isolate results for reporting purposes, and the desire to get recognition for a specific output posed significant barrier to effective coordination and mainstreaming. The Government of Ethiopia recognizing the need for effective coordination and leadership for the multi-sectoral HIV program established the HIV Prevention and Control Office (HAPCO). HAPCO was established by proclamation and initially was accountable to the Prime Minster Office. However, despite multi-sectoralism being the main guiding principle of the SPM, HAPCO s organizational structure was modified and its accountability was limited to the Federal Ministry of Health. Whether this arrangement has been helpful to advance the main mission of the organization can be judged from the findings of the evaluation. In general, the SPM for the period was developed with due considerations of the major challenges and with great hope to make a bigger and more sustained impact in fighting HIV. It was developed to effectively coordinate and lead the multi-sectoral response of the Government of Ethiopia and its partners in a more efficient manner by promoting joint planning, implementation and evaluation processes. The six major thematic areas of the SPM were capacity building; social mobilization and community empowerment; Integration with health programs; leadership and mainstreaming; coordination and networking; and targeted response. The SPM has not been evaluated since it was launched and no adjustment was made to the original plan, despite a number of issues and opportunities that necessitated revision. Thus, it was found imperative to evaluate the SPM before developing the next SPM. The aim of this evaluation was to assess whether the objectives of the SPM were met or not; identifying and documenting lessons learnt; and to forward recommendations relevant to the development of the next SPM for the periods

16 2. OBJECTIVES OF THE EVALUATAION The objectives of the evaluation included: Update of the current epidemiological situation; Update of the current response; Assess lessons learnt and best practices; and Forward recommendations for the SPM 3. METHODS OF EVALUATION The Federal HAPCO established a Steering Committee composed of members from key stakeholders to guide the evaluation process. The Steering Committee led the process of establishing an independent evaluation team and provided the terms of reference for the evaluation. The methods of data collection included desk review of available documents and reports, observations during HAPCO s review and planning meetings, conducting questionnaire survey among stakeholders, key informant interviews, and field observations. The Evaluation Team visited all regions and contacted key stakeholders of the HIV program. Regional Health Bureau and HAPCO offices facilitated contacting the key stakeholders. An interview guide was prepared and used during the evaluation. Appropriate adjustments were made on the interview guide as necessary to obtain relevant information from stakeholders. Most of the interviews were done with individuals; however, some interviews were done with a group of 2-5 people. In addition, further analysis of the data from the BSS, DHS, ANC and Global Fund evaluation survey was done to illustrate some trends in prevalence, knowledge, and risk behaviours related to HIV. Utmost effort was made to collect as much evidence as possible during the data collection period; which was between 6 October and 21 November The period, however, was very short for such a big evaluation exercise. The field stays were very short and not sufficient to make thorough field observations. A number of documents were obtained during the field work, but it is important to note that some key documents were not easily available. Of particular importance to mention is the lack of numeric and objective evidences in many of the sector agencies. Lessons Learnt during the SPM implementation period that were neither documented nor known by the interviewed key persons are likely to be missed. However, the Evaluation Team appreciated the unreserved cooperation of all stakeholders despite their busy schedule and a short notice for meetings. The Team visited most of the major sectoral agencies at the federal and regional offices, which included: HAPCO, health, education, agriculture, road and transport authority, women affairs, youth and sport, and labour and social affairs. The Team also interviewed key informants from major CBOs, CSOs, universities, Iddir networks, association of PLHIV, and major NGOs during the field visits. At federal level besides sector ministries the team also had discussion with UN agencies, major partner organizations, major NGO; and Uniformed Services. 15

17 A questionnaire survey was conducted in Dire Dawa to collect relevant information from participants of the HAPCO Joint Review Meeting attendants. The questionnaire was focused on obtaining information about the SPM and its components. Over 150 participants who came from all regions of the country responded to the questionnaire. No new quantitative data was collected for the purpose of this evaluation. Every effort has been made by the Evaluation Team to put together the vast amount of information from documented sources and interview materials into coherent summary along the objectives of the evaluation. Analysis of available information was made by the SPM thematic areas and other relevant issues that need to be given emphasis are addressed separately. The Team had several meetings discussing the various versions of draft reports. Further inputs from the Evaluation Steering Committee and the stakeholders are expected. There are limitations in using the data sources obtained for evaluation purpose. The data sources were not meant neither for use for such evaluation nor for trend analysis. So the trends shown in this evaluation are meant to give sense of what is going on rather than presenting conclusive facts. They were used to show crude indicative trends. The sampling methodology and the purposes of the data sources were different. So any doubts on the validity of the observed trends are reasonable. 16

18 4. FINDINGS OF THE EVALUATION The evaluation findings drawn from the reviewed documents, field observations and interviewing key informants in the various governmental, nongovernmental organizations, and people infected and affected by HIV are presented below in various subsections. The subsections are based on the thematic areas of the current SPM and also because of their relevance for future recommendations THE STRATEGIC PLAN FOR MULTISECTORAL RESPONSE ( ) Most of the key informants indicated that they have very little knowledge about the process that led to the development of the SPM. However, the majority of respondents know the document and its thematic areas (Figure 1). Majority also reported that they have used the SPM mainly for planning purposes (Fig 2-3). When respondents were asked about the achievement level, none of the thematic areas obtained over 40 % rating (Figure 4). During the field interviews also many of the respondents said that the SPM heavily gravitates towards the health sector response and had limited use for the non-health sector response. Many respondents emphasized that effective multi-sectoral response to HIV must have balanced interventions in prevention, treatment, and care and support. Such vast responsibilities cannot be handled by only one sector and that was why the multi-sectoral response was envisaged in the first place. The SPM tended to undermine the non-health sector contributions and initiatives. As shown in Figure 5, over 50% of the respondents would not recommend using a similar SPM for the next period. The SPM had no clear monitoring and evaluation plan to track progress. Information and data systems were not appropriately organized in all sectors except health, which also undermines the non-health sector contributions. Further, efforts to track progress were incomplete because of unclear and immeasurable indicators. Some of the indicators in the SPM, besides being not SMART, lacked hierarchy; meaning no indication as to which indicators are useful at what levels. No clear goal was set for research and monitoring hot spots in Ethiopia. Many of the informants expressed their concern about the lack of up-to-date information on the epidemic and the impact of the interventions. The efforts made to collect and reanalyze available data as well as conducting new data collection was very much appreciated, but recognized as inadequate to effectively guide interventions. Phenomenal achievements were made utilizing opportunities created at the national and global levels in the later part of the SPM implementation period. However, midway adjustments were not made in the SPM and thus, emerging developments were not fully aligned with the strategic plan to maintain its position as the one lead document. 17

19 Figure 1: Key Stakeholders awareness of the SPM ( ). Survey Conducted at the review Meeting, October Figure 2: Use of the SPM by Key Stakeholders. Survey Conducted at the review Meeting, October Figure 3: Specific use of the SPM by key stakeholders. Survey Conducted at the review Meeting, October

20 Figure 4: Key stakeholders assessment of efforts made to achieve multisectoral response during Survey Conducted at the review Meeting, October Figure 5: Key stakeholders response to recommending the use of the same SPM for the next planning period. Survey Conducted at the review Meeting, October

21 The following recommendations are forwarded for considerations in the preparation of the next SPM: The process of developing a national SPM must involve all stakeholders to ensure that the concerns, potentials, and opportunities of all sectors are taken into account and maintain the multi-sectoral approach. The involvement and the role of the non-health sector as well as the non-public sector stakeholders need to be clearly defined and accountably bestowed as appropriate. An effective system of monitoring and evaluation must be part of the SPM. Indicators must be SMART and hierarchical so that timely actions can be taken when appropriate at all levels and by all stakeholders. Mechanisms for mid-term adjustment of the SPM are necessary to take into consideration emerging developments and opportunities during the implementation period. Indentifying the priority research needs and coordination of research and surveillance must be taken as core elements of the next SPM. Clarify the need for developing comprehensive annual operation plan based on the SPM to translate the strategic plans into action CURRENT STATUS OF HIV EPIDEMIC IN ETHIOPIA The current status of the epidemic is assessed based on the available information from the Ministry of Health, HAPCO, published literature and other unpublished reports HIV Prevalence The HIV prevalence in Ethiopia is assessed based on two information systems: the ANC based estimates and DHS conducted in Both systems had certain limitations and the controversy arising from the limitations forced the Federal Ministry of Health to issue a single estimate derived from both information sources; which was 2.1% for the nation. Figure 6 shows the projections made based the single point estimation for the SPM period. According to that projection, the prevalence of the national HIV prevalence shows no significant change in both rural and urban areas during the SPM period; the same was true for the incidence of HIV. 20

22 Figure 6: Adult HIV prevalence by residence, Single Point Estimate. As shown in Figure 7 and 8, in the past HIV has affected more the urban areas and females; that trend is going to continue according to the projection. Very important evidence that emerged from the analysis of the 2005 DHS data is that small market towns in Ethiopia exhibited an increased prevalence compared to big towns (Figure 9). The fact that small towns in Ethiopia are commercial administrative points can serve as a bridging site for urban to rural spread of HIV 1. Other sexually transmitted infections that are relevant to the prevention and control of HIV are not systematically monitored and no recent data is available to make reasonable estimate of the national prevalence and the trends over time. Figure 7: New infections by sex and residence. (Source single estimate) 1 Berhane Y, Mekonnen Y, Seyoum E, Gelmon L, and Wilson D. HIV in Ethiopia - an Epidemiological Synthesis. April Published by The World Bank with the Ethiopia HIV Prevention and Control Office (HAPCO) available at: 21

23 Figure 8: HIV prevalence by level of education. (Source single estimate) Figure 9: HIV prevalence by type of residence in Ethiopia. Source: Epidemiological Synthesis; based on DHS 2005 data HIV Knowledge Population based studies on comprehensive knowledge 2 about HIV prevention and transmission showed that the proportion of women with correct knowledge declined from 16% reported by EDHS 2005 to 12.5% reported by the Global Fund Evaluation in The highest, 19.1%, was reported in Addis Ababa. According to the Global Fund evaluation report, knowledge level was lowest among women who are older than 30 years, married, lowest wealth index, rural, uneducated, and from emerging regions. Although direct comparison of the two sources has to be done cautiously; the observed trend in both adult and youth subpopulation is alarming (Figure 10 & 11). 2 Comprehensive knowledge about HIV is defined as: 1) knowing that both condom use and limiting sex partners to one uninfected person are HIV prevention methods, 2) being aware that a healthy-looking person can have HIV, and 3) rejecting the two most common local misconceptions that HIV can be transmitted through mosquito bites and by sharing food. 22

24 Figure 10: Comprehensive knowledge about HIV among women aged (Source: DHS 2005 and Global Fund Evaluation Report 2008) Knowledge on the three programmatically important HIV prevention method and comprehensive knowledge among youth 15 24, in 2005 and BSS2005 (OSY 15 24) GF2008 (15 24) comprehensive knowledge about AIDS Limiting sexual intercourse to one uninfected partner Use condom every time they have sex Abstain from sexual intercourse 23 Figure 11: Comprehensive knowledge about HIV among youth aged (Source: DHS 2005 (out of school) and Global Fund Evaluation Report 2008) HIV Risk Behaviours Comparing the EDHS in 2005 and Global Fund evaluation in 2008; the proportion of women having had two or more partners increased from 0.2% to 1.3%; while having had higher risk sexual intercourse rose from 2.7% to 5.3% (Figure 12). The increment might be partly accountable to the large proportion of women included from Addis Ababa in the recent survey. The use of condom at higher-risk sex in the past 12 months increased from 24% to 46.4% during the same period. High risk sexual behaviours were more common among younger 15-19, never married, had secondary or higher education, and wealthiest. As shown in Figure 13, the prevalence of higher-risk sexual behaviour was highest in Addis Ababa (14.3 percent). Only 46.4% of those used condom during high risk sexual intercourse. The findings clearly indicate high risk sexual behaviours have not been curtailed during the SPM implementation period.

25 Figure 12: High Risk Sexual Behaviours among women aged (Source: DHS 2005 and Global Fund Evaluation Report 2008) Figure 13: Percentage who had higher-risk intercourse in the past 12 months among sexually active in the last 12 months. (Source: Reconstructed from Global Fund Evaluation Report.) Vulnerability Factors Mobile work: migratory agricultural workers and construction (road and building) workers have been reported to be among the major high risk groups in many parts of Ethiopia. No preparations in terms of reducing vulnerability and risk to HIV were done to appropriately handle large number of young mobile workers who are living under difficult conditions. Unrestrained School Environment: The increasing vulnerability and high risk sexual behaviours among students have been emphasized at all levels and in all regions. Students studying away from home in pre-colleges and universities manifest high risk sexual behaviours including engagement in transactional sex. Some mentioned the spread of open unsafe sexual practices into elementary schools. University students' sexual practice was observed to be incompatible with their knowledge of HIV; unprotected and risky sexual behaviours very common. Risky sexual 24