Mid-Term Review of the Project Linking HIV and Sexual and Reproductive Health and Rights in Southern Africa Project Report

Transcription

1 Mid-Term Review of the Project Linking HIV and Sexual and Reproductive Health and Rights in Southern Africa Project Report 6/3/013 Health and Development Africa Philip Browne / Zipho Dube Sesung Health Post in the Letlhakeng District, Botswana

2 TABLE OF CONTENTS ACKNOWLEDGEMENTS... IV LIST OF ACRONYMS... V EXECUTIVE SUMMARY... VI SECTION 1.0 LINKAGES PROJECT MID TERM REVIEW BACKGROUND PROJECT CONTEXT PURPOSE AND OBJECTIVES OF THE MID TERM REVIEW Purpose Objectives EXTENT OF PARTICIPATION BY DIFFERENT STAKEHOLDERS REPORT STRUCTURE... 4 SECTION.0 REVIEW METHODOLOGY OVERVIEW OF THE REVIEW APPROACH DATA COLLECTION METHODS Preliminary Consultative Meetings and Review Preparations Document Review Interviews Field Visits to Selected Project Countries DATA COMPILATION, ENTRY AND ANALYSIS STUDY LIMITATIONS... 7 SECTION 3.0: REVIEW FINDINGS AND DISCUSSIONS: GENERAL ASPECTS INTRODUCTION: CONTEXTUAL FACTORS PROJECT RELEVANCE... 8 SECTION 4.0 RESULT AREA ONE: SRHR AND HIV LINKAGES INTEGRATED IN NATIONAL HEALTH AND DEVELOPMENT IN 7 COUNTRIES REVIEW FINDINGS Completion of Rapid Assessments Technical Consultations Advocacy for SRHR/HIV Integration Scaling up Integrated Programme Linkages Policy and Planning Developments Engaging Civil Society in Integration Processes CHALLENGES AND EMERGING UNDERSTANDING SECTION 5.0 RESULT AREA TWO: IMPROVED UPTAKE AND DELIVERY OF INTEGRATED QUALITY SERVICES FOR HIV AND SRHR IN THREE COUNTRIES (MALAWI, SWAZILAND AND BOTSWANA) INTRODUCTION REVIEW FINDINGS Operational Workforce Strategies Rights-based Education to Address Discrimination and Stigma Increasing Male Involvement Capacity Strengthening for Programme Managers and Service Providers Security of RH and HIV/AIDS Commodities Piloting New Integrated Approaches Contribution of Non-health Sector in Successful Models CHALLENGES AND EMERGING UNDERSTANDINGS... SECTION 6.0: RESULTS AREA THREE: BEST PRACTICE MODELS DISSEMINATED TO SUPPORT SCALING UP HIV AND SRHR LINKAGES INTRODUCTION REVIEW FINDINGS Generating Learning and Good Practice Knowledge Sharing... 4 ii P a g e

3 6.3 CHALLENGES AND EMERGING UNDERSTANDING... 5 SECTION 7.0 CROSS CUTTING CONSIDERATIONS REVIEW FINDINGS PROMOTING A RIGHTS-BASED APPROACH TO INTEGRATION ADDRESSING GBV WITHIN THE INTEGRATION PROCESS CONTINUOUS MONITORING AND EVALUATION OF THE INTEGRATION PROJECT PROJECT VISIBILITY HARMONISATION OF PARTNER INTERVENTIONS SADC Policy Initiatives SUSTAINABILITY... 3 SECTION 8.0 PROJECT EFFECTIVENESS CONSIDERATIONS GOING FORWARD RECOMMENDATIONS CONCLUSION SECTION 10: ANNEXES REFERENCES LIST OF PEOPLE INTERVIEWED INTERVIEW GUIDE iii P a g e

4 ACKNOWLEDGEMENTS This Mid Term Review report is a result of collaborative effort by many individuals, too numerous to mention. The Review is being conducted from 03 rd April to 1 th June, 013. The process of undertaking the assignment entailed review of documents, examination of systems, interviews with national and international staff in the UN regional and country offices, Ministries of Health and Implementing Partners. We wish to express our thanks and appreciation to the UNFPA and UNAIDS regional teams for their guidance and technical direction during the process of this review, and for supporting us in analyzing critical SRHR and HIV issues. We are also extremely appreciative of the time and support provided by the country project teams, officials from the various Ministries of Health (MoH) and other government Ministries, National AIDS Councils (NACs), Southern Africa Development Community (SADC) and from the implementing partners. Their inputs and experiences have provided a significant way forward for furthering the improvement in the quality of life of the people in the Southern Africa through the integration of sexual and reproductive health and HIV prevention, treatment, care and support. We would also like to thank EU colleagues in Brussels and at the delegations in Namibia, Swaziland and Botswana for sharing their insights with us, both in person and via telecons. We extend our thanks to all relevant people who, in one way or another, facilitated our field work and for the invaluable information, insights, guidance and effective support-both technical and administrative provided to us. We are highly appreciative of their co-operation and the level of logistical support accorded to us, as well as for their participation in the assessment process as a learning component. In particular we would like to thank those dedicated women and men working at health facilities in Namibia, Botswana and Swaziland who gave time unstintingly from their heavy workloads to share their knowledge and practice with us. The complete list of those interviewed for the report is included as Annex 10.. iv P a g e

5 LIST OF ACRONYMS AfDB AIDS ANC ART AU BCC BOFWA BONELA CBO CO DHMTs EHP EU FBO FP GBV HF HIS HIV HMIS HTC IEC IPPF LGBTI M&E MoH MDGS MMC MNH MPOA NAC NGO NSF OPD PEP PHU PLHIV PMTCT PR PSI RH SADC Sida SRH SRHR STIs TB TWG UNFPA WHO YFHS African Development Bank Acquired Immunodeficiency Syndrome Antenatal Care Anti Retroviral Therapy African Union Behavioral Change and Communication Botswana Family Welfare Association Botswana Network on Ethics, Law and AIDS Community Based Organization Country Office District Health Management Teams Essential Health Care Package European Union Faith Based Organization Family Planning Gender Based Violence Health Facility Health Information Systems Human Immunodeficiency Virus Health Management Information system HIV Testing and Counseling Information Education and Communication International Planned Parenthood Federation Lesbian, Gay, Bi-sexual, Transgender and Intersex Monitoring and Evaluation Ministry of Health Millennium Development Goals Male Medical Circumcision Maternal and Neonatal Health Maputo Plan of Action National AIDS Council Non-Governmental Organization National Strategic Framework Out Patient Department Post Exposure Prophylaxis Public Health Unit People Living with HIV Prevention of Mother to Child Transmission of HIV Principle Recipient (Global Fund) Population Services International Reproductive Health Southern Africa Development Community Swedish International Development Cooperation Agency Sexual and Reproductive Health Sexual and Reproductive Health and Rights Sexually Transmitted Infections Tuberculosis Technical Working Group United Nations Population Fund World Health Organisation Youth Friendly Health Services v P a g e

6 EXECUTIVE SUMMARY In response to the strengthening policy commitments and expanding evidence base on the effectiveness of HIV/SRHR integration the European Union (EU) agreed to fund a regional seven country project aimed at strengthening SRH/HIV linkages at the policy, service delivery and knowledge generation levels. This is clearly articulated in the Contribution Agreement signed with UNFPA, and providing for joint implementation with UNAIDS. The purpose of the Midterm Review (MTR) of the Joint UNFPA & UNAIDS project on Linking HIV and Sexual Reproductive Health in Southern Africa has been to assess the overall performance of the project progress in the seven countries (Botswana, Lesotho, Malawi, Namibia, Swaziland, Zambia and Zimbabwe) against the agreed activities and objectives as outlined in the regional and country log frames as well as country annual work plans. The Review has attempted to address, understand and assess the full range of project objectives and collect evidence that should assist the European Union and its partners in better understanding progress on impact measured in alignment with the log frame indicators and assessed against the key review criteria. The Mid Term Review was a participatory process that actively engaged representatives of the project stakeholders with prime interest in the process. This included the close involvement of EC both in the development of TOR, selection of consultant and as key informant. Through its engagement with project teams, UN partners, donors, government officials, CSOs and EC the review team took note of some of the contextual factors that both facilitate and impede the process of creating linkages between SRHR and HIV services, and that will determine the longer term sustainability of the integration approach. It should be noted that the review team is aware that although the report is a summary of all seven countries being assessed, it is clear that different countries are at different levels of implementation, and that there are different capacities, capabilities and enabling environments in each of these countries. This report is not a comparative study, but does attempt to highlight where some of these differences between countries are. An important aspect of this review has been to consider and assess the extent to which the linkages project is strengthening the global integration agenda and regional roll out through the Maputo Plan of Action (MPOA). In particular the review has set out to understand how the project is supplementing the MPOA commitment to integrating STI/HIV/AIDS and SRHR programmes and services in the seven participating countries as per the stated goal of the project. The review looked in detail at the three project results areas outlined in the regional project logical framework. The first result area focused on the extent to which the project is bringing about shifts in national level policies and strategies to include in an explicit way the integration of SRHR and HIV. The second result area reviewed focused on the extent to which there has been increased uptake and delivery of integrated quality services for HIV and SRHR in Malawi, Swaziland and Botswana, as well as in the other four countries where additional UNFPA resources were accessed to begin integrated service delivery activities. The third result area reviewed focused on the extent to which the project, through its policy engagements and implementation at service delivery level, is generating new learning, knowledge and best practice models that will inform the evolving process of scaling up integrated SRH and HIV services in the region. The review findings have emerged from an assessment of the degree to which the project is relevant to the health system needs of individual countries, and the extent to which it supports regional initiatives to promote SRHR/HIV linkages. In sum the project at midpoint is well on-track across all three results areas as set out in the regional logical framework, country level logical frameworks and annual work plans. Significant progress has been made in all seven countries in adapting and strengthening SRH and HIV policies and strategies to incorporate the concept and practice of integrated services. Most countries are in the early stages of implementing result area two and it is still too early to have a clear sense of the kind of impact that the project is having in this area, but early results from countries such as Swaziland, Malawi and Botswana suggest that gains are being made and the move towards integration is gaining traction. Countries have made progress on achieving progress under result area three, with a growing volume of knowledge material being generated through project activities, but this still requires a more structured approach so that key learning, innovations and case studies are not lost or overlooked. vi P a g e

7 Through a process of document review and interviews with key stakeholders it became evident that the project is strategically placed within an overall strategic re-alignment in the region around the issue of health system integration, including those outlined in the Maputo Plan of Action and the SADC SRH and HIV strategies. This re-alignment has been underpinned by the global and regional discourse around the value-add of integration to health systems; The project has been successful in facilitating a set of interventions designed to build a strong evidence base for promoting the integration agenda in the seven participating countries. Each country has completed a Rapid Assessment that has provided a detailed set of findings and recommendations. A number of other countries have completed a baseline survey of their selected pilot sites and these have provided important information on how best to map out integration strategies at the facility level; The project is being implemented in a context where there are very real challenges for coordination. These challenges relate to a number of issues. Firstly the coordination architecture in countries (with steering committees, TWGs and sub-committees) is quite onerous and in some instances there are duplications and overlaps that could be eliminated through a streamlining process. Concerns were expressed in some countries that participation in the project coordinating structures has been poor, with people citing commitment issues and time constraints as contributing factors. There is also a level of uncertainty around the respective roles and responsibilities of UNFPA and UNAIDS within the project, which has generated some unfulfilled expectations as well as concerns that the project is viewed as a UNFPA initiative rather than a joint UNFPA/UNAIDS intervention. Planning of activities for the project has clearly linked the needs of participating countries with the wider SRHR/HIV linkages agenda. The Rapid Assessments provided strong evidence bases and problem analysis was based on a logical framework approach which clearly defined linkages on causes, core problem and effects. The process of developing the regional and country level logical frameworks has demonstrated a commitment to strategically aligning project activities with integration objectives contained in national policy frameworks and priorities. There is strong correlation among programme thematic objectives, problem analysis and the project activities as they are articulated in the logical framework; From discussions with Ministries of Health in Swaziland, Namibia and Botswana it is evident that the project objectives are very relevant in contributing to the delivery of comprehensive, effective and better quality SRH and HIV services within a primary health care environment. Project activities fit well within the overall government development strategies and policies in that while the implementing partners provide implementation structures, the project brings expertise and resources to support national delivery of the components; The interventions are aimed at providing high-quality, gender-responsive and integrated SRHR and HIV services. The relevance of the project to date is that it has harnessed a multi-sectoral approach to strengthen conceptualisation of integration and enhance the availability and utilisation of integrated health services. The project has in addition clearly aimed at developing interventions that build on supplementary components such as gender equality, male involvement and PLWA in an attempt to leverage integration as a platform for addressing inequality, lack of respect for rights, unequal sexual relationships and teenage pregnancy. It is evident that the project s rights-based interventions are both relevant and challenging in that they involve efforts to align cultural and social norms and practices with an inclusive development discourse and agenda. In general terms the societies and the health seeking behaviour of people in the seven participating countries are informed by cultural norms, values, customs and associated social practices that have a powerful influence on community life. One of the challenges for the project - especially when it comes to integration - is that health issues related to sexual norms and practices remain a contested terrain and require multi-dimensional responses. In terms of implementation at the service delivery level the project is still at an early stage and it is therefore not possible at this point to assess the degree to which integration is achieving critical outcomes. The project is also hampered by a lack of measureable integration indicators that can track effectiveness in areas such as quality of services, client satisfaction, cost-effectiveness and process efficiencies. Despite assumptions being made about the potential quality and cost effectiveness of integration, rigorous assessments are limited. Evidence emerging from the vii P a g e

8 INTEGRA research programme, which is a five year research programme on integration that has been conducted in Kenya, Malawi and Swaziland 1. The study used a combination of routine service statistics and process analysis, clinic- and cohort-based quantitative and qualitative behavioural research, community surveys and economic analysis, this project is assessing the benefits and costs of different models for delivering HIV and SRH services. Based on the findings the review team clustered a set of recommendations around key project components: Policy and Strategy It is critical to the process of integration that the project supports countries to continually assess and review their SRH and HIV policies and strategies to ensure that they address the concept of linked services. In this context country project teams should continue to advocate with policy and decision makers to ensure that the necessary changes are reviewed and operationalized; Country project teams should highlight the issue of sustainability with representatives from the Ministries of Health to ensure that the benefits of integration will continue well beyond the end of the EU funding at the end of the four year period, including how to absorb human resources and maintain the project-funded salaries of health care workers, M&E officers and other project staff currently located within UNFPA; There is a need to ensure through continuous monitoring - that integration does not overburden existing services in a way that compromises service quality, that integration actually improves health care provision, and that human resource strategies account for any increased workloads for staff who take on new integration responsibilities over and above their designated duties. Ministries of Health in the participating countries may want to look at the feasibility of including such assessments in their regular staff performance reviews; As soon as possible country project teams should undertake a mapping exercise to identify donor funded health programmes and projects that have overlaps with the linkages project and start building coalitions. Capacity Development Country project teams must support Ministries of Health to focus on the training of health care workers specifically to help them engage with strategies and practices for integration that can be tailored to the needs of facilities so that these processes are effective for both the clients and health care workers; The project, working collaboratively with Ministries of Health, must ensure that specialized training and ongoing mentoring and support needs required by staff to meet the complex SRH needs of HIV-positive people effectively continue in a structured manner, and that they support training for community health workers / health education workers in basic understanding of gender issues and strategies to promote male uptake of services; The project must continue to find practical ways of addressing issues of stigma and discrimination from and towards health care providers, as these have the potential to undermine the effectiveness of integrated services for certain clients, no matter how efficient they are in other respects. The project must, therefore, work closely with Ministries of Health to provide specialised training that addresses discriminatory practices, with a focus on providing ongoing sensitisation, rights-based training and work around values clarification; There is a very evident need to continue working with M&E Units in Ministries of Health, DHMTs and facility staff responsible for data capture to strengthen their capacity in tracking and monitoring integrated data this will be increasingly necessary once the new integration indicators come on stream. 1 viii P a g e

9 Service Delivery Level There is need for further assessment to identify where registers being used at facilities can be streamlined to reduce the administrative work load on health care workers, allowing them to focus on providing quality HIV and SRHR services to clients; The project should continue to explore ways of adapting services to attract men and young people and increase the uptake of services, and work to deconstruct assumptions that see SRH, and especially family planning, as women s business. The project must, therefore, explore ways of ensuring that the package of SRHR and HIV services are not overly geared to the needs of women, but also incorporate services that address men s SRH needs, including prostate/testicular cancer screening, erectile dysfunction and some of the psycho-social issues that impact on male sexuality; The project must, wherever possible, utilize good practice around reaching those who are most vulnerable but least likely to access services, such as young people and key populations such as sex workers, men who have sex with men and various categories of mobile populations; At present the approach to GBV appears to be inconsistent, and it is therefore imperative that the project incorporates violence against women as a core component of the integration process, and ensures that screening for GBV and effective referrals to other safety and justice facilities becomes part of the standard integrated package of services; Additional funding coming into the project should be directed towards key implementation issues which have not been funded in the last two years, and should in particular support facilities that cannot provide comprehensive integration specific services owing to a lack of equipment, commodities, space at the facilities and lack of staff; The project should continue to support and guide management at facility level to continuously assess their infrastructural constraints, and through experimentation and adaptation find the most practical and effective ways to structure integrated patient flows for greatest impact. Reaching Key Populations Where strategic and within the boundaries of national policy discourses the project should advocate for an ongoing review of legislative and common law provisions that continue to criminalise and stigmatise sex work, homosexuality, sex between men and abortion. The project should wherever possible and appropriate engage with senior government officials, parliamentarians, civil society leaders, private sector and traditional leadership around evolving norms and attitudes related to HIV status, sex work, sexual orientation and gender equality that are informing a more progressive provision of SHR and HIV services and promote the principle of universal access; The project should promote further action participatory research approaches to explore in more detail the issue of self-stigmatisation that has been evidenced both anecdotally and through a number of country Stigma Index reports; The project must continue to actively engage with PLWA networks to encourage and support their inclusion in technical working groups and on the ground at district and facility level so that ongoing integration is informed by the needs of HIV+ and HIV affected groups. Strengthening Community Involvement Each pilot health facility should strengthen community mobilization activities and collaboration with community groups to deliver integrated services, with a focus on promoting the involvement of men and youth in service delivery; The project should continue to strengthen its advocacy engagement with community leaders including traditional leadership, local level politicians and faith-based leaders to address prevailing socio-cultural norms, assumptions and practices around SRH and HIV in a proactive way as a means to shifting community and individual health seeking behaviour and to stimulate discussion around potential policy approaches to engaging men and boys in achieving gender equality and health equity. ix P a g e

10 Monitoring and Evaluation There is an urgent need to develop and operationalise project specific indicators for the linkages project in order to get more rigorous outcome level reporting directly associated with the integration process. The regional project team must, as far as possible, expedite the process of developing project specific indicators for integration project in order to get more rigorous reporting directly associated with the integration process. Developing a few SMART integration indicators for the project needs to be prioritized as the project is already moving into its third year and the impact of the project cannot be clearly measured with existing MoH / logical framework indicators; There is a high workload created by paper based M&E systems, so the project should propose innovative ways of decreasing this load through the introduction of electronic data capturing and provide training for the necessary staff that will be in charge of capturing this data into the system. With additional funding coming on stream the project should undertake a feasibility study to assess whether it is possible to provide all the pilot sites with the necessary IT infrastructure and set up electronic data capture systems. On a country by country basis the regional project team should assess the M&E needs of the project, and where necessary motivate for the hiring or secondment of a dedicated M&E officer for the project, and then engage with the respective Ministries of Health to find ways of addressing the ongoing need for M&E Officers who are dedicated to the project and who will be responsible for the close monitoring of both project implementation and impact. The RST should also develop a concrete plan to ensure that project activities over the final year and a half can be measured against an agreed set of integration indicators. Knowledge Management Level As part of the knowledge management process the project should ensure that interventions for specific groups such as young people, men and vulnerable groups are well documented, with a particular focus on what works and why. The project should intensify its collaboration with CSOs such as SafAIDS to intensify the development of tailored messaging for men, young people and vulnerable groups to encourage utilization of existing services, and to ensure that messages are packaged so that they reflect men-friendly SRH services; The regional project team, together with the country teams, must continue to identify strategic fora at global, continental, regional and country level where the documented success stories of the project can be profiled and key learning shared. Project Management At the strategic level the regional project management team should review current country level project coordination modalities to ensure that they are working optimally, and to address any obstacles to effective project implementation; At the regional and country level the project must ensure that the respective roles of UNFPA and UNAIDS are clearly defined, well-understood at the country level, and add maximum technical value to the process of project implementation; Project teams should continue to work closely with their MoH counterparts to address the challenge of programmatic silos, and to assess areas where overlaps and duplications are occurring and where efficiencies can be introduced; Project teams should undertake a mapping exercise to identify organisations that represent key populations and then follow up to see where these groupings can be brought into technical and implementation processes. Further efforts must then be made by project teams to engage key population groups in technical and planning fora so that they are able to highlight their needs and requirements and ensure that these are included in ongoing integration processes. Project Visibility x P a g e

11 The regional project management team should work with country project teams to review their visibility and communication plans to ensure that they are more than just compliance documents, but that they are structured in a way that provides value to the project as a whole; The regional project management team must continue to share ideas around visibility, for example by showcasing Swaziland s Phila Uphephe branding through posters, banners and other promotional material and how these are utilized as advocacy and information sharing tools at facility level; Predictable and Sustainable Funding Through the project country teams should provide motivation to donors around the value-add of moving away from parallel to integrated SRHR/HIV services, and sustaining support for integrated policies and services within a reasonable funding horizon; For those countries where implementation through CSOs is already underway the project must ensure that funding flows are as predictable and timely to ensure that undue financial pressure is placed on these organizations; In countries where Global Funds (GF) grants are being renegotiated, or where new concept notes are being prepared, project teams should ensure that they are actively engaged in GF discussions and preparation processes so that they can insert the integration agenda in a strategic way that is aligned with the Investment Framework approach and the GF s new funding mechanisms. Partnerships The project must continue to ensure that collaboration between Ministries of Health, the EU, SADC, UNFPA, UNAIDS and civil society organisations both regionally and at country-level continue to be strengthened throughout the duration of the project, and that emphasis be placed on strengthening engagement with EU programme coordinators at country level and with SADC at the regional level; The project, both at regional and country level, should be more proactive in identifying partnerships with other key role-players who may be working in the area of health services integration in some way to explore to what extent implementation synergies and possible funding opportunities are possible for improved harmonisation. xi P a g e

12 Transform existing sexual and reproductive health and HIV/AIDS policies, programmes and services to ensure: That sexual and reproductive health, HIV/AIDS and integrated initiatives are all built on a fundamental commitment to respect, protect and promote human rights; That the creativity and capacity of communities and of nongovernmental organizations are fully engaged towards the achievement of these goals; Recognition of, and response to, the sexual and reproductive health needs and human rights of people living with HIV; Special efforts to reach priority populations most under-served by current efforts, including poor women, young people and marginalized populations; That family planning and voluntary counseling and testing are included in prevention of mother-tochild transmission programmes, as endorsed in the Glion Call to Action ; Provision of an essential package of sexual and reproductive health information and services to all people reached by HIV/AIDS programmes; Provision of an essential package of HIV/AIDS information and services to all people reached by sexual and reproductive health programmes; and Adequate, accessible, affordable and acceptable supplies of essential HIV/AIDS and sexual and reproductive health related commodities, including male and female condoms and STI diagnostics and drugs. The New York Call to Commitment: Linking HIV/AIDS and Sexual and Reproductive Health 005 SECTION LINKAGES PROJECT MID TERM REVIEW BACKGROUND Project Context Over the past decade there has been a growing understanding that the integration of sexual and reproductive health and rights (SRHR) and HIV/AIDS can have a range of public health benefits. Commitments have been made a range of international forums, including: Maybe add the HLM target #10? MDGs: Linking SRH Services and an Effective Global Response to HIV (010); Amsterdam Statement on Sexual and Reproductive Health and Rights for People Living with HIV (007); Consensus Statement: Achieving Universal Access to Comprehensive Prevention of Mother-to-Child Transmission Services (007); UNGASS Political Declaration on AIDS (006); Call to Action: Towards an HIV-Free and AIDS-Free Generation (005); World Summit Outcome (005); New York Call to Commitment: Linking HIV/AIDS and Sexual and Reproductive Health (004);The Glion Call to Action (004). These global trends have been domesticated at the continental and regional levels in sub-saharan Africa. The Maputo Plan of Action, signed in 006, called on African Union (AU) member states to strengthen commitment to achieving universal access to sexual and reproductive health services, including family planning, and recognize and support the contribution of these services to HIV prevention. One of the Plan s key strategies for operationalising the SRH Policy framework is Integrating STI/HIV/AIDS, and SRHR programmes and services, including reproductive cancers, to maximize the effectiveness of resource utilization and to attain a synergetic complementary of the two strategies 3 These commitments signaled an important step in efforts already underway to strengthen linkages between SRH and HIV/AIDS programmes with the aim enhancing a range of public health benefits. In 010 the Southern Africa 3 Maputo Plan of Action Pg.. Maputo Plan of Action Pg Page

13 Development Community (SADC) recognized that strengthening the linkages between SRHR and HIV as critical to achieving its target of a 50% reduction in new HIV infections by 015. The Sexual and Reproductive Health Business Plan for the SADC Region maps out a number of key SRH priorities across Member States that underpin an integration agenda 4 : Integrating SRH with HIV and AIDS, TB and Malaria including PMTCT and nutrition; Engendering SRH interventions and ensuring human rights based programming; Targeting vulnerable groups including orphans, vulnerable children, youth and their carers; Strengthening the early diagnosis and treatment for reproductive health cancers; Enhancing sexual reproductive health services for adolescent and youth who constitute the majority of people in the region; Prevention and management of gender-based violence. A critical rationale for integration is that it has the potential to minimize missed health opportunities and thereby increase access and coverage of services for more people including vulnerable populations, and ensure services for people living with HIV that meet their needs and respect their rights. This is based on the understanding that the target groups for SRH and HIV services are generally the same, specifically in regard to shared root causes and the direct relation to each other in terms of sexual transmission of HIV and HIV-related maternal mortality and cervical cancer. While progress was being made at the regional level WHO was one of the organizations taking a lead role in defining the concept of integration linkages, or the policy, programmes, services and advocacy synergies between SRH and HIV are approaches that have the potential to increase universal access to both sexual and reproductive health as well as HIV prevention and care 5. At sub-regional level the Integra Initiative, which is a five-year research project to gather evidence in Kenya, Malawi and Swaziland for Unsafe sex can put people at risk for HIV and other STIs, as well as for unwanted pregnancy. Adolescents are the target of sex education and life skills programmes to delay sexual debut, have healthy relationships, prevent unplanned pregnancies, and prevent STIs, including HIV. In every country pregnant women are the key target group for antenatal care and safe delivery, and are also a primary target group for HIV testing and counseling. Pregnant women who test positive for HIV are also the target group for services to prevent motherto-child transmission (MTCT) of HIV WHO, 010 delivering integrated HIV and Sexual and Reproductive Health (SRH) services in high and medium HIV prevalence settings, has also been yielding positive research findings and evidence of good practice. In response to the strengthening policy commitments and expanding evidence base on the effectiveness of integration the European Union (EU) agreed to fund a regional seven country project aimed at strengthening SRH/HIV linkages at the policy, service delivery and knowledge generation levels. This is clearly articulated in the Contribution Agreement signed with UNFPA, and providing for joint implementation with UNAIDS: In this context, this project intends to support the EU s partner countries in overcoming barriers to strengthening linkages between SRHR and HIV policies, programmes and services. The project will focus on catalytic action in selected pilot countries in Southern Africa and will stimulate scaling-up in other countries by means of regional-level action. Southern Africa is the region most heavily affected by HIV in the world, with HIV prevalence rates of more than 10% in the adult population in nine of the ten countries and more than 0% among women attending antenatal clinics. While there is a renewed political commitment in many countries in the region dramatically to step up and refocus action on HIV and SRHR, resources for programmes aiming explicitly to strengthen links between SRHR and HIV are scarce 6. 4 SADC Sexual and Reproductive Health Business Plan for the SADC Region. Pg European Union Annex 1 to Contribution Agreement: Linking HIV and Sexual and Reproductive Health and Rights in Southern Africa, pg. 3. P a g e

14 1. Purpose and Objectives of the Mid Term Review 1..1 Purpose The purpose of the Midterm Review (MTR) of the Joint UNFPA & UNAIDS project on Linking HIV and Sexual Reproductive Health in Southern Africa is to assess the overall performance of the project progress in the seven countries (Botswana, Lesotho, Malawi, Namibia, Swaziland, Zambia and Zimbabwe) against the agreed activities and objectives as outlined in the regional and country log frames as well as country annual work plans. This will be done with the framework of the project goal: Support at least 7 countries in Southern Africa in addressing barriers to efficient and effective linkages between HIV and SRHR policies and services as part of health systems strengthening to increase access to and use of a broad range of quality services, to appropriately include essential actions in the education, justice and gender sectors, and to achieve the goals of universal access to reproductive health (MDGs 3, 4 and 5) and HIV prevention, treatment, care, and support (MDG 6) by 015. An additional aim of the review is to provide recommendations on how to enhance project efficiency and effectiveness for the remaining lifespan of the project. The review will focus on both the programmatic and financial components of the project. 1.. Objectives This is an independent Mid Term Review of the Linking HIV and Sexual Reproductive Health and Rights in Southern Africa project. The purpose of the review is to assess progress made to date, and to enhance project efficiency and effectiveness for the remaining time of the project. The Review has attempted to address, understand and assess the full range of project objectives and collect evidence that should assist the European Union and its partners in better understanding progress on impact measured in alignment with the log frame indicators and assessed against the key review criteria. Therefore the objective of the Midterm Review of the project on Linking HIV and Sexual Reproductive Health in Southern Africa was to assess the overall performance of the project progress in the seven countries (Botswana, Lesotho, Malawi, Namibia, Swaziland, Zambia and Zimbabwe) against the agreed activities and objectives as outlined in the regional and country log frames as well as country annual work plans. The Review had a specific focus on the implementation experience against the expected results areas in each of the countries. The package of catalytic action for strengthening linkages between HIV and SRHR differs from one country to another, depending on the national context, the findings of the rapid assessments, baseline studies and agreed priorities. Countries were, however, expected to contribute to the achievement of results areas one and three, with three of the countries (Malawi, Botswana and Swaziland) reporting on all three results areas. However, the other 4 countries also expressed their interest in undertaking work under result area, so during 01 UNFPA mobilized core resources for the 4 countries to start initiatives under this area. SIDA funds have subsequently been mobilized to cover the initiatives of the 4 countries under result area for the remaining project period ( ). The expected results and main activities were further defined and adapted to the national context during the inception phase and throughout the process of implementation. Country ownership and the aid effectiveness agenda were the guiding principles of all activities in this project arranged by result according to the three programmatic dimensions of linkages outlined in the Maputo Plan of Action: Advocacy/Policy, Capacity Building/Systems, and Service Delivery. 3 P a g e

15 1.3 Extent of Participation by Different Stakeholders The Mid Term Review was a participatory process that actively engaged representatives of the project stakeholders with prime interest in the process. This included implementing partners (Government line Ministries and NGOs) at operational and national levels, as well as at district structures and facilities. In countries where field visits were undertaken UN and EU Country Offices were also engaged through planning, technical guidance and input in the evaluation process. The Mid Term Review was also extensively informed by the perspectives and experiences of health facility staff responsible for overseeing and delivering the integrated services. It was not a requirement of the review that beneficiaries should be surveyed for their perspectives on the quality and effectiveness of services in an integrated SRH/HIV environment. This decision was made based on the key constraints that included the limited timeframe for the review, the lengthy process involved in setting up focus group discussions and study protocol requirements around conducting exit interviews that generally require lengthy approval processes by research and ethics committees. 1.4 Report Structure The structure of the Mid Term Review comprises an executive summary, evaluation background, methodology used, findings and discussions, relevance, efficiency, effectiveness, impact, challenges, lessons learnt, sustainability, conclusions and recommendations. Under findings and discussions, the presentation is structured around the three project results areas: Result Area One Result Area Two Result Area Three SRHR and HIV linkages integrated in national health and development in 7 seven countries Improved uptake and delivery of integrated quality services for HIV and SRHR in three countries (Namibia, Swaziland and Botswana) Table 1: Project Results Areas Best practice models disseminated to support scaling up of HIV and SRHR linkages The Review also spells out key achievements, challenges, emerging learning and major recommendations under each result area of the project. The findings are a representation of the input of key informants, observations, as well as researchers analysis augmented by the document review in the course of the review. The Review also assesses the extent to which a number of cross-cutting project considerations are evident and being addressed in the process of implementation. These cross-cutting issues are outlined in the regional logical framework: Strengthening civil society participation; Promoting a rights-based approach to integration; Increased involvement of men and vulnerable groups; Addressing GBV within the integration process; Continuous monitoring and evaluation of integration project. 4 P a g e

16 SECTION.0 REVIEW METHODOLOGY.1 Overview of the Review Approach Responding to the purpose of the Linkages Project, descriptive Review designs using both qualitative and quantitative methodology were employed in order to tap into various evaluation approaches deriving from outcomes that the Project was designed to accomplish. The study employed a variety of technique to collect data and analyze and assess implementation progress in the seven countries. The sampling used was primarily purposive sampling, as a form of non-probability sampling. This was done given that the target population was known, and who within that target population was most likely to provide relevant information and insight regarding the project. The validity / reliability of the information provided will be assessed when feedback is provided by key stakeholders. REVIEW PHASE DETAILS DELIVERABLES Desk Phase Review of programme documentation and other key secondary data Inception Phase Preparation of Inception Report with design, methodology and data collection tools Inception Report Field Phase Undertake primary data collection through key informant interviews with a range of project stakeholders Draft Report Analysis of data & preparation of draft report, highlighting review findings and recommendations Preliminary Findings Draft Report Validation Phase Presentation of preliminary review findings and validation of all data and information Final Report Preparation of final MTR report, incorporating issues arising from client and stakeholder feedback Table : Review Methodology Final Report UNFPA and UNAIDS Country Office staff and partner organizations were engaged at the regional and national levels. The study has also made significant use of secondary data and project document review.. Data Collection Methods The Review collected data from key informants and sample implementing partners by each project result area. The evaluations primarily used a qualitative research approach to access and elicit information, and the wide range of people interviewed also allowed for some measure of triangulation to take place. The approach was voluntary participation in which informants from all seven participating countries were 5 P a g e

17 engaged. This was intended to ensure that all components of the programme were covered and that there was uniform representation of the countries in all the study areas. The data collection process commenced on 15 th April and went up to 31st May 013 which included an inception meeting with UNFPA and UNAIDS, interviews with country participants at a regional finance meeting in Johannesburg on the 11 th and 1 th of April, as well as field interviews with selected partners and stakeholders in Namibia, Botswana and Swaziland...1 Preliminary Consultative Meetings and Review Preparations During this stage, the Review core team undertook preliminary review of project documentation and held preliminary discussions with UNFPA and UNAIDS Regional Offices, including the Regional Project Coordinator and Regional M&E Officer, in order to determine appropriate areas of focus and reaching consensus on the review process and access to necessary data... Document Review A range of regional and country documents that address issues of sexual and reproductive health and HIV and AIDS were reviewed. Documents were analyzed in order to obtain qualitative information to substantiate findings from key informants and from site visits. Relevant documents including key project documents (Contribution Agreement, Regional logical framework and work plan, country work plans and logframes, country Rapid Assessments) were used to obtain this picture. The documents facilitated the process of building secondary information that guided other information gathering processes. In addition, this helped to deepen understanding of key issues and interventions that the project needs to focus on as it moves increasingly into the implementation phase...3 Interviews The Review targeted project partners and stakeholders at the regional and country levels. As part of the data collection process, the review team carried out semi-structured interviews to obtain in-depth information from progress made in implementing the project. In depth interviews with key informants were undertaken in order to understand the progress which has been made so far in regard to the three components of the project with a focus on understanding the extent to which the integrated approach is enhancing access to and utilization of SRH and HIV services among the targeted population. A broad range of key informant in-depth interviews were done with various representatives of the implementing partners as shown in Annex 10.. A specific semi-structured questionnaire/checklist was developed for use in these sessions and are attached as annex Field Visits to Selected Project Countries Three country field visits were undertaken in May and June 013 to collect specific / stratified group information representing special interests within sampled project entities. The countries visited were Namibia, Botswana and Swaziland. The rationale for the sample selection was to take the most advanced performing and the less advanced performing among the 3 countries that had initially worked on all three result areas (Swaziland and Botswana), and the average performing country (Namibia) out of the four countries that had initially only worked on two of the result areas. The review was conducted in the three countries, and combined extensive interactions with key policy, technical and project level stakeholders, together with site visits to a range of facilities where implementation was already in progress, or else about to be rolled out. 6 P a g e

18 .4 Data Compilation, Entry and Analysis The data collection tools generated data in both qualitative and to a limited extent in quantitative form. Qualitative data included responses of interviews with key informants and facility staff in selected sites. Data collected through in depth interviews were analyzed through data source triangulation. Content analysis was done in order to surface common themes, trends and concepts. Codes were developed from analysis in which major categories and themes were identified and put into meaningful sections for discussions. The qualitative data collected was processed and summarized based on key domains established during document review, the field survey, and interview notes. In most countries the project is at various stages of implementation, and the M&E systems for the project are still under construction. What little quantitative data there is has been derived from various reports and where possible aligned to the key identified domains. In essence it has been the qualitative set of information that has proven most useful in generating insights into thematic issues. This was critical in the assessment of overall performance of the project in order to provide supportive recommendations for the last two years of the project..5 Study Limitations In undertaking the Review the review team experienced a number of challenges: Time: The time available for the Review was quite limited. Within a period of six weeks the team was required to develop and pilot tools, conduct field work, and analyze data. In addition, interviews, and document reviews were undertaken in that time. Availability of quantitative integration data: While it had been intention of the Review Team to collect primary utilization data at the health facility level, this was not possible as records and summary statistics of service utilization were generally not readily available in summarized form. Hawthorne Effect: This phenomenon was noted to some extent as some of the respondents have been used to reviewers / evaluators coming to talk to them and to some degree they are primed to provide standard responses. In some cases this presented a challenge in terms of understanding some of the constraining factors. Level and quality of indicators: The project is to some extent limited by indicators that are not necessarily appropriate for measuring integration, with M&E systems characterised by compartmentalized programme areas which are not systemically aligned with what the project has been attempting to achieve. Unavailability of key partners: The Review Team was not able to access a number of key partners during the country visits. Not being able to engage with WHO or UNICEF in the three countries visited, for example, means that a key dimension of integration as a health systems approach was not adequately covered. Representivity of Field Data: Only three of the seven participating countries were visited. As countries are at different levels of implementation the perspectives gained from Namibia, Botswana and Swaziland may not fully represent the project progress in the other four countries. 7 P a g e

19 SECTION 3.0: REVIEW FINDINGS AND DISCUSSIONS: GENERAL ASPECTS 3.1 Introduction: Contextual Factors Through its engagement with project teams, UN partners, donors, government officials and CSOs the review team took note of some of the contextual factors that both facilitate and impede the process of creating linkages between SRHR and HIV services, and that will determine the longer term sustainability of the integration approach. Many of these factors are discussed in more detail in other sections of the review, but there are number of factors that that need to be flagged up front. The purpose for this is that any assessment of the project needs to take these factors into account and to understand the complex health systems environment within which integration is taking place. In all of the participating countries the AIDS response was from the outset a generally successful emergency intervention, but also one that resulted in strongly vertical institutional arrangements and programmes. HIV programming has taken place at different levels, with either ministries of health or NACs coordinating multi-sectoral programming, directorates within the MoH operating HIV/AIDS programmes, project management units managing Global Fund grants (as PRs) and PEPFAR funds, and other government ministries operating special HIV/AIDS units; The HIV/AIDS sector in particular has over the years developed a strong culture of individual programming that has not necessarily linked effectively with the broader primary health care and more specifically SRHR environments; Within some Ministries of Health there has been a distinct separation between the HIV and SRH Directorates with no real joint programming or facilitated strategic operational planning; In many of the participating countries donors are scaling back support to HIV programmes and placing increased pressure on countries to fund more significant portions of their own responses, which in turn is requiring a re-assessment of HIV policy and planning; The purpose, nature, speed and the extent of integration varies considerably, a fact that is determined by the intervention complexity, the health system characteristics and the national contextual factors, and the capacity and commitment of health care providers to develop local solutions to address emergent problems; The emergence of the integration approach offers multiple opportunities for HIV/AIDS responses to link with existing SRH services, and to create efficiencies to the benefit of both; It should be noted that the review team is aware that although the report is a summary of all seven countries being assessed, it is clear that different countries are at different levels of implementation, and that there are different capacities, capabilities and enabling environments in each these countries. This report is not a comparative study, but does attempt to highlight where some of these differences between countries are. 3. Project Relevance An important aspect of this review has been to consider and assess the extent to which the linkages project is strengthening the global integration agenda and regional role out through the Maputo Plan of Action (MPOA). In particular the review has set out to understand how the project is supplementing the MPOA commitment to integrating STI/HIV/AIDS and SRHR programmes and services in the seven participating countries as per the stated goal of the project: Support at least 7 countries in Southern Africa in addressing barriers to efficient and effective linkages between HIV and SRHR policies and services as part of health systems strengthening to increase access to and use of a broad range of quality services, to appropriately include essential actions in the education, 8 P a g e

20 justice and gender sectors, and to achieve the goals of universal access to reproductive health (MDGs 3, 4 and 5) and HIV prevention, treatment, care, and support (MDG 6) by The following table provides an overview of review findings that assess the degree to which the project is relevant to the health system needs of individual countries, and the extent to which it supports regional initiatives to promote SRHR/HIV linkages. Strategic relevance Building on evidence base Coordination Planning 1 Through a process of document review and interviews with key stakeholders it became evident that the project is strategically placed within an overall strategic re-alignment in the region around the issue of health system integration, including those outlined in the Maputo Plan of Action and the SADC SRH and HIV strategies. This re-alignment has been underpinned by the global and regional discourse around the value-add of integration to health systems. The project has been successful in facilitating a set of interventions designed to build a strong evidence base for promoting the integration agenda in the seven participating countries. Each country has completed a Rapid Assessment that has provided a detailed set of findings and recommendations. A number of other countries have completed a baseline survey of their selected pilot sites and these have provided important information on how best to map out integration strategies at the facility level. The project is being implemented in a context where there are very real challenges for coordination. These challenges relate to a number of issues. Firstly the coordination architecture in countries (with steering committees, TWGs and sub-committees) is quite onerous and in some instances there are duplications and overlaps that could be eliminated through a streamlining process. Concerns were expressed in some countries that participation in the project coordinating structures has been poor, with people citing commitment issues and time constraints as contributing factors. There is also a level of uncertainty around the respective roles and responsibilities of UNFPA and UNAIDS within the project, which has generated some unfulfilled expectations as well as concerns that the project is viewed as a UNFPA initiative rather than a joint UNFPA/UNAIDS intervention. Planning of activities for the project has clearly linked the needs of participating countries with the wider SRHR/HIV linkages agenda. The Rapid Assessments provided strong evidence bases and problem analysis was based on a logical framework approach which clearly defined linkages on causes, core problem and effects. The process of developing the regional and country level logical frameworks has demonstrated a commitment to strategically aligning project activities with integration objectives contained in national policy frameworks and priorities. There is strong correlation among programme thematic objectives, problem analysis and the project activities as they are articulated in the logical framework. 7 SRHR/HIV Linkages Regional Logical Framework, pg P a g e

21 Alignment with national health priorities Rights-based approach Sensitivity to national contexts Effectiveness From discussions with Ministries of Health in Swaziland, Namibia and Botswana it is evident that the project objectives are very relevant in contributing to the delivery of comprehensive, effective and better quality SRH and HIV services within a primary health care environment. Project activities fit well within the overall government development strategies and policies in that while the implementing partners provide implementation structures, the project brings expertise and resources to support national delivery of the components. The interventions are aimed at providing high-quality, genderresponsive and integrated SRHR and HIV services. The relevance of the project to date is that it has harnessed a multi-sectoral approach to strengthen conceptualisation of integration and enhance the availability and utilisation of integrated health services. The project has in addition clearly aimed at developing interventions that build on supplementary components such as gender equality, male involvement and PLWA in an attempt to leverage integration as a platform for addressing inequality, lack of respect for rights, unequal sexual relationships and teenage pregnancy. It is evident that the project s rights-based interventions are both relevant and challenging in that they involve efforts to align cultural and social norms and practices with an inclusive development discourse and agenda. In general terms the societies and the health seeking behaviour of people in the seven participating countries are informed by cultural norms, values, customs and associated social practices that have a powerful influence on community life. One of the challenges for the project - especially when it comes to integration - is that health issues related to sexual norms and practices remain a contested terrain and require multi-dimensional responses. In terms of implementation at the service delivery level the project is still at an early stage and it is therefore not possible at this point to assess the degree to which integration is achieving critical outcomes. The project is also hampered by a lack of measureable integration indicators that can track effectiveness in areas such as quality of services, client satisfaction, cost-effectiveness and process efficiencies. Despite assumptions being made about the potential quality and cost effectiveness of integration, rigorous assessments are limited. Evidence emerging from the INTEGRA research programme, which is a five year research programme on integration that has been conducted in Kenya, Malawi and Swaziland 8. The study used a combination of routine service statistics and process analysis, clinic- and cohort-based quantitative and qualitative behavioural research, community surveys and economic analysis, this project is assessing the benefits and costs of different models for delivering HIV and SRH services. Progress made but further 1 Good progress adjustments needed 3 Strategic re-assessment required P a g e

22 SECTION 4.0 RESULT AREA ONE: SRHR AND HIV LINKAGES INTEGRATED IN NATIONAL HEALTH AND DEVELOPMENT IN 7 COUNTRIES 4.1 Review Findings The first result area for the project has a focus on bringing about shifts in national level policies and strategies to include in an explicit way the integration of SRHR and HIV. The logic for this is that more detailed policy-level support for integration will have a downstream impact on linked service delivery at the facility level. The regional logical framework identifies four indicators that are intended to measure progress made in this important strategic area. No. of countries with defined, costed, and effectively promoted strategies to link HIV and SRHR No. of countries with developed national health and development strategic and operational plans which incorporate scaling up SRHR and HIV No. of countries with improved and inclusive coordination for SRHR and HIV No. of countries with key policy and legal barriers defined and addressed through community action, advocacy and policy dialogue These indicators were intended to provide guidance for each country to then move ahead and develop their own country-level logical frameworks with indicators aligned to national health sector processes. A significant aspect of this process has been the clear commitment of the project teams and their partners to ensure that the linkages project is not a stand-alone intervention but part of government s overall health sector approach to integration. What also emerged from discussions with both policy makers and practitioners is that the discourse of integration has in many ways become standard practice, and that it has stimulated informed and constructive dialogue around the benefits and challenges of linking SRHR and HIV services. Within the project the standard model of SRHR/HIV linkages is represented in an inter-connected and bidirectional system. In developing their Sexual and Reproductive Health Rights (SRHR) and HIV&AIDS Linkages Integration Strategy and Implementation Plan Botswana has further developed the conceptual model to include a broader range of integrated services including GBV, post-abortion care and child welfare 9 : 9 Ministry of Health. 01. Sexual and Reproductive Health Rights (SRHR) and HIV&AIDS Linkages Integration Strategy and Implementation Plan. Pg P a g e

23 The project has clearly demonstrated that the practice of integrating SRHR and HIV services is complex, and constrained by a number of capacity and infrastructural factors. In discussions with a wide range of stakeholders at policy, planning and service delivery level these factors were consistently articulated as follows: The issue of facility infrastructure, and the current physical options (space, accessibility and configuration) available to the facility for integrating services; The attitude of health care providers and their willingness to adapt to new practices and ways of doing business; Patient loads and the ability of health care providers to manage this within an integrated environment; The capacity of health care providers to provide a set of integrated services effectively and with due consideration given to issues of quality; Patient demand and expectations. The review team were able to visit a sample of health facilities and observe the three models in practice. The following table represents some of the significant observations: Nurse 1: ANC Nurse : ART Nurse 4: Pap Smear / VIA Kiosk / One Stop Shop: Health Centre/Post/Mobile Clinic This model is being used in the Sesung Health Post in Botswana. Situated in the Letlakheng District it services a small rural community. The health post provides a comprehensive set of integrated services in one room. This model is also being used at the NAPPA Clinic in Windhoek, Namibia. This clinic is situated in Katatura, which is densely populated urban area within the capital. This centre operates out of two containers, each of which has a nurse that provides a comprehensive set of integrated services. It was evident at both facilities that the nurses were competent and understood both the rationale for integration and the practice of providing integrated services. It was notable, however, that at the Namibia site the HTC service was provided separately in line with stringent national protocols for testing. Supermarket: Clinic This model is being used at the Mochudi Clinic in Nurse : FP Botswana and the Siphofaneni Clinic in Swaziland. In both these facilities integrated services are provided in separate rooms within the same building. In the case of the Mochudi Clinic porta-cabins have been procured through the project to provide additional space. In HCW 1: HTC both facilities a patient flow process has been developed and FP and HTC, are provided in each room. It was evident that in both facilities the physical space is a constraint to effective integration, but the process has been well integrated and staff members clearly understand the requirements of integration. NURSE 1 Pregnancy Check up Family ppanning HTC ART Initiation 1 P a g e

24 ART ANC OPD TB FP Pharmacy Mall: Hospital This model is being used at the Mankanye Government Hospital in Ngwempisi, Swaziland. This is a large district hospital with maternity that serves as one of the five project pilot sites ( Centres of Excellence ) in Swaziland. This facility provided a very good example of how integration can be practiced within a large facility where sections are dispersed across different parts of the building. A well-informed and enthusiastic group of senior nurses, including one project champion, facilitated a tour of the facility. Of particular interest was the way in which family planning and HTC was integrated across a range of SRH and HIV service entry points Completion of Rapid Assessments A starting point for all of the participating countries has been the completion of a Rapid Assessment that were intended to inform strategic country-level processes of integration and to provide a comprehensive evidence base for planning and implementation. At the conceptual level it is clear that this exercise was useful in providing participating countries with a clearer understanding of what integration means and what the requirements are. Further down the line a number of countries have undertaken baseline studies for the pilot sites where the service delivery component of the project is being rolled out. A significant element of these Rapid Assessments was that through their findings and recommendations they provided a clear road map for countries to follow as they went about implementing their projects. An example would be in Swaziland, where the Rapid Assessment recommended that the country should review its draft SRH Policy to ensure that it responded adequately to the imperatives of integration. During their field visit to Swaziland (May 17-1) the reviewers learned that the revised SRH Policy now included integration as a core principle, and that the policy was awaiting cabinet approval. There was some concern, however, that in some cases the information that came out of the Rapid Assessments was problematic as in some cases data had been poorly recorded Technical Consultations It is evident from discussions across all seven countries that prior to this EU project, service delivery integration was taking place in various forms often by necessity in smaller health facilities. The challenge for most countries was that this form of integration tended to be ad hoc, uncoordinated and not guided by clear policy or integration guidelines. This lack of coordination at the systems level meant that national and district M&E systems were not able to collect linkages data. At the same time the existence of vertical HIV and SRH directorates within Ministries of Health and the generally weak levels of coordination mechanisms between SRH and HIV led to programmes that were not optimally linked. The review process has found that the advent of the project created a greater level of focus for the integration discourse, and has led to project teams that have been working to ensure that the project is not a stand-alone intervention but part of government s overall programme on linking health services 10. This increased focus on integration has clearly led through the project to an enhanced level of technical consultation at both the national and regional levels. Annual country reports and field visits have demonstrated that technical consultations have taken place with national stakeholders and that the enhanced level of consultation has seen the emergence of a number of key integration outcomes. A significant development arising from the consultations was the 10 Interview with Deputy Director of Health in Swaziland, 17 May P a g e

25 endorsement of the findings of the Rapid Assessments and agreement to follow up on their recommendations. Progress has also been made in establishing technical sub-committees to work on project-related elements including M&E, communications and visibility. The review has found, however, that these sub-committees are not always able to meet on a regular basis with the same key people often being members of multiple committees. This has led in a number of instances to delays in processes, for example in Namibia where progress on developing a draft report on legal barriers to SRHR has taken longer than anticipated and will only be completed in mid In Zimbabwe a national meeting with stakeholders was hosted by the MoH in 011, and brought together relevant departments, parliamentarians, civil society, key populations, health care sector and the National AIDS Council (NAC) to sensitise and do advocacy around integrated services. A key outcome was that consensus was achieved among key stakeholders on the way forward, as well as agreement on a definition of integration 1. This component of the project has demonstrated the importance of extensive stakeholder engagement and the need to ensure that there is high level political / policy buy in. An important value-add that has emerged from the project has been the stimulation of a broader understanding of a set of three different models of integration that can be applied at facility level to streamline the delivery of integrated services. From a strategic level it has been an important development that has shaped the understanding of health sector administrators and facility staff in terms of how integration can be managed within the spatial dimensions and available resources at different kinds of health facilities. Going forward the project should continue to ensure that at the technical and policy level that SRH/HIV linkages as a concept and practice become embedded within Ministries of Health and informs their planning, budgeting and implementation processes. This will require respective Ministries of Health to strengthen joint planning processes between SHR, RH and HIV units, and facilitate joint planning between Ministries of Health, donor agencies, UN partners and civil society implementing partners and ensure that decentralised health structures are included as key role players Advocacy for SRHR/HIV Integration A key component of the project is the need to advocate for closer linkages between HIV/AIDS interventions and sexual and reproductive health care. This element of the project is geared to raising awareness and understanding of the potential value of SRHR/HIV integration and its relevance in terms of public health benefits, economic efficiency and the promotion of human rights. The intention of advocacy around SRHR/HIV linkages has been to generate increased and wide-ranging policy support for the key principles and essential practices required for integration, and to promote the scaling up of integration at the facility level. It was evident in the field visits that a considerable amount of advocacy work has been done at national level and that there is a heightened awareness of integration as a health systems approach. It is also clear that countries have targeted their advocacy messages to key constituencies and utilised a range of advocacy strategies to do this, including engagement with high profile figures in support of integration. Advocacy efforts in the different countries have targeted the following stakeholder groups: Advocacy with Parliamentarians; Advocacy with high profile individuals; Advocacy with Civil Society, including organisations of PLWA; Advocacy with donors There are numerous examples in each of the seven countries of significant advocacy interventions. In Namibia advocacy meetings with parliamentarians and UN partners on Linkages and Integration of SRHR took place in 01. The meeting was conducted in collaboration with NAPPA, UNFPA and UNAIDS, with the aim of creating awareness and understanding on the linkages and integration of SRHR and HIV. In Zambia, the Ministry of Health (MOH) in collaboration with the Ministry of Community Development, Mother and Child Health, the United Nations, and the Southern Africa HIV/AIDS Information Dissemination Service 11 SRHR/HIV Linkages Interim Annual Report 013, pg Telephonic interview with Zimbabwe Country Team, 0 May P a g e

26 (SAfAIDS) held a High Level Policy Dialogue on addressing barriers and opportunities for strengthening Sexual Reproductive Health Rights and HIV Linkages. In Lesotho the project team held meetings with the Global Fund s Country Coordination Mechanisms in order to influence the inclusion of SRH agenda in the GF s proposal development. In Zimbabwe a series of national and provincial stakeholder consultations were facilitated during 01 through the high level advocacy and sensitization meetings which were attended by policy makers, parliamentarians and programme managers. This enabled the project to sensitize policy makers on the importance of linking SRHR and HIV at policy, systems and service delivery levels 13. In another intervention the Ministry of Health and Child Welfare, with support from UNFPA and EU, has undertaken advocacy efforts targeting policy makers and aimed at encouraging and engaging key decisionmakers such as Members of Parliament, local leaders and local government representatives to support HIV and SRHR programmes 14. In Malawi, UNFPA and UNAIDS have used national HIV and AIDS reviews to advocate for the importance of the different government entities coordinating SRH and HIV to always be present in each other s review meetings to strengthen integration amidst the vertical programming currently in place Scaling up Integrated Programme Linkages One of the major expectations of the project is that initiatives undertaken at the policy and implementation levels will establish a systemic model for integration that can be scaled up over time. It is in this context that since project inception the seven participating countries have been developing a consolidated package of actions to address agreed integrated service delivery priorities. The main focus has been on developing operational guidelines for service delivery and for putting in place a results-oriented performance management framework through the development of M&E plans. Work in most of the countries on developing operational guidelines has been ongoing, with a strong focus on creating harmonized approaches to integrated SRHR and HIV service provision. The review team has noted the fact that across all of the countries work is being done both at the conceptual and the technical levels to revise existing service delivery protocols and guidelines to ensure that they are aligned to an integrated approach across a comprehensive set of SRH and HIV services. At the same time the review team was impressed with the level of innovative thinking that the project is stimulating, and the degree to which officials and facility staff are responding in an informed manner to the complexities of integrating services (including FP, STI, PMTCT, HTC, ASRH, ART, ANC, PNC) and at the same time looking at intensifying their focus on other key areas such as MMC, adolescent SRH and cervical cancer screening. Across all of the countries there are various levels of commitment from Ministries of Health to support the ongoing process of integrating SRH/HIV services, with the longer-term view of scaling up the approach beyond pilot sites. The comprehensive Sexual and Reproductive Health Rights and HIV& AIDS Linkages Integration Strategy that has been in developed in Botswana sets out clear frameworks for governance and implementation, and in doing so creates a solid platform for scaling up the programme beyond the pilot phase. In Lesotho the SRH technical working group subcommittee has identified priorities for scaling up SRH and HIV linkages, and clearly identified linkage areas that need to be strengthened. Zambia is in the process of developing national minimum standards (guidelines) for integration of SRH and HIV. Both Botswana and Zimbabwe have been developing data collection tools to capture SRHR and HIV integration. Overall, however, there remains a need to ensure that clear and practical integration guidelines are developed, shared and piloted with DHMTs and facility staff, tested and assessed at the pilot sites, and then rolled out to all country health facilities as a platform for introducing integrated SRHR and HIV services Policy and Planning Developments The project works with a clear understanding that in order for integration to be sustainable it needs to support countries in ensuring that priority linkages principles are integrated into national health and 13 Zimbabwe project Annual Report 01, pg Zimbabwe Project Annual Report 01, pg P a g e

27 development policies and plans. In doing this the project is also supporting the process of harmonization with the principles of the MPoA. The review team has found that participating countries are moving ahead in this area and substantial work is underway to ensure that the principles of integration are addressed in the review of SRH and HIV policies and frameworks. It should be noted that the project has not attempted to impose any kind of template or roadmap, and that countries are addressing these issues in a range of different ways. In Lesotho and Botswana plans are underway to undertake a mapping and analysis of existing SRH and HIV policies, frameworks and guidelines in order to identify gaps and make recommendations. Through the provision of technical inputs the project has supported the Swaziland MoH to finalise the review of their SRH Policy, and there is an opportunity to support NERCHA in its current work on revising the country s NSF 15. Namibia has facilitated working sessions to review SRH and HIV prevention strategies that are currently being developed (Family Planning, Male Circumcision, Condoms, PMTCT, HTC) in order to enhance linkages between the different programmes and to promote combination prevention. Zambia is currently mapping and reviewing various HIV and RH policy documents, and principles of SRHR/HIV linkages have been incorporated into the National Health Policy and Strategic Plan, National AIDS Strategic Framework (NASF), Human Resource for Health strategy, Community Health Assistant strategy, and the Maternal Newborn and Child Health roadmap. Zambia is also planning to develop an integrated minimum package of services for adolescents, which include youth friendly health standards. Malawi has reviewed its Sexual Reproductive Health Strategy, National HIV and AIDS Policy and the NSF to ensure that SRHR/HIV linkages are included, and are also in the process of developing an SHRH/HIV Strategy to further guide integration processes Engaging Civil Society in Integration Processes It is evident that the project has recognized the importance of the role that civil society plays in supporting governments in the region to provide health care services, and has looked to strengthen those partnerships in the context of integration. The regional project logical framework identifies a number of areas where civil society is expected to add value to the provision of integrated SRH/HIV services. Under Result Area One the regional project logical framework identifies one of the key activities as support(ing) capacities of civil society organisations, people living with HIV and representative of key populations to meaningfully engage in the above consultations and processes (1.6) and under Result Area Two the logical framework identifies activities for building capacity of programme managers and service providers in governmental and community-based organizations to implement SRHR and HIV integrated services (.4). One of the expected outcomes of the project is that the capacity of civil society to engage substantively in technical consultations and processes around integration and in particular those representing PLHIV and other key populations such as sex workers, MSM and mobile populations will be strengthened. Depending on local contexts the project has taken a number of different approaches to engaging with civil society. What is clearly evident, however, is that there is an understanding that at the policy and strategy level different civil society groupings play important roles in national policy value chains. This is clearly reflected in the case of Lesotho where the Lesotho Planning Parenthood Association (LPPA) and the Christian Health Association (CHAL) and in Botswana where the Botswana Family Welfare Association (BOFWA) sit as members of the SRH Technical Working Group (TWG). There is also a clear understanding that these organisations generally have a greater degree of access to key population communities and are able to articulate their health needs more accurately. To date the review team has found that the project has engaged with civil society at three levels: Utilisation of technical capacity: Across all the participating countries civil society organisations have been invited to sit on national technical committees, where they are able to bring their particular expertise and knowledge of working with a range of different stakeholders at community level. Many of the civil society organisations are members or affiliates of the IPPF, and bring a wealth of knowledge on SRH and rights-related issues; Utilisation of advocacy capacity: CSOs in participating countries generally have access to local communities and to local leadership structures, and a good understanding of community dynamics 15 Interview with NERCHA staff in Swaziland, 18 May P a g e

28 that influence health seeking behaviour. The project is increasingly able to utilise their community mobilisation capacity to strengthen various sub-components of the project such as male involvement, gender based violence and youth; Utilisation of implementation capacity: A range of civil society organisations have been identified to support the service delivery component of the project. In some cases CSOs such as Family Life Association of Swaziland (FLAS) in Swaziland and Namibia Planned Parenthood Association (NAPPA) in Namibia are already operating health facilities and as a result have been able to leverage their experience in providing various kinds of integrated services to further strengthen the integration approach. The review team has found that the increased involvement of CSOs provides an opportunity for the project to strengthen links with key populations and to build on their particular knowledge and expertise. In Botswana the project will be working with the Botswana Network on Ethics and Law and HIV/AIDS (BONELA), which presents an opportunity to engage more effectively with sex worker and LGBTI communities in order to understand their health needs within an integrated SRH/HIV environment. Work with organisations such as SAfAIDS in Swaziland is strengthening the ability of the project to access local communities through community mobilisation interventions. In Swaziland FLAS brings expertise in operating youth friendly centres, which provide guidance to other pilot sites looking to attract adolescents and young people to utilize integrated services. Accessing young people and adolescents is also a focus In Zambia where a number of CSOs are members of the expanded Adolescent Technical Working Group. In addition, the SRHR/HIV project has been leveraged through Population Action International (PAI) who have funded SAfAIDS and Youth Vision Zambia to promote CSO participation in the national integration agenda. In Malawi, the project is working with the Family Planning Association of Malawi (FPAM) to strengthen the process of SRH/HIV integration, and to strengthen services for most at risk populations such as adolescents living with HIV and sex workers. 4. Challenges and Emerging Understanding Verticalised SRH and HIV programming within Ministries of Health places constraints on the effective integration of SRH and HIV services, particularly in the areas of joint planning and budgeting; The verticalisation of programmes has, for historical reasons been linked to the need for emergency responses, been reinforced by donor funding for HIV programmes and in some countries this continues to limit the potential of SRHR/HIV integration; As part of the project initiation process coordination mechanisms were established in all participating countries but evidence suggests that in some cases these are not always working optimally as a result of inconsistent participation; A number of countries have indicated that organisations of PLWA are not well-represented on coordinating committees and technical working groups, and that representation from the LGBTI community is negligible; Concerns have been expressed at country level about the lack of organisations representing women s issues in both technical and implementation areas, and that this is an area that requires further attention in order to ensure that issues of gender inequality within the provision of SRH and HIV services is addressed. 17 P a g e

29 SECTION 5.0 RESULT AREA TWO: IMPROVED UPTAKE AND DELIVERY OF INTEGRATED QUALITY SERVICES FOR HIV AND SRHR IN THREE COUNTRIES (MALAWI, SWAZILAND AND BOTSWANA) 5.1 Introduction The project seeks to attain the outputs under this result area by improving the uptake and delivery of integrated quality services for HIV and SRHR in Malawi, Swaziland and Botswana, as well as in the other four countries where additional UNFPA resources were accessed to begin integrated service delivery activities. In order to better understand the extent to which policy level shifts towards integration are being put into effect, at the service delivery interface, the review team had the opportunity to visit a sample of pilot sites in Namibia, Botswana and Swaziland (as per the rationale for the selection of country field visits set out in the methodology section). These site visits provided an opportunity for the reviewers to observe integration in action and to engage in some depth with health facility staff who are promoting integration. The site visits also provided an opportunity for the reviewers to meet with a number of District Health Management Teams (DHMT) to get their insights on progress being made and challenges being experienced. The reviewers visited the following linkages pilot sites 16 : Country Facilities Visited Namibia NAPPA Clinic (Windhoek) Epako Clinic (Gobabis) Botswana Mochudi Clinic (Kathleng District) Oodi Clinic (Kathleng District) Sesung Health Post (Letlhakeng District) Letlhakeng Clinic (Letlhakeng District) Swaziland Mankanyane Hospital Siphofaneni Clinic Mbabane Public Health Unit FLAS Manzini Clinic Matsanjeni Health Centre Table 3: Facilities Visited 5. Review Findings 5..1 Operational Workforce Strategies Namibia, Botswana and Swaziland have undertaken baseline assessments of the facilities chosen to be part of the integration programme. In these studies it was evident that in many facilities integrated services already existed by necessity, mostly due to shortage of staff or the structure of the facilities. Facilities were introduced to the three models of integration and were asked to use the model that would best fit the facility. The aim of having this operational workforce strategy in place was to support the implementation of integrated services in a structured manner. The NAPPA clinic in Windhoek adopted the first model of integration 17. The facility management noted that the clinic was previously set up so that various services were available in different rooms and as it is a small facility it often didn t work very well. With the introduction of integration the clinic has been restructured so that all services are provided together at one entry point with the exception of HTC which is still provided separately. Putting in place the operational strategy of the clinic in terms within the framework of the selected integration model has allowed the facilities to restructure to provide integration services in the most effective way. 16 In Swaziland the pilot sites are referred to as Centres of Excellence 17 This is the so-called kiosk model that operates all services out of a single room. 18 P a g e

30 5.. Rights-based Education to Address Discrimination and Stigma The evolution of the HIV epidemic in the southern Africa region has created a set of linked rights-based challenges that are still being grappled with. A key project assumption is that the integration of SRH and HIV has the potential to generate effective approaches to eliminating stigma and discrimination by and towards health care providers, increase the involvement of men and ensure that vulnerable groups have unimpeded access to health services. One of the evident successes of the project is that it is stimulating a more open and solution-driven dialogue around a number of rights-based issues: Privacy and Confidentiality: In most of the project countries HIV has been dealt with as a stand-alone health issue and many facilities were configured in response to the requirements of HIV as an emergency response. As a result many facilities have separate rooms and areas within the facility that are designated specifically for the provision of HIV services, and often have stand-alone ART clinics where patients collect their ARVs. The roll-out of the integrated approach has allowed for a fundamental re-think on facility layout and a move towards the integration of dispensaries to include ART as opposed to having a separate stand-alone ART clinic at facilities. In Botswana the stand-alone clinics have been called Infectious Disease Control Clinics (IDCCs), but now they are evolving into Comprehensive Care Centres (CCCs) that will provide integrated SRH and HIV services including ANC, PNC, FP, Screening for Cervical Cancer, HIV testing for adherence partners and dry blood spot (DBS) testing for HIV-exposed babies 18. This serves as a means to reduce stigma and discrimination towards men and women living with HIV. This is key achievement in terms of addressing the issue of stigma as this offers HIV positive clients an enhanced degree of privacy and dignity. The move towards integrating the clinics was evident in field visits to the Siphofaneni clinic and Matsenjeni Clinic in Swaziland where they had integrated the dispensaries so that all clients can receive their treatment from the same dispensary. Universal Access: In its many discussions with government health officials, health care workers and CSOs the review team heard two very distinct discourses. On the one hand universal access was upheld as a core principle of health systems with the assurance that all clients receive health services in an equitable and non-exclusionary manner. On the other hand the review team heard that challenges still exist at points of service where clients experience stigmatizing responses to particular health issues, including teenage pregnancy, contraception for adolescents, sexual orientation, HIV status and STIs. In this regard the project has facilitated a more nuanced discussion around pre-service and in-service training and ongoing capacity development needs for health providers within the context of integration, and the need to include areas such as the rights-based approach to health care provision, gender equality, understanding the needs of key populations, and values and role clarification. It was also evident, however, that there is a fairly high level of discomfort among nurses and officials when it comes to strategizing around how best to provide services that meet the needs of sex workers and MSM Increasing Male Involvement The project has clearly prioritised male involvement in the design of service delivery integration, and targets both male access to services and men accompanying their partners to receive services. There is evidence at both strategy and implementation level within the project that there is a strong commitment to male involvement in the provision of integrated SRHR/HIV services. Despite this the evidence is clear that the provision of SRH services in particular is customarily viewed as a women s issue. It is clear that male health seeking behaviour and involvement in the uptake of health services is not a project-specific issue but part of a wider set of socio-cultural norms and practices in the region. The review team was able to observe that men are less likely than women to visit health clinics, citing reasons such as cultural norms, not wanting to wait in long queues and having work commitments. It was clear to the review team that patriarchal assumptions and gender disparities continue to play a critical role in determining the health 18 Botswana Project Annual Report, pg P a g e

31 seeking behaviour of men and women. At the same time, amongst both health officials and facility staff, there appears to be a limited understanding of male health seeking behaviour and even less understanding around those of MSM. Staff members generally lack a clear understanding of strategies that could engage men more effectively or how to engage with and understand the issue of masculinities and how this drives socio-cultural and health seeking behaviour. An additional confounding factor is that legislation and regulations around age of consent to marriage, to sex, to HIV testing and access to contraception are not always consistent and can create anomalies which impact negatively on effective integration approaches. Interestingly the review team learned that in Swaziland male consent is required for neo-natal male circumcision. One of the opportunities that the project is providing is to shape the integration process through innovative approaches that facilitate increased male involvement. In Malawi the health facilities have introduced love letters which are notes given to women to take home to their partners after they have visited a health facility. These notes encourage partners to come to health facilities and access ANC, HTC and family planning services with the women. In other health facilities across the seven countries incentives have been introduced to attract men to come to the facilities, including giving them preferential access to services. The project should be cautious in this regard, however, as these kinds of approaches may create perverse incentives and reinforce existing gender inequalities rather than resolving the issue of men coming to health facilities. In discussions with health providers it was evident that facilities do encourage women to come to the health facilities with their partners. In observing patient attendance and flow at the pilot sites however, it was evident to the review team that men were very much in the minority at health clinics, and that their visits were more likely to be in relation to HIV services such as HTC and ART rather than reproductive health services. Despite these challenges the project is now providing opportunities for progressive CSOs such as NAPPA in Namibia to test out approaches that may in time change male health seeking practices 19. At the same there are other ongoing initiatives in a number of the countries such as the Clinton Health Access Initiative (CHAI) community mobilization interventions in Swaziland where the project can develop synergies that can be mutually advantageous. The review team found that at facility level staff described a range of different community mobilisation / advocacy / IEC initiatives aimed at promoting male involvement, but little evidence that this was translating into a significant uptake of services by men. The project has identified young people as important group who need to be targeted in the provision of SRH and HIV health services. The project creates an opportunity to supplement existing initiatives around adolescent SRH and to support countries in increasing the uptake of SRH and HIV services by young people. This will, however, require greater effort in providing youth friendly services that enable young people to come to facilities and receive integrated services in a conducive environment. In Swaziland FLAS, which is one of the implementing partners in the integration programme, provides a youth friendly facility in one of their two clinic buildings. This facility provides an area for them to socialize, play games and relax while waiting to see the health care workers. FLAS feel that this approach encourages young people to utilize the facility as they do not have to queue in line with adults and can receive all the services they need without being exposed to the rest of the community. The reviewers were concerned to note, however, that at a number of clinics in Namibia and Botswana youth corners had been closed due to reasons such as lack of funding and lack of physical space. The review team found that vulnerable groups such as sex workers and LGBTI groups are not being specifically targeted, despite the fact that these represent key risk populations in the context of SRH and HIV. In most cases the review team was informed that universal access is a core principle of primary health care, and that services were available to all clients regardless of status. There was ample evidence that health care workers have received various kinds of training to be able to deal with vulnerable groups with the same care and attitude as with all other clients seeking services and to be sensitive to issues of stigma and discrimination. The challenge is that in all the participating countries restrictive legislation around sex work, homosexuality and abortion and fear of criminalization serves as a factor that is likely to deter people from seeking services open to the general public. 19 Interview with NAPPA staff at the NAPPA clinic in Windhoek, Namibia. 0 P a g e

32 5..4 Capacity Strengthening for Programme Managers and Service Providers The design of the project includes capacity development for programme managers and service providers in government and community-based organizations aimed at equipping them with the necessary knowledge and skills required to implement SRHR and HIV integrated services. Through the project a range of capacity development interventions have been undertaken to capacitate facility staff to provide efficient integrated SRH and HIV services. The training initiatives have varied across the different countries, and include M&E training, values clarification, and the provision of integrated services including presentations on the possible models for implementing SRHR/HIV linkages training. During the week of the review team s field visit to Botswana the project coordinator was completing the last round of in-depth training for staff working in the pilot sites, including the use of the monthly data reporting tool 0. A key achievement for the project has been the identification of mentors and champions within facilities to support the integration of SRH and HIV services. Through the project in Swaziland champions have been identified at each of the five centres of excellence, and the champions work with regional mentors who are also supporting the project in assisting the facilities to scale up SRH/HIV integrated services Security of RH and HIV/AIDS Commodities In order to strengthen the process of integration there has been a need for the project to support facilities through the provision of reproductive health and HIV commodities. The commodities procured through the project include test kits, scales, beds and portacabins. At the same time the project has been able to build strong working partnerships with Ministries of Health in each country, which in turn has strengthened the sense of country ownership of the integration agenda. In their role as principal partners in the project Ministries of Health have increasingly been supporting the project through the provision of family planning and other SRH and HIV commodities. Although there are still countries with facilities that have very few commodities, the review team found that in the facilities visited in Namibia, Botswana and Swaziland the health care providers at the facilities reported that there were no major challenges in acquiring the required commodities for FP and SRH or ensuring the security and regulation of these stocks. It was noted, however, that there is still room for improvement in terms of equipment such as beds at the facilities. The equipment supplied through the project are branded with project and funder logos that demonstrate the partnership between Ministries of Health, UNFPA, UNAIDS and the EU Piloting New Integrated Approaches One of the objectives of the project is to generate new practices that can support integration processes, and pilot new integrated approaches with district and primary health care services and community health workers. In part this approach is assisting facilities to transition clients from one service provision paradigm to another, and is designed to avoid client confusion and disorientation. In some of the bigger facilities that are operating the mall model of integration clients are being accompanied by health care providers from one service point to the next if they have been referred within the facility. This approach works to ensure that loss of clients and uptake of services is minimized. In Swaziland for example some of the centres of excellence are working with MM mentors to facilitate movement around the facility. The approach is clearly creating efficiencies for both the client and for health care workers, who can then continue to see other clients while the other is being accompanied within the facility to receive services from another health care worker. In Swaziland this method has been effective in those facilities that have adopted the supermarket and mall models of integration Contribution of Non-health Sector in Successful Models One of the outputs of the project is to analyse and define the possible contribution of non-health sectors such as education, law and law enforcement, gender and youth to the development of successful integration models, and find ways of engaging with non-health sector interventions to complement what the project is attempting to achieve. The review has found that this is quite a challenging element of the 0 Botswana Project Annual Report 01, pg P a g e

33 project as it requires significant efforts to engage with the relevant partner Ministries and other implementing agencies. At the same time it is clear that there are opportunities to engage with important interventions underway in the region in the areas of youth friendly services, comprehensive sexuality education and gender based violence. Overall, however, there is not much evidence from the project that these kinds of engagements are being actively pursued. Issues related to adolescent SRHR and the high prevalence of HIV in young people make this area a critical component of integration. In Zambia the project has partnered with UNESCO in the development of a Comprehensive Sexuality Education (CSE) programme work plan that identifies linkages between CSE programmes and SRHR/HIV linkages. This partnership includes Comprehensive Sexuality Education training for teachers and support to a pilot intervention in the Copper Belt province. Gender Based Violence (GBV) is an equally important component of the SRHR/HIV integration process, and its significance is highlighted in a number of country Rapid Assessments (Zambia, Swaziland, Botswana). The Zimbabwe project team attended the East, Central and Southern African Health Community (ECSA-HC) pre-conference workshop in Arusha in 01 aimed at scaling up the campaign on advocacy for effective implementation of sexual and gender based violence initiatives in the ECSA Health Community. Participants attending the workshop were primarily Reproductive Health Managers, GBV focal points, Public Relations Officers and health journalists from ECSA Health Community member states. The preworkshop was part of an integrated policy development process in the region, and aimed to share emerging lessons on SGBV and identify regional advocacy concerns. This level of engagement needs to be further explored as countries look to strengthen integrated services for survivors of SGBV through HIV counselling and testing, post exposure prophylaxis, emergence contraception, psycho social support and referral for forensic tests. 5.3 Challenges and Emerging Understandings The implementation phase of the project (service delivery at pilot sites) has had a good start but there are a number of challenges which need to be addressed in order improve the implementation of the integration program. Waiting Time: Integration has increased the number of services provided to a client thus impacting on the time health care worker spend with one client. Providing a full set of SRH/HIV services to clients means that each patient can spend up to 30 minutes with the health care worker and even up to 45 minutes at the first ANC visit. This means that clients waiting to see the health care worker often find themselves waiting longer period of time than the time they spent at facilities during previous visits. This can have a negative impact on health seeking behaviour as some clients will be discouraged from seeking services because of longer waiting times; However, in the Namibia experience, a time motion study has suggested the opposite. The provision of integrated services at the health facility every day of the week seems to have streamlined patient-flow across the week and reducing waiting time bottlenecks. Registers at Facilities: Health care workers are responsible for capturing client information into registers for each client at every visit. Integration means many different services are provided by the health care workers and therefore different registers have to be complete for each service. In many cases health care workers are sitting with at least five registers which they have to complete for each client, creating a huge burden on the health care workers as they have to balance the P a g e

34 service provision aspect as well as the administrative aspect of their day to day work. While this is a challenge across the health care system, the introduction of an integrated approach does have the potential to increase the burden of registries in the short term while countries look at ways to develop integrated registers; Attitudes and Management within Facilities: The success of integration clearly lies with the health care workers and the management of the facilities. The review team found that in facilities that had staff motivated to re-organise and adapt to the requirements of an integrated approach processes appeared to work more effectively. Mankanyane Government Hospital in Swaziland and Mochudi Clinic in Botswana are good examples of how integration can work effectively when staff are positive about integration and flexible around work flow arrangements. At the NAPPA clinic in Namibia it was evident that the positive attitude of the staff assisted in the restructuring of the clinic to provide a range of services to clients at one visit, and even though the facility had only started to implement integration two weeks prior to the field visit it was already possible to see some of the emerging benefits of integration; Screening of non-communicable diseases: Integration has created an opportunity to screen clients for other non-communicable illnesses at their visits. Some countries such as Botswana have prioritized cervical cancer screening, but there are clearly a range of other possibilities that countries could include as integration becomes embedded in the work of the facilities. These would include screening for lifestyle diseases such as hypertension and diabetes, as well as male-oriented services such as prostate cancer screening; Gender Inequalities and Cultural Norms: Gender inequalities and cultural norms are evidently a major challenge for effective SRH/HIV integration. The review team found that many women who are counseled about family planning opt out citing the fact that they could not discuss these issues with their partners. Given the fact that men are reluctant to come to clinics with their partners barriers are created for women who may want to access specific services on their visits to the clinic. The review team was told on numerous occasions by facility staff that men are not visible in the clinics because services are not adequately tailored to their specific needs; Funding Flows: There is a perception at country level that the flow of funds from the European Union to UNFPA, and then to implementing partners, is a challenge and that in a number of instances it has created implementation delays and significant time lags in disbursements. This stems from a lack of understanding by some countries of the contractual arrangements around funding as set out in the Contribution Agreement. The Regional team must continue to engage with the country teams to ensure that there is a clear understanding of the funding modalities, together with the importance of efficient budgeting, forecasting and financial reporting to ensure that shortfalls are not experienced. SECTION 6.0: RESULTS AREA THREE: BEST PRACTICE MODELS DISSEMINATED TO SUPPORT SCALING UP HIV AND SRHR LINKAGES 6.1 Introduction A key component of the project is that it should, through its policy engagements and implementation at service delivery level, generate new learning, knowledge and best practice models that will inform the evolving process of scaling up integrated SRH and HIV services in the region. In line with the regional project logframe countries should work towards documenting and disseminating lessons learned and identify bottlenecks and best practice models at the policy, system, and service delivery levels. 6. Review Findings 3 P a g e

35 The review team found that this was the project Result Area where the least tangible progress has been made, especially in the area of emerging good practice from integrated service delivery. This is understandable, however, given that the roll-out of integrated service delivery in pilot sites has only started in earnest in the last year and that it is perhaps premature to expect significant outcome level learning to have emerged in such a short period. There is an expectation that this area will be strengthened as more pilot sites come on line in the various countries and integration practice starts to generate information, experiences and data Generating Learning and Good Practice Expected outputs of the project in this regard include documenting lessons learned and identifying bottlenecks and best practice models at the policy, system, and service delivery levels. It was further expected that these would be packaged and disseminated as widely as possible to stimulate ongoing theory and practice around integration. The review team has found a number of significant developments in this area. The Rapid Assessments developed in each of the participating countries highlighted the gaps, bottlenecks and opportunities that existed in each country and provided recommendations for taking the integration agenda forward. In Swaziland SafAIDS has been contracted to develop a project documentation strategy. The draft Documentation Strategy has been developed and some training has been conducted for the M&E group for the SRH/HIV integration project. A short documentary film on SRH/HIV Linkages and integration of services within the five Centres of Excellence has also been developed but not yet released. In Malawi the project highlighted the achievements made at the Nkumba health centre, and articles were published in two of the main daily national newspapers on two occasions for the visibility of the program during the third quarter. Other visibility materials produced included banners which have been shared in all the 15 implementing health facilities and also shared with partners together with information leaflets. As part of advocacy, Malawi also initiated a SRHR/HIV linkages program with Radio Islam that raised awareness among Muslim communities in Mangochi on reproductive health issues, HIV prevention and related socio-cultural issues. In Zambia civil society organizations on the technical working group, through funding from PAI, developed an advocacy film on promoting and strengthening SRHR and HIV linkages. The short film was screened at the International AIDS Conference (IAC) in Washington DC in July, 01, as well as at the High Level Policy Dialogue on opportunities and barriers to strengthening SRHR-HIV linkages in Zambia in 01. The Zimbabwe experience with good practice on integrated Emergence Obstetric and Neonatal Care and PMTCT training of service providers in Zimbabwe was presented at the 01 FP conference in London as well as at the International AIDS Conference in Washington in July 01. Advocacy meeting have been held with Members of Parliament and representative from the Coalition of African Parliamentarians against HIV and AIDS (CAPAH), focusing on providing MPs with the requisite knowledge and skills to support their legislative mandate and constituency obligations around reproductive health issues. 6.. Knowledge Sharing Expected outputs of the project in this regard include convening regional consultations with project countries to share their linkages/integration experiences through South-South cooperation, including via the AU/SADC and other relevant continental and global frameworks. South-South cooperation has been successfully promoted through a number of study tours. Two teams from Ministries of Health in Botswana and Zimbabwe, together with the project coordinators, undertook study tours to Kenya during 01 to learn more about different integration models, some of which were later adapted to strengthen the Botswana initiatives. The review team found that both country teams had found the visits very informative in terms of increasing understanding of how integration can work in practice and how best to set up their own pilot sites. As part of the South-South cooperation component the Lesotho team, consisting of the SRH Manager and HIV Manager of the MOHSW and the National Project Coordinator from UNFPA, visited Swaziland with the purpose of better understanding project operational arrangements for the implementation of the linkages project, and to understand the framework for establishing Centres of Excellence that have successfully been implementing linkages between SRHR and HIV. 4 P a g e

36 The project has had a number of opportunities to showcase the linkages project to a much wider audience at a number of international and regional conferences. Swaziland made a poster presentation on SRH/HIV Integration at the 01 International AIDS Conference 01 in Washington. At the same forum the Regional Project Coordinator presented experiences from the project. This was done as an introduction to a skills building session on using a tool developed by SafAIDS for addressing LGBTI, SRHR and HIV issues. The tool has been pre-tested with health service providers and community groups in Zimbabwe and received positive feedback. UNFPA and UNAIDS, under the umbrella of the H4+, co-organised a satellite session on cost efficiencies of SRH/HIV integration. A model was presented predicting high potential cost-effectiveness of expanding the Investment Framework approach to family planning and maternal and child health. Several other sessions highlighted the implementation research gaps and called for more and better understanding of when to integrate, how best to create linkages, what model to use and in which settings. Country delegations from the project countries of Botswana, Malawi, Swaziland, Zambia and Zimbabwe attended the 01 international conference on Integration for Impact Reproductive Health & HIV services in Sub-Saharan Africa in Nairobi, Kenya. This conference had a focus on research findings on the impact of integrating HIV and reproductive health services incl. family planning, maternal and child health, STI prevention and cervical cancer screening, as well as strategies for strengthening integration polices and translating research into practice. The conference was divided into two tracks, Models of RH/HIV Integration and Policy and Organizational change. Three abstracts from the project (Regional level, Malawi and Swaziland) had been submitted and accepted as oral and poster presentation. The Regional Project Coordinator presented the abstract on Use of rapid assessment tool to strengthen linkages between SRHR and HIV under the Policy and Organizational change track, a poster presentation from Malawi on how the project has progressed from policy to practice in integration of SRHR/HIV services and a poster on SRH/HIV Integration from Swaziland. This conference also saw the launching of the project s website in collaboration with IPPF ( The website showcases current project innovation and good practices relating to SRHR and HIV linkages and integration in the UNAIDS/UNFPA SRHR-HIV Linkages project as well as the IPPF led INTEGRA project in Kenya, Malawi and Swaziland. The project was represented during the launch of the research findings from the INTEGRA Initiative in March 013 in London. The Rapid Assessment on Integration of Sexual Reproductive Health and HIV in Namibia was presented at the 01 5 th Africa Conference on Sexual Health and Rights in Namibia, and the report was distributed during the conference. In addition, a Youth Health Forum entitled Champions for Change, which focuses on SHR and HIV linkages, was launched at the youth pre-conference to the 5 th Africa conference on Sexual Health and Rights with the support of UNAIDS and UNFPA. From a monitoring and evaluation perspective the project is represented in the global working group led by IPPF that is developing a global compendium of integration indicators. The rationale for this work has been the critical challenge of assessing the effectiveness of programming responses to SRH and HIV linkages due to the lack of appropriate and agreed-upon indicators. The project has provided substantial input into the process and attended a meeting in London in March 013 to finalize the first iteration of the compendium of indicators. Since then UNAIDS, in its role as technical M&E lead for the project, has followed up by organising a regional M&E meeting at the end of May 013 in Johannesburg to discuss the feasibility of field-testing three of the proposed indicators in the project countries and agree on a way forward. 6.3 Challenges and Emerging Understanding The review team heard, on numerous occasions, that staff members at facility level have been doing integration before the advent of the project. While this may be true in effect, it has clearly happened in a fairly ad hoc way, driven mainly by necessity. As the project becomes more service-delivery focused it will be increasingly necessary to document and assess the different ways in which integration is being implemented within different countries and in different facilities. What the project is very evidently doing is bringing a form and structure to the process of linking services no longer by necessity but based on sound principles of effectiveness and quality of care. 5 P a g e

37 At the same time the review team has been able to observe that as the project brings a more structured approach to the process of integrating SRHR and HIV services both MoH officials and health providers at facility level are beginning to find new ways of delivering services using the three models of integration where appropriate; There is a concern, however, that significant implementation achievements may be seen as business as usual and therefore not tracked or recorded as best practice; In order for pilot sites to be able to demonstrate outcomes under Results Area Three the country project teams will have to support a rigorous and sustained system of documenting new and innovative practices that make linkages work in the clinical environment; Project teams should not assume that nurses and other health care workers have the required capacities to be able to write up good practices, or processes that they have put into practice at the various facilities; The project teams will need to identify simple methodologies for capturing innovations and turning them into story lines and case studies. There may also be opportunities to use various kinds of multi-media approaches that can be used to share knowledge and practice between countries, as well as with a wider community of practice. 6 P a g e

38 SECTION 7.0 CROSS CUTTING CONSIDERATIONS 7.1 Review Findings This section presents a set of cross-cutting issues which were identified within all the countries and across the three results areas identified within the project. The linkages project should consider how different and innovative approaches can be used to address the issue and strengthen project effectiveness and the role of integration. 7. Promoting a Rights-based Approach to Integration The project is quite explicit in calling for the design of national level programmes that will support rights education, access to equitable health services and SRHR, and address discrimination and stigma including through redress mechanisms 1. In broad terms the review team found that this is an area that has yet to gain significant traction in terms of project implementation. What came across quite clearly in discussion with project teams, government officials and health care workers is that many of the rights-based issues are politically and socially sensitive and tend to have a polarizing effect. In discussing issues such as gender equality, HIV status, abortion, sexual orientation, sex work and young people s sexuality it was evident that there is a considerable divergence of views and many grey areas that remain unaddressed. The review team found that at the facility level many of the rights-based issues are poorly understood and that values clarification training has not necessarily addressed issues of prejudice and discrimination. Across all countries the review team was told that SRHR and HIV health responses are often shaped by local contexts that are created by local norms, myths, practices and beliefs. Socio-economic realities present other barriers that stem from socio-cultural, gender and age differences as well as geographical and transportation challenges that may result in women, newborns, children and adolescent girls being discriminated against when trying to access essential health services. The challenge for SRHR/HIV integration is that stigma and discrimination can lead to human rights violations that undermine the principle of universal access which is upheld at the policy level by all participating countries. Despite considerable efforts by Ministries of Health and civil society organizations to ensure that HIV and SRH services are provided in a non-discriminatory way the review team heard on numerous occasions that there are still challenges around the stigmatization of patients and discriminatory practices on the part of health care workers. It is in this regard that the project should continue to pro-actively promote this component of the project and support work being done by implementing partners to increase awareness of rights-based issues amongst national cadres of health care providers and officials and work to modify poorly founded and discriminatory values. 7.3 Addressing GBV within the Integration Process The project clearly recognizes that SRHR requires structural interventions to shift social norms towards building acceptance and demand for inclusive, rights-based services, to endorse sexual rights for all and to strengthen political commitment to combating gender-based violence (GBV). In the context of sexual and reproductive health GBV has been linked to an increased risk of unwanted pregnancies, pregnancy complications, gynecological disorders, unsafe abortions, miscarriages, and sexually transmitted infections, including HIV and AIDS. The fear of violence may also hinder women's ability to seek and access treatment and care. In raising the issue of GBV with a range of project stakeholders the review team found that while the problem is recognised, there appear to be limited responses at the facility and community level. The 1 Regional Project Logframe, Result Area., pg. 3. Contribution Agreement with the European Union, pg P a g e

39 review team found that this is a key human rights issue which is not being adequately addressed in the pilot health facilities. While the integration process provides an ideal opportunity to screen for gender based violence, this is not a routine practice for health care workers and there was a sense that they view GBV as a problem that is outside of their ambit. This could be related to the fact the health care workers are not adequately sensitised or trained to deal with GBV beyond providing basic health services and emergency responses such as the provision of PEP. There is clearly an opportunity to use the platform of integrated services to screen for GBV and have in place a structured referral system to assist women and girls in accessing their health and safety entitlements. Gender based violence remains a major SRHR issue in Southern Africa and opportunities that this project offers should be utilised to both promote more intensified dialogue on the issue and to ensure that any minimum package of integrated services includes the dimension of GBV. This is an area where experienced SRHR partners (UN agencies, civil society organisations, other donor agencies) with an understanding of the causes of GBV and required responses should be engaged to share their expertise through mentorship and training. 7.4 Continuous Monitoring and Evaluation of the Integration Project The regional logical framework is structured around a set of outcomes and activities that have a total of 38 indicators for measuring progress. This indicates the commitment of the project to measureable results but also raises concerns around the ability of the project to use these to measure progress on the project. Rapid Assessments conducted in the seven countries have been useful tools for assessing the state of affairs on specific issues related to integration, and highlighting key areas for strengthening country level M&E processes to accommodate integration processes. The Rapid Assessments made a number of recommendations that were applicable across the participating countries: The Public Health and HIV and AIDS Departments need to collaborate more strongly in terms of planning, budgeting, training, monitoring and supervision of linked HIV and SRH programmes (Botswana); Strengthen M&E systems in order to effectively monitor and evaluate integration programmes and facilitate joint follow-up of patients, reduce excessive paperwork and time that healthcare workers take to fill the paper forms, and help improve data quality (Lesotho); Strengthening health monitoring systems through staff training on the use of integrated monitoring tools and capacity building on data synthesis for SRH and HIV (Malawi); Strengthening the monitoring and evaluation (M&E) framework to include SRH and HIV integration (Zambia); Update the existing M&E framework to include indicators on bi-directional integrated HIV and SRH services (Namibia). From a project design perspective there is clear evidence that national governments and partners collaborated in the development of the main project documents. The Executive summary of EU SRHR and HIV linkages project and EU SRH and HIV linkages project logical framework were developed with participation of programme managers and M&E officers from MoH, UNFPA, and UNAIDS. The M&E registers and tools of the pilot for integration of SRHR and HIV are being developed with participation of health care workers from the pilot sites, programme managers and M&E staffs from MoH, UNFPA, and UNAIDS. However, overall it is difficult to get a clear sense of effective M&E coordination at the country level. From a policy and strategy perspective these recommendations continue to be relevant as the project reaches its mid-term mark. In most of the countries HIV and AIDS National Strategic Frameworks (NSF) address key HIV prevention, treatment, care and support issues in a very comprehensive manner, capturing some key SRH and HIV linkage activities, particularly around PMTCT. However, in many cases these SRH and HIV linkages are generally not defined as one of the key result areas for the plans, and activities proposed are neither exhaustive nor systematic. In some countries such as Zimbabwe and Swaziland the current NSF is under review and integration is being incorporated as a guiding principle. It is also evident that participating countries are aiming to develop guidelines and strategies after the implementation of the 8 P a g e

40 integration pilot which is either currently being implemented or in the planning phase. HIV/AIDS strategies will be reviewed and updated to ensure they incorporate integration of SRHR and HIV. In Zambia for example SRH and HIV/AIDS are linked to the national M&E Plan and a separate plan for the linkages project is under development. Botswana has developed a detailed SRHR and HIV/AIDS Linkages Integration Strategy and Implementation Plan with indicators and in Swaziland further work will be done on operationalising the revised SRH Policy once approved by cabinet. Despite progress in this area the verticalisation of existing SRH and HIV programmes remains a challenge to the creation of M&E synergies around integration. At the implementation level it is evident that the M&E Units within Ministries of Health are generally stretched and under-resourced in terms of both physical and human resources 3. Countries have HMIS officers at the national, regional and district levels and M&E staff are qualified with a mix of backgrounds in M&E, Demography, Statistics, Information Technology and Public Health. In some countries data clerks have been recruited with donor funding and based at the district level/facility level as well as at the national level. The capacity on data management is in some cases limited at these sub-national levels. Generally no specific managers are assigned to the role of tracking integration, but various programme managers ensure the use of this information to inform implementation decisions. Both the site visits to facilities in Namibia, Botswana and Swaziland and in discussion with key government and UN stakeholders indicated that data management at the facility level is onerous. Health workers in facilities are required to work with multiple registries, and this clearly places a high administrative demand on facility staff. In preparation for the project all participating countries developed logical frameworks derived and adapted from the regional logical framework. The regional and country level log frames have detailed sets of indicators, but from the outset the challenge is that: Most of the indicators are either impact or process (output) level; There are few indicators that can measure integration outcomes; Currently there are few indicators that can measure the effectiveness of integration as opposed to the process of integration. Throughout the review process it has been very evident that the regional and country teams are aware of this challenge and the fact that this area has been challenging for countries as there has been little guidance on integration indicators. A few countries have embarked on identifying potential SRHR and HIV indicators to use, but overall there is not as yet an agreed set of outcome indicators for integration. Nevertheless, it should be recognised that in-depth work is being done at various levels to develop a small set of outcome level integration indicators. In this regard Swaziland participates in the global steering committee that is currently developing a compendium of indicators to be used for measuring SRH-HIV linkages/integration. There is also an expectation that the additional Sida funding will support increased M&E and strategic information on HIV-SRHR linkages to ensure that programming in this area is based on the latest evidence, results are effectively monitored and progress is evaluated, documented and disseminated. At the country level project teams have started to develop tools for measuring SRHR and HIV integration and some of these are already being tested at the pilot sites. It is anticipated that the findings from these pilots will provide guidance to the M&E system/plan which will be reviewed to ensure that specific indicators measuring integration are included. Baselines conducted at pilot sites (Botswana, Swaziland) provide a good evidence base for the development of integration indicators, and in Zimbabwe, a team of consultants has been developing SRHR and HIV integrated data collection tools and a compendium of indicators and a guide for every indicator has been developed. In Botswana a tool has been developed (SRHR/HIV Linkages District Monthly Report Form) to assist facility level staff in the collection of integration data. 3 Much of the information in this section was provided in responses to an M&E systems questionnaire that was completed by each of the participating countries. 9 P a g e

41 In the logical frameworks technically sound data sources have been identified for all project indicators (including project activity monitoring, health services statistics, population-based surveys, and sentinel site surveillance). Routine and period data is generally well-systematised in the seven countries, and where required for new emerging issues such as integration existing tools can be modified. The frequency of data collection is generally feasible for all indicators where they are standardised and required for national reporting purposes. There is however a concern about data quality, which is acknowledged to be variable and there are some concerns around compliance with data capturing requirements 4. At facility level transfer of data from tally sheets to registers and then to aggregation in routine reports may not always be accurate. There are some concerns around the interface between paper based and electronic data systems and the potential risks of double counting when capturing integrated data. This is linked to general concerns at country level with capacity issues and the need for ongoing M&E capacity strengthening initiatives as well as routine mentorship and support for facilities that are implementing an integrated approach. One current challenge for project M&E is the issue of attribution, and understanding the extent to which integration is having a measureable impact on the quality of services being provided. At this stage the project lacks adequate measures for understanding observed changes or results achieved through project implementation. While there are numerous indicators that measure either sexual and reproductive health programmes or HIV programmes, there are very few internationally recognised indicators that measure linked SRH and HIV programmes. Therefore a compendium of SRH and HIV indicators is needed to increase the measurability, monitoring, accountability and effective implementation of these programmes. Within the broad range of services provided through SRHR and HIV it is critical that the project is able to assign a reasonable level of attribution to the linkages intervention or to the utilization of services within facilities. In Swaziland the Ministry of Health M&E Unit has started to collect integration data from the pilot sites (Centres of Excellence) and these are yielding some interesting trends 5. The following two graphs highlight some interesting attribution issues that can inform analysis of the project impact. The first shows the significant increase in the uptake of family planning commodities (not disaggregated by commodity) as the pilot facilities scale up FP provision across multiple SRH and HIV entry points, and suggests that the provision of integrated services is succeeding in this area. The second graph is counter intuitive in that it shows a decrease in the number of women being tested at ANC during a period when the provision of HTC has been scaled up at ANC. More detailed analysis suggests that the success of increased family planning has led to a decrease in pregnancies with a subsequent decrease in the utilization of ANC facilities. Fig. 1: Uptake of FP Commodities at CoEs Fig : Number of Women Tested at ANC In discussion with MoH M&E officers in Botswana and Swaziland 5 Data provided by the MoH M&E officer in Swaziland 30 P a g e