Brothel Based Sex Worker. BCC. Behavior Change Communication. BCCP.
Bangladesh Center for Communication Programmes. CBO. Community-Based ...
DOCUMENTATION AND LESSONS LEARNT IN A
PROGRAM OF HIV TARGETED INTERVENTIONS FOR HIGH RISK GROUPS IN BANGLADESH
Under the management of UNICEF Bangladesh country office
2 Acknowledgements The support of various people in compiling this report is acknowledged. Many gave up their valuable time to share their knowledge and experience of HAPP/HATI as well as broader issues relevant to HIV in Bangladesh. The names of those who participated in stakeholder interviews or workshops are listed in Appendix 1. The author would like to acknowledge the support of Bridget Job Johnson the HIV/AIDS specialist in the UNICEF Bangladesh Country Office and particularly the HAPP/HATI team Dr. Najmul Hussein, Muhammad Ehsanul Haque, Dr. Hashina Begum, Syed Imtiaz Ahmed, Morshed Bilal Khan, Akhtar Jahan Shilpy, Fakhrunnessa Lipi, for giving generously of their time, when other work demands of completing the program have weighed heavily on them.
Disclaimer: This report was commissioned by the Bangladesh UNICEF Country Office. However the views contained are those of the author and do not necessarily reflect those of UNICEF.
David Fowler: The HIV/AIDS Prevention Program (HAPP) and HIV/AIDS Targeted Intervention Program (HATI): Documentation and Lessons Learnt in a Program of HIV Targeted Interventions for High Risk Groups in Bangladesh. Dhaka, May 2009.
3 List of Acronyms ACC AIDS BBSW BCC BCCP CBO CSW DGHS DFID DIC EoI FHI SW GoB HAIF HAPP HATI HBSW HIV ICDDR,B IDA IDU JHU/CCP MARP MoHFW MoU MSA MSM MSW NASP NGO PCA PNS PE RfP SBSW SCF SHG SMC STI TA TOR TOT UN UNAIDS UNICEF VCT
Advocacy and Communication Component Acquired Immuno-deficiency Syndrome Brothel Based Sex Worker Behavior Change Communication Bangladesh Center for Communication Programmes Community-Based Organization Commercial Sex Worker Directorate General of Health Services Department for International Development, UK Drop-in-Center Expression of Interest Family Health International Sex Worker Government of Bangladesh HIV and AIDS Intervention Fund HIV and AIDS Prevention Project HIV and AIDS Targeted Interventions Hotel Based Sex Worker Human Immuno-deficiency Virus International Centre for Diarrhoeal Diseases Research, Bangladesh International Development Association Injecting Drug User John Hopkins University Center for Communication Programs Most At Risk Population(s) Ministry of Health and Family Welfare Memorandum of Understanding Management Support Agency Man having Sex with Man Male Sex Worker National AIDS/STD Programme Non-Governmental Organization Project Cooperation Agreement Procurement of NGO Services Peer Educator Request for Proposal Street Based Sex Worker Save the Children Fund Self Help Group Social Marketing Company Sexually Transmitted Infections Technical Assistance Terms of Reference Training of Trainers United Nations United Nations Joint Programme on AIDS United Nations Children's Fund Voluntary Counseling and Testing
4 TABLE OF CONTENTS List of Acronyms ...........................................................................................................3 Executive Summary .......................................................................................................1 1.0 BACKGROUND ...............................................................................................5 1.1 December 2000 – June 2003. HAPP established but project implementation delayed. ................................................................................................................................6 1.2 June 2003 – June 2005 Mid Term Review results in major restructure and implementation accelerates....................................................................................8 1.3 July 2005 to June 2006 Extension of HAPP (second phase) but significant interruption to service delivery ..............................................................................8 1.4 July 2006 to December 2007. Extension of HAPP (third phase) Improvements in coordination, coverage and quality ........................................................................9 1.5 January 2008 – December 2008 UNICEF contracted to continue coordination under HIV and Targeted Interventions (HATI) Contract ..............................................11 1.6 HAPP/HATI Documentation Project.............................................................12 2.0 GOALS AND OUTCOMES..................................................................................13 2.1 Goals and Outcomes: Lessons Learnt............................................................14 3.0 SERVICE DELIVERY..........................................................................................15 3.1 Service Coverage ...........................................................................................16 3.2 Quality of Services.........................................................................................17 3.2.1 Drop In Centre Model.................................................................................18 3.2.2 Critical gaps in Range of Services ..............................................................19 3.2.3 Addressing vulnerability.............................................................................19 3.3 Programme Design Issues..............................................................................20 3.3.1 Injecting Drug Use Programme Design......................................................20 3.3.2 Female Sex Worker Interventions ..............................................................21 3.3.3 Men who have Sex with Men Programme Design .....................................22 3.3.4 Clients of Sex Workers Programme Design ...............................................22 3.3.5 Prison Interventions ....................................................................................23 3.4 Service Delivery: Lessons Learnt ..................................................................23 4.0 OVERSIGHT AND COORDINATION and Critical issues .................................25 Critical issues:......................................................................................................25 4.1 Lessons Learnt ...............................................................................................27 5.0 PROGRAM MANAGEMENT..............................................................................28 5.1 Program Planning, Monitoring and Evaluation .............................................28 5.2 Consortium Modality .....................................................................................30 5.3 Management Agency/continuity plan (UNICEF)..........................................30 5.4 Programme Management: Lessons Learnt.....................................................31 6.0 FINANCIAL MANAGEMENT ............................................................................32 6.1 Procurement of essential commodities ..........................................................33 6.2 NGO Financial Management .........................................................................33 6.3 Lessons Learnt ...............................................................................................34 7.0 CAPACITY DEVELOPMENT .............................................................................35 7.1 Capacity Development: Lessons Learnt ........................................................37 8.0 TRANSITION OF HATI FROM UNICEF ...........................................................38 8.1 NGO contracts and funding: ..........................................................................39 8.2 Quality assurance and Monitoring:................................................................40 8.3 Supply and procurement: ...............................................................................41 8.4 Programme Management Capacity................................................................41
5 9.0 IMPLICATIONS FOR UNICEF ...........................................................................42 9.1 Core Mandate: Minimizing the impact of HIV on children ..........................42 9.2 Management systems .....................................................................................44 9.3 Exit Strategy...................................................................................................45 9.4 Lessons Learnt ...............................................................................................45 Appendix 1 Terms of Reference ..................................................................................47 Appendix 2 List of people consulted ...........................................................................48 Appendix 3 List of Implementing Agencies - Activities and Geographical Coverage49 Appendix 4 Situation Assessment and Programme Design.........................................53 Appendix 5 Syringe and Needle Distribution......................................................61
1
Executive Summary This report documents the processes, achievements/outcomes and lessons learnt in managing the implementation of HIV prevention targeted interventions for high risk groups (Injecting Drug Users, Sex Workers, Clients of Sex Workers and Men who have Sex with Men/transgender) in Bangladesh under the HIV/AIDS Prevention Project (HAPP) and HIV/AIDS Targeted Interventions (HATI) project 1 . The HIV prevention targeted interventions under HAPP/HATI were managed by the UNICEF Bangladesh Country Office from 2004 to 2008. Bangladesh, unlike most other countries in the world with a similar mix of risk patterns (large sex work industry, significant IDU population) and vulnerability (e.g. high levels of poverty, large scale internal population movement), has been successful in keeping HIV prevalence very low. To a significant extent, this is probably attributable to a willingness by government to acknowledge the existence of high risk groups and risk behaviors and a willingness to initiate effective interventions earlier rather than later, high quality interventions by NGOs, strong technical support from international agencies as well as local agencies such as ICDDR, B and a clear strategic focus by donor agencies. Regardless of the above, among IDUs, in Central Bangladesh, HIV prevalence has risen to 7% and is reported to have reached 11% in one area of Dhaka where injecting drug use is high. Furthermore, while localized, there are initial signs that HIV is beginning to spread among IDUs in other locations and among sex workers 2 . HAPP/HATI has been the largest program of targeted interventions for IDUs and sex workers in Bangladesh over the past five years. Evidence reviewed in preparing this report, indicates that the high level of coverage and quality of targeted interventions has contributed to maintaining low HIV incidence among sex workers and reduced the extent to which HIV prevalence has increased among IDUs. This report describes the approach and lessons learnt in program strategy and implementation in the areas of service delivery, mechanisms for oversight and coordination, management systems, capacity development and technical input. It also discusses matters related to the transition of HATI management/coordination from UNICEF to National AIDS/STD Programme (NASP) and future implications for UNICEF in managing such programmes. Service Delivery At the end of 2008 HAPP/HATI services were provided by 37 NGOs through 146 Drop In Centers (DICs) and outreach services. NGOs were organized into 12 consortiums. Core services included HIV education, condom use demonstration and 1
HAPP was funded through a development credit from the World Bank and grant from DFID from December 2000 till December 2007. A similar programme, HATI, was funded by the Government of Bangladesh through the Health, Nutrition and Population Sector Programme (HNPSP) till the end of 2008. 2 Khan, M.I; HIV/AIDS Epidemic: Bangladesh Perspective. World AIDS Day, December 1, 2008. Report by Dr. Md. Ishaque Khan. Line Director NASP & SBTP. Published in Articles of Souvenir – 2008. Ministry of Health and Family Welfare
2 distribution, needle/syringe distribution, STI treatment and referral, referral to other services and local level advocacy. During the period HAPP/HATI has been implemented, the number of IDUs, brothel based sex workers and hotel/residence based sex workers reached by the targeted interventions increased significantly and the quality of services improved. However, the number of street based sex workers 3 reached through HAPP/HATI and other programmes may be inadequate to maintain low levels of HIV transmission. The number of clients of sex workers and MSM reached through HATI (or through other programmes) is not adequate to stop HIV transmission among these groups increasing if a critical level of HIV prevalence is reached. Given the estimated large size of the client of sex workers and MSM populations, as well as other factors, reconsideration is required of an effective prevention strategy to reach these groups.
Bangladesh is the only country in the developing world that has been successful in scaling up its public sector needle/syringe program to the stage where the majority of IDUs regularly use it to access new needles and syringes. This reflects the high strategic priority given to harm reduction and the pragmatism and urgency adopted in scaling up service provision. The rate of HIV increase among IDUs in Bangladesh is significantly slower then in comparable countries where most IDUs are not in contact with needle/syringe programs. (See chart below 4 ).
60 50 40 30 20 10
19 95 19 96 19 97 19 98 19 99 20 00 20 01 20 02 20 03 20 04 20 05 20 06 20 07
0 19 93
Percentage HIV infected
HIV Infection among IDUss
Wuxhou
3
Jakarta
Hanoi
Karachi
Dhaka
Sex Workers are also targeted through FHI managed projects and through GFATM Round 6 projects. In the 2006/07 Behavioral Surveillance Survey there was a significant increase in the number of street based and brothel based sex workers reporting consistent condom use in the last week. This may be an indication of increased service coverage across different funding streams. Because service definitions of coverage differ across different programs it is not possible to confidently assess the adequacy of coverage. 4 Dhaka infection rate applied to chart from UNAIDS. Redefining AIDS in Asia: Crafting an Effective Response .Report of the Commission on AIDS in Asia Oxford University Press. 2008 p43
3 Oversight and coordination Poor coordination between donors, government, contracting agencies and technical support agencies has been a major factor in HAPP/HATI failing to achieve its full potential. It has been the major cause of disruptions to funding provision. It has meant that problems and proposed remedial actions identified in various review missions were delayed or not implemented. It has been a blockage to sharing strategic information that could have led to earlier program improvements. Some potential synergies that could have been realized between HAPP/HATI and other programs have not occurred. A key barrier to more effective coordination has been the lack of an effective oversight structure in which all key partners including implementing agencies and affected groups participated. Arguably an oversight committee with membership of senior representatives of partner agencies that met regularly could have: - identified implementation problems on a timely basis and agreed to remedial actions and timelines; - monitored adherence to agreed actions - advocated at senior levels for further action if required Coordination between different funding streams for HIV in Bangladesh has also been an obstacle to effective programming. There is significant overlap between target populations and activities funded through HAPP/HATI; the USAID funded IMPACT/BAP implemented by FHI and the Global Fund Round six programme. Program Management Despite the negative impact of ongoing programme interruptions, particularly on planning, the management of service delivery at the central level in HAPP/HATI and management at the field level has been of a high standard. The modality of contracting implementing NGOs through consortia has worked well. Policy frameworks and monitoring procedures have focused management on priority outcomes. The HAPP/HATI teams within the UNICEF head office have had the right mix of skills for overall management coordination and support. Uncertainty regarding continuity of funding was an obstacle to further strengthening of management and ongoing planning. In each phase of HAPP/HATI it has resulted in a crisis management approach for significant periods, preoccupation about impact of break in service provision, high turnover of staff at head office and field level. This loss of institutional memory has undermined learning from past mistakes. Financial and Supplies Management Dispersal of funds was repeatedly characterized by delays which did not reflect an appropriate balance between procedures and outcome. Lack of clarity regarding financial requirements, and financial management capacity within NGO consortia has contributed to mediocre performance among some agencies at the field level in financial management.
4 Capacity Development Frequent contact by HAPP/HATI staff with implementing agencies has contributed to capacity development through problem identification and rectification. Also various workshops have been conducted on specific skill areas. However, the absence of a coordinated and strategic approach to capacity development of NGOs (within HAPP/HATI and across funding streams) has left gaps in this area. HAPP/HATI Management Implications for UNICEF Addressing HIV/AIDS programming is one of the UNICEF global priorities. The core mandate of UNICEF in this regard is overseeing the rights and welfare of children. In Bangladesh, at this point in time, reducing the impact of HIV on children will be best achieved, by maintaining low HIV prevalence. The contribution that UNICEF has made to achieve this goal through its management of targeted interventions under HAPP/HATI is commendable. HIV/AIDS Interventions for Most at Risk Groups is outside UNICEF’s usual focus of work. Regardless UNICEF has effectively marshaled its management capacity and technical expertise in contributing to successfully scaling up what is probably the only national needle/syringe exchange program in the developing world that has been successful in achieving population coverage. It has also played a critical role in scaling up the provision of services for sex workers. While high risk group interventions covered under HAPP/HATI are outside UNICEF’s usual areas of work it is believed that the results achieved in the project have directly contributed to results in UNICEF focal interest areas of preventing HIV infection in children and young people in the light of the following: - many people commence sex work or male to male sexual activity while children or adolescents - many people become injecting drug users while young - the vast majority of injecting drug users, sex workers, clients of sex workers and MSM are in the child bearing age group - service providers in Bangladesh estimate 40% of sex workers have children - most IDUs and MSM in Bangladesh have female partners and potentially (if HIV rates do not remain low) pose a significant risk of HIV transmission to them - clients of sex workers are the most likely route of transmission to women in the broader population in the early stage of any escalation in HIV - parent to child HIV transmission is most likely to occur among high risk groups Conclusion Bangladesh is one of the few countries in the developing world that has maintained low HIV prevalence through deliberate and concerted action. The maintenance of low HIV prevalence in Bangladesh has benefited by a clear and correct strategic focus, commitment by key agencies across sectors (donors, government, UN, NGOs) and the quality of support provided. Any weaknesses, recommendations and lessons learnt, identified in this report, should be read in this context.
5
1.0 BACKGROUND At the time HAPP was first funded the HIV prevalence in the general population of Bangladesh was low. However, among IDUs, prevalence was estimated at 2.5%. Experience from neighboring countries showed that HIV infection rates among IDUs can rise significantly in just a few months because of extensive sharing of needles/syringes. Furthermore, Bangladesh had a large commercial sex work industry with roughly 36,000 workers, each with estimated 3-4 clients daily. Among sex workers, STI rates were high and condom use low 5 . Progress prior to the establishment of HAPP in addressing HIV included: - establishment of a National AIDS Committee and an STD/AIDS Program Unit in the Ministry of Health and Family Welfare (MOHFW) - development of a national AIDS policy - active engagement by NGOs in HIV/AIDS activities, particularly in working with marginalized and hard-to-reach groups - funding provision by multilateral and bilateral development partners However as noted in the HAPP project appraisal document, 6 implementation of planed interventions was slow; plans needed to be prioritized; the quality of interventions needed to be strengthened; and selected components with high returns needed to be expanded. Furthermore coverage 7 of high risk groups was low, at most reaching 10%. This section describes key overall developments during the implementation of HAPP/HATI. The table below summarizes these developments. Table 1: Summary of key developments under HAPP/HATI PERIOD KEY ASPECT MAJOR DEVELOPMENTS December HAPP established but *$52.59 million allocated for HAPP with 2000 – June project implementation closing date June 2005 2003 delayed *Ministry of Health and Family Welfare to manage, coordinate and provide oversight *Les then 10% of funds spent June 2003 – Mid Term Review results *UNICEF contracted to manage High June 2005 in major restructure and Risk Group Interventions and implementation Advocacy/Communication Components accelerates *Despite significant delays most NGOs contracted and commence service delivery July 2005 to Extension of HAPP *HAPP extended for 1 year June 2006 (second phase) but *NGO disbursements delayed 5
till
World Bank. Project Appraisal Document on a Proposed Credit in the amount of SDR 30.8 million (US$40million equivalent) to the Peoples Republic of Bangladesh for an HIV/AIDS Prevention Project Report No: 21299-BD. Health, Nutrition and Population Sector Unit South Asia Region. November 17, 2000 6 Ibid p4 7 The term coverage has different meanings in various reports regarding HIV in Bangladesh. Those meanings range from the number of people who have any contact with services over a specific period of time, to the number of people receiving a minimum set of services.
6 significant interruption to November/December 2005 service delivery *Service interruptions in second half of 2005 *Loss of many experienced staff in UNICEF and NGOs due to funding uncertainty July 2006 to Extension of HAPP (third *Contract and funding dispersal delays in December phase) Improvements in second half of 2006 2007 coordination, coverage *2007 (compared to 2006) number of and quality target population reached doubled, needle/syringe distribution increased 30% and condom distribution more then doubled *Regular coordination meetings between management and implementing agencies *Operational systems, guidelines and protocols improved January UNICEF contracted to *Contract between NASP and UNICEF 2008 – continue coordination not signed till April December under HIV and Targeted *UNICEF provide funds from internal 2008 Interventions - HATI sources to NGOs for January/February Contract *Full funding dispersed to NGOs in June *Reduction in needle/syringe distribution 1st half of year, but very significant increase 2nd half *Service quality improvement systems developed and implemented *More systematic approach to capacity development adopted
1.1 December 2000 – June 2003. HAPP established but project implementation delayed. The HIV/AIDS Prevention Project in Bangladesh was first funded in December 2000, through a Development Credit Agreement between the Government of the People’s Republic of Bangladesh and the International Development Association (IDA) 8 . The project was expected to be completed by December 31, 2004 but with a closing date of June 30, 2005. In addition to $US40 million allocated through the Development Credit Agreement, the United Kingdom Department for International Development (DFID) agreed to allocate $US10 million and the Government of Bangladesh agreed to allocate $US2.59 million. The objective of HAPP was “to assist the Borrower to prevent the Human Immunodeficiency Virus (HIV) from gaining a larger foothold within high risk
8
Development Credit Agreement. (HIV/AIDS Prevention Project) between People’s Republic of Bangladesh and International development Association. Dated December 26, 2000. Credit Number 3441 BD
7 groups and limit its spread into the general population, without stigmatizing the high risk groups”. 9 The project was to be delivered through four components: - High Risk Group Interventions (Commercial Sex Workers, clients of Commercial Sex Workers, Men Having Sex With Men, and Injecting Drug Users) - Communication and Advocacy (Advocacy to key stakeholders and critical intermediaries; awareness campaigns for the general public) - Blood Safety - Project Support and Institutional Strengthening (National STD/AIDS Program management and capacity building, implementing a NGO contract management system, and providing training on interventions among High Risk Groups; as well as monitoring, evaluation and operational Research) It was intended that overall management, coordination and oversight of the project would occur through the Health and Population Sector Program (HPSP) of the Ministry of Health and Family Welfare (MOHFW) while targeted interventions would be delivered by NGOs. Arrangements for the delivery of other services (e.g. surveillance and initiatives related to Blood Safety) were not detailed. By June 2003 very little implementation had occurred. Only 7.9% of IDA funds had been disbursed and 1.3% of DFID funds spent. 10 The World Bank has attributed poor implementation to inadequate preparation and inadequate risk mitigation measures in relation to certain assumptions in project design. Specifically the World Bank notes that a strategic implementation plan was deferred to the first year of implementation but still not completed 2 years after commencement. The World Bank disputes and identifies lack of adequate risk mitigation measures regarding the following assumptions made in project design: - that contracting of NGOs could be adequately undertaken by NASP - that NASP had the capacity to implement the activities assigned to it for phase 111 The World Bank also disputes the assumption “That there was a need to rush the project through because of the "rapidly closing window of opportunity to prevent an HIV/AIDS epidemic" 12 . In retrospect, there was time to defer project implementation given that infection rates did not escalate rapidly during the initial period that implementation was meant to occur. However, given the experience of sudden and rapid escalation of HIV transmission among IDUs elsewhere in the world before and since, this was not an unreasonable assumption to be made. As discussed further in this report in section 4, an oversight committee with representation from all partners including implementing agencies and organizations representing targeted populations, could have been an effective mechanism for addressing shortcomings in the original design in a more urgent manner.
9
Ibid. World Bank. Bangladesh HIV/AIDS Prevention Project (HAPP)-Credit 3441-BD. June 2003 Mid Term Review Aide memoire.p1 11 World Bank. Implementation Completion and Results Report. Report No: ICR0000833. World Bank Human Development Unit. South Asia Region. June 2008 p3 10
12
Ibid.
8
1.2 June 2003 – June 2005 Mid Term Review results in major restructure and implementation accelerates The June 2003 World Bank led Mid Term Review made recommendations to significantly restructure the project. The most important of these were: -
contract UN agencies to manage two of the four components (UNICEF – High Risk Group Interventions and Advocacy/Communication; WHO – Blood Safety); and provide substantial support for one component (UNFPA – Project Support and Institutional Strengthening)
-
Reduce funding by 50% (given that 50% of the existing budget was unlikely to be spent)
-
Procurement of NGO services through 2 projects administered by UNICEF; (1) Procurement of NGO services (PNS) through five packages for most at risk groups (2) HIV/AIDS Intervention Fund (HAIF) for allocation of grants up to $20,000 to organizations for activities/groups not covered through PNS
The implementation of the recommendations to restructure HAPP was delayed. The selection and signing of contracts with NGOs to deliver services for high risk groups was not completed till August 2004. There were also significant delays in the placement of UNFPA consultants to assist in strengthening the NASP, and signing of the WHO blood safety contract (September 2004). In April 2005 a joint review mission reported significant progress in project implementation. Under the Procurement of NGO Services, 34 NGOs had been contracted, and 143 Drop In Centers (DICs) and 30 outreach services were operating in 46 districts in all 6 divisions of Bangladesh. Out of 1185 applications for funding through HAIF, 58 had been selected. In April 2005, 19 DICs and one treatment center for IDUs in Dhaka, operated by CARE and previously funded by DFID, were included in HAPP. It was estimated at the time that 78.53% of IDUs and between 82% and 91% of CSWs (depending on category) were being reached through interventions. The advocacy and communication component of HAPP was outsourced by UNICEF to John Hopkins University Center of Communications Programs (JHU/CCP). By April 2005, some advocacy materials had been developed, technical assistance had been provided to implementing agencies and progress was being made in the development of a communication strategy. The April 2005 Joint Review Mission Report also noted that the NASP was still not functioning adequately.
1.3 July 2005 to June 2006 Extension of HAPP (second phase) but significant interruption to service delivery Based on the progress that had been made, the late commencement of HAPP and the availability of unspent funds, the April 2005 joint review mission recommended a one year extension to the HAPP.
9 During the second phase of HAPP there were significant interruptions to service delivery. The amendments to the Cooperation Agreement for Project Support (Procurement of NGO Services) with UNICEF were not signed till 11 August, 2005. Agreements with NGOs were not signed till September/October and disbursements did not occur till November/December. While some NGOs resumed operation of DICs in September, anecdotally it is reported that the full range of services were not provided. Despite the interruptions, there were reported improvements in service delivery during the second phase. They included a significant increase in the number of needles/syringes distributed, increased advocacy at the local level and increased availability of communication materials. There were no new proposals invited in the second phase for HAIF funding. Funding for most HAIF projects was disbursed late in phase 1 and consequently implementation continued in phase 2 without a need for new disbursement. Some additional projects were selected from the original submissions and received funding during this phase. A significant level of assistance was provided by the HAPP team in developing capacity on proposal development and project implementation. It was reported by the April 2005 joint review mission that capacity building and institutional strengthening of NASP was limited. UNFPA consultants, rather than building the capacity of NASP, were largely undertaking line management functions themselves. The main achievement in communication and advocacy was the development of a National HIV and AIDS Communication Strategy. However the April 2006, Joint Review Mission described the document as not being sufficiently aligned to the need to build community support for High Risk Group Interventions. The UNICEF phase 2 completion report also highlighted the lack of effectiveness of advocacy at the local level.
1.4 July 2006 to December 2007. Extension of HAPP (third phase) Improvements in coordination, coverage and quality The HAPP project was again extended from July 1, 2006 to December 31, 2007 as recommended by the April 2006 joint review mission. The April 2006 joint review mission reported that the Management Support Agency (a body to be selected by the MOHFW to manage the contracting of NGO-delivered services) would not be operational by July 1, 2006 and consequently there would be a significant interruption to NGO service delivery. Changes and priorities recommended by the April 2006, joint review mission included: -
A clear transition plan for the transfer of HAPP to full operation under HNPSP
-
A focus on fewer but more effective interventions
-
Provision of uninterrupted and scaled up service provision for high risk groups including Male Sex Workers (MSWs) and MSM
10 -
Dropping of HAIF and inclusion of HAIF interventions for high risk groups under PNS
-
Reorientation of communication strategy with priority given to facilitating objective 1 “Provide support and services to the Priority groups” and include a key overarching objective of empowerment and involvement of the populations most at risk.
-
Establishment of a small working group for ongoing coordination to meet on a regular basis (NASP, UNICEF, UNFPA, UNAIDS, DFID, GFATM and World Bank)
-
Target clients of sex workers rather then internal migrants
A joint review mission conducted in August 2006 recommended the inclusion of prison populations as a high risk group. The August mission also recommended that funded activities be restricted to: -
Peer education
-
Condom promotion and distribution
-
DICs supported by outreach
-
STI treatment
-
Harm reduction
-
Local level advocacy
There were again major delays in contractual arrangements with UNICEF. The Project Cooperation Agreement was not signed till December 2006, and UNICEF did not sign Project Cooperation Agreements (PCAs) with consortium lead NGOs till January 2007. This resulted in a reduction in service provision and the loss of a large number of trained employees in the second half of 2006. Coordination improved at all levels during 2007. Meetings were conducted between key stakeholders. Monthly coordination meeting were held with HAPP implementing agencies. As a result guidelines to enhance service quality were developed in areas such as STIs, drug user interventions and VCT. Modifications to service delivery also resulted from better coordination. These changes included, increasing supply of STI medicines, introducing health cards for STI patients, increasing number of STI sessions, strengthening infection control procedures, STI partner management, formalizing referral mechanisms, increasing support for abscess management, facilitating self help groups, increasing supply of condoms and needle/syringes and strengthening linkages with detoxification/treatment services. Financial and performance monitoring systems were improved including monitoring through more regular visits by HAPP and NASP staff to implementing agencies.
11 During the third phase, 14 consortia with 29 national/local NGOs and 9 self help groups operated in 43 districts through 145 DICs 13 . The most impressive development during the third phase was a large increase in coverage and provision of specific services. The number of target people reached more than doubled from 2006 to 2007. Needle and syringe distribution increased by approximately 30% and condom distribution more than doubled. Through phase 3, institutional issues especially leadership, short tenure of key staff, and capacity constraints related to NASP 14 continued to affect implementation.
1.5 January 2008 – December 2008 UNICEF contracted to continue coordination under HIV and Targeted Interventions (HATI) Contract A joint review mission conducted in April/May 2007 noted that the Management Support Agency (MSA) would not be fully functional by January 2008, and recommended that the contract with UNICEF be extended for a further 18 months from January 1, 2008. MOHFW subsequently approved TORs for reengaging UNICEF for a period of twelve months to continue with the implementation of targeted interventions. The final implementation supervision mission conducted in October 2007 made the following recommendations relevant to HATI:
13
-
improve targeting, quality and coverage of interventions with high risk groups, particularly the IDUs (more regular coverage, lower peer to client ratio, build capacity of self help groups, greater involvement of target populations at all levels)
-
focus on implementing the Harm Reduction Strategy
-
proactive coordination across the 3 funding streams for targeted interventions (HAPP/HNPSP, GFATM and UNAID) including monthly coordination meetings between NASP, UNICEF, FHI and SCF-USA
-
systematic approach to capacity development
-
ensure contracting with UNICEF occurs in a timeframe that avoids interruption to service provision
-
establish mechanisms to transfer knowledge and experience from UNICEF to MSA
-
Initiate interventions with prisons and VCT
-
Increase advocacy capacity of NGOs
All data in this report unless otherwise referenced is sourced from internal HAPP/HATI management reports. 14 Bangladesh: HIV/AIDS Prevention Project (HAPP) (Cr.3441-BD). Final Implementation Supervision Mission: October 22-29, 2007 Aide-Memoire p4
12 -
Expeditious release of surveillance results; dissemination by January 2008 of results of 6th Behavioral Surveillance, 8th Serological Surveillance and size estimation of the high risk groups
The HATI agreement between UNICEF and NASP which was supposed to have been signed before end 2007 to ensure no break in service delivery was not signed till 9 April, 2008. Funding was received by UNICEF in June 2008 and disbursed to implementing agencies in June 2008. To avoid break in services provision, UNICEF provided funds from its own sources to implementing NGOs between January and February 2008. The late signing of the agreement between UNICEF and NASP in 2008 impacted on both the procurement of essential commodities and the capacity of implementing agencies to deliver services between March and July. During the first 6 months of 2008 an average of 189,116 syringes were distributed a month. This represented an approximate 33% decline on the average number of syringes distributed monthly compared to the last 4 months of 2007 (average of 283,673). After disbursement of funds mid year, the average number of syringes distributed monthly in the following 3 months was 266,835. This is an increase of approximately 41% on the average number of syringes distributed monthly, between the first 6 months of 2008 and the months of July, September and October. Systems to enhance quality of service provision were strengthened. Measures include the adoption of clear service definitions/standards, procedures to better monitor and benchmark performance against standards and better prioritization of technical support. A more systematic and participatory approach to capacity development of implementing NGOs was implemented. The priority areas focused on during the final phase of HATI were: STI management; DIC management; HIV/AIDS Counseling and Peer Education. The results of the 6th round of behavioral surveillance and 8th round of serological surveillance were not released before the end of 2008. The revision of size estimations of high risk groups had not been formally adopted before the end of 2008. There were not monthly coordination meetings across lead agencies from the three funding streams.
1.6 HAPP/HATI Documentation Project UNICEF appointed a consultant to documents the processes, achievements/outcomes and lessons learnt in managing the implementation of HIV prevention targeted interventions for high risk populations (Injecting Drug Users, Sex Workers, Clients of Sex Workers and Men who have Sex with Men/transgender) in Bangladesh under the HIV/AIDS Prevention Project (HAPP) and HIV/AIDS Targeted Interventions (HATI) project. This report is the result of that project. The project was undertaken from October 22 till December 18. The methodology used included: - documentation review - key informant interviews
13 -
NGO workshop Site visits
In addition the consultant was briefed at the start of the project by the UNICEF HIV/AIDS Specialist and members of the HATI team. They were also available for ongoing advice throughout the project and provided extensive feedback on a draft report.
2.0 GOALS AND OUTCOMES The goal of HAPP/HATI is: To prevent the Human Immunodeficiency Virus (HIV) from gaining a larger foothold within high risk groups and to limit its spread into the general population, without stigmatizing the high risk groups. The prevalence of HIV infection remains low in Bangladesh. It is estimated that between 7,500 and 12,000 people are living with HIV in the country as at end 2007. There are significantly sized high risk group populations including sex workers, IDUs and MSM. HIV infection among sex workers and MSM is still low. However among IDUs, HIV infection is increasing. There is a concentrated epidemic among specific groups of IDUs in Dhaka with recent surveys indicating prevalence of around 7% 15 . Review of the progress and achievements of HAPP/HATI, indicates the program has been instrumental in preventing HIV from gaining a larger foothold within some high risk groups and thereby limiting its spread to the wider population. The coverage and quality of programming has been sufficient to contribute to a reduction in risk behavior among Commercial Sex Workers (CSWs) sufficient to maintain low levels of HIV in the current Bangladesh context 16 . It is likely that coverage and quality of programming among IDUs has been sufficient to stop a more rapid increase in HIV 17 15
World Bank. Implementation Completion and Results Report. Report No: ICR0000833. World Bank Human Development Unit. South Asia Region. June 2008 piii 16 The current Bangladesh context is one where HIV prevalence is very low among the general population. HIV among female injecting drug users (of whom approximately 50% engage in sex work – 7th national serological surveillance study) is still relatively low. HIV is also very low among MSM, among whom the majority have sex with male CSWs and a significant number have sex with female CSWs – (Chan, P.A; Khan, O.A. Risk Factors for HIV infection in Males who have Sex with Males in Bangladesh in BMC Public Health2007 7:153). Furthermore it is also believed that until recently, travel by CSWs to higher prevalence neighbouring countries for work, and clients of sex workers (particularly in border areas) from higher prevalence neighbouring countries has not been high. Therefore the risk of CSWs becoming infected is low. However, in the near future this context could change as a result of the significant risk of a greatly accelerated increase of HIV among IDUs, unsettled political conditions in neighbouring countries and reported increase in the number of people seeking refuge in Bangladesh, and the possibility of increased incidence among MSM. The level of sex without condoms in the context of sex work, although decreasing over the HAPP/HATI period is still high. If the current context in Bangladesh changes as described, HIV could significantly increase among CSWs. 17
It is difficult in a country wide program to directly attribute reductions in risk to interventions. The underlying logic of the HIV strategy in Bangladesh is that achieving adequate coverage and quality in interventions will result in changes in risk factors. Evidence presented in this report illustrates significant increased reach among some target groups and a reduction in risk (reduced sharing of syringes, increased condom use as well as reductions in STIs).
14 although the increase is still of significant concern. Evidence shows that condom use has increased among CSWs and sharing of injecting equipment has decreased among IDUs. STI service provision among CSWs and IDUs has increased and there has been a reduction in STI rates. This has reduced biological vulnerability to HIV sexual transmission. The current reach of targeted interventions among clients of sex workers and MSM is not sufficient to attribute ongoing low rates of HIV infection. This is discussed further in section 3. The work of other agencies has also contributed to achieving the goal of HAPP/HATI. In particular, FHI and UNAIDS have provided technical support that has been instrumental in redesigning and supporting interventions as well as implementing complimentary activities. Serological and behavioral surveillance as well as some operational research undertaken by ICDDR, B has provided world class quality strategic information. There have been program design faults, gaps in service provision and mediocre quality in some areas of implementation. Under different circumstances, these difficulties may have severely undermined the achievements of HAPP/HATI to date. More importantly if they are not adequately addressed for the future, they could undermine ongoing programming and thereby result in HIV gaining a foothold among high risk groups. In order of importance these issues are: • Ensuring no gaps in the availability of funds for service delivery (through better oversight/coordination among stakeholders and longer term funding) • Ensuring adequacy of availability of condoms among sex workers and MSM, and needles/syringes among IDUs (through improvements in program design and clearer policy guidelines ensuring no disruption in service delivery) • Continuing improvement in the design and quality of interventions (through better coordination of technical inputs, strengthening of systems for ongoing quality improvement, and increased involvement of NGOs and affected populations) • Establishing coordination mechanism across different funding streams and between key actors to reduce duplication and enhance quality The following sections of this report, describe in more detail, issues that impact on the achievement of goals and outcomes in the areas of: - service delivery - oversight and coordination between stakeholders - program management - technical support and capacity development - funding and financial management - strategic information, monitoring and evaluation
2.1 Goals and Outcomes: Lessons Learnt •
Scaling up implementation should not be delayed until high quality capacity is established. Scaling up interventions targeting high risk populations to achieve adequate coverage while general population HIV prevalence is still
15 low can be a significant factor in maintaining low prevalence. The following matters should be considered in scaling up. ¾ High quality technical support in design of interventions including utilization of behavioral surveillance data can make a significant contribution to scaling up interventions. ¾ International agencies that have technical expertise in all relevant areas but especially program implementation can facilitate an urgent response to achieve significant coverage ¾ Implementation experience is an essential ingredient in capacity development. NGO capacity for implementation can be built gradually to a significantly high standard. •
The following issues need to be addressed if low prevalence among Most at Risk Populations is to be sustained: ¾ Ensuring no gaps in the availability of funds for service delivery (through better oversight/coordination among stakeholders and longer term funding) ¾ Ensuring adequacy of availability of condoms among sex workers and MSM, and needles/syringes among IDUs (through improvements in program design and clearer policy guidelines ensuring no disruption in service delivery) ¾ Continuing improvement in the design and quality of interventions (through better coordination of technical inputs, strengthening of systems for ongoing quality improvement, and increased involvement of NGOs and affected populations) ¾ Establishing coordination mechanism across different funding streams and between key actors to reduce duplication and enhance quality
3.0 SERVICE DELIVERY HAPP/HATI since its inception has delivered a package of services to high risk groups through Drop In Centers (DICs) and associated outreach. As of December 2008, there are 146 DICs where services are provided by 32 NGOs, organized into 12 consortia. The table below shows the current services provided under HATI in each package. Table 2: Service packages provided through HATI TARGET SERVICES PROVIDED (services underlined are provided POPULATION in each consortium of services) Injecting Drug Needle/Syringe exchange; condom use demonstration and Users distribution; syndromic management of STIs and referral; abscess management; health/peer education; provision and/or referral to detoxification; referral to VCCT; resting/recreation facility; crisis care shelter; prison intervention; police training;
16
Street Based Sex Workers
Hotel and Residence Based Sex Workers Brothel Based Sex Workers Clients of Workers
Sex
Men who have Sex with Men (MSM)
local level advocacy condom use demonstration and distribution; syndromic management of STIs and referral; health/peer education; counseling; resting/recreation facility; non formal education; income generating activity; local level advocacy condom use demonstration and distribution; syndromic management of STIs and referral; health/peer education; counseling; local level advocacy condom use demonstration and distribution; syndromic management of STIs and referral; health/peer education; counseling; pre schooling; local level advocacy condom use demonstration and distribution; syndromic management of STIs and referral; health/peer education; counseling; local level advocacy Health/Peer Education; syndromic management of STIs; condom use demonstration and distribution; counseling; referral; personal support; advocacy
3.1 Service Coverage Table 3 shows the estimated population group size of high risk groups used for program planning. Table 4 shows the estimated percentage of clients reached through targeted interventions. Table3: High Risk Group population size estimates Population at higher risk IDU Brothel Based Sex Workers Street Based Sex Workers Hotel/Residence Based Sex Workers Total Sex Workers Male sex workers, MSM, Hijras 18 Clients of female sex workers
18
Low range 20,000 3,600
High range 40,000 4,000
37,000
66,000
14,000
20,000
54,600
90,000
40,000
150,000
1,882,080
3,136,800
The estimated size of the MSM population is almost certainly too low. A study conducted in 2005 of men aged 18-49, showed that 17.5% had had pre or extra marital vaginal or anal sex in the last year. The study also showed 8.8% had sex with a female sex worker and 2.9% had sex with males or transgender. Based on the size of the male population in Bangladesh in this age bracket, this would indicated approximately 550,000 men aged 18-49 had sex with another man or transgender person. Study results reported in Chowdhury, M.E; Anwar I. Alam, N. et al. Assessment of sexual behaviour of men in Bangladesh: a methodological experiment. FHI and ICDDR,B Dhaka September 2006
17 Table 4: Estimated percentage of high risk groups reached through targeted interventions 19 High Risk Population 2001 2007 SBSWs Dhaka 41% 56% SBSWs Chittagong 6% 87% MSW Dhaka 42% 48% MSM Dhaka 32% 15% Rickshaw drivers Dhaka 0% 3% Truckers Dhaka 0-1% 3%
The distribution of syringes/needles and condoms has increased significantly since HAPP/HATI commenced the delivery of targeted interventions. On an annual basis the number of needles/syringes distributed has more then doubled. CHART: Estimated number of syringes distributed through Harm Reduction Programs in Bangladesh 2004 -2008 IDU syringe distribution 2004-2008
Number distributed
3,500,000 3,000,000 2,500,000 2,000,000 1,500,000 1,000,000 500,000 0 2004 2005 2006 2007 2008 Year
See appendix 5 for methodology
3.2 Quality of Services Under the HATI program a comprehensive contact is identified as a minimum service level. Definitions of comprehensive contacts are outlined in the table below. TABLE 5: Comprehensive contact definition Target Population Comprehensive Contact Sex Worker Contact at least 4 times a month Every contact includes condoms/lubricant and education 19
World Bank. Implementation Completion and Results Report. Report No: ICR0000833. World Bank Human Development Unit. South Asia Region. June 2008 piii
18
Injecting Drug User
MSM and Hijra
Clients Workers
of
Monthly STI check up Contact at least 4 times a month Every contact includes needles/syringes and education
Contact at least 4 times a month Every contact includes distribution of condoms/lubricant and education Monthly STI check up Sex Contact at least 4 times a month Every contact includes distribution of condoms/lubricant and education Quarterly STI check up
There is evidence to suggest that the quality of interventions conducted under HAPP/HATI has significantly reduced the risk of HIV transmission. Specifically: - HIV prevalence among all high risk groups except IDUs remains low - Mathematical modeling based on the delivery of needle/syringe services in Bangladesh indicates HIV rates among IDUs would have been much higher in the absence of services (the modeling based on the CARE SHAKTI project in 2000-2002 indicated that without ongoing needle/exchange the prevalence of HIV among IDUs would be 42%) 20 - STI rates among all high risk groups are declining - Condom use among all high risk groups is increasing - Sharing of injecting equipment among IDUs is declining The lack of formalized and functioning planning and coordination mechanisms between lead agencies across the programmatic response to HIV in Bangladesh is an ongoing barrier to improving the quality of services. It is most likely contributing to duplication in service provision, resulting in inefficient capacity development and use of technical support and is a barrier to evaluation. In addition to BAP, GFATM funded programs and HAPP/HATI; there are also a large number of other HIV related activities being implemented in Bangladesh. There has been debate about the quality of interventions over the HAPP/HATI period. Issues have included: - the efficacy and effectiveness of the DIC model - critical gaps in services available to clients - the competencies (e.g. peer education, HIV knowledge, STI treatment) of staff to deliver quality services – (discussed later under capacity development) - whether interventions should address broader vulnerability - the appropriateness of program design for IDUs, MSM, clients of Sex Workers, Prison populations
3.2.1 Drop in Centre Model
20
Foss, A.M. Watts, C.H. Vickerman, P. et.al Could the CARE SHAKTI intervention for injecting drug users be maintaining the low HIV prevalence in Dhaka, Bangladesh. Addiction 2007 102(1): 114-25
19 Initially there was concern regarding the DIC model of service delivery. However the provision of outreach has become an integral part of the model implemented for each package.
3.2.2 Critical gaps in Range of Services Discussion regarding the range of services has been focused on the following topics: - whether a standard package of services should be provided for each target population or a more flexible approach adopted - whether service packages should include interventions addressing issues that arguably contribute to vulnerability (e.g. employment, housing etc) - specifically among IDUs whether a much broader service package should be provided Over time HAPP/HATI has developed a standardized package of services based on evidence of best practice. It also allows comparison of performance between different agencies and investigation of significant variation. Understanding variation can contribute to improving practice. Within the context of a standard package there is scope for some flexibility (e.g. methodologies used in peer education and outreach).
3.2.3 Addressing vulnerability There has been debate in Bangladesh and internationally, regarding the role of HIV prevention strategies in addressing broader issues of vulnerability which some argue determine risk contexts. There have been some activities conducted under HAPP/HATI that address vulnerability. In targeted interventions for high risk groups, the matter of addressing issues of broader vulnerability ideally should be determined on the basis of their likely impact on short term HIV risk. HIV transmission among IDUs and MSM populations can escalate very quickly and therefore reducing risk behavior must be prioritized. However issues such as police harassment or other factors that may impede access must also be addressed. 21 Furthermore, if providing other services increases access to the target population it may be justified. It is possible within the structure of providing a standardized service package to allocate funds for pilot interventions and assess their impact through comparison with services where those interventions are not provided. Anecdotal evidence received in the process of developing this report indicated that addressing the education needs of the children of sex workers in some instances, increased the credibility of service and resulted in increased access 22 . This also
21
Local level advocacy is undertaken by all services. In addition to meetings with local leaders (including police) many services have established management/advisory structures which include local leaders. Anecdotally it is reported that these structures have significantly contributed to acceptance of services in local areas. 22 The children of sex workers at a particular brothel were being denied access to the local school related to issues of lack of identity papers and lack of pre school learning.
20 reportedly helped in local level advocacy undertaken by the service. Piloting of such interventions should be integrated into a small operations research allocation. The possibility that the rights of children of most at risk groups are being infringed more generally in accessing services is an issue of concern for UNICEF and should be investigated.
3.3 Programme Design Issues As outlined in section 3.0 a package of services has been identified for each high risk group to be delivered through Drop in Centers and outreach.
3.3.1 Injecting Drug Use Programme Design Currently both the CARE and Padakhep Consortiums (services targeted at IDUs) which include a number of other NGOs provide the following services: - Needle/Syringe exchange - Condom promotion/distribution - Peer education - Outreach - Abscess management - Resting/recreation facility - Referral to VCT and detoxification centers - Local level advocacy It has been suggested at times, that services targeting IDUs should also provide a broad range of social services as well as detoxification, drug treatment and psychosocial support. While hypothetically addressing such issues might reduce likelihood of IDUs engaging in risk practices (either reduction in injecting drug use or reduction in sharing) there is little evidence to support the effectiveness of risk reduction through such a proposition. At a policy level harm reduction needs to be seen as part of a continuum of drug services that include supply reduction, demand reduction (including treatment), and harm reduction. Appropriate referral procedures from harm reduction services to treatment services need to be in place (and in some instances collocation may be possible). However drug use needs to be seen as a chronic relapsing condition. In countries where treatment (other then substitution therapy) is readily available, most people require more then one attempt before stopping their use. Many drug users eventually stop after several attempts but other will be life long users (particularly in the absence of substitution therapy). The primary role of HIV funded services in regard to treatment programs (except for substitution therapy) for drug users should be referral to other services. There is some level of international consensus that reaching 60% of the IDU population is adequate to control HIV transmission. However as noted in a report
21 assessing targeted interventions in Bangladesh under HAPP 23 , this target should be treated with caution. It does not take account of the frequency of injecting among those reached (i.e. the effectiveness of a daily user not sharing will be far greater then a very occasional user not sharing). Furthermore it does not take account of the background prevalence of HIV in the IDU population, which is a major determinant of risk. Ensuring continuity of needle/syringe access over time and availability of equipment and geographic proximity at times IDUs are injecting is essential if sharing is to be minimized. In preparing this report, service providers noted that there are periods late in the evening and early in the morning, when equipment is not available. A rapid assessment regarding the locations and extent to which services are not available at times of significant drug injecting will be useful in shedding further light on possible gaps. Services funded under HAPP/HATI have also targeted heroin smokers. This behavior often precedes injecting drugs. Between the 5th and 6th rounds of behavioral surveillance in Bangladesh there was a significant decline in the number of heroin smokers who also injected drugs. This appears to be contrary to a view held by some opponents of needle/syringe programmes that needle/syringe programmes encourage injecting. The impact of providing such services should be further investigated in order to better assess the potential benefit of collocating services targeting IDUs and other drug users as well as contribute to the broader debate regarding the impact of needle/syringe programs on overall injecting behavior.
3.3.2 Female Sex Worker Interventions Distribution of condoms, provision of STI services, and behavior change communication (primarily through outreach and peer education) are the key interventions that were implemented under HAPP/HATI to reduce risk of HIV transmission among female sex workers. Because of difficulties related to the data, and overlap with services provided through the USAID/FHI BAP Program it is not possible to accurately ascertain gaps in service provision. However reported reductions in risk behaviors and reductions in STIs, indicate that HIV programs conducted across funding streams in Bangladesh are having some positive effect. There is a need to undertake a systematic assessment of interventions for female sex workers in Bangladesh. Although condom use has increased as has STI diagnosis and treatment, significant numbers of sex workers continue to have unsafe sex and do not use STI services. A systematic assessment would include: - qualitative research with female sex workers to identify obstacles and barriers to accessing STI services and increasing condom use - exploration of different service delivery modalities (e.g. STI outreach clinics ) to address barriers and obstacles - cost/benefit analysis of including supplementary health and other services - better understanding the potential role of self help groups 23
Bondurant, T; Azariah, S; Janssen, P. Towards a coordinated national response for Targeted Interventions in Bangladesh. A brief review and look forward. 12 November 2007 p34
22
3.3.3 Men who have Sex with Men Programme Design The size of the sex worker and IDU populations are small enough to reach through direct contact interventions (e.g. peer education). However the same may not apply to MSM and clients of sex workers. Furthermore the current reach of interventions targeted at these groups is very low. The population of MSM is diverse and can be sub divided in various ways (e.g. identity, frequency of MSM activity, sexual role etc). For the purposes of program design (based on considerations of reach, social interaction, identity and risk) it may be useful to categorize MSM in Bangladesh as gay (or otherwise identifying as homosexual), Hijra, male sex workers or not gay identified 24 . The numbers that identify as gay, Hijra or male sex workers currently are probably sufficiently small to utilize a DIC/outreach model. These groups may be the most sexually active and therefore intensive peer based interventions may be justifiable on a cost benefit basis. However, the number of people who engage in male-to-male sex who do not identify as gay, Hijra or male sex workers is much higher. Further consideration needs to be given to design of interventions to reach these men. More generally further consideration needs to be given to interventions for MSM. Identity among MSM is a fluid phenomenon at any one time and over time. There is significant overlap between the different MSM categories. Many of those who may personally identify as homosexual do not do so socially. Furthermore many MSM also have sex with women. While DIC and outreach should remain part of a package of interventions for MSM, other interventions are also needed. Patterns of sexual networking, use of internet and other matters need to be considered in design of interventions.
3.3.4 Clients of Sex Workers Programme Design The estimated number of men who are clients of sex workers in Bangladesh is too large to reach through direct contact interventions. For direct contact intervention, it may be more useful to consider other population groups who share some other identity or collective status, who at the same time are more likely to be clients of sex workers (and perhaps engage more frequently in other at risk behaviors). There is for example extensive evidence that mobile populations (e.g. truckers), other transport workers (e.g. rickshaw pullers) and Bangladeshi who are working overseas are more likely to engage in high risk behaviors. 24
It is recognized that sexual practices and identities need to be considered within specific local historical, social and cultural contexts. It has been reported that in Bangladesh, men who adopt a passive role in male to male sex generally referred to as Kothis are more likely to adopt a feminine identity and be more clearly identifiable as homosexual. However the identity that many seek may be that of a woman rather then an identity more associated with Western notions of gay. Many however argue that gay identity is becoming increasingly internationalized and adapted to local situations. Shivananda Khan provides evidence of significant variations related to identity, class, and understandings of sexual practice among men in Bangladesh who are involved in sex work. Reference: Khan, S. Through a Window Darkly: Men Who Sell Sex to Men in India and Bangladesh. Book chapter in Aggletion, P. (Ed). Men Who Sell Sex: International Perspectives on Male Prostitution and AIDS. Temple University. December 1998.
23
3.3.5 Prison Interventions The joint review mission led by the World Bank in March 2006 recommended that HAPP should begin to work with prison populations. In the period since, Padakhep has implemented some outreach activities to prison populations. However the scope and reach has been limited. In large part the limitations of work undertaken by HAPP targeted at prison populations can be attributed to the lack of an overall implementation plan for the National Harm Reduction Strategy. In comparison to the implementation of community based harm reduction services, where HAPP has a lead implementation role (and consequently is in a position to adopt a strategic approach to implementation) this is not the case with prisons. Consequently prison interventions are ad hoc and unlikely to significantly contribute to the overall strategic objective for prisons in the National Harm Reduction Strategy. The National Harm Reduction Strategy for Drug Use and HIV 2004-2010 includes as “Strategy 10: Introduce harm reduction measures into prisons that can significantly bolster preventing the transmission of HIV/AIDS in the prison community and the wider community in the interests of public health”. 25 Implementation activities proposed include: - drug detoxification - staff training - pre release programs linking inmates to services outside prisons - vocational training and education However for this to occur an implementation plan is required that: - prioritizes objectives - identifies roles and responsibilities - specifies modalities for implementation - outlines budget required - identifies capacity development and strategic information needs - outlines a monitoring and evaluation system
3.4 Service Delivery: Lessons Learnt
25
•
Under HAPP/HATI lack of data that can be compared over time has been a barrier to assessing effectiveness of interventions. Service definitions and related indicators should be carefully considered and adopted at the start of program implementation. This will help ensure effective monitoring, evaluation and quality improvement. It is recognized that learning through implementation, and further technical input over time may result in changes. In most cases some basic indicators can be maintained. E.g. number and frequency of clients receiving condoms, syringes.
•
Standardized service packages developed in the HAPP Phase 3 and implemented under HATI, are a transparent management tool to promote compliance with best practice. Standardized service packages (i.e. minimum
National AIDS/STD Programme (NASP) DGHS, MOHFW. National Harm Reduction Strategy for Drug Use and HIV 2004-2010. August 2005. p18
24 service guidelines) with flexibility to modify the methodologies of interventions (e.g. different peer education methodologies) contribute to ongoing quality improvement, monitoring and evaluation. •
The majority of MSM and clients of sex workers have not been reached through the service modality of Drop in Centers and outreach. Population size and diversity must be considered in determining service modalities for different Most at Risk sub groups. Because of large, diverse and dispersed population size, DICs and outreach are not an appropriate service modality for all MSM sub populations and clients of sex workers
•
Significant numbers of sex workers and Injecting Drug Users have been reached through HAPP/HATI. Drop in Centers (DICs) with associated outreach are an effective service modality for achieving coverage of quality services for sex workers and IDUs.
•
It has been difficult to target clients of sex workers. Lack of shared identity among clients of sex workers is a major challenge to effective targeting. Further consideration is needed of effective strategies including specifically targeting population groups who are more likely to be clients of sex workers (e.g. transport workers).
•
MSM are a diverse population group. A more comprehensive strategy is required to effectively target MSM including sub targeting of key population segments. DICs and outreach (to strengthen peer support, community empowerment and policy advocacy) are likely to be part of a more comprehensive strategy.
•
Most members of high risk groups who have been covered under HAPP/HATI are significantly socially disadvantaged and marginalized. Risk reduction must be the focus of targeted interventions among high risk groups because of the immediacy of HIV transmission risk. Vulnerability reduction where it clearly directly impacts on risk reduction (e.g. police harassment interfering with distribution of essential services) should also be part of targeted interventions. Other vulnerability interventions should be considered in the context of their likely impact on services (e.g. the provision of education services for the children of sex workers might improve service acceptability). Partnerships should be made with other funding programmes and service delivery agencies to address vulnerability among high risk groups.
•
Many IDUs who access HATI services are motivated to give up drug use. However provision of drug treatment services is very expensive and of limited effectiveness. Access to injecting equipment must be the highest priority in HIV prevention packages targeted at IDUs followed by substitution therapy. Funds should not be allocated for detoxification or drug treatment at the expense of harm reduction services. HAPP/HATI has had little success in implementing interventions in prison settings. Lack of an operational framework for the harm reduction strategy is
25 a significant obstacle to effective interventions in prison settings. Specifically in relation to prisons an implementation plan is required that: ¾ prioritizes objectives ¾ identifies roles and responsibilities ¾ specifies modalities for implementation ¾ outlines budget required ¾ identifies capacity development and strategic information needs ¾ outlines a monitoring and evaluation system
4.0 OVERSIGHT AND COORDINATION and Critical issues Documentation and reports from major stakeholders indicate that significant shortfall in the coordination between stakeholders was a major factor in HAPP/HATI failing to achieve its full potential. There were major disruptions to funding and as a result to services which were avoidable. Remedial actions identified by various joint project review missions have been delayed or not implemented. This gap has been a blockage to sharing of strategic information that could have led to concrete program improvements. It prevented potential synergies that could have been realized between HAPP/HATI and other programs from being realized. Notably, the project design document which was developed with high participation from all key stakeholders identified potential decline in Government commitment, as well as inadequate leadership and institutional capacity as being major risks to HAPP. The proposed mitigation measures were essentially the Government rectifying these identified weaknesses. The failure from the beginning to put in place an oversight structure for HAPP that met on a regular basis, has meant that the respective strengths of the various partners have not been coordinated in rectifying weaknesses. The process for identifying overall program weaknesses and recommending rectification measures has been through joint review missions led by the World Bank (Up to twice a year). Monitoring of actions recommended (and informally agreed to), usually occurs through the subsequent joint review mission. While advice provided has usually been of excellent quality (though sometimes inconsistent with previous missions), the follow up mechanism has not worked.
Critical issues: The lack of an oversight and coordination mechanism for HAPP/HATI has undermined accountability and transparency in decision making. The bilateral approach to relationships seemed to have reinforced a culture of blaming others (not at the table) for faults and gaps in programming. It has meant that priority is not given to key decision points and processes even when commitments are made (e.g. ensuring ongoing funding is in place to avoid disruption to service provision).
26 Those most affected by implementation decisions are High Risk Groups (sometimes represented by Self Help Groups - SHGs), lead agencies and implementing agencies. There was no indication that the target groups were treated as equal partners in HAPP/HATI decision making. Although there are indications that there were some consultations with these groups and their input valued, they were seldom a part of the formal decision making process. Their absence from the decision making table is believed to have contributed to poor prioritization in decision making (e.g. interruptions to critical service delivery) and what would seem like an associated lack of accountability by decision makers. In regard to other important decisions (e.g. changes to program design), their contribution while often (but not always) sought is not necessarily given sufficient regard. To some extent the lack of urgency in follow up, reflects a deeper challenge to government implementation of programs such as HIV in development contexts. Infectious diseases such as HIV (particularly when targeting populations where transmission can escalate quickly) require an urgent approach to scaling up and consistency in service provision (particularly the distribution of essential commodities) over a number of years. However the consequences, for the health system, of failing to act (massive increased demand for health services, increased expenditure) and for society as a whole are not felt till some years later. For health decision makers, the hypothetical consequences of HIV need to be balanced against urgent and immediate realities such as hospital beds not being available and patients being turned away from clinics because of staff shortages. In developing countries these issues are often compounded by longer term approaches to strengthening health systems. Many developing countries have been encouraged (and perhaps required because of funding sources) to adopt a sector wide approach. The basic rationale of sector wide approaches to avoid duplication and waste through vertical programmes, needs based prioritization and ensure core functions and related staff competencies are provided across the health system in an effective and efficient manner is commendable. However the process of developing a sector wide approach needs to be sufficiently flexible to accommodate the more urgent response often required in the area of infectious diseases. TABLE 6: Organizational strategic considerations HIV Health System Management TIME PROGRAM HORIZON SUSTAINABILITY (more then 10 years SECTOR WIDE HIV
20+ Years
Important
5-10 Years Not Important (or less)
in Sector Wide Approaches and URGENCY IN DECISION MAKING Not urgent Urgent
FLEXIBILITY IN DECISION MAKING Not very Important Important
The implementation of HAPP/HATI has required compliance with the policy, funding and performance requirements of a range of agencies, operationalization through different managements systems, and effective use of technical support from different
27 sources. The table below illustrates the key organizational decision makers in HAPP/HATI across the domains of funding, management, policy and technical input. Table 7: HAPP/HATI Organizational Inputs FUNDING POLICY MANAGEMENT TECHNICAL International International International World Bank World Bank World Bank DFID DFID DFID UNICEF UNICEF UNICEF National National National National World Bank GOB/NASP UNICEF World Bank DFID UNICEF World Bank UNICEF UNICEF World Bank DFID UNAIDS GOB/NASP GOB/NASP FHI Consortia GOB/NASP ICDDR,B
IMPLEMENTING AGENCIES Consortia, Implementing NGOs, Implementing SHGs, GOB; Other agencies Relationship between agencies in the above table are formal (e.g. agreed contractual arrangements) and informal (e.g. ad hoc meetings and processes to resolve issues/problems). Almost all formal relationships are bilateral. Those that are not generally involved few organizations. The most notable of these are joint review missions led by the World Bank, which usually includes other donors, the GOB and technical experts. Informal relationships are often bilateral. Those that have wider participation are generally ad hoc and do not have mechanisms empowered to follow up on any agreements reached.
4.1 Lessons Learnt •
HAPP/HATI did not have an oversight structured committee that included all key stakeholders. This had significant impact on quality and consistency of service delivery. Programmes involving several funding, planning and implementation partners require oversight structures/committees. All key partners should be represented including government, funders, management agencies, implementing agencies, technical support agencies, UN, affected communities. Committees should provide advice on key issues and rectification measures and monitor follow up to decisions. They should meet on a regular basis (at least four times a year). Key action points in implementation plans should be reported against at all meetings.
•
Lack of involvement of affected populations in oversight in decision making contributed to some key issues not being adequately prioritized (e.g.
28 disruption to service provision). Affected populations and implementing agencies must be included in oversight structures/ committees. •
Joint review missions have been effective in identifying weaknesses and recommending rectification measures, but have not provided an effective system for ensuring follow up implementation. An oversight committee would provide a mechanism for follow up.
•
The long term focus of sector wide approaches can be a barrier to addressing urgent organizational needs and responses that are critical for the effectiveness of HIV projects such as HAPP/HATI. Development of health system sector wide approaches needs to be sufficiently flexible to accommodate more urgent responses often required for infectious diseases. One option (used by Health Ministries in some countries to implement Global Fund Programs) is the establishment of a Program Management Unit that has a high level of operational autonomy subject to adherence to approved policies and procedures.
5.0 PROGRAM MANAGEMENT Short term funding and delays in funding disbursement have been significant obstacles to good program management. They have, at best, truncated processes and often undermined a results based approach to management 26 . A results based approach is one in which impact and outcome will be used to make changes to programs including reallocation of funding, retargeting of interventions and changing the package of services to be delivered. However the repeated need to reduce service provision, re-enter into service outlets/premises lease agreements and reestablish full service provision (three times since implementation of targeted interventions commenced in late 2004) has meant that the HAPP/HATI team in UNICEF and managers in consortia and implementing agencies have had to devote considerable amount of their time on inputs (contractual arrangements, fund disbursement etc), originally designed for longer periods to achieve outputs within a short period. Uncertainty and delays in funding resulted in high staff turnover (both at the implementing NGO and the UNICEF HAPP/HATI project team levels). This has negatively impacted on institutional memory, often resulting in failure to learn from past mistakes and lack of continuity in the building of management systems.
5.1 Program Planning, Monitoring and Evaluation The approach to planning, monitoring and evaluation has been piecemeal. There was no overall evaluation framework which clearly links assumptions and provides logical linkages between inputs, outputs, outcomes and impact over a specified time frame for implementation. Formal monitoring occurred through financial reporting and reporting against performance indicators (however definitions of indicators have 26
Rodriguez-Garcia R, Kusek J.Z; Planning and Managing for HIV Results. A Handbook. World Bank Global HIV/AIDS Program. September 2007
29 changed over the HAPP/HATI period making it difficult to compare performance over time). Monitoring also occurs through regular field visits by HAPP/HATI staff. Lack of coordination and shared monitoring systems between different funding streams (HAPP/HATI; IMPACT/BAP; GFATM), makes it difficult to attribute outputs to specific programmes. For the purpose of quality management planning and quality improvement, the need for standard service definitions (e.g. comprehensive coverage, minimum service guidelines), related monitoring processes and tools and training of agencies in their utilization has been recognized since the beginning of HAPP. However it is only during the last phase of HAPP and during HATI that major progress has been made in these areas. The lack of attention given to the basic components of management information systems has been a barrier to a results based approach to management planning 27 . The management of a programme being delivered through a large number and range of external agencies requires development, circulation and training in standard operating procedures. These procedures improve programme management in implementing interventions as well as enhance transparency and governance. Such an approach was largely absent until the latter part of HAPP and during HATI (e.g. UNICEF financial guidelines specifically adapted to HAPP were not disseminated till October 2007). A review conducted of HAPP in late 2007 noted that NGOs considered the current grant management system to be rigid and unresponsive to need. An example was given where an NGO was unable to distribute additional condoms to female sex workers because of limitations imposed through a quota. 28 Clearly under any circumstances such a restriction would be absurd (while there is some suggestion that this may have been the result of a misunderstanding, that such a misunderstanding would occur, is troubling). Again the broader observation of rigidity needs to be considered in the context of the urgency of funding disbursement (whereby revision of funding conditions was a low priority) and the need to comply with management requirements of the World Bank, UNICEF and the Government of Bangladesh. In seeking submissions from agencies for 2008, HATI provided a template that categorized activities in a manner closely aligned with models of best practice in interventions. The HATI team also consulted more with agencies in the preparation of proposals. However given the possibility of rapid changes in need, especially for condoms and needles/syringes there needs to be some flexibility in contractual agreements. Despite the weaknesses there have been improvements in management planning over the course of HAPP/HATI. Since 2004, evidence of effectiveness in targeted 27
A results based approach to planning would clearly outline the assumptions and logical links between inputs, outputs, outcomes and impact over a specified time frame for implementation. It would also clearly delineate roles and responsibilities, align capacity development and strategic information with service delivery and clearly define key decision making points and processes. 28
Bondurant, T; Azariah, S; Janssen, P. Towards a coordinated national response for Targeted Interventions in Bangladesh. A brief review and look forward. 12 November 2007
30 interventions (drawn from both international experience as well as operational research including evaluation conducted in Bangladesh) has led to improved programming as well as contracting arrangements with consortia. The results log frame adopted under HATI which consortia report against, include indicators that are clearly aligned with coverage and quality of service provision. In so far as the results log frames include common indicators across specific implementation packages (e.g. IDU, Street Based Sex Workers) as well as across all packages, they also provide a structure for ongoing quality improvement based on comparison of performance. Performance can be measured against inputs, variation identified and investigated and improvements made to interventions.
5.2 Consortium Modality The HAPP/HATI modality of contracting implementing agencies through consortia has worked well. At the program level it has reduced transaction costs, and allowed devolution of some management functions (ongoing performance and financial monitoring). Implementing agencies at a workshop in November identified the following advantages of the consortia approach: - incorporates a diversified skill base - allows sharing of different learning as well as policies and procedures - ensures certainty and transparency of project supervision - facilitates team work - builds shared responsibility and accountability - enhances the possibility of less experienced agencies participating in HAPP/HATI through capacity development - facilitates coverage across geographic areas - improves coordination - strengthens good governance - improves quality - reduces risks - improves access to technical support - creates administration efficiencies - improves advocacy through a collective voice and mutual support Issues related to funding delays (from the consortia lead agency to implementing agencies), failure to pass on information (e.g. communication between consortia lead agencies and HATI team not being passed on to implementing agencies) and decision making were also raised by agencies. Most agencies felt these issues could be resolved through greater transparency and a more participatory approach.
5.3 Management Agency/continuity plan (UNICEF) The lack of transition management plan has been a fundamental flaw contributing to the repeated interruptions in HAPP/HATI. To ensure all stakeholders are aware of
31 arrangements regarding the ongoing implementation of targeted interventions, consideration could be given to preparing a transition plan that includes: -
specific actions to be taken by the MSA in selecting and contracting organizations for the delivery of HIV targeted interventions arrangements for the procurement of essential commodities an outline of functions to be performed by NASP in managing contracted agencies an outline of functions to be performed by NASP in enhancing quality of targeted interventions actions to be taken in establishing capacity to provide management support and technical assistance to NGOs in relation to the delivery of targeted interventions (e.g. procedures for the establishment and selection of staff; arrangements for the contracting of functions)
The structure of the HAPP/HATI team within UNICEF has contributed to ongoing quality improvement within the program. The team included expertise across financial and performance management, HIV/AIDS technical content and organizational development. The relatively small size of the team has also meant that the respective competencies, in each of these skill areas have been well coordinated. It is unclear how the functions performed by the UNICEF HAPP/HATI team will be provided in the future.
5.4 Programme Management: Lessons Learnt •
Short term funding and repeated interruptions to programming undermined a results based approach to management. Implementing agencies should be contracted for a period of five years subject to performance.
•
Lack of clarity in logical assumptions linking inputs, outputs, outcomes and impact have been a barrier in the design of a useful monitoring and evaluation framework for HAPP/HATI. A results based approach is particularly important when new interventions and service delivery arrangements are being implemented. Management information systems should include standard service definitions and monitoring systems aligned with overall monitoring/evaluation plans. Where service definitions change over the course of a program, core elements should be maintained that allow comparisons over time.
•
Despite some weaknesses in program design, particularly in monitoring and evaluation, the overall quality of interventions has been good. Bangladesh has core strengths in strategic information and human resource capacity that provide strong inputs to program implementation. In future program development these strengths should be complemented with technical support in program design, particularly operational planning, monitoring and evaluation.
32 •
The quality of interventions has improved over time. The structure of the HAPP/HATI team within UNICEF has contributed to ongoing quality improvement within the program. The team has included expertise across financial and performance management, HIV/AIDS technical content and organizational development. The results log frame developed during HAPP and improved under HATI is an extremely effective tool for ongoing quality improvement. Management of a program of targeted interventions should include included expertise across financial and performance management, HIV/AIDS technical content and organizational development.
•
When funds have been available to implementing agencies, implementation has been efficient. The consortium modality of contracting a large number of implementing agencies through lead agencies has worked well. The consortium model should be maintained in ongoing programs for NGO implementation of targeted interventions.
•
Standardized service packages under HAPP/HATI have helped ensure best practice and guide programme implementation. Standardized service packages should be maintained in ongoing programs for NGO implementation of targeted interventions.
6.0 FINANCIAL MANAGEMENT The implications of short term funding, and the impact of interruptions to funding have already been discussed in this report. Any program of targeted interventions should be for duration of 5 years with no interruption to funding flow. This time frame is required to build institutional expertise in the technical content area, implement quality and sustainable service delivery systems and ensure staffing continuity. Implementing agencies selected at the commencement of the funding period should be contracted for the whole period, subject to, compliance with funding and performance agreements and mid term performance review. A programme review should occur sufficiently ahead of the completion of the five years, to determine ongoing arrangements. The table below details the delays that have occurred in program implementation. Table 8: Contracting and funding delay in implementation of HAPP/HATI Implementation period Agreement with Funds dispersed to UNICEF signed implementing agencies HAPP July 2001 till June October 2003 August 2004 Phase 1 2005 HAPP July 2005 till June August 2005 November 2005 Phase 2 2006 HAPP July 2006 till December 2006 January 2007 Phase 3 December 2007 HATI January 2008 till April 2008 June 2008 December 2008 Note:
33 1. Under the original agreement between the Government of Bangladesh and the International Development Association of the World Bank, UNICEF was not included. Following a World Bank mid term review in mid 2003, UNICEF was requested and agreed to manage two components of the original agreement (High Risk Group Interventions – comprised of Procurement of NGO services and HIV/AIDS Intervention fund 29 as well as Advocacy/Communication). Advocacy/Communication was subsequently sub contracted by UNICEF to John Hopkins University Center of Communications Programmes. 2. In January 2008 UNICEF from its own finances allocated funds to implementing agencies to continue operations for two months.
6.1 Procurement of essential commodities Procedures for procurement of essential commodities (condoms, needles/syringes, STI medicines) and other supplies have changed over the course of HAPP/HATI. Currently essential commodities and capital goods are procured by UNICEF. During the third phase of HAPP they were procured by implementing agencies. The advantages of centralized procurement are: • quality control • avoidance of corrupt practices • authority to adjust budgets if required Centralized procurement resulted in lengthy delays because of complex procedures, lack of prioritization given by procurement staff to the peculiarity of the needs of a specific program area like HAPP/HATI, inability to respond to increased needs by a specific agency and sometimes what would seem like very stringent high quality standards. Delays in the procurement of condoms and needles/syringes are detrimental to effective and uninterrupted service delivery. These supplies are crucial to procedures and services that can not be deferred. If they are not available, sex workers will have sex without condoms and IDUs will share needles/syringes. In the future, if centralized procurement of essential commodities is to be used for implementation of high risk group targeted interventions, it is very important to develop a risk management plan that identifies risks related to procurement and mitigation measures. Alternatively consideration should be given to devolving procurement of these commodities. If procurement of essential commodities is devolved to implementing agencies then some flexibility should be given to incur additional expenditure (to that budgeted) on these goods. Procedures to avoid corrupt practices and assure quality control are discussed further below.
6.2 NGO Financial Management
29
Under the HIV/AIDS Intervention Fund (HAIF) small grants up to $20,000 were provided to NGOs. Although anecdotally it is reported that HAIF resulted in increased capacity among small NGOs, it was discontinued in 2006 because of its time consuming nature and poor targeting.
34 A performance audit of the NGOs that implemented HAPP from November 2006 till December 2007 was undertaken at the end of 2007. 30 The audit which reported on the effectiveness of the financial management of NGOs involved examination of records and interviews with key staff from all implementing NGOs and 37 Drop In Centers (DICs). The audit identified a number of deficiencies in financial management by different agencies 31 . Broadly they can be grouped as follows: - procedures that could be (but not necessarily were) associated with corrupt practices by individuals (e.g. payments made against salaries in excess of entitlement as per attendance or letter of appointment) - procedures that could imply favoritism between lead agencies and partner agencies (e.g. use of different types of MOUs) - lack of transparency in staff recruitment (e.g. staff recruited without advertisement of position) - failure to comply with UNICEF financial procedures (e.g. 2 signatories being used to authorize transactions rather then 3 as required by UNICEF) - inadequate management of stocks (e.g. non maintenance of consumable stock registers) - inadequate filing of records (e.g. staff personnel files not including CVs, appointment letters etc) Four of the 12 Lead agencies do not regularly conduct an external audit. As noted in the report, UNICEF did not provide specific HAPP Financial Management Guidelines till October 2007. Until then NGOs followed generic UNICEF guidelines. It could be assumed that financial management at the implementing agency level has improved as a result of the issuing of the Financial Management Guidelines and UNICEF coordinated training for DIC managers since October 2007. In addition, the detailed investigation undertaken through the performance audit has almost certainly provided a useful tool in focusing the attention of implementing agencies on the quality of financial management expected.
6.3 Lessons Learnt •
30
The short duration of contract with implementing agencies has been the main factor in interruption to services. A national programme of targeted interventions should have five year duration. Implementing agencies should be contracted for five years, subject to compliance with financial and performance requirements and the findings of a mid term review.
Faiz, N; Chowdhury, W; Huq, M.Z; et.al Performance Audit of NGO Implemented Activities under the HIV/AIDS Prevention Project (HAPP) Final Report. Hlsp Dhaka 24 January 2008. 31 These deficiencies occurred in specific agencies. They should not be generalized to all agencies.
35 •
There was poor compliance with financial procedures among some agencies. Clear financial management guidelines for the operation of all implementing agencies strengthen compliance with financial requirements. Overall program financial management of implementing agencies should include - requirement of external audit of all lead agencies on an annual basis - regular monitoring of all implementing agencies to ensure compliance with financial and other management guidelines (possibly contracted to an external agency - provision of orientation of all new staff on an annual basis to financial management requirements of HAPP/HATI
•
Procurement of essential commodities by UNICEF created disruptions to supply and necessitated compliance with inappropriate standards. A risk management plan that identifies risks related to procurement and mitigation measures should be developed. Alternatively consideration should be given to devolving procurement of these commodities. Training and appropriate orientation to facilitate effective use of financial management guidelines for all implementing agencies and to strengthen financial accountability should be provided at program commencement.
•
7.0 CAPACITY DEVELOPMENT In the original HAPP design, capacity development of NGOs was included under component four “Project Support and Institutional Strengthening”. Institutional strengthening was primarily meant to build the capacity of the NASP to manage HAPP/HATI. Responsibility for institutional strengthening was given to UNFPA following the 2003 Mid Term Review. Throughout the HAPP/HATI period there have been disagreements between partners regarding the approach to institutional strengthening. The overall approach to capacity development of NGOs throughout HAPP/HATI has been ad hoc. It has been hampered by a lack of agreement between all key partners regarding the scope of capacity development (e.g. human resource capacity development, organizational development). There was confusion about roles and responsibilities. Priorities were inadequately defined. There was no common agreement about methodologies and approaches (e.g. generic or applied content, one off training workshops or integrated ongoing processes involving follow up and assessment of participants etc). During the HAPP period in 2004 NASP with support from UNICEF conducted a consultative process through which a draft capacity development plan for NASP was produced which also in part addressed the needs of implementing NGOs. However the Joint Review Mission conducted in October 2004 criticized the plan for among other things being too focused on human resource capacity development. 32 In 2008 a 32
Interestingly the previous World Bank led joint review mission in January 2004 in commenting (although noting that measures to avoid loss of institutional memory and capacity need to be addressed)
36 more modest capacity development planning exercise was undertaken by HATI. Needs were identified based on field visits and from secondary sources (project proposals, NGO Coordination Meeting recommendations). Confusion regarding responsibility for capacity development can be partly attributed to the transfer of responsibility from NASP for the management of all components of HAPP to the three UN agencies. UNFPA was contracted to implement the component Project Support and Institutional Strengthening which included capacity development for implementing agencies. Confusion has been further exacerbated by weak coordination structures involving different funding streams (HAPP/HATI; GFATM; BAP) each of which need to develop the capacity of the NGO sector to implement HIV activity. Regardless of the above, capacity of implementing NGOs and individual staff to implement services targeted at high risk groups has improved over the period HAPP/HATI has operated. This is reflected in increased service coverage and ongoing reductions in risk behavior. However in the absence of any systematic approach to capacity development, these improvements are most likely attributable to lessons learnt on the job through implementing HAPP/HATI for over 4 years, relatively frequent contact with HAPP/HATI staff, a pre existing skills base within the Bangladesh NGO sector, the availability of high quality technical support from international agencies and ICDDR, B and some training provided through HAPP/HATI. The approach adopted through HAPP/HATI to capacity development, has been to identify needs through observation during agency monitoring visits as well as discussion in meetings with implementing agencies and NASP. Provision of capacity development has usually occurred through workshops and direct assistance from HAPP/HATI staff. In addition, lead agencies have conducted orientation and training for partner agencies (who also in some cases have provided additional training). In some cases, NGOs have also developed capacity through observation visits to other NGOs and information sharing through local networks. Over the HAPP period workshop training was provided on: - peer education and outreach work - STI management - Local level advocacy - Use of folk and local media - Gender and Human Rights - Financial management - DIC management training - Proposal development During HATI training was provided on: - DIC Management - HIV/AIDS Counseling - Peer education on what should be included stated “the plan should include the various categories and levels of personnel who would receive training, the skills which would be acquired, the rationale for each training, the manner and other such important aspects”.
37
During the closing stage of HAPP, UNICEF organized a series of workshops with implementing agencies to develop logical frameworks for monitoring each of the 6 intervention packages (IDU, BBSWs, HRSWs, SBSWs, CSWs, and MSM/Hijras). This exercise was useful in further developing the planning and monitoring capacity of agencies. Several lead agency representatives interviewed in late 2007 noted that workshops were “generic training sessions for staff and peer educators working in all HAPP packages, although the nature and needs of the target populations differed from package to package”. 33 They also commented negatively on the timing of training which was delivered towards the end of the HAPP funding period. In summary the following conclusions can be drawn about the approach to capacity development through HAPP/HATI 1. There was no systematic assessment of the organizational and human resource needs for implementation. Even in the one occasion an attempt was made there was no implementation 2. There was no functional analysis of service provision requirements and identification of core competencies required by staff to deliver services 3. There was no assessment of shared capacity development needs across different programs (HAPP/HATI, GFATM, BAP) and attempt to develop a joint capacity development strategy and plan 4. Systematically incorporating findings from different activities of HAPP/HATI (e.g. proposal review; field visits) into an ongoing capacity development process has only happened on an ad hoc basis 5. There is an over reliance on workshops as a methodology for capacity development
7.1 Capacity Development: Lessons Learnt • ¾ ¾ ¾ ¾ ¾ •
33
A capacity development plan should be developed at program commencement based on a comprehensive assessment of human resource and organizational development needs. This should include: functional analysis of service provision requirements and identification of core competencies required by staff to deliver services prioritization of capacity development needs identification of roles and responsibilities to deliver capacity development -agreement regarding methodologies and approaches -coordination with programs provided through other funding streams in order to minimize confusion and duplication An existing generic skills base applicable to HIV should be given high priority in the selection of implementing agencies
Faiz, N; Chowdhury, W; Huq, M.Z; et.al Performance Audit of NGO Implemented Activities under the HIV/AIDS Prevention Project (HAPP) Final Report. Hlsp Dhaka 24 January 2008. p11
38 •
Learning through on the job experience should be incorporated into capacity development plans
•
Mechanisms to ensure access to high quality technical support from within and outside the program should be included in the capacity development plan
•
Regular liaison between implementing agencies and central program staff assists in identifying capacity weaknesses and providing on the job capacity development. Procedures to incorporate findings from field visits should be incorporated into capacity development plans.
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A range of capacity development methodologies should be utilized. In so far as practical, methodologies should incorporate opportunities to consolidate, strengthen and build upon learning. Mentoring and partnership arrangements should be considered as methodologies to facilitate follow up. An over reliance on one off workshops without follow up should be avoided.
8.0 TRANSITION OF HATI FROM UNICEF Management by UNICEF of the HIV and AIDS Targeted Interventions (HATI) project is due for completion at the end of December 2008. It has previously been agreed that a Management Support Agency selected by the Ministry of Health and Family Welfare will manage the contracting of NGOs to deliver targeted interventions beyond 2008. It is unclear at the time of writing this report the exact details, modalities and roles and responsibilities for transition and project management and oversight beyond. This section discusses implications and options regarding the transfer of responsibility. The staff of NASP has participated in all coordination meetings conducted by HATI with implementing agencies during 2008 and therefore have some familiarity with existing implementation arrangements. However the role of the MSA is more narrowly related to contractual arrangement and the staff has no previous involvement with HATI. This might be addressed through temporary employment or secondment to the MSA of staff previously employed under HATI. The current (HATI) contractual agreement between the Ministry of Health and Family Welfare and UNICEF covers activities in the following areas: • NGOs contracted and funds dispersed in a timely manner • Quality, comprehensiveness and coverage of the interventions enhanced • NGOs capacity increased focused on: programme management, financial management, technical issues, quality of care, gender, human rights, legal issues and monitoring • Strengthen coordination and networking with NASP, implementing agencies and other stakeholders
39
8.1 NGO contracts and funding: Implementing agencies were originally selected during phase 1 of HATI. The Government of Bangladesh called for Expressions of Interest in 2001. Approximately 550 EOIs were received. In 2003/04 UNICEF screened the EOIs to assess their capacity to implement the targeted interventions. Requests for proposals were sought from those agencies that were short listed. Following technical review, implementing agencies were selected. Contracts were extended with most of these agencies for phases 2 and 3 of HAPP. At the end of HAPP Phase 3, UNICEF sought technical proposals from existing implementing agencies for implementation under HATI. UNICEF has contractual arrangements (Project Cooperation Agreements) with 11 NGOs heading consortia consisting of 37 NGOs, self help groups and Community Based Organizations in total, to deliver HIV and AIDS targeted interventions (HATI Project). Procedures for selection of NGOs were in accordance with an agreement between UNICEF and the Government of the People’s Republic of Bangladesh Ministry of Health and Family Welfare (MOHFW) dated April 2008. The lead agencies undertaking implementation of HIV/AIDS targeted interventions through the HIV/AIDS Prevention Project (HAPP) were invited to respond to a request for proposals. The Project Cooperation Agreements cover the period from January till December 31, 2008. Transfer Arrangement: The MOHFW has contracted a Management Support Agency (MSA) to assist in the management of contractual arrangements with external agencies in the delivery of services. This will include the delivery by NGOs of HIV/AIDS targeted interventions after the transfer of responsibility for HATI. The MSA has initiated actions to recruit implementing agencies. However it is unlikely that selection and contracting can be completed till sometime into 2009 and thus continuity of service provision without disruption effective 1 January 2009 remains a concern. Continuity of service provision is the most important priority in ensuring HIV transmission does not increase during the transition period. In particular, it is essential that injecting equipment and condoms continue to be available. Any significant interruption to the supply of injecting equipment creates significant risk of a rapid escalation of HIV transmission among IDUs. Rapid escalation of HIV transmission has occurred in many part of the world While less immediate there are also other significant costs resulting from interruption to service provision. As noted by the Mid Term Review of the Bangladesh Health, Nutrition and Population Sector Program (HNPSP): “The field level consequences of loss of confidence in the NGO service provider and dispersion of the targeted community can cause irreparable harm to the project.” 34 In regard to contracts with agencies selected to implement interventions after the transition period the following recommendation of the Mid Term Review of HNPSP is noted: “To ensure continuity
34
Bangladesh Health Nutrition and Population Sector Program. Mid Term Review. March-April 2008 Draft Aide Memoire. P9/10
40 contracts must be issued to cover the entire duration of HNPSP with a clause for extension if performance is satisfactory and finances are available” 35 :
8.2 Quality assurance and Monitoring: UNICEF has engaged with other partners including NASP in the development of service frameworks (e.g. service definitions, minimum service guidelines and indicators), planning tools (e.g. local mapping processes) and IEC products. A systematic approach has been adopted by the UNICEF HATI team in integrating frameworks into contractual agreements and monitoring systems (reporting against modified logical framework). Specific trainings as well as regular liaison with implementing agencies have been used to enhance compliance with frameworks, and capacity to implement quality interventions including maximizing coverage. The overall management of the UNICEF HATI team has been well structured, and staff recruited with appropriate technical skills, to both implement the functional management requirements of contracting service delivery through NGOs as well as enhance the quality of services provided UNICEF also has entered a contract with RTM International to monitor NGO compliance with HATI Project Cooperation Agreements. RTM has been contracted to: - identify the strengths and weaknesses in reporting and recording tools and recommend measures for improvement - collect, compile, analyze and summarize the monthly programmatic and financial reports of 12 consortia - provide technical assistance to NGOs in modifying the logical framework, reporting and recording formats and indicators, if required - visit DICs, PNGOS and Lead Agencies to validate the information provided by the NGOs which include – financial, programmatic and management reports - arrange dissemination event with all the partner NGOs, NASP, UNICEF and other stakeholders Transfer arrangement: As previously mentioned there seems to be lack of clarity on how these aspects of the project will be addressed. It is necessary that appropriate staff be designated to undertake similar functions to those currently performed by HATI staff. However this may require a management and functional analysis (similar to one undertaken in 2007) in order to develop job descriptions and determine management line responsibility. Lead time for staff recruitment procedures needs to be factored into the planning.
35
Bangladesh Health Nutrition and Population Sector Program. Mid Term Review. March-April 2008 Draft Aide Memoire. P14
41 There are no obvious obstacles to adopting/adapting the systems, policies and procedures used by HATI in enhancing the quality of interventions. Responsibility for technical support and capacity development could be contracted out. This could be to an agency that has the technical capacity across the HATI intervention areas, as well as expertise in capacity development. Where such an agency has capacity gaps, sub contracts could be entered into. To ensure an integrated and sustained approach, it is preferable to contract one umbrella agency rather then enter into numerous contracts. The type of monitoring agency arrangement with RTM currently in place could continue during the interim period.
8.3 Supply and procurement: Current situation: UNICEF procures essential commodities (e.g. condoms, needles/syringes, STI medicines) for distribution by NGOs as per the details explained earlier in this document. All essential commodities until the end of 2008 had been procured and delivered to all lead implementing NGOs. Transfer Arrangements There is no obvious plan in place to ensure that essential supplies are in place at service delivery points effective 1 January 2009. It is crucial that a plan be put in place urgently to ensure supplies do not run out.
8.4 Programme Management Capacity Current Situation There are regular meetings with NASP, and NASP participates in joint monitoring visits and NGO coordination meetings. As discussed above there is ongoing liaison with implementing agencies and meetings between implementing agencies. As discussed in this report coordination between all stakeholders on a multi lateral basis remains inadequate. The UNICEF HATI team has integrated management capacity development into all stages of program management. Technical assistance in identifying capacity gaps and remedial action was provided to NGOs in developing project proposals, and training has been made available to implementing agencies. Regular monitoring visits have facilitated ongoing assessment of management and capacity gaps and identification of opportunities for remedial action. The development of individual log frames for each consortium has been an extremely valuable management tool for building an outcome orientation in the management approach of agencies. Reviewing progress against the log frames at regular NGO Coordination meetings allows agencies to benchmark their performance, thereby engaging in a quality improvement management system. The involvement of NASP in monitoring visits had leant legitimacy to government ownership of the project.
42
Transfer Arrangements Coordination and networking between stakeholders is not an immediate priority for the purpose of transitioning HATI. However it is perhaps the most important factor over time in enhancing the effectiveness of specific programs such as HATI as well as the overall effectiveness of the Bangladesh response to HIV. The involvement of NASP as the government body with ultimate oversight for the targeted interventions in participating in joint monitoring visits and NGO coordination meetings is believed to be useful for management continuity. There are no obvious obstacles to the continuation of this approach.
9.0 IMPLICATIONS FOR UNICEF UNICEF primarily as an Agency with the mandate of overseeing the fulfillment of rights and overseeing the welfare of Children has a significant part to play in HIV and AIDS responses. Millions of Children all over the world are affected by HIV and AIDS but the extent of this in Bangladesh is currently unknown. The HIV status of parents directly affects children and thus the role that UNICEF had played in the management of HAPP/HATI which is believed to have contributed to maintaining HIV low prevalence in Bangladesh in effect has benefited children. However, the focus of the HAPP/HATI project on High Risk Groups is not a usual area of work for UNICEF. Therefore the contribution of UNICEF in this area is commendable. Managing the HAPP/HATI has been a challenging experience for UNICEF. UNICEF has management strengths and capacity to mobilize technical support that is often lacking among other partners in developing countries. This is the key reason UNICEF Bangladesh Country Office became involved in HAPP/HATI. It is unlikely that HAPP/HATI will be the last time that UNICEF is called upon in Bangladesh or elsewhere to provide assistance outside its core areas of focus. For this reason it is useful to reflect on the experience of UNICEF in managing the HAPP/HATI project.
9.1 Core Mandate: Minimizing the impact of HIV on children The Asian Epidemic Model posits that the most effective HIV prevention strategy in low prevalence countries in Asia, is to focus on those population groups most at risk and likely to be a bridge for transmission to the wider community. This model is now broadly accepted across the HIV sector. In Bangladesh, as in many parts of Asia, those populations are injecting drug users, commercial sex workers, clients of sex workers and men who have sex with men. Ultimately, reducing the impact of HIV on children will be best achieved, by maintaining low HIV prevalence. For this reason alone, UNICEF’s involvement in HAPP/HATI has been consistent with its core mandate.
43 Furthermore, involvement in HAPP/HATI is consistent with Key Result Area 3 of UNICEF’s Medium Term Strategic Plan of reduced adolescent risk to HIV/AIDS. Adolescents are part of the communities most at risk of HIV. Most women commence sex work while still adolescents and it is estimated that approximately 40% of sex workers have children. Many injecting drug users are adolescents. Also injecting drug users have children. Those young people who are sex workers or injecting drug users are often among the most marginalized of a country’s youth. Most MSM, commence male to male sex while still young. In many countries, particularly where male to male sex is highly stigmatized, young MSM are more likely to become infected because of ignorance about risk. In addition the majority of MSM also have sex with women and therefore pose a higher risk of HIV infection to the broader community and particularly to young women in the Child Bearing as many of them move on to the marriage phase of their lives. The majority of high risk populations are in the child bearing age range and the risk of parent to child transmission is higher then in the general population. If low rates of HIV are not maintained in these population groups, their children will also be the first to suffer the other impacts of HIV at the family level. (E.g. discrimination, loss of parents etc). The figure below shows the likely percentage of HIV infections that can be prevented among young people in high risk groups compared to the general population of young people 36 .
36
UNAIDS. Redefining AIDS in Asia: Crafting an Effective Response .Report of the Commission on AIDS in Asia Oxford University Press. 2008
44
9.2 Management systems UNICEF’s management systems have been effective in enabling HAPP/HATI implementation, but at times been an obstacle to timely implementation especially the delivery of essential commodities. UNICEF systems and the confidence in those by other key stakeholders enabled agreements with the government and donors, the establishment of a team within UNICEF to manage HAPP/HATI, contracting arrangements with implementing partners, performance and financial monitoring and procurement of essential commodities. Over time the performance monitoring system that has been developed by UNICEF for the HAPP/HATI has improved significantly. In particular the log frame in use provides information that facilitates a result based approach to planning and management. It clearly reflects the logical links between inputs, outputs and outcomes. As such it not only serves the purpose of monitoring and evaluation, but would be a useful learning and planning tool for implementing agencies. UNICEF’s procurement procedures were not particularly responsive to the needs of HAPP/HATI. While procurement by UNICEF ensures quality of goods, the system was not sufficiently flexible to respond to changes in utilization patterns (which can change quickly). This was a major problem in a program like HAPP/HATI where access to needles/syringes and condoms are essential to adopt safe practices and have to be available at all times. In regard to some other goods the quality standards of
45 UNICEF which had to be adhered to may be inappropriate for the context in which they are being used. (e.g. examination beds too large for space available). As an international agency the need for approval from international headquarters can also be a management obstacle. While this is essential and appreciated it was obvious that significant amount of time was taken by this process. The trade off between time and quality did not seem to have been taken into account. These delays had significant impact on the service delivery and timing.
9.3 Exit Strategy Initially UNICEF’s involvement in managing the HAPP project was contractually agreed to end in June 2005. However a no cost extension was agreed to until June 30 2006. Thereafter, another phase of HAPP was agreed until December 2007. Finally, UNICEF agreed to implement HATI till the end of DECEMBER 2008. The ongoing need to implement targeted interventions and lack of longer term planning has placed UNICEF in an unenviable position. The contractual agreement for HATI states UNICEF’s responsibility for facilitating a smooth transition of the project. It is possible, but by no means certain, that had a transition plan been developed and all the parties (donors, government and UNICEF) participated in an oversight committee for HAPP/HATI a smooth transition may have occurred and the frequent interruptions to the program been avoided. The lack of an oversight body for HAPP/HATI, that met regularly, was discussed earlier in this report. In particular, attention was drawn to the bilateral nature of key relationships regarding HAPP/HATI where responsibility for cause of failure can always be attributed elsewhere. Furthermore the lack of opportunity for target groups and implementing agencies to participate with other partners in project oversight meant that those most affected by program decisions had no forum to advocate for the interests of the population they serve.
9.4 Lessons Learnt •
UNICEF Bangladesh Country Office has generic high quality management capacities which most likely are replicated in some other UNICEF country offices. Where there is an urgent need to implement national programmes that impact on its core mandate but are outside its usual areas of work UNICEF should consider the possibility of involvement. However such consideration should be subject to appropriate oversight structures involving government, funders, implementing agencies and affected populations. It should also be subject to an agreed exit strategy within a specified timeframe that incorporates arrangements for transition of management responsibility to another agency
•
The capacity of UNICEF to manage large scale NGO service procurement was well demonstrated. The experience of managing HAPP/HATI has provided lessons for UNICEF (as documented in this report) that can further enhance that capacity. The lessons learnt from HAPP/HATI should be
46 reviewed when UNICEF undertakes other projects involving procurement of NGO services. •
Without necessarily working directly with Children, by working to reduce infection among High Risk Populations, UNICEF can make significant contribution to a achieving its broader vision of preventing HIV infection and burden among children. UNICEF should build on the partnerships it has developed through HAPP/HATI in addressing the impact of HIV transmission among MARPs on its broader HIV mandate. Opportunities range from advocating for measures to reduce HIV risk among MARPs to working with agencies to incorporate services for the children of MARPs.
•
The centralized procurement systems of UNICEF can be problematic in managing supply of essential commodities in an often rapidly changing context. A risk assessment should be undertaken where this is the case and risk mitigation measures adopted.
•
UNICEF’s bilateral approach to formal relationships with donors, governments and other key partners can be an obstacle to effective programmes oversight. Oversight committees involving all key partners should be established when implementing large and complex programs.
•
There are various risks in undertaking the management of any major project. A significant risk in undertaking responsibility for HAPP/HATI has been interruption to service provision at the end of the contract period. A risk assessment which identifies risks and mitigations measures should be undertaken by UNICEF before initially committing to a management role in large and complex programs.
47
Appendix 1 Terms of Reference To assist UNICEF in documenting the processes, achievements/outcomes and lessons learnt of the HAPP/HATI project with emphasis on: • Measure project goals versus achievement • NGO selection and contracting process • Channeling of fund • Capacity building of NGOs • Financial implementation and monitoring • Programme implementation and monitoring • Co-ordination with other stakeholders • Issues that needs to be addressed to facilitate the effective hand over of the project by UNICEF • Good practices and lessons learnt that could inform future UNICEF Bangladesh Country Office HIV/AIDS programming Through:
Conducting a review of available relevant program document and interviews/consultations with relevant UNICEF staff and partners and producing a report that outlines the above plus experience of UNICEF.
End product/ deliverable: Comprehensive report of HAPP/HATI project processes and implementation, outcomes, achievements, constrains, lessons learnt, good practices and issues to address to facilitate a smooth project hand over and good practices and lessons learnt that could inform future UNICEF Bangladesh Country Office HIV/AIDS programming
48
Appendix 2 List of people consulted Dr. Md. Ishaque Khan Dr. Ferdous Alam Shibib Dr. Md. Hanif Uddin Dr. Hasan Mahmud Dan Odallo Rokhsana Reza Misti McDowell K.S.M. Tarique Khondkar Taufiq Alhosainy Tasnim Azim Nafisa Lira Huq ATTENDED IMPEMENTING PARTNERS WORKSHOP Md. Khaza Mohiuddin Lovelu Md. Sayeedur Rahman Md. Shah Alam Sarder Md. Belayet Hossain Mead Md. Shahadat Hossain Md. Shariful Islam Pinky Sikdar Dr. Sk. Motiur Rahman Md. Shahin Al Mamun M. A. Majid Md. Abul Kalam Azad Md. Sadikur Rahman Nasima Begum Babul Adhikary Hassam Imam Shaon Akhtaruzzamen S P Chowdhury Nitai kanti Das S. M. Rezaul Islam Md. Elias Fakir Md. Waziullah Patwary Shaheda Wahab Afroza Akhter Monju Monowar Hossain M. S. Mukti Dr. Md. Abul Khair Md. Shamsad Kabir Rahima Sultana Kazal Md. Abul Bashar Tabussum Ara Rina Abdul Momin Shafiqul Islam
Line Director, NASP Program Manager NASP Deputy Program Manager NASP Deputy Program Manager NASP UNAIDS Country Director Consultant M/E UNAIDS Country Director, FHI Senior Program Officer, FHI Program Officer, FHI Director HIV/AIDS Programme, ICDDR,B Assistant Scientist, ICDDR,B
Project Officer; JJS Team Leader; Padakhep Consortium Team Leader; BRAC Team Leader; VARD Project Manager; USS Executive Director; JJKS President; BHS Team Leader CDS Project Manager BHS Executive Director; Hilaishi Bd Acting Project Manager; Prova Raj Monitoring/Evaluation Officer; VHSS Project Officer; PSKP Team leader; DORP Team leader; HASAB Team Leader PSTC Project Coordinator; PSTC Team Leader; PSTC Team Leader; BSWS Project Officer; ODPUP Team Leader; PIACT Project Coordinator; Nari Unnayo Shakti Executive Director; KMSS Executive Director; SAS Executive Director; Mukto Akash-B General Manager; MSCS Project Manager; SHSP Executive Director; AVAS Executive Director; APOSH Project Manager; Nuri Maitree Project Manager; Nan Unnayashahsti AFO; DNS
49 Tarikul Islam Sayeeda Sukhami Golam Tareque Ali Hossain Dr. Selina Ferdous Nafisa Lina Huq Mohammed Hafijul Islam
Executive Director; ACLAB Director; ORA Officer; Lighthouse Project Officer; SAS Barisal Team leader; Care Assistant Scientist; ICDDR,B Project Officer; HASAB
Street Based Sex Workers
Injecting Drug Users
Appendix 3 List of Implementing Agencies - Activities and Geographical Coverage Lead NGO
Consortium Members/ Partner NGOs
Major Activities
CARE Bangladesh
• Marie Stopes Clinic Society (MSCS) • APOSH • Light House • JJKS • PROYAS • PROVA
Padakhep Manabik Unnayan Kendra
• RRC (Rural Research Center) • Moytree Bangladesh • SAS • KMSS
DORP (Development Organization of the Rural Poor)
• Nari Maitree • NUS (Nari Unnayan Shakti) • ACLAB
• STI management • Condom promotion • Needle/Syringe Exchange • Abscess Management • Resting/recreation facility • Crisis care shelter • Mobile harm reduction and STI Services • Referral to VCCT and Detox • Training to police • Local level advocacy • STI management • Condom promotion • Needle/syringe Exchange • Abscess Management • Resting/recreation facility • Detox camp • Prison intervention • Peer education • Local level advocacy • Condom promotion • STI management • Peer education • Health education • Resting/recreation facility • Local level advocacy
PIACT (Program for Introduction and Adoption of Contraceptive Technology)
(none)
• • • • • • • • •
Condom promotion STI management Peer education Health ed / counseling Non-formal education Income generating activity Outreach folk performance Resting/recreation facility Local level advocacy
Geographical Coverage Divisions Dhaka, Rajshahi, Sylhet, Chittagong
Barisal, Khulna
Barisal, Chittagong, Sylhet
Dhaka, Rajshahi, Khulna
50 Lead NGO
Consortium Members/ Partner NGOs
• AVAS • Light House • ORA (Organization for Rural Advancement)
• • • • •
Condom promotion STI management Peer education Health ed / counseling Local level advocacy
Chittagong Rajshahi, Barisal, Khulna, Dhaka
VARD (Voluntary Association for Rural Development)
• CRIS • AID (Association for Integrated Development)
• • • • •
Condom promotion STI management Peer education Health ed / counseling Local level advocacy
Sylhet, Chittagong (Comilla only)
HASAB (HIV/AIDS and SDT Alliance Bangladesh)
• JJS • PSKP
• • • • •
Condom promotion STI management Peer education Health ed / counseling Local level advocacy
Dhaka, Rajshahi, Khulna
BRAC (Bangladesh Rural Advancement Committee)
• NUS (Nari Unnayan Shakti) • VHSS (Voluntary Health Services Society) • Hitaishi Bangladesh
• • • • •
Condom promotion STI management Peer education Health ed / counseling Local level advocacy
Sylhet, Barisal, Chittagong
BSWS
• ODPUP • SAS • Light House
• • • • • • • • • • • •
DIC centre Social interaction Sexual health education Condom promotion Counseling Clinical services \ Referral services Outreach Peer education Condom promotion Personal support Referral to DIC Advocacy Awareness raising STI service Other DIC services
Barisal, Rajshahi, Chittagong Dhaka Khulna
Brothel Based Sex Workers
Condom promotion STI management Peer education Health ed / counseling Pre-schooling at brothel Local level advocacy
Hotel and Residence Based Sex Workers
• • • • • •
CDS (Center Development Services)
Clients of Sex workers
Geographical Coverage Divisions Dhaka, Barisal (8 brothels) Khulna (6 brothels)
• ICDDR,B • CHCP (Community Health Care Project) • PSTC (Population Services and Training Center)
BWHC (Bangladesh Women’s Health Coalition)
Men Having Sex with Men (3)
Major Activities
for
• Badhan Shongha
Hijra
No partner
• • •
Dhaka Corporation
City
51 Lead NGO
Consortium Members/ Partner NGOs
HASAB
No partner
Major Activities
• Social mapping • Outreach activities through peer educators • Recreational education • STI through PNS-DIC and referral
Geographical Coverage Divisions Dhaka (Mymensingh only)
52
53
Appendix 4 Situation Assessment and Programme Design At the time the HAPP was designed the prevalence of HIV in Bangladesh was believed to be still low. At the end of 1999, only 126 HIV cases had been notified 37 . However the actual number was believed to be much higher. While the prevalence of HIV was believed to be low, many of the factors associated with rapid increases in other Asian countries were present in Bangladesh. There was a large commercial sex industry involving an estimated 36,000 commercial sex workers (CSWs). Among CSWs condom use was low and STI rates were high. There was a significant injecting drug use population – estimated at the time to number 12,000- among whom HIV prevalence was already believed to have reached 2.5%. Clients of CSWs (estimated to number 700,000) and Men who have Sex with Men (MSM) were also identified as high risk groups. Other key risk factors were a largely unscreened blood supply and travel to and from neighboring countries with much higher HIV prevalence 38 . In the eight years since the HAPP was designed, HIV prevalence has remained low in the general population and among commercial sex workers. There has been a reduction in estimated prevalence of STIs among CSWs. However among IDUs estimated HIV prevalence has risen significantly and has reached epidemic proportions in some parts of Dhaka. The population size estimates of high risk groups have also increased. This is largely a result of methodological improvements rather then an actual increase in population sizes. There is also some evidence to suggest a reduction in risk behaviors among CSWs, clients of CSWs and IDUs. However the reduction of needle sharing among IDUs has not been linear. It is reported that needle sharing among IDUs has increased during periods when needle exchange services were not provided. HAPP Project Design The design of HAPP drew upon lessons learnt internationally, and an assessment of implementation options in Bangladesh. Overall strategic considerations based on international experience were: - early aggressive prevention is the most effective strategy because of the high speed of HIV transmission
37
Ministry of Health and Family Welfare. Bangladesh Country Profile on HIV and AIDS. National AIDS/STD Programme (NASP) p17 38 World Bank. Project Appraisal Document on a Proposed Credit in the amount of SDR 30.8 million (US$40million equivalent) to the Peoples Republic of Bangladesh for an HIV/AIDS Prevention Project Report No: 21299-BD. Health, Nutrition and Population Sector Unit South Asia Region. November 17, 2000 p3
54 -
-
Intervention among poor and marginalized groups at high risk of becoming infected is the most effective way to reduce transmission at the early stages of an epidemic Targeted interventions need to be coupled with broader based advocacy and awareness to prevent discrimination that would prevent behavior change Identifying and reaching risk behavior groups remains difficult Advocacy and coordination among various sectors, including the private sector, needs to be developed 39
Lessons from Bangladesh included: - interventions need to remove constraints to safe behavior - social factors (e.g. violence, migration) affect HIV/AIDS prevention - existing NGO efforts in reproductive health have paved the way for STD and HIV work by establishing strong relationships with local people - HPSP will be used to ensure HIV/AIDS prevention is an integral part of the health sector - Experience from the Bangladesh Integrated Nutrition Project and the National Nutrition Project shows that, by developing adequate contracting and sub contracting mechanisms, NGOs can be effective partners in implementation of large scale programs. 40 The project appraisal document also identified that about 50 NGOs were already actively engaged in HIV/AIDS related activities, particularly in working with marginalized and hard- to- reach risk groups. However it was noted “implementation of the existing plans has been very slow; the plans need to be prioritized; the quality of interventions needs to be strengthened; and selected components with high returns need to be expanded”. 41 Based on the above assessment, the key project directions identified were: • Scale up behavioral change activities and health promotion interventions for high risk behaviors and vulnerable groups, seeking to achieve a high coverage of high risk populations; • Expand advocacy and awareness efforts for the population at large • Promote social acceptability of condom use and ensure adequate supply and access • create an enabling environment • strengthen GOB capacity for program planning, implementation, monitoring and evaluation 39
World Bank Project Appraisal Document on a Proposed Credit in the amount of SDR 30.8 Million ($US40.0 Million Equivalent) to the People’s Republic of Bangladesh for an HIV/AIDS Prevention Project. Report No: 21299-BD. World Bank. Health, Nutrition and Population Sector Unit South Asia Region. November 17, 2000 p14 40 World Bank Project Appraisal Document on a Proposed Credit in the amount of SDR 30.8 Million ($US40.0 Million Equivalent) to the People’s Republic of Bangladesh for an HIV/AIDS Prevention Project. Report No: 21299-BD. World Bank. Health, Nutrition and Population Sector Unit South Asia Region. November 17, 2000 p14 41
World Bank Project Appraisal Document on a Proposed Credit in the amount of SDR 30.8 Million ($US40.0 Million Equivalent) to the People’s Republic of Bangladesh for an HIV/AIDS Prevention Project. Report No:21299-BD. World Bank. Health, Nutrition and Population Sector Unit South Asia Region. November 17, 2000 p4
55 • •
promote NGO capacity for program planning, implementation, monitoring and evaluation Strengthen mechanisms for collaboration and coordination within and between Government, the non-government sector, development partner agencies, and other stakeholders
In promoting behavioral change among high risk populations, the project appraisal document stated that NGOs would be able “to include some activities which address socio-economic constraints”. 42 It was claimed that in some contexts this is necessary for targeted populations to adopt safer behavior. The project appraisal document identified a need for expanded advocacy and awareness effort for the population at large to help create and enabling environment as well as addressing “groups at risk of contracting and spreading the infection, such as adolescents”. 43 Operationally it was intended that HAPP would be implemented as a private/public sector initiative. Overall project coordination and oversight would occur through the Directorate General of Health Services of the Ministry of Health with the STD/AIDS Program Unit as the implementing body. Delivery of services aimed at high risk groups, some communications and awareness raising campaigns for the general public, and selected monitoring and evaluation activities would be contracted to the NGO and/or the private-for-profit sector. Support for surveillance, operational research, and independent monitoring would be sought from the International Centre for Diarrhoeal Diseases Research, Bangladesh (ICDDR,B) Institute of Epidemiology and Disease Control Research (IEDCR) and other independent agencies. It was intended that within the Ministry of Health, HAPP project cycle management procedures such as annual operational planning, financial management and reporting, and performance reviews would be synchronized with HPSP processes and procedures. During year 1 of HAPP, the scaling up of programs among high risk groups by a selected number of experienced NGOs with a proven track record, and selection of other NGOs was to occur. Other activities undertaken in year 1 largely related to the design, preparation and/or piloting of awareness and communication activities as well as the blood safety and monitoring/evaluation components. Full implementation of project activities was to occur from year 2. The project design identified the following critical risks as substantial (S), modest (M) or high (H) in the project design: • inadequate scaling up (M) 42
World Bank Project Appraisal Document on a Proposed Credit in the amount of SDR 30.8 Million ($US40.0 Million Equivalent) to the People’s Republic of Bangladesh for an HIV/AIDS Prevention Project. Report No:21299-BD. World Bank. Health, Nutrition and Population Sector Unit South Asia Region. November 17, 2000 p22 43 World Bank Project Appraisal Document on a Proposed Credit in the amount of SDR 30.8 Million ($US40.0 Million Equivalent) to the People’s Republic of Bangladesh for an HIV/AIDS Prevention Project. Report No:21299-BD. World Bank. Health, Nutrition and Population Sector Unit South Asia Region. November 17, 2000 p13
56 • • • • • • • • • • •
program not effective in modifying behavior (M) decline in Government commitment (S) reach adversely affected through repressive measures by GOB (M) inadequate leadership, institutional and management capacity in the STD/AIDS Unit, coupled with frequent changes of management and key staff (H) delays in operationalizing GOB/NGO collaboration (H) insufficient NGO capacity (S) sector wide approach of HPSP undermined (M) weak procurement capacity (S) weak financial management (S) inadequate capacity re surveillance (M) delay in project preparation in Year1 (M)
Risk mitigation measures were also identified. The following table lists those risks that eventually delayed implementation and resulted in significant changes to project design following the mid term review in 2003. Table: Critical Risks, Rating and Risk Mitigation Measure 44 Risk Rating Risk Mitigation Measure Inadequate leadership, H MOHFW to staff regular positions in the institutional and STD/AIDS Unit with competent officials, management capacity in the and guarantee their continuity for the STD/AIDS Unit, coupled duration of the project. TA for the STD/AIDS with frequent changes of Unit in four areas is in place already. management and key staff Delays in operationalising H To mitigate this risk, GOB would complete GOB/NGO collaboration detailed Strategic Implementation Plan (SIP) completed by October 31,2001, including clearly defined eligibility criteria for NGO proposals; a transparent and efficient mechanism for contracting out of services to NGOs for Years 2,3 and 4 agreed on and established. Initially, GOB may use UNAID’s assistance in developing a list of appropriate NGOs. Project preparation in would M The project identifies clear time-bound not be completed during benchmarks. Year1 of project implementation REPORT OF THE COMMISSION ON AIDS IN ASIA In June 2006, an independent commission was appointed to undertake a comprehensive review of HIV/AIDS in Asia. The commission presented its report to 44
World Bank Project Appraisal Document on a Proposed Credit in the amount of SDR 30.8 Million ($US40.0 Million Equivalent) to the People’s Republic of Bangladesh for an HIV/AIDS Prevention Project. Report No:21299-BD. World Bank. Health, Nutrition and Population Sector Unit South Asia Region. November 17, 2000 pp. 25,26
57 the UN Secretary General in March 2008. The key findings of the report were consistent with the strategic directions adopted by HAPP in Bangladesh, almost 8 years earlier. The report noted: Although the epidemics vary considerably from country to country, they share important characteristics, namely that they are centered mainly around: unprotected paid sex, the sharing of contaminated needles and syringes by injecting drug users, and unprotected sex between men 45 . The reports recommendations on prevention included: Prevention programmes must focus on interventions that have been shown to work and that can reduce the maximum number of new HIV infections. Governments can do the following: • Facilitate and support the introduction of integrated, comprehensive harmreduction programmes that provide a full range of services to reduce HIV transmission in drug injectors: The harm reduction package should include needle-exchange, drug substitution, and condom use components, as well as referral services (for HIV testing and antiretroviral treatment). • Increase the consistent use of condoms during paid sex: More sex work interventions based on peer education should be introduced and scaled up. • Reduce HIV transmission among men who buy sex: clients of sex workers must be a central focus of HIV prevention programmes in Asia. To reach clients of sex workers, HIV education and services (such as treatment for sexually transmitted infections, and condom promotion) should be provided in work settings that tend to be associated with demand for sex work • Reduce HIV transmission during sex between men • Protect wives of men who buy sex, inject drugs or have sex with other men: High-quality operational research is needed to improve HIV interventions aimed at reaching those women who are likely to be exposed to HIV by their husbands. • Reproductive health services should be used as an entry point to increase women’s access to HIV prevention, testing, and referral services. Improvements in the accessibility and quality of antenatal care and institutional delivery are needed to improve access to HIV (as well as other health care) services. The recommendations of the Commission were based upon analysis of epidemiological patterns of HIV infection in Asia, behavioral studies, specially commissioned research and costing studies. The following section presents some of the figures and tables in the report particularly relevant to the current situation in Bangladesh. HIV among can escalate rapidly once a critical level of infection is established.
45
UNAIDS. Redefining AIDS in Asia: Crafting an Effective Response .Report of the Commission on AIDS in Asia Oxford University Press. 2008. p2.
58 The following figure illustrates the increase in HIV infection among IDUs in some cities where there was no significant level of needle and syringe distribution service provided. The level of HIV infection among IDUs in Dhaka has been superimposed on the figure included in the report. In each of the cities apart from Dhaka the prevalence of HIV among IDUs escalated quickly once the prevalence of HIV among IDUs passed 2%. By the time HIV prevalence passed 2% among IDUs in Dhaka (2003) a needle and syringe distribution program was well established with a significant number of IDUs receiving needles and syringes. Distribution has more then doubled since then. This is most likely the reason prevalence has increased at a much slower pace then in other cities.
60 50 40 30 20 10
19 95 19 96 19 97 19 98 19 99 20 00 20 01 20 02 20 03 20 04 20 05 20 06 20 07
0
19 93
Percentage HIV infected
HIV Infection among IDUss
Wuxhou
Jakarta
Hanoi
Karachi
Dhaka
HIV prevalence escalates among IDUS before increasing among Sex workers. Many female injecting drug users are sex workers. Many male IDUs are clients of sex workers. In the 2006 Bangladesh Behavioral Surveillance study, 66.4% of male IDUs reported buying sex from female sex workers in the past year. The following figure show increased HIV prevalence among female sex workers in Jakarta after high prevalence was established among IDUs.
59
Male clients of sex workers are a key bridging population to the wider community. The following table models the spread from sex work to the wider community. In Bangladesh the round six behavioral survey reported that the mean number of clients per week for female sex workers was as follows: - Brothel based sex workers (national)19 - Street based sex workers (Dhaka) 13.8 - Hotel based sex workers (Dhaka) 42 Just fewer than 10 % of Bangladeshi men are reported to have bought sex in the past year. This would place Bangladesh between the yellow and green lines in the figure below.
60
The HIV epidemic model is different in Asia to elsewhere in the world. Never married women in Asia are much less likely to have sexual intercourse then elsewhere in the world. Consequently HIV first becomes established among groups at greater risk (IDUS, sex workers, MSM) before spreading to the sexual partners of these groups.
61
Appendix 5 Syringe and Needle Distribution
Estimated number of syringes distributed to IDUs in Bangladesh Syringes Total Syringes distributed Distributed Through HIV IDU programs By CARE 1998 143,929 1999 664,662 2000 961,235 2001 908,644 2002 463,297 2003 813,364 2004 Q1 285205 245639 234085 252183 1017112 2005Qtr1 20673 Qtr 2 176596 Qtr3 187142 Qtr 4 241530 Total 781535 Est. 930,026 1011002 Est. 1,203,092 2006 qtr1 377,426 390,826 310,950 239,178 Total 1318380 Est. 1,568,8722 2007 (i) 345260 Est. 410,859 475456 Est. 565,792 Est. 649,123 Est. 851,018 Total Est. 2,476,792 2008 Qtr 1 514409 597,667 510025 664,529 642281 800,807 (i)
Because of reporting inconsistencies, an estimate has been made of total syringes distributed annually and for the first two quarters of 2007. CARE and Padakhep are the two agencies distributing needles and syringes. Based on other data it is estimated that Padakhep distributes approximately 19% of the total number of syringes. From July 2007 actual reported syringe distribution for both CARE and Padakhep is included. (ii) The information by quarter for 2007 has been adjusted as follows: - Quarter 3 is June, July and August 2007 - In Quarter 4. 1,134, 691 syringes were distributed; the number in the table is averaged out to provide a three month estimate for comparison purposes.
62 (iii)
In 2005 CARE was first funded through HAPP. Previously it was funded through DFID. It is believed that the number of syringes distributed, reported to HAPP does not include syringes purchased through remaining DFID funds. The higher number of syringes distributed in 2005 by CARE, is sourced from the following report commissioned by CARE. CARE Bangladesh. Drug Users at Risk to HIV Documenting our Experience 2000-2005 June 2006 p21 (iii) An estimated total for 2008 is 2,863,810. This estimate is based on a final quarter estimate of 800,807 (the same as quarter 3). The actual number is likely to be higher, given the increase across quarters to date in 2008.
