SANIGEST INTERNACIONAL S.A. Lucia Kossarova June 6, 2007

1. Regional Capacity Assessment in the HIV/AIDS Area in Eastern Europe and the Commonwealth of Independent States - UNDP Regional CenterBratislava, Slovak Republic SANIGEST INTERNACIONAL S.A. Lucia Kossarova June 6, 2007

2. General Objectives of the Project • Methodology • Main Findings and Recommendations • Regional • Country Specific • Lessons Learned • Next Steps

3. Regional Capacity Assessment • Regional Challenges • Lack of Multi-sectoral approaches linking different stakeholders & coord. • Lack of approaches looking at short-term and long-term horizon • Major increase in resources available (Global Fund, WB, Gov.) • Weak/variable health systems and implementation capacity • Regional Capacity Assessment • 5 Countries • Stand-alone methodology and tool • Policy recommendations at country • and regional level • Follow-on projects? + • UNDP Mandate • HIV/AIDS and Human Development • Governance of the HIV/AIDS Response

4. Project Objective and Results • Objective: • Systematic analysis of capacity requirements to meet the long-term needs for organization and management of the thematic area of HIV/AIDS in Eastern Europe and the Commonwealth of Independent States (CIS). Capacity constraints should be identified at 3 levels: i) Enabling Environment; ii) HIV/AIDS Thematic Level; iii) Organizational Level • Results: • Analysis of needs for short and long-term capacity building in individual countries • Regional recommendations • Tested methodology with assessment tools for the three levels of assessment

5. General Objectives of the Project • Methodology • Main Findings and Recommendations • Regional • Country Specific • Lessons Learned • Next Steps

6. Who should use this methodology? • Internal planning purposes for international aid agencies • Policymakers and program planners • Other relevant decision makers • Key governmental civil servants and technical staff responsible for implementing the HIV/AIDS program • NGOs and civil society organizations • Researchers who may be seeking particular tools to study institutional/organizational needs

7. Key Requirements • Key requirements for a successful capacity assessment: • A coherent conceptual framework • Appropriate empirical and analytic methods • Capacity to carry out the analysis • Buy-in and participation by responsible local authorities • Recognition of the need for continuous adjustment based on national realities • Solid level of organization to carry out day-to-day work • Partial or full utilization of methodology and tools, depending on local conditions

8. Conceptual Framework

9. Desirable Outcomes and Gap Analysis

10. Rapid Assessment and Response Approach • Requirements of the methodology for the current task: • Speed • Cost-effectiveness • Practical relevance to intervention and problem solving • Use of existing information and reports • Multiple methods and data sources • Use of a combination of hypothesis testing and inductive approaches • Adequacy for public health response • Multi-level analysis • Reliability, validity, and triangulation

11. Method Overview

12. Quantification of the Questionnaire • Scores do not have an absolute meaning but may be used for relative comparisons WITHIN the country

13. General Objectives of the Project • Methodology • Main Findings and Recommendations • Regional • Country Specific • Lessons Learned • Next Steps

14. General Objectives of the Project • Methodology • Main Findings and Recommendations • Regional • Country Specific • Lessons Learned • Next Steps

15. Regional Findings – Common Challenges and Achievements • Achievements: • Dramatic expansion in access to ART (GFATM) • All countries have adopted the Three One’s principle (except Russia which still significantly lags behind) • Great advances by all in w/respect to policy frameworks and improving the main legislation relating to AIDS and the corresponding risk groups • Except in Croatia, epidemic is mainly being fueled by sharing contaminated equipment. All the countries (excluding where there is no harm reduction) have embraced the principle that the potential double harm of injecting opiates and HIV, Hepatitis C/B infection can be reduced by courageous policies (most successful Croatia-methadone countrywide) • Availability of laboratory testing is up to par

16. Regional Findings – Common Challenges and Achievements • Challenges: • Need to encourage more PLHIV to come forward and seek ART - GIPA • Slowest progress in the M&E area (except in Croatia and Moldova) • Not enough emphasis on changing the traditional surveillance methods by adopting 2nd generation surveillance • Although some progress, there still is a great deal of stigma, discrimination and intolerance both by the general public as well as by the medical profession and police towards PLHIV, MSM, SWs, and IDUs • Confidentiality of test results and the HIV positive status of PLHIV remains an issue in all countries • Law enforcement; inclusion of components related to the HIV/AIDS law within the university curriculum and educational/training campaigns aimed at law-enforcement institutions essential • All countries (except perhaps Moldova) some negative experiences with mass media • All countries have improved their involvement of NGOs working on prevention. In Croatia and Kyrgyzstan, active NGOs are functioning relatively well, but there are still not enough to meet the demand for an effective HIV/AIDS response. In Tajikistan, Russia, and to a lesser extent Moldova, the NGO sector remains very weak • Poor economic status of several of the countries: a significant brain drain and corruption • There is not enough proper pre- and post-test counseling • Officials in Tajikistan and Russia are still receiving objections from various interest groups to introducing methadone, despite scientific evidence in its favor

17. Regional Recommendations • Political Commitment • Highest level of political leadership essential to maintain high level of commitment • High level commitment should include a public recognition of the need to support vulnerable groups and help encourage them to seek services, as well as to reduce the level of public stigma surrounding these groups • Financial Resources • In the medium-long term, sustainable way of funding of HIV/AIDS must be identified (finance more affordable activities first; select most appropriate ARV, regional purchasing, health tax on cigarettes/alcohol; expand current insurance schemes) • Prevention • Plan and fund a national communication framework consolidating all IEC efforts • Strengthen capacity of NGOs and expand their activities especially among vulnerable groups • Scale-up harm reduction activities • Treatment and Care • Understand lack of access to ART and scale-up • Monitoring the Epidemic • Support the concept of and provide resources for a single M&E system as well as continue improving and expanding 2nd generation surveillance

18. General Objectives of the Project • Methodology • Main Findings and Recommendations • Regional • Country Specific • Lessons Learned • Next Steps

19. MOLDOVA – Main Findings • Enabling environment level: • Positive aspects: civil society groups and the government provide training on harm reduction at the local level; the recognition of vulnerable groups (IDUs, SWs, MSM, mobile populations, orphans, and pregnant women); and the existence of the necessary support from Parliament in order to approve the legislation to strengthen the HIV/AIDS response in the country • Challenges: influence of the Orthodox Church on political decisions related to the National Response; the existence of taboos and social prejudices which create the grounds for discrimination of people at risk and PLHIV; overdependence of the civil society on donors; absence of an all encompassing system of National HIV/AIDS Accounts; significant issues with regard to illegal drug trafficking and human resource needs. • HIV/AIDS thematic area level: • Positive aspects: existence of anti-discriminatory laws; the implementation of a harm reduction program; the existence of an operational CCM and its recognition by all stakeholders as an open forum for making decisions • Challenges: enforcement of anti-discriminatory laws; the implementation of serious prevention among MSM and SW; the universality of access to VCT services; appropriate access to knowledge and information; and the way in which the government addresses the situation facing the break away region of Transnistria.

20. MOLDOVA - Overview of Scores

21. MOLDOVA – Recommendations – Enabling Env. Level

22. MOLDOVA – Recommendations – HIV/AIDS Thematic L.

23. TAJIKISTAN – Summary Findings • Enabling environment level: • Positive aspects: necessary laws in place, including human rights laws; gradual involvement of ministries besides the MoH; and less police interference with harm reduction activities • Challenges: real ownership of the HIV/AIDS response by the government; strong reliance on donors both technically and financially; overall lack of coordination among donors; prevailing stigma and discrimination against PLHIV and vulnerable groups (especially MSM) by the general population, police, and health care staff; gender inequality; severe issue of drug trafficking; overall lack of governmental support for NGOs; absence of substitution therapies; and a general shortage of qualified HR to work with HIV/AIDS patients • HIV/AIDS thematic area level: • Positive aspects: basic legal framework in place; Three Ones principle is being implemented • Challenges: law enforcement is lacking; PLHIV are not sufficiently involved in policy and decision making; weak capacity of the health care system with respect to surveillance, prevention, VCT, treatment uptake, and rehabilitation and social services for IDUs; prevention of MTCT and blood safety is not ensured; while the general population and the non-health care sectors are aware of HIV/AIDS, they largely lack the appropriate knowledge about the ways to prevent transmission; there is a general lack of openness in policy development and decision making

24. TAJIKISTAN - Overview of Scores

25. TAJIKISTAN – Recommendations - Enabling Env. Level

26. TAJIKISTAN – Recommendations - HIV/AIDS Thematic L.

27. KYRGYZSTAN – Summary Findings • Enabling environment level: • Positive aspects: improved political leadership where government officials speak publicly about HIV/AIDS; necessary human rights laws in place; private sector represented in the CMCC; NGOs working relatively well; substitution therapy available • Challenges: over-reliance on donors; lack of financial support of NGOs; prevailing stigma and discrimination against vulnerable groups (MSM) and PLHIV by the general population, police, and health care staff; and gender stereotypes which create problems for women to exercise their rights; severe issue w/drug trafficking; and qualified HR needed to work with HIV/AIDS patients • HIV/AIDS thematic area level: • Positive aspects: legal framework in place; Three Ones principle is being implemented with solid coordination and a promising M&E unit • Challenges: weakenforcement of human rights and anti-discriminatory laws; lack of transparency; weak capacity of the health care system with respect to surveillance, prevention, VCT, treatment coverage, and rehabilitation and social services for IDUs; while general awareness of the existence of the epidemic, there are still many misconceptions and taboos regarding modes of transmission and vulnerable groups

28. KYRGYZSTAN - Overview of Scores

29. KYRGYZSTAN – Recommendations - Enabling Env. Level

30. KYRGYZSTAN – Recommendations - HIV/AIDS Thematic L.

31. RUSSIA – Summary Findings • Enabling environment level: • Positive aspects: improved political leadership and donor coordination; financial resources increasing; involvement of the Russian Orthodox Church in the response; no longer financial or technical dependence on donors; slow but increasing involvement of the private sector in HIV/AIDS prevention activities • Challenges: exclusive ownership of the HIV/AIDS issues by the MoHSD; stigma and discrimination against PLHIV and vulnerable groups by the general population, police and health care staff; lack of recognition of the civil society and NGOs by the government as equal partners; continuing drug problem; absence of substitution therapies; and lack of qualified HR to work with HIV/AIDS patients • HIV/AIDS thematic area level: • Positive aspects: basic legal framework in place; a high proportion of the Russian citizens tested for HIV; awareness of HIV/AIDS in society is slowly improving • Challenges: law enforcement; implementation of Three Ones lacking in nearly all areas; weak capacity of the public health system to respond to the increasing demand for treatment; insufficient access to information, prevention, VCT, and to palliative care for PLHIV, as well as rehabilitation and reintegration programs for IDUs

32. RUSSIA - Recommendations for UNDP • Strengthen organizational capacity of NGOs’ (service delivery) • Set up a broad forum, linked to the proposed High Level Commission on HIV/AIDS , to discuss controversial policies and programs (e.g. substitution therapy) at the professional level based on international experiences • Assist in the setting up the High Level Commission on HIV/AIDS with a single policy framework agreed by all stakeholders through several key activities

33. General Objectives of the Project • Methodology • Main Findings and Recommendations • Regional • Country Specific • Lessons Learned

34. Lessons Learned • Buy-in for the assessment is essential from all counterparts. In the case of Russia, not only UNDP but all the UN agencies • Sufficient involvement of the focal point in the HIV/AIDS area and his/her access to most of the relevant documents • A binominal questionnaire could not be implemented • One standard questionnaire for all stakeholders was most suitable • Adjustments in the calculation of the score were necessary • The questions that appear under each section have been revised after every single country visit with a team of HIV/AIDS experts with the aim to have questions that are • Simple but not plain (both for the interviewer and the interviewee) • Without a double meaning • Equally easy to understand in different countries which are at different stages of development • Precise in asking what is meant to be asked • Consistent in respecting the people being interviewed • Sensitive conditions – application of topic guide instead of questionnaire

35. Lessons Learned • In some countries the questionnaire proved to be difficult to use because the questions were too general and similar assessments have already been carried out. Therefore, the scoring exercise was not applied either (Russia). • Balance between external and local consultants • Meet with 1 representative of the organization or if more people, clarify who will be the principal person answering the questions and how the others should participate. • Usefulness of the organizational level assessment as a case study. In future assessments, it may prove valuable to have several in depth organizational assessments • The assessment was carried out in the capital city only but can equally be carried out in one/all region/s

36. General Objectives of the Project • Methodology • Main Findings and Recommendations • Regional • Country Specific • Lessons Learned • Next Steps

37. Next Steps – Use of Methodology and Findings • Advocacy tool in itself • Review recommendations with country stakeholders and take necessary follow up actions/projects: SHORT vs. LONG term • Carry out the same capacity assessment in other countries • Adapt capacity assessment to the specific needs of a country and conduct it periodically to enable countries to assess and monitor their performance over time, with regards to several elements within the enabling environment and HIV/AIDS thematic area • Adapt capacity assessment methodology and tools to allow international agencies/stakeholders monitor and evaluate their activities in the area of HIV/AIDS at the different levels (enabling, HIV/AIDS thematic) and their contribution to the country HIV/AIDS response

38. THANK YOU FOR YOUR ATTENTION

39. CROATIA (Pilot) - Main Findings • Focus on accession to the EU; Croatia will no longer be eligible for donor support but government will take on the full costs of ART • However, a major concern about preventive activities and provision of counseling and psycho-social services, which have been provided under the GFATM project • Significant progress in decrease of overall drug trafficking since the war • Considerable shortage of high quality HR in the MOHSW and a general lack of public health specialists • Capacity of HIV/AIDS specific NGOs is low • Laws relating to HIV/AIDS are minimal; public health laws which also cover HIV/AIDS, confidentiality and anti-discriminatory laws need amendments and some new laws should be created to protect PLHIV • Growing negative influence of the church on prevention messages relating to safer sex and condom promotion • Challenge to obtain more accurate nationally representative data, and with respect to HIV/AIDS research findings, to ensure better coordination and compatibility • Overall, given the small epidemic in Croatia, the current response is sufficient but there is no strategic approach to HIV/AIDS

40. CROATIA (Pilot) – Recommendations