Republic of the Philippines Philippine National AIDS Council Mid-Term Review Report – Fourth AIDS Medium Term Plan 2005-2010 December 2008 Mid-Term Assessment of AIDS Medium Term Plan IV AAcckknnoowwlleeddggeemmeenntt The review team members wish to express their sincere thanks and gratitude to the Government of Philippines and in particular, the members of the Philippines National AIDS Council and Secretariat for making possible this mid-term review. Throughout the review, the PNAC Secretariat worked tirelessly to make sure all aspects of the review proceeded smoothly and to provide the team with any help and guidance needed along the way. The review team consisted of major players within the national AIDS program like PNAC Secretariat, Department of Health, National AIDS and STI Prevention and Control Program, National Epidemiology Center, UNAIDS, WHO and the Tropical Disease Foundation. Similarly, representatives of implementing partner organisations took time to present their programme activities, provide thoughtful answers to the review team’s questions, and in some cases to facilitate and accommodate visits to activity sites. Special thanks to the Technical Support Facility, South East Asia and Pacific without whose support this review would not have happened. This midterm review would not have been completed without the full cooperation and invaluable insights of all concerned. Dr Angela Chaudhuri Team Leader Swasti- Health Resource Center Technical Support Facility- South East Asia and Pacific 2 | P a g e Mid-Term Assessment of AIDS Medium Term Plan IV List of abbreviations AMTP AIDS Medium Term Plan ARV Anti-retroviral drugs CRIS Country Response Information System CHED Commission of Higher Education DDB Dangerous Drugs Board DOH Department of Health DOLE Department of Labor and Employment GIPA Greater involvement of persons with HIV and AIDS HACT HIV AIDS Core Teams HRG High Risk Group IDU/s Injecting drug users IHBSS Integrated HIV Behavioral Serologic Surveillance LAC Local AIDS Council LGU Local Government Unit MARP/s Most-at-Risk Population/s MDG/s Millennium Development Goals MSM/s Males having sex with Males MTPDP Medium Term Philippine Development Plan NASPCP National AIDS STI Prevention and Control Program NEC National Epidemiology Center NEDA National Economic and Development Authority NGOs Non-Government Organizations NHSSS National HIV and AIDS Sentinel Surveillance System OFW Overseas Filipino Worker OSY Out-of-School Youth PIP/s People in prostitution PLHIV/s People Living with HIV PNAC Philippine National AIDS Council RA 8504 Republic Act 8504, The Philippine AIDS Prevention and Control Act of 1998 SHC Social Hygiene Clinic SSESS Sentinel STI Etiologic Surveillance System STI Sexually Transmitted Infections UNGASS UN General Assembly Special Session on HIV and AIDS VCT Voluntary Counselling and Testing 3 | P a g e Mid-Term Assessment of AIDS Medium Term Plan IV Table of contents Acknowledgement ........................................................................................... 2 1 Executive Summary ....................................................................... 5 2 Introduction .................................................................................... 7 2.1 Background .................................................................................... 7 2.2 Objectives and Scope of the review ............................................... 7 2.3 Assessment Framework .................................................................. 8 2.4 Guiding Principles ........................................................................ 10 2.5 Methodology ................................................................................ 10 2.6 Factors Affecting Assessment ...................................................... 12 2.7 Team ............................................................................................. 12 3 Findings ....................................................................................... 14 3.1 Situation and Context ................................................................... 14 3.2 The Plan and its Relevance ........................................................... 21 3.3 Program progress .......................................................................... 23 3.4 Inhibitory Factors ......................................................................... 29 4 Recommendations and Ways Forward ........................................ 35 4.1 Program Design and Strategy ....................................................... 35 4.2 Systems Strengthening ................................................................. 37 5 Moving Forward .......................................................................... 39 6 Annexures .................................................................................... 40 6.1 Annex A: Terms of Reference ...................................................... 40 6.2 Annex B: List of Review Team Members .................................... 44 6.3 Annex C: Evaluation Framework and Tools ................................ 45 6.4 Annex D: Inception Report .......................................................... 56 6.5 Annex E: Actions taken against recommendations of the AMTP III review ...................................................................................... 72 6.6 Annex F: Program Progress.......................................................... 74  4 | P a g e Mid-Term Assessment of AIDS Medium Term Plan IV 11 EExxeeccuuttiivvee SSuummmmaarryy T he AIDS Medium Term Plan IV of the Philippines was conceptualized and prepared through a robust and wide consultative process which was inclusive of civil society, different agencies of the government, multi lateral and bilateral agencies as well as corporates. The period of this plan is from 2005 to 2010. The Philippine National AIDS Council is responsible for overseeing the program implementation plan of the country. In this regard, the PNAC commissioned a mid term assessment of the plan in order to draw lessons from the first half of the plan, and to apply these in the second half of the plan i.e. 2009 and 2010. The assessment will also look into the performance of the council, and suggest improvements for the same. Broadly the plan addresses the drivers of the epidemic, the trend of the epidemic and how they have been able to cap the increasing trend of HIV, to a limited extent. The country has indeed identified the focal points of the epidemic, and has programs in place to address these populations. However, the scale of programs has been far from sufficient. The current prevalence, although low, has proved to be a deterrent towards accessing or gaining funds for HIV interventions. Local initiatives show a mixed response. Where there is funding from external donors like Global Fund, it seems there is impetus to push for adoption of a local AIDS council. Success stories are seen in areas where there seems to be an external push to the programs and high levels of advocacy with the Local Government Units. There have been examples of functioning LACs without Global Fund grants, however these are few. Local response has been plagued with issues of opposing political and religious views as well as an insufficient budget. The sustainability of the local response also seems to hinge on a few well meaning dedicated individuals rather than a systemic or institutional model of sustainability. The financial requirement for 2007 and 2008 is about Php 849 million (UNGASS 2008). Given the average total spending of about Php 311 million per year, there is a funding gap of about Php227 million or Php113.5 million per year. There are contributions from external agencies like Global Fund through its two rounds for HIV (Round 5 and Round 6), however these are insufficient. The national budgetary commitments are insufficient, although a precise amount has been difficult to determine, since unit costings were not available. The Philippines National AIDS Council is responsible for policy making and overseeing the program. Therefore, its performance is critical to outputs and outcomes of the program. The multi- sectoral dimensions of the council have led credence to the value of multi- pronged multi- dimensional nature of the national HIV program. However, there have been several issues that have plagued the PNAC, particularly, the slow decision- making processes of the council. The acceleration needed for the national program has largely remained unachieved because of this very reason. 5 | P a g e Mid-Term Assessment of AIDS Medium Term Plan IV Areas that need focus for the next two years include geographical mapping of the ‘Most at risk’ populations, since it seems, from the assessment, that the numbers have been by and large under-estimated. Unit costing and costing guidelines need to be defined, so as to be able to plan appropriately for the program and estimate the funding gaps. There have been a couple of capacity assessments done for the PNAC. Both the assessments have similar and sound recommendations for improved functioning of the PNAC, and these needs to be followed up strongly. Program areas that need strengthening include nuancing and categorization of migrant workers, the program monitoring and evaluation systems, packaging the services as an essential package of services along with operational guidelines. In summary, the national HIV response has managed to maintain the low prevalence of the epidemic and now needs to focus on enhancing and improving the quality of the programs on ground, enhanced speed of direction and policy making, as well as institutional strengthening- both locally and national- in order to make the necessary impact. 6 | P a g e Mid-Term Assessment of AIDS Medium Term Plan IV 22 IInnttrroodduuccttiioonn 2.1 Background The Philippine National AIDS Council (PNAC) was created in 1992 by Executive Order No. 39 as an advisory body to the Office of the President on all matters related to AIDS. It was reconstituted by virtue of Republic Act 8504 as the central advisory, planning and policy making body on the prevention and control of HIV and AIDS in the country. Made up of 26 members from the government, civil society and organization of people living with HIV, the Council envisions a fully empowered national coordinating body where different individuals and sectors work in partnership to prevent the transmission of the virus and lessen its impact on the affected persons in particular and society in general. The national response to the AIDS epidemic of the country is embodied in the AIDS Medium Term Plan IV (2005-2010). The goal of the AMTP IV is to prevent further spread of HIV infection and reduce the impact of AIDS on individuals, families, and communities. It is articulated in more detailed form, with corresponding resource requirements, in the Operational Plan (2007-2008). Under the leadership of PNAC, both documents came about after a series of consultations with various stakeholders. The Operational Plan reflects priority activities that need to be accomplished before 2010 by the AMTP IV. The mid-term assessment of the 4th AIDS Medium Term Plan (AMTP IV), due in 2008, was endorsed by the PNAC during its plenary in April 2007. The PNAC Secretariat approached the Technical Support Facility of the South East Asia Pacific for funding and technical support to lead the assessment. TSF-SEAP approached Swasti- a health resource center for this purpose. This is the mid term assessment report of the AIDS Medium Term Plan IV of the Philippines. 2.2 Objectives and Scope of the review A Mid-Term Assessment of AMTP IV is being conducted in order to review achievements and lessons from the first half of the program, so as to inform the second half of the program and provide guidance towards the development of a subsequent medium term plan. The primary purpose of this assessment is to determine the AMTP IV accomplishments to date, the status of achieving its targets, the relevance and adequacy of current strategies, and to develop recommendations to address identified data and response gaps. In the same manner, good practices and successful strategies will be highlighted in this assessment. Further, the mid-term assessment will determine how the AMTP IV responds to international and regional commitments like Global Campaign Unite for Children, Unite against AIDS, Millennium Development Goal (MDG) and Association of Southeast Asian Nation (ASEAN) Declaration, principles and framework like the “Three Ones” and “Universal Access” and other new international guidance, and how to incorporate these. Finally the findings of this 7 | P a g e Mid-Term Assessment of AIDS Medium Term Plan IV assessment will provide or guide PNAC in the conduct of the end-term assessment of AMTP IV in 2010. The period assessed includes 2005 to 2008 (June). The outputs of the Assessment include: 1. Evaluation Framework and Tools (attached as annexure to the report) 2. Inception Report (attached as annexure to the report) 3. Assessment Report, with key recommendations for the second phase of AMTP IV 2.3 Assessment Framework According to the Terms of Reference, the review looks at the AMTP IV for relevance, appropriateness, responsiveness, extent of coverage and quality with respect to implementation of the country program. The review also assesses PNAC’s performance and effectiveness of governance, partnerships and leadership in the context of implementing the AMTP IV. The assessment framework provides a lens for assessment, a structure for analysis and reporting, with a perspective for future action. The framework structures the issues and questions as indicators that can be gauged during the assessment. It also identifies the range of documents to be reviewed and key informants to be interviewed for each question. This framework is an important part of the assessment process and not an end-product and has been finalized along with the assessment team and presented to various key stakeholders. 8 | P a g e Mid-Term Assessment of AIDS Medium Term Plan IV Conceptual Framework for Mid Term Assessment: AIDS Medium Term Plan IV Objectives - Take stock of HIV & AIDS situation and responses (Policy and strategies) - Assessment of the performance of PNAC (Outputs, processes and outcomes) - Assessment of the governance, leadership and partnerships required for an effective response Context Analysis Structures and Resources - Status and trend of epidemic - Financial Adequacy, efficiencies - Dynamics of HIV/ AIDS in the - Human Resources: numbers, country capacities - Responses to trend ( policy, - Institutional structures strategies), - Systems efficiency and - Global Commitments, responses responsiveness inalowprevalentsettings Governance, Leadership and PROGRAM PERFORMANCE Partnerships - Outcomes and outputs - Key stakeholders, roles - Strategies and activities - Level of involvement - Capacities and resource - Quality of partnerships allocation - Style of Leadership, - Financial effeciency effectiveness - Need and reach of program and - Partnerships and roles withni services PNAC Governance mechanisms ASSESSMENT Innovative Ideas Experiences emerging from and Good similar contexts Practices RECOMMENDATIONS Program focus, strategies Delivery structures,systems Prioritisation based on and partnerships epidemic and resources 9 | P a g e Mid-Term Assessment of AIDS Medium Term Plan IV 2.4 Guiding Principles Guiding Principles used in the assessment include: 1. Driven on country’s needs 2. Participatory in nature, including field level implementers 3. Appreciative enquiry 4. Collective learning approach 5. Data collection based on standardized methodologies 6. Tools developed collectively in consultation with assessment team which included key staff at the PNAC, National Epidemiology Center (NEC), UNAIDS and Department of Health (DOH). 7. Criteria for site selection - nine sites, proposed 8. Differentiation of information-- fact and perception 2.5 Methodology The assessment framework provides a basis for development of interview questions. By matching questions to sources of data from framework tables, respondents or documents, the review team prepared interview guides for specific individuals and organisations such as Focal Point for surveillance (NEC), Program Director of National AIDS and STD Control Program (NASCP), local chief executives, and other key informants etc. The review methodology comprises a mix of site visits and observation, telephone and face-to-face interviews, discussion groups, desk-based research and review of existing reports and secondary data. 2.5.1 Methods Document review against structured checklist These were used to help analyse the content of key documents such as policies, strategies, annual work plans, surveillance reports, progress reports and evaluation reports. Checklists help to ensure comprehensive coverage against the evaluation questions and a consistent approach to document review. Policy/Decision making timeline This is a visual means of recording and presenting key events in the evolution and implementation of a decision or policy. PNAC being a large committee with a multitude of stakeholders, it becomes particularly important to assess the quality of PNAC meetings particularly in decision-making and policy development and implementation. The ‘minutes’ of the last five meetings have been used for analysis, wherein two decision-making topics were taken and these were followed for action and implementation. Semi-structured interview guides Interview guides will be developed prior to discussions to help ensure systematic coverage of questions and issues by smaller teams/team members working individually. The topics have been developed around the assessment questions, but grouped and focussed according to the organisation or individual being interviewed. The semi-structured nature of the interviews and discussions allows 10 | P a g e