UNICEF EQG CO - PMTCT Evaluation 1 Final Report SUMMATIVE EVALUATION OF UNICEF’S PREVENTION OF MOTHER TO CHILD TRANSMISSION (PMTCT) DECENTRALIZATION TASK-SHIFTING PROJECT IN EQUATORIAL GUINEA (2015-2018) UNICEF Equatorial Guinea EVALUATION REPORT Sara Vaca, January 2019
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UNICEF EQG CO - PMTCT Evaluation 1 Final Report
SUMMATIVE EVALUATION OF UNICEF’S PREVENTION OF
MOTHER TO CHILD TRANSMISSION (PMTCT)
DECENTRALIZATION TASK-SHIFTING PROJECT
IN EQUATORIAL GUINEA (2015-2018)
UNICEF Equatorial Guinea
EVALUATION REPORT
Sara Vaca, January 2019
UNICEF EQG CO - PMTCT Evaluation 2 Final Report
Evaluation Report 10th January 2019
Evaluation team
Evaluator Sara Vaca Independent international consultant.
3. The Programme ................................................................................................................................................ 13
4. Evaluation Purpose, Objectives and Scope ..................................................................................................... 15
6.6. Equity, Gender and Human Rights .......................................................................................................... 46
7. GOOD PRACTICES ......................................................................................................................................... 50
Annex 6. List of people met ................................................................................................................................. 60
Annex 10: Estudios de Caso de Centros Sanitarios ............................................................................................. 70
Annex 11. Other qualitative data ........................................................................................................................ 84
UNICEF EQG CO - PMTCT Evaluation 4 Final Report
TABLE OF FIGURES
Figure 1: Table of the key PMTCT indicators. Source: http://aidsinfo.unaids.org/, 2017 .................................. 7
Figure 2: Age pyramid in Equatorial Guinea (2016).
United Nations International Children's Emergency Fund
Unidad Referencia de Enfermedades Infecciosas
UNICEF EQG CO - PMTCT Evaluation 6 Final Report
1. Executive Summary
INTRODUCION
About HIV in Equatorial Guinea
With HIV prevalence estimated at 6.2% in 2014 (UNAIDS), Equatorial Guinea has taken steps to scale
up its response to HIV in the last years. The country is fully funding its HIV response and access to
treatment is free of charge. The opening of additional health centers has allowed Equatorial Guinea to
scale up its programme to eliminate mother-to-child transmission of HIV. Estimated coverage of
pregnant women who access antiretroviral medicines increased from 61% in 2011 to 74% in 2014.
About the National Prevention of Mother To Child Transmission Programme
After the first HIV Strategy approved in 2003 in the country, the new “National Strategy for accelerating the access to PMTCT services” was adopted in 2014 by the EQG, the MoHWB had to start decentralizing
the services to pregnant women living with HIV to prevent vertical transmission.
The programme consisted in training the health workers involved services (maternity, laboratories and
pharmacies) and supervision visits to monitor the service quality. It was undertaken along 2 phases: a
pilot was first implemented at Bioko island (2015-2016), followed by a second one in the Continental
Region (2017-2018).
About the evaluation
This summative evaluation of the PMTCT Decentralization Task-Shifting project (2015-2018) sets a
precedent for UNICEF Equatorial Guinea (EQG) Country Office (CO), as it is the first such exercise
conducted in-country since 2011.
Following UNICEF’s Evaluation Policy, the evaluation revolves around three key questions: Is the right
thing being done? Is it being done well? Are there better ways of doing it? With respect to the national
PMTCT decentralized programme, this evaluation will assess the level of progress attained to this day at
the national level, including what has been achieved, what is left to do and the way forward.
The evaluation was managed by UNICEF EQG CO in close collaboration with the Ministry of Health
and Well Being (MoHWB). Due the highly participatory nature of this evaluation, the team that
conducted it consisted of an international external consultant hired by UNICEF and a national consultant
from the MoHWB (former HIV General Director): the decision to proceed this way was meant to assure
not only that the views of both UNICEF and the national government be equally taken into account but
that their respective capacity be increased as a result of this exercise. That having been said, the
following measures were taken in order to protect the independence of this evaluation: the engagement
of the UNICEF Regional Evaluation Adviser for West and Central Africa as well as the review of the
report by a national independent expert.
The evaluation results from a mix of approaches: it combines the features of an Equity and Gender-
focused evaluation with those of a Theory-based approach; facilitation was also widely used throughout
the project to foster internal capacity development. The evaluation questions were axed around four of
the five DAC criteria (Relevance, Efficacy, Efficiency and Sustainability) and two additional ones put
forward by the UNICEF CO: UNICEF’s strategic positioning and Equity & Human Rights.
The evaluation covered the project implementation period (from early 2015 to mid-2018) nationwide.
Given the upstream character of the programme (focused in the decentralization rather than in the
quality of services), the sampling privileged institutional informants. As a result of the sampling focus
(and other related ethical reasons), only a few PMTCT users were consulted as part of this evaluation.
An additional number of interviews with the relevant stakeholders were held during the two weeks of
fieldwork and 8 case studies were conducted, mostly pertaining to healthcare centers at national,
province and district levels.
KEY FINDINGS (by evaluation criterion)
Relevance
Eliminating vertical HIV transmission is relevant in EQG as it responds to an existing need: to halt the
rate of new infections which has continued to grow in the last years and which makes HIV one of the
first causes of child mortality at the national level. The national PTMCT programme is and remains a
country priority, as attested by the government’s decision not only to buy all anti-retrovirals but also to
substantively fund UNICEF’s second phase of the programme. It is also important at the CO level, as
Effectiveness
Regarding the project expected intermediate results (outputs) (Contribution to universal access to PMTCT services), the programme has succeeded in moving access remarkably forward, by making the
services available in all the 18 districts of the country (before the programme they were only present in
the 5 districts: Malabo, Bata, Evinayong, Mongomo y Ebibeyín). Besides, the staff at 33 other local centers
have been trained and are expected to be able provide PTMCT services in the next phase of the
decentralization process.
However, it was not possible to assess the impact of the programme in reducing the vertical transmission
as there is no reliable data on the number of pregnant women expected, pregnant women living with
HIV and number of exposed children that are living with HIV: there have been discrepancies in the
Global AIDS Monitoring (GAM) Report. Below is the official data available:
Based on the strong political willingness demonstrated thus far, Equatorial Guinea (EQG) aims to reach
the end of mother to child HIV
transmission (EMTCT) in the near
future. Therefore, in order assist the
country’s government in this noble
effort, UNICEF EQG has
commissioned an external evaluation
of the interventions it funded over the
last four years (2015-2018) within the
scope of the broader national PMTCT
programme. The evaluation objective
is to measure the progress made to this
date as well as to identify lessons
learned and missed opportunities to
build upon, in view of the scaling up of
PMTCT activities and the completion
of the ongoing decentralization
process.
This evaluation is even more relevant
if one takes into account that the only
special serological cohort study ever
carried out in Equatorial Guinea dates
back to 2011. This study, which
assessed the rate of HIV/AIDS vertical
transmission to children, indicated
that the vertical transmission in
children whose mothers received ART was 16% (3/19), compared to 43% (10/23) in children whose
mothers did not receive it (p = 0.05), and 8% (1/13) in children whose mothers received ART and the
child postnatal prophylaxis (p <0.05). In the demographic study EDSGE-I (Encuesta Demográfica y de Salud, 2011), 42% of women who had been pregnant in the previous two years said that they had been
asked for the HIV test. Given all of the above, the conclusion is that, should a strategy of prevention of
mother-to-child transmission be implemented systematically, the probability of vertical transmission
can be significantly reduced to less than 1%.
To the contrary, if no systematic strategy is adopted, the prevalence of HIV in the young population
(more so, among women) will continue to remain high and that, in turn, this will increase the risk of
TMCT (as per UNAIDS estimations, approximately 40-45% of the children born of these women will be
infected with HIV thus bringing the total of adults and children living with HIV to 53 000 [44 000 - 68
000] (http://aidsinfo.unaids.org/ 2017).
ONUSIDA data for EQG was reviewed based on the last Census done in 2015
EQUATORIAL GUINEASELECTED TRENDS
AIDS Deaths Number of people living with HIV
New HIV Infections Percent of people living with HIV receiving ART
3. The Programme The object of the evaluation is the Prevention Mother to Child Transmission (PMTC) Decentralized
Task-Shifting programme. Specialized units in the Bata and Malabo UREIs have been managing cases of
mothers and children living with HIV who needed treatment since 2003. Four additional health centers
followed: two health care centers (Maria Rafols and Maria Gay in Bata) in 2009 and two province
hospitals (Mongomo and Ebibeyín) in 2010. In 2013 the new international guidelines on PMCT were
issued and validated by EQG in 2014.
The logic of the programme consisted in reinforcing, first, the capacity of health workers (doctors,
nurses, laboratory and pharmacy staff of each health center) through ad-hoc HIV Vertical Transmission
Prevention training in different services areas (maternity, laboratories and pharmacies, such as) at
regional, province and district level. Training was provided by a partner, the Instituto de Salud Carlos
III (ISCIII). Once the personnel was trained, mixed teams from the MoHWB, ISCIII and UNICEF
conducted supervision visits to reinforce good practices and refine the practices which would eventually
lead to a decrease in the MTCT rate at the national level. The programme also included supervision visits
to monitor the service quality. The Project/Programe was undertaken in 2 phases:
A pilot was undertaken at Bioko island (2015-
2016): in 2015 the decentralization started in
Bioko island. The strategy was piloted in the
island region, including Annobón. With the
elaboration of the “Strategy for accelerating universal access to PMTCT services” treatment
protocols were simplified and Option B+ was
adopted. Requirements to become healthcare
center providing PMTCT services were: to
have prenatal and maternity services, to have a
laboratory and to have a functioning
pharmacy.
A multi-sectorial team was formed to
coordinate the fight against HIV at national
level, including all relevant actors: MoHWB,
UN Agencies and some local civil society
organizations. The team, which was less active during the end of 2016 but was reactivated at the end of
2017, made several efforts to attain the programme objectives, as spelled out in the project results
framework (see below)
General objective
Decrease the vertical transmission to less than 5% in Equatorial Guinea.
Specific objectives
- Train 144 PMTCT service providers integrated in the 54 health care centers to apply PMTCT
- Reinforce primary healthcare PMTCT attention
- Reinforce the procurement system of PMTCT material
- Plan a monitoring system for the strategy
- Correct bad practices in the strategy implementation
FASE I – Nivel Provincial
Reunión en un lugar en Bata durante dos días sucesivos durante toda la mañana = 44 personas, 2 Reuniones de 22 personas Participan a las personas responsables de PTMH.
- Hospital Regional de Bata (Planificación Familiar, Maternidad, y Pediatría ) A: 10
- Centro Medico La Paz de Biyendem A: 2 - INSESO Bata A: 2 - Centro Medico Guinea Salud: 4 - HP de Mongomo A: 6 - Clínica Guadalupe de Mongomo A: 2 - INSESO Mongomo A: 2 - Hospital Provincial de Ebibeyin A: 6 - INSESO Ebebiyin A: 2 - Hospital Provincial de Evinayong: 6 - Centro Luis Amigo: 2
En Proceso: 16 Centros Sanitarios
Región Insular
Planificado:
11 Centros Sanitarios Nivel Provincial
R. Continental
Planificado:
43 Centros Sanitarios Nivel Distrital y CS
R. Continental
La Puesta en Marcha de La Estrategia de PTMH
Figure 5: Number of PMTCT centers per region
UNICEF EQG CO - PMTCT Evaluation 14 Final Report
A second phase was implemented in the Continental Region (2017-2018).
The global strategy “Start free, stay free, AIDS free” was launched and
adopted by EQG, as framework of this second phase, which involved UN
agencies in the national response to HIV, as delegated by the government:
START FREE Reduce the number of children newly infected annually to less than 40,000 by 2018 and 20,000 by 2020. Reach and sustain 95% of pregnant women living with HIV with lifelong HIV treatment by 2018.
STAY FREE Reduce the number of new HIV infections among adolescents and young women (aged 10–24) to less than 100 000 by 2020.
The program Theory of Change (ToC) below was reconstructed by the evaluation team in collaboration
with the CO team during the evaluation, to support the understanding of the mechanisms and
assumptions underlying the logframe objectives:
Figure 6: Theory of Change rebuilt with the PMTCT Team during the evaluation
Eliminated vertical transmission of HIV
Inter-sectorial group working
for coordination
Assumption:Pre-natal care improves
Technicalsupport is
coordinated
Advocacyabout the need
of a national plan
PTMTC servicesnot available at
all levels
National fundsmobilized for
PMTCT
Legal framework(outdated law,
2012 NationalPlan)
Unbalanced powerrelations between men
and women (use of preservative,
intergenerations unions)
Stigma and discrimination to the
virus (reinforced bythe law)
Limited use of preservaative
Limited intersectorial coordination
(health, education,gender, social)
Limitedknowledge of
the disease
Adopción de Estrategias
internacionales (Start free,
90.90.90)
Increase servicesquality
Reinforce compliancewith inspections of the
Ministry of Health
Reinforcecompliance with
follow-up mechanisms
New NationalPlan approved
Impact
Outc
om
es
Bott
lenecks
Str
ate
gie
sO
utp
uts
Path
ways
of
change
Path
ways
of
change
Prevention of HIV Mother to Child Transmission (PMTCT)
SDG Target 3.3. Ending AIDS as a public health threat by 2030
Technicalsupport
For suppliesprovision
Improvingpregnant
women HIV Diagnosis
Training ofhealth
Personnel- PTMH
- Dignos
IncreasingAccess to PMTCT
services(coverage)
Population knowsHIV better
Attitudes change
UNICEF for every child
Enabling Environment Demand
Evaluation PMTCT – UNICEF Equatorial Guinea
Supply
Theory of Change
Preganant women Access PMTCT services
Descentralizationstrategy scaled up
Sensitizationcampaigns and
prevenion tours
Increases % pregnantwomen that complete the
9 months treatment
Enhancing accessof pregnant women
to PMTCT services
Increase the % of infected kids
with treatmentIncrease the % of exposed kids
not infected HIV positive women whoare kept alive
UNICEF EQG CO - PMTCT Evaluation 15 Final Report
4. Evaluation Purpose, Objectives and Scope The UNICEF Equatorial Guinea Country Office (CO) has therefore commissioned an external summative
evaluation of UNICEF’s Prevention of Mother to Child HIV transmission (PMTCT) Decentralization
Task-Shifting Project, with a double purpose:
1. To provide solid evidence to stakeholders and donors about the progress made in contributing to the
elimination of TMTC and the creation of an AIDS-free generation, thanks to the scale-up of the
PMTCT programme. In terms of accountability, this evaluation is expected to provide donors
(vertical accountability) and expected beneficiaries (horizontal accountability) with accurate
information on the extent to which UNICEF’s efforts to scale up PMTCT programme contributed,
not only to the elimination of MTCT, but also to the creation of an AIDS-free children generation.
With this mind, the evaluation aims to illustrate how the different Programs strategies have evolved
over time and what has worked or not worked, and why.
2. To enlighten and contribute to learning regarding how the PMTCT programme has contributed to
the EMTCT and has positioned UNICEF within the HIV-AIDS community (learning purpose).
This evaluation has major implications for UNICEF’s future work and partnerships towards ending AIDS
as a public health threat by 2030 (SDG 3.3), as many actors at different levels are expecting the evaluation
findings and conclusion to inform their respective programme and policy designs, and will shape the
national response to continue advancing towards the elimination of MTCT of the HIV. In terms of
learning, the evaluation especially focused on the past years of UNICEF’s PMTCT engagement (2015-
June 2018) and its findings will inform:
• UNICEF’s contribution to the national Government’s PTMCT Programme as well as the UNICEF
Strategic Plan HIV outcome;
• UNICEF positioning in the post-2015 HIV agenda as guided by the UNAIDS 2016-2021 strategy and
the 2030 Agenda for Sustainable Development.
• UNICEF strategic direction and partnerships/advocacy as well as programme strategies (sectoral and
cross-cutting) effort aimed to achieve the results outlined in the Strategic Plan;
• Positioning within the HIV-AIDS global community, including UNICEF’s partners at all levels.
UNICEF sections and offices at all levels (HQ, Regional and Country Offices) constitute an important
audience as the evaluation will provide evidence on what works and why.
This is how the different evaluation users are expected to use the evaluation results (according to the
Terms of Reference):
Evaluation Users Evaluation USE
UNICEF EQG CO
(Management)
Resources mobilization for increase resources for fighting HIV and PMTCT.
Accountability to the government and donors.
UNICEF Health Section
(HIV)
Inform the formulation and implementation of PMTCT intervention in the new
CP 2019 – 2023. Inform the content of new partnership agreements with other
in-country institutions (Fundacion Religiosos para Salud, ISCIII)
MoHWB (HIV National
Program)
Improve the PMTCT intervention in the health centers nationwide
Inform the sections on recommendation in the eMTCT plan.
MoHWB (Primary
Health Care)
Inform the design of a new coordination strategy with MoHWB HIV Program
with a specific focus on PMTCT
Instituto de Salud
Carlos III
Inform the content of the Health component of their new cooperation Plan with
the EQG government
Figure 7: Evaluation users
UNICEF EQG CO - PMTCT Evaluation 16 Final Report
Evaluation Objectives
The objectives of this evaluation are:
- To document the key achievements as well as missed opportunities associated with UNICEF’s
engagement to in-country partners in support of improved PMTCT outcomes over the past years;
- To identify lessons learned about strategies and processes that proved particularly effective in
promoting PMTCT at the national level;
- To generate recommendations that could contribute to achieve better results, as per the distinct
information needs of the different evaluation users.
Scope
The evaluation covered UNICEF PMTCT programme and examined the organizations’ engagement at
country level. While UNICEF’s HIV response is known to be comprehensive, the evaluation focused on
the following:
Time frame: the evaluation uses a three-years and a
half perspective (January 1st, 2015 to June 30th,
2018), to examine key decision points and
choices made over the years in order to
understand how well UNICEF and partners
influence, learn and react, as well as to
understand the basis of present choices.
Institutional focus: the evaluation will focus on
the UNICEF PMTCT programme response.
However, the evaluation will assess UNICEF’s
strategic positioning, at two levels:
Comparative Advantage of UNICEF and
Resource mobilization.
Programmatic focus: In addition, the
evaluation must account for other dynamics
while assessing UNICEF’s contribution to global outcomes. The evaluation will assess particular
strategies UNICEF has engaged into to contribute to PMTCT programming:
1. Strategic information, knowledge generation and dissemination: the contribution to regional, global
and national policies and strategies through evidence generated by UNICEF and partner supported
research and programming as well as through its global data, estimation and progress reporting; and
the translation of global policies and evidence into national plans, operational guidance and tools.
2. UNICEF has engaged in joint planning, technical assistance, advocacy and field visits with partners:
working with the government at different levels to support the implementation of policies.
3. Thematic leadership, advocacy and partnership: the ability to foster or to be effective within
partnerships by leveraging corporate knowledge and assets to become a trusted advisor for donors,
national governments, and other national stakeholders; the ability to influence national PMTCT
agenda. UNICEF accomplishes its mandate by building strategic and operational partnerships and
leveraging resources at all levels
Geographic focus: the evaluation will assess the UNICEF PMTCT programme response at national,
regional, province, district and local levels.
Figure 8: Evaluation Scope
UNICEF EQG CO - PMTCT Evaluation 17 Final Report
Out of the scope: the evaluation will not cover epidemiologic and service delivery quality aspects, as
these are not direct responsibility of UNICEF and they are addressed through publications done by
UNICEF and other stakeholders on these topics.
Evaluation management and team
The evaluation was managed by the Strategic Planning Manager in collaboration with the CO Head of
Health (based in Bata) and the CO HIV Specialist (based in Malabo) and with the overall technical
support of the UNICEF Regional Evaluation Adviser (based in Dakar).
5. Evaluation Design Following the UNEG Guidelines (‘Integrating Gender and Equity in Evaluations’), the UNICEF
Evaluation Policy and the instructions included in GEROS Handbook, the evaluation resulted from the
combination of the following approaches:
Gender and Equity-
focused
A Gender and Equity-focused approach, which would devote special attention
to Human and Children Rights issues, and to how the differences between
groups (e.g. through the disaggregation of the population by different
variables, such as sex, origin, location, wealth groups, religion, age, among
others) may determine specific situations of vulnerability, specifically for
women and girls. The evaluation looked into: (i) how the design of the services
and its provision are adapted to these groups’ needs; (ii) how HIV information
as well as reproductive health services were specifically age-appropriate; (iii)
to what extent special strategies were adopted to address high levels of sexual
violence;; and (iv) to what extent males were engaged in the programme
processes and dynamics.
Theory-based design
A theory-based design was used to increase confidence that the intervention
contributed to the outcome, rather than establishing attribution and definitive
proof. This method was especially useful as there was no counterfactual. It
demonstrates the probability that the programme has contributed to the
desired outcomes by building a well-evidenced causal chain case. All of this
provided a solid base for an iterative process of collecting and analyzing
additional evidence over time to strengthen the contribution story. To foster
learning, the evaluator conducted a ToC workshop with the UNICEF team, to
rebuild the theory.
Systematic analyses
of qualitative data
Qualitative analysis was critical to ensure transparency and enable the
evaluation team’s interpretations of the data to be based on participants’ views.
Thematic analysis5 involved six steps from the spoken text of participants (i.e.
the data) to the evaluation team’s interpretation –organized into mid-level
categories- and the organization by themes. Relationships between these
organizing themes were identified in order to finally group them into global
themes, which summarized all of the issues being explored by the participants.
Analysis began concurrently with data collection in order for the evaluation
team to consider the early themes emerging from interviews and FGDs and to
clarify, confirm and explore participants’ various views during the fieldwork.
level hospital later) could address the treatment needed by those women detected and for their babies
once they were born.
In order to have better access to the PTMCT services, pregnant women living with HIV and their
children needed specialized centers closer to their homes; what was needed, too, was greater awareness
of the need to protect the life of both mothers living with HIV and their babies. In order to address the
need, the programme focused more on the strengthening of the supply of PTMCT services (hardware-
type interventions) and, to a lesser degree, on the generation of PTMCT demand (software-type
intervention).
6.1.2. To what extent has UNICEF supported national government priorities?
To which extent PMTCTis relevant for the government (priorities, resources allocated, etc.)?
Findings
triangulated by:
Methods Sources
Desk review, Interviews MoHWB, UNICEF
Fighting for HIV prevention and elimination is one of the EQG government’s priorities. It is one of the
key strategies included the National Plan of Development (“Plan de Accion del Sexto Programa Pais 2013-2017 entre el Gobierno de la Republica de Guinea Ecuatorial y el Fondo de Poblacion de las Naciones Unidas”): PMTCT falls under the Result 1 (Improved Mother and Neonatal Health); Gender
Equity and Population and Development are featured in the two other Plan’s results.
The structure of the Ministry of Health and Well Being confirms such centrality of PTMCT in the
national agenda: two of the five General Directors deal specifically with HIV prevention and treatment.
However, the two directors in question have very limited human resources (one-person teams) and no
resources dedicated to M&E.
Figure 13: Structure of the Ministry of Health and Well Being related to PMTCT
UNICEF EQG CO - PMTCT Evaluation 27 Final Report
Another challenge related to the way the minister has structured HIV services is that PMTCT services
are provided by Family Planning services at the hospitals, which depend on the National Manager of
Sexual and Reproductive Health (SRH) lead. Therefore, even though all services are merged in the
maternity and general consultations at local centers level, health workers end up receiving instructions
regarding PMTCP from two different departments within the same ministry.
The government has been involved in ending PTMCT and strengthened its national response. As of 2017,
the national government delegated the HIV response to the UN system and, to allow its
operationalization, made available a 2 million USD budget (450,000 USD were allocated UNICEF): that
does not only reflect the strategic importance that the government assigns to PTMCT but also attests to
UNICEF’s support to decentralize PMTCT services in response to a concrete EQG government’s concern.
6.1.3. To what extent is this programme relevant to the UNICEF Country Programme and Strategic
Plan?
Findings
triangulated by:
Methods Sources
Desk review, Interviews UNICEF, external sources
For UNICEF, PTMC is also a priority programme, especially given that HIV represents one of the main
causes of child mortality in the country, followed by malaria and neonatal disorders.
UNICEF EQG CO - PMTCT Evaluation 28 Final Report
Figure 14: Mortality trend and Top 10 causes of death in 2017. Source: http://www.healthdata.org/equatorial-guinea
Beyond other priorities in the region such as reducing malnutrition, malaria, child’s marriage and
education, HIV is a critical problem affecting children. At UNICEF Strategic level, PMTCT is a key
component contribute to “Survival and striving”, one of the main axes of UNICEF Global Strategic Plan
(2018-2021).
Regarding the EQG CO, as part of the present Country Program Document 2013-2017/Ext 2018, fighting
HIV is part of the first result (“Fortalecimiento de las capacidades nacionales relativas a instrumentos de financiacion y dotacion de servicios para combatir el VIH/SIDA”), present in the Results framework.
In the new coming Country Programme 2019-2023, HIV is again a key component of the Health are
within survival and strive.
Finally, the programme is also aligned with the international guidelines such as:
1. SDG 3 “Ensure healthy lives and promote wellbeing for all at all ages“,
2. SDG 4 “Ensure inclusive and equitable quality education and promote lifelong learning
Figure 18: Detail of the health centers involved in the Decentralization
The evaluation team reconstructed the Programme ToC the PMTCT UNICEF team at the beginning of
the field work, as a way to a common understanding of the Programme logic. As the methodology section
describes, the evaluation used a Theory-based approach to validate which parts of the theory have been
validated. The analysis concluded that the theory held true for most of the intermediate results necessary
to achieve the outputs. The coverage of the access to services was limited and the users’ attitudes hasn’t
greatly changed either (yellow boxes represent intermediate results not fully achieved).
UNICEF EQG CO - PMTCT Evaluation 32 Final Report
Figure 19: Theory of Change of the programme (in yellow, intermediate outputs not fully achieved)
The data needed to calculate the transmission rate is not reliable. Field work confirmed that there are 3
potential sources of data: the data from the consultations done by doctors, midwives and nurses; the data
collected in the laboratories; and the data collected by the health center pharmacies. However, they are
not systematically collected and consolidated at regional or central level due to several reasons. First, the
lack of templates and protocols to consolidate medical registries and individual templates. Second, the
Eliminated vertical transmission of HIV
Inter-sectorial group working
for coordination
Technicalsupport is
coordinated
Advocacyabout the need
of a national plan
PTMTC servicesnot available at
all levels
National fundsmobilized for
PMTCT
Legal framework(outdated law,
2012 NationalPlan)
Unbalanced powerrelations between men
and women (use of preservative,
intergenerations unions)
Stigma and discrimination to the
virus (reinforced bythe law)
Limited use of preservaative
Limited intersectorial coordination
(health, education, gender, social)
Limitedknowledge of
the disease
Adopción de Estrategias
internacionales (Start free,
90.90.90)
Increase servicesquality
Reinforce compliancewith inspections of the
Ministry of Health
Reinforcecompliance with
follow-up mechanisms
New NationalPlan approved
Im
pact
Outcom
es
Bottle
necks
Strategie
sO
utputs
Pathw
ays
of
change
Pathw
ays
of
change
Prevention of HIV Mother to Child Transmission (PMTCT)
SDG Target 3.3. Ending AIDS as a public health threat by 2030
Technicalsupport
For suppliesprovision
Improvingpregnant
women HIV Diagnosis
Training ofhealth
Personnel- PTMH
- Dignos
IncreasingAccess to PMTCT
services(coverage)
Population knowsHIV better
Attitudes change
UNICEF for every child
Enabling Environment Demand
Evaluation PMTCT – UNICEF Equatorial Guinea
Supply
Theory of Change
Preganant women Access PMTCT services
Descentralizationstrategy scaled up
Sensitizationcampaigns and
prevenion tours
Increases % pregnantwomen that complete the
9 months treatment
Enhancing accessof pregnant women
to PMTCT services
Increase the % of infected kids
with treatmentIncrease the % of exposed kids
not infected HIV positive women whoare kept alive
Intermediate results thathave not been observed
UNICEF EQG CO - PMTCT Evaluation 33 Final Report
monthly reports produced by the centers are submitted to different statistic centers and none of them
reach central level at the MoHWB. Third, there is no MoHWB data staff allocated to PMTCT.
Due to the lack of resources in the two General Directions in charge of HIV, they did not produce their
own data (which means going in person to each head of province or district to retrieve the data in hard
copies), so they rather rely on the data provided by the Pharmacy supply chain responsible. As a
consequence, the only secondary quantitative data that the evaluation team could consult was the level
of drugs consumptions between January and August 2018 (such data was collected during the last
supervision mission conducted by him.
Figure 20: Data of patients under HIV treatment January-August 2018. (according to
the MoHWB pharmacy supply chain registries).
A further tool used to measure the results and the progress of the programme’s achievements has been
an analysis of the UNICEF MORES determinants within the scope of the different interventions
implemented during the PTMCT services decentralization process. The rubric depicted baseline and
current situation (labeled respectively as “before” and “after” columns), by also breaking PMTCT services
into the various MORES determinants.
Depending on the attained level of progress, the rubric will point to a different color, as per the legend
below:
Very good, sufficient / achieved and consolidated
Existing, good but room for improvement and consolidation
Existing but not totally achieved or not totally satisfactory
Non-convenient, non-existing
Thanks to the rubric, the PMTCT services were analyzed according to each one of the identified
determinants. That allowed judging the situation before and after the programme, as well as appreciating
which dimensions have moved forward:
UNICEF EQG CO - PMTCT Evaluation 34 Final Report
AREAS DETERMINANTS BEFORE AFTER COMMENTS
ENABLING
ENVIRONMENT
1) Societal norms
At the decision-makers level, HIV is
part of the government agenda.
Existing HIV law but with deficiencies.
2) Legal
framework
The strategy is a solid first step, but a
National Plan is still missing
3) Budget /
expenditure
A 2 million USD budget was allocated
by the Government to the HIV
program.
4) Coordination
Coordination between actors has
improved (example: between services
within health centers, such as
laboratory, pharmacy and doctors; also
between centers when one supply is
out of stock)
SUPPLY
5) Availability
inputs
The services were not available before
the programme but are available now
and working with standardized quality.
Medicines and inputs are in place7 at
healthcare centers.
6) Availability
staff
Practitioners at each district health
center can provide PMTCT services.
DEMAND
7) Access Access has been enhanced from
provincial level to district level.
8) Practices and
beliefs
At community level, still many women
do not use healthcare centers and men
do not feel involved. Weak knowledge
of HIV.
9) Continuity of
use
Although HIV is no longer a taboo,
there are still many myths and stigma
around it. The system has a weak
retention level.
QUALITY 10) Quality
Transmission mother to child of HIV
rate still unclear. Early Infant
Diagnose is not available and the
actual protocol recommended HIV
testing at 6 months. With low patient
retention, children exposed to HIV
are lost by the system, so no evidence
that our target is reached.
Figure 21: Analysis of achievements following UNICEF's MORES determinants
7 There has been a plan for making medicines and HIV tests available. The procurement system (needs planning, orders,
stocking and stock management) has been reinforced to assure the needed medicines, tests and artificial milk are available.
In order to do it, a module of training was included to manage inputs to avoid stock shortages and the expiration of
diagnosis tests and medicines.
UNICEF EQG CO - PMTCT Evaluation 35 Final Report
6.2.2. To what extent was UNICEF reactive to the circumstances? What trade-offs were made to ensure
that partnership arrangements could work as intended? What were the related risks?
Findings
triangulated by:
Methods Sources
Desk review, Interviews MoHWB, CSOs, UN agencies
According to the partners (including the MoHWB, other UN Agencies and CSOs), UNICEF has kept a
proactive attitude along the programme, adapting to the circumstances and using their resources and
potential influence to support the government and cover the gaps the system.
At the beginning of the programme, the CO managed to formalize the legal agreements with the
MoHWB and the training partner (ISCIII): that allowed the start of the pilot implementation as well as
its successful completion.
After the depletion of the CO’s core funds, UNICEF reacted by started making advocacy efforts towards
the adoption of the “Start free, stay free, AIDS free” international strategy and the mobilization of funds
(2 million USD): that resulted/translated into the opening of negotiations within the UN System.
By commissioning this evaluation, first one of its kind for both the UNICEF CO and the MoHWB,
UNICEF demonstrated a certain adaptive response. That is all the more critical as the evidence and
situation analysis generated by this evaluation are expected to boost the next phase of the programme
implementation.
6.2.3. To what extent have these partnerships helped national PMTCT programme achieve their
national goals and targets? To what extent have partnerships contributed to the achievement of global
PMTCT targets?
Findings
triangulated by:
Methods Sources
Desk review, Interviews, Observation MoHWB, UNICEF, UN agencies,
CSOs, FRS, Health centers
The three-partners relationship among the MoHWB, UNICEF and the ISCIII has been very beneficial
to the success of the envisaged decentralization process. UNICEF has been supporting the government
for years through the MoHWB among other ministries. The ISCIII, too, has been working with the
MoHWB for a long period. The preexisting relationship with the MoHWB is one of the reasons, along
with their technical capacities, why UNICEF selected this organization (ISCIII) to support the
decentralization process. UNICEF’s support has been positively judged as proactive and reactive by the
MoHWB.
Each one of the three partners performed a different set of tasks and responsibilities as per the table
below.
Actor Role and Responsibility
MoHWB
(specifically the General
Director of HIV
Assistance and Treatment)
• Leader of the decentralization process and last responsible entity with
respect to the provision of PMTCT services to the population.
• Provided with funds in the second part (as of end of 2017) and delegating
the HIV response to the UN System.
• Coordinating with UNICEF the programme activities.
UNICEF EQG CO - PMTCT Evaluation 36 Final Report
• Provided the drugs, test and other materials
UNICEF
• Main partner supporting the decentralization. Leader in the design of the
plan, financial and institutional support.
• Elaborating the drafts of strategies, programme documents, ToR for
trainers and local coordinators, that the MoHWB would later validate.
• Managing the funds, supporting in the training phase, as well as in the
monitoring of the training and supervision phase.
• Coaching at central and local level.
ISCIII
• Providers of the training of trainers.
• Providers of the training to the health centers.
• Elaboration of the training materials and leaflet.
• Part of the supervision visits team.
Figure 22: Roles and responsibilities by Partner involved in the programme
Other partners played a less principal role in the decentralization of PMTCT services. The World Health
Organization (WHO) and UNFPA participated in the design and validation of the decentralization plan,
as well as technical support in the evaluation of the programme. WHO was in charge of monitoring the
pilot evolution once the second phase of extension to the continent started. UNFPA had a role fostering
promotion of prevention messages and UNAIDS was also commissioned by the MoHWB for other tasks
(with half of the budget allocated to them), but in general these agencies faced problems deblocking the
funds and to this date their activities in these issues have remained very limited.
It is worth mentioning, too, that the structure of the Ministry has made the coordination with PMTCT
services in occasions challenging (see Figure 13 in page 25). While the two General Directors in charge
of HIV are have been available (the General Director Assistance, Control and Treatment of HIV/AIDS is
the actual leader of the programme), the health workers being trained and in charge of providing the
PMTCT services are in fact under the Hospital Coordination General Manager and under the Family
Planning team, which falls under the Sexual and Reproductive Health National Director. That said, at
local level those services are merged (provided by the practitioners) who are usually generalist doctors,
obstetricians, nurses and midwives. Besides, the ministry’s structure changes very frequently (every 2
years approximately), which increases the coordination issues with new teams and challenges.
6.2.4. To what extent has UNICEF contributed to the building of national systems? How have focus on
achieving goals been balanced with the drawbacks of vertical programmes (example: through fostering
coordination with Sexual and Reproductive Health programme)?
Findings
triangulated by:
Methods Sources
Desk review, Interviews, Observation MoHWB, Health centers, UNICEF
The progress observed after the start of the programme is mostly imbedded within the national health
care system. The programme has come to reinforce the local capacities: the partners’ interventions have
been punctual and focused on coordination rather than the replacement of national actors.
In order to better understand the impact experienced in the national systems, a Capacities Reinforcement Framework was used to allow mapping changes in capacities, according to their types and their level:
UNICEF EQG CO - PMTCT Evaluation 37 Final Report
MAPPING OF ACHIEVEMENTS USING THE CAPACITIES REINFORCEMENT FRAMEWORK
PROCESSES PRODUCTS RESULTS IMPACT
SYSTEM
(Expected
National Plan)
(Desired: 0%
discriminatory
legal framework)
PMTCT services
available at 100%
districts
(Aimed: AIDS free
new generations)
ORGANIZATION
(MoHWB)
“Strategy for the
acceleration to
universal access of
HIV MTCT
services”
STAFF
Healthcare
workers know
how to provide
PMTCT services
COMMUNITIES
They start going to
their health care
center for PMTCT
(Expected: HIV
Transmission
MTC < 5%)
Figure 23: Mapping of achievements according to the Capacities Reinforcement Framework
As it can be observed, having PMTCT services available at district level is a result that all the system
benefits from (not only at the MoHWB level). Other changes at System level haven’t been achieved yet.
However, at organizational level, the Healthcare system has validated some international guidelines and
has elaborated the “Strategy for acceleration of HIV Mother to Child Transmission prevention and
elimination”. At personnel level, more than 300 health workers know how to provide PMTCT services.
Meanwhile, at the community level, pregnant women have started being consistently tested for HIV and
those positive, to use the services and to understand the importance of their treatment and the baby’s.
6.2.5. What were the unexpected (positive and negative) outcomes of the PTMCT Programme?
Findings
triangulated by:
Methods Sources
Desk review, Interviews, Observation MoHWB, Health centers, UNICEF,
UN agencies, CSOs
The evaluation systematically tried to identify unexpected effects and found some.
First, by delegating the management of these funds to the UN system, the government staff missed the
opportunity of reinforcing their own management capacities: the initial lack of human resources could
have been solved by hiring ad-hoc staff.
UNICEF EQG CO - PMTCT Evaluation 38 Final Report
Second, by preventing mothers living with HIV from breastfeeding, a number of known risks is being
avoided. However, there are two unexpected outcomes associated with this: providing artificial milk
(which is commonly used by women and is expensive) for free, constitutes an extra motivation for
mothers to honor their monthly visits to collect their treatment. On the other hand, while only 56% of
the population has access to safe water, fostering artificial milk consumption may increase risks of
intestinal disorders in babies if the water and bottles are not properly clean.
Third, the (4) doctors who were trained as PMTCT coordinators suffered from the misunderstanding of
their own role by their colleagues, who believed that they were being treated with privilege and
receiving big sums of money, which was not the case.
Fourth, rotation of PTMCT-trained health workers among different health centers present a challenge
as it may weaken the PMTCT taskforce providing services in the center. That said, it may have
unintended positive effects such as when highly-trained workers arrive to a center where these or other
services were not provided, reinforcing the capacities of the new center.
Fifth, as the training provided integrated PMTCT and ARV treatment, not only for pregnant women,
but for adults and children too, the programme has contributed to the decentralization of ARV treatment
beyond PMTCT, for adults and children too (several of the visited centers were providing with treatment
to patients of their influence area). This is key for the mothers who become users of this service once the
baby is 2 years old, and to reduce new transmissions and keep patients alive beyond the target population
of vertical transmission.
6.2.6. To what extent has UNICEF contributed to the resource mobilization national goals so that the
national plan could be achieved? To what extent did UNICEF’s resource mobilization efforts garner
funds relative to the investment of time and resources? To what extent has UNICEF provided effective
support for countries to access funds for PMTCT program from other sources?
Findings
triangulated by:
Methods Sources
Desk review, Interviews MoHWB, UNICEF
UNICEF has supported the mobilization of national funds to reduce mother to child HIV transmission.
By supporting the pilot first, making it viable and successful, and by making the decentralization a reality
later on, UNICEF assisted the government in gathering sufficient evidence that could help it to showcase
examples of viable and successful EMTCT policies implemented in the country, especially as part of their
respective advocacy and resource mobilization efforts.
At moment, UNICEF is advocating for the resource mobilization from Global Fund, since the country is
become again eligible to Global Fund Grants. This is an opportunity to reinforce the Government’s national
HIV response, especially among adolescents et young girls.
b) Processes
6.2.7. To what extent are there gaps, overlaps and/or missed opportunities in programming that arise
from UNICEF’s organization structure?
UNICEF EQG CO - PMTCT Evaluation 39 Final Report
6.2.8. How has UNICEF organized internally to address PMTCT? To what extent has UNICEF capitalized
on its structures and presence between sectors to achieve its intended results?
Findings
triangulated by:
Methods Sources
Desk review, Interviews, Observation MoHWB, Health centers, UNICEF
UNICEF’s processes to respond and support the MoHWB seem to be simple and effective. The human
resources allocated by UNICEF to support the programme (basically the National Head of Health
programmes and the international HIV Specialist) have shown proper competences, skills and attitude
to manage the programme and seem to have a direct causal relation with its progress.
On the other hand, no overlaps between UNICEF and public officers have been identified. However, the
evaluation team concluded that a bigger team (from the ministry and from UNICEF) may have made
feasible to focus beyond implementation and allow a deeper understanding and a timelier resolution of
the PTMCT data availability problem, which was observed at the healthcare system level.
The pilot approach to start in small scale and scaling up later has also proved to be a good strategy: that
avoided the risk of engaging right away into a model that may have proved non-feasible at the national
level.
UNICEF monitoring could have been more ambitious and have drawn more conclusions. Missing data
actually provided by the new PMTCT services could have been identified and solved before the
programme had ended and the evaluation had started, by defining and mending the protocol and tools.
6.2.9. To what extent UNICEF has utilized evidence from trials/ pilot tests interventions to inform
scaling up of proven effective approaches? Has UNICEF facilitated learning and knowledge sharing
between partners and national counterparts to inform adoption and scaling up of proven effective
approaches?
Findings
triangulated by:
Methods Sources
Desk review, Interviews, Observation MoHWB, Health centers, UNICEF
As mentioned before, UNICEF used the data and evidence generated by the implementation of the pilot,
and gathered in a report, to discuss and elaborate the scaling up plan with the government. It included
guidelines on how to proceed to the next phase. The delay of time between the end of the pilot and the
scaling up programme was reasonable and due to external reasons, out of the CO control. This allowed
that many of the actors involved in the pilot were also involved in the scaling up, which was another
success factor.
6.2.10. To what extent has UNICEF translated global policies and strategies through user-friendly tools
(documents) for use in national PMTCT program?
Findings
triangulated by:
Methods Sources
Desk review, Interviews MoHWB, Health centers, UNICEF
UNICEF EQG CO - PMTCT Evaluation 40 Final Report
The products produced as fruit of the collaboration of
UNICEF with the government are technical and valid
tools customized to their purpose and users. The
“Strategy for accelerating universal access to HIV
PMTCT” sets a framework that allows all actors working
in PMTCT to align their respective practices and
interventions with the new recommendations and
actions to be implemented.
Furthermore, the protocol “Guidelines for use of ARC for prevention
and treatment of HIV” is meant to update and merge former guidelines
for health practitioners.
Additional resources produced during the programme implementation
include: an analysis of bottlenecks was conducted, a “Plan to reduce the
new infections in adults”, a publication on “Strategies of community
actions to increase the number of children tested out of the PMTCT
programme: and a “Strategy of HIV prevention in youth”.
6.3. Efficiency
6.3.1. What is the return on UNICEF investments in the areas of PTMCT advocacy and partnerships? To
what extent did these efforts “pay off” in a tangible manner?
Findings
triangulated by:
Methods Sources
Desk review, Interviews MoHWB, Health centers, UNICEF
When talking about return on investment (ROI), it is critical to understand that a literal analysis of the
value realized as compared to the value invested (usually measured in money) implies dealing with many
attribution and valuation problems, which was not realistic to undertake in this evaluation, which mostly
looks at process and intermediate results and not impact. Therefore, the return analysed in this
evaluation is understood as the appreciation of the changes in comparison with the resources invested
to make them happen.
UNICEF EQG CO - PMTCT Evaluation 41 Final Report
The first thing to establish is the amount of the financial efforts made by UNICEF to support the
decentralization of PMTCT. Overall, the resources utilized reached 273,299.44 USD for a 3-and-a half-
year programme, including a 2-month extension (May and June 2018).
Several methodologies were used to assess the efficiency of the programme in question.
First, taking a break-even analysis, it can be assessed if the results achieved described in the Efficacy
section added a value estimated in these costs.
Second, calculating the unit cost of several of the outputs is another method to provide further elements
to the efficiency analysis. The number of people trained was 355. Therefore, the cost of training (219.954)
per person trained in the continent (including a 2 days training and 4 visits of supervision and
monitoring) was 619 USD. In the pilot was 821 USD per person (36,965 USD / 45 people trained).
The number of new centers rose from 7 to 36. Therefore, the average cost of implementing the Program
in each one of the 29 new centers has been of 7,584 USD, with the understanding knowing that the main
investment (the training) was done in a total of 69 centers (33 should implement soon as they have
already been selected for fulfilling the requirements and trained). Once that final phase is completed,
the cost per center will be more of 3,500 UDS per center (29+33 centers will have been implemented).
Figure 24: Cost of the decentralisation programme (Source: UNICEF)
Finally, calculating the cost of the decentralization (273.299 USD) for people served by the services
(number expected of pregnant women (4.5% of population), their partners and children under 15), the
decentralization has costed 5 USD per person. Ideally, some of these indicators should be compared to
other countries undertaking similar projects. However, comparing the cost of implementing PTMCT in
other countries was considered but there were too many variables not easy to compare, such as the
baseline situation, the population and distribution in the country’s territory, the penetration of the HIV
in the country.
UNICEF EQG CO - PMTCT Evaluation 42 Final Report
Finally, comparing the PTMCT with other programmes such as the Malaria in the Bioko Island (with a
much bigger budget), may give the idea of how much this programme has achieved with limited funds.
6.3.2. To what extent did UNICEF’s global, regional and country-level programs pursue and attain
output-level results through the least costly means?
Findings
triangulated by:
Methods Sources
Desk review, Interviews, Observation MoHWB, Health centers, UNICEF
The budget of the programme is straight forward, with only 2 concepts: training in the pilot and training
in the continent, and two minor support actions. UNICEF followed its procurement guidelines and
procedures to hire the services related to this programme. For each purchase or contract, at least 3
quotations for the same services were obtained to assure that the least costly providers were selected, for
similar quality of services.
That said, the contract with the ISCIII was a service contract with a-year-long duration, while in
practice, their services were not continually used along the 12 months but punctually, due to the need
of their expertise only in different periods of implementation (when the training or supervision visits
were conducted). Therefore, now that a pool of professionals has been trained, some savings could have
been done by using another type of contract, whereby only actually worked days were invoiced.
6.3.3. To what extent has UNICEF capitalized on inter-sectoral linkages to bolster resources for
PMTCT (e.g. social protection, education, health)?
Findings
triangulated by:
Methods Sources
Desk review, Interviews UNICEF
This is one of the weaknesses of the programme: the process did not either explore or capitalize on the
linkages existing across sectors (example: with Nutrition and Education areas). Apart from the support
to the elaboration of an HIV/STI module for secondary school in 2016, UNICEF has been more focused
on health aspects and outputs and outcomes, not addressing the social and economic dimensions of the
issue.
6.3.4. To what extent was value for money considered in decision-making?
Findings
triangulated by:
Methods Sources
Desk review, Interviews, Observation MoHWB, Health centers, UNICEF
Decisions taken in phase 1 (the pilot) and 2 (decentralization in the continent) seem to have been rational
and done by consensus. There is no evidence of wastes of resources from the limited budget. Evidence
was also found that value for money, while it was not the main criteria for decision-making, was
considered, according to the programme managers of each partner.
UNICEF EQG CO - PMTCT Evaluation 43 Final Report
6.4. Sustainibility
6.4.1. To what extent has UNICEF strengthened national M&E capacity? To what extent have these
efforts strengthened countries’ ability to focus on issues of equity? To what extent have these efforts
strengthened countries’ ability to generate and use data for accountability and learning for PMTCT
program? To what extent have UNICEF’s mandate, structures and resources contributed to sustainable
country-led PMTCT program?
6.4.2. To what extent has UNICEF supported the development of costed national plans for the
elimination of MTCT in the country?
Findings
triangulated by:
Methods Sources
Desk review, Interviews, Observation MoHWB, Health centers, UNICEF,
UN Agencies, CSOs
Given the design of the programme, progress in the decentralization is based and relying on the national
healthcare system capacities, at all levels (processes, products and staff). While other projects and
decentralization schemes are supported by external resources, the involvement of UNICEF or other
partners such as ISCIII was punctual and always aimed at strengthening the national counterparts.
For the continental phase (scaling up phase), the programme design provided for the training of a team
of 4 local doctors as PMTCT coordinators. These four staff conduced the analysis of healthcare centers,
received the Training of Trainers course and were part of the facilitators that delivered the training to
the health centers targeted by the programme. They were also part of the teams doing the centers
supervision visits. The fact of being 4 helped assuring their continued presence. That notwithstanding,
only two of the four are temporarily active (one is in maternity leave and the other one on military
training leave). Although formally they no longer hold this position (the programme stopped paying
them in June), they are part of the national healthcare system (they are based in the Bata Regional
Hospital) and continue to conduct informal supervision in the maternity services of their hospital. Their
role and function as PMTCT coordinators could be easily restarted.
As shown earlier, the analysis and mapping of the results achieved with the programme (see Capacities
Framework, figure 23 in page 34), reveals that these improvements are happening at both the
organization level (MoHWB) and at the staff level. The more these changes gravitate towards the right
top area of the above-mentioned table, the more they appears to be sustainable as they mean changes at
system and impact levels.
The fact of having PMTCT services available at district level is a result at system level, and other changes
at this level (such as the HIV National Plan) would increase the probabilities of sustainability of the
achievements. Other necessary steps have been taken, like the strategy for accelerating universal access
and ensuring that an important number of health workers are able to provide these services.
To the contrary, the changes observed at community level are small and their dimension is unknown
(the proportion of pregnant women who go to the healthcare center for visits and labor, and the
proportion of HIV positive pregnant women who follow their treatment). As a result, it would be a bit
premature to talk about sustainability of these changes. The behaviour changes (changes in knowledge,
attitudes and behavior) occurring among the groups targeted by the Programme should be further
investigated.
Overall, in order to make the progress sustainable over time, three key factors were identified:
- First, veiling for the consistency of good PMTCT practices consolidated. This can only be done
restarting the supervision visits to monitor medical, logistics and reporting practices.
UNICEF EQG CO - PMTCT Evaluation 44 Final Report
- Improving the national health information system is key to monitoring the attained progress and
understanding the level and quality performance of the services in each context.
- The assurance of stock availability is essential: discontinuities in stock availabilities would have a
critical negative impact in the supply and demand of PMTCT services. Therefore, the programme
must pay special attention to assure existences in the next phase where other 33 centers will start
consuming and ordering these products at national level.
6.4.3. To what extent has UNICEF incorporated sustainability considerations in its work at country
levels?
Findings
triangulated by:
Methods Sources
Desk review, Interviews, Observation MoHWB, Health centers, UNICEF
Mechanisms of sustainability put in place by the programme have already been mentioned: grounding
the provision of services on the existing healthcare system is the main and most efficient mechanism
used. In that sense, if UNICEF stopped working in PMTCT in the country, the national healthcare system
can still provide these services, though the evolution of future quality will still depend on how the 3rd
phase of the decentralization that starts now will be managed for finalization and consolidation.
However, other minor mechanisms have to be considered to support the continuity and quality of the
services. For example, given the high rotation of staff within the health centers (many professionals are
muted every two years), it is key that the PMTCT services are assured by more than one person (in
average 5 people were trained per center, but often in reality the PMTCT services leadership informally
relies on one or two), and training materials (in brief format but with deep enough information) should
be available so that newcomers can be self-trained.
Another mechanism that would increase the sustainability of the changes and the quality in general
would be clarifying the communication mechanisms of the programme. In the field many examples of
miscommunication were related by the healthcare workers encountered. Examples:
- “The nurse of my center has gone to training but I’m not aware why” (director of a health center);
- “They sent Nistatina in the last order and we do not know how to use it. We assume is for the baby
(it is a syrup) but we are waiting for instructions”;
- “They said they are going to bring new registry books”;
- “They told us to start giving 4 units of artificial milk instead of 6. Then 2 instead of 4”;
- “They said they are going to change the general registry format”.
Establishing clear top-down communication mechanisms (and if possible bottom-up too) would help
have more standardized levels of awareness of news in this area and a more confident network of
professionals engaged into reducing HIV vertical transmission.
6.5. Leadership
6.5.1. To what extent are there comparative advantages based on UNICEF’s mandate, structures and
resource? To what extent does UNICEF have a comparative advantage and demonstrate added value
in taking a leadership role in PMTCT forums vis-a-vis others players?
UNICEF EQG CO - PMTCT Evaluation 45 Final Report
6.5.2. In case of comparative advantages, to what extent has UNICEF leveraged them fully in in
pursuit of its intended results?
Findings
triangulated by:
Methods Sources
Desk review, Interviews, Observation MoHWB, Health centers, UNICEF,
UN Agencies, CSOs
As one of the respondents said, “UNICEF’s competitive advantage is being UNICEF” (in terms of
resources, capacities, image and mandate). It includes establishing an effective presence at the country
levels, technical capacity, ability to play a convening role. They have also shown their ability to adapt
based on new scientific and operational information, such as their reaction when new international
guidelines were issued.
The creation of a position based in Bata to provide a closer follow-up to the phase in the continental
region was also a way to materialize UNICEF’s resources for contributing achieving better results.
UNICEF has also proved their ability to generate the required funds for PMTCT programme and projects
that UNICEF supports. Ability to leverage major funders’ resources to achieve UNICEF strategic
priorities in PMTCT may be part of the next phase, once the services are available at local level, reliable
data about the phenomenon is available and ideally a national plan is issued, to raise a compelling case
in from of potential donors.
6.5.3. To what extent did UNICEF’s leadership role in PMTCT forums contribute to the
achievement of its strategic priorities?
6.5.4. How does UNICEF view its leadership priorities? How does it view its role and focus? Do
these views vary across the organization? Is there coherence in its leadership vision?
Findings
triangulated by:
Methods Sources
Desk review, Interviews, Observation MoHWB, Health centers, UNICEF,
UN Agencies, CSOs
According to the stakeholders mapping elaborated to reflect the different actors working in PMTCT,
reviewed and adapted to after the field work, UNICEF seems to have been the leader in supporting the
government to decentralize PMTCT services at district level.
UNICEF took the leadership in the intervention design, in the institutional support, and financial
support, as well as in the implementation. In addition, UNICEF involved and hired ISCIII as technical
leaders, and led the follow-up with the 4 coordinator doctors during the monitoring phase. At the same
time, UNICEF had an inclusive approach, involving other UN agencies such as WHO and UNAIDS.
As the mapping shows, the criticality of UNICEF role is all the more relevant given the paucity of actors
working on PMTCT in EQG (Figure below XX). The Figure is really hard to read..please nearlge the
fonts).
UNICEF EQG CO - PMTCT Evaluation 46 Final Report
Figure 25: PMTCT Stakeholders Mapping
Apart from the Ministry of Health and Well Being, no other ministries seem to be having a multisectoral
role. On the international cooperation sphere, the Instituto de Salud Carlos III is also the leader who has
been working with the ministry for a long time.
The evaluation used an attempt to reconstruct the counterfactual by asking the stakeholders what would
have happened if UNICEF had not been present in the last 3 and a half years in the PMTCT. The answers
were unanimous to agree that the decentralization would not have been at this stage: “Many people
talked about it but nothing happened”. Therefore, UNICEF’s leadership steering different actors will
seems to have been a key success factor to have reached the present level of decentralization.
6.6. Equity, Gender and Human Rights
6.6.1. To what extent did UNICEF contribute to Human Right and Gender approach in PMTCT
program?
6.6.2. To what extent did the UNICEF CO contribute to Equity approach in PMTCT programme?
Findings
triangulated by:
Methods Sources
Desk review, Interviews, Observation MoHWB, Health centers, UNICEF,
UN Agencies, CSOs
The programme has contributed to improve the lives of many people living with HIV in different ways.
First, it contributed to decreasing the stigma produced by having to go for treatment to a specialized
center, clearly identified by the population a place for people with infectious diseases. By receiving
Stakeholders mappingActors National International / Multilateral
Public
Private
Population
Fundacion de
Religiosos
para la Salud/
Instituto de Salud Carlos III/ISCIII
Implementation partners Strategic partners
Pregantwomen
Men AdolescentsYoung Ethnicities DisabilitiesSexual
diversity
MoHWB
Health centers
Associations
Breastfeadingwomen
0-18m children
UN
WHO
UNFPA
UNAIDS
UNICEF
Iglesia católica
Sectas
Healers
Prenatal
Maternity
Justiceministry
Pediatrics
Laboratory
Pharmacia
Logistics
SIS
Statistic
UNICEF EQG CO - PMTCT Evaluation 47 Final Report
treatment in regular consultation rooms at the same centers, getting treatment from the regular
pharmacies, HIV patients can keep their condition more confidential nowadays.
Second, the programme clearly contributed to bringing access to services closer to the target population:
thanks to the programe, pregnant women from lower wealth groups, who could not afford to get
transportation to go to the region or province capital center in the past8, can now access the ARV
treatment they need.
Therefore, the main direct beneficiaries of the programme are women in reproductive age and babies
and young children. However, the programme has not done relevant contributions to address the root
causes of gender inequity around PMTCT. The programme has focused in helping pregnant women to
have access to PMTCT services but there is no component of the intervention trying to address husband’s
and men disengagement with HIV or to improve the dialogue within the couple that makes the woman
confident to discuss it when they learn that the test is positive. Likewise, the programme did not tackle
the fact that it is mostly women who take the babies to visits and for treatment, including components
addressed to men.
6.6.3. To what extent PMTCT has contributed reducing the vulnerability of women and girls to HIV
infection, and how? (via increasing the access to age-appropriate HIV information as well as
reproductive health services? via male involvement to PMTCT services can enhance HIV testing and
retention on treatment?).
Findings
triangulated by:
Methods Sources
Desk review, Interviews, Observation MoHWB, Health centers, UNICEF,
UN Agencies, CSOs
By giving mothers living with HIV enhanced access to PMTCT services, the vulnerability associated
with their condition is reduced by giving them access to free treatment closer to their homes. However,
the partner or family testing is not included in the protocol. Only some centers have the practice of
providing the woman the prescription for the husband’s test, but no enforcement or evidence of the
partner’s practices and results.
Concerning the extent to which the programme was able to tackle discrimination and promote a better
realization of Human Rights, it is worth mentioning that the local population still finds stigmatizing
going to the reference centers. Even in Family Planning centers in big hospitals, pregnant women notice
if another one leaves the consultation room carrying milk formula (as they know that means she is HIV
positive). Therefore, having these services available at health centers is a positive thing to reduce stigma
(they use same center, same rooms, same healthcare staff, same pharmacy).
8 Women used to tell the local health centers where they get tested that they did not have the 2 000 FCFAs (about 4 USD) to go to the
district center to get the treatment.
UNICEF EQG CO - PMTCT Evaluation 48 Final Report
The evaluation used a Gender analysis, as a tool to disaggregate effects of the programme in women and
men, analyzing how pregnancy, HIV and maternity affects differently each of them:
WOMEN MEN
Before being
diagnosed
They go to the doctor often, when
“something hurts”. They usually go to pass
their prenatal controls by themselves. Often
they only come when they have “a big
belly”.
Even those who are not familiar with HIV
accept to be tested and if positive, to be
treated.
Men do not frequent health centers
unless for serious cases. They are
expected to be strong, have many kids
and women.
They do not use to go to prenatal
visits with their wife or take the kids
to the doctor.
Only in some young couples, men can
be seen accompanying the woman to
pregnancy controls.
After having
been diagnosed
During counseling after the test, if positive,
some cry, others do not accept it (small
proportion) and in general they accept to
take the treatment.
They give priority to the baby wellbeing.
They face internal conflict to tell their
husband. While they should inform him
and encourage him to be tested too, many
do not even tell them.
In some centers, they provide them the
prescription for the husband test, but there
is no way to follow up if she gave him or if
he did it.
In the few cases where the woman
tells him, many react badly (ignoring
or even worse).
Even during sensitization community
sessions, many act as if the virus does
not exist.
Prevalence rate: 8% Prevalence rate: 3%
Before the
programme
They had to go periodically to the UREIs
and justify why they had to go that often in
front of their partner
They didn’t understand why the
women had to visit the hospital every
month if she was not “sick”.
After the
programme
At the specialized centers they give them
treatment and they refer them to the closer
center in their area.
This makes it easier to get their medicines.
In some cases other pregnant women notice
if one leaves the consultation room with
artificial milk, so HIV positive women hide
it. Others getting free artificial milk
(breastfeeding is rare) encourage them to
follow their treatment as the milk is costly.
No remarkable changes in men after
the programme.
Figure 26: Gender Analysis on how PMTCT affects women and men
UNICEF EQG CO - PMTCT Evaluation 49 Final Report
6.6.4. To what extent has UNICEF role enhanced pursue of exposed child rights? How has that
contributed to decrease the spreading of HIV and the impact of the epidemic on children and families?
Findings
triangulated by:
Methods Sources
Desk review, Interviews MoHWB, UNICEF
As mentioned earlier, the actual progamme contribution to reduce vertical transmission cannot be
assessed due to lack of reliable data, but the intervention’s logic clearly puts exposed children’s rights as
defined by the Convention on the Rights of the Child (CRC) and the general recommendations of the
Committee on the Elimination of Discrimination against Women (CEDAW) at the center of the
intervention. By reducing the possibilities of transmission during pregnancy, and increasing the
possibilities of protection with prophylaxis and artificial milk instead of breastfeeding, their possibilities
to get an AIDS free start increase. At the same time, making treatment more available to keep their
mothers alive also redounds on their rights.
UNICEF also has advocacy initiatives to mobilize resources and start EID in the country. EID by
GeneXpert9 will contribute to reduce the infant mortality by putting early on ARV treatment all children
infected by vertical transmission. The GeneXpert machines could be also used to do the follow-up of
viral load among pregnant women.
6.6.5. How has the programme enhanced service access and utilization for the most disadvantaged and
excluded women and children across factors such as geographic location, gender inequality, economic
status, social and cultural?
Findings
triangulated by:
Methods Sources
Desk review, Interviews, Observation MoHWB, Health centers, UNICEF,
UN Agencies, CSOs
Even though the decentralization works on the line of making services more accessible to more remote
populations, the fact that still people living in villages may be more vulnerable to vertical transmission
is due to several reasons. First, they have less access to healthcare services (access to the head of the
district is often complicated), less access to information (no electricity or radio reaches all rural areas),
and it is harder for health workers to trace them as often there is no phone network.
Therefore, not until the access to services is granted at local level (mainly by engaging with primary
health mobile workers that go to the villages) will the system have made available the services to reach
the possibly most vulnerable population (up till now, for rural areas, only women with interest and
means manage to go for their treatment).
If that is the case, central-to-local decentralization programmes like this one could be perpetuating
inequities if they do not reach a sufficient level of implementation at rural level, as people living in urban
context can be more and more familiarized with HIV and get relatively easy access to treatment, while
people living in rural areas could be more affected by the condition, more unaware and have still more
difficult access to services.
9 The GeneXpert test is test measurement of blood plasma HIV-1 RNA concentration (known as HIV viral load) using nucleic acid-
based molecular diagnostic assays.
UNICEF EQG CO - PMTCT Evaluation 50 Final Report
7. GOOD PRACTICES The evaluation has allowed the identification of some good practices that have contributed to the
observed results. At the central and programme management level:
• Decentralizing is in itself a good, necessary practice that allows PLWHIV to normalize their
treatment and follow-up of their condition. All the changes in protocol to make the PMTCT services
more normalized and merged with other regular services contribute to reduce stigma and deal with
the syndrome. For example, reducing the number of test controls from monthly to quarterly in the
protocol is also a good practice that builds on the same logic of reducing stigma and difficulties to
get treated. Normalizing the prescriptions, pharmacies and consultation rooms for PMTCT and HIV
patients in general creates less stigma.
• Improvements in the technology of the test and treatment (more sophisticated and precise test, ARV
drugs combined in one instead of having several, quick tests with alternative algorithm) also make
the patients’ life easier.
• Having tested the model at small scale and having succeeded scaling it up later is a good strategy that
not all policies managed to opt for.
• The decision of bringing a first batch of tests, medicines and milk during one the first supervision
visit was key to a timelier start of services provision, which may have otherwise been delayed for
months or even never have taken place.
At the healthcare providers level, some good practices were identified, which, although not included in
the protocol or provided by the programme itself, are successfully featured by some individual initiatives:
• Some centers provide pregnant women living with HIV with a prescription for their husbands to get
tested: this led many men to go to a laboratory and get tested, too.
• Some centers use core funds from the resources generated through the administration of HIV test to
call patients that have missed their treatment. In some extreme cases, healthcare workers have even
taken their vehicles and taken the medicine to the woman’s home.
• Some centers design and produce their own registry book when the one which they are given does
not facilitate follow-up (with no columns per month). They also produce their photocopies when
the programme do not provide them.
Lessons Learned • Supervision visits are key to consolidating the decentralization of a new service, as it makes both
quality of services and practices improve, and practitioners feel more confident. When
systematically asked about how can the programme improve, the healthcare providers consulted
during the evaluation all mentioned more training and periodic (monthly or quarterly) supervision
visits.
• If the coverage of pregnant women tested does not reach the majority of estimated pregnant women
once the decentralization is finished, and once data about services provided are reliable, the system
will have to go beyond the healthcare approach to a more sociological dimension.
• Some countries in the region (as Angola, Rwanda, Senegal, Tanzania and Zimbawe) have contributed
to the decentralization of ARV provision at the community level and have developed community
follow-up mechanisms.
UNICEF EQG CO - PMTCT Evaluation 51 Final Report
8. CONCLUSIONS In order to increase the traceability between findings and conclusions, here is the summary of findings
and the consequences and implications of them. To identify their origin, it is specified the section where
those findings were presented:
FINDINGS CONCLUSIONS
The decentralization is working-in-progress
and a reality at district level, but it is not
finalized or consolidated. Access to PMTCT is
available at district level but many differences
are observed in the implementation levels of
different parts of the system. (6.2.1, page 27).
The closer PMTCT services get to the 30% of the
population living in rural areas, the bigger possibility
the country has to reach 100% of women tested and
treated.
Involving Primary Attention Health agents may be
needed to reach such a penetration level.
It is not possible to know the progress made in
reducing vertical transmission as there is no
reliable, consolidated data (6.2.1, p. 31).
This evaluability (ability to be evaluated) issue makes
the efforts’ results difficult to measure.
Few actors work in the country on PMTCT, so
they often have multiple roles (6.5.3, p.43)
In order to mobilize the population in order to reach
more people, UNICEF and the Government would need
to expand and involve other actors to have enough
critical mass.
Many women start having conscience of the
issue and more women accept to do the test and
start treatment in case of positive results.
However, it is estimated that still 40% of
women give birth through traditional methods
(6.6.3, p.44)
The approach of making the service available may not
suffice for those women who do not demand them
despite the government’s pursuit of the elimination of
vertical transmission.
Many women who start treatment stop coming
to the centers and the programme has weak
follow-up mechanisms. Coordination
mechanisms within the different services in the
centers are also not systematic (6.2.1 and 6.2.7)
If the services are there but the follow up is not done,
the objectives will not be achieved either.
Not putting in place systematic mechanisms for
following up the patient since its caption until their
medical release is a lost opportunity.
UNICEF seems to have been the leader
implementing the decentralization (6.5.1. p. 42)
UNICEF is capable of pursuing and contributing to the
consolidation of the decentralization and is in a position
to look for further synergies and alliances for bigger
impact.
PMTCT leadership at healthcare center level is
very variable across the directors, doctors (local
and/or Cubans), midwives, etc.
It would be desirable to unify this role, but informal
local champions seem to take the leadership according
to apparently personal sympathy for the service.
NGOs working with PLWHIV have roles of
support but their coverage is very limited
The PLWHIV voice is difficult to collect in order to
understand their experience of the services.
Stock breaks seem to be anecdotic and no
relevant ones were identified at local or general
level. The artificial milk is the item that more
often is scarce, and one of the HIV test reactive
(punctual) (6.2.1).
The procurement team has to keep up the good work
and continue focusing in covering the needs, mostly
when 33 new centers are expected to implement the
PMTCT services in the following phase.
Figure 27: Table of correlation between Key Findings and Key Conclusions
UNICEF EQG CO - PMTCT Evaluation 52 Final Report
In summary, given the size and progress made by the country, HIV could be controlled and eliminated
in the next decades.
Remaining challenges:
• The healthcare system is generally well equipped in terms of infrastructures and staff. However,
important challenges remain in the field. For example, some district hospitals visited do not have
running water (Niefang, Nsok Nzomo), or hygiene standards in toilets is not ideal (Ebibeyín province
hospital). Some healthcare centers premises are small, and the same room is used as laboratory (one
table) and as vaccination place (another table in a small room).
• The system is more focused in reducing vertical transmission amongst the users of the formal
healthcare system, leaving citizens using traditional methods out of the prevention circuit.
• The whole PMTCT put in place will not achieve its results (eliminate vertical transmission) if the
mother is not regular in her visits to the healthcare center, both while pregnant and when the baby
is born. However, taking a look at the registry books of the centers reveals that many patients
interrupt their treatment and the centers do not often have the budget (10 000 -15 000 FCFAs /
month, around 20 USD) to call them to remind them, encourage them and follow up on their
treatment.
• Once the baby is tested positive and they are out of the programme, the mother goes back to be an
HIV positive adult (not a pregnant woman anymore) who often has to go back to the UREI for
treatment as the decentralization of HIV treatment for adults is not implemented in many centers
yet.
• The system lacks reflective thinking at many levels: due to lack of means, time or encouragement,
very few cases were found where a doctor or a center director elaborated monthly or yearly statistics,
to analyze the performance and impact of their work in PMTCT.
• Men’s relationship and involvement with the mother’s HIV condition remains a weakness as many
do not tell their husbands and those who do, husbands do not seem to be affected by it.
• In well-functioning healthcare centers, the system provides them with medicines and inputs
(delivered to their premises) and the centers provide with periodic data (sent either by hard or soft
copies). However, in the EQG health system, health centers have to find the means to go fetch the
medicines to their closest reference general warehouse and at the same time, officers at area, region
and central level have to go themselves to fetch the data (as there is no systematic circuit to send
them monthly or periodically).
Lastly, the evaluation used a last tool (a tensiometer10) to provide general insights about other aspects of
the programme. It consists of an assessment of the different dimensions UNICEF had to balance while
implementing the programme as expected. Without including a judgement (the tool does not specify
where UNICEF should be placed), and for the issues that most outstood, this would be the programme’s
42.- Ernesto Nvo Ada Técnico de laboratorio HOSPITAL DE EBEBIYI
43.- Dr. Rubén Mariano
Rodríguez Brigada médico cubano
HOSPITAL DE NSOK-
SOMO
44.- Dra. Demetria Pilar eki Directora HOSPITAL DE AÑISOK
UNICEF EQG CO - PMTCT Evaluation 63 Final Report
Annex 7. Evaluation tools (interviews guidelines)
QUESTIONNAIRE FOR INTERVIEWS WITH UNICEF STAFF
1.1. To what extent has UNICEF identified and addressed priority needs for SI/KM products and services
in support of national PMTCT program?
1.2. To what extent has UNICEF supported national governments to leverage funds, both domestic and
external, in a manner consistent with country context (e.g. middle-income, low-income)?
2.1. To what extent did the Programme attain its intended results at country level/regional level/global
level?
2.2. What trade-offs were made to ensure that partnership arrangements could work as intended? What
were the related risks?
2.3. To what extent have these partnerships helped national PMTCT programme achieve their national
goals and targets? To what extent have partnerships contributed to the achievement of global PMTCT
targets?
2.4. To what extent has UNICEF contributed to the building of national systems? How have focus on
achieving goals been balanced with the drawbacks of vertical programmes?
2.5. What were the unexpected (positive and negative) outcomes of the PTMCT PRogramme?
2.6. To what extent have the resource mobilization goals of the national plan been achieved?
2.6. To what extent are there gaps, overlaps and/or missed opportunities in programming that arise from
UNICEF’s organization structure?
2.7. To what extent has UNICEF capitalized on its structures and presence between sectors to achieve its
intended results as per the Strategic Plan and Global Plan for
elimination?
2.8. How has UNICEF organized internally to address PMTCT?
2.9. To what extent UNICEF has utilized evidence from trials/ pilot tests interventions to inform scaling
up of proven effective approaches? Has UNICEF facilitated learning and knowledge sharing between
partners and national counterparts to inform adoption and scaling up of proven effective approaches?
2.10. To what extent has UNICEF translated global policies and strategies through user-friendly
platforms and tools for use in national PMTCT program?
2.11. To what extent has UNICEF utilized its structures and resources across levels in a coordinated
manner to achieve its intended results as per the Strategic Plan and Global Plan for elimination?
3.1. What is the return on UNICEF investments in the areas of PTMCT advocacy and partnerships? To
what extent did these efforts “pay off” in a tangible manner?
UNICEF EQG CO - PMTCT Evaluation 64 Final Report
3.3. To what extent did UNICEF’s global, regional and country-level programs pursue and attain output-
level results through the least costly means?
3.4. To what extent has UNICEF capitalized on inter-sectoral linkages to bolster resources for PMTCT
(e.g. social protection, education, health)?
3.5. To what extent did UNICEF’s resource mobilization efforts garner funds relative to the investment
of time and resources?
3.6. To what extent was value for money considered in decision-making?
3.7. To what extent has UNICEF provided effective support for countries to access funds for PMTCT
program from other sources?
4.3. To what extent has UNICEF incorporated sustainability considerations in its work at country levels?
6.1. To what extent did UNICEF contribute to Human Right and Gender approach in PMTCT program?
6.2. To what extent did the UNICEF CO contribute to equity approach in PMTCT programme?
6.3. To what extent PMTCT has contributed reducing the vulnerability of women and girls to HIV
infection, and how? (via increasing the access to age-appropriate HIV information as well as reproductive
health services? via male involvement to PMTCT services can enhance HIV testing and retention on
treatment?).
6.4. To what extent has UNICEF role enhanced pursue of child rights? How has that contributed to
decrease the spreading of HIV and the impact of the epidemic on children and families?
6.5. How has the programme enhanced service access and utilization for the most disadvantaged and
excluded women and children across factors such as geographic location, gender inequality, economic
status, social and cultural?
QUESTIONNAIRE FOR INTERVIEWS WITH MOH STAFF
1.1. To what extent has UNICEF identified and addressed priority needs for SI/KM products and services
in support of national PMTCT program?
1.2. To what extent has UNICEF supported national governments to leverage funds, both domestic and
external, in a manner consistent with country context (e.g. middle-income, low-income)?
2.1. To what extent did the Programme attain its intended results at country level/regional level/global
level?
2.2. What trade-offs were made to ensure that partnership arrangements could work as intended? What
were the related risks?
UNICEF EQG CO - PMTCT Evaluation 65 Final Report
2.3. To what extent have these partnerships helped national PMTCT programme achieve their national
goals and targets? To what extent have partnerships contributed to the achievement of global PMTCT
targets?
2.4. To what extent has UNICEF contributed to the building of national systems? How have focus on
achieving goals been balanced with the drawbacks of vertical programmes?
2.5. What were the unexpected (positive and negative) outcomes of the PTMCT PRogramme?
2.6. To what extent have the resource mobilization goals of the national plan been achieved?
2.6. To what extent are there gaps, overlaps and/or missed opportunities in programming that arise from
UNICEF’s organization structure?
2.7. To what extent has UNICEF capitalized on its structures and presence between sectors to achieve its
intended results as per the Strategic Plan and Global Plan for elimination?
2.9. To what extent UNICEF has utilized evidence from trials/ pilot tests interventions to inform scaling
up of proven effective approaches? Has UNICEF facilitated learning and knowledge sharing between
partners and national counterparts to inform adoption and scaling up of proven effective approaches?
2.10. To what extent has UNICEF translated global policies and strategies through user-friendly
platforms and tools for use in national PMTCT program?
3.1. What is the return on UNICEF investments in the areas of PTMCT advocacy and partnerships? To
what extent did these efforts “pay off” in a tangible manner?
3.3. To what extent did UNICEF’s global, regional and country-level programs pursue and attain output-
level results through the least costly means?
3.4. To what extent has UNICEF capitalized on inter-sectoral linkages to bolster resources for PMTCT
(e.g. social protection, education, health)?
3.5. To what extent did UNICEF’s resource mobilization efforts garner funds relative to the investment
of time and resources?
4.1. To what extent have UNICEF’s mandate, structures and resources contributed to sustainable
country-led PMTCT program?
4.2. To what extent has UNICEF supported the development of costed national plans for the elimination
of MTCT in the country?
4.3. To what extent has UNICEF incorporated sustainability considerations in its work at country levels?
4.4. To what extent has UNICEF strengthened national M&E capacity? To what extent have these efforts
strengthened countries’ ability to focus on issues of equity? To what extent have these efforts
strengthened countries’ ability to generate and use data for accountability and learning for PMTCT
program?
UNICEF EQG CO - PMTCT Evaluation 66 Final Report
5.1. To what extent are there comparative advantages based on UNICEF’s mandate, structures and
resource?
5.2. To what extent does UNICEF have a comparative advantage and demonstrate added value in taking
a leadership role in PMTCT forums vis-a-vis others players?
5.3. To what extent did UNICEF’s leadership role in PMTCT forums contribute to the achievement of
its strategic priorities?
5.3. In case of comparative advantages, to what extent has UNICEF leveraged them fully in in pursuit of
its intended results?
6.1. To what extent did UNICEF contribute to Human Right and Gender approach in PMTCT program?
6.2. To what extent did the UNICEF CO contribute to equity approach in PMTCT programme?
6.3. To what extent PMTCT has contributed reducing the vulnerability of women and girls to HIV
infection, and how? (via increasing the access to age-appropriate HIV information as well as reproductive
health services?; via male involvement to PMTCT services can enhance HIV testing and retention on
treatment?).
6.4. To what extent has UNICEF role enhanced pursue of child rights? How has that contributed to
decrease the spreading of HIV and the impact of the epidemic on children and families?
6.5. How has the programme enhanced service access and utilization for the most disadvantaged and
excluded women and children across factors such as geographic location, gender inequality, economic
status, social and cultural?
QUESTIONNAIRE FOR INTERVIEWS WITH OTHER PARTNERS
1.1. To what extent has UNICEF identified and addressed priority needs for SI/KM products and services
in support of national PMTCT program?
1.2. To what extent has UNICEF supported national governments to leverage funds, both domestic and
external, in a manner consistent with country context (e.g. middle-income, low-income)?
2.1. To what extent did the Programme attain its intended results at country level/regional level/global
level?
2.2. What trade-offs were made to ensure that partnership arrangements could work as intended? What
were the related risks?
2.3. To what extent have these partnerships helped national PMTCT programme achieve their national
goals and targets? To what extent have partnerships contributed to the achievement of global PMTCT
targets?
2.4. To what extent has UNICEF contributed to the building of national systems? How have focus on
achieving goals been balanced with the drawbacks of vertical programmes?
UNICEF EQG CO - PMTCT Evaluation 67 Final Report
2.5. What were the unexpected (positive and negative) outcomes of the PTMCT PRogramme?
2.6. To what extent are there gaps, overlaps and/or missed opportunities in programming that arise from
UNICEF’s organization structure?
2.7. To what extent has UNICEF capitalized on its structures and presence between sectors to achieve its
intended results as per the Strategic Plan and Global Plan for elimination?
2.9. To what extent UNICEF has utilized evidence from trials/ pilot tests interventions to inform scaling
up of proven effective approaches? Has UNICEF facilitated learning and knowledge sharing between
partners and national counterparts to inform adoption and scaling up of proven effective approaches?
2.10. To what extent has UNICEF translated global policies and strategies through user-friendly
platforms and tools for use in national PMTCT program?
3.3. To what extent did UNICEF’s global, regional and country-level programs pursue and attain output-
level results through the least costly means?
3.4. To what extent has UNICEF capitalized on inter-sectoral linkages to bolster resources for PMTCT
(e.g. social protection, education, health)?
4.1. To what extent have UNICEF’s mandate, structures and resources contributed to sustainable
country-led PMTCT program?
4.2. To what extent has UNICEF supported the development of costed national plans for the elimination
of MTCT in the country?
4.3. To what extent has UNICEF incorporated sustainability considerations in its work at country levels?
4.4. To what extent has UNICEF strengthened national M&E capacity? To what extent have these efforts
strengthened countries’ ability to focus on issues of equity? To what extent have these efforts
strengthened countries’ ability to generate and use data for accountability and learning for PMTCT
program?
5.1. To what extent are there comparative advantages based on UNICEF’s mandate, structures and
resource?
5.2. To what extent does UNICEF have a comparative advantage and demonstrate added value in taking
a leadership role in PMTCT forums vis-a-vis others players?
5.3. To what extent did UNICEF’s leadership role in PMTCT forums contribute to the achievement of
its strategic priorities?
5.3. In case of comparative advantages, to what extent has UNICEF leveraged them fully in in pursuit of
its intended results?
6.1. To what extent did UNICEF contribute to Human Right and Gender approach in PMTCT program?
6.2. To what extent did the UNICEF CO contribute to equity approach in PMTCT programme?
UNICEF EQG CO - PMTCT Evaluation 68 Final Report
6.3. To what extent PMTCT has contributed reducing the vulnerability of women and girls to HIV
infection, and how? (via increasing the access to age-appropriate HIV information as well as reproductive
health services?; via male involvement to PMTCT services can enhance HIV testing and retention on
treatment?).
6.4. To what extent has UNICEF role enhanced pursue of child rights? How has that contributed to
decrease the spreading of HIV and the impact of the epidemic on children and families?
6.5. How has the programme enhanced service access and utilization for the most disadvantaged and
excluded women and children across factors such as geographic location, gender inequality, economic
status, social and cultural?
Annex 8. Principles Of Ethical Conduct Of Evaluation The final evaluation of the joint program was carried out according to the ethical principles and standards
defined by the United Nations Evaluation Group (UNEG).
• Anonymity and confidentiality. The evaluation must respect the rights of the people who
provide information, guaranteeing their anonymity and confidentiality.
• Responsibility. The report should include any conflicts or differences of opinion that may have
arisen between the consultants or between the consultant and the radio managers regarding the
conclusions and / or recommendations of the evaluation. The entire team must confirm the
results presented, any disagreements to be indicated.
• Integrity. The evaluator will need to highlight issues that are not specifically mentioned in the
ToR, to obtain a more complete analysis of the partnership.
• Independence. The consultant must ensure that he / she remains independent of the program
under review, and he / she should not be involved in its management or any part of it
• Incidents. If problems arise during fieldwork, or at any other point in the evaluation, they should
be reported immediately to the Monitoring and Evaluation Specialist at UNICEF. If this is not
done, the existence of such problems can in no way be used to justify the failure to achieve the
results expected by UNICEF in these ToR.
• Validation of information. The consultant must ensure the accuracy of the information gathered
during the preparation of the reports and will be responsible for the information presented in
the final report.
• Intellectual property. Using the different sources of information, the consultant must respect
the intellectual property rights of the institutions and communities examined.
• Submission of reports. If the submission of reports is postponed, or if the quality of the submitted
reports is significantly worse than agreed, the sanctions provided for in these terms of reference
will apply. The Evaluation team will need to ensure the timely submission of deliverables as well
as the conformity of the draft and final report with the GEROS Evaluation Quality Assurance
criteria as well as the UNEG Quality Checklist for Evaluation Reports.
UNICEF EQG CO - PMTCT Evaluation 69 Final Report
Annex 9: Preliminary results presentations (links) To UNICEF team: