Evaluation database

Evaluation report

2004 MOZ: Prevention of Mother-to-Child Transmission of HIV in Manica and Sofala Provinces: A Quantitative and Qualitative Project Evaluation

Author: Sheldon, S.

Executive summary

Background:

The project to be evaluated had completed a two-year phase. It is of significant interest to UNICEF and Health alliance International (HAI), as it is a pilot project where the two agencies have worked together with the satblsihment of the first PMTCT sites in Mozambique in 2002. The intention of the evaluation was to provide information on the successes and constraints of this project in order to provide material for implementing future initiatives planned between the two agencies.

Purpose/Objective:

• To assess the quality of key activities of the PMTCT services provided; especially voluntary counselling and testing.
• To measure the influence of the PMTCT project on the barriers related to stigma and women’s power in decision-making.
• To identify successes, strengths, and strategies that can be replicated, as well as constraints that impede attainment of project objectives.

Methodology:

Quantitative Instrument: Fifty-seven (57) exit interviews designed to measure satisfaction with services were conducted with mothers leaving testing and counseling services. At each of the five sites, all exiting mothers were interviewed during one full day of operations

Qualitative Instruments: Focus group discussions. At each of the project health centers, a focus group discussion was held with members of Positive Mothers Clubs. The goal was to provoke discussion amongst HIV+ mothers and mothers-to-be concerning complex topics; including: Infant feeding, Empowerment (Involvement of Husband + Family Planning) and Stigma + Confidentiality.

Semi-Structured Interviews: In-depth semi-structured interviews were conducted with two health personnel at each project health center, usually one HIV testing counselor and one MCH nurse. Interview topics included training received, adherence to established protocols, knowledge of MTCT, thoughts on women’s empowerment and infant feeding, and general comment on project implementation.

Findings and Conclusions:

1. Successful implementation and management of the PVT program is rooted in a strong partnership between DPS, HAI and UNICEF. The experience of creating coordination mechanisms and defining clear roles of DPS, HAI and UNICEF can be reviewed as an illustrative example in development of best practices in the implementation of the National Strategic Plan’s integrated networks for prevention and treatment for HIV/AIDS.

2. Integration of PVT services into prenatal and primary care services is crucial.The program has demonstrated increasing program attendance and adherence over time because women are empowered to make their own choices when PVT services are integrated into routine prenatal care.

3. The development of a successful PVT program can be a catalyst to reinforce all components of the MCH program. Many MCH program aspects are not directly dependant on PVT, but because of the increased vulnerability of seropositive mothers, it is imperative that associated services be strengthened.  Further integration of PVT services should be pursued, including in institutional births, child monitoring, family planning, nutritional counseling, post birth follow-up, and partner counseling.

4. Health facilities and trained health personnel are the single most limiting factor in terms of project expansion.

5. Ongoing training needs must be regularly addressed. The provision of training is one of the most important functions of national and provincial management. Unless managers, counselors, MCH nurses, and Day Hospital staff have appropriate knowledge, skills, and attitudes, the PVT project is only partially effective.

6. IEC can be a powerful mobilization tool in increasing uptake of testing and associated PVT services. Interpersonal and mass communications has proven to be effective in mobilizing and informing mothers about PVT services. Expansion and standardization of strategies and messages is needed to support a complete IEC campaign.

7. Stigma and discrimination of seropositive women are important aspects that must be considered in expansion of PVT services.

8. Greater partner involvement is essential.

9. Women must be rallied as peer educators and program advocates. The best mechanism for mobilizing women and encouraging adherence to the PVT project is involving women themselves as project activists – otherwise the project runs a great risk of continuing to lose women.

10. Comprehensive monitoring and reporting systems can best illustrate project successes and ongoing challenges.

Recommendations:

• Maintain advocacy with central government and international donors to increase funding for human resources in the health sector.
• Promote full integration of PVT into MCH services, moving towards a cadre of MCH nurses with full training in HIV counseling and testing as well as other aspects of PVT.
• As an interim measure, create a pool of trained ‘on call’ HIV lay counselors in each province that can be summoned when needed.
• Explore creative staffing ideas, using community leaders, traditional healers and birth attendants, and ‘graduated’ positive mothers as peer educators to provide onsite and community-based educational/information sessions
• Reinforce referral and monitoring links between the PVT project and the HIV/AIDS support services in both provinces
• Referral routinely occurs between specific PVT project services; i.e. from prenatal consult to HIV testing center; and from testing center to mother support groups, day hospital, and maternity. Uptake remains a challenge in all cases; particularly in relation to birthing in maternities, as discussed above.
• Formalize partnerships with local and community groups, specifying roles and providing capacity building where needed.
• Encourage partner testing and tracking through implementation of a coded invitation card system.
• Barriers to uptake of post-partum counseling and family planning services must also be addressed. Where deemed necessary, expansion of service hours should be considered.

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