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Evaluation report

2012 Ukraine: ‘Prevention of Mother-to-Child Transmission and Improving Neonatal Outcomes among Drug-Dependent Pregnant Women and Children Born to Them in Three Cities in Ukraine’



Author: Tamar Gotsadze MD., PhD., Public Health Specialist

Executive summary

"With the aim to continuously improve transparency and use of evaluation, UNICEF Evaluation Office manages the "Global Evaluation Reports Oversight System". Within this system, an external independent company reviews and rates all evaluation reports. Please ensure that you check the quality of this evaluation report, whether it is "Outstanding, Best Practice", "Highly Satisfactory", "Mostly Satisfactory" or "Unsatisfactory" before using it. You will find the link to the quality rating below, labeled as 'Part 2' of the report."

Background:

Ukraine has the highest adult HIV prevalence in all of Europe and Central Asia, with an estimated HIV prevalence rate of 1.1% among the adult population. This prevalence is significantly higher than any other European or CIS country. The HIV epidemic is predominantly driven by injecting drug use and is increasingly affecting women. In fact, Ukraine is facing a dual epidemic of HIV and drug use.  

While injecting drug use remains the primary route of transmission of HIV, heterosexual transmission in Ukraine is growing. Women are more prone to infection due to their biological and social vulnerability.  They now represent 45% of all adults living with HIV in Ukraine, and most of them are of reproductive age.  In 2011, more than 5,000 pregnancies were registered among HIV-positive women.  The HIV prevalence among pregnant women in Ukraine is the highest in Europe. The absolute number of children infected with HIV through mother-to-child transmission (MTCT) continues to increase, as there is a yearly 20-30% increase in HIV-infected pregnant women. According to Ministry of Health statistics, 32,504 children were born to HIV-positive mothers between 1995 and 2012: 21,916 with negative HIV status; 6,735 children awaiting confirmation of their HIV status; 2,814 with HIV-positive status; and 752 having AIDS and 287 children having died of AIDS.

Although important progress in prevention of mother-to-child HIV transmission (PMTCT) programmes that has led to a decrease of HIV transmission to babies from 20% in 2000 to 4.9% in 2009, serious issues and challenges remain.

Purpose/Objective:

The purpose of the assignment was to carry out the interim assessment of the pilot project ‘Prevention of Mother-to-Child Transmission and Improving Neonatal Outcomes among Drug-Dependent Pregnant Women and Children Born to Them in Three Cities in Ukraine’ (hereinafter Project) in order to develop the recommendations on how to achieve the goal of a project and formulation of the future interventions in a context beyond the medical.

The current assessment report documents results and the lessons learned specifically on “what worked” and “what did not work” and answer the question of how to strengthen social services enabling it to identify women vulnerabilities at early stages as an entry point to the system of integrated treatment and care for them and their children.  

The assessment immensely benefited from collective contributions by concerned stakeholders, the project staff, decision makers, donors and project beneficiaries. It looked at project’s   a) achievements, strengths, shortcomings and weaknesses; b) outlined remaining key bottlenecks, including policies, practices and other structural barriers in medical and social areas for the Project implementation.  

Based on the findings the report provides strategic, policy and implementation recommendations of how to strengthen the on-going Project in order to guarantee achievement of its key outcome as well as ensure the model’s efficiency and sustainability in future.

Methodology:

METHODOLOGY:  The assessment methodology comprised of a mix of site visits and observation, face-to-face semi structured interviews of key informants, focus group discussions, desk-based research and review of existing reports, documents and secondary data. Desk Review - Review of documents was a major part of the assessment. 

Semi-structured Interviews - for the key informants on the national, regional and municipal levels, policy makers and relevant public institutions/entities, UNICEF and project staff, administrative staff of service provider institutions, NGOs etc. 

Appreciative enquiry - An approach was used to explore successes and positive experiences in dialogue with individuals and groups of people and have been applied in order to strengthen understanding of why something worked well, and how success could be replicated. 

Field Analysis - to gain an overview of the different forces driving or resisting change that the project is trying to bring.

Focused Group Discussions (FGDs) - Three FGD comprise of: i)drug-dependent pregnant women who used the services; ii) Drug-dependent pregnant women who did not use the services; iii) Integrated service provision teams and iv) Public sector social workers.  

Triangulation of findings - Finally the examination of data from the above sources were carried out to arrive at conclusions and formulate recommendations. 

Ethical Issues - to minimize disruptions in respondents work process and ensure confidentiality. 

Data Sourses – People, Site visits, Documents and Quantitative Analysis. 

Findings and Conclusions:

HIGH RELEVANCE - The Intervention is highly relevant in advocating and facilitating achievement of the National HIV/AIDS strategy goals as well as contributes to the prevention of mother to child transmission and ensures quality MCH service provision to the target beneficiaries. 

OWNERSHIP - The demonstrated ownership from the government is observed.  The MOH and local health authorities established supportive legal environment that regulates delivery of medical services to the beneficiaries through integrated care model.  

ENABLING ENVIRONMENT - Basic enabling environment set by the project supported the introduction of integrated care model. Trainings supported by the project stimulated change of their behavior, attitude and practice towards drug dependent women.

ENROLLMENT AND HIGH BENEFICIARY SATISFACTION - The project clients being treated as human first time in their lives. This inspired them to share experience to their former community members and spread the information about available services. 

PUBLIC AND CIVIL SOCIETY PARTNERSHIP - The project successfuly demonstrated close partnership between public and civil society organizations. It stimulated government contracting out of selected social services to NGOs, being innovative in Ukraine’s history.

NOTICEABLE IMPROVEMENT OF ATTITUDE TOWARDS BENEFICIARIES - The project facilitated the recognition of pregnant drug-addicted women as a target group for integrated services by the health and social sector authorities. 

PROSPECTS OF SUSTAINABILITY - The positive experience stimulates local governments to replicate the model to other cities. These developments demonstrate effectiveness of the pilot and ensure sustainability of project achievements. The integrated care model in itself and a need for service package expansion and strengthening social services, breeds discussions and facilitates close inter-sectoral cooperation and collaboration of health and social sector partners.

Recommendations:

1. Expansion of Target Group and Outreach Activities
2. Ensure Service Integration  
- Define basic package of services to be provided by ICM
- Introduce effective Case Management Function as a transitional model
- Develop integrated treatment guidelines/protocols 
- Develop staffing norms and job descriptions
- Design assessment tools
- Staff Training - To develop integrated training curricula including assessment techniques, evidence based interventions, referral systems, coordination of care and review mechanisms, training in case management and development of integrated care plans
- Formulate ICM funding and incentives based reimbursement Methodologies
3. Ensure Sustainability of Integrated Care Model
- Promote rights of service users
- Promote Top Down Integration -  In order to mitigate the political risks and vulnerability of the model and ensure its sustainability the government is advised to promote “top down” integration. 
- Integration of the ICM model in the new five year National AIDS strategy
- Develop National legislation regulating ICM 
- Harmonization of existing legislation 
4. Intensify Advocacy Efforts  - To strengthen advocacy efforts from UNICEF, ensuring active engagement of the policy makers in formulation of the social and health sector reform agenda
5. Enhance Information/Communication Activities
6. Development of Comprehensive M&E   Framework and System

Lessons Learned:

The pilots have not yet been able to completely fulfill the goal of bridging the health care and social systems in order to improve the continuity of care and outcomes for patients. The main reason is the legal and regulatory structure of Ukraine’s medical and social systems, uncertainty with ongoing reforms in both sectors, funding issues and staffing shortages. But it is clear that Project is contributing to improvements in access to care and treatment and increasing cooperation across medical disciplines. Pilot project model, being successful, has huge potential to reshape Ukrainian health and social sectors for the better, and not only for people dealing with drug dependency.  

The project has other positive tangible result. Staff cited feelings that they are now better able to serve their clients under the IC model. “We got used to our patients, learned to trust each other and now we see them, I’d say, almost like relatives,” (the head of maternity department at Dnepropetrovsk). Patients’ experiences have mirrored this: “I like the attitude of the medical staff very much. They are kind and supportive, and they treat us as equals. It’s the furthest thing from many other clinics.” (the words of Natalia, a participant in the Dnipropetrovsk ICM programme)



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