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Evaluation report

2012 Belarus: Country-led PMTCT Programme Progress Evaluation in the Republic of Belarus



Author: UNICEF expert Mariam Jashi, Abrazhey Alesya, Barsukov Alexander, Strupovets Svetlana

Executive summary

Background:

HIV epidemic continues to spread in Belarus with 10% increase of officially registered cases annually and  13,726 (114 per 100,000) citizens living with HIV as of 1 August 2012.  However the real figure is likely to be much higher, and is estimated to be exceeding 30,000 HIV positive people.

Since 2005 sexual route of HIV transmission has prevailed, raising from 57.2% in 2005 up to 77.2% in 2012. The shift in transmission modes resulted in a growing number of HIV cases among women of reproductive age, pregnant women and children born to HIV positive mothers. As of 1 August 2012, 2,126 children were born to mothers living with HIV (126 in 7 months 2012). Despite a range of proactive preventive efforts and information education campaigns more than 50% of pregnant women still learn about their HIV positive status during pregnancy and 25-29% of them choose to terminate the pregnancy.

National HIV Prevention Programme for 2011-2015 aims at elimination of mother to child transmission of HIV by 2015 and envisages health system strengthening, upgrading professional qualifications, etc. The majority (60%) of the National HIV Prevention Programme activites are financed through the Global Fund grants. In 2011 Belarus experienced financial crisis that can have negative implications on the state commitments to financing the National HIV Prevention Programme and reaching national goals of zero new HIV infections by 2015.

PMTCT programme evaluation is essential for identifying key remaining bottlenecks in regulatory frameworks, budgeting, institutional capacities and service provision. It is critical for designing a strategic national response that comprehensively address all major constraining factors in prevention, treatment, care and support to HIV positive mothers and their newborns, and ultimately to virtual elimination of MTCT.

Purpose/Objective:

•To identify existing gaps, bottlenecks and challenges and assess the rendered PMTCT services versus following determinant categories: enabling environment,  supply, demand and quality;
•To assess feasibility and accessibility of services for most-at-risk population groups (HIV positive pregnant women, women of sex business, drug dependent pregnant women with HIV);
•To work out conclusions and recommendations in the improvement of the quality of PMTCT services for the MoH;
•To develop recommendations for further UNICEF PMTCT strategic interventions within the framework of the implementation of UNICEF CPD for Belarus for 2011-2015.

Methodology:

The evaluation methodology included desk review and analysis of the relevant policy documents, existing statistical data and results of the qualitative surveys of semi-structured interviews with health system managers, questionnaire of health care providers and service consumers (pregnant women or just delivered) and non-structured interviewers with the representatives of the MoH, WHO, UNDP, Global Fund Grants implementation unit, NGOs, researchers and academicians of Belarusian Medical Academy of Postgraduate Education (BelMAPE).  

The evaluation tools were developed based on PMTCT Evaluation Protocol developed by UNICEF expert and piloted in 2009 in Belarus. The evaluation logic envisaged the availability of the same blocks of questions in the survey tools in order to be able to assess the current situation, achieved results, progress and reveal the remained bottlenecks.  

The evaluation was conducted in the most epidemiologically disadvantage regions of Belarus: Gomel, Minsk and Minsk region, Zhlobin, Svetlogorsk and Soligorsk. The regions were selected based on the high HIV prevalence and health workers experience in implementing PMTCT interventions.

The survey covered 577 respondents including 379 women, 177 health care providers and 21 health managers of antenatal care clinics. Special measures were put in place to ensure that the sociological survey process is ethical. The source of information was protected and known just to the interviewer.

Findings and Conclusions:

Achievements:
•Belarus is one of the 12 countries with more than 80% coverage of ARVs. Since 2003 PMTCT services have been integrated into the primary health care system and became accessible for PLHIV national wide
•The current PMTCT Protocol is in line with 2010 WHO recommendations for PMTCT 
•All HIV positive mothers were supplied with formulas for feeding of newborns in 2011
•The majority of PMTCT indicators recommended by WHO were incorporated in the national monitoring system
•Close cooperation between women’s outpatients clinics, department of infectious diseases  and children's polyclinics especially at regional level is in place
•PMTCT program is integrated into the system of postgraduate physician qualification upgrade in BelMAPO. System of the on-the-job trainings and staff orientation is in place
•Internal quality control system is in place in all health care institutions provided services to HIV positive pregnant women and newborns
•The majority of the recommendations of 2009 PMTCT evaluation has already completed or in the stage of realization

Constraints:
•Issues of drug dependent pregnant women are not reflected in PMTCT Protocol
•Uninterrupted supply of ARVs is the most crucial issue after completion of realization of GFATM funded project in 2015
•47% and 51% of pregnant women found their positive HIV status during pregnancy in 2011-2012  correspondingly 
•The external PMTCT control is not always clear and regular conducted
•The inconsistency between the national and regional level reported data reflected the low quality of data collection and gave the rise of doubt of PMTCT progress achieved

Recommendations:

Revision of PMTCT protocols: regular update of PMTCT protocols in accordance with WHO recommendations including new schemes of ARV prophylaxis, recommendations on drug dependency of HIV pregnant women and tuberculosis vaccination of newborns to HIV positive mothers

Rapid test for HIV diagnosis: introduce and mandate the use of HIV rapid tests for I and II screening of pregnant women 

Monitoring and Evaluation system: update the existing PMTCT monitoring protocols with the issues of HIV positive drug dependant pregnant women, pay special attention to the additional in-depth analysis and research to generate evidence based decision, develop and integrate special computer system for HIV monitoring and data analysis

Supply: the MoH must incorporate the effective planning, financing and monitoring systems to ensure timely delivery and uninterrupted access to services for PLHIV including ARVs for PMTCT.

Staff issues: special attention should be paid to the effective human resources policy and planning including the development of the system of incentives to reduce employee turnover and ensure professional staff consolidation (obstetrician/gynecologists and specialist on infectious diseases) in Zhlobin and Svetlogorsk

Sustainability of regular staff training: focus on the pre- and post- diploma training of health care providers especially nurses and midwives on PMTCT emphasizing adherence to ARVs and drug addiction during pregnancy. 

Services improvement: envisage the psychological services provision in the antenatal care clinics

Recommendations on the priorities of MoH and UNICEF/UNDP collaboration in 2013-2015 years:
(a) to continue the financial and expert support to ensure sustainability of staff training programmes in BelMAPE, (b) scale up collaboration with AIDS-service NGOs,
(c) mobilization of the additional resources of GFATM for PMTCT programmes development.

Lessons Learned:

In order to ensure objectivity country led PMTCT evaluation was carried out by an international expert in close collaboration with national evaluation team of the Ministry of Health (MoH) and UNICEF/UNDP Belarus.
To ensure national ownership the PMTCT evaluation  methodology and composition of the evaluation team was approved by the order of the MoH # 1167 on October 3, 2012.



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