2018 Equatorial Guinea: Evaluation of PMTCT programme in EQG (2015-2018)
Author: Sara VACA (inter. consultant), Graciano Vicente E.N.MICUE (nat. consultant)
With the aim to continuously improve transparency and use of evaluation, UNICEF Evaluation Office manages the "Global Evaluation Reports Oversight System (GEROS)". Within this system, an external independent company reviews and rates all evaluation reports. The quality rating scale for evaluation reports is as follows: “Highly Satisfactory”, “Satisfactory”, “Fair” or “Unsatisfactory”. You will find the link to the quality rating below, labelled as ‘Part 2’ of the report, and the executive feedback summary labelled as ‘Part 3’.
Equatorial Guinea (EQG) population is predominantly young (45 % under 15 years old) with a natality rate around 42 per 1000 and mortality rate of 16 per 1000. Life expectancy is 49 years for men and 53 for women. Literacy rates in adults reached 87% in 2009. 76% of the population lives in urban areas.
The first HIV testing materials arrived in country in 2000 and the first treatments and medicines in 2003. After the adoption of the “National Strategy for accelerating the access to PMTCT services” in 2014 by the EQG, the Ministry of Health and Well- Being( MoHWB) had to start decentralizing the services to pregnant women living with HIV to prevent vertical transmission. With HIV prevalence estimated at 6.5% [5.3 – 8.4] in 2017, Equatorial Guinea has taken steps to scale up its response to HIV. The country is fully funding its HIV response and access to treatment is free of charge. The opening of additional health centers has allowed EQG to scale up its programme to eliminate MTCT of HIV. Estimated coverage of pregnant women who access antiretroviral medicines increased from 61%3 in 2011 to 74% in 2014.4 The country’s President recently announced the country is committed to working closely with UNAIDS towards ending the AIDS epidemic by 2030.
Based on the strong political willingness demonstrated thus far, EQG aims to reach the end of MTCT in the near future. Therefore, in order to assist the country’s government in this 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 decentralization process.
The UNICEF Equatorial Guinea Country Office (CO) has therefore commissioned an external formative evaluation of UNICEF’s 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).
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.
The proposed methodology is based on experience in designing similar evaluations, fed by the CO’s and Reference Group’s inputs. The evaluation team has started to develop a detailed design, analytical methods and tools during the scoping phase based on key informant interviews and document review.
Methods for data collection
The evaluation used a mix of qualitative and quantitative data and analytical methods (mixed methods approach).
• Quantitative methods involved trends analysis that retrace the evolution of the national PMTCT programming context in terms of quantitative data.
• Qualitative methods gathered data from key informants and stakeholders for in-depth analysis and triangulation purposes. Documentation and secondary data generated over the period were reviewed using structured methods.
Both data were analyzed separately and compared, trying to explain the first one with changes occurred in resources, policies, strategies, guidance, etc. to assess whether and how UNICEF’s response adapted to an evolving context.
The methods used comprise:
- review of documents and secondary data from the government and other reliable organisations
- key informant and stakeholder interviews;
- focus group discussions
- in-depth case studies and
- observation at some visits to health centers
- Triangulation of sources, researchers (when possible) and methods was sought for each evaluation question. Data from these sources, collected through the different methods, were triangulated to assess similarities and differences.
Methods for analysis
- When saturation of messages occurs, extra validation was sought by informal daily debriefings with the team and by formal validation during the preliminary findings workshop at the end of the mission. In case of discrepant evidence or inconclusive findings, additional data were required to complement data about the programme. It was important to talk to key decision-takers and implementers at different levels.
Findings and conclusions:
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.
Regarding the project expected intermediate results (Contribution to universal access to
PMTCT services), the PMTCT services are available in all the 18 districts of the country (before the programme they were only present in the 5 districts). The PMTCT coverage increased from 17% in 2010 to 64% in 2017.
The cost of decentralization programme (delegated directly to UNICEF) was below 300,000 USD, that placed the program in the medium range, while the progress achieved is visible and valuable. No relevant evidence was found of inefficient use of the funds.
The progress made in the national health care system is consistent and is embedded in the national
existing capacities. Resident staff trained in PMTCT are part of the existing health workers in
national structures, and 4 medical officers were trained as part of national pool of PMTCT trainer.
Not many actors work in PMTCT in EQG. Among them, UNICEF has been the leader in supporting
the Ministry during the decentralization process, while having at the same time a proactive role
taking initiatives to foster progress while leaving the leadership to the government.
Gender & Equity
The programme fosters exposed new-born babies having AIDS-free start by preventing the MTCT, and it enhances the well-being of mothers living with HIV by making access to PMTCT services easier, merged with regular health care facilities.
The programme does not work with men or male youth, to make HIV more acceptable in society and within the couple.
As conclusion, the PMTCT decentralization has made great progress between 2015-2018 with UNICEF support and now, PMTC services are closer to rural population.
1. Finalize decentralization at local Health Center level.
UNICEF: Provide technical support to the MoHWB on the elaboration of the implementation plan of the next phase
2. Consolidate the ongoing decentralization through a plan of periodic supervisions to strengthen the PMTCT practices, especially in the areas of prenatal and newborn care as well as laboratory and pharmacy.
UNICEF: Provide technical support and follow-up on the definition and implementation of routine supervision mechanisms
3. Consider the potential synergies with Primary Health Attention (at health posts and health agent levels) for a deeper penetration of the PMTCT services
UNICEF: Support extra training sessions on PMTCT to involve Primary Health staff
4. Create a clear, realistic mechanism to report on PMTCT data (from collected at individual level to consolidated at district, province, region and national levels)
UNICEF: Suggest a specific tool/s and protocol to collect PMTCT data using the existing ones
5. Conduct an independent study (co-managed by MoHWB and UNICEF) to generate reliable data about the real dimensions of HIV Mother to Child Transmission.
UNICEF: Develop a ToR for the proposed study and assist with the identification of
those who will conduct it (as needed). Consider partnering with UNFPA or other relevant partners
(such as academics).
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.
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.
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)
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
Some countries in the region (as Angola, Rwanda, Senegal, Tanzania y Zimbawe) have
contributed to the decentralization of ARV provision at the community level and have developed
community follow-up mechanisms.
Full report in PDF
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