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Evaluation database

Evaluation report

2016 Namibia: Evaluation of Namibia’s PMTCT Programme



Executive summary

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’.

Background:

The Government of the Republic of Namibia (GRN) has implemented a program for prevention of mother-to-child transmission of HIV (PMTCT) for the last 12 years. In 2013, a National Strategy and Action Plan (NSAP) for Elimination of Mother-to-Child Transmission of HIV (eMTCT) and Keeping Their Mothers Alive was adopted. To find out the progress on the plan for eMTCT as well as the facilitating and constraining factors, the Ministry of Health and Social Services (MoHSS), UNICEF and UNAIDS  organized for this evaluation. This evaluation assessed achievement on targets outlined in the NSAP as well as the global criteria for validation of pre-elimination of eMTCT of Human Immunodeficiency Virus (HIV).
Progress on eMTCT can be assessed using pre-elimination or elimination criteria. To qualify for elimination or pre-elimination validation, a country has to meet a set of process and impact targets. Elimination process targets include achievement of coverage equal to more than 95% on antenatal care (ANC) attendance, HIV testing during pregnancy and coverage of antiretroviral therapy (ART) during pregnancy; impact indicators include a mother to child (MTCT) rate of less than 5% and a case rate of less than 50 new HIV infections due to MTCT per 100,000 live births. Breastfeeding countries with HIV- prevalence > 2% among the general population can be validated for pre-elimination rather than elimination of MTCT. Pre-elimination is an attempt to recognize the progress that has been made in PMTCT of HIV in high burden countries. Validation for pre-elimination requires process indicator targets lower than those for elimination i.e. coverage equal to or above 90% on ANC attendance, HIV testing among pregnant women and antiretroviral coverage for pregnant women living with HIV. There is no pediatric new HIV infection case rate requirement for pre-elimination but the MTCT rate must be below 5%.

Purpose/Objective:

The objectives of the evaluation were tri-fold

  1. To contribute to improving the MoHSS’s accountability for its performance and results by defining key achievements as well as missed opportunities in support of improved PMTCT outcomes over the past decade.
  2. To generate evidence and learning to guide
    1. the effective action towards quality monitoring and reporting towards eMTCT
    2. an effective roadmap to overcome the remaining barriers and bottlenecks to reach elimination ii) MoHSS positioning in eMTCT, Sustainable Development Goals (SDGs) and the post 2015 HIV agenda as guided by the UNAIDS 2016-2021 strategy.
  3. The findings and recommendations generated by the consultancy will be used to determine Namibia’s qualification to submit an application towards the eMTCT validation and accreditation process. The findings will also influence strategic direction and partnerships/advocacy as well as programme strategies to achieve the results and targets outlined by the National Strategic Framework (NSF). The findings will provide insights into the continuum of care for the PMTCT cascade; through early treatment and retention. In addition, the consultancy will provide smart recommendations on how the MoHSS can best re-position the PMTCT programme vis-à-vis the UNAIDS Strategy and the 2030 Agenda for Sustainable Development. The findings of the evaluation will also support Namibia’s application towards the eMTCT validation and accreditation process.

Methodology:

The evaluation combined both quantitative and qualitative information. Quantitative information was largely secondary data obtained from routinely collected program data, review of implementation progress reports and population-based surveys. The only routinely collected program data available for this evaluation were for the year 2015. Qualitative data were obtained from key informants (KIs) in Kavango, Zambezi, Ohangwena, Otjozondjupa and Khomas regions.

Quantitative data provided information on coverage and impact while qualitative data provided information on the weakness and strength of the program as well as opinions of stakeholders on the different program components and implementation strategies. The evaluation used a Theory of Change (ToC) approach to compare the activities planned and results achieved against those anticipated for the different PMTCT interventions and outcomes.

The prevalence of HIV in Namibia is generalized but heterogeneous. About 80% of people living with HIV (PLWHIV) reside in seven (Kavango, Zambezi, Ohangwena, Khomas, Omusati, Oshana and Oshikoto) out of thirteen regions. The same regions also have comparatively higher number of health facilities and population density.

The limitations for the evaluation were:

  • Routine collected data were only available for 2015 and had no data on number HIV-exposed infants born, tested for HIV or tested positive with DNA PCR.
  • There were contradictions between data from Spectrum modeling and directly collected data that could not be resolved.
  • Only data from health facilities in the public sector were available.

Findings and Conclusions:

The GRN provides strong political, administrative, and financial leadership and support for the HIV/AIDS response including PMTCT. The GRN has demonstrated its commitment of ownership of the national response by steadily increasing its proportion of expenditures to the HIV/AIDS response over past years, which currently represents 64%% of the total HIV/AIDS spending. However the GRN faces challenges with numbers and turnover of the human resources for health in the public sector. The quality and quantity of PMTCT services offered in the private sector (where 8% women gave birth in 2013) is not well documented. Program officers at district and regional Primary Health Care (PHC) departments reported that the large number of programs to supervise compromises the attention given to PMTCT. PMTCT was noted to be well integrated in Maternal and Child Health (MCH) services especially at the health centre and clinic levels. Some health centres and clinics reported inadequate space especially for storage of commodities and counseling.  Guidance, including tools for data collection and submission has been produced and disseminated. However, the routinely collected data did not cover all the targets in the NSAP for eMTCT and global guidance indicators. Some PMTCT mothers and infants received follow-up services at facilities where they are not registered (visitors) and could be regarded as lost to follow-up where they are registered and yet there are not. There is need for data quality assessment of routinely collected data. In addition, cohort monitoring and/or a directly measured baseline MTCT rate would be useful to validate and better understand the accuracy of available programmatic data vis-a-vis modeled estimates. It will also be used to make comparisons in future to assess progress on eMTCT. A directly measured baseline can be obtained by testing all children during their first immunization clinic visit combined with active follow up of exposed infants.

Recommendations:

  1. Strengthen focused ANC attendance (at least 4 visits) nationally.
  2. Strengthen HTC and ART for PMTCT in Omaheke and Otjozondjupa regions
  3. Strengthen supply chain management for PMTCT commodities (RDTs, nevirapine suspension).
  4. Expand HTC especially through community based testing and strengthen linkages to care and treatment as well as retention in chronic care for people living with HIV.
  5. Strengthen and document repeat testing of pregnant women who initially tested HIV negative.
  6. Identify and document breastfeeding women who did not test for HIV during pregnancy and offer them HTC.
  7. Document reasons for ART refusal so that they may be acted upon.
  8. Assess retention in chronic care through age disaggregation of data on retention among women starting ART through PMTCT paying particular attention to adolescents and young women.
  9. Regularly assess adherence to ART during ANC, child birth and postpartum.
  10. Offer HTC to all infants with unknown or uncertain HIV status and for all children with a parent living with HIV.
  11. Strengthen clinic-based data systems for identification, pro-actively pursue follow-up, DNA PCR testing and reporting of HIV-exposed infants until the end of breastfeeding.
  12. Ensure regular reporting of numbers tested at the end of breastfeeding.
  13. Provide regular training, support-supervision and mentoring on how to fill in mother-baby follow-up registers.
  14. Conduct a data  quality assessment for PMTCT
  15. Adopt of treatment as prevention through treatment of all PLWHIV irrespective of CD4 count.
  16. Strengthen integration of HIV and family planning by building capacity of health care workers to assess and satisfy need for family planning. Pay particular attention to the needs of adolescents.
  17. Prioritize viral load testing of pregnant and breastfeeding women so as to enhance adherence support and offer prolonged infant prophylaxis for women with unsuppressed viral load.


Full report in PDF

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Report information

Year:
2016

Country:
Namibia

Region:
ESAR

Type:
Evaluation

Theme:
HIV/AIDS - Preventing Mother To Child Transmission

Partners:
Ministry of Health and Social services

Language:
English

Sequence #:
2016/006

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