sahara country updates
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TRANSCRIPT
5th SAHARA Conference
Dr Sibongile DludluUNAIDS RST/ESA
Male circumcision Country Updates
Johannesburg, South Africa01 December 2009
Outline
• Review key elements for country MC
Programming
• Give an analysis of country implementation
• Outline some challenges and constraints
• Consider facilitating factors
Global RecommendationsGlobal Recommendations• Countries with high prevalence (>15%), generalized
heterosexual HIV epidemics and low rates of MC should consider urgently scaling up access to MC services
• 13 countries identified: Botswana, Kenya, Lesotho, Malawi, Mozambique, Namibia, Rwanda, South Africa, Swaziland, Tanzania, Uganda, Zambia and Zimbabwe
• Consider ethics, communication, culture, health systems, funding, gender, comprehensive prevention strategies
UN Support ActionsUN Support ActionsUN Agencies have a joint work plan:
The goal of the UN partners joint work plan on male circumcision is to assist countries to make evidence-based policy and programme decisions to improve the availability, accessibility and safety of male circumcision and reproductive health services as an integral component of comprehensive HIV prevention strategies
UN Support ActionsUN Support Actions
The objectives are to:
1. Set global norms and standards
2. Provide technical support to countries
3. Conduct high level advocacy and develop global communication strategies and messages
4. Coordinate the setting of global research priorities, and develop systems for monitoring and evaluation of male circumcision services
The UN partners are working
together to develop resources to
support programme scale up:
• Information/Advocacy documents
• Guidance documents
• Tools
• Reports
• The Male Circumcision Clearing House
UN Tools and Guidelines to Support UN Tools and Guidelines to Support ImplementationImplementation
Developed by the World Health Organization (WHO), the
Joint United Nations Programme on HIV/AIDS
(UNAIDS), the AIDS Vaccine Advocacy Coalition(AVAC), and
Family Health International (FHI)
Operational Guidance Operational Guidance
1. Leadership and partnership
2. Situation analysis
3. Advocacy
4. Enabling policy and regulatory environment
5. Strategy and operational plan
6. Quality assurance and improvement
7. Human resource development
8. Commodity security
9. Social change communication
10. Monitoring and evaluation
Key elements for operationalizing MC services
Two years later……How far have countries moved How far have countries moved How far have countries moved How far have countries moved How far have countries moved How far have countries moved How far have countries moved How far have countries moved ……………………????????????????????????
Situation AnalysisSituation Analysis• A situation analysis is to determine attitudes, beliefs,
practices and socio cultural aspects of MC, policy and regulatory framework, health system readiness
• Some countries have done comprehensive SA –Botswana, Lesotho, Namibia, Uganda, Zambia, Zimbabwe
• Others rapid assessment - Swaziland (Key informants, Facility readiness), Rwanda (facility readiness)
• Some still in progress – Malawi, Tanzania
PolicyPolicyNotable differences in approach:
• Botswana no separate policy but strategy with policy elements
• Kenya policy guidelines
• Lesotho, Namibia, Swaziland, Uganda and Zimbabwe, dedicated policies (drafts completed)
• Zambia – Information note to Cabinet – not policy
StrategyStrategy• Country strategies developed that include:
– Objectives, target population, numbers of men to be reached, costs, service delivery strategies, resource mobilization, monitoring and evaluation
• Decision Makers' Programme Planning Tool to determine cost, impact, pace of scale up
• Most countries have 'catch-up' strategies to reach adult men – Botswana, Kenya, Swaziland, Zimbabwe, Zambia
• But longer term neonatal circumcision also being considered in Botswana, Swaziland, Zambia
Progress in other Key ElementsProgress in other Key Elements• Quality Assurance being implemented in Kenya, and Swaziland using WHO Guide and Toolkit
• Regional and country trainings in almost all countries
• Communication strategies under development in Kenya, Namibia, Swaziland – UN Toolkit under development
• M&E Indicators gradually being introduced into HMIS – Botswana, Kenya
Progress on Male Circumcision
Zambia: Situation analysis, trainings, strategy & Implementation plan, service delivery
Botswana: Situation analysis, DMPPT, strategy, training, M&E, communications and QA
SwazilandSituation analysis, policy, strategy & Implementation plan, leg/regulatory assessment, trainings, QA, M&E draft, comms draft
Kenya: national guidance & strategy, situation analysis, guidelines, training, Quality Assurance guide, expanded service delivery, communication & advocacy under development, M&E, research
Rwanda advocacy campaign, situation assessment underway, services in military Uganda
Situation analysis, policy development, Comms draft
Namibia:Champions visit, advocacy, DMPPT,draftpolicy, strategy, training and QA planned, communications plan
Lesotho: advocacy, situation analysis, policy development, draft strategy & comms
Tanzania, MalawiSituation analysis, pilot service sites
Snapshot of country progress
Zimbabwe
Zambia
Uganda
Tanzania
Swaziland
South Africa
Rwanda
Namibia
Mozambique
Malawi
Lesotho
Kenya
Botswana
Service delivery M & E
Quality Assu
Training II
Training I
Policy &
RegSituation
analyLeadership I II
Service Delivery Service Delivery
How many circumcisions have been done?
Service Delivery Service Delivery
• Kenya - Cumulatively 40,000 MC’s done by October 2009
• Zimbabwe - 4 sites, 1818 men circumcised as of June 2009
• UTH Zambia – 2500 in 6-month
Adverse event rates remain low <3%
Challenges and Challenges and ConstraintsConstraints
• Human resource constraints- For country programming at national level, staff already
overloaded
- For service delivery – lack of personnel, staff mobility
• Political support – it has been a process to get political buy-in in some countries, also delays due to elections, set backs with change of government
• Funding – countries not clear on what funds are available and how to access
Challenges and Challenges and ConstraintsConstraints
• Traditional providers – almost all countries have them but no clear guidance on how to involve them
• Communication – partial protection, issues of risk compensation, how to develop strategies and tools
• HIV positive men – how service delivery sites will handle without stigma and discrimination
• Implications for women – how to involve women in service delivery, monitor and evaluate for adverse societal effects
Facilitating FactorsFacilitating Factors• Level of political commitment now in almost all countries
• Country Champions
• Leadership and coordination- Of the UN, with WHO leading joint UN team- UN coordination with other partners- MoH leadership and collaboration with NACs- National multi-stakeholder MC Task Forces and focal persons
- Countries with well coordinated TF making more rapid progress
- Replication at provincial level
Facilitating FactorsFacilitating Factors• Engagement of key stakeholders in countries with
extensive consultations – with traditional providers, women, young people
• Availability of tools and guidelines and increasing technical support
• Funding support - PEPFAR, Gates, GFATM
• Subtle country peer pressure through experiences sharing
• Innovative models to improve the efficiency of services
Acknowledgements
•Country Male Circumcision Task Forces
•UN Male Circumcision Working Group, Geneva
•UN Inter Agency Working Group (IATT)
•Implementing partners supporting MC roll out in countries