unicef eqg co - pmtct evaluation evalu ation r epor t · unidad referencia de enfermedades...

UNICEF EQG CO - PMTCT Evaluation 1 Final Report

SUMMATIVE EVALUATION OF UNICEF’S PREVENTION OF

MOTHER TO CHILD TRANSMISSION (PMTCT)

DECENTRALIZATION TASK-SHIFTING PROJECT

IN EQUATORIAL GUINEA (2015-2018)

UNICEF Equatorial Guinea

EVALUATION REPORT

Sara Vaca, January 2019


Evaluation Report 10th January 2019

Evaluation team

Evaluator Sara Vaca Independent international consultant.

Lead evaluator and evaluation report author.

Field support Dr. Graciano

Vicente National consultant

Evaluation

managers

Manuel Nzi

Nzang UNICEF EQG CO Health Programmes Coordinator

Andrea Djassi UNICEF EQG CO HIV Specialist

Alejandro

Agüero UNICEF EQG CO Strategy Planning Manager

RO support

Michele Tarsilla UNICEF WCARO M&E Regional Evaluation Advisor

Landry Dongmo

Tsague UNICEF WCARO HIV/AIDS Regional Advisor

(For more details of each member’s role, see section 11, page 15, of the Inception Report).

Initial considerations This evaluation was the first one commissioned by UNICEF Equatorial Guinea Country Office since 2011.

Therefore, many expectations were raised about the process and its results. Linked to this fact, and although

not explicitly mentioned in the ToR, the CO and Regional Office expressed their expectation that the

evaluation would reinforce internal evaluative capacity along the process.

The evaluator would like to thank UNICEF Guinea Equatorial Country Office, the Ministry of Health and

Well Being (MHWB) at all levels and other partners for their availability and positive attitude towards the

successful completion of the evaluation.

The evaluation process and debriefing presentations were conducted in Spanish, while the inception and final

reports were redacted in English for facilitating dissemination and sharing with the UNICEF Regional Office

for West and Central Africa (WCARO) experts. The evaluation was conducted by an international evaluator

and a national expert with solid expertise in the Equatorial Guinea’s health sector. Both of them were UNICEF

to conduct the fieldwork with independence and impartiality.

By demand of the ToRs and the commissioners, this report is particularly brief (50 pages plus annexes) to

facilitate its reading and foster its use. Therefore, all sections, including answers to the evaluation questions,

have been limited to their basic key points.

Most pictures and figures included in the report were developed by the evaluator (for those that weren’t, the

related source was mentioned in the text.


TABLE OF CONTENTS

1. Executive Summary ........................................................................................................................................... 6

2. Background ...................................................................................................................................................... 10

3. The Programme ................................................................................................................................................ 13

4. Evaluation Purpose, Objectives and Scope ..................................................................................................... 15

5. Evaluation Design ............................................................................................................................................ 17

6. FINDINGS ........................................................................................................................................................ 25

6.1. Relevance .................................................................................................................................................. 25

6.2. Effectiveness ............................................................................................................................................. 29

6.3. Efficiency .................................................................................................................................................. 40

6.4. Sustainibility ............................................................................................................................................. 43

6.5. Leadership ................................................................................................................................................. 44

6.6. Equity, Gender and Human Rights .......................................................................................................... 46

7. GOOD PRACTICES ......................................................................................................................................... 50

Lessons Learned ............................................................................................................................................... 50

8. CONCLUSIONS ............................................................................................................................................... 51

9. RECOMMENDATIONS .................................................................................................................................. 53

Annexes ................................................................................................................................................................ 56

Annex 1: Terms of Reference (link) .................................................................................................................... 56

Annex 2: Inception report (link) ......................................................................................................................... 56

Annex 3. Key Reference Documents .................................................................................................................. 56

Annex 4. HIV Legal Framework ......................................................................................................................... 56

Annex 5. Evaluation Matrix ................................................................................................................................ 58

Annex 6. List of people met ................................................................................................................................. 60

Annex 7. Evaluation tools (interviews guidelines) ............................................................................................. 63

Annex 8. Principles Of Ethical Conduct Of Evaluation ..................................................................................... 68

Annex 9: Preliminary results presentations (links) ............................................................................................ 69

Annex 10: Estudios de Caso de Centros Sanitarios ............................................................................................. 70

Annex 11. Other qualitative data ........................................................................................................................ 84


TABLE OF FIGURES

Figure 1: Table of the key PMTCT indicators. Source: http://aidsinfo.unaids.org/, 2017 .................................. 7

Figure 2: Age pyramid in Equatorial Guinea (2016).

https://www.indexmundi.com/equatorial_guinea/age_structure.html ............................................................. 11

Figure 3: AIDS and HIV trends in EQG (2000-2016) ......................................................................................... 11

Figure 4: People living with HIV (2000-2016) ................................................................................................... 12

Figure 5: Number of PMTCT centers per region ................................................................................................ 13

Figure 6: Theory of Change rebuilt with the PMTCT Team during the evaluation ........................................ 14

Figure 7: Evaluation users .................................................................................................................................... 15

Figure 8: Evaluation Scope .................................................................................................................................. 16

Figure 9: Number of healthcare centers visited during the fieldwork, by province and level ........................ 22

Figure 10: List of limitations and mitigation measures ...................................................................................... 23

Figure 11: Phases and products of the evaluation .............................................................................................. 24

Figure 12: Trend of new HIV infections in EQG ............................................................................................... 25

Figure 13: Structure of the Ministry of Health and Well Being related to PMTCT ......................................... 26

Figure 14: Mortality trend and Top 10 causes of death in 2017. Source:

http://www.healthdata.org/equatorial-guinea.................................................................................................... 28

Figure 15: Health centers providing PMTCT services before and after the decentralization. Source: UNICEF

.............................................................................................................................................................................. 29

Figure 16: Follow-up of the Indicators set for the Decentralization Process .................................................... 30

Figure 17: Detail of the coverage indicator of the Decentralization process .................................................... 30

Figure 18: Detail of the health centers involved in the Decentralization ......................................................... 31

Figure 19: Theory of Change of the programme (in yellow, intermediate outputs not fully achieved) ......... 32

Figure 20: Data of patients under HIV treatment January-August 2018.

(according to the MoHWB pharmacy supply chain registries). ........................................................................ 33

Figure 21: Analysis of achievements following UNICEF's MORES determinants ........................................... 34

Figure 22: Roles and responsibilities by Partner involved in the programme .................................................. 36

Figure 23: Mapping of achievements according to the Capacities Reinforcement Framework ....................... 37

Figure 24: Cost of the decentralisation programme (Source: UNICEF) ............................................................ 41

Figure 25: PMTCT Stakeholders Mapping .......................................................................................................... 46

Figure 26: Gender Analysis on how PMTCT affects women and men ............................................................. 48

Figure 27: Table of correlation between Key Findings and Key Conclusions .................................................. 51

Figure 28: Tensiometer of different dimensions to be balanced ........................................................................ 53

Figure 29: Table of the 5 key Recommendations (including MoHWB and UNICEF partnership roles)......... 54


ACRONYMS

ARV Antirretroviral

CO Country Office

EQG

HIV

INSESO

ISCIII

Equatorial Guinea

Human Immunodeficiency Virus

Instituto Nacional de la Seguridad Social

Instituto de Salud Carlos III

MINSABS

(MoHWB)

Ministerio Sanidad y Bienestar Social

(Ministry of Health and WellBeing).

OMS

PLWHIV

Organización Mundial de la Salud (WHO)

People living with HIV

PMTCT Prevention Mother to Child Transmission

ROI

TAR

Return on Investment

Tratamiento antirretrovírico (Antirretroviral treatment)

UNFPA

UNICEF

UREI

United Nations Fund for the Population

United Nations International Children's Emergency Fund

Unidad Referencia de Enfermedades Infecciosas


1. Executive Summary

INTRODUCION

About HIV in Equatorial Guinea

With HIV prevalence estimated at 6.2% in 2014 (UNAIDS), Equatorial Guinea has taken steps to scale

up its response to HIV in the last years. The country is fully funding its HIV response and access to

treatment is free of charge. The opening of additional health centers has allowed Equatorial Guinea to

scale up its programme to eliminate mother-to-child transmission of HIV. Estimated coverage of

pregnant women who access antiretroviral medicines increased from 61% in 2011 to 74% in 2014.

About the National Prevention of Mother To Child Transmission Programme

After the first HIV Strategy approved in 2003 in the country, the new “National Strategy for accelerating the access to PMTCT services” was adopted in 2014 by the EQG, the MoHWB had to start decentralizing

the services to pregnant women living with HIV to prevent vertical transmission.

The programme consisted in training the health workers involved services (maternity, laboratories and

pharmacies) and supervision visits to monitor the service quality. It was undertaken along 2 phases: a

pilot was first implemented at Bioko island (2015-2016), followed by a second one in the Continental

Region (2017-2018).

About the evaluation

This summative evaluation of the PMTCT Decentralization Task-Shifting project (2015-2018) sets a

precedent for UNICEF Equatorial Guinea (EQG) Country Office (CO), as it is the first such exercise

conducted in-country since 2011.

Following UNICEF’s Evaluation Policy, the evaluation revolves around three key questions: Is the right

thing being done? Is it being done well? Are there better ways of doing it? With respect to the national

PMTCT decentralized programme, this evaluation will assess the level of progress attained to this day at

the national level, including what has been achieved, what is left to do and the way forward.

The evaluation was managed by UNICEF EQG CO in close collaboration with the Ministry of Health

and Well Being (MoHWB). Due the highly participatory nature of this evaluation, the team that

conducted it consisted of an international external consultant hired by UNICEF and a national consultant

from the MoHWB (former HIV General Director): the decision to proceed this way was meant to assure

not only that the views of both UNICEF and the national government be equally taken into account but

that their respective capacity be increased as a result of this exercise. That having been said, the

following measures were taken in order to protect the independence of this evaluation: the engagement

of the UNICEF Regional Evaluation Adviser for West and Central Africa as well as the review of the

report by a national independent expert.

The evaluation results from a mix of approaches: it combines the features of an Equity and Gender-

focused evaluation with those of a Theory-based approach; facilitation was also widely used throughout

the project to foster internal capacity development. The evaluation questions were axed around four of

the five DAC criteria (Relevance, Efficacy, Efficiency and Sustainability) and two additional ones put

forward by the UNICEF CO: UNICEF’s strategic positioning and Equity & Human Rights.

The evaluation covered the project implementation period (from early 2015 to mid-2018) nationwide.

Given the upstream character of the programme (focused in the decentralization rather than in the

quality of services), the sampling privileged institutional informants. As a result of the sampling focus

https://www.unicef.org/about/execboard/files/2013-14-Revised_Evaluation_Policy_UNICEF-18Apr13.pdf


(and other related ethical reasons), only a few PMTCT users were consulted as part of this evaluation.

An additional number of interviews with the relevant stakeholders were held during the two weeks of

fieldwork and 8 case studies were conducted, mostly pertaining to healthcare centers at national,

province and district levels.

KEY FINDINGS (by evaluation criterion)

Relevance

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. The national PTMCT programme is and remains a

country priority, as attested by the government’s decision not only to buy all anti-retrovirals but also to

substantively fund UNICEF’s second phase of the programme. It is also important at the CO level, as

Effectiveness

Regarding the project expected intermediate results (outputs) (Contribution to universal access to PMTCT services), the programme has succeeded in moving access remarkably forward, by making the

services available in all the 18 districts of the country (before the programme they were only present in

the 5 districts: Malabo, Bata, Evinayong, Mongomo y Ebibeyín). Besides, the staff at 33 other local centers

have been trained and are expected to be able provide PTMCT services in the next phase of the

decentralization process.

However, it was not possible to assess the impact of the programme in reducing the vertical transmission

as there is no reliable data on the number of pregnant women expected, pregnant women living with

HIV and number of exposed children that are living with HIV: there have been discrepancies in the

Global AIDS Monitoring (GAM) Report. Below is the official data available:

Indicator 2010 2017

PMTCT coverage (%) Source: Factsheet Equatorial Guinea http://aidsinfo.unaids.org/

17 [13 - 20] %

64 [49 - 82] %

Indicator 2017

Pregnant women needing ARV for PMTCT (#) 2400 [1800 - 3000]

Pregnant women who received ARV for PMTCT (#) 1516

New HIV infections averted due to PMTCT (%) <500 [<200 - <500]

Number of HIV-exposed children who are uninfected 15 000 [11 000 - 19 000]

Figure 1: Table of the key PMTCT indicators. Source: http://aidsinfo.unaids.org/, 2017

Furthermore, the decentralization is contributing to: (i) making the virus better known among the

population; (ii) systematically testing all pregnant women who go for a pre-natal visit; and (iii) reducing

the stigma linked to users’ visit of specialized infectious diseases centers: this was possible by transferring

the provision of PTMCT services to “regular” primary health facilities.

http://aidsinfo.unaids.org/


Efficiency

The evaluation questions about the project efficiency revolved around the worth of the investment made.

There were limited elements to judge the program based on this criterium: it was not possible to know

the cost of similar projects, either in terms of funds, human resources and the distribution of supplies.

However, the cost of decentralization programme (delegated directly to UNICEF) was below 300,000

USD, which placed the program in the medium range (considering small projects under 50,000 USD and

big projects above 500,000 USD), and the progress achieved is visible and valuable. No relevant evidence

was found of inefficient use of the funds.

Sustainability

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. Given all of

the above, once the decentralization process is completed at local level (not only at district level), the

project achievements are expected to be sustainable over time. However, for that to happen, it is essential

that good practices identified thus far be consolidated through regular supervision visits, and well-

targeted strategies (such as the production and dissemination of PMTCT training materials) be adopted

to prevent capacity loss due to rotation.

Leadership

Not many actors work in PMTCT in EQG. Among the few that do so, UNICEF has played a pivotal role

in supporting the Ministry during the decentralization process. However, despite taking such a proactive

role in fostering progress within the sector, UNICEF has ensured that the government could exercise its

leadership the most effectively possible.

Gender and Equity

The programme aims to offer exposed new-born babies an AIDS-free start in their life, by preventing

the vertical transmission. It also enhances the well-being of mothers living with HIV by making their

access to PMTCT services easier (closer to their home and merged with regular health care facilities),

instead of having to go to an Infection Diseases Center which causes unnecessary stigma. This fosters

equity as does the fact that the financial and logistic access to PMTCT are made easier for women living

in rural areas (it becomes affordable for more women to access the services at district level than at

province level).

However, the programme does not work with men or male youth, as a strategy to make HIV more

acceptable in society and within the couple. Likewise, as long as central-to-local decentralization is not

fully completed, the risk of inequities being perpetuated among the targeted population still exists as

people living in urban contexts may be more familiarized with HIV and get relatively easier access to

treatment than people living in rural areas.

OVERALL CONCLUSION

Based on all these findings, the evaluation team concluded that the PMTCT decentralization has made

great progress during the implementation of this UNICEF-supported programme. In addition, services

are now available at healthcare points closer to the rural populations nationwide. The next phase will be

key to finalizing the decentralization process currently underway and to consolidating the achievements

made to this date. Since reliable data about the baseline and present state of HIV infection and vertical

transmission is not available, the extent to which the programme will attain its key objective (reducing

new mother-to-child transmission) could only be assessed once the lack of data will be adequately

tackled and effectively addressed.


KEY RECOMMENDATIONS

Based on the evaluation conclusions, below are the key recommendations aimed at the UNICEF CO as

well as MoHWB:

Recommendations MoHWB UNICEF

1. Finalize decentralization at

local Health Center level.

a) Elaborate implementation plan

for all the targeted centers,

including those that have received

training and have fulfilled pre-

requirements

b) 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.

a) Define the periodic supervision

mechanism (number and technical

level of supervisors, frequency,

timing of visits, budget)


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

a) Meeting between the HIV and

the Primary Health teams at the

ministry to explore synergies and

formally involve Primary Health in

the new HIV Strategy or National

Plan

b) 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)

c) Verify and approve the data

collection tools and protocol.

d) Provide sufficient photocopies

of the data collection tools at

healthcare center level

e) Follow-up of data circuits

protocols

a) Confirm existing routine

data circuits at healthcare

center level.

b) 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.

a) Discuss and find sources of

funding for this study

c) Approve ToR.

b) 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).

No relevant recommendations were identified for other stakeholders and partners (such as other UN

Agencies or the national partner for training) with less decision-making potential for the next phase.


2. Background The transmission of HIV from a mother living with HIV to her child during pregnancy, labour, delivery

or breastfeeding is called vertical or mother-to-child transmission (MTCT). In the absence of any

interventions during these stages, rates of HIV transmission from mother-to-child can oscillate between

15-45%. MTCT can be nearly fully prevented if both the mother and the baby are provided with anti-

retroviral (ARV) drugs as early as possible in pregnancy and during the period of breastfeeding.

WHO recommends lifelong antiretroviral therapy (ART) for all people living with HIV (PLWH),

regardless of their CD4 count clinical stage of disease, and this includes women who are either pregnant

or breastfeeding. In 2017, 80% of the estimated 1.1 million pregnant women living with HIV globally

received ARV treatments to prevent transmission to their children. A growing number of countries are

achieving very low MTCT rates and some others (Armenia, Belarus, Cuba and Thailand) have been

formally validated for elimination of MTCT of HIV as a public health problem. Several countries with a

high burden of HIV infection are also progressing along the path to elimination1. HIV can be suppressed

by combination ART consisting of 3 or more ARV drugs. ART does not cure HIV infection but suppresses

viral replication within a person's body and allows an individual's immune system to strengthen and

regain the capacity to fight off infections consequently the reduction of HIV transmission.

In 2016, WHO released the second edition of the Consolidated guidelines on the use of antiretroviral

drugs for treating and preventing HIV infection. These guidelines recommend to provide lifelong ART

to all people living with HIV, including children, adolescents and adults, pregnant and breastfeeding

women, regardless of clinical status or CD4 cell count. By mid-2018, 163 countries already have adopted

this recommendation, which covers 98% of all PLHIV globally.

The 2016 guidelines include new alternative ARV options with better tolerability, higher efficacy, and

lower rates of treatment discontinuation when compared with medicines being used currently:

dolutegravir and low-dose efavirenz for first-line therapy, and raltegravir and darunavir/ritonavir for

second-line therapy.

Transition to dolutegravir has already started in 24 low and middle-income countries and is expected to

improve the durability of the treatment and the quality of care of people living with HIV. Despite

improvements, limited options remain for infants and young children. For this reason, WHO and

partners are coordinating efforts to enable a faster and more effective development and introduction of

age-appropriate pediatric formulations of antiretrovirals.

In addition, 1 in 3 people living with HIV present to care with advanced disease, at low CD4 counts and

at high risk of serious illness and death. To reduce this risk, WHO recommends that these patients

receive a “package of care” that includes testing for and prevention of the most common serious

infections that can cause death, such as tuberculosis and cryptococcal meningitis, in addition to ART.

Based on WHO’s new recommendations to treat all people living with HIV, the number of people

eligible for ART has increased from 28 to all 36.9 million people living with HIV.

In 2017, 21.7 million people living with HIV were receiving ART globally. In 2017, a global ART

coverage of 59% of adults and children living with HIV was reached. However, more efforts are needed

to scale up treatment, particularly for children and adolescents. Only 52% of them were receiving ARVs

at the end of 2017 and WHO is supporting countries to accelerate their efforts to timely diagnose and

1 http://www.who.int/news-room/fact-sheets/detail/hiv-aids

https://www.who.int/hiv/pub/arv/arv-2016/en/

https://www.who.int/hiv/pub/arv/arv-2016/en/

http://www.who.int/news-room/fact-sheets/detail/hiv-aids


treat these vulnerable populations. Expanding access to treatment is at the heart of a set of targets for

2020 which aim to bring the world on track to end the AIDS epidemic by 20302.

HIV in Equatorial Guinea

EQG population is predominantly young

(45 % under 15 years old) with a natality

rate around 42 per 1000 and a mortality

rate of 16 per 1000 compared with

mortality in Cuba (5,3). Life expectancy is

49 years for men and 53 for women (worst

results in Spanish-speaking countries).

Only 4% of the population is above 65

years old.

Literacy rates in adults was 52% in

1992,but had reached 87% in 2009. Most

of the population lives in urban areas and

approximately 30% in rural areas.

HIV became known in the country later

than in the rest of the region. 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

Equatorial Guinea to scale up its

programme to eliminate mother-to-

child transmission 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.

2 http://www.who.int/news-room/fact-sheets/detail/hiv-aids 3 http://www.unaids.org/en/resources/presscenter/featurestories/2015/november/20151127_equatorialguinea 4 ONUSIDA estimate for 2011: 9% [7 -11]

ONUSIDA estimate for 2014: 59% [45 - 72]

ONUSIDA estimate for 2017: 64% [ 49 – 82]

EQUATORIAL GUINEASELECTED TRENDS

AIDS Deaths Number of people living with HIV

New HIV Infections Percent of people living with HIV receiving ART

0

200

400

600

800

1,000

1,200

1,400

1,600

1,800

2000 2002 2004 2006 2008 2010 2012 2014 2016

AIDS Deaths

Lower and upperlimits

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

45,000

50,000

2000 2002 2004 2006 2008 2010 2012 2014 2016

Number of peopleliving with HIV


0

10

20

30

40

50

60

2000 2002 2004 2006 2008 2010 2012 2014 2016

Percent of peopleliving with HIV

receiving ART


0

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

4,500

2000 2002 2004 2006 2008 2010 2012 2014 2016

New HIV infections


Figure 3: AIDS and HIV trends in EQG (2000-2016)

Figure 2: Age pyramid in Equatorial Guinea (2016). https://www.indexmundi.com/equatorial_guinea/age_structure.html

http://www.unaids.org/en/resources/presscentre/


Based on the strong political willingness demonstrated thus far, Equatorial Guinea (EQG) aims to reach

the end of mother to child HIV

transmission (EMTCT) in the near

future. Therefore, in order assist the

country’s government in this noble

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 ongoing decentralization

process.

This evaluation is even more relevant

if one takes into account that the only

special serological cohort study ever

carried out in Equatorial Guinea dates

back to 2011. This study, which

assessed the rate of HIV/AIDS vertical

transmission to children, indicated

that the vertical transmission in

children whose mothers received ART was 16% (3/19), compared to 43% (10/23) in children whose

mothers did not receive it (p = 0.05), and 8% (1/13) in children whose mothers received ART and the

child postnatal prophylaxis (p <0.05). In the demographic study EDSGE-I (Encuesta Demográfica y de Salud, 2011), 42% of women who had been pregnant in the previous two years said that they had been

asked for the HIV test. Given all of the above, the conclusion is that, should a strategy of prevention of

mother-to-child transmission be implemented systematically, the probability of vertical transmission

can be significantly reduced to less than 1%.

To the contrary, if no systematic strategy is adopted, the prevalence of HIV in the young population

(more so, among women) will continue to remain high and that, in turn, this will increase the risk of

TMCT (as per UNAIDS estimations, approximately 40-45% of the children born of these women will be

infected with HIV thus bringing the total of adults and children living with HIV to 53 000 [44 000 - 68

000] (http://aidsinfo.unaids.org/ 2017).

ONUSIDA data for EQG was reviewed based on the last Census done in 2015

EQUATORIAL GUINEASELECTED TRENDS

AIDS Deaths Number of people living with HIV

New HIV Infections Percent of people living with HIV receiving ART

0

200

400

600

800

1,000

1,200

1,400

1,600

1,800

2000 2002 2004 2006 2008 2010 2012 2014 2016

AIDS Deaths


0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

45,000

50,000

2000 2002 2004 2006 2008 2010 2012 2014 2016

Number of peopleliving with HIV


0

10

20

30

40

50

60

2000 2002 2004 2006 2008 2010 2012 2014 2016

Percent of peopleliving with HIV

receiving ART


0

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

4,500

2000 2002 2004 2006 2008 2010 2012 2014 2016

New HIV infections


Figure 4: People living with HIV (2000-2016)



3. The Programme The object of the evaluation is the Prevention Mother to Child Transmission (PMTC) Decentralized

Task-Shifting programme. Specialized units in the Bata and Malabo UREIs have been managing cases of

mothers and children living with HIV who needed treatment since 2003. Four additional health centers

followed: two health care centers (Maria Rafols and Maria Gay in Bata) in 2009 and two province

hospitals (Mongomo and Ebibeyín) in 2010. In 2013 the new international guidelines on PMCT were

issued and validated by EQG in 2014.

The logic of the programme consisted in reinforcing, first, the capacity of health workers (doctors,

nurses, laboratory and pharmacy staff of each health center) through ad-hoc HIV Vertical Transmission

Prevention training in different services areas (maternity, laboratories and pharmacies, such as) at

regional, province and district level. Training was provided by a partner, the Instituto de Salud Carlos

III (ISCIII). Once the personnel was trained, mixed teams from the MoHWB, ISCIII and UNICEF

conducted supervision visits to reinforce good practices and refine the practices which would eventually

lead to a decrease in the MTCT rate at the national level. The programme also included supervision visits

to monitor the service quality. The Project/Programe was undertaken in 2 phases:

A pilot was undertaken at Bioko island (2015-

2016): in 2015 the decentralization started in

Bioko island. The strategy was piloted in the

island region, including Annobón. With the

elaboration of the “Strategy for accelerating universal access to PMTCT services” treatment

protocols were simplified and Option B+ was

adopted. Requirements to become healthcare

center providing PMTCT services were: to

have prenatal and maternity services, to have a

laboratory and to have a functioning

pharmacy.

A multi-sectorial team was formed to

coordinate the fight against HIV at national

level, including all relevant actors: MoHWB,

UN Agencies and some local civil society

organizations. The team, which was less active during the end of 2016 but was reactivated at the end of

2017, made several efforts to attain the programme objectives, as spelled out in the project results

framework (see below)

General objective

Decrease the vertical transmission to less than 5% in Equatorial Guinea.

Specific objectives

- Train 144 PMTCT service providers integrated in the 54 health care centers to apply PMTCT

- Reinforce primary healthcare PMTCT attention

- Reinforce the procurement system of PMTCT material

- Plan a monitoring system for the strategy

- Correct bad practices in the strategy implementation

FASE I – Nivel Provincial

Reunión en un lugar en Bata durante dos días sucesivos durante toda la mañana = 44 personas, 2 Reuniones de 22 personas Participan a las personas responsables de PTMH.

- Hospital Regional de Bata (Planificación Familiar, Maternidad, y Pediatría ) A: 10

- Centro Medico La Paz de Biyendem A: 2 - INSESO Bata A: 2 - Centro Medico Guinea Salud: 4 - HP de Mongomo A: 6 - Clínica Guadalupe de Mongomo A: 2 - INSESO Mongomo A: 2 - Hospital Provincial de Ebibeyin A: 6 - INSESO Ebebiyin A: 2 - Hospital Provincial de Evinayong: 6 - Centro Luis Amigo: 2

En Proceso: 16 Centros Sanitarios

Región Insular

Planificado:

11 Centros Sanitarios Nivel Provincial

R. Continental

Planificado:

43 Centros Sanitarios Nivel Distrital y CS

R. Continental

La Puesta en Marcha de La Estrategia de PTMH

Figure 5: Number of PMTCT centers per region


A second phase was implemented in the Continental Region (2017-2018).

The global strategy “Start free, stay free, AIDS free” was launched and

adopted by EQG, as framework of this second phase, which involved UN

agencies in the national response to HIV, as delegated by the government:

START FREE Reduce the number of children newly infected annually to less than 40,000 by 2018 and 20,000 by 2020. Reach and sustain 95% of pregnant women living with HIV with lifelong HIV treatment by 2018.

STAY FREE Reduce the number of new HIV infections among adolescents and young women (aged 10–24) to less than 100 000 by 2020.

The program Theory of Change (ToC) below was reconstructed by the evaluation team in collaboration

with the CO team during the evaluation, to support the understanding of the mechanisms and

assumptions underlying the logframe objectives:

Figure 6: Theory of Change rebuilt with the PMTCT Team during the evaluation

Eliminated vertical transmission of HIV

Inter-sectorial group working

for coordination

Assumption:Pre-natal care improves

Technicalsupport is

coordinated

Advocacyabout the need

of a national plan

PTMTC servicesnot available at

all levels

National fundsmobilized for

PMTCT

Legal framework(outdated law,

2012 NationalPlan)

Unbalanced powerrelations between men

and women (use of preservative,

intergenerations unions)

Stigma and discrimination to the

virus (reinforced bythe law)

Limited use of preservaative

Limited intersectorial coordination

(health, education,gender, social)

Limitedknowledge of

the disease

Adopción de Estrategias

internacionales (Start free,

90.90.90)

Increase servicesquality

Reinforce compliancewith inspections of the

Ministry of Health

Reinforcecompliance with

follow-up mechanisms

New NationalPlan approved

Impact

Outc

om

es

Bott

lenecks

Str

ate

gie

sO

utp

uts

Path

ways

of

change

Path

ways

of

change

Prevention of HIV Mother to Child Transmission (PMTCT)

SDG Target 3.3. Ending AIDS as a public health threat by 2030

Technicalsupport

For suppliesprovision

Improvingpregnant

women HIV Diagnosis

Training ofhealth

Personnel- PTMH

- Dignos

IncreasingAccess to PMTCT

services(coverage)

Population knowsHIV better

Attitudes change

UNICEF for every child

Enabling Environment Demand

Evaluation PMTCT – UNICEF Equatorial Guinea

Supply

Theory of Change

Preganant women Access PMTCT services

Descentralizationstrategy scaled up

Sensitizationcampaigns and

prevenion tours

Increases % pregnantwomen that complete the

9 months treatment

Enhancing accessof pregnant women

to PMTCT services

Increase the % of infected kids

with treatmentIncrease the % of exposed kids

not infected HIV positive women whoare kept alive


4. Evaluation Purpose, Objectives and Scope The UNICEF Equatorial Guinea Country Office (CO) has therefore commissioned an external summative

evaluation of UNICEF’s Prevention of Mother to Child HIV transmission (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).

This evaluation has major implications for UNICEF’s future work and partnerships towards ending AIDS

as a public health threat by 2030 (SDG 3.3), as many actors at different levels are expecting the evaluation

findings and conclusion to inform their respective programme and policy designs, and will shape the

national response to continue advancing towards the elimination of MTCT of the HIV. In terms of

learning, the evaluation especially focused on the past years of UNICEF’s PMTCT engagement (2015-

June 2018) and its findings will inform:

• UNICEF’s contribution to the national Government’s PTMCT Programme as well as the UNICEF

Strategic Plan HIV outcome;

• UNICEF positioning in the post-2015 HIV agenda as guided by the UNAIDS 2016-2021 strategy and

the 2030 Agenda for Sustainable Development.

• UNICEF strategic direction and partnerships/advocacy as well as programme strategies (sectoral and

cross-cutting) effort aimed to achieve the results outlined in the Strategic Plan;

• Positioning within the HIV-AIDS global community, including UNICEF’s partners at all levels.

UNICEF sections and offices at all levels (HQ, Regional and Country Offices) constitute an important

audience as the evaluation will provide evidence on what works and why.

This is how the different evaluation users are expected to use the evaluation results (according to the

Terms of Reference):

Evaluation Users Evaluation USE

UNICEF EQG CO

(Management)

Resources mobilization for increase resources for fighting HIV and PMTCT.

Accountability to the government and donors.

UNICEF Health Section

(HIV)

Inform the formulation and implementation of PMTCT intervention in the new

CP 2019 – 2023. Inform the content of new partnership agreements with other

in-country institutions (Fundacion Religiosos para Salud, ISCIII)

MoHWB (HIV National

Program)

Improve the PMTCT intervention in the health centers nationwide

Inform the sections on recommendation in the eMTCT plan.

MoHWB (Primary

Health Care)

Inform the design of a new coordination strategy with MoHWB HIV Program

with a specific focus on PMTCT

Instituto de Salud

Carlos III

Inform the content of the Health component of their new cooperation Plan with

the EQG government

Figure 7: Evaluation users


Evaluation Objectives

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.

Scope

The evaluation covered UNICEF PMTCT programme and examined the organizations’ engagement at

country level. While UNICEF’s HIV response is known to be comprehensive, the evaluation focused on

the following:

Time frame: the evaluation uses a three-years and a

half perspective (January 1st, 2015 to June 30th,

2018), to examine key decision points and

choices made over the years in order to

understand how well UNICEF and partners

influence, learn and react, as well as to

understand the basis of present choices.

Institutional focus: the evaluation will focus on

the UNICEF PMTCT programme response.

However, the evaluation will assess UNICEF’s

strategic positioning, at two levels:

Comparative Advantage of UNICEF and

Resource mobilization.

Programmatic focus: In addition, the

evaluation must account for other dynamics

while assessing UNICEF’s contribution to global outcomes. The evaluation will assess particular

strategies UNICEF has engaged into to contribute to PMTCT programming:

1. Strategic information, knowledge generation and dissemination: the contribution to regional, global

and national policies and strategies through evidence generated by UNICEF and partner supported

research and programming as well as through its global data, estimation and progress reporting; and

the translation of global policies and evidence into national plans, operational guidance and tools.

2. UNICEF has engaged in joint planning, technical assistance, advocacy and field visits with partners:

working with the government at different levels to support the implementation of policies.

3. Thematic leadership, advocacy and partnership: the ability to foster or to be effective within

partnerships by leveraging corporate knowledge and assets to become a trusted advisor for donors,

national governments, and other national stakeholders; the ability to influence national PMTCT

agenda. UNICEF accomplishes its mandate by building strategic and operational partnerships and

leveraging resources at all levels

Geographic focus: the evaluation will assess the UNICEF PMTCT programme response at national,

regional, province, district and local levels.

Figure 8: Evaluation Scope


Out of the scope: the evaluation will not cover epidemiologic and service delivery quality aspects, as

these are not direct responsibility of UNICEF and they are addressed through publications done by

UNICEF and other stakeholders on these topics.

Evaluation management and team

The evaluation was managed by the Strategic Planning Manager in collaboration with the CO Head of

Health (based in Bata) and the CO HIV Specialist (based in Malabo) and with the overall technical

support of the UNICEF Regional Evaluation Adviser (based in Dakar).

5. Evaluation Design Following the UNEG Guidelines (‘Integrating Gender and Equity in Evaluations’), the UNICEF

Evaluation Policy and the instructions included in GEROS Handbook, the evaluation resulted from the

combination of the following approaches:

Gender and Equity-

focused

A Gender and Equity-focused approach, which would devote special attention

to Human and Children Rights issues, and to how the differences between

groups (e.g. through the disaggregation of the population by different

variables, such as sex, origin, location, wealth groups, religion, age, among

others) may determine specific situations of vulnerability, specifically for

women and girls. The evaluation looked into: (i) how the design of the services

and its provision are adapted to these groups’ needs; (ii) how HIV information

as well as reproductive health services were specifically age-appropriate; (iii)

to what extent special strategies were adopted to address high levels of sexual

violence;; and (iv) to what extent males were engaged in the programme

processes and dynamics.

Theory-based design

A theory-based design was used to increase confidence that the intervention

contributed to the outcome, rather than establishing attribution and definitive

proof. This method was especially useful as there was no counterfactual. It

demonstrates the probability that the programme has contributed to the

desired outcomes by building a well-evidenced causal chain case. All of this

provided a solid base for an iterative process of collecting and analyzing

additional evidence over time to strengthen the contribution story. To foster

learning, the evaluator conducted a ToC workshop with the UNICEF team, to

rebuild the theory.

Systematic analyses

of qualitative data

Qualitative analysis was critical to ensure transparency and enable the

evaluation team’s interpretations of the data to be based on participants’ views.

Thematic analysis5 involved six steps from the spoken text of participants (i.e.

the data) to the evaluation team’s interpretation –organized into mid-level

categories- and the organization by themes. Relationships between these

organizing themes were identified in order to finally group them into global

themes, which summarized all of the issues being explored by the participants.

Analysis began concurrently with data collection in order for the evaluation

team to consider the early themes emerging from interviews and FGDs and to

clarify, confirm and explore participants’ various views during the fieldwork.

5 developed by Attride-Stirling (2001).

https://www.unicef.org/evaluation/files/GEROS_Handbook_FINAL_summary.pdf


As saturation began to emerge during primary data collection (same issues

were repeated across participants), the evaluation team had the confidence

that a comprehensive set of themes has been gathered, and post-data

collection analysis could begin.

Synthesizing

evidence

The last phase of data analysis involved synthesizing the evidence from the

different data sources (including quantitative secondary and some primary data)

to develop key findings and conclusions in correspondence of each evaluation

question. This phase included carefully drawing together findings from the

document review, the ToC workshop, the KIIs and FGDs, and the review of

quantitative outcome data. The evaluation team examined the collected evidence

to assess whether (i) the programme theory of change worked as expected; and (ii)

the different interventions contributed to the desired intermediate outcomes. In

order to reinforce the credibility and validity of the findings, the evaluation

triangulated preliminary findings using secondary data its validity and reliability,

ultimately arriving at the conclusions of the evaluation.

Facilitation approach

The evaluator led the process with a facilitation approach: taking the initiative

and final responsibility, but always from an inclusive and participatory

approach, allowing all parts involved to be considered during the decisions

made throughout the evaluation process. Beyond seeing the evaluation as a

process for obtaining a product (the evaluation report), the consultant

understood the evaluation process as rich as the result and strived to get the

involvement and buy-in of all the parts.

Evaluation Criteria The evaluation questions were framed by four of the OECD-DAC criteria: Relevance, Effectiveness,

Efficiency, and Sustainability6, understood as per their standard definitions. The Impact criterium was not

included due to the lack of counterfactual and the timing of the evaluation.

In addition to these four dimensions of PMTCT programming, the evaluation will pay attention to cross-

cutting issues that resulted in two other criteria (UNICEF strategic positioning and leadership, and

Equity, Gender and Human Rights), understood as:

o Gender: gender inequality heightens the vulnerability of women and girls to HIV infection,

particularly where access to age-appropriate HIV information as well as reproductive health services

-necessary to prevent HIV infection- are unavailable or inaccessible, or where levels of sexual

violence are high. It has also been demonstrated that male involvement to PMTCT services can

enhance HIV testing and retention on treatment.

o Equity: promoting equity in service access and utilization for the most disadvantaged and excluded

women and children is at the heart of UNICEF’s work. Various factors such as geographic location,

gender inequality, economic status, social and cultural norms have contributed to enduring

disparities in the PMTCT response.

o Child rights and HIV are closely linked. A lack of respect for human rights fuels the spread of HIV

and exacerbates the impact of the epidemic on children and families.

Evaluation Questions

6 The evaluation will not attempt to assess the impact of the PMTCT programming on issues of mortality, cases averted, or indirect

outcomes like education enrollment. It is known that there is insufficient data and that the multiplicity of contributing factors makes it

impossible to isolate the effect of UNICEF or the strategies it has supported.


The evaluation was guided by the questions initially defined in the Terms of Reference (ToR). However,

given the high number of initial questions (31 plus the programmatic focus, plus the cross-cutting issues),

the evaluator and evaluation managers worked during the inception phase to reorganize them and to

prioritize the most relevant ones (highlighted in blue), in order to better focus the field work and

enhance the quality and completeness of the evaluation results.

As many of the original questions referred to Strategic Positioning, Comparative Advantage and

Leadership, a new evaluation criterium, which lumped them all together, was added. Likewise, in order

to give Gender, Equity & Human Rights more visibility within the scope of the evaluation data collection

and analyses, a number of new related questions were identified and grouped under a new (6th)

criterium:

EVALUATION QUESTIONS

1. Relevance

1.1. To what extent has UNICEF identified and addressed priority needs of the population?

1.2. To what extent has UNICEF supported national government priorities? To which extent PMTC

is relevant for the government (priorities, resources allocated, etc.)?

1.3. To what extent is this programme relevant to the CP and the Strategic Plan?

2. Effectiveness

a) Effects

2.1. To what extent did the Programme attain its intended results at country level and contributed

to expected results at regional level/global level?

2.2. To what extent was UNICEF reactive to the circumstances? What trade-offs were made to

ensure that partnership arrangements could work as intended? What were the related risks?

2.3. To what extent have these partnerships helped national PMTCT programme achieve their

national goals and targets? To what extent have partnerships contributed to the achievement of

global PMTCT targets?

2.4. To what extent has UNICEF contributed to the building of national systems? How have focus

on achieving goals been balanced with the drawbacks of vertical programmes (example: through

fostering coordination with Sexual and Reproductive Health programme)?

2.5. What were the unexpected (positive and negative) outcomes of the PTMCT Programme?

2.6. To what extent have UNICEF contributed to the resource mobilization national goals so that

the national plan could be achieved? To what extent did UNICEF’s resource mobilization efforts

garner funds relative to the investment of time and resources? To what extent has UNICEF provided

effective support for countries to access funds for PMTCT program from other sources?

b) Processes

2.7. To what extent are there gaps, overlaps and/or missed opportunities in programming that arise

from UNICEF’s organization structure?

2.8. How has UNICEF organized internally to address PMTCT? To what extent has UNICEF

capitalized on its structures and presence between sectors to achieve its intended results as per the

Strategic Plan and Global Plan for elimination?

2.9. To what extent UNICEF has utilized evidence from trials/ pilot tests interventions to inform

scaling up of proven effective approaches? Has UNICEF facilitated learning and knowledge sharing

between partners and national counterparts to inform adoption and scaling up of proven effective

approaches?


2.10. To what extent has UNICEF translated global policies and strategies through user-friendly

tools (documents) for use in national PMTCT program?

3. Efficiency

3.1. What is the return on UNICEF investments in the areas of PTMCT advocacy and partnerships?

To what extent did these efforts “pay off” in a tangible manner?

3.2. To what extent did UNICEF’s global, regional and country-level programs pursue and attain

output-level results through the least costly means?

3.3. To what extent has UNICEF capitalized on inter-sectoral linkages to bolster resources for

PMTCT (e.g. social protection, education, health)?

3.4. To what extent was value for money considered in decision-making?

4. Sustainability

4.1. To what extent has UNICEF strengthened national M&E capacity? To what extent have these

efforts strengthened countries’ ability to focus on issues of equity? To what extent have these efforts

strengthened countries’ ability to generate and use data for accountability and learning for PMTCT

program? To what extent have UNICEF’s mandate, structures and resources contributed to

sustainable country-led PMTCT program?

4.2. To what extent has UNICEF supported the development of costed national plans for the

elimination of MTCT in the country?

4.3. To what extent has UNICEF incorporated sustainability considerations in its work at country

levels?

5. Strategic positioning, competitive advantage and leadership

5.1. To what extent are there comparative advantages based on UNICEF’s mandate, structures and

resource? To what extent does UNICEF have a comparative advantage and demonstrate added value

in taking a leadership role in PMTCT forums vis-a-vis other players?

5.2. In case of comparative advantages, to what extent has UNICEF leveraged them fully in in

pursuit of its intended results?

5.3. To what extent did UNICEF’s leadership role in PMTCT forums contribute to the achievement

of its strategic priorities?

5.4. How does UNICEF view its leadership priorities? How does it view its role and focus? Do these

views vary across the organization? Is there coherence in its leadership vision?

6. Equity and Human Rights

6.1. To what extent did UNICEF contribute to Human Right and Gender approach in PMTCT

program?

6.2. To what extent did the UNICEF CO contribute to Equity approach in PMTCT programme?

6.3. To what extent PMTCT has contributed reducing the vulnerability of women and girls to HIV

infection, and how? (via increasing the access to age-appropriate HIV information as well as

reproductive health services? via male involvement to PMTCT services can enhance HIV testing

and retention on treatment?).


6.4. To what extent has UNICEF role enhanced pursue of exposed child rights? How has that

contributed to decrease the spreading of HIV and the impact of the epidemic on children and

families?

6.5. How has the programme enhanced service access and utilization for the most disadvantaged

and excluded women and children across factors such as geographic location, gender inequality,

economic status, social and cultural?

All these questions were operationalized in the Evaluation Matrix (Annex 5) and were answered one by

one, as shown in the Findings section of this report.

Methodology

The proposed methodology benefited from the inputs provided by the CO staff and the Reference Group

members as well as from the evaluator’s experience in designing similar evaluations in the past. The

evaluation team developed a detailed design, analytical methods and tools during the scoping phase,

based on the key informant interviews and an in-depth review of the programme documentation (see

link to the Inception report in Annex 2).

Data collection methods

During the field work phase, the evaluation team used a mix of qualitative and quantitative data (mixed

methods approach) for performing the envisaged data collection and analysis:

• Quantitative methods included, among others, trends analysis: this allowed retracing the

evolution of the national PMTCT programming context in terms of quantitative variables, such

as expected number of pregnant women, pregnant women living with HIV, pregnant women

living with HIV under treatment, exposed children, exposed children receiving treatment,

among others.

• Qualitative methods made it possible to gather data from key informants and stakeholders for

in-depth analysis and triangulation purposes. Documentation and secondary data generated over

the programme implementation period were also reviewed using structured methods.

Both types of data were analyzed separately and compared in an effort to (i) explain the multiple changes

occurred both in terms of level and quality of resources, policies, strategies and guidance (used and

developed during the programme implementation); and (ii) to assess whether and how UNICEF’s

response adapted to an evolving context. However, due to the unreliability of quantitative data available,

the comparative analysis was inconclusive/

The methods to be used were:

• review of documents and secondary data from the government and other sources,

• key informant and stakeholder interviews,

• case studies of the healthcare centers,

• and observation.

Stakeholders’ mapping

To support the sampling process of the key informants to interview as part of this evaluation, a

stakeholder mapping was conducted at the beginning of the evaluation (and reviewed after the

completion of the fieldwork). This exercise allowed both the evaluator and the UNICEF CI to define

which actors were critical and which were desirable to be invited to an interview (see in section 6.5.

Leadership).


Data sources

Data sources Information sought

HIV programme

monitoring system To collect PMTCT programme process and output data

UNICEF Health Section

(HIV)

UNICEF regular monitoring of their performance collected in the UNICEF

country and regional programme documents, annual and progress reports as

well as other internal materials

Partners Qualitative data on UNICEF’s performance and contribution

Quantitative estimations from UNAIDS (Spectrum)

Other stakeholders Such as health workers or health service users, to assess the changes in terms

of HIV prevention and treatment

A purposeful sampling process was conducted for the two last groups. The criteria used to identify whom

to interview included the following: the level of capacity to influence EMTCT policies, the relevance of

their role in the programme, the degree of representativeness of one the most critical decision-making

groups or of one of the identified vulnerable groups, the geographical residence (urban/rural/province),

For the sake of sampling the health centers to be visited, the Reference Group suggested some selection

criteria during the inception phase: overall, such criteria were aimed to obtain a sample of center that

were as institutionally diverse as possible (regional hospital, UREI, provincial hospital, district hospital,

health center), as presented in the table below:

Figure 9: Number of healthcare centers visited during the fieldwork, by province and level

Evaluation matrix

The link between Evaluation Questions, Methods and Data sources can be found in the Evaluation

Matrix (Annex 5), and practical operationalization in the Evaluation Tools (questionnaires and interview

guidelines) in Annex 7.

Triangulation of sources, researchers (when possible) and methods were sought for each of the key

evaluation questions. Data from these sources, collected through the different methods, was triangulated

to assess similarities and differences.

Methods for analysis

When saturation of messages occurred (triangulated data throws similar findings), 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 was required to complement data about the programme. It was important to talk to key

decision-takers and implementers at different levels.

Justification for the collection & analysis methods

The preliminary analysis of the methods indicated in the ToR (the analysis was conducted before the

inception report was submitted) confirmed that the suggested methodology seemed reasonable. That

having been said, some of the evaluation questions and approaches were adequately customized in order

to better address the evaluation questions. Experience also shows that the data collection methods which

the evaluation opted for (desk review, interviews, group discussions and case studies), are common

methods with high potential to collect relevant quantities of quality data.

Limitations of the evaluation

Considering the evaluation context and the design and methodologies proposed, the evaluation faced

some limitations and risks that were mitigated in the measure of possible:

Phases and deliverables

The evaluation was implemented through these phases and producing these deliverables

LIMITATIONS MITIGATION MEASURES

Limited time to collect right-holder

level data (target population: all

pregnant women living with HIV)

The evaluation tried to build on secondary quantitative data and

collect qualitative primary data, to complement each other.

Insufficient quantitative data

available

The evaluation built on updated monitoring data available through

reliable sources such as the MoHWB and UNAIDS

Inadequate interpretation of the

data found by the evaluation team

Validation of preliminary finding allow the team to ensure the data

accuracy

Stakeholders not comfortable saying

the truth

UNICEF team did not participate in the interviews with partners to

give them the space to express themselves freely

Relevant people not available at

healthcare centers level

It was difficult to contact the centers in advance (telephone numbers

not easily available) so the planned visits were improvised. However,

health workers trained and involved in PMTCT were always found

and accepted to be interviewed.

Users voice not easy to get

The evaluation sought to meet civil society organizations gathering

HIV patients. Three local organizations were found and met, all of

relative small size. However, there is no CSO or institution that

represent the voice of PLWHIV at national level.

Potential interference of the

National consultant from the

MoHWB with the evaluation

results

The terms of reference clearly stated the responsibilities of each

member of the evaluation team and were discussed during the

inception phase. The external evaluator led the evaluation work with

independence and the national consultant had an advisor role. The

CO conducted a continuous follow-up to identify and mediate in any

potential situation that may have appeared during the field visits.

However, no conflict or tensions were observed during the

fieldwork.

Figure 10: List of limitations and mitigation measures


PHASE DEADLINE RESPONSIBLE LANGUAGE STATUS

Inception Report 12/11/2018 Sara Vaca English Done

Power Point Presentation on

preliminary findings 30/11/2018 Sara Vaca Spanish Done

1st Draft Report 07/12/2018 Sara Vaca English Done

Summary of discussions held

during the evaluation

recommendations validation

workshop

14/12/2018 Sara Vaca Spanish Done

2nd Draft Report 14/12/2018 Sara Vaca English Done

Final Evaluation Report 20/12/2018 Sara Vaca English In progress

Figure 11: Phases and products of the evaluation

The evaluation was carried out according to the ethical principles and standards defined by the United

Nations Evaluation Group (UNEG) (See in Annex 8).


6. FINDINGS Following the results of the data collection and data analysis process, below are the findings, organized

around the different evaluation criteria (the evaluation addressed the evaluation questions – one by one-

corresponding to each one of the 6 evaluation criteria). In order to be more realistic in terms of the

number of questions which this evaluation could address within the allotted timeframe, some of the ToR

questions (highlighted in blue) were deemed as “critical: while others were deemed as “desirable” but

not critical (in gray). Answers to critical questions contain deeper evidence and analysis, while answers

to non-critical questions often feature shorter responses capturing the evaluator’s key considerations. On

two occasions, two evaluation questions were combined as their respective responses were related and

their content overlapped. For the sake of transparency and accountability, all the evaluation questions

are displayed and answered individually.

6.1. Relevance

6.1.1. To what extent has UNICEF identified and addressed priority needs of the population?

Findings

triangulated by:

Methods Sources

Desk review MoHWB, UN

Out of the 53000 adults and children living with HIV [44 000 - 68 000, http://aidsinfo.unaids.org/, 2017]

in the country, it is estimated that every year 1,800 women living with HIV get pregnant. However, the

proportion of those among them who are under treatment is still unclear (while the 2016 data attested

to 90% coverage, the 2017 figures has not been validated by the MoHWB yet).

According to UNAIDS data (Spectrum), new HIV infections are still increasing in Equatorial Guinea:

Figure 12: Trend of new HIV infections in EQG

Before the programme implementation started, pregnant women were tested for HIV in some districts.

But only some reference centers (in Malabo and Bata, first, and in 2 health centers and at a province-



level hospital later) could address the treatment needed by those women detected and for their babies

once they were born.

In order to have better access to the PTMCT services, pregnant women living with HIV and their

children needed specialized centers closer to their homes; what was needed, too, was greater awareness

of the need to protect the life of both mothers living with HIV and their babies. In order to address the

need, the programme focused more on the strengthening of the supply of PTMCT services (hardware-

type interventions) and, to a lesser degree, on the generation of PTMCT demand (software-type

intervention).

6.1.2. To what extent has UNICEF supported national government priorities?

To which extent PMTCTis relevant for the government (priorities, resources allocated, etc.)?

Findings

triangulated by:

Methods Sources

Desk review, Interviews MoHWB, UNICEF

Fighting for HIV prevention and elimination is one of the EQG government’s priorities. It is one of the

key strategies included the National Plan of Development (“Plan de Accion del Sexto Programa Pais 2013-2017 entre el Gobierno de la Republica de Guinea Ecuatorial y el Fondo de Poblacion de las Naciones Unidas”): PMTCT falls under the Result 1 (Improved Mother and Neonatal Health); Gender

Equity and Population and Development are featured in the two other Plan’s results.

The structure of the Ministry of Health and Well Being confirms such centrality of PTMCT in the

national agenda: two of the five General Directors deal specifically with HIV prevention and treatment.

However, the two directors in question have very limited human resources (one-person teams) and no

resources dedicated to M&E.

Figure 13: Structure of the Ministry of Health and Well Being related to PMTCT


Another challenge related to the way the minister has structured HIV services is that PMTCT services

are provided by Family Planning services at the hospitals, which depend on the National Manager of

Sexual and Reproductive Health (SRH) lead. Therefore, even though all services are merged in the

maternity and general consultations at local centers level, health workers end up receiving instructions

regarding PMTCP from two different departments within the same ministry.

The government has been involved in ending PTMCT and strengthened its national response. As of 2017,

the national government delegated the HIV response to the UN system and, to allow its

operationalization, made available a 2 million USD budget (450,000 USD were allocated UNICEF): that

does not only reflect the strategic importance that the government assigns to PTMCT but also attests to

UNICEF’s support to decentralize PMTCT services in response to a concrete EQG government’s concern.

6.1.3. To what extent is this programme relevant to the UNICEF Country Programme and Strategic

Plan?

Findings

triangulated by:

Methods Sources

Desk review, Interviews UNICEF, external sources

For UNICEF, PTMC is also a priority programme, especially given that HIV represents one of the main

causes of child mortality in the country, followed by malaria and neonatal disorders.


Figure 14: Mortality trend and Top 10 causes of death in 2017. Source: http://www.healthdata.org/equatorial-guinea

Beyond other priorities in the region such as reducing malnutrition, malaria, child’s marriage and

education, HIV is a critical problem affecting children. At UNICEF Strategic level, PMTCT is a key

component contribute to “Survival and striving”, one of the main axes of UNICEF Global Strategic Plan

(2018-2021).

Regarding the EQG CO, as part of the present Country Program Document 2013-2017/Ext 2018, fighting

HIV is part of the first result (“Fortalecimiento de las capacidades nacionales relativas a instrumentos de financiacion y dotacion de servicios para combatir el VIH/SIDA”), present in the Results framework.

In the new coming Country Programme 2019-2023, HIV is again a key component of the Health are

within survival and strive.

Finally, the programme is also aligned with the international guidelines such as:

1. SDG 3 “Ensure healthy lives and promote wellbeing for all at all ages“,

2. SDG 4 “Ensure inclusive and equitable quality education and promote lifelong learning

opportunities for all”,

https://sustainabledevelopment.un.org/sdg3




3. SDG 5 “Achieve gender equality and empower all women and girls” and

4. SDG 10 “Reduce inequality within and among countries”

5. Universal Health coverage;

6. WHO plan for health sector 2016-2021;

7. Test & Treat to reached 90-90-90 objective

8. Start free, Stay free, AIDS free;

9. UNICEF Strategic Plan 2018 – 2021;

10. UNICEF Strategy for Health 2016 – 2030;

11. West and Central Africa Regional Priorities 2016 – 2021.

6.2. Effectiveness

a) Effects

6.2.1. To what extent did the Programme attain its intended results at country level and contributed

to expected results at regional level/global level?

Findings

triangulated by:

Methods Sources

Desk review, Interviews, Observation MoHWB, Health centers, UNICEF

The programme is in progress to achieve its intended intermediate results (the decentralization of

services), but there is no evidence to judge whether the main objective (reduce the vertical transmission

to 5%) is being reached.

Regarding the decentralization, the monitoring reports of the PMTCT UNICEF team included the graph

below to show that only the Regional capitals and the provincial capitals in the continental region had

PMTCT services available before the decentralization programme. The graphs also show that 36 centers

were trained and equipped to provide PMTCT services after the start of the programme (first the pilot

in Bioko island and then the extension in the continual area).

Figure 15: Health centers providing PMTCT services before and after the decentralization. Source: UNICEF

In order to assess further the effectiveness of the program, the evaluation team assessed the extent to

which the programme envisaged objectives were attained during the three- and half-year

implementation period (see the figure below).

1

3

1

1

Acurenam

Akonibe

Nsork

1

Nsok Nsomo

PMTCT Health Centers before decentralization: 7

6

42

18

1

11

2

2

1

11

11Acurenam

Akonibe

Nsork

1 1

Nsok Nsomo1

PM TCT Health Centers after decentralization: 36



https://www.who.int/hiv/strategy2016-2021/ghss-hiv/en/

http://www.unaids.org/en/resources/909090

http://www.unaids.org/sites/default/files/media_asset/JC2869_Be%20Free%20Booklet_A4.pdf

https://www.unicef.org/publications/files/UNICEF_Strategic_Plan_2018-2021.pdf

https://www.unicef.org/health/files/UNICEF_Health_Strategy_Final.pdf


General

objective

Decrease vertical HIV transmission

below 5% in EQG

Official data from UNAIDS, no validated by EQG

Pregnant women needing ARV for PMTCT (#)2400 [1800 -

3000]

Pregnant women who received ARV for PMTCT (#)1516

Coverage: 84%

New HIV infections averted due to PMTCT (%) <500 [<200

- <500]

Number of HIV-exposed children who are uninfected 15

000 [11 000 - 19 000]

http://aidsinfo.unaids.org/, 2017

Specific

objectives

Train 144 health workers in PMTCT services in the

54 health centers to apply the PMTCT protocol

Reinforce PMTCT activities in the Primary Health

Attention

Reinforce the procurement system of the health

centers to apply PMTCT

Programme a monitoring system for the strategy Partial (initial, but no

systematic)

Correct bad practices in the strategy implementation

54 health centers are integrated in the PMTCT health

centers network providing option B+.

Partial (52%)

Figure 16: Follow-up of the Indicators set for the Decentralization Process

There are 13 centers in the islands (Bioko and Annobón), where implementation was completed at 100%

during the pilot, and there are 55 centers at the continental region, where implementation was achieved

at 40%:

INDICATOR % # OF CENTERS

Total coverage (both regions) 52% (36 out of 69)

Coverage in Island Region 100% (14 out of 14)

Coverage in Continental Region 40% (22 out of 55)

Coverage Regional and Provincial hospitals 100% (8 out of 8)

Coverage District hospitals 100% (9 out of 9)

Coverage Health centers 14% (5 out of 36)

Figure 17: Detail of the coverage indicator of the Decentralization process

By looking in details into the implementation rate in the continental region, the evaluation team

conclude that the implementation has reached the regional, provincial and district level but not the local

level (healthcare centers in the neighborhoods or villages).



Figure 18: Detail of the health centers involved in the Decentralization

The evaluation team reconstructed the Programme ToC the PMTCT UNICEF team at the beginning of

the field work, as a way to a common understanding of the Programme logic. As the methodology section

describes, the evaluation used a Theory-based approach to validate which parts of the theory have been

validated. The analysis concluded that the theory held true for most of the intermediate results necessary

to achieve the outputs. The coverage of the access to services was limited and the users’ attitudes hasn’t

greatly changed either (yellow boxes represent intermediate results not fully achieved).


Figure 19: Theory of Change of the programme (in yellow, intermediate outputs not fully achieved)

The data needed to calculate the transmission rate is not reliable. Field work confirmed that there are 3

potential sources of data: the data from the consultations done by doctors, midwives and nurses; the data

collected in the laboratories; and the data collected by the health center pharmacies. However, they are

not systematically collected and consolidated at regional or central level due to several reasons. First, the

lack of templates and protocols to consolidate medical registries and individual templates. Second, the

Eliminated vertical transmission of HIV

Inter-sectorial group working

for coordination

Technicalsupport is

coordinated

Advocacyabout the need

of a national plan

PTMTC servicesnot available at

all levels

National fundsmobilized for

PMTCT

Legal framework(outdated law,

2012 NationalPlan)

Unbalanced powerrelations between men

and women (use of preservative,

intergenerations unions)

Stigma and discrimination to the

virus (reinforced bythe law)

Limited use of preservaative

Limited intersectorial coordination

(health, education, gender, social)

Limitedknowledge of

the disease

Adopción de Estrategias

internacionales (Start free,

90.90.90)

Increase servicesquality

Reinforce compliancewith inspections of the

Ministry of Health

Reinforcecompliance with

follow-up mechanisms

New NationalPlan approved

Im

pact

Outcom

es

Bottle

necks

Strategie

sO

utputs

Pathw

ays

of

change

Pathw

ays

of

change

Prevention of HIV Mother to Child Transmission (PMTCT)

SDG Target 3.3. Ending AIDS as a public health threat by 2030

Technicalsupport

For suppliesprovision

Improvingpregnant

women HIV Diagnosis

Training ofhealth

Personnel- PTMH

- Dignos

IncreasingAccess to PMTCT

services(coverage)

Population knowsHIV better

Attitudes change

UNICEF for every child

Enabling Environment Demand

Evaluation PMTCT – UNICEF Equatorial Guinea

Supply

Theory of Change

Preganant women Access PMTCT services

Descentralizationstrategy scaled up

Sensitizationcampaigns and

prevenion tours

Increases % pregnantwomen that complete the

9 months treatment

Enhancing accessof pregnant women

to PMTCT services

Increase the % of infected kids

with treatmentIncrease the % of exposed kids

not infected HIV positive women whoare kept alive

Intermediate results thathave not been observed


monthly reports produced by the centers are submitted to different statistic centers and none of them

reach central level at the MoHWB. Third, there is no MoHWB data staff allocated to PMTCT.

Due to the lack of resources in the two General Directions in charge of HIV, they did not produce their

own data (which means going in person to each head of province or district to retrieve the data in hard

copies), so they rather rely on the data provided by the Pharmacy supply chain responsible. As a

consequence, the only secondary quantitative data that the evaluation team could consult was the level

of drugs consumptions between January and August 2018 (such data was collected during the last

supervision mission conducted by him.

Figure 20: Data of patients under HIV treatment January-August 2018. (according to

the MoHWB pharmacy supply chain registries).

A further tool used to measure the results and the progress of the programme’s achievements has been

an analysis of the UNICEF MORES determinants within the scope of the different interventions

implemented during the PTMCT services decentralization process. The rubric depicted baseline and

current situation (labeled respectively as “before” and “after” columns), by also breaking PMTCT services

into the various MORES determinants.

Depending on the attained level of progress, the rubric will point to a different color, as per the legend

below:

Very good, sufficient / achieved and consolidated

Existing, good but room for improvement and consolidation

Existing but not totally achieved or not totally satisfactory

Non-convenient, non-existing

Thanks to the rubric, the PMTCT services were analyzed according to each one of the identified

determinants. That allowed judging the situation before and after the programme, as well as appreciating

which dimensions have moved forward:


AREAS DETERMINANTS BEFORE AFTER COMMENTS

ENABLING

ENVIRONMENT

1) Societal norms

At the decision-makers level, HIV is

part of the government agenda.

Existing HIV law but with deficiencies.

2) Legal

framework

The strategy is a solid first step, but a

National Plan is still missing

3) Budget /

expenditure

A 2 million USD budget was allocated

by the Government to the HIV

program.

4) Coordination

Coordination between actors has

improved (example: between services

within health centers, such as

laboratory, pharmacy and doctors; also

between centers when one supply is

out of stock)

SUPPLY

5) Availability

inputs

The services were not available before

the programme but are available now

and working with standardized quality.

Medicines and inputs are in place7 at

healthcare centers.

6) Availability

staff

Practitioners at each district health

center can provide PMTCT services.

DEMAND

7) Access Access has been enhanced from

provincial level to district level.

8) Practices and

beliefs

At community level, still many women

do not use healthcare centers and men

do not feel involved. Weak knowledge

of HIV.

9) Continuity of

use

Although HIV is no longer a taboo,

there are still many myths and stigma

around it. The system has a weak

retention level.

QUALITY 10) Quality

Transmission mother to child of HIV

rate still unclear. Early Infant

Diagnose is not available and the

actual protocol recommended HIV

testing at 6 months. With low patient

retention, children exposed to HIV

are lost by the system, so no evidence

that our target is reached.

Figure 21: Analysis of achievements following UNICEF's MORES determinants

7 There has been a plan for making medicines and HIV tests available. The procurement system (needs planning, orders,

stocking and stock management) has been reinforced to assure the needed medicines, tests and artificial milk are available.

In order to do it, a module of training was included to manage inputs to avoid stock shortages and the expiration of

diagnosis tests and medicines.


6.2.2. To what extent was UNICEF reactive to the circumstances? What trade-offs were made to ensure

that partnership arrangements could work as intended? What were the related risks?

Findings

triangulated by:

Methods Sources

Desk review, Interviews MoHWB, CSOs, UN agencies

According to the partners (including the MoHWB, other UN Agencies and CSOs), UNICEF has kept a

proactive attitude along the programme, adapting to the circumstances and using their resources and

potential influence to support the government and cover the gaps the system.

At the beginning of the programme, the CO managed to formalize the legal agreements with the

MoHWB and the training partner (ISCIII): that allowed the start of the pilot implementation as well as

its successful completion.

After the depletion of the CO’s core funds, UNICEF reacted by started making advocacy efforts towards

the adoption of the “Start free, stay free, AIDS free” international strategy and the mobilization of funds

(2 million USD): that resulted/translated into the opening of negotiations within the UN System.

By commissioning this evaluation, first one of its kind for both the UNICEF CO and the MoHWB,

UNICEF demonstrated a certain adaptive response. That is all the more critical as the evidence and

situation analysis generated by this evaluation are expected to boost the next phase of the programme

implementation.

6.2.3. To what extent have these partnerships helped national PMTCT programme achieve their

national goals and targets? To what extent have partnerships contributed to the achievement of global

PMTCT targets?

Findings

triangulated by:

Methods Sources

Desk review, Interviews, Observation MoHWB, UNICEF, UN agencies,

CSOs, FRS, Health centers

The three-partners relationship among the MoHWB, UNICEF and the ISCIII has been very beneficial

to the success of the envisaged decentralization process. UNICEF has been supporting the government

for years through the MoHWB among other ministries. The ISCIII, too, has been working with the

MoHWB for a long period. The preexisting relationship with the MoHWB is one of the reasons, along

with their technical capacities, why UNICEF selected this organization (ISCIII) to support the

decentralization process. UNICEF’s support has been positively judged as proactive and reactive by the

MoHWB.

Each one of the three partners performed a different set of tasks and responsibilities as per the table

below.

Actor Role and Responsibility

MoHWB

(specifically the General

Director of HIV

Assistance and Treatment)

• Leader of the decentralization process and last responsible entity with

respect to the provision of PMTCT services to the population.

• Provided with funds in the second part (as of end of 2017) and delegating

the HIV response to the UN System.

• Coordinating with UNICEF the programme activities.


• Provided the drugs, test and other materials

UNICEF

• Main partner supporting the decentralization. Leader in the design of the

plan, financial and institutional support.

• Elaborating the drafts of strategies, programme documents, ToR for

trainers and local coordinators, that the MoHWB would later validate.

• Managing the funds, supporting in the training phase, as well as in the

monitoring of the training and supervision phase.

• Coaching at central and local level.

ISCIII

• Providers of the training of trainers.

• Providers of the training to the health centers.

• Elaboration of the training materials and leaflet.

• Part of the supervision visits team.

Figure 22: Roles and responsibilities by Partner involved in the programme

Other partners played a less principal role in the decentralization of PMTCT services. The World Health

Organization (WHO) and UNFPA participated in the design and validation of the decentralization plan,

as well as technical support in the evaluation of the programme. WHO was in charge of monitoring the

pilot evolution once the second phase of extension to the continent started. UNFPA had a role fostering

promotion of prevention messages and UNAIDS was also commissioned by the MoHWB for other tasks

(with half of the budget allocated to them), but in general these agencies faced problems deblocking the

funds and to this date their activities in these issues have remained very limited.

It is worth mentioning, too, that the structure of the Ministry has made the coordination with PMTCT

services in occasions challenging (see Figure 13 in page 25). While the two General Directors in charge

of HIV are have been available (the General Director Assistance, Control and Treatment of HIV/AIDS is

the actual leader of the programme), the health workers being trained and in charge of providing the

PMTCT services are in fact under the Hospital Coordination General Manager and under the Family

Planning team, which falls under the Sexual and Reproductive Health National Director. That said, at

local level those services are merged (provided by the practitioners) who are usually generalist doctors,

obstetricians, nurses and midwives. Besides, the ministry’s structure changes very frequently (every 2

years approximately), which increases the coordination issues with new teams and challenges.

6.2.4. To what extent has UNICEF contributed to the building of national systems? How have focus on

achieving goals been balanced with the drawbacks of vertical programmes (example: through fostering

coordination with Sexual and Reproductive Health programme)?

Findings

triangulated by:

Methods Sources


The progress observed after the start of the programme is mostly imbedded within the national health

care system. The programme has come to reinforce the local capacities: the partners’ interventions have

been punctual and focused on coordination rather than the replacement of national actors.

In order to better understand the impact experienced in the national systems, a Capacities Reinforcement Framework was used to allow mapping changes in capacities, according to their types and their level:


MAPPING OF ACHIEVEMENTS USING THE CAPACITIES REINFORCEMENT FRAMEWORK

PROCESSES PRODUCTS RESULTS IMPACT

SYSTEM

(Expected

National Plan)

(Desired: 0%

discriminatory

legal framework)

PMTCT services

available at 100%

districts

(Aimed: AIDS free

new generations)

ORGANIZATION

(MoHWB)

“Strategy for the

acceleration to

universal access of

HIV MTCT

services”

STAFF

Healthcare

workers know

how to provide

PMTCT services

COMMUNITIES

They start going to

their health care

center for PMTCT

(Expected: HIV

Transmission

MTC < 5%)

Figure 23: Mapping of achievements according to the Capacities Reinforcement Framework

As it can be observed, having PMTCT services available at district level is a result that all the system

benefits from (not only at the MoHWB level). Other changes at System level haven’t been achieved yet.

However, at organizational level, the Healthcare system has validated some international guidelines and

has elaborated the “Strategy for acceleration of HIV Mother to Child Transmission prevention and

elimination”. At personnel level, more than 300 health workers know how to provide PMTCT services.

Meanwhile, at the community level, pregnant women have started being consistently tested for HIV and

those positive, to use the services and to understand the importance of their treatment and the baby’s.

6.2.5. What were the unexpected (positive and negative) outcomes of the PTMCT Programme?

Findings

triangulated by:

Methods Sources

Desk review, Interviews, Observation MoHWB, Health centers, UNICEF,

UN agencies, CSOs

The evaluation systematically tried to identify unexpected effects and found some.

First, by delegating the management of these funds to the UN system, the government staff missed the

opportunity of reinforcing their own management capacities: the initial lack of human resources could

have been solved by hiring ad-hoc staff.


Second, by preventing mothers living with HIV from breastfeeding, a number of known risks is being

avoided. However, there are two unexpected outcomes associated with this: providing artificial milk

(which is commonly used by women and is expensive) for free, constitutes an extra motivation for

mothers to honor their monthly visits to collect their treatment. On the other hand, while only 56% of

the population has access to safe water, fostering artificial milk consumption may increase risks of

intestinal disorders in babies if the water and bottles are not properly clean.

Third, the (4) doctors who were trained as PMTCT coordinators suffered from the misunderstanding of

their own role by their colleagues, who believed that they were being treated with privilege and

receiving big sums of money, which was not the case.

Fourth, rotation of PTMCT-trained health workers among different health centers present a challenge

as it may weaken the PMTCT taskforce providing services in the center. That said, it may have

unintended positive effects such as when highly-trained workers arrive to a center where these or other

services were not provided, reinforcing the capacities of the new center.

Fifth, as the training provided integrated PMTCT and ARV treatment, not only for pregnant women,

but for adults and children too, the programme has contributed to the decentralization of ARV treatment

beyond PMTCT, for adults and children too (several of the visited centers were providing with treatment

to patients of their influence area). This is key for the mothers who become users of this service once the

baby is 2 years old, and to reduce new transmissions and keep patients alive beyond the target population

of vertical transmission.

6.2.6. To what extent has UNICEF contributed to the resource mobilization national goals so that the

national plan could be achieved? To what extent did UNICEF’s resource mobilization efforts garner

funds relative to the investment of time and resources? To what extent has UNICEF provided effective

support for countries to access funds for PMTCT program from other sources?

Findings

triangulated by:

Methods Sources


UNICEF has supported the mobilization of national funds to reduce mother to child HIV transmission.

By supporting the pilot first, making it viable and successful, and by making the decentralization a reality

later on, UNICEF assisted the government in gathering sufficient evidence that could help it to showcase

examples of viable and successful EMTCT policies implemented in the country, especially as part of their

respective advocacy and resource mobilization efforts.

At moment, UNICEF is advocating for the resource mobilization from Global Fund, since the country is

become again eligible to Global Fund Grants. This is an opportunity to reinforce the Government’s national

HIV response, especially among adolescents et young girls.

b) Processes

6.2.7. To what extent are there gaps, overlaps and/or missed opportunities in programming that arise

from UNICEF’s organization structure?


6.2.8. How has UNICEF organized internally to address PMTCT? To what extent has UNICEF capitalized

on its structures and presence between sectors to achieve its intended results?

Findings

triangulated by:

Methods Sources


UNICEF’s processes to respond and support the MoHWB seem to be simple and effective. The human

resources allocated by UNICEF to support the programme (basically the National Head of Health

programmes and the international HIV Specialist) have shown proper competences, skills and attitude

to manage the programme and seem to have a direct causal relation with its progress.

On the other hand, no overlaps between UNICEF and public officers have been identified. However, the

evaluation team concluded that a bigger team (from the ministry and from UNICEF) may have made

feasible to focus beyond implementation and allow a deeper understanding and a timelier resolution of

the PTMCT data availability problem, which was observed at the healthcare system level.

The pilot approach to start in small scale and scaling up later has also proved to be a good strategy: that

avoided the risk of engaging right away into a model that may have proved non-feasible at the national

level.

UNICEF monitoring could have been more ambitious and have drawn more conclusions. Missing data

actually provided by the new PMTCT services could have been identified and solved before the

programme had ended and the evaluation had started, by defining and mending the protocol and tools.

6.2.9. To what extent UNICEF has utilized evidence from trials/ pilot tests interventions to inform

scaling up of proven effective approaches? Has UNICEF facilitated learning and knowledge sharing

between partners and national counterparts to inform adoption and scaling up of proven effective

approaches?

Findings

triangulated by:

Methods Sources


As mentioned before, UNICEF used the data and evidence generated by the implementation of the pilot,

and gathered in a report, to discuss and elaborate the scaling up plan with the government. It included

guidelines on how to proceed to the next phase. The delay of time between the end of the pilot and the

scaling up programme was reasonable and due to external reasons, out of the CO control. This allowed

that many of the actors involved in the pilot were also involved in the scaling up, which was another

success factor.

6.2.10. To what extent has UNICEF translated global policies and strategies through user-friendly tools

(documents) for use in national PMTCT program?

Findings

triangulated by:

Methods Sources

Desk review, Interviews MoHWB, Health centers, UNICEF


The products produced as fruit of the collaboration of

UNICEF with the government are technical and valid

tools customized to their purpose and users. The

“Strategy for accelerating universal access to HIV

PMTCT” sets a framework that allows all actors working

in PMTCT to align their respective practices and

interventions with the new recommendations and

actions to be implemented.

Furthermore, the protocol “Guidelines for use of ARC for prevention

and treatment of HIV” is meant to update and merge former guidelines

for health practitioners.

Additional resources produced during the programme implementation

include: an analysis of bottlenecks was conducted, a “Plan to reduce the

new infections in adults”, a publication on “Strategies of community

actions to increase the number of children tested out of the PMTCT

programme: and a “Strategy of HIV prevention in youth”.

6.3. Efficiency

6.3.1. What is the return on UNICEF investments in the areas of PTMCT advocacy and partnerships? To

what extent did these efforts “pay off” in a tangible manner?

Findings

triangulated by:

Methods Sources

Desk review, Interviews MoHWB, Health centers, UNICEF

When talking about return on investment (ROI), it is critical to understand that a literal analysis of the

value realized as compared to the value invested (usually measured in money) implies dealing with many

attribution and valuation problems, which was not realistic to undertake in this evaluation, which mostly

looks at process and intermediate results and not impact. Therefore, the return analysed in this

evaluation is understood as the appreciation of the changes in comparison with the resources invested

to make them happen.


The first thing to establish is the amount of the financial efforts made by UNICEF to support the

decentralization of PMTCT. Overall, the resources utilized reached 273,299.44 USD for a 3-and-a half-

year programme, including a 2-month extension (May and June 2018).

Several methodologies were used to assess the efficiency of the programme in question.

First, taking a break-even analysis, it can be assessed if the results achieved described in the Efficacy

section added a value estimated in these costs.

Second, calculating the unit cost of several of the outputs is another method to provide further elements

to the efficiency analysis. The number of people trained was 355. Therefore, the cost of training (219.954)

per person trained in the continent (including a 2 days training and 4 visits of supervision and

monitoring) was 619 USD. In the pilot was 821 USD per person (36,965 USD / 45 people trained).

The number of new centers rose from 7 to 36. Therefore, the average cost of implementing the Program

in each one of the 29 new centers has been of 7,584 USD, with the understanding knowing that the main

investment (the training) was done in a total of 69 centers (33 should implement soon as they have

already been selected for fulfilling the requirements and trained). Once that final phase is completed,

the cost per center will be more of 3,500 UDS per center (29+33 centers will have been implemented).

Figure 24: Cost of the decentralisation programme (Source: UNICEF)

Finally, calculating the cost of the decentralization (273.299 USD) for people served by the services

(number expected of pregnant women (4.5% of population), their partners and children under 15), the

decentralization has costed 5 USD per person. Ideally, some of these indicators should be compared to

other countries undertaking similar projects. However, comparing the cost of implementing PTMCT in

other countries was considered but there were too many variables not easy to compare, such as the

baseline situation, the population and distribution in the country’s territory, the penetration of the HIV

in the country.


Finally, comparing the PTMCT with other programmes such as the Malaria in the Bioko Island (with a

much bigger budget), may give the idea of how much this programme has achieved with limited funds.

6.3.2. To what extent did UNICEF’s global, regional and country-level programs pursue and attain

output-level results through the least costly means?

Findings

triangulated by:

Methods Sources


The budget of the programme is straight forward, with only 2 concepts: training in the pilot and training

in the continent, and two minor support actions. UNICEF followed its procurement guidelines and

procedures to hire the services related to this programme. For each purchase or contract, at least 3

quotations for the same services were obtained to assure that the least costly providers were selected, for

similar quality of services.

That said, the contract with the ISCIII was a service contract with a-year-long duration, while in

practice, their services were not continually used along the 12 months but punctually, due to the need

of their expertise only in different periods of implementation (when the training or supervision visits

were conducted). Therefore, now that a pool of professionals has been trained, some savings could have

been done by using another type of contract, whereby only actually worked days were invoiced.

6.3.3. To what extent has UNICEF capitalized on inter-sectoral linkages to bolster resources for

PMTCT (e.g. social protection, education, health)?

Findings

triangulated by:

Methods Sources

Desk review, Interviews UNICEF

This is one of the weaknesses of the programme: the process did not either explore or capitalize on the

linkages existing across sectors (example: with Nutrition and Education areas). Apart from the support

to the elaboration of an HIV/STI module for secondary school in 2016, UNICEF has been more focused

on health aspects and outputs and outcomes, not addressing the social and economic dimensions of the

issue.

6.3.4. To what extent was value for money considered in decision-making?

Findings

triangulated by:

Methods Sources


Decisions taken in phase 1 (the pilot) and 2 (decentralization in the continent) seem to have been rational

and done by consensus. There is no evidence of wastes of resources from the limited budget. Evidence

was also found that value for money, while it was not the main criteria for decision-making, was

considered, according to the programme managers of each partner.


6.4. Sustainibility

6.4.1. To what extent has UNICEF strengthened national M&E capacity? To what extent have these

efforts strengthened countries’ ability to focus on issues of equity? To what extent have these efforts


program? To what extent have UNICEF’s mandate, structures and resources contributed to sustainable

country-led PMTCT program?

6.4.2. To what extent has UNICEF supported the development of costed national plans for the

elimination of MTCT in the country?

Findings

triangulated by:

Methods Sources


UN Agencies, CSOs

Given the design of the programme, progress in the decentralization is based and relying on the national

healthcare system capacities, at all levels (processes, products and staff). While other projects and

decentralization schemes are supported by external resources, the involvement of UNICEF or other

partners such as ISCIII was punctual and always aimed at strengthening the national counterparts.

For the continental phase (scaling up phase), the programme design provided for the training of a team

of 4 local doctors as PMTCT coordinators. These four staff conduced the analysis of healthcare centers,

received the Training of Trainers course and were part of the facilitators that delivered the training to

the health centers targeted by the programme. They were also part of the teams doing the centers

supervision visits. The fact of being 4 helped assuring their continued presence. That notwithstanding,

only two of the four are temporarily active (one is in maternity leave and the other one on military

training leave). Although formally they no longer hold this position (the programme stopped paying

them in June), they are part of the national healthcare system (they are based in the Bata Regional

Hospital) and continue to conduct informal supervision in the maternity services of their hospital. Their

role and function as PMTCT coordinators could be easily restarted.

As shown earlier, the analysis and mapping of the results achieved with the programme (see Capacities

Framework, figure 23 in page 34), reveals that these improvements are happening at both the

organization level (MoHWB) and at the staff level. The more these changes gravitate towards the right

top area of the above-mentioned table, the more they appears to be sustainable as they mean changes at

system and impact levels.

The fact of having PMTCT services available at district level is a result at system level, and other changes

at this level (such as the HIV National Plan) would increase the probabilities of sustainability of the

achievements. Other necessary steps have been taken, like the strategy for accelerating universal access

and ensuring that an important number of health workers are able to provide these services.

To the contrary, the changes observed at community level are small and their dimension is unknown

(the proportion of pregnant women who go to the healthcare center for visits and labor, and the

proportion of HIV positive pregnant women who follow their treatment). As a result, it would be a bit

premature to talk about sustainability of these changes. The behaviour changes (changes in knowledge,

attitudes and behavior) occurring among the groups targeted by the Programme should be further

investigated.

Overall, in order to make the progress sustainable over time, three key factors were identified:

- First, veiling for the consistency of good PMTCT practices consolidated. This can only be done

restarting the supervision visits to monitor medical, logistics and reporting practices.


- Improving the national health information system is key to monitoring the attained progress and

understanding the level and quality performance of the services in each context.

- The assurance of stock availability is essential: discontinuities in stock availabilities would have a

critical negative impact in the supply and demand of PMTCT services. Therefore, the programme

must pay special attention to assure existences in the next phase where other 33 centers will start

consuming and ordering these products at national level.

6.4.3. To what extent has UNICEF incorporated sustainability considerations in its work at country

levels?

Findings

triangulated by:

Methods Sources


Mechanisms of sustainability put in place by the programme have already been mentioned: grounding

the provision of services on the existing healthcare system is the main and most efficient mechanism

used. In that sense, if UNICEF stopped working in PMTCT in the country, the national healthcare system

can still provide these services, though the evolution of future quality will still depend on how the 3rd

phase of the decentralization that starts now will be managed for finalization and consolidation.

However, other minor mechanisms have to be considered to support the continuity and quality of the

services. For example, given the high rotation of staff within the health centers (many professionals are

muted every two years), it is key that the PMTCT services are assured by more than one person (in

average 5 people were trained per center, but often in reality the PMTCT services leadership informally

relies on one or two), and training materials (in brief format but with deep enough information) should

be available so that newcomers can be self-trained.

Another mechanism that would increase the sustainability of the changes and the quality in general

would be clarifying the communication mechanisms of the programme. In the field many examples of

miscommunication were related by the healthcare workers encountered. Examples:

- “The nurse of my center has gone to training but I’m not aware why” (director of a health center);

- “They sent Nistatina in the last order and we do not know how to use it. We assume is for the baby

(it is a syrup) but we are waiting for instructions”;

- “They said they are going to bring new registry books”;

- “They told us to start giving 4 units of artificial milk instead of 6. Then 2 instead of 4”;

- “They said they are going to change the general registry format”.

Establishing clear top-down communication mechanisms (and if possible bottom-up too) would help

have more standardized levels of awareness of news in this area and a more confident network of

professionals engaged into reducing HIV vertical transmission.

6.5. Leadership

6.5.1. To what extent are there comparative advantages based on UNICEF’s mandate, structures and

resource? To what extent does UNICEF have a comparative advantage and demonstrate added value

in taking a leadership role in PMTCT forums vis-a-vis others players?


6.5.2. In case of comparative advantages, to what extent has UNICEF leveraged them fully in in

pursuit of its intended results?

Findings

triangulated by:

Methods Sources


UN Agencies, CSOs

As one of the respondents said, “UNICEF’s competitive advantage is being UNICEF” (in terms of

resources, capacities, image and mandate). It includes establishing an effective presence at the country

levels, technical capacity, ability to play a convening role. They have also shown their ability to adapt

based on new scientific and operational information, such as their reaction when new international

guidelines were issued.

The creation of a position based in Bata to provide a closer follow-up to the phase in the continental

region was also a way to materialize UNICEF’s resources for contributing achieving better results.

UNICEF has also proved their ability to generate the required funds for PMTCT programme and projects

that UNICEF supports. Ability to leverage major funders’ resources to achieve UNICEF strategic

priorities in PMTCT may be part of the next phase, once the services are available at local level, reliable

data about the phenomenon is available and ideally a national plan is issued, to raise a compelling case

in from of potential donors.

6.5.3. To what extent did UNICEF’s leadership role in PMTCT forums contribute to the

achievement of its strategic priorities?

6.5.4. How does UNICEF view its leadership priorities? How does it view its role and focus? Do

these views vary across the organization? Is there coherence in its leadership vision?

Findings

triangulated by:

Methods Sources


UN Agencies, CSOs

According to the stakeholders mapping elaborated to reflect the different actors working in PMTCT,

reviewed and adapted to after the field work, UNICEF seems to have been the leader in supporting the

government to decentralize PMTCT services at district level.

UNICEF took the leadership in the intervention design, in the institutional support, and financial

support, as well as in the implementation. In addition, UNICEF involved and hired ISCIII as technical

leaders, and led the follow-up with the 4 coordinator doctors during the monitoring phase. At the same

time, UNICEF had an inclusive approach, involving other UN agencies such as WHO and UNAIDS.

As the mapping shows, the criticality of UNICEF role is all the more relevant given the paucity of actors

working on PMTCT in EQG (Figure below XX). The Figure is really hard to read..please nearlge the

fonts).


Figure 25: PMTCT Stakeholders Mapping

Apart from the Ministry of Health and Well Being, no other ministries seem to be having a multisectoral

role. On the international cooperation sphere, the Instituto de Salud Carlos III is also the leader who has

been working with the ministry for a long time.

The evaluation used an attempt to reconstruct the counterfactual by asking the stakeholders what would

have happened if UNICEF had not been present in the last 3 and a half years in the PMTCT. The answers

were unanimous to agree that the decentralization would not have been at this stage: “Many people

talked about it but nothing happened”. Therefore, UNICEF’s leadership steering different actors will

seems to have been a key success factor to have reached the present level of decentralization.

6.6. Equity, Gender and Human Rights

6.6.1. To what extent did UNICEF contribute to Human Right and Gender approach in PMTCT

program?

6.6.2. To what extent did the UNICEF CO contribute to Equity approach in PMTCT programme?

Findings

triangulated by:

Methods Sources


UN Agencies, CSOs

The programme has contributed to improve the lives of many people living with HIV in different ways.

First, it contributed to decreasing the stigma produced by having to go for treatment to a specialized

center, clearly identified by the population a place for people with infectious diseases. By receiving

Stakeholders mappingActors National International / Multilateral

Public

Private

Population

Fundacion de

Religiosos

para la Salud/

Instituto de Salud Carlos III/ISCIII

Implementation partners Strategic partners

Pregantwomen

Men AdolescentsYoung Ethnicities DisabilitiesSexual

diversity

MoHWB

Health centers

Associations

Breastfeadingwomen

0-18m children

UN

WHO

UNFPA

UNAIDS

UNICEF

Iglesia católica

Sectas

Healers

Prenatal

Maternity

Justiceministry

Pediatrics

Laboratory

Pharmacia

Logistics

SIS

Statistic


treatment in regular consultation rooms at the same centers, getting treatment from the regular

pharmacies, HIV patients can keep their condition more confidential nowadays.

Second, the programme clearly contributed to bringing access to services closer to the target population:

thanks to the programe, pregnant women from lower wealth groups, who could not afford to get

transportation to go to the region or province capital center in the past8, can now access the ARV

treatment they need.

Therefore, the main direct beneficiaries of the programme are women in reproductive age and babies

and young children. However, the programme has not done relevant contributions to address the root

causes of gender inequity around PMTCT. The programme has focused in helping pregnant women to

have access to PMTCT services but there is no component of the intervention trying to address husband’s

and men disengagement with HIV or to improve the dialogue within the couple that makes the woman

confident to discuss it when they learn that the test is positive. Likewise, the programme did not tackle

the fact that it is mostly women who take the babies to visits and for treatment, including components

addressed to men.

6.6.3. To what extent PMTCT has contributed reducing the vulnerability of women and girls to HIV

infection, and how? (via increasing the access to age-appropriate HIV information as well as

reproductive health services? via male involvement to PMTCT services can enhance HIV testing and

retention on treatment?).

Findings

triangulated by:

Methods Sources


UN Agencies, CSOs

By giving mothers living with HIV enhanced access to PMTCT services, the vulnerability associated

with their condition is reduced by giving them access to free treatment closer to their homes. However,

the partner or family testing is not included in the protocol. Only some centers have the practice of

providing the woman the prescription for the husband’s test, but no enforcement or evidence of the

partner’s practices and results.

Concerning the extent to which the programme was able to tackle discrimination and promote a better

realization of Human Rights, it is worth mentioning that the local population still finds stigmatizing

going to the reference centers. Even in Family Planning centers in big hospitals, pregnant women notice

if another one leaves the consultation room carrying milk formula (as they know that means she is HIV

positive). Therefore, having these services available at health centers is a positive thing to reduce stigma

(they use same center, same rooms, same healthcare staff, same pharmacy).

8 Women used to tell the local health centers where they get tested that they did not have the 2 000 FCFAs (about 4 USD) to go to the

district center to get the treatment.


The evaluation used a Gender analysis, as a tool to disaggregate effects of the programme in women and

men, analyzing how pregnancy, HIV and maternity affects differently each of them:

WOMEN MEN

Before being

diagnosed

They go to the doctor often, when

“something hurts”. They usually go to pass

their prenatal controls by themselves. Often

they only come when they have “a big

belly”.

Even those who are not familiar with HIV

accept to be tested and if positive, to be

treated.

Men do not frequent health centers

unless for serious cases. They are

expected to be strong, have many kids

and women.

They do not use to go to prenatal

visits with their wife or take the kids

to the doctor.

Only in some young couples, men can

be seen accompanying the woman to

pregnancy controls.

After having

been diagnosed

During counseling after the test, if positive,

some cry, others do not accept it (small

proportion) and in general they accept to

take the treatment.

They give priority to the baby wellbeing.

They face internal conflict to tell their

husband. While they should inform him

and encourage him to be tested too, many

do not even tell them.

In some centers, they provide them the

prescription for the husband test, but there

is no way to follow up if she gave him or if

he did it.

In the few cases where the woman

tells him, many react badly (ignoring

or even worse).

Even during sensitization community

sessions, many act as if the virus does

not exist.

Prevalence rate: 8% Prevalence rate: 3%

Before the

programme

They had to go periodically to the UREIs

and justify why they had to go that often in

front of their partner

They didn’t understand why the

women had to visit the hospital every

month if she was not “sick”.

After the

programme

At the specialized centers they give them

treatment and they refer them to the closer

center in their area.

This makes it easier to get their medicines.

In some cases other pregnant women notice

if one leaves the consultation room with

artificial milk, so HIV positive women hide

it. Others getting free artificial milk

(breastfeeding is rare) encourage them to

follow their treatment as the milk is costly.

No remarkable changes in men after

the programme.

Figure 26: Gender Analysis on how PMTCT affects women and men


6.6.4. To what extent has UNICEF role enhanced pursue of exposed child rights? How has that

contributed to decrease the spreading of HIV and the impact of the epidemic on children and families?

Findings

triangulated by:

Methods Sources


As mentioned earlier, the actual progamme contribution to reduce vertical transmission cannot be

assessed due to lack of reliable data, but the intervention’s logic clearly puts exposed children’s rights as

defined by the Convention on the Rights of the Child (CRC) and the general recommendations of the

Committee on the Elimination of Discrimination against Women (CEDAW) at the center of the

intervention. By reducing the possibilities of transmission during pregnancy, and increasing the

possibilities of protection with prophylaxis and artificial milk instead of breastfeeding, their possibilities

to get an AIDS free start increase. At the same time, making treatment more available to keep their

mothers alive also redounds on their rights.

UNICEF also has advocacy initiatives to mobilize resources and start EID in the country. EID by

GeneXpert9 will contribute to reduce the infant mortality by putting early on ARV treatment all children

infected by vertical transmission. The GeneXpert machines could be also used to do the follow-up of

viral load among pregnant women.

6.6.5. How has the programme enhanced service access and utilization for the most disadvantaged and

excluded women and children across factors such as geographic location, gender inequality, economic

status, social and cultural?

Findings

triangulated by:

Methods Sources


UN Agencies, CSOs

Even though the decentralization works on the line of making services more accessible to more remote

populations, the fact that still people living in villages may be more vulnerable to vertical transmission

is due to several reasons. First, they have less access to healthcare services (access to the head of the

district is often complicated), less access to information (no electricity or radio reaches all rural areas),

and it is harder for health workers to trace them as often there is no phone network.

Therefore, not until the access to services is granted at local level (mainly by engaging with primary

health mobile workers that go to the villages) will the system have made available the services to reach

the possibly most vulnerable population (up till now, for rural areas, only women with interest and

means manage to go for their treatment).

If that is the case, central-to-local decentralization programmes like this one could be perpetuating

inequities if they do not reach a sufficient level of implementation at rural level, as people living in urban

context can be more and more familiarized with HIV and get relatively easy access to treatment, while

people living in rural areas could be more affected by the condition, more unaware and have still more

difficult access to services.

9 The GeneXpert test is test measurement of blood plasma HIV-1 RNA concentration (known as HIV viral load) using nucleic acid-

based molecular diagnostic assays.


7. GOOD PRACTICES The evaluation has allowed the identification of some good practices that have contributed to the

observed results. At the central and programme management level:

• Decentralizing is in itself a good, necessary practice that allows PLWHIV to normalize their

treatment and follow-up of their condition. 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. Normalizing the prescriptions, pharmacies and consultation rooms for PMTCT and HIV

patients in general creates less stigma.

• Improvements in the technology of the test and treatment (more sophisticated and precise test, ARV

drugs combined in one instead of having several, quick tests with alternative algorithm) also make

the patients’ life easier.

• 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.

At the healthcare providers level, some good practices were identified, which, although not included in

the protocol or provided by the programme itself, are successfully featured by some individual initiatives:

• Some centers provide pregnant women living with HIV with a prescription for their husbands to get

tested: this led many men to go to a laboratory and get tested, too.

• Some centers use core funds from the resources generated through the administration of HIV test to

call patients that have missed their treatment. In some extreme cases, healthcare workers have even

taken their vehicles and taken the medicine to the woman’s home.

• Some centers design and produce their own registry book when the one which they are given does

not facilitate follow-up (with no columns per month). They also produce their photocopies when

the programme do not provide them.

Lessons Learned • 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) supervision

visits.

• 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 dimension.

• Some countries in the region (as Angola, Rwanda, Senegal, Tanzania and Zimbawe) have contributed

to the decentralization of ARV provision at the community level and have developed community

follow-up mechanisms.


8. CONCLUSIONS In order to increase the traceability between findings and conclusions, here is the summary of findings

and the consequences and implications of them. To identify their origin, it is specified the section where

those findings were presented:

FINDINGS CONCLUSIONS

The decentralization is working-in-progress

and a reality at district level, but it is not

finalized or consolidated. Access to PMTCT is

available at district level but many differences

are observed in the implementation levels of

different parts of the system. (6.2.1, page 27).

The closer PMTCT services get to the 30% of the

population living in rural areas, the bigger possibility

the country has to reach 100% of women tested and

treated.

Involving Primary Attention Health agents may be

needed to reach such a penetration level.

It is not possible to know the progress made in

reducing vertical transmission as there is no

reliable, consolidated data (6.2.1, p. 31).

This evaluability (ability to be evaluated) issue makes

the efforts’ results difficult to measure.

Few actors work in the country on PMTCT, so

they often have multiple roles (6.5.3, p.43)

In order to mobilize the population in order to reach

more people, UNICEF and the Government would need

to expand and involve other actors to have enough

critical mass.

Many women start having conscience of the

issue and more women accept to do the test and

start treatment in case of positive results.

However, it is estimated that still 40% of

women give birth through traditional methods

(6.6.3, p.44)

The approach of making the service available may not

suffice for those women who do not demand them

despite the government’s pursuit of the elimination of

vertical transmission.

Many women who start treatment stop coming

to the centers and the programme has weak

follow-up mechanisms. Coordination

mechanisms within the different services in the

centers are also not systematic (6.2.1 and 6.2.7)

If the services are there but the follow up is not done,

the objectives will not be achieved either.

Not putting in place systematic mechanisms for

following up the patient since its caption until their

medical release is a lost opportunity.

UNICEF seems to have been the leader

implementing the decentralization (6.5.1. p. 42)

UNICEF is capable of pursuing and contributing to the

consolidation of the decentralization and is in a position

to look for further synergies and alliances for bigger

impact.

PMTCT leadership at healthcare center level is

very variable across the directors, doctors (local

and/or Cubans), midwives, etc.

It would be desirable to unify this role, but informal

local champions seem to take the leadership according

to apparently personal sympathy for the service.

NGOs working with PLWHIV have roles of

support but their coverage is very limited

The PLWHIV voice is difficult to collect in order to

understand their experience of the services.

Stock breaks seem to be anecdotic and no

relevant ones were identified at local or general

level. The artificial milk is the item that more

often is scarce, and one of the HIV test reactive

(punctual) (6.2.1).

The procurement team has to keep up the good work

and continue focusing in covering the needs, mostly

when 33 new centers are expected to implement the

PMTCT services in the following phase.

Figure 27: Table of correlation between Key Findings and Key Conclusions


In summary, given the size and progress made by the country, HIV could be controlled and eliminated

in the next decades.

Remaining challenges:

• The healthcare system is generally well equipped in terms of infrastructures and staff. However,

important challenges remain in the field. For example, some district hospitals visited do not have

running water (Niefang, Nsok Nzomo), or hygiene standards in toilets is not ideal (Ebibeyín province

hospital). Some healthcare centers premises are small, and the same room is used as laboratory (one

table) and as vaccination place (another table in a small room).

• The system is more focused in reducing vertical transmission amongst the users of the formal

healthcare system, leaving citizens using traditional methods out of the prevention circuit.

• The whole PMTCT put in place will not achieve its results (eliminate vertical transmission) if the

mother is not regular in her visits to the healthcare center, both while pregnant and when the baby

is born. However, taking a look at the registry books of the centers reveals that many patients

interrupt their treatment and the centers do not often have the budget (10 000 -15 000 FCFAs /

month, around 20 USD) to call them to remind them, encourage them and follow up on their

treatment.

• Once the baby is tested positive and they are out of the programme, the mother goes back to be an

HIV positive adult (not a pregnant woman anymore) who often has to go back to the UREI for

treatment as the decentralization of HIV treatment for adults is not implemented in many centers

yet.

• The system lacks reflective thinking at many levels: due to lack of means, time or encouragement,

very few cases were found where a doctor or a center director elaborated monthly or yearly statistics,

to analyze the performance and impact of their work in PMTCT.

• Men’s relationship and involvement with the mother’s HIV condition remains a weakness as many

do not tell their husbands and those who do, husbands do not seem to be affected by it.

• In well-functioning healthcare centers, the system provides them with medicines and inputs

(delivered to their premises) and the centers provide with periodic data (sent either by hard or soft

copies). However, in the EQG health system, health centers have to find the means to go fetch the

medicines to their closest reference general warehouse and at the same time, officers at area, region

and central level have to go themselves to fetch the data (as there is no systematic circuit to send

them monthly or periodically).

Lastly, the evaluation used a last tool (a tensiometer10) to provide general insights about other aspects of

the programme. It consists of an assessment of the different dimensions UNICEF had to balance while

implementing the programme as expected. Without including a judgement (the tool does not specify

where UNICEF should be placed), and for the issues that most outstood, this would be the programme’s

situation:

10 Vaca, 2016. http://www.saravaca.com/project/tensiometers/

http://www.saravaca.com/project/tensiometers/


Figure 28: Tensiometer of different dimensions to be balanced

Though it was focused in their mandate of making every child survive and strive, the programme also

responded to the countries’ priorities. If focused much more on supporting the government than in

strengthening the civil society, either directly or through CSOs. It had some advocacy components along

its implementation (like when it had to be defended that decentralizing meant to delegate the

management of ARV to midwives and nurses too, for example), but it was more focused in reinforcing

local capacities. Regarding the choice of covering a small number of centers and focus on quality or a

bigger number of centers focusing in coverage, the programme is found to be balanced. Also regarding

the time and resources spent in reinforcing central and local resources of the national system. Finally,

although monitoring has been taking place and has followed up the activities, the intervention was more

focused in implementing than in the data or analysis of the implementation.

9. RECOMMENDATIONS After the field work, data collection, data analysis and discussions with all stakeholders, the evaluator

came up with 5 main recommendations considered critical and of most priority. In line with the highly

participatory nature of the overall evaluation, the evaluation team made sure that these

recommendations be discussed and validated during two debriefing sessions (one with the UNICEF CO

team and another one with the Ministry of Health and Well Being). They are all considered Strategical

Recommendations, except from number 4 which would be more Operational.

Recommendations MoHWB UNICEF

1. Finalize decentralization at

local Health Center level.

a) Elaborate implementation plan

for all the targeted centers,

including those that have received

training and have fulfilled pre-

requirements


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.

a) Define the periodic supervision

mechanism (number and technical

level of supervisors, frequency,

timing of visits, budget)


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

a) Meeting between the HIV and

the Primary Health teams at the

ministry to explore synergies and

formally involve Primary Health in

the new HIV Strategy or National

Plan

b) 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)

c) Verify and approve the data

collection tools and protocol.

d) Provide sufficient photocopies

of the data collection tools at

healthcare center level

e) Follow-up of data circuits

protocols

a) Confirm existing routine

data circuits at healthcare

center level.

b) 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.

a) Discuss and find sources of

funding for this study

c) Approve ToR.

b) 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).

Figure 29: Table of the 5 key Recommendations (including MoHWB and UNICEF partnership roles)

No relevant recommendations were identified at this stage for other stakeholders that are also identified

as users of the evaluation. However, the evaluator also suggested a list of other ideas to be considered

and potentially adopted by the partners in case any of them is feasible and impactful enough to be added

to the main ones:

1. Pursue advocating for a HIV prevention/elimination National Plan.

2. Advocacy for reviewing the national legal framework to identify and suggest changes in laws

promoting PLWHIV discrimination (example: it is a requirement to get a scholarship not to have

any infectious disease)

3. Strengthen the rescue mechanisms of patients. All pregnant women living with HIV must be in

treatment or justified their absence (displacement, death, abortion, mobile does not work).

4. Improve communication channels of information from the national direction of the programme to

the different levels about trainings going on, news in the tools or other news. Consider creating a

WhatsApp network of PMTCT health workers (similar to the one used by for HIV and TB issues).

Improve the communication network about the program: establish communication mechanisms.

5. Identify the network of "Friends / defenders / champions of PMTCT" in each center and put them

in contact with each other (give annual recognitions)

6. Consider including in the protocol those women who give birth out of the Health: when detected

by pediatrics or vaccination services, they should be tested.

7. Develop more training materials for new staff joining the centers that missed the face-to-face

trainings. Review and protect the PMTCT teaching materials (brochure) so that new staff is up-to-

date without attending training


8. Include sexual and reproductive education in the Education System plans.

9. Greater emphasis on the use, not only accessibility, of services (Art. 23, 24 of the HIV Law).

10. Perform an evaluability analysis before setting a non-measurable objective (such as% of

transmission)

11. Explore more partnerships (UNFPA for study, Red Cross for village-level dissemination)

12. Support the digitization and information of the health system. The country has been working on the

digitalization of the Health System for some years (presently on-going), that is the reason why the

evaluation only builds on the present manual systems and do not mentions the very needed

digitalization of data.


Annexes

Annex 1: Terms of Reference (link) https://www.dropbox.com/s/3n63og5aj2anwyc/Rev_ToR%20of%20PMTCT%20Evaluation%20in%20E

QG%20Final%20Draft%2025%20Sept%202018_16h_MicheleFInal%20%28002%29.docx?dl=0

Annex 2: Inception report (link) https://www.dropbox.com/s/79l5c8ineg5w6x5/Inception%20Report%20v.3.docx?dl=0

Annex 3. Key Reference Documents • UNICEF Strategic Plan 2014-2017 ; UNICEF Strategic Plan 2018-2021

• UNICEF Country Programme document (CPD 2013-2017 & CPD 2019-2023)

• Situation Analysis of Children in Equatorial Guinea 2016

• Demographic Health Survey – Ministry of Health 2011

• UNICEF MODA (Multiple Overlapping Deprivations Analysis) 2014

• Study on minors affected by HIV/Aids 2016

• Study on adherence and treatment of HIV/AIDS patients 2014

• National Strategy of access to PTMH services 2014

• Study on pediatric management of HIV/Aids 2017

• Start Free, Stay Free, Aids Free – UNAIDS strategy

• Start Free, Stay Free, Aids Free – UNAIDS strategy (National Strategy Plan)

• Report GARPR 2016-2017

• On the fast track to end Aids UNAIDS Strategy 2016-2021

• Unified Budget Result and Accountability Framework (UBRAF) 2017-2021

• Une cible ambitieuse de traitement pour aider à mettre fin à l’épidémie du sida

• C Wettstein, C Mugglin, N Blaser- AIDS (London, 2012 - ncbi.nlm.nih.gov. Missed opportunities

to prevent mother-to-child-transmission in sub-Saharan Africa: systematic review and meta-

analysis

• The magnitude of loss to follow-up of HIV-exposed infants along the prevention of mother-to-

child HIV transmission continuum of care: a systematic review and meta-analysis. Euphemia L.

Sibanda,a,b Ian V.D. Weller,b James G. Hakim,c and Frances M. Cowana,b

• Plan de descentralización de la PTMH a nivel nacional

• opciones de tratamiento de los niños siguiendo las directivas de la OMS

Annex 4. HIV Legal Framework 1988: Decreto N.º3 Creación del Comité Nacional de Prevención y lucha contra las ITS y el Sida

1993–1995 : Primer plan a mediano plazo

1996–2000: secundo plan a mediano plazo

2000: Marco estratégico 2001 – 2005

2011: Decreto N.º 78/2001 Aprobación del Plan de M&E 2002-2006 y Plan de Urgencia 2002-2003

2003: Estrategia de PTMH

2004: Estrategia de Marketing social del preservativo

2005: Proyecto de reforzamiento de la PTMH

2005: Ley sobre la Protección de las PVVIH

2006: Estrategia de la aceleración de la prevención de VIH

https://www.dropbox.com/s/3n63og5aj2anwyc/Rev_ToR%20of%20PMTCT%20Evaluation%20in%20EQG%20Final%20Draft%2025%20Sept%202018_16h_MicheleFInal%20%28002%29.docx?dl=0

https://www.dropbox.com/s/3n63og5aj2anwyc/Rev_ToR%20of%20PMTCT%20Evaluation%20in%20EQG%20Final%20Draft%2025%20Sept%202018_16h_MicheleFInal%20%28002%29.docx?dl=0

https://www.dropbox.com/s/79l5c8ineg5w6x5/Inception%20Report%20v.3.docx?dl=0

https://scholar.google.fr/citations?user=xkn66FYAAAAJ&hl=en&oi=sra

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3741537/



https://www.ncbi.nlm.nih.gov/pubmed/?term=Sibanda%20EL%5BAuthor%5D&cauthor=true&cauthor_uid=24056068

https://www.ncbi.nlm.nih.gov/pubmed/?term=Sibanda%20EL%5BAuthor%5D&cauthor=true&cauthor_uid=24056068

https://www.ncbi.nlm.nih.gov/pubmed/?term=Weller%20IV%5BAuthor%5D&cauthor=true&cauthor_uid=24056068

https://www.ncbi.nlm.nih.gov/pubmed/?term=Hakim%20JG%5BAuthor%5D&cauthor=true&cauthor_uid=24056068

https://www.ncbi.nlm.nih.gov/pubmed/?term=Cowan%20FM%5BAuthor%5D&cauthor=true&cauthor_uid=24056068


2006: Decreto de Ley que incorpora la gratuidad en el tratamiento y la extensión del TAR

2014: estrategia de la aceleración del acceso a la PTMH

2018: Guía integrada del uso de los ARV


Annex 5. Evaluation Matrix


Annex 6. List of people met

This is the list of people met during the evaluation:


N.- Nombre y Apellidos

Responsablidad Institución

1.- Dra. Gloria NSENG

NCHAMA

D .Gral. Asistencia,

Control y Seguimiento de

VIIH/SIDA

MINSABS

2.- Dr. Nemesio ABESO EYI

D.GRAL. Prevención y

sensibilización de

VIH/SIDA

MINSABS

3.- Antero Almeida De Pina Representante País UNICEF

4.- Andrea Robalo Djassi Punto Focal de PTMH UNICEF

5.- Manuel Nsi Nzang UNICEF

6.- Dra. LAO SEOANE,

Angela Katherine

Responsable del Programa

VIH/SIDA OMS

7.- Jeanne SECK Representante ONUSIDA

8.- Donaciano Eyegue

Mangue

Responsable del programa

VIH/SISA FNUAP

9.-

Ignasi De Juan-Creix y

Bretón Gerente

Fundación Religiosos para la

Salud (FRS)

11.- Don. Juan Manuel NDEME

NSOGO

Jefe de Servicio de

Laboratorio MINSABS

12.- Dr. Vicente Urbano NSUE Médico Internista Hospital Malabo

13.-

Don. Deogracias NSHO

ELA

Jefe de Servicio de

Farmacia MINSABS

14.- Dra. Josefa Responsable SSR MINSABS

15.-

José María Responsable

Instituto Salud Carlos III

(ISCIII)

16.- Dr. Brajano Cirujano UREI DE MALABO

19.- Maricarmen Juliana Evung Enfermera

PLANIFICACION

FAMILIAR, HOSP.

MALABO

20.- Dr. Gabriel ASAMA

ASAMA

Pediatra. Punto Focal

VIH/SIDA HOSP. LOERI COMBA

21.- Dra. Gloria Afang Mekina

Mbasogo Atención Prenatal HOSP. LOERI COMBA

22.- Dra. Paulina DJOMBE Directora CENTRO DE SALUD

SAMPAKA

23.- Dra. Borabota Jefe de PTMH CENTRO DE SALUD

SAMPAKA

24.- Milagrosa Mokuy Mitogo Enfermera. Directora CENTRO DE SALUD

BUENA ESPERANZA

25.- Dra. Yanislidi B.

QUINTANA Ginecóloga HOSPITAL DE LUBA

26.- Dr. Gabriel MBO EDU

ADA Médico HOSPITAL DE LUBA

27.- Marcia MECHA SILA Jefa de Enfermería HOSPITAL DE LUBA


28.- Dra. Verónica Bendomo Jefa de Servicio UREI DE BATA

29.- Dr. Fructuoso Coordinador PTMH HOSPITAL DE BATA

31.- Dr. Manuel Eyene Coordinador PTMH HOSPITAL DE BATA

32.- Antonina Salud Positiva ONG BATA

33.- Josefina Salud Positiva ONG MALABO

34.- Beti Amusida ONG BATA

35.- Sinforosa Asama ONG BATA

36.- Dr. Matindi Director HOSPITAL DE NIEFANG

37.- Ángel Miko Director CENTRO DE SALUD DE

NKUMEKIEÑ

38.- Hermana Sofía Mulunga Directora CENTRO DE SALUD

MARIA GAY

39.- Alberto Ochaga Director CENTRO DE SALUD LA

LIBERTAD

40.- Dr. César Isaac Rodriguez Pediatra. Cubano HOSPITAL DE EBEBIYIN

41.- Amparo Mboyo Comadrona Planificación Familiar.

HOOSPITAL DE EBEBIYIN

42.- Ernesto Nvo Ada Técnico de laboratorio HOSPITAL DE EBEBIYI

43.- Dr. Rubén Mariano

Rodríguez Brigada médico cubano

HOSPITAL DE NSOK-

SOMO

44.- Dra. Demetria Pilar eki Directora HOSPITAL DE AÑISOK


Annex 7. Evaluation tools (interviews guidelines)

QUESTIONNAIRE FOR INTERVIEWS WITH UNICEF STAFF

1.1. To what extent has UNICEF identified and addressed priority needs for SI/KM products and services

in support of national PMTCT program?

1.2. To what extent has UNICEF supported national governments to leverage funds, both domestic and

external, in a manner consistent with country context (e.g. middle-income, low-income)?

2.1. To what extent did the Programme attain its intended results at country level/regional level/global

level?

2.2. What trade-offs were made to ensure that partnership arrangements could work as intended? What

were the related risks?

2.3. To what extent have these partnerships helped national PMTCT programme achieve their national

goals and targets? To what extent have partnerships contributed to the achievement of global PMTCT

targets?

2.4. To what extent has UNICEF contributed to the building of national systems? How have focus on

achieving goals been balanced with the drawbacks of vertical programmes?

2.5. What were the unexpected (positive and negative) outcomes of the PTMCT PRogramme?

2.6. To what extent have the resource mobilization goals of the national plan been achieved?

2.6. To what extent are there gaps, overlaps and/or missed opportunities in programming that arise from

UNICEF’s organization structure?

2.7. To what extent has UNICEF capitalized on its structures and presence between sectors to achieve its

intended results as per the Strategic Plan and Global Plan for

elimination?

2.8. How has UNICEF organized internally to address PMTCT?

2.9. To what extent UNICEF has utilized evidence from trials/ pilot tests interventions to inform scaling

up of proven effective approaches? Has UNICEF facilitated learning and knowledge sharing between

partners and national counterparts to inform adoption and scaling up of proven effective approaches?


platforms and tools for use in national PMTCT program?

2.11. To what extent has UNICEF utilized its structures and resources across levels in a coordinated

manner to achieve its intended results as per the Strategic Plan and Global Plan for elimination?

3.1. What is the return on UNICEF investments in the areas of PTMCT advocacy and partnerships? To



3.3. To what extent did UNICEF’s global, regional and country-level programs pursue and attain output-

level results through the least costly means?

3.4. To what extent has UNICEF capitalized on inter-sectoral linkages to bolster resources for PMTCT

(e.g. social protection, education, health)?

3.5. To what extent did UNICEF’s resource mobilization efforts garner funds relative to the investment

of time and resources?

3.6. To what extent was value for money considered in decision-making?

3.7. To what extent has UNICEF provided effective support for countries to access funds for PMTCT

program from other sources?

4.3. To what extent has UNICEF incorporated sustainability considerations in its work at country levels?

6.1. To what extent did UNICEF contribute to Human Right and Gender approach in PMTCT program?

6.2. To what extent did the UNICEF CO contribute to equity approach in PMTCT programme?


infection, and how? (via increasing the access to age-appropriate HIV information as well as reproductive

health services? via male involvement to PMTCT services can enhance HIV testing and retention on

treatment?).

6.4. To what extent has UNICEF role enhanced pursue of child rights? How has that contributed to

decrease the spreading of HIV and the impact of the epidemic on children and families?

6.5. How has the programme enhanced service access and utilization for the most disadvantaged and



QUESTIONNAIRE FOR INTERVIEWS WITH MOH STAFF






level?






targets?




2.6. To what extent have the resource mobilization goals of the national plan been achieved?




intended results as per the Strategic Plan and Global Plan for elimination?






3.1. What is the return on UNICEF investments in the areas of PTMCT advocacy and partnerships? To






3.5. To what extent did UNICEF’s resource mobilization efforts garner funds relative to the investment

of time and resources?

4.1. To what extent have UNICEF’s mandate, structures and resources contributed to sustainable


4.2. To what extent has UNICEF supported the development of costed national plans for the elimination

of MTCT in the country?


4.4. To what extent has UNICEF strengthened national M&E capacity? To what extent have these efforts

strengthened countries’ ability to focus on issues of equity? To what extent have these efforts


program?



resource?

5.2. To what extent does UNICEF have a comparative advantage and demonstrate added value in taking

a leadership role in PMTCT forums vis-a-vis others players?

5.3. To what extent did UNICEF’s leadership role in PMTCT forums contribute to the achievement of

its strategic priorities?

5.3. In case of comparative advantages, to what extent has UNICEF leveraged them fully in in pursuit of

its intended results?





health services?; via male involvement to PMTCT services can enhance HIV testing and retention on

treatment?).






QUESTIONNAIRE FOR INTERVIEWS WITH OTHER PARTNERS






level?





targets?








intended results as per the Strategic Plan and Global Plan for elimination?










4.1. To what extent have UNICEF’s mandate, structures and resources contributed to sustainable


4.2. To what extent has UNICEF supported the development of costed national plans for the elimination

of MTCT in the country?


4.4. To what extent has UNICEF strengthened national M&E capacity? To what extent have these efforts

strengthened countries’ ability to focus on issues of equity? To what extent have these efforts


program?


resource?

5.2. To what extent does UNICEF have a comparative advantage and demonstrate added value in taking

a leadership role in PMTCT forums vis-a-vis others players?

5.3. To what extent did UNICEF’s leadership role in PMTCT forums contribute to the achievement of

its strategic priorities?

5.3. In case of comparative advantages, to what extent has UNICEF leveraged them fully in in pursuit of

its intended results?






health services?; via male involvement to PMTCT services can enhance HIV testing and retention on

treatment?).






Annex 8. Principles Of Ethical Conduct Of Evaluation The final evaluation of the joint program was carried out according to the ethical principles and standards

defined by the United Nations Evaluation Group (UNEG).

• Anonymity and confidentiality. The evaluation must respect the rights of the people who

provide information, guaranteeing their anonymity and confidentiality.

• Responsibility. The report should include any conflicts or differences of opinion that may have

arisen between the consultants or between the consultant and the radio managers regarding the

conclusions and / or recommendations of the evaluation. The entire team must confirm the

results presented, any disagreements to be indicated.

• Integrity. The evaluator will need to highlight issues that are not specifically mentioned in the

ToR, to obtain a more complete analysis of the partnership.

• Independence. The consultant must ensure that he / she remains independent of the program

under review, and he / she should not be involved in its management or any part of it

• Incidents. If problems arise during fieldwork, or at any other point in the evaluation, they should

be reported immediately to the Monitoring and Evaluation Specialist at UNICEF. If this is not

done, the existence of such problems can in no way be used to justify the failure to achieve the

results expected by UNICEF in these ToR.

• Validation of information. The consultant must ensure the accuracy of the information gathered

during the preparation of the reports and will be responsible for the information presented in

the final report.

• Intellectual property. Using the different sources of information, the consultant must respect

the intellectual property rights of the institutions and communities examined.

• Submission of reports. If the submission of reports is postponed, or if the quality of the submitted

reports is significantly worse than agreed, the sanctions provided for in these terms of reference

will apply. The Evaluation team will need to ensure the timely submission of deliverables as well

as the conformity of the draft and final report with the GEROS Evaluation Quality Assurance

criteria as well as the UNEG Quality Checklist for Evaluation Reports.


Annex 9: Preliminary results presentations (links) To UNICEF team:

https://www.dropbox.com/s/rtufe7dfaiqq1k3/Presentaci%C3%B3n%20Resultados%20PTMH%20UNIC

EF.pptx?dl=0

To Ministry of Health and Well Being:

https://www.dropbox.com/s/ukaubsyqf9vmldx/Presentaci%C3%B3n%20Resultados%20PTMH%20Min

San.pptx?dl=0

https://www.dropbox.com/s/rtufe7dfaiqq1k3/Presentaci%C3%B3n%20Resultados%20PTMH%20UNICEF.pptx?dl=0

https://www.dropbox.com/s/rtufe7dfaiqq1k3/Presentaci%C3%B3n%20Resultados%20PTMH%20UNICEF.pptx?dl=0

https://www.dropbox.com/s/ukaubsyqf9vmldx/Presentaci%C3%B3n%20Resultados%20PTMH%20MinSan.pptx?dl=0

https://www.dropbox.com/s/ukaubsyqf9vmldx/Presentaci%C3%B3n%20Resultados%20PTMH%20MinSan.pptx?dl=0


Annex 10: Estudios de Caso de Centros Sanitarios

ESTUDIO DE CASO 1

Nombre Centro Madre Alfonsa Cavín

Municipio Sampaca

Provincia Malabo

Fecha visita 21 Noviembre 2018

Interlocutores Directora y Doctora PTMH

Inicio del programa 2015

Personal formado en

PTMH

La doctora en 2016.

“Vemos reciclajes de formación en la tele pero a nosotros nunca nos

convocan”.

Visitas de supervisión

recibidas

Ultima en 2016

Monitoreo de pacientes Les dan medicamentos y cita cada mes para tener más control. “Si

damos para 3 meses ya no vienen más”.

Rellenan el libro y la ficha si tuvieran.

Mandan el informe mensual a APS cada mes, pero el libro de registro

no es fiable porque cada vez viene un niño se apunta otra vez.

Desde septiembre no tienen fichas de seguimiento impresas (que son

más útiles para ellas). La directora ha ido personalmente al

ministerio, pero no ha conseguido hablar con la DG (que estaba

hablando con nosotros). El centro no tiene fondos para fotocopias.

Aprovisionamiento Al principio traían hasta el centro (Deogracias pasó dos veces). Ahora

si no vienen a hacer control de stock, no hay medio de comunicación

para los nuevos pedidos. No ha habido rupturas de stock, pero ahora

tienen que ir en taxi a buscar los materiales


Resultados (¿mejoras?) - En general sí han disminuido el número de niños infectados

(ninguno constatado desde 2015). En 2016, 14 de 19 finalizaron

el tratamiento (5 desaparecidos), en 2018, 2 de 8 (6

desaparecidos). Un niño fallecido en 2015 y ninguno después.

- Descentralización de PTMH conseguida

- Pocas roturas de stock

Desafíos Como no tienen saldo suficiente (unos 15.000FCFAs para todo el mes

que se agotan el día 15 o 20), no pueden hacer llamadas para

seguimiento de las pacientes

No hay un mecanismo para registrar y seguir a los adultos

seropositivos (como las madres tras dar a luz) así que han hecho un

cuadro

Otros - Algunos días reciben 40 pacientes. Otros días menos.

- Falta de comunicación: “Han mandado Nistatina y no sabemos

para qué (como es jarabe, deducimos que es para el niño, pero

estamos esperando instrucciones)”. “Cambiaron de 6 a 4 botes

de leche y no sabemos porqué”. Los niños del primer trimestre,

bien, pero insuficiente para los niños de 4 a 6 meses.

- Hay áreas geográficas en esta área que son foco de infección

(como Sera y Potao, campamentos militares hacinados). “Estos

lugares me preocupan mucho”.

- No se hace discriminación, se les trata igual que a los demás y

con confidencialidad.

- Los hombres no se acercan. Actúa como si no fuera con ellos.

- Los 4 botes de leche al mes son suficientes para los bebés

durante el primer trimestre pero escasea para el segundo

(aunque a partir del 5º mes se empieza con la alimentación

mixta)

Sus sugerencias para la

mejora

- Supervisiones mensuales, o al menos trimestrales

- Reciclajes de formación

- Una fotocopiadora

- “A ver si un día nos felicitan”.

CONCLUSIONES - Centro con dificultades

- ¿El piloto realizado en 2016, abandonado?

- La doctora hace un pequeño análisis anual, pero por sí misma:

el sistema no fomenta la reflexión analítica colectiva


ESTUDIO DE CASO 2

Nombre Hospital Provincial de Luba

Municipio Luba

Provincia Luba


Interlocutores Doctora PTMH, Doctor Prenatal, Enfermera Neonatal

Inicio del programa 2016 (solo iban a la UREI para ver el CD4)

Personal formado en

PTMH

Llegaron a principios de este año, con lo cual no han recibido

formación. La doctora (cubana) ha tenido que buscar información

por su cuenta o preguntar a colegas en Malabo.


recibidas

El Dtor. Nacional de VIH nos vino a visitar al principio (cuando había

el ministerio de la lucha contra el SIDA)

Alguna visita.

Monitoreo de pacientes A pesar de tener Atripla en formato 3 meses, dan 30 comprimidos

para que vuelvan mensualmente. Y les dan vitaminas gratis también

No hacen listado de pacientes porque son 4 y las conocen.

Mandan informe mensual a APS.

Hay un informe semanal (para epidemiología)

Aprovisionamiento La enfermera y farmacéutica los cargan en el coche del programa de

la lucha contra el cáncer de útero si el coche de APS está en Malabo

y toman un taxi para volver.

Resultados (mejoras?)

Desafíos

Otros - Los médicos y personal de guardia que nos atienden a la entrada

no conocen PTMH


mejora

-


CONCLUSIONES -

ESTUDIO DE CASO 3

Nombre Hospital Policlínico Lorey Comba

Municipio Malabo

Provincia Malabo


Interlocutores Doctores prenatales, Doctores neonatos

Inicio del programa 2016

Personal formado en

PTMH

Nadie aun (en breve por lo visto)

Los responsables PTMH son líderes informales, los de tratamiento

neonatal.


recibidas

La Dtora. Gertrudis vino en 2017.

Monitoreo de pacientes Atienden a aseguradas y no aseguradas, pero precio distinto

(1000FCFAs y 2000FCFAs la consulta prenatal, gratis y 25.000 FCFAs

partos). No hacen resúmenes ni sacan estadísticas.

Las mujeres no embarazadas tienen que volver a la UREI.

Aprovisionamiento

Resultados (mejoras?) Antes de 2015 los medicamentos estaban solo en la UREI, así que las

gestantes se quejaban después de una espera de quizá 3 horas para la

consulta tener que ir a otro sitio a por la medicación (y eso que está al

lado).

Ahora ya tienen provisiones y están en la misma farmacia general, no

en diferentes estancias.


Desafíos - Llegan algunas pacientes a por Atripla y no tienen ficha

porque el médico no les abrió ficha.

Otros El centro cuenta con 3 psicólogas


mejora

- Descentralización del servicio para adultos no solo PTMH

- Supervisiones si no mensuales, trimestrales (para identificar

problemas a tiempo, motivación, auto rendición de cuentas,

corrige malas prácticas, mejora continua)

- Formaciones

- Convenio con una compañía telefónica para poder rescatar casos

- Que hay retroalimentación

- Que los códigos únicos de cada paciente salten en el sistema si se

traslada, si coge medicación en varios centros

CONCLUSIONES -


ESTUDIO DE CASO 4

Nombre Hospital de Niefang

Municipio Niefang

Provincia Bienayong


Interlocutores Director, Enfermera de farmacia

Inicio del programa Noviembre 2017

El director piensa que antes de fin de año darán tratamiento a los

adultos también.

Personal formado en

PTMH

En noviembre de 2017 se formó a 5 médicos, laboratorio y farmacia.

Fue como un recordatorio menos para los nuevos.

Los 4 técnicos obstétricos. Tienen 2 ginecólogos.


recibidas

Los médicos coordinadores han venido dos veces en el último año y

dan recomendaciones como dejar estas dos fichas a la vista.


Monitoreo de pacientes No hacen pero la disminución en pedido de leche NAN edad 1 y leche

NAN edad 2 (de 64 a 22) lo explican porque hay menos que vienen, se

pierden.

Seguimiento de niños (lo calculamos usando el registro):

De 20 niños, 2 altas, 4 continúan en tratamiento, 1 fallecimiento y 13

perdidos.


No tienen fichas de niños expuestos en el paritorio, pero porque abren

la ficha a los 6 días.

A partir de los 6 meses del parto la mujer tiene que ir a la UREI de Bata

o al centro de tratamiento de Binayong, que es de referencia, pero está

más lejos.

Aprovisionamiento Hubo monitoreo de stock hace 3-4 meses porque al principio su cabeza

de provincia (Benayong) no calculaba para ellos.

Hace poco hubo una distribución general a todos los hospitales que

bajaron a Bata a recibir la medicación (*?).

Resultados (¿mejoras?) En el paritorio, ya tienen Atripla y jarabe, porque la farmacia no está

abierta 24h y si llega y no estaba tomando tratamiento le dan Atripla

nada más llegar con trabajo de parto.

Han dado de alta a dos bebés de 7 meses.

Desafíos El hospital no tiene agua (por problemas de impago). En el laboratorio

tienen cubos de agua

No tienen sobres para meter los resultados de las serologías


Faltan recursos (digitalizar para seguimiento en tiempo real y gente de

estadísticas).

Otros - Aquí no parece haber estigma con los botes de leche

- Han tenido 10 partos desde junio

- La planificación familiar no se demanda mucho aquí. Muy poco

consumo de anticonceptivos.


mejora

- Tener medios para llamar y hacer seguimiento

CONCLUSIONES -


ESTUDIO DE CASO 5

Nombre Centro de Salud Mkumekieñ

Municipio Mkumekieñ

Provincia Niefang


Interlocutores Director, Técnico de laboratorio, Enfermera de farmacia

Inicio del programa Noviembre 2017 (parcial: por ahora sólo tests)

Personal formado en

PTMH

La semana pasada, la enfermera de farmacia asistió a la formación,

pero no el director ni el laboratorio


recibidas

Ninguna. Desde que se incorporó el director del hospital de Niefang

hace un año ha ido a varias reuniones, pero no a supervisión. Ninguna

a nivel regional o central tampoco.

Monitoreo de pacientes Solo hacen test a las gestantes. Tratamiento y seguimiento es referido

a Niefang, pero saben que hay mujeres que no van porque dicen no

tener dinero para el boleto (1000 FCFA).

Aprovisionamiento N/A aún.

Resultados (¿mejoras?) Al menos las gestantes no tienen que ir a Niefang para hacerse el test.

Desafíos - Hay mujeres que dan a luz por parto tradicional (unas 4 al mes).

De ellas, la mitad no habían pisado el centro de salud para

control prenatal. Cuando traen al bebé para vacunación no hay

constancia de si son seropositivas o no.

- Los medios son limitados (misma sala pequeña es laboratorio y

sala de vacunación)


Otros - Tiene un frigorífico donado por UNICEF para vacunación que

se alimenta con un panel solar.

- Los días 13 de cada mes hay mercadillo así que aprovechan para

hacer vacunación y sensibilizaciones en el centro. También

salen una o dos veces por semana para dar charlas y promoción

de la salud en otros sitios. También trabajan con consejos de

poblado.

- Hay 20 consejos en este municipio.


mejora

- Supervisión (y eso que no han empezado), para detectar sus

problemas y ayudarles a solucionarlos.

CONCLUSIONES - La descentralización está aún en proceso y no es una realidad

aun en todos los centros sanitarios de municipios.


ESTUDIO DE CASO 6

Nombre Centro de Salud Buena Esperanza

Municipio Malabo

Provincia Malabo


Interlocutores Directora, Enfermera de farmacia

Inicio del programa Mitad de 2015/2016

Personal formado en

PTMH

Todos: equipo de farmacia PTMH (2 de los 7, aunque están formando

a una 3ª persona), los de atención neonatal y los de laboratorio

(durante 3 días)


recibidas

Varias de la Dtora. Gloria (DG VIH) y Dra. Katy (OMS)

A veces viene Deogracias (para farmacia y laboratorio)

Monitoreo de pacientes Saca un saldo de 5.000 FCFAs para hacer seguimiento y llamar

(aunque primero verifica en la farmacia si no cogió para 3 meses,

como a las que están en reposo, aunque la pauta normal es 30

comprimidos para que vuelvan, según la Dtora. Gloria).

Aprovisionamiento Envían ellos el informe, hacen copias y los distribuyen a los distintos

programas.

Resultados (¿mejoras?) También dan tratamiento a adultos (les llamaron y les explicaron que

los enfermos también pueden venir aquí a por tratamiento).

Mayor conciencia, han disminuido los casos nuevos.

Desafíos Ninguno señalable.

Otros - Aprecian mucho las supervisiones: se detectan errores de como

rellenar el libro de registro, por ejemplo.


- Nos agradecen la visita porque les ayuda a trabajar mucho

mejor.


mejora

- Reciclajes continuos, cada tres meses.

CONCLUSIONES - Centro modélico.

Annex 11. Other qualitative data

OPINIONS AND MYTHS HEARD DURING THE FIELDWORK:

- Getting HIV is bad luck (unknown causes)

- We are a small country, if we use preservatives we are not going to grow

- Sobre todo las mujeres deben saber cómo se pone el preservativo

- Dar preservativos es apología del sexo o la prostitución

- Muchos desincentivos para el condón: “si la niña le dice que lo quiere hacer con preservativo le pagan

10.000FCFA, en lugar de 100.000FCFAs”

- “La gente prefiere morir que reconocer que tiene VIH”

- Mentalidad reinantes es que “solo los enfermos van al hospital”, no hay concepto de previsión.

- Incultura: “El jarabe (profilaxis) fue lo que mató o empeoró al niño”

- Una directora de un centro les dice a las mujeres: “si ves a tu marido con un preservativo, dale cinco

besos, porque ya que sale y que la fidelidad es muy difícil, al menos no va a traerte enfermedades ni

hijos”.

- “De Bata a Malabo hay años luz”

- Hay gente que prefiere desplazarse 200 km. Porque no es el personal sanitario, a veces también los

conocidos difunden “Le vi en la UREI”.

- “Cambian las estrategias y los protocolos, pero no la realidad”, haciendo referencia a la mentalidad

de la población y que no acuden mucho.

- Some people infect people out of spite.

- Some people pay others HIV positive patients to get medicines from several healthcare centers,

making profit of the lack of data consolidation.