EAST AFRICAN COMMUNITY ZERO DRAFT HIV and AIDS/STI and TB Multisectoral Strategic Plan and Implementation Framework 2015 - 2020 EAC Secretariat, P. O. Box 1096, Arusha, Tanzania. Tel:+255 27 2162102/ 2162191 Fax: +255 27 2504255/2504481 E-Mail: [email protected] Website: http//www.eac.int August 2014 i Table of contents Acronyms and abbreviations................................................................................................................................ iii Acknowledgement ................................................................................................................................................ v Preamble ............................................................................................................................................................. vii Chapter One .......................................................................................................................................................... 1 1.1 Regional Economic Communities .............................................................................................................. 1 1.1.1 East Africa Community ....................................................................................................................... 1 1.1.2 EAC Members States in other Regional Economic Communities ....................................................... 1 1.2 EAC protocols............................................................................................................................................. 2 1.2.1 EAC Health protocol ............................................................................................................................ 2 1.2.1 Other EAC protocols............................................................................................................................ 3 1.3 HIV&AIDS/ STI and TB and Situation ...................................................................................................... 3 1.3.1 HIV and AIDS ..................................................................................................................................... 3 1.3.2 Sexually Transmitted Infections .......................................................................................................... 4 1.3.3 Tuberculosis ......................................................................................................................................... 5 Chapter Two.......................................................................................................................................................... 6 2.1 Background information ............................................................................................................................. 6 2.1.1 EAC HIV and AIDS strategic plan ...................................................................................................... 6 2.1.2 EAC STI and TB strategic plans .......................................................................................................... 7 2.2 Review of EAC HIV and AIDS strategic plan 2012/2014 ......................................................................... 7 2.2.1 The HIV and AIDS response in the region .......................................................................................... 7 2.2.2 SWOT Analysis ................................................................................................................................... 7 2.3 Development of the Strategic Plan.............................................................................................................. 9 2.3.1 Rationale for review of the strategic plan ............................................................................................ 9 2.3.2 The strategic planning process ............................................................................................................. 9 Chapter Three...................................................................................................................................................... 10 3.1 Strategic intents......................................................................................................................................... 10 3.1.1 Vision, mission and goal .................................................................................................................... 10 3.1.2 Key result areas .................................................................................................................................. 10 3.2 Alignment to the overall EAC strategic plan, EAC protocol on health .................................................... 12 3.3 Guiding principles ..................................................................................................................................... 12 3.4 Programme goal and strategic objectives.................................................................................................. 12 3.4.1 Key Result Area 1 - A committed and proactive regional and national leadership. .......................... 12 3.4.2 Key Result Area 2 - Scale up accessibility, affordability and availability of HIV and AIDS Prevention, Care, Treatment and Support Services in the region ............................................................... 15 3.4.3 Key Result Area 3 - Evidence based policies and guidelines are in place to inform the regional HIV and AIDS/TB and STI interventions ........................................................................................................... 16 3.4.4 Key Result Area 4 - Regional programmes targeting mobile and key population in the EAC Region .................................................................................................................................................................... 17 3.4.5 Key Result Area 5: Research and knowledge management ............................................................... 19 Chapter Four: FRAMEWORK FOR IMPLEMENATION ................................................................................ 21 4.1 Institutional arrangements ......................................................................................................................... 21 4.1.1 Organizational Strategies ................................................................................................................... 21 4.1.2 Roles and Responsibilities of Stakeholders ....................................................................................... 21 4.1.3 Coordination of strategic plan implementation .................................................................................. 21 4.1.4 Communicating the plan .................................................................................................................... 21 4.2 Monitoring and Evaluation ....................................................................................................................... 22 4.3 Funding, Sustainability and Risk Management ........................................................................................ 22 4.3.1 Funding the Strategy .......................................................................................................................... 22 4.3.2 Sustainability Plan.............................................................................................................................. 22 4.3.3 Risk Management Plan ...................................................................................................................... 23 i Appendices.......................................................................................................................................................... 24 Appendix 1: The logical framework matrix .................................................................................................... 24 Appendix 2: Annual operational plan 2015/16 ............................................................................................... 28 Appendix 3: Risk analysis and mitigation plan .............................................................................................. 29 ii Acronyms and abbreviations AIDS ANC ART ARV BCC BDHS COMESA CSO CSW DRC EA EAC FSW GARPR GFATM GLIA HAU HCT HIV HMIS IEC IGAD KDHS KNASP LVBC M&E MARP MDA MDG MOH MSM MTCT NAC NMSF NSP PEPFAR PLHIV PMTCT RDHS REC SADC Acquired Immune Deficiency Syndrome Ante Natal Clinic Anti Retroviral Treatment Anti Retro Viral Behavior Change Communication Burundi Demographic and Health Survey Common Market for Eastern and Southern Africa Civil Society Organization Commercial Sex Workers Democratic Republic of Congo East Africa East African Community Female Sex Workers Global AIDS Response Progress report Global Fund for Fighting AIDS, Tuberculosis and Malaria Great Lakes Initiative on AIDS HIV and AIDS Unit HIV Counselling and Testing Human Immune Virus Health Management Information System Information, Education and Communication The Intergovernmental Authority on Development Kenya Demographic and Health Survey Kenya National HIV and AIDS Strategic Plan Lake Victoria Basin Commission Monitoring and Evaluation Most At Risk Population Ministries, Departments and Agencies Millennium Development Goal Ministry of Health Men having sex with Men Mother to Child Transmission National AIDS Council National Multi-sectoral Strategic Framework National Strategic Plan President's Emergency Plan for AIDS Relief Person Living with HIV Prevention of Mother to Child Transmission Rwanda Demographic and Health Survey Regional Economic Community South African Development Community iii SGBV SMC SRH STI SWOT TACAIDS TB TDHS THMIS TWG TWG UAC UAIS UDHS UHSBS UNAIDS WB WHO ZAC ZNSP Sexual and Gender Based Violence Safe Male Circumcision Sexual Reproductive Health Sexually Transmitted Infection Strengths, Weaknesses, Opportunities and Threats Tanzania Commission for AIDS Tuberculosis Tanzania Demographic and Health Survey Tanzania HIV and AIDS and Malaria Indicator Survey Technical Working Group Technical Working Group Uganda AIDS Commission Uganda AIDS Indicator Survey Uganda Demographic and Health Survey Uganda HIV Sero-Behavioural Survey Joint United Nations Programme on AIDS World Bank World Health Organization Zanzibar AIDS Commission Zanzibar National HIV&AIDS Strategic Plan iv Acknowledgement v EAC HIV and AIDS Program Vision An East African Community free of HIV and AIDS, TB and STIs Mission To provide coordinated, evidence based and effective regional HIV and AIDS, TB and STIs response Guiding Principles • Respect for human rights by adopting the rights based approach as defined in the international instruments • Respect for autonomy for the partner states • Consideration for gender dimension including equity and other rights based approaches • Integration, cost effectiveness and evidence based planning and response • Capacity building for partner states in the HIV/AIDS/TB/STI response • Meaning involvement of affected communities including the key populations Niche Regional coordination of the HIV and AIDS, TB and STIs response vi Preamble This plan lays out the strategic intents for East African Community (EAC) HIV and AIDS programme for the period 2015-2020. The strategic plan will set the boundaries within which the EAC will implement its HIV and AIDS, TB and STIs interventions within the ambits of its mandate. The plan will further be a tool for resource mobilization as well as being a reference point for addressing HIV and AIDS, TB and STIs issues that are transboundary in nature within the region. The strategic plan review process: The EAC Secretariat adopted an extensive consultation process of its stakeholders both in the public and private sector domains. This was done in order to take into account the changes in the socio-political, economic, technological and legal environs, and how they influence the dynamics of the HIV and AIDS, TB and STIs response. The approach further sought to generate buy-in by the different stakeholders for purposes of joint ownership and implementation of the strategic plan. To this end, consultative workshops, individual country assessment of areas of focus and assessment of performance of the previous strategy were carried out. East African Community HIV and AIDS programme strategic intents: Through a consultative approach, the vision and mission were reviewed in the context of policy, legislation, technological, political and economical landscape dynamics. These will guide the strategic intents and priority setting in the HIV and AIDS, TB and STIs response. The overall thrust of this plan is to contribute to the reduction in the incidence of HIV, TB and STIs infection in the EAC region in order to secure sustained socioeconomic development. In order to achieve the strategic intents, the EAC Secretariat will depend on the financial, political and technical support from the member states as well as development partners. The secretariat will adopt effective and efficient strategies while mitigating risks to have a more significant impact on the lives of the people in the EAC region and other parts of Africa and the world. Organization of the strategic plan: The strategic plan is organized as follows: Chapter one provides the contextual analysis of HIV and AIDS, TB and STIs globally and in the EA region in particular. Chapter two outlines the background information about EAC HIV and AIDS, TB and STIs program and its past performance. Chapter three delves into the strategic intents based on the gaps identified in the contextual analysis. Chapter four details the institutional arrangement for implementing the plan. The risk analysis and mitigation plan, the monitoring and evaluation framework, and organizational structure are provided as appendices. vii Chapter One 1.1 Regional Economic Communities 1.1.1 East Africa Community East African Community (EAC) is the regional intergovernmental organization of the Republics of Burundi, Kenya, Rwanda, United Republic of Tanzania and the Republic of Uganda. The Treaty establishing the EAC was signed on November 30, 1999. The vision of EAC is to attain a prosperous, competitive, secure and politically united East Africa. The Mission is to widen and deepen economic, political, social and cultural integration in order to improve the quality of life of the people of East Africa through increased competitiveness, value added production, enhanced trade and investment. The Brand of the East African Community is ‘‘One People, One Destiny’’. To-date, the EAC Treaty and the associated protocols signed and implemented have resulted in the achievements of gradual currency convertibility and macro-economic convergence; adoption of common travel documents, work permits and fees for education, tourism, etc; common negotiating frameworks; substantial progress in harmonization of academic and professional qualifications; free movement of capital and harmonization of transport facilitating instruments. Furthermore, there are now many on-going processes to move the EAC to the next phase of integration into a Monetary Union and ultimately a Political Federation of the East African States. The headquarters of the EAC is at Arusha in Tanzania 1.1.2 EAC Members States in other Regional Economic Communities In addition to EAC, there are other regional economic communities (REC) that the five partner states belong. These include Common Market for Eastern and Southern Africa (COMESA), The Southern African Development Community (SADC) and The Intergovernmental Authority on Development (IGAD), Southern African Development Community (SADC): SADC was established in 1992 as a regional economic community with a commitment to regional integration and poverty eradication within Southern Africa through economic development and ensuring peace and security. SADC has 15 member states including Tanzania in EAC and Angola, Botswana, Democratic Republic of Congo, Lesotho, Madagascar, Malawi, Mauritius, Mozambique, Namibia, Seychelles, South Africa, Swaziland, Zambia and Zimbabwe. Common Market for Eastern and Southern Africa (COMESA): COMESA was formed in 1994 to replace the former Preferential Trade Area (PTA) which had existed from the earlier days of 1981. It is constituted by 19 member states, namely, Burundi, Kenya, Rwanda, Uganda, Libya, Egypt, Sudan, Eritrea, Djibouti, Ethiopia, DRC, Madagascar, Malawi, Mauritius, Zambia, Zimbabwe, Swaziland, Comoros and Seychelles. The partner states have agreed to co-operate in developing their natural and human resources for the good of all their people' and as such it has a wide-ranging series of objectives which necessarily include in its priorities the promotion of peace and security in the region. The Intergovernmental Authority on Development (IGAD): IGAD was created in 1996 to supersede the Intergovernmental Authority on Drought and Development (IGADD) founded earlier in 1986. The Authority has seven members, namely, Kenya and Uganda of EAC and Djibouti, Ethiopia, Somalia, Sudan and Eritrea. One of the objectives of IGAD is to promote and realize the objectives of the Common Market for Eastern and Southern Africa (COMESA) and the African Economic Community. 1 Africa Union: The Sirte Extraordinary Session (1999) of African Heads of State decided to establish an African Union with the vision of: “An integrated, prosperous and peaceful Africa, driven by its own citizens and representing a dynamic force in global arena.” One of the key objectives of AU is to work with relevant international partners in the eradication of preventable diseases and the promotion of good health on the continent; it also endevours to coordinate and harmonize the policies between the existing and future Regional Economic Communities for the gradual attainment of the objectives of the Union. Against this background, NEPAD is a programme of the African Union (AU), adopted in 2001 the African leaders in 2001 adopted The New Partnership for Africa's Development (NEPAD) as a programme of the AU with the primary objectives of poverty eradication, promotion of sustainable growth and development, and the empowerment of women through building genuine partnerships at country, regional and global levels. NEPAD is active in six thematic areas, namely, -Regional Integration and Infrastructure that is pertinent in this study. The other five areas are Agriculture and Food Security; Climate Change and Natural Resource Management; Human Development; Economic and Corporate Governance; and Cross-cutting Issues, including Gender, Capacity Development and ICT. 1.2 EAC protocols 1.2.1 EAC Health protocol The East African Legislative Assembly passed a Bill in 2012 requiring governments to ensure that persons living with or affected by HIV and AIDS are protected from all forms of abuse, discrimination and are provided with appropriate support, care and treatment services. Thereafter, in 2013, the EAC agreed on a protocol on Health whose purpose is to give guidance on how to govern regional co-operation on health and related matters among the Partner States. The vision of the protocol is to have a harmonized and integrated regional health system and services for the improvement of the health and general wellbeing of the peoples of the Community. The protocol also states that it’s mission is to provide legal mechanisms for coordination and integration of health systems and services in order to enhance the health of the people in the Community, as spelt out in Article 118 of the Treaty. In line with this, the principal objective of the protocol is to establish, harmonize and operationalize regional health policies and legal frameworks and mechanisms, to facilitate and govern regional cooperation on health and related matters among the Partner States. In general, the Partner States also agreed to cooperate in strengthening regional collaboration and coordination in the health sector, including HIV & AIDS and sexually transmitted infections control and management. Other relevant articles are as shown in the table below. Table: Selected Articles in the EAC Protocol on Health AREAS OF COOPERATION Cooperation on health systems development and strengthening, health research and policy Cooperation in disease prevention and control Cooperation on HIV and AIDS and sexually transmitted infections prevention, control and management Cooperation in sexual and reproductive health and rights ARTICLES Article 7: Health Systems Article 8: Regulation of Training, Licensing and Practice of Health Professions Article 10: Prevention and Control of Communicable and NonCommunicable Diseases Article 10: Joint Cross-Border Disease Surveillance and Response Article 11: Epidemiological Surveillance Article 12: Improving Medical Laboratory Services Article 15: Social Mobilization to Prevent and Control Diseases Article 16: Exchange of Surveillance and Epidemic Information Article 21: Prevention and Control Measures Article 22: HIV and AIDS Treatment, Care and Support Article 23: Sexual and Reproductive Health and Rights and Gender Health Issues 2 Cooperation in medicines, food safety and quality Article 24: Integration in Sexual and Reproductive Health Services Article 28: Regulation of Medicines and Food Safety and Quality Article 29: Promotion of Local Pharmaceutical Production and Pooled bulk Procurement of Medicines and Health Supplies 1.2.1 Other EAC protocols The EAC partner states have signed other protocols that have a bearing on the social and economic well being of the population in the individual countries. This includes the Monetary Union Protocol and Protocol on the Establishment of the East African Community Common Market. The objective of the Monetary Union is to promote and maintain monetary and financial stability aimed at facilitating economic integration to attain sustainable growth and development of the the community. On the other hand the Protocol on the Establishment of the East African Community Common Market provides for free movement of goods; free movement of persons and labour; rights of establishment and residence; and free movement of services. These two protocols significantly enhance particularly trans-boundary movement of the population which is highly associated with elevating the risk and vulnerability to infection from HIV, TB and STI. 1.3 HIV&AIDS/ STI and TB and Situation 1.3.1 HIV and AIDS According to the UNAIDS1 report, the estimated prevalence of HIV among adults 15-49 years of age in 2012 was 1.3% in Burundi, 6.1% in Kenya, 2.9% in Rwanda, 7.2% in Uganda and 5.1% in Tanzania. These levels were the lowest ever for Burundi, Kenya and Rwanda since the 1990s. For Uganda the prevalence was similar to the situation in 2000 while for Tanzania it was similar to that observed in 1991 (Figure 1). HIV prevalence had peaked at around 5% between 1995 and 1997 in Burundi, at 10% between 1996 and 1998 in Kenya, at 6% in Rwanda between 1990 and 1994 and at 8% in Tanzania between 1994 and 1998. Since that time there has been a consistent downward trend in prevalence for these four partner states. For Uganda, the epidemic had been at its worst in the late 1980’s where prevalence was as high as 18% among adults. It then showed a decline throughout the 1990s but prevalence started to increase again since around 2004. 1 3 Figure 1: Trend in HIV Prevalence in East Africa Partner States, 1990-2012 Burundi Kenya Rwanda Uganda Tanzania 14 Prevalence (%) of HIV 12 10 8 6 4 2 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 0 Source: UNAIDS Report on the Global AIDS Epidemic - 2013 In 2012, there was a total of 333,400 new infections in the region with the majority being found in Kenya, Tanzania and Uganda. In general, about 4.9 million people were living with HIV out of which nearly 2 million were eligible for ART although only 75% of these were receiving treatment. Since ART became more widely available in the region, there has been a consistent decline in the number of AIDS related deaths in all the countries in the East African Community. Thus, in 2012, a total of 210,000 people were estimated to have died from AIDS with the majority being in Tanzania, Kenya and Uganda (24%) as is shown in the table below. Table: Key Features of HIV epidemic in EAC Partner States, 2012 Partner New PLHIV Number of Adults Deaths States Infection Eligible for Adults on ART ART (%) Burundi 4,600 89,000 40,000 67 4,800 Kenya 98,000 1,600,000 680,000 81 57,000 Rwanda 7,800 210,000 110,000 97 5,600 Tanzania 83,000 1,500,000 580,000 68 80,000 Uganda 140,000 1,500,000 580,000 70 63,000 TOTAL 333,400 4,899,000 1,990,000 75 210,400 Source: UNAIDS Report on the Global AIDS Epidemic - 2013 1.3.2 Sexually Transmitted Infections The Sub-Saharan Africa has the highest rates of classical STIs per capita worldwide. For 1999, WHO estimated that in the sub-Saharan Africa, the prevalence of the curable bacterial STIs gonorrhoea, chlamydia, syphilis and trichomoniasis alone was 12%, and that there were 69 million new cases of these STIs annually. Information about infection rates is hard to come by, especially for many developing countries. No single organisation regularly collates STI statistics worldwide, and different countries have different types and levels of reporting systems. 4 In Kenya the MARPs Surveillance Report of 2012 notes that among female sex workers 15.3 had bacterial vaginosis, 29.3% had HIV, 22% syphilis, 10.3% Trichomonas vaginalis, 1.1% vaginal N. gonorrheoaea and 3.1% vaginal C. trachomatis. Similarly in Uganda, the 2010 Crane survey revealed that among female sex workers, 68% of the respondents were diagnosed with an STI in the survey. Thirty-three percent had bacterial vaginosis, 33% had HIV, 0.9% syphilis, 9% Trichomonas vaginalis, 8% vaginal N. gonorrheoaea and 4% vaginal C. trachomatis. In Rwanda, Braunstein et al., 2011, reported prevalence rats of 24% and 59.8% for HIV and HSV-2 respectively among female sex workers in Kigali. In a community-based survey in Northern Tanzania, Ghebremichael et al, 2014, reports that half of the women tested positive for at least one STI. Forty three percent HSV-2, 11% had HIV, 11% Trichomonas, 3.2% Mycoplasma Genitalium, 2.5% syphilis, 1.8% chlamydia and 0.2 % had gonorrhea. 1.3.3 Tuberculosis Globally, there are 22 high-burden countries that account for approximately 80% of all new TB cases arising each year; out of these, nine are in Sub-Saharan Africa including Kenya, Uganda and Tanzania in East Africa. According to the WHO report of 20122, the estimates of the burden of disease caused by TB in the EAC in 2012 are as follows: (a) incident cases range from 78,000 to 120,000 (b) prevalent cases are from 82,000 to 120,000 people and (c) deaths due to TB is from 5,000 to nearly 10,000. Most cases were in Kenya. The HIV positive incident TB cases were less than 50% as is shown in the table below. Table 1: Estimated burden of disease caused by TB, 2011 (Number in Thousands) Population Mortality Prevalence Incidence HIV Positive Incident TB Cases Kenya 41,610 9.2 120 120 47 Uganda 34,509 5 63 67 35 Tanzania 46,218 6.4 82 78 30 Source: WHO (2012). Global Tuberculosis Report 2012. 2 5 Chapter Two 2.1 Background information 2.1.1 EAC HIV and AIDS strategic plan The national responses to HIV and AIDS in the five EAC countries are guided by their respective national strategic plan as is shown in the table below. In the strategic plans, truckers, host communities, returnees, women and girls affected by sexual and gender based violence, migrant workers, IDUs, MSMs, women petty traders, married couples and young women are mentioned as important target populations. However, the recent Annual EAC report has noted that size estimation of these populations is still a major challenge. Hence, the EAC needs to ensure that the region has adequate capacity and information for guiding the development of effective strategies for an integrated HIV and health service provision to the population in the transport corridor of the region. Table 2: National Strategic Plans for EAC Partner States Partner State Burundi Kenya Rwanda Tanzania Mainland Zanzibar Uganda National HIV and AIDS Strategic Plan National Strategic Plan on HIV/AIDS Control Kenya National HIV and AIDS Strategic Plan III National Strategic Plan on HIV and AIDS National Multi-sectoral Strategic Framework on HIV and AIDS Zanzibar National HIV&AIDS Strategic Plan National HIV and AIDS Strategic Plan Timeframe 2007-2011 2009/10–2012/13 2009-2012 2008-2012 2011-2016 2011/12-2014/15 The Burundi strategic plan has four strategic lines. Strategic Line 1 is on reducing the STI/HIV transmission through the increase and the extension of prevention activities deemed effective while Strategic Line 2 is on improvement of PLWHA well-being and quality of life. Poverty reduction and other HIV vulnerability influencing factors are captured under Strategic Line 3 while Strategic Line 4 deals with Improvement of the management and the coordination of the National Policy on HIV/AIDS. Currently, however, a new strategic plan 2012-2016 is being prepared. The current Kenya National HIV and AIDS Strategic Plan III 2009/10–2012/13 (KNASP III) has four pillars. The goal of pillar 1 is to achieve Universal Access targets for an integrated, prioritized package of prevention, treatment, care and support services by 2013. Under Pillar 2, the goal is to achieve comprehensive integration of HIV prevention, treatment and socio-economic protection interventions in all areas of the public and private sectors, as well as civil society, in a harmonized and aligned manner. The goal of Pillar 3 is to strengthen community capacity towards achieving Universal Access and social transformation for an AIDScompetent society. Lastly, under Pillar 4, the goal is to create an enabling environment for implementation of all pillars through strengthened policy, leadership, oversight, partnership, and governance at national and decentralized levels The Rwanda plan has three goals or impact areas, namely, the incidence of HIV in the general population is halved by 2012; morbidity and mortality among people living with HIV are reduced; and people infected and affected by HIV have the same opportunities as the general population. Uganda’s strategic plan also has four goals, namely, to reduce HIV incidence by 30% by 2015; to improve the quality of life of PLHIV by mitigating the health effects of HIV and AIDS by 2015; to improve the quality of life of PLHIV, OVC and other vulnerable populations by 2015; and to to build an effective and efficient system that ensures quality, equitable and timely service delivery by 2015. 6 In Tanzania, the second National Multi-sectoral Strategic Framework (NMSF) on HIV and AIDS provides strategic guidance in the national response and has eight goals, namely, to (1) create a political, social, economic and cultural environment for the national response to HIV (2) reduce the HIV transmission (3) reduce morbidity and mortality due to HIV and AIDS (4) improve the quality of life of PLHIV and those affected by HIV and AIDS, (5) use relevant and comprehensive evidence provided in HIV-related planning and decision-making (6) provide well – coordinated, effective, transparent, accountable and sustainable leadership and management structures (7) provide financial, human and technical resources for the implementation of the national response to HIV and (8) translate the NMSF into well-defined operational plans at national and local government authority levels. For Zanzibar, their plan has five strategic priority areas, namely, prevention of new infections; treatment, care and support of the PLHIV; mitigation of socio-economic impact of the epidemic; creation of an enabling environment; and research, monitoring and evaluation. 2.1.2 EAC STI and TB strategic plans Since the emergence of HIV in the 1980s, STI control efforts in East Africa have increasingly been defined in relation to HIV programme priorities. Although HIV is itself an STI, efforts to prevent its transmission are largely managed through programmes that are funded, implemented and evaluated independently of other STI control efforts. Such a fractured paradigm in East Africa has had unfortunate consequences. Too often, neglected STI programmes – the foundation upon which HIV prevention efforts were built – collapse due to reduced funding. As a result, In some member states, STI clinics and services are understaffed, understocked or disappearing altogether; pregnant women may be offered HIV tests but are no longer screened for syphilis; and STI reporting, an important marker of sexual transmission trends, has largely collapsed. There are strategic plans for TB in all the EAC partner states 2.2 Review of EAC HIV and AIDS strategic plan 2012/2014 2.2.1 The HIV and AIDS response in the region The EAC strategic plan3 for addressing HIV/AIDS had four objectives, namely, (i) To scale up regional and national leadership involvement, commitment and ownership for sustainability of HIV and AIDS response (ii) To facilitate the adoption, harmonization and implementation of international and regional protocols, guideline, policies and strategies; (iii) To improve the designing, management, and sustainability of HIV responses at national and regional level; and (iv) To strengthen the coordination and implementation of regional responses for mobile and key populations in the EAC region. 2.2.2 SWOT Analysis Strengths and weaknesses: Strengths are factors which the EAC partner states and the Secretariat can optimize to deliver on this strategic plan while the weaknesses should be addressed to minimize their negative impacts on achievement of the desired outcomes in the implementation of the strategic plan. The table below summarizes the identified strengths and weaknesses. 3 EAC (2012). Realigned EAC HIV and AIDS Multisectoral Strategic Plan (2012-2014) 7 Strengths 1 Legal and political mandate drawn from the EAC treaty 2 Programming and policy framework - national multisectoral Strategies and plans 3 There are institutional arrangements and structures (NACs/CNLS, including decentralized service delivery structures) 4 There is strong leadership and political commitment and support from partner states 5 The EAC Secretariat has qualified and committed human resource and expertise 6 There is research capacity to generate evidence to inform regional interventions 7 Availability of experiences and best practice from other RECs to inform programming 8 Good relations and established partnerships with other RECs 9 There is political stability in the EAC region conducive for effective programming Weaknesses 1 There exist many unharmonized strategic plans within the partner states thus leading to duplication and resource misallocation 2 The shortage of sufficient number of staff at the EAC secretariat affects the scope and scale of programming 3 The multiplicity in planning cycles across the partner states minimizes the effectiveness in coordination of monitoring performance in the region 4 The capacity by EAC secretariat to monitor work plans and provide technical support to partner states is limited by small number of staff 5 Weak financial base affects the scope and scale of programs Opportunities and Threats: Opportunities are factors in the external environment to the EAC secretariat and its partner states that can be harnessed to support implementation of the strategic plan. On the other hand, threats are factors that are likely to interfere with the achievement of the desired outcomes in the implementation of the strategic plan. In both cases, they present as global or regional changes in policies, politics, laws, science and technology, economic climate, social trends among others that directly or indirectly impact on implementation of strategic plan. The table below outlines some of these factors. Opportunities 1 Willingness and commitment of donors to support interventions (GF-New Funding Model, WB, SIDA, CHAI, UN family, PEPFAR) 2 There is room for integration of TB and HIV interventions under NFM 3 Presence of other Regional Economic and Health Communities (SADC, ECASA, GLIA) 4 Presence of CSOs to support implementation of programs 5 Improving political willingness to health interventions 6 Establishment of sustainable funding mechanism (AIDS Trust Funds) 7 Implementation of Maputo declaration (declaration of diseases such as TB, HIV as emergency) 8 Potential for local production of commodities and bulk procurement 9 Potential for technical expertise e.g. for joint research with academic institutions in the region 10 Existing Common Market protocol (and other legal regional, continental and international instruments and frameworks within and with the EAC) 11 On-going harmonization processes within the Health Sector (e.g. Medicines regulation harmonization) 12 New technologies for prevention 8 Threats 1 Delayed contributions from the partner states 2 inadequate capacity in Human Resources at EAC 3 Lack of enough professional staff – adequate number of staff 4 Sustainability of fund at EAC 5 Inadequate of harmonized focus at the partners states level 6 Political instabilities & elections 7 Outbreak of communicable diseases 8 Dependency on external donors 9 Rapid change of global policies/guidelines that affect EAC Partner States 10 Coalition of the willing 11 Competition between/among RECs 12 Post 2015-agenda ----what will the focus be? 13 Other competing agendas at the international level 14 Competing mandates – e.g between EAC and ECSA Lessons learnt 2.3 Development of the Strategic Plan 2.3.1 Rationale for review of the strategic plan This strategic plan is designed to address changes in the HIV/AIDS, TB and STIs context globally and in the EAC region in particular. It recognizes the new threats and opportunities that have emerged overtime within the realms of the EAC and the need to improve on the efficiency in the way the EAC Secretariat and partners state do business. The strategic plan will further serve as a resource mobilization tool given the changing priorities not captured in the previous strategic plan. The strategic plan is designed for the EAC secretariat and the partner states in order to address HIV/AIDS, TB and STIs issues which are transboundary in nature and upon which individual states do not have the sole mandate to manage. Some of these issues require managing through strategies that take into account economies of scale, and comparative advantage of individual partner states. The EAC Secretariat will therefore support partner countries to look at global and regional issues related to HIV/AIDS/TB/SRH in a coordinated manner through fostering regional capacity in research, knowledge management and monitoring and evaluation. This plan will also provide a linkage with other partner state strategic plans as well as other existing plans of the EAC and other regional economic blocks through setting the agenda to guide other sectors and to mainstream some of the activities in their work plans. It will further create a linkage with other social sector plans under the EAC secretariat like tourist, education, transport and infrastructure at country level in order to foster coordination, minimizing duplication of efforts and efficient resource use through strategic focus on high impact areas that are of transboundary in nature. Furthermore, this strategy will enhance cross country learning through adoption of good practices, developing uniform standards and continuity of interventions across the regions. It will also enable partner countries belong to more than one REC to make guided commitments beyond health. 2.3.2 The strategic planning process The EAC Secretariat adopted an extensive consultation process of its stakeholders both in the public and private sector domains. This was done in order to take into account the changes in the socio-political, economic, technological and legal environs, and how they influence the dynamics of the HIV and AIDS, TB and STIs response. The approach further sought to generate buy-in by the different stakeholders for purposes of joint ownership and implementation of the strategic plan. To this end, consultative workshops, individual country assessment of areas of focus and assessment of performance of the previous strategy were carried out. 9 Chapter Three 3.1 Strategic intents 3.1.1 Vision, mission and goal Vision: An East African Community free of HIV and AIDS, TB and STIs Mission: To provide coordinated, evidence based and effective regional HIV and AIDS, TB and STIs response Goal: Reduced incidence of HIV, TB and STIs infection in the East African region in order to secure sustained socio- economic development 3.1.2 Key result areas This strategic plan will be guided by the following key result areas which will be the basis for program development. Key results areas 1 2 3 4 5 Description A committed and proactive regional and national leadership Scale-up accessibility, affordability and availability of HIV and AIDS Prevention, Care, Treatment and Support Services in the region Evidence based policies and guidelines are in place to inform the regional HIV and AIDS/TB and STI interventions Regional programmes targeting mobile and key population in the EAC region Research and knowledge management Conceptual framework The EAC HIV/AIDS, TB and STI strategic plan will have regional and national commitment central to the entire strategy as illustrate in the wheel and hub framework in Figure 1 below. This strategic focus is underpinned by the role that leadership and commitment play in guiding the political and technical direction within the dynamic environmental context of the EAC HIV and AIDS, TB and STIs response. 10 Figure 1: The wheel and hub to the EAC HIV and AIDS, TB and STIs response The regional and national political and technical commitment is the hub of EAC and whose strength will define realization of the other program components and the overall goal which is to “Reduce the incidence of HIV, TB and STIs infection in the East African region in order to secure sustained socioeconomic development”. Realizing this goal will contribute to health outcomes that benefits the population targeted by this strategic plan. The four key result areas namely: 1) Scale up accessibility, affordability and availability of HIV and AIDS Prevention, Care, Treatment and Support Services in the region; 2) Evidence based policies and guidelines are in place to inform the regional HIV and AIDS/TB and STI interventions; 3) Regional programmes targeting mobile and key population in the EAC Region; and 4) Research and knowledge management be coordinated and through strong leadership and commitment guided towards realizing the overall goal. It is expected that the EAC Secretariat will routinely monitor and manage contextual changes on the external environment which have a bearing on realization of the goal; and address them accordingly. A comprehensive results chain that shows the relationships among the key result areas will be detailed out in the M&E plan guided by the log frame in this strategy including impact, outcome, and output indicators. 11 3.2 Alignment to the overall EAC strategic plan, EAC protocol on health There is a strong linkage between the EAC Development Strategy 2011/12-2015/16, the EAC Protocol on Health and the EAC strategic plan on HIV/AIDS, TB and STI in terms of vision, goal and objectives as is summarized in the table below. This underscores the fact that indeed EAC (a) in the response to HIV/AIDS, TB and STI, is complaint with other EAC instruments for enhancing cooperation in the region, (b) is going to focus on aspects of the health protocol that it has comparative advantage in coordinating and/or facilitating implementation by the partner states (c) will be contributing to the regional and national goals and aspirations as encapsulated in the overarching EAC development strategy. Table: Alignment between EAC strategic plan, EAC protocol on health and EAC Development Strategy Vision Mission Goal EAC Development Strategy 2011/12-2015/16 To attain a prosperous, competitive, secure and politically united East Africa To widen and deepen economic, political, social and cultural integration in order to improve the quality of life of the people of East Africa through increased competitiveness, value added production, enhanced trade and investment. To develop policies and programmes aimed at widening and deepening cooperation among the Partner States in political, social and cultural fields; research and technology, defense, security and legal and judicial affairs. EAC Protocol on health 2013 To have a harmonized and integrated regional health system and services for the improvement of the health and general well-being of the peoples of the Community To provide legal mechanisms for coordination and integration of health systems and services in order to enhance the health of the people in the Community, To establish, harmonize and operationalize regional health policies and legal frameworks and mechanisms, to facilitate and govern regional cooperation on health and related matters among the Partner States. EAC HIV/AIDS, TB and STI Strategic Plan 2015-2020 An East African Community free of HIV and AIDS, TB and STIs To provide coordinated, evidence based and effective regional HIV and AIDS, TB and STIs response To reduced incidence of HIV, TB and STIs infection in the East African Community region in order to secure sustained socio- economic development 3.3 Guiding principles In implementing this strategic plan, the EAC Secretariat and partner states will be guided by the following principles: • Respect for human rights by adopting the rights based approach as defined in the international instruments • Respect for autonomy for the partner states • Consideration for gender dimension including equity and other rights based approaches • Integration, cost effectiveness and evidence based planning and response • Capacity building for partner states in the HIV/AIDS/TB/STI response • Meaning involvement of affected communities including the key populations 3.4 Programme goal and strategic objectives 3.4.1 Key Result Area 1 - A committed and proactive regional and national leadership. Rationale 12 Commitment: Unlike SADC, there is no HIV and AIDS political declaration by the EAC Summit of Heads of State. Recently, a comprehensive analysis of HIV and AIDS legislation, bills, policies and strategies in the EAC was carried out. The study found that there are laws that protect against HIVrelated discrimination and those that are counterproductive to the fight against HIV and AIDS in the region. A number of strategic gaps and challenges in these legal and regulatory frameworks of Partner States in relation to the EAC HIV and AIDS Prevention and Management Bill were identified that need to be addressed. The partner states have different comparative advantage and expertise in responding to the epidemic in various areas of the response. By promoting centre/country of excellence in respective partner states, the EAC could benefit from regional technical support as these centres/countries of excellence become platforms for experiential learning and technical backstopping to the others. Coordination: Although there are respective M&E systems to support the implementation of the partner state NSP, there is no clear relationship and guide between (a) EAC M&E and country M&E groups and (b) African Union and EAC formats of reporting. Partner states only report in compliance with UNGASS and AU requirements but with no report to EAC which makes it difficult to compare performance across partner states except only by using population based survey results like those from AIDS Indicator and Demographic and Health Surveys that are carried out every five years. In addition, the multiplicity in planning cycles across the partner states minimizes the effectiveness in coordination of monitoring performance in the region. This further aggravated by the limited capacity by EAC secretariat to monitor work plans and provide technical support to partner states is limited by small number of staff. Advocacy: There is need to increase advocacy and sensitization of leaders in EAC region in order to ensure that HIV remains a key agenda within political and policy settings of partner states. This will also help to strengthen political leadership and commitment for addressing the HIV and AIDS epidemic in the region. The committees in both the national and regional (EALA) parliaments in particular need to be sensitized on HIV/AIDS issues in general but also on issues that have a regional dimensions like key population, cross-border divers of the epidemic etc. It is also apparent that HIV and AIDS are not adequately mainstreamed into EAC development programmes, protocols and policies and laws thus making it difficult for the response to be multi-sectoral. To-date, too, there is limited advocacy and mobilization tools for supporting the involvement and commitment of political, cultural and religious leaders at national and sub-national levels in the response. All this will need strategic high level advocacy for the development of a well designed cross-border heath programme addressing the key issues within these transport corridors. Funding: Provision of adequate resources in a timely manner is one of the key pre-requisites for the region response to HIV and AIDS epidemic; this should be accompanied with effective and efficient allocation and utilization of the resources. Domestic investment in HIV and AIDS has continued to increase in the partners states although in-general, the amounts remain lower than the contribution from development partners. Based on the national AIDS Spending Assessment, all the five Eastern Africa countries have a donor dependency of over 50%. In particular, Tanzania falls within the 50-74% external resource dependency bracket while Burundi, Kenya, Rwanda and Uganda are ranked within the 75-100% bracket. The major multilateral funding agencies for HIV epidemic in the region include GFATM, World Bank, European Commission and UN-agencies. It will be necessary to ensure that the existing DPs are retained as funders of national and regional HIV and AIDS interventions. It will also be necessary to bridge the resource gaps by working out strategies for bringing on board the emerging economies of the BRICS countries (i.e. Brazil, Russia, India, China and South Africa) to provide resources for implementing this strategic plan. South Africa, for instance, is a major investor in the East African region which is also the destination of many manufactured goods from 13 India and China. Hence, it would be appropriate for them to support the region in its aspiration for a HIV and AIDS, TB and sexually transmitted disease population. Mainstreaming: There has been much talk about mainstreaming of cross-cutting issues such as AIDS, gender and human rights. However, there is need to have deliberate effort towards actualizing this aspiration. Hence, the EAC will need to develop or adapt appropriate tools for building the capacity of partner states and CSOs for mainstream HIV/AIDS, gender and human rights in EAC programmes, protocol etc. The EAC will also need to empower the CSOs in the region to (a) engage in advocacy, lobbying and negotiation on behalf of right holders including the marginalized groups and MARPs (b) promote social accountability and participation (c) accountability from the public and non-public duty bearers. Strategic Objective: To scale up regional and national leadership involvement, commitment and ownership for sustainability of HIV and AIDS response Expected results Results Indicators Increased commitment among leaders of partner states Number of protocols on HIV/AID, TB and in HIV/AID, TB and STI response STI response signed Amount o resources committed to the HIV/AID, TB and STI response Increase domestic financing by establishing a Regional Regional fund for HIV, AIDS and TB Fund for HIV, AIDS and TB and Partner States also established progressively increase their respective domestic budget for HIV and AIDS interventions, and health in general to 15% of national budget in line with the Abuja Declaration of 2001. Coordination and partnership of HIV/AIDS, TB and Guidelines for HIV/AID, TB and STI STI strengthened response developed and disseminated Awareness and advocacy on HIV/AIDS, TB and STI EAC HIV/AID, TB and STI advocacy strengthened strategy developed Number of regional advocacy events conducted Increased effort in mobilization of internal and Proportion of the strategic plan budget external resources for HIV/AIDS, TB and STI funded strengthened Mainstreaming, joint accountability and reporting on Number of reports generated HIV/AIDS, TB and STI strengthened Strategic actions Commitment: Improve the legal and policy environment that discriminate and/or impact on the rights MARPs Advocate for harmonization and/or amendment of existing laws and policies that have been identified to affect the regional response to HIV/AIDS Promote stewardship in the response by facilitating partner states in leading the response in areas where they have a comparative advantage. Coordination and Partnership: 14 Strengthen coordination and partnership among leaders in government, civil society, private sector, religious and cultural institutions in the region in supporting the implementation of this strategic plan Strengthen regional network of associations and/organizations on AIDS for improving coordination and involvement of civil society and private sector in the response to HIV and AIDS epidemic in the region Develop a minimum set of standard indicators, guidelines and tools/format for reporting on the implementation of EAC strategic plans by partner states and the secretariat Advocacy: Generate and disseminate strategic information and messages to support various high profile leaders’ advocacy efforts on health, HIV, AIDS and TB in the region ensure that HIV and AIDS is mainstreamed in EAC programmes and policies and resources mobilized to support the same ensure that programmes, protocols and policies and laws that relate to regional response to HIV and AIDS are signed, implemented and monitored at regional and national levels Funding: Increase domestic financing by establishing a Regional Fund for HIV, AIDS and TB and Partner States also progressively increase their respective domestic budget for HIV and AIDS interventions, and health in general to 15% of national budget in line with the Abuja Declaration of 2001. Mobilize more external support from traditional and non-traditional funders of health and HIV and AIDS programmes to provide resources for health, HIV, AIDS and TB in the region Accountability: Strengthen joint accountability and reporting mechanism 3.4.2 Key Result Area 2 - Scale up accessibility, affordability and availability of HIV and AIDS Prevention, Care, Treatment and Support Services in the region Rationale The EAC Secretariat and partner states’ response to HIV, STIs and TB is based on the understanding that the public interest is best served when there is universal access to HIV, STIs and TB services. In scaling up towards universal access, EAC Secretariat and partner states efforts are currently constrained by a lack of health workers, other challenges to scaling up services include the high cost, weak processes for procurement and supply chain management, the low availability of and delays in the delivery of drugs and limited access to entry-point services. High user charges for laboratory tests constitute another barrier to treatment access. Strategic Objective: To facilitate the adoption, harmonization and implementation of international and regional protocols, guidelines, policies and strategies EAC Member States have committed themselves to the fight against HIV, STIs and TB. To this end Member States have signed and ratified a number of regional and international declarations. These include the EAC Protocol on Health, which prioritises coperation on HIV and AIDS and sexually transmitted infections prevention, control and management; cooperation in medicines, food safety and quality and calls for harmonisation of policies and strategies aimed at these priorities. The rationale for using harmonized standards is to ensure that similar methods are consistently applied by the EAC Member States. 15 Expected results Results Indicators Harmonized management of HIV, Number of minimum standards for the management of HIV, STIs and TB in EAC STI & TB ratified and adopted by EAC member states Strengthened reference laboratory Minimum SOPs for reference laboratories ratified and adopted capacity in EAC by EAC member states Number of regional reference laboratory meeting the minimum SOPs Strategic actions Harmonization of HIV, STIs and TB policies and management guidelines: This is critical in a region where a significant proportion of the population is routinely engaged in cross border movement. Harmonized policies will ensure that migrant and vulnerable populations especially are able to receive standardized HIV, STIs and TB services. This strategic plan particularly urges the EAC secretariat and members states to prioritize the harmonization of Tuberculosis guidelines especially Multi – Drug Resistant TB (MDR TB) diagnosis and management Harmonize Pharmaceutical laws/Policies/standards legal frameworks: One of the priority health activities identified within the scope and mandate of the EAC cooperation is the harmonization of medicines registration to attain good control of pharmaceutical standards within the community. The formation of an EAC Custom Union in 2005 provides the impetus for the harmonization of medicines regulatory systems in the EAC partner states. Strengthening regional reference laboratory capacity: This strategic plan urges member states to harmonize the operations of laboratories. This is encapsulated within the EAC protocol on health which calla upon members states to corporate with respect to case definitions and notification systems. There is need for a common denominator to describe national and regional reference laboratories describing their roles and functions. Advocate for Pooled bulk procurement: joint purchasing is an efficient strategy that will help resolve the current challenges faced by EAC member states i.e. high medicines prices, poor quality and other bottlenecks generally associated with Procurement and Supply Chains of Essential Medicines. This can be achieved by supporting the establish an EAC Health Secretariat Task force on Pooled Procurement to be responsible for: the development of an EAC operational plan for the implementation of regional pooled procurement including budget and timeframe; Identifying relevant structures at country and regional levels for coordinating pooled procurement activities (e.g. forecasting/quantification, financing and price monitoring) and developing initial Group Contracting pilot program for the purchase of a select number of essential medicines HR capacity 3.4.3 Key Result Area 3 - Evidence based policies and guidelines are in place to inform the regional HIV and AIDS/TB and STI interventions Rationale 16 There is a considerable gap between what research shows is effective and the policies that are enacted and enforced. Research is most likely to influence policy development through an extended process of communication and interaction. In part, the research–policy interface is made more complex by the nature of scientific information, which is often vast, uneven in quality, and inaccessible to policymakers. The EAC Secretariat and partner states’ response to HIV, STIs and TB is driven by a commitment to provide effective intervention guided by Evidence based policies and guidelines. This is in line with Article 118 of the Treaty of the establishment of the East African Community, where member states resolved to cooperate with one another in the area of health, social and cultural field, in particular, in the field of research, health policy and practice. Strategic Objective: To improve the development, design, management, implementation and sustainability of HIV, STI &TB responses at national and regional level Results EAC relevant research conducted A coordinated EAC disease surveillance system Indicators EAC research agenda ratified and adopted by member states Number of EAC lead research projects conducted Use of research findings Minimum standards for HIV, STI & TB disease surveillance system ratified and adopted by EAC member states Synchronization of surveillance system Strategic actions Strengthen surveillance systems for HIV, STIs & TB in the region: This strategic plan calls on the EAC secretariat and member states to create a harmonized and strengthened regional surveillance system. EAC member states are generating information from different systems, such as public health surveillance systems, surveys, operations research and existing routine information systems. Hence, there is need to harmonise the surveillance methods to facilitate comparison of indicators across EAC Member States. In this regard priority areas include Strengthening cross border surveillance for MDR TB (especially among refugee and immigrant populations), strengthen surveillance for HIV and AIDS, and STIS in the region. 3.4.4 Key Result Area 4 - Regional programmes targeting mobile and key population in the EAC Region. Rationale Meaningful involvement of PLHIV and Key populations: Many HIV/AIDS/TB/STI programs are designed and implemented with minimal involvement of the target beneficiaries. As a result, some of the programs do not yield the desired effect thus contributing to resource wastage. This affects service uptake given the failure to address the socio-cultural dynamics that influence health seeking behaviours of the different key populations. Integrating sexual and reproductive health issues: In some cases, programs that are designed focus on specific areas like HIV/AIDS/TB/STI in the main without integrating SRH. As a result, the target groups have to seek for these services from other providers which is costly, time wasting and inconveniencing. To this end, adherence to treatment is affected thus contributing do drug resistance and relapse into overt clinical situations. 17 Legal environment: There is no harmonized legal environment on sexual minorities in the EA region. As a result, interventions targeting this category of key population are fragmented. In some of the partner states, sexual minorities have been forced to operate underground through restrictive legislation. The effects of this situation include limited access to HIV/AIDS/TB/STI services of MSM, LGBTI who are mobile sex workers and their families thus contributing to spread of infections. Coordination with NACs and CSOs: The individual NACs have their own strategic plans which guide specific country responses. However, this creates room for lack of coordination in programming for mobile and key populations. As a result, the response to HIV/AIDS/TB and STIs is not coordinated thus contributing to resources wastage. Capacity building: NACs have country specific capacities to the HIV/AIDS/TB and STI response. This also applies to Civil Society Organizations (CSOs). However, the target populations for this strategic plan are transboundary in nature. As a result, individual NACs and CSOs are unable to provide the specific services to the mobile and key populations due to limited capacities. Strategic Objective: To strengthen capacities of NACs and CSOs to develop and implement regional programmes targeting mobile and key populations in the EAC Region. Expected results Results Increased availability of integrated services for mobile and key populations Conducive legislative regimes for sexual minorities Harmonized programs for mobile and key populations Capacities of NACs and CSOs in key and mobile population programming enhanced Indicators Number of service points for mobile and key populations in the partner states Number of partner states with policies and programs that promote access to services by sexual minorities Number of partner states adopting EAC guidelines for mobile and key populations’ programming Number of partner states and CSOs providing mobile and key populations’ specific interventions Strategic actions Meaningful involvement of PLHIV and Key populations: The EAC Secretariat will involve the cross border key populations including young people, women and children living with HIV and AIDS, TB and STIs, mobile populations along the transport corridors and persons with disabilities. This will facilitate development of interventions that address the specific needs of the target group sub categories. Integrating sexual and reproductive health issues: EAC secretariat will develop guidelines for integration of SRH services into partner state cross border programs for key populations. Legal environment: EAC Secretariat will advocate for harmonization of legislation related to sexual minorities with the view of improving access to services across the region. It will further support efforts towards building linkages between networks of associations for sexual minorities in the region for purposes of advocacy on legislation that impact on them. Coordination with NACs and CSOs: EAC Secretariat will support efforts aimed at harmonizing regional programs for key and mobile populations in the EA region. This will be through establishing clear linkages to the partner states’ National Strategic Plans for HIV/AIDS/TB and STIs. It will further strengthen mechanisms for collaboration with the National AIDS Councils and Commissions. 18 Capacity building: EAC Secretariat will support development of specific capacities of NACs and CSOs to address the HIV/AIDS/TB and STI response across borders 3.4.5 Key Result Area 5: Research and knowledge management Rationale Development of a common HIV, STIs and TB research agenda: High impact interventions require scientific research to inform programming in a systematic and coordinated manner within the region. However, the different response in the partner states does not provide for coordinated research which is currently fragmented. The dynamic nature of the HIV/AIDS/TB and STI response globally and within the EAC region provide a challenging environment within which information can be collated, packaged and access by partner states. This creates a situation where partner states face challenges in accessing strategic information from local and international researches in real time due to limitations in tools or media of access. It further affects adoption of harmonized approach to using research findings to inform programs and influence the advocacy agenda as well as facilitating allocation of resources for research. Information exchange: It is important to exchange information about the good practices on HIV/AIDS/STIs and TB programming and research. This is premised on the current scenario in the EAC region where partner states have accumulated useful information about their interventions but it is not shared out with other states. This has resulted into failure in cross learning which would otherwise improve service standards within the region. Capacity building in research and knowledge management: Currently, partner states are carrying out a number of researches in HIV/AIDS/STIs and TB areas. The capacities to carry out these researches differ from one state to the other and depending on the level of scientific advancement. This difference in research capacities across partner states does not auger well for uniformity in the HIV/AIDS/STIs and TB response in the region yet mutual benefits would be realized from cross learning. The monitoring and evaluation systems: The individual partner states have their own M&E systems for HIV/AIDS/STIs and TB response where specific information is generated and used. There is no overarching system that brings together the individual state M&E systems where information on transboundary information can be aggregated. This capacity gap to develop and manage an overarching and integrated M&E system for the EAC region exists at the EAC Secretariat thus affecting the benefits that would accrue from an umbrella information collation source and tracking individual partner state performance. Strategic Objective: To strengthen strategic information generation and management for HIV and AIDS, TB, STIs response in the EAC region. Expected results Results Indicators Capacity of EAC Secretariat and partner states to Number of researches conducted conduct scientific research strengthened Strategic information on HIV/AIDS/TB and STI Number of partner states accessing response generated and disseminated information on HIV/AIDS/TB and STI to inform their programs Evidence based advocacy for the HIV/AIDS/TB and Number of partner states using research STI response enhanced findings to inform advocacy 19 Strategic actions Development of a common HIV, STIs and TB research agenda: The EAC Secretariat will support development of a common research agenda to address key regional specific HIV, STIs and TB knowledge. It will further ensure that research is prioritized towards relevant areas of importance to the EAC member states in terms of influencing policies and programs. This will support the processes of sourcing and allocation of resources for research. Research coordination: The EAC Secretariat will facilitate and coordinate scientific research in regional studies to establish the burden of HIV/AIDS/TB and STI as well as exchange of new information within the region. It will further identify, document, disseminate and facilitate replication of best practices in HIV/AIDS/TB and STI programming, legislation and policy development and implementation. The EAC secretariat will design mechanism for promoting the use of regionally generated evidence to guide change in for example treatment guidelines through building its capacity and that of the partner states. A regional think tank will be put in place to act as a platform for fostering debates and knowledge sharing based on research findings. The EAC Secretariat will have the responsibility of collating information and packaging it for use via different avenues appropriate to the current technological era. Information exchange: The EAC Secretariat will support exchange visits to facilitate information exchange among partner states. It will further create a platform where on a regular basis partner states will converge to share state of the art developments in the HIV/AIDS/TB and STI response. Where possible, a journal for publishing research findings will be set up to provide a credible source of scientific information on the HIV/AIDS/TB and STI response in the region in addition to scientific conferences to share key research finding and revitalizing the think tank concept. Monitoring and evaluation: The EAC Secretariat will strengthen its M&E system in order to generate information which will guide programming through sharing of best practices and facilitating harmonized performance tracking. The individual partner state M&E systems will act as building blocks where the Secretariat will be the overall collection base for performance monitoring and evaluation. The Secretariat will set performance benchmarks where partner states will be gauged and the high performer will be used as learning fora for others. The Secretariat will further revitalize its M&E system to match with the challenges that go with a regional level performance tracking requirements. Capacity building in research and knowledge management: The EAC Secretariat will support capacity building efforts for partner states in research and knowledge management. It will further build its own capacity in the same area as well through borrowing expertise from the respective partner countries and working with other international research institutions. 20 Chapter Four: FRAMEWORK FOR IMPLEMENATION 4.1 Institutional arrangements 4.1.1 Organizational Strategies The foundation for delivering on the EAC HIV/AIDS/TB/STI strategic intents will be the “wheel and hub” model which will be used to operationalize the strategic plan. The different components of the model will provide mutually reinforcing interventions that rationalizes efforts to strengthen EAC Secretariat HIV/AIDS/TB/STI response in the region. Review of EAC Secretariat structure and policies: The EAC Secretariat will be required to review its organizational structure and institutional policies in order to have a robust system which will translate the strategic intents into tangible results that are measurable and commensurate with resource investment. Key among policies for consideration will be the human resources management arrangement. This will require identification of vital positions for filling in addition to review of performance contracting arrangements. Alignment with partner state operational plans: This strategic plan will act as a framework to guide EAC Secretariat in the HIV/AIDS/TB and STI response in the region. However, the Secretariat will take into account the individual partners country specific needs in line with the political commitments of the EAC. To this end, all interventions on HIV/AIDS/TB and STIs will be grounded on the partner states needs that are transboundary in nature. The EAC Secretariat will therefore adopt a progressive realignment of its interventions over the next five years as it takes into account the changes in context. Gender mainstreaming and targeting of the key and mobile populations: This strategic plan recognizes the central role gender issues play in the HIV/AIDS/TB and STI response. The EAC Secretariat integrate gender concerns into the design, implementation, monitoring and evaluation of operations, policies, plans, programmes, activities and projects, at all levels. This will include, but not be limited to integrating gender responsive indicators in its M&E framework and plan. 4.1.2 Roles and Responsibilities of Stakeholders Xx Networking and Partnership: The successful implementation of the strategic plan will require strengthening the capacity of EAC Secretariat to effectively carry out its responsibilities. Linkages with RECs, NACs, CSOs and partners states will be vital. This will call for improving internal and external communication channels and strategic information sharing. EAC Secretariat will further communicate this strategic plan and clarify on the roles and responsibilities of the partner states as one of the measures of enhancing ownership of the plan. 4.1.3 Coordination of strategic plan implementation Governance The EAC Secretariat 4.1.4 Communicating the plan Xx 21 4.2 Monitoring and Evaluation Monitoring, evaluation and reviews: On annual basis, the EAC Secretariat will develop an operational plan which will be synchronized with those of the partner countries. At the end of each year, a review will be carried out to establish progress of implementation and address changes in context. Periodical evaluations i.e. at mid-term to provide opportunities for adjustments and end-term to assess the extent of realization of expected outcomes and impact. Results oriented approach: The EAC Secretariat will be accountable for realizing the results set forth in this strategic plan. Staff contractual arrangements will be target to generation of specific results under this strategic plan and their performance will be routinely reviewed against mutually agreed upon targets. The indicators set against each of the results will be the basis for performance measurement. The logical framework annexed to this strategy provides the overall results based and monitoring and evaluation arrangement for this strategic plan. 4.3 Funding, Sustainability and Risk Management 4.3.1 Funding the Strategy Resource allocative efficiency: The “wheel and hub” model will provide guidance in resource allocation. The resource allocation modalities for programmatic interventions will be based on strategic areas that generate optimal results for this strategic plan. In addition, the EAC Secretariat will strengthen its in house quality assurance and M&E functions; review and improve the existing value for money audits. Cost containment will be adapted with regard to ensuring that management costs do not overshadow programmatic costs. Funding the strategic plan: At the core, this strategic plan will be funded largely from contributions by partner states. Traditionally, partner states make annual contributions from which the health sector under which the HIV/AIDS/TB and STI program is funded. Experience has shown that the share of the EAC budget allocated to health has not grown in tandem with the programmatic needs. The illusion that the health sector at the EAC Secretariat receives a lot of funding from development partners has continued to undermine the scope and scale of services. As a mitigation measure, the HIV/AIDS/TB and STI program at the EAC Secretariat will mobilize additional resources from development partners to supplement the internal efforts. Resource requirements Table 2: Financial outlay Sources of funds 4.3.2 Sustainability Plan Sustainability plan: The EAC Secretariat will adopt the following measures to sustain its strategic intents. Institutional sustainability will focus on the relevance of existing systems, policies, procedures and guidelines through periodical reviews. This will ensure that they address emerging needs, challenges and lessons learnt. Specifically, the following will be reviewed annually: Strategic Plan; Operational Work plans; Organizational Structure; Administrative and Financial Management systems; and Human Resource Management policies and procedures; and the M&E system. For all this to work out, it will require high-level commitment by the leadership of the EAC. Programme sustainability will require expanding into new interventions to address key and mobile population through innovative methods for 22 service delivery. It will further require application of evidence-based approach across all strategies through operational research and managing information for influencing the development agenda in the HIV/AIDS/TB and STI response. Financial sustainability will entail diversification of funding sources, instituting cost containment measures as well as strengthening allocative efficiency. 4.3.3 Risk Management Plan Risk assessment and mitigation plan: In developing this strategic plan, critical assumptions which are the conditions that would be necessary for production of the desired results and the corresponding performance indicators were made. One key element of risk management is the diversification of the funding base. The EAC HIV/AIDS/TB and STI Programme has identified areas for expanding its scope of interventions but remains heavily dependent on a limited pool of donor and core funding from the contributions made by partner states. This sets a stage for more efforts to identify other funding sources to meet its strategic imperatives. A detailed risk analysis and mitigation plan is hereto attached. (We shall have to discuss the perceived risks and mitigation measures with the Secretariat). 23 Appendices Appendix 1: The logical framework matrix Narrative summary Performance measurement (Indicators) Means of verification Assumptions Goal: Reduced incidence of HIV, TB and STIs infection in the East African region in order to secure sustained socio- economic development Impact Improved welfare of the EAC population Reduction in new HIV, TB and STIs infections in the East Annual review reports, Regional evaluations, African region surveillance and research reports Key Result Area 1 - A committed and proactive regional and national leadership. Strategic Objective 1: To scale up regional and national leadership involvement, commitment and ownership for sustainability of HIV and AIDS response Outcomes Increased commitment among leaders of Number of protocols on HIV/AID, TB and STI response partner states in HIV/AID, TB and STI signed response Amount o resources committed to the HIV/AID, TB and STI response Increase domestic financing by establishing a Regional fund for HIV, AIDS and TB established Regional Fund for HIV, AIDS and TB and Partner States also progressively increase their respective domestic budget for HIV and AIDS interventions, and health in general to 15% of national budget in line with the Abuja Declaration of 2001. Coordination and partnership of HIV/AIDS, Guidelines for HIV/AID, TB and STI response developed TB and STI strengthened and disseminated Awareness and advocacy on HIV/AIDS, TB EAC HIV/AID, TB and STI advocacy strategy developed and STI strengthened Number of regional advocacy events conducted Increased effort in mobilization of internal Proportion of the strategic plan budget funded and external resources for HIV/AIDS, TB Amount of money mobilized from traditional and nonand STI strengthened traditional sources Mainstreaming, joint accountability and Number of reports compiled and shared reporting on HIV/AIDS, TB and STI strengthened Outputs Improve the legal and policy environment Number of policies that impact on MARPS developed 24 Narrative summary Performance measurement (Indicators) Means of verification Assumptions that discriminate and/or impact on the rights MARPs Advocate for harmonization and/or Number of laws and policies harmonized/amended amendment of existing laws and policies that have been identified to affect the regional response to HIV/AIDS Promote stewardship in the response by Guidelines for harmonized response developed facilitating partner states in leading the response in areas where they have a comparative advantage. Strengthen coordination and partnership Dissemination events for the strategic plan conducted among leaders in government, civil society, private sector, religious and cultural institutions in the region in supporting the implementation of this strategic plan Strengthen regional network of associations Number of regional coordination events involving CS and and/organizations on AIDS for improving private sector conducted coordination and involvement of civil society and private sector in the response to HIV and AIDS epidemic in the region Develop a minimum set of standard Reporting guidelines for the strategic plan developed indicators, guidelines and tools/format for reporting on the implementation of EAC strategic plans by partner states and the secretariat Generate and disseminate strategic Number of information packs on health, HIV, AIDS and TB information and messages to support various in the region disseminated high profile leaders’ advocacy efforts on health, HIV, AIDS and TB in the region Ensure that HIV and AIDS is mainstreamed Guidelines for health, HIV, AIDS and TB mainstreaming in in EAC programmes and policies and the region developed resources mobilized to support the same Ensure that programmes, protocols and Number of programmes, protocols and policies and laws policies and laws that relate to regional implemented and monitored at regional and national levels response to HIV and AIDS are signed, implemented and monitored at regional and national levels Key Result Area 2 - Scale up accessibility, affordability and availability of HIV/AIDS, STIs and TB Services in the region Strategic Objective: To facilitate the adoption, harmonization and implementation of international and regional protocols, guidelines, policies and 25 Narrative summary strategies Outcomes Harmonized management of HIV, STIs and TB in EAC Strengthened reference laboratory capacity in EAC Performance measurement (Indicators) Number of minimum standards for the management of HIV, STI & TB ratified and adopted by EAC member states Minimum SOPs for reference laboratories ratified and adopted by EAC member states Number of regional reference laboratory meeting the minimum SOPs Means of verification Assumptions Annual review reports, Regional evaluations Outputs Standardized HIV, STIs and TB Number of harmonized policies and management Annual review reports, management in the EAC region quarterly reports guidelines developed Common Pharmaceutical Number of harmonized Pharmaceutical laws/Policies/standards legal frameworks for laws/Policies/standards legal frameworks for the EAC the EAC region region developed Strengthened regional reference laboratory Functional regional reference laboratory capacity in place Annual review reports, quarterly reports capacity Availability of drugs and medical supplies Pooled bulk procurement systems developed and improved implemented Key Result Area 3 - Evidence based policies and guidelines are in place to inform the regional HIV, STIs & TB interventions Strategic Objective 3: To improve the development, design, management, implementation and sustainability of HIV, STI &TB responses at national and regional level Outcomes A coordinated EAC disease surveillance Minimum standards for HIV, STI & TB disease Annual review reports, system surveillance system ratified and adopted by EAC Regional evaluations, surveillance and member states Surveillance system for for HIV, STI & TB in the EAC research reports region synchronized Outputs Functional regional surveillance system Number of regional surveillance reports generated and Annual review reports, quarterly reports disseminated Key Result Area 4 - Regional programmes targeting mobile and key population in the EAC Region. Strategic Objective 4: To strengthen capacities of NACs and CSOs to develop and implement regional programmes targeting mobile and key populations in the EAC Region. Outcomes Increased availability of integrated services Number of service points for mobile and key populations for mobile and key populations in the partner states Conducive legislative regimes for sexual Number of partner states with policies and programs that Annual review reports, 26 Narrative summary minorities Harmonized programs for mobile and key populations Capacities of NACs and CSOs in key and mobile population programming enhanced Outputs Meaningful involvement of PLHIV and Key populations Sexual and reproductive health issues integrated into HIV/AIDS/STI and TB interventions Legal environment for MARPs improved Performance measurement (Indicators) promote access to services by sexual minorities Number of partner states adopting EAC guidelines for mobile and key populations’ programming Number of partner states and CSOs providing mobile and key populations’ specific interventions Means of verification Regional evaluations, surveillance and research reports Assumptions Guidelines for meaningful involvement of PLHIV for the EAC region developed and disseminated Guidelines for integration of sexual and reproductive Annual review reports, health issues into HIV/AIDS/STI and TB interventions quarterly reports developed and disseminated Number of partner states with legislation supporting access to services by MARPS Coordination with NACs and CSOs Guidelines for coordination of NACs and CSOs in the enhanced EAC region developed and disseminated Capacities for HIV/AIDS/STI and TB Number of capacity building interventions for programming improved HIV/AIDS/STI and TB conducted Key Result Area 5: Research and knowledge management Strategic Objective 5: To strengthen strategic information generation and management for HIV and AIDS, TB, STIs response in the EAC region. Outcomes Capacity of EAC Secretariat and partner Number of researches conducted states to conduct scientific research strengthened Annual review reports, Strategic information on HIV/AIDS/TB and Number of partner states accessing information on Regional evaluations, surveillance and STI response generated and disseminated HIV/AIDS/TB and STI to inform their programs Evidence based advocacy for the Number of partner states using research findings to inform research reports HIV/AIDS/TB and STI response enhanced advocacy Outputs Harmonized HIV, STIs and TB research in Common HIV, STIs and TB research agenda developed the EAC region Coordinated HIV, STIs and TB research Coordination guidelines for HIV, STIs and TB research Annual review reports, quarterly reports developed Information exchange mechanisms Number of information exchange fora conducted developed Monitoring and evaluation of HIV, STIs and A functional regional M&E system in place TB developed Capacity building in research and knowledge Number of partner states supported to implement their management enhanced research agenda 27 Appendix 2: Annual operational plan 2015/16 28 Appendix 3: Risk analysis and mitigation plan High Impact Medium Impact Low Probability Medium Probability High Probability Low Impact 29
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