THE STATE AND HIV/AIDS CONTROL IN : A STUDY OF STATE AGENCY FOR THE CONTROL OF AIDS (ENSACA)

BY ANIAGOLU, JOSEPHINE N. REG. NO: PG/M.Sc/12/61392

DEPARTMENT OF PUBLIC ADMINISTRATION AND LOCAL GOVERNMENT, FACULTY OF THE SOCIAL SCIENCES UNIVERSITY OF NIGERIA,

NOVEMBER, 2013

TITLE PAGE

THE STATE AND HIV/AIDS CONTROL IN NIGERIA: A STUDY OF AGENCY FOR THE CONTROL OF AIDS (ENSACA)

BY: ANIAGOLU, JOSEPHINE N. REG. NO. PG/M.SC/12/61392 .

A PROJECT SUBMITTED TO THE DEPARTMENT OF PUBLIC ADMINISTRATION AND LOCAL GOVERNMENT. FACULTY OF SOCIAL SCIENCES, UNIVERSITY OF NIGERIA, NSUKKA (UNN) IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE AWARD OF MASTER OF SCIENCE (M.SC) DEGREE IN PUBLIC ADMINISTRATION.

SUPERVISOR: PROF. C. OFUEBE

NOVEMBER, 2013.

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CERTIFICATION

This is to certify that Aniagolu, Josephine N , a postgraduate student of the Department of Public Administration and Local Government, University of Nigeria, Nsukka and with Reg. No. PG/M.SC/12/61392 has satisfactorily completed the requirements for the award of the degree of Master of Science (M.Sc) in Public Administration (Human Resources Management). The work embodied in this thesis is original and has not been submitted in part or full for any degree of this or any other University.

Aniagolu, Josephine N. ………………. ………………. (Researcher) Sign Date

Prof. C. Ofuebe, …………… …………….. (Supervisor) Sign Date

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APPROVAL PAGE

This work has been approved for the Department of Public Administration and Local Government , University of Nigeria, Nsukka.

By

Prof. C. Ofuebe ……………….. ………………. (Supervisor) Sign Date

Dr. (Mrs) S.UAgu ……………… ……………… (Head of Department) Sign Date

PROF. C.O.T. Ugwu ……………… …………….. (Dean, Faculty of Soc. Sc.) Sign Date

…………………………. ………………. …………… (External Examiner) Sign Date.

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DEDICATION

This work is dedicated to the one who gives me life, protects me, provides for me, the one who cherishes me to the point of dying to save me - my Lord Jesus Christ.

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ACKNOWLEDGEMENT

I wish to thank the Almighty God who gave me the capacity, acumen, wherewithal and good health to venture into and complete this academic pursuit. May all the glory go to His holy name.

Special thanks to my Project Supervisor, Professor ChikelueOfuebe for his patience in supervising the work and encouraging me to strive for excellence. I wish to acknowledge the Head of Department Dr. (Mrs) S.U. Agu and other Lecturers in the Department of Public Administration and Local Government in the name of Professor F.C. Okoli, Prof. R.C. Onah, Prof. Fab. O. Onah, Prof. C. Oguonu, Dr.Agalamanyi, Dr. (Mrs) M.A.O Obi, Dr. B.A. Amujiri and Dr.Ikeanyifor all the knowledge they imparted to me which has made me a better person qualitatively.

I acknowledge my brother and his wife, Dr. & Mrs. Celestine Aniagolu who supported me financially in this study. I wish to thank my Executive Secretary, Dr. Edith Okolo who is also a Special Adviser to the Governor on Health, for understanding and permitting me to study and deliver on my assignments at the same time. Hearty thanks to my colleagues at work especially Mrs. Franca Nwokolo, Mrs.AmakaOkeke, Mr.EmekaOkoli, Mrs.ObiomaUgwu, Mrs.DorathyEzeokeagu, Mrs. Monica Bebia, ChidinmaUkoha, and Mrs. Patty Ugwu who were resource persons and provided me with the raw data needed for this research.

My classmates were wonderful, especially UgwuibeAmaechi, AgboOluchi, the class representative(JideObaru) and others who fed me with the information needed, since I was commuting from Enugu to Nsukka for this study. May God bless you all.

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TABLE OF CONTENTS

Title Page ------i Certification ------ii Approval Page ------iii Dedication ------iv Acknowledgement ------v Table of Contents ------vi List of Tables ------viii List of Figures and Charts ------ix List of Acronyms and Abbreviations ------x Abstract ------xiii CHAPTER ONE: INTRODUCTION

1.1 Background to the Study ------1 1.2 Statement of the Problem ------3 1.3 Objectives of the Study ------5 1.4 Significance of the Study ------5 1.5 Scope and Limitations of the Study: ------6

CHAPTER TWO: LITERATURE REVIEW 2.1 Introduction: ------8 2.1.1 Country Profile ------9 2.1.2 Population ------9 2.1.3 Administration ------9 2.1.4 Epidemiology of HIV and AIDS ------10 2.1.5 Knowledge, Attitudes And Behaviours ------12 2.1.6 National Response to HIV/AIDS ------12 2.1.7 HIV/AIDS Program Development Project (HPDP – 2) - - - - 15 2.1.8 Achievements of HPDP-1 ------15 2.1.9 National Strategic Framework: ------16 2.1.10 National Economic Empowerment and Development - - - - 17 2.1.11 Linkage among NSF, NEEDS, MDG2 & HPDP-2 Goal - - - 17 2.1.12 State Response to HIV/AIDS: ------18 2.1.13 Stakeholders in the State Response ------19 2.1.14 Funding Sources: ------19 2.1.15 Number of FunctionalHiv/Aids Sites: ------19 2.1.16 Gap in Literature ------20 2.2 Hypothesis: ------20 2.3 Operationalization of Key Concepts: ------21 2.4 Methodology ------22 2.4.1 Theoretical Framework: ------21 2.4.2 Research Design: ------22 2.4.3 Method of Data Collection: ------22 2.4.3.1Population of the Study ------23 2.4.3.2 Sampling Technique: ------24 2.4.3.3 Sources of Data Collection ------25

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2.4.3.4 Tests of Validity and Reliability of Research Instruments - - - 26 2.4.3.5 Method of Data Analysis: ------27

CHAPTER THREE: THE STUDY AREA/GENERAL INFORMATION 3.1 Study Area: ------28 3.2 Enugu State Agency for the Control of HIV/AIDS (ENSACA): - - 29 3.2.1 The Principle of “THREE ONES”: ------30 3.2.2 Coordinating Authority at the State Level - - - - - 32 3.2.3 Functions of SACA ------32 3.2.4 Functions and Composition of the Governing Board Of SACA - - 33 3.2.5 Structure and Functions of the Departments Within SACA - - - 34 3.3 Enugu State HIV/AIDS Epidemiology ------35 3.4 Basic Facts About HIV/AIDS ------36

CHAPTER FOUR: DATA PRESENTATION, ANALYSIS AND FINDINGS

4.0 Data Presentation ------38 4.1 Analysis and Interpretation of Research Questions - - - - 40 4.1.1 Research Question 1 ------40 4.1.2 Research Question 2 ------41 4.1.3 Research Question 3 ------43 4.2 Testing of Hypotheses ------56 4.2.1 Testing Hypothesis I ------56 4.2.2 Testing Hypothesis 2 ------58 4.3 National Harmonized Organisational Capacity - - - - - 59 4.3.1 ENSACA NHOCAT Dashboard ------60

CHAPTER FIVE: SUMMARY, CONCLUSION AND RECOMMENDATIONS

5.1 Summary ------64 5.2 Conclusion ------65 5.3 Recommendations ------66 References Appendices Appendix A Appendix B

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LIST OF TABLES

TABLE 2.1: Distribution of HTC and ART Centres by LGA in Enugu State - - 20

TABLE 2.4.3.1 Population Distribution Table - - - - - 24

TABLE 2.4.3.2 Sample Size Distribution ------24

TABLE 4.1.1: To what extent do you agree to the assertion that the provision of financial, human and infrastructural resources by the State has positive impact on the control of HIV/AIDS in Enugu State? - - - 40

TABLE 4.1.2: To what extent do you agree to the assertion that Enugu State Agency for the Control of AIDS (ENSACA) has the capacity to coordinatate the HIV/AIDS response programmes in Enugu State? - - - - - 41

TABLE 4.1.3: Factors that should be put in place to provide the way forward in the response to HIV/AIDS in Enugu State ------44

TABLE 4.1.4: Showing Factors that impact positively on the control of HIV/AIDS - 49

TABLE 4.1.6: Factors Challenging The Response To Hiv/Aids Response In The State - - 53

TABLE 4.1.7:Possible Suggestions to ENSACA towards the control of the Scourge of HIV/AIDS in Enugu State - - - - - 55

TABLE 4.3.4:Showing Health Sector HIV Data for the Year 2013 - - - 62

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LIST OF FIGURES

Fig 1 . HIV PREVALENCE TREND IN NIGERIA 1991-2010 - - - - 3 Fig. 2: HIV PREVALENCE MAP NIGERIA: ------12

Fig. 3: MAP OF ENUGU STATE SHOWING 17 LGAS - - - - - 28 Fig. 5: TRENDS IN ENUGU STATE HIV SERO PREVALENCE RATES FROM 1991– 2010 ------35

BAR CHART 4.1.1 Showing Respondents perception towards the provision of financial, human and infrastructural resources by the State having positive impact on the Control of HIV/AIDS. ------41

PIE CHART 4.1.2 : Showing Respondents' perception towards Enugu State Agency 's (ENSACA) Capacity for the Control of AIDS programmes in Enugu State ------43

BAR CHART 4.1.3 :Showing Distribution of Factors That Should Be Put In Place To Provide The Way Forward In The Response To Hiv/Aids In Enugu State - 50

BAR CHART 4.1.4: Showing Responses on Suggested Factors that should be put in place to improve ensaca’s capacity for the response - - - 51

BAR CHART 4.1.5: Showing Distribution of Factors That Impact Positively on the Control of HIV/AIDS ------52

BAR CHART 4.1.6 Showing Challenges Hindering ENSACA from delivering its Mandate 54

BAR CHART 4.2.1: Showing The Distribution Of Repondents On Whether The Provision Of Financial, Human And Infrastructural Resources By The State Has A Positive Impact On The Control OfHiv/AIDS In Enugu State -57

BAR CHART 4.2.2: Showing The Distribution Of Respondents On Whether Ensaca Has The Capacity To Coordinate The HIV/AIDS Response Programmes In The State? ------59

BAR CHART 4.3.2: Representing ENSACA’s NHOCAT SCORE - - - 61

BAR CHART 4.3.4: Showing the Health Sector HIV/AIDS Data For 2013 - - 63

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ACRONYMS/ABBREVIATIONS

AIDS ACQUIRED IMMUNE DEFICIENCY SYNDROME

ANC ANTE NATAL CLINIC

APIN AIDS PREVENTION INITIATIVE NIGERIA

ART ANTIRETROVIRAL THERAPY

BCC BEHAVIOURAL CHANGE COMMUNICATION

BSS BEHAVIOURAL SURVEILLANCE SURVEY

CBOs COMMUNITY-BASED ORGANIZATION

CCCRN CENTRE FOR CLINICAL CASE & RESEARCH NIGERIA

CPS COUNTRY PARTNERSHIP STRATEGY

CRS CATHOLIC RELIEF SERVICES

CSOs CIVIL SOCIETY ORGANIZATIONS

DFID UNITED KINGDOM DEPARTMENT FOR INTERNATIONAL DEPARTMENT

DHBs DISTRICT HEALTH AUTHORITIES

DHS DISTRICT HEALTH SYSTEM

DPs DEVELOPMENT PARTNERS

ECEWS EXCELLENCE COMMUNITY EDUCATIONS WELFARE SCHEME

ENR ENHANCING NIGERIA’S RESPONSE TO HIV

ENSACA ENUGU STATE AGENCY FOR THE CONTROL OF AIDS

FBOs FAITH-BASED ORGANIZATION

FCT FEDERAL CAPITAL TERRITORY

FMOH FEDERAL MINISTRY OF HEALTH

FSW FEMALE SEX WORKERS

GFATM GLOBAL FUND TO FIGHT HIV/AIDS, TUBERCLOSIS AND MALARIA

GHO GLOBAL HEALTH OBSERVATORY

GoN GOVERNMENT OF NIGERIA

HCT HIV COUNSELING AND TESTING

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HCW HEALTH CARE WORKERS

HEAP HIV/AIDS EMERGENCY ACTION PLAN

HIV HUMAN IMMUNO-DEFICIENCY VIRUS

HPDP-2 HIV/AIDS PROGRAMME DEVELOPMENT PROJECT 2

IBSS INTEGRATED BIO-BEHAVIOURAL SURVEILLANCE SURVEY

IDUs INJECTING DRUG USERS

JSI JOHN-SNOW INTERNATIONAL

LACAs LOCAL ACTION COMMITTEE ON AIDS

LEEDS LOCAL ECONOMIC EMPOWERMENT AND DEVELOPMENT STRATEGY

MARPs MOST-AT-RISK-POPULATIONS

M&E MONITORING AND EVALUATION

MOT MODE OF TRANSMISSION STUDY

MSM MEN WHO HAVE SEX WITH MEN

NACA NATIONAL AGENCY FOR THE CONTROL OF AIDS

NARHS NATIONAL HIV/AIDS AND REPRODUCTIVE HEALTH SURVEY

NC NORTH CENTRAL

NDHS NATIONAL DEMOGRAPHIC HEALTH SURVEY

NE NORTH EAST

NEACA NATIONAL EXPERT ADVISORY COMMITTEE ON AIDS

NEC NATIONAL ECONOMIC COUNCIL

NEEDS NATIONAL ECONOMIC EMPOWERMENT AND DEVELOPMENT STRATEGY

NGOs NON GOVERNMENTAL ORGANIZATIONS

NMA NIGERIAN MEDICAL ASSOCIATION

NNRIMS NIGERIAN NATIONAL RESPONSE MANAGEMENT INFORMATION SYSTEM

NSF NATIONAL STRATEGIC FRAMEWORK NW NORTH WEST

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PCA PRESIDENTIAL COUNCIL ON AIDS PCRP PRESIDENT’S COMPREHENSIVE RESPONSE PLAN PEPFAR PRESIDENT’S EMERGENCY PLAN FOR AIDS RELIEF PERP PRESIDENT’S EMERGENCY RESPONSE PLAN PIM PROJECT IMPLEMENTATION MANNUAL PLWA PEOPLE LIVING WITH AIDS PLWHA PEOPLE LIVING WITH HIV AND AIDS PMTCT PREVENTION OF MOTHER-TO-CHILD-TRANSMISSION PPFN PLANNED PARENTHOOD FEDERATION OF NIGERIA PWD PEOPLE WITH DISABILITIES SACA STATE AGENCY FOR THE CONTROL OF AIDS SASCP STATE AIDS/STD CONTROL PROGRAMME SE SOUTH EAST SEEDS STATE ECONOMIC EMPOWERMENT AND DEVELOPMENT STRATEGY SFH SOCIETY FOR FAMILY HEALTH SOP STANDARD OPERATIONAL PROCEDURES SS SOUTH SOUTH STI SEXUALLY TRANSMITTED DISEASES SW SOUTH WEST TWGs TECHNICAL WORKING GROUP UNAIDS JOINT UNITED NATIONS ON HIV/AIDS UNFPA UNITED NATIONS POPULATION FUND UNICEF UNITED NATIONS INTERNATIONAL CHILDREN EDUCATION FUND USG UNITED STATES GOVERNMENT VC VULNERABLE CHILDREN WHO WORLD HEALTH ORGANIZATION

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ABSTRACT

According to Federal Ministry of Health’s Sentinel Survey of 2010, the prevalence rate of HIV/AIDS in Enugu State is 5.1% which is above the national rate of 4.1%. This study focused on Enugu State Agency for the Control of AIDS (ENSACA), the organization mandated with the multi-sector response to HIV/AIDS in Enugu State; to ascertain whether it has the capacity to deliver on its mandate. Methodologically, the study used instruments like questionnaires and the National Harmonized Organizational Capacity Assessment Tool (NHOCAT) a tool used nationally to assess organizations’ capacity in the HIV/AIDS response, to assess ENSACA’s capacity to deliver the response in the State. The results confirmed that ENSACA has the capacity to deal with the response, though there are still room for improvement. This study also delved into finding out whether the provision of financial, human and infrastructural resources by the State, has any impact on the control of HIV/AIDS in Enugu State. The results from the Binomial Statistical test carried out, showed that there is a 99% assurance that the provision of financial, human and infrastructural resources by the State impacts positively on the control of HIV/AIDS in the State. The study recommended that the following factors should be put in place to help in the response to HIV/AIDS in the State: capacity building of staff at all levels, more technical assistance and support from the government, more care and support to People Living with HIV/AIDS, proper Supply Chain of ART and other consumables, aggressive media hype for HCT & PMTCT, improving the HIV/AIDS database for monitoring and evaluation system, release of timely information to policy makers through Fact Sheets, qualitative and effective reporting at all levels, discipline and responsible dispatch of duties by staff at all levels, becoming a global stakeholder and reference point through website information, provision of sufficient vehicles, sensitization on the anti-discrimination and stigma law, developing proper referral systems and follow up of positive patients, provision of Mobile HCT Vans, transparency at all levels, proper motivation of staff for hard work, provision of more Comprehensive sites and the provision of office equipment and physical infrastructure for the response.

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CHAPTER ONE

INTRODUCTION

1.1 BACKGROUND TO THE STUDY:

According to Okoye [www.cokoye.com] the first two cases of HIV and AIDS in Nigeria were identified in 1985 and were reported at an international AIDS Conference in 1986. In 1987 the

Nigerian Health sector established the National AIDS Advisory Committee, which was shortly followed by the establishment of the National Expert Advisory Committee on AIDS

(NEACA).At first the Nigerian government was slow to respond to the increasing rates of HIV transmission and it was only in 1991 that the Federal Ministry of Health made their first attempt to assess the situation of HIV/AIDS in Nigeria. Global AIDS Response Progress

Report (GARPF 2012) reported that the results showed that around 1.8 percent of the population of Nigeria were infected with HIV. Subsequent surveillance reports revealed that during the 1990s HIV prevalence rose from 3.8 percent in 1983 to 5.4 per cent in 1999.

Following a peak of 5.8 per cent in 2001, HIV prevalence then declined steadily throughout the decade with 4.1 percent in 2010 as reported by the 2010 Sentinel Surveillance Survey.

During President Obasanjo’s regime in 1999, HIV prevention, treatment and care became one of the government’s primary concerns. The President’s Committee on AIDS and the National

Action Committee on AIDS (NACA) were created, and in 2001, the government set up a three- year HIV/AIDS Emergency Action Plan (HEAP). In the same year, Obasanjo hosted the organization of African Unity’s first African Summit on HIV/AIDS, Tuberculosis, and other

Related Infectious Diseases (Adeyi et al 2006 in Okoye[Internet]).In 2005 a new framework was developed covering the period from 2005 to 2009. Despite increased efforts to control the epidemic, by 2006 it was estimated that just 10 per cent of HIV – infected women and men were receiving antiretroviral therapy and only 7 per cent of pregnant women were receiving treatment to reduce the risk of mother-to-child transmission of HIV (UNAIDS 2008).

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In 2010 NACA launched its comprehensive National Strategic Framework to cover 2010 to

2015, which required an estimated #756 billion (around US $5billion) to implement (All Africa

2010, 30 th March).According to NACA (2009) some of the main aims included in the framework are to reach 80 per cent of sexually active adults and 80 per cent of Most-at-risk- populations (MARPS), with HIV counselling and testing by 2015, ensure 80 per cent of eligible children are receiving antiretroviral therapy (ART) by 2015, and to improve access to quality care and support services to at least 50 per cent of people living with HIV/AIDS by

2015.Despite being the largest oil producer in Africa and the 12 th largest in the world, (Official

Energy Statistics from the United States Government 2007), Nigeria is ranked 156 out of 187 on the United Nations Development Programme (UNDP 2011) Human Poverty Index. This poor development position has meant that Nigeria is faced with huge challenges in fighting its

HIV and AIDS epidemic.

As a consequence, the Federal Government in 2012 came up with the Presidential

Comprehensive Response Plan (PCRP). According to the President’s Comprehensive

Response Plan document (2012) “Nigeria carries the 2 nd highest burden of HIV globally. The prevalence of HIV in Nigeria as at 2010 was 4.1 per cent (PCRP 2012). Women and children constitute the largest percentage of those infected and affected in Nigeria. Analysis of the 2010 national HIV prevalence report shows that 58 per cent of People Living with HIV (PLHIV) population are women.The number of persons living with HIV (PLHIV) at the end of 2011 in

Nigeria was about 3.4 million (PCRP 2012). An estimated 388,864 became newly infected with HIV in 2011 and an estimated 217,148 people died from AIDS related causes in 2006. In addition, the number of persons requiring ART rose to about 1.66 million.Although the national median HIV prevalence has been reducing since 2002, other indices continue to worsen.”

According to the Standard Operational Manual of the National Agency for the control of AIDS

(NACA), “Nigeria’s response to HIV/AIDS has progressed from a health sector focus to multi-

2 faceted and multi-sectoral approach that cuts across the three tiers of government. Despite achievements towards control of HIV/AIDS, there still exist capacity gaps for effective planning, budgeting, coordination and delivery of HIV/AIDS relat monitoring and evaluation of the response most especially at the state and local government levels.”

Fig 1. HIV PREVALENCE TREND IN NIGERIA 1991

Source: Technical report on National HIV Sero Pr egnant Women Attending Antenatal Clinics in Nigeria.

1.2 STATEMENT OF THE PROBLEM:

The Global Health Observatory (GHO 2011), from AIDS-related causes worldwide is steadily decreasing from a peak of 2.3 million in 2005 to an estimated 1.7 million in 2011. AIDS

Africa, Sout h and South East Asia and Caribbean and has continued subsequently. Two signal developments have caused this decline: first, the increased availability of antiretroviral therapy, as well as care and support to people living with HIV, especially in Sub Sah fewer people newly infected with HIV since the peak in 1997.

The effects of antiretroviral therapy are especially evident in Sub people dying from AIDS related causes in Sub -Saharan Africa declined by 32% from 2005 to

2011, although the region still accounted for 70% of all the people dying from AIDS in 2011.

According to the President’s Comprehensive Response Plan (2012), Nigeria has pursued a vision to halt and reverse the HIV and AIDS epidemic in the country in line with global commitments.

With the valuable support of local and international partners, the country has seen the epidemic profile change significantly from a HIV prevalence rate of 5.8% in 2001 to 4.1% in 2010.

Nigeria has the 2 nd highest HIV burden in the world with 3.4 million people (PCRP 2012) estimated to be living with HIV in 2012. At the end of December 2012, only 491,021 HIV positive populations of 1.6 million were accessing ART (30% of national need). This exemplifies the scale of the service gaps and the urgent need to address them.

Attaining the status of a country with stable change in the incidence rate of HIV infection among adults 15-49 years old between 2001 and 2011 is a significant achievement, but the overall gaps in access to HIV/AIDS service remains a great challenge. Systemic reviews of the national response have identified key challenges which revolve around limited domestic financing of the response, weak coordination at national and state levels, inadequate State government contribution to resourcing the response; challenges with human resources for health, weak supply chain management systems, limited service delivery capacity and limited access to HIV services.

AIDS related deaths in Nigeria amount to about 220,000 annually and affects mostly the working age group of 15 – 59 years (PCRP 2012). This means that if the virus is not controlled on time, the working population will be reduced to the barest minimum and this will in turn affect production of goods and services, which will subsequently impact negatively on the economy.The urgency of the situation caught the attention of His Excellency Dr. GoodluckEbele Jonathan GCON GCFR, the President of the Federal Republic of Nigeria, who in demonstrating high level of commitment to the national response to HIV, requested the development of a comprehensive response plan to bridge existing gaps and establish the framework for achieving global targets by 2015.

The President’s Emergency Response Plan for HIV/AIDS in Nigeria (PERP 2013-2015) is a

4 response tool to the challenges facing the national response. It is designed with the mindset of addressing the challenges to HIV/AIDS response in Nigeria like provision of finances, Health

Centres, Human resources, infrastructure, consumables, capacity building of stakeholders etc. The

PERP framework will be cascaded down to the States and Local governments.

In addressing this topic the following research questions have been proposed:

i. Does the provision of financial, human and infrastructural resources by the State have

any impact on the control of HIV/AIDS in Enugu State?

ii. Has Enugu State Agency for the Control of AIDS (ENSACA) the capacity to

coordinate the HIV/AIDS response programmes in Enugu State?

iii. What are the factors that should be put in place to provide the way forward in the

response to HIV/AIDS in Enugu State?

1.3 OBJECTIVES OF THE STUDY:

The broad objective of this study is to find out the factors that impacts on the control of HIV/AIDS in the State, to assess the capacity of the coordinating body to control HIV/AIDS in the State and to find out what should be done to halt the spread of HIV/AIDS in the State.

The specific objectives of this study are :

i. To find out whether the provision of financial, human and infrastructural resources by

the State, has any impact on the control of HIV/AIDS in Enugu State.

ii. To assess the capacity ofEnugu State Agency for the Control of AIDS (ENSACA), to

coordinate the HIV/AIDS response in Enugu State.

iii. To ascertain those factors that should be put in place to move the response to

HIV/AIDS in Enugu State forward.

1.4 SIGNIFICANCE OF THE STUDY:

This study has a theoretical significance because it has added to the frontiers of knowledge as both scholars and students in the area of HIV/AIDS will as a result of this study advance their knowledge by having an insight into the subject from the administrative point of view. Hitherto,

5 materials on HIV/AIDS dwelt m ore on the clinical, preventive andcurative aspects of HIV/A IDS .

This study has an empirical importance as the findings and recommendations will be used by

ENSACA and its Stakeholders to improve on their service delivery on HIV/AIDS in the State.

In the light of the fact that HIV/AIDS pandemic is threatening to wipe out the working populations around the world, this study also has economic significance, as HIV/AIDS counselling and testing will help the working population know their HIV status and help the HIV/AIDS positive populations access their drugs and live positively and remain productive for the rest of their lives.

HIV/AIDS if well managed is not the worst killer; there are other diseases like cancers, diabetes and hypertension which kill much faster than HIV/AIDS.

The study also has ethical significance as it advocates abstinence from sex among the Youth as a way of avoiding HIV/AIDS and other sexually transmitted diseases. This study has social significance as discrimination and stigmatization of people living with HIV/AIDS was discouraged. Stigmatization and discrimination helps to propagate the virus as positive patients go underground and continue to perpetuate and spread the virus; whereas if they are accepted and respected, they will come out openly to declare their status and will be helped to access drugs and live positively and productively.

1.5 SCOPE AND LIMITATIONS OF THE STUDY :

The scope of this study is Enugu State and specifically Enugu State Agency for the Control of

AIDS (ENSACA) as it pertains to its coordinating and controlling of the multi sector response to

HIV & AIDS in Enugu State. The health sector response includes all the activities of the State

Ministry of Health, the State Health Board,Tertiary Health Facilities, District Hospitals,

Comprehensive Sites and Health Facilities in the State, while the non Health sector response includes the activities of Civil Society Organizations, Networks, Support Groups, and Faith-Based

Organisations.

The limitation of the study was the inability to study the activities of all the health sector and non health sector institutions in the State on HIV & AIDS. Another challenge encountered in the

6 process of this study wa s the difficulty in determining the HIV & AIDS resource gap in the State as the Enugu State Agency for the Control of AIDS (ENSACA) does not know the resource envelope and work plan of Implementing Partners due to the lack of a State Unified Operational

Plan (SUOP). However, the process to harmonize a state-wide work plan for HIV/AIDS intervention in 2014 has been kick started.

CHAPTER TWO

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LITERATURE REVIEW

2.1 INTRODUCTION:

This section will try to review the relevant literature on this subject under the following topics: Country profile and epidemiology of HIV and AIDS, Knowledge, attitudes and behaviours, the national response to HIV/AIDS, the National Strategic framework, the State response to HIV/AIDS, Stakeholders of HIV/AIDS response in the State, and funding sources for HIV/AIDS programme activities.

According to National HIV Sero-prevalence Sentinel Survey (2010), Nigeria reported her first

AIDS cases in 1986 and since then, the HIV and AIDS epidemics have continued to spread and attract due attention. In 1991, the country initiated a HIV sero-prevalence sentinel survey among the antenatal clinic attendees; the survey commenced with a few states and progressively expanded until all the states became involved by 1999. The Ante Natal Clinic

(ANC) biological survey conforms to the first generation surveillance system. It determines

HIV prevalence among the sentinel population at fairly regular and short intervals and it is used to track the trend and distribution of the HIV epidemic across the country. The HIV prevalence obtained from the ANC survey is used to estimate prevalence in the general population. The 2010 round of the ANC HIV sentinel survey is the ninth in the series in

Nigeria. In 2008, the survey included the simultaneous collection of data from the

HCT/PMTCT services of the participating sentinel sites for the purpose of comparison with the

ANC survey data. This exercise was maintained in 2010.

In line with the World Health Organization (WHO) guidelines for progress towards the second generation surveillance system, a Behavioural Surveillance Survey (BSS) was introduced in

2002; it expanded to an Integrated Bio- Behavioural Surveillance Survey (IBBSS) in 2007.

Similarly, a general population-based behavioural survey termed National HIV/AIDS and

Reproductive Health Survey (NARHS) was introduced in 2003. In order to generate general

8 direct population HIV prevalence, a biological component was incorporated into NARHS in

2007.

2.1.1 Country Profile

Nigeria lies within latitudes 4 o 1' and 13 o 9' North and longitudes 2 o 2' and 14 o 30' East. It is bordered in the north by Niger Republic; in the north east by the Republic of Chad; in the east by the Republic of Cameroun; in the west by the Republic of Benin and in the south by the

Atlantic Ocean. It has a total surface area of approximately 923,768 square kilometres making her the 15th largest country in Africa (ANC Sentinel Survey 2010).

Nigeria has a tropical climate with distinct wet and dry seasons associated with the movement of the two dominant winds—the rain-bearing south westerly winds and the cold, dry, and dusty north easterly winds commonly referred to as the Harmattan. The dry season occurs from

October to March with a spell of cool, dry, and dusty Harmattan wind felt in December and

January. The wet season occurs from April to September.

2.1.2 Population

Federal Republic of Nigeria Official Gazette (2007) reported that Nigeria remains the most populous country in Africa with a population of 140, 003,542 and a growth rate of 3.2%.

According to National Population Census (2006), approximately two-thirds of the population live in rural areas. Nigeria has a relatively young population with a median age of 17 years

(NDHS 2003); however, the population figures vary widely across the states, just like the terrain and land mass.

2.1.3 Administration

Nigeria became a political entity through the amalgamation of the Northern and Southern

Protectorates and the Lagos Colony by the British Empire colonial administration in 1914. The entity gained political independence in 1960 with three functioning regions (North, East and

West) and became a Republic in 1963. In 1967, 12 States were carved out from the three

Regions.

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Currently, Nigeria is a democratic Federal Republic consisting of 36 States and the Federal

Capital Territory (FCT). The States and the FCT are organized for political administration and arefurther divided into 774 Local Government Areas. They have also been grouped mainly on the basis ofgeographical proximity into six geo-political zones, namely North Central (NC),

North East (NE),North West (NW), South East (SE), South South (SS) and South West (SW).

The zones differ fromeach other in size, population, ecological characteristics, language, culture, settlement patterns,economic opportunities and historical background.

2.1.4 Epidemiology of HIV and AIDS

Globally, the pandemic of HIV and AIDS has continued to constitute serious health and socio economic challenges for more than two decades. In underdeveloped and developing countries, it has reversed many of the health and developmental gains over the past three decades as reflected by indices such as life expectancy at birth and infant mortality rate among others. The epidemic has also facilitated the re-emergence of disease conditions such as pulmonary tuberculosis and other opportunistic infections.

According to UNAIDS HIV epidemic update (2010), as at the end of 2009, about 33.3 million persons were estimated to be infected with HIV globally. Of these, 22.5 million (i.e. 68% of the global total) were in Sub-Saharan Africa, and about 2.98 million in Nigeria. Thus, Nigeria has the second highest number of people living with HIV in the world after South Africa.

Since the first case of AIDS in Nigeria was reported in 1986, the HIV and AIDS epidemics have continued to evolve. The first sentinel surveillance survey showed HIV prevalence rate of

1.8% in 1991. Subsequent sentinel surveys showed increasing prevalence rates of up to 5.8% in

2001 and then a decline to 4.4% in 2005. However, the 2008 prevalence of 4.6% showed a slight reversal in the downward trend, thereby generating some interest.The HIV epidemic, as monitored through prevalence rates, appears to show some consistencyin the national trend; however, there has been wide variation across the States and sites with a numberof consistent hot spots. HIV prevalence has consistently remained high in some States and low inothers.

10

While the prevalence has shown a consistent decline in some States, it has been fluctuating inothers. Since 2003, all the States in the country have had ageneralized epidemic.

Estimates from the 2008 ANC survey showed that 2.87 million persons were living with HIVin

Nigeria. The survey showed highest HIV prevalence among women aged 25-29 years

(5.6%)followed closely by those aged 30-34 years (4.9%). Also, the survey showed highest prevalenceamong women with only secondary level education (5.8%). NARHS survey(2007) showed an overall HIV prevalence of 3.6% (4.0% among females and 3.2% males). Among the high risk groups, female sex workers constitute an important reservoir of HIVinfection for continuous transmission to the general population. HIV prevalence among this group hasremained high and on the increase from 17.5% among brothel based Female Sex Workers

(FSW) in1991 through 22.5% in 1993 (FMOH high risk survey) to 37.4% in 2007 (IBBSS,

2007).

Fig. 2: HIV PREVALENCE MAP NIGERIA :

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2.1.5 KNOWLEDGE, ATTITUDES AND BEHAVIOURS

NARHS survey (2007) explained that AIDS cases are becoming very visible in Nigeria. About one out of every four persons in Nigeria had seen someone with HIV or known someone who died of AIDS. In addition, awareness of HIV and AIDS was generally very high (93.8%).

However, correct knowledge of all the routes of HIV transmission and two methods of prevention have remained low (54% and 52.5% respectively).

Furthermore, the use of condom in the last sex act was low (16%) despite the fact that sexual transmission is the predominant mode of HIV spread in Nigeria.

2.1.6 NATIONAL RESPONSETO HIV/AIDS

A national health sector-based response was established in 1986 as a result of the emergence of

HIV epidemic in the country with the Federal, State and LGA structures driving the response.

In 2000, an expanded national multisectoral response was put in place with the establishment12

12 of a Presidential Council on AIDS (PCA) and National Action Committee on AIDS (NACA) to drive the response.

State Action Committees on AIDS (SACA) and Local Government Action Committees on

AIDS (LACA) also came into operation. NACA and some of the SACA have since become statutory agencies in order to enhance their performance. Since then, prevention, treatment, care and support interventions have continued to expand impressively. These interventions are guided by the appropriate policies (e.g. National HIV/AIDS Policy), strategic plans (e.g. HIV and AIDS Emergency Action Plan - HEAP and National Strategic Framework - NSF) and guidelines (e.g. ART,PMTCT and HCT).

Currently, HIV Counselling and Testing (HCT) and Anti-Retroviral Therapy (ART) care are the rapidly expanding interventions. The multi-sectoral response has resulted in an improved resource mobilization and coordination of all the stakeholders (Public, Private, Civil Societies and Development Partners) through the application of the principle of “Three Ones” i.e. one national structure, one strategic plan and one monitoring and evaluation framework.

Prevention of Mother-to-Child Transmission (PMTCT) has equally been rapidly expanding through the effort of governmental and non-governmental organizations, and international partners.

The President’s Emergency Response Plan for HIV/AIDS in Nigeria (PERP), came on board in

2013 as the latest National response to HIV/AIDS and will run till 2015. PERP (2013) reported inter alia that Nigeria has pursued a vision to halt and reverse the HIV and AIDS epidemic in the country in line with several global commitments. With the valuable support of local and international partners, the country has seen the epidemic profile change significantly from the early days of the national response in 2002 to what we have today.

PERP (2013) posited that attaining the status of a country with stable change in the incidence rate of HIV infection among adults 15–49 years old, 2001–2011 is a significant achievement but the overall gaps in service access greatly overweigh this. This becomes all the more

13 important with wider reaching implications in the context that Nigeria has the second highest

HIV burden in the world with 3,459,363 people estimated to be living with HIV in 2012. With only 472,000 HIV positive persons out of an eligible population of 1,449,166 having access to

ART (33% of need) (PERP 2013), this exemplifies the scale of the gaps and the urgent need to address them. Systemic reviews of the national response have identified key challenges to revolve around limited domestic financing of the response, weak coordination at national and state levels, limited state government contribution to resourcing the response; challenges with human resources for health, weak supply systems; limited service delivery capacity and limited service access by the needing population.

The urgency of the situation has required the attention of His Excellency Dr GoodluckEbele

Jonathan the Executive President of the Federal Republic of Nigeria who in demonstrating high levels of commitment to the response, requested the development of an emergency response plan to quickly bridge existing gaps and lay framework for achieving global targets by 2015.

The President’s Emergency Response Plan for HIV/AIDS in Nigeria (PERP 2013-2015) is a response tool to the challenges facing the national response. It is designed with the mindset of addressing priority system and service delivery challenges to the HIV and AIDS response in

Nigeria.

The goal of the PERP is to accelerate the implementation of key interventions over a two year

period to bridge existing service access gaps, address key financial, system and coordination

challenges and promote greater responsibility for the HIV response at federal and State levels.

Specifically, the PERP plan aims to avail 40 million men and women aged 15 and older knowledge of their HIV status; put an additional 400,000 eligible adults and children on ART; provide ART for 80,000 HIV pregnant women for PMTCT, provide access to combination prevention services for 500,000 MARPS and 4 million young person’s and activate 500 new

PMTCT and 1000 ART service delivery points across the country.

Participation of the private sector, civil societies, bilateral (USG/PEPFAR, DFID) and multinational organizations, PLWAs and United Nation Agencies has continued to improve

14 over the years. In addition,more resources have been accessed from the governments, private enterprises, Global Fund to fight HIV/AIDS, Tuberculosis and Malaria (GFATM)) and

Development Partners.

2.1.7 HIV/AIDS PROGRAM DEVELOPMENT PROJECT (HPDP – 2)

According to the Project Implementation Manual (2009), the main goal of the Second

HIV/AIDS Program Development Project (HPDP-2) is to reduce the risk of HIV infections by scaling up prevention interventions and to increase access to and utilization of HIV counselling, testing, care and support services. This will assist Nigeria to build on the achievements recorded through the World Bank-funded HIV/AIDS Program Development

Project (HPDP-1) at all levels of the country’s administration and in all sectors. Project 1 became effective in April 2002. It supported Nigeria’s HIV/AIDS Emergency Action Plan

(HEAP) from 2001 to 2009. Project 2 has been divided into three components similar to

Project 1.

These are:

i) Expanding the Public Sector Response;

ii) Expanding the Civil and Private Sector Engagement and Response through the

HIV/ADS Fund (HAF); and

iii) Strengthening Mechanisms for Project Coordination and Management.

2.1.8 ACHIEVEMENTS OF HPDP-1

During the period 2001 to present, the National response to HIV/AIDS has expanded with increasing resources from the Federal Government of Nigeria, State Governments and thescale up of international development assistance through major funding agencies and partners.The

HPDP investment has contributed significantly to the evolution of institutions in Nigeria, atall levels of the HIV response, and thus has substantially strengthened Nigeria's capacity tomount a strong campaign against HIV/AIDS epidemic in the country.

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However, epidemiological surveys showed that much still needs to be done. Forinstance, sentinel survey revealed slight decline from the national average HIV prevalence ratefrom

5.8% in 2001, through 5.0% in 2003, to 4.4% in 2005 (Federal Ministry of Health 2006), yetthe prevalence rate is still technically too close to the brink of an exponential rise. Most of thoseinfected are in the economically active age group and 56% of them are women. World

Bank’sfurther support was thus required as contribution towards scaling up of the national response,through completion of implementation of the National Strategic Framework for

Action 2005 -2009 (NSF1); including preparation and implementation of NSF 2,

Implementation of theNational Prevention Plan, revised BCC Strategy and support the implementation of NNRIMSoperational plan (2006-2010). The indicative cost of HPDP 2 has been estimated at US$225.00 million.

2.1.9 NATIONAL STRATEGIC FRAMEWORK:

The project derives its overall policy context from the 1ST National Strategic Framework

(NSF 1) 2005 – 2009 . Also fundamental to the strategic context are the National Health Sector

Bill and the National Economic Council (NEC) resolution on political commitment and scaling up of multi sectoral response in the country. The document (NSF), which costed version was produced in 2007 has since its development in 2005 constituted the basis for HIV/AIDS control projects and programs by all stakeholders and support by Nigeria’s development partners.

Themain goal of the NSF 1 is to increase access to comprehensive gender sensitive prevention, care and treatment and support services to the general population, PLWA and orphans and vulnerable children by 50% in 2009 and mitigate HIV/AIDS; strengthen capacity at all levels for implementation, monitoring and evaluation of the HIV/AIDS response; and to improve the policy environment. HPDP-2 supported thedevelopment of the second National Strategic

Framework 2010-2015 (NSF 2) and States Strategic Plans. The State Strategic Plan (SSP) keyed into the National Strategic Plan (NSP).

2.1.10 National Economic Empowerment and Development

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The Nigerian government developed the National Economic Empowerment and Development

Strategy (NEEDS) in 2004 as a home-grown poverty reduction strategy paper. The

NEEDSrecognized HIV/AIDS as a crosscutting issue, with links to education, health, agriculture,defence, labour, and other sectors. It noted that if not adequately contained, the epidemic wouldprove to be the greatest single obstacle to reaching national poverty reduction and other targetsfor social and economic development. The overall goal of the NEEDS

HIV/AIDS policy is tocontrol the spread of HIV/AIDS in Nigeria, provide equitable care and support for those infectedwith HIV/AIDS, and mitigate its impact to the point where it is no longer of public health, social,or economic concern. The goal of HPDP-2 dovetails into the overall goal of the NEEDS HIVPolicy. The implementation of the project will contribute to creating an environment in which allNigerians will be able to live socially and economically productive lives free of the disease andits effects.

2.1.11 Linkage among NSF, NEEDS, MDG2 & HPDP-2 Goal

According to the Project Implementation Manual (2009), the goals of NSF 1, World Bank strategic agenda and the Country Partnership Strategy (CPS) on HIV/AIDS are related to one of the three pillars of Nigeria’s National Economic Empowerment and Development Strategy

(NEEDS), the corresponding State Economic Empowerment and Development Strategy

(SEEDS), the Local Economic Empowerment and Development Strategy (LEEDS); and the recently launched GoN’s Agenda for Development by year 2020. They collectively articulate

GoN’s key poverty reduction strategy, which were being implemented bythe three tiers of government though with varying degrees of success. The ultimate goals, as reflected in the

Proposed HPDP-2 are to contribute to measures for meeting the sixth Millennium Development

Goal (MDG), which is on Combating HIV/AIDS and other communicable diseases.

2.1.12 STATE RESPONSE TO HIV/AIDS:

The State response through Enugu State Agency for the Control of AIDS (ENSACA), keys into the National Strategic Framework (NSF) making use of the State Strategic Plan (SSP). It

17 also adopts the principle of the “Three Ones” i.e. one coordinating body in the State, one

Strategic Plan (SSP) and one monitoring and evaluation mechanism – DHIS.

The State response as well as the National response works within six thematic areas namely:

 Prevention  Treatment  Care and Support  Policy, Advocacy, Human Rights and Legal Issues  Institutional Architecture, Systems, Coordination and Resourcing  Monitoring and Evaluation Though ENSACA has no existing Board at the moment, but it has the following Technical

Working Groups (TWGs) to help it deliver on its mandate of coordinating the multi sector response to HIV/AIDS in the State.

i. Prevention TWG

ii. Gender, Advocacy and Policy TWG

iii. Strategic Knowledge Management TWG

iv. Resource Mobilization TWG

v. Prevention of Mother to Child Transmission (PMTCT) TWG

ENSACA has twenty-five personnel in its employment and has 4 departments namely:

i. Strategic Partnership and Coordination: responsible for coordinating

activities of the LACAs, CSOs, Private Sector and Development Partners and

for all the issues relating to advocacy, policy, plan and resource mobilization.

ii. Strategic Knowledge Management: responsible for all data collection and

management, monitoring, evaluation, research and knowledge management

issues.

iii. Programme: responsible for technical and programmatic issues relating to

Prevention, Treatment, Care and Support as well as coordinating the activities

of the Line Ministries and LACAs.

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iv. Finance and Administration: responsible for managing the finances of the

organization including the payroll, personnel, office management, procurement,

legal and general administration issues.

2.1.13 STAKEHOLDERS IN THE STATE RESPONSE

Working with ENSACA in the State response to HIV/AIDS are the following organisations:

i. People Living with HIV/AIDS (PLWHA) ii. Line Ministries iii. Development Partners iv. Civil Society Organisations (CSOs) v. Networks vi. Faith-Based Organisations (FBO) vii. Local Action Committee on AIDS (LACAs) viii. Community Based Organisations (CBOs) ix. Non Governmental Organisations (NGOs)

2.1.14 FUNDING SOURCES:

ENSACA carries out its HIV/AIDS intervention activities with World Bank fund and the corresponding State Counterpart fund. Other funding sources are through Implementing

Partners funded by DFID, Global Fund, USAID, PEPFAR, UNICEF, WHO or funds resourced internally from the Private Sector by the Resource Mobilization Unit.

2.1.15 NUMBER OF FUNCTIONAL HIV/AIDS SITES:

Enugu State has a total of 311Testing and Counselling Sites, including 21 Comprehensive Sites and 270 PMTCT Sites.

Table 2.1: Distribution of HTC and ART Centres by LGA in Enugu State

S/N LGA Total # of Total # of Total # Total # of Total # of ART PMTCT of HTC Intervention Sites Sites Sites 1. 0 14 14 28 14 2. 1 15 15 31 15 3. 4 11 11 26 11

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4. 3 10 11 24 11 5. 2 8 10 20 10 6. 0 37 37 74 37 7. 0 17 19 36 19 8. 1 30 31 62 31 9. 0 5 21 26 21 10. 1 30 31 62 31 11. 0 7 7 14 7 12. 2 16 16 34 16 13. Nsukka 4 17 18 39 18 14. 2 15 15 32 15 15. 0 13 28 41 28 16. Udi 1 20 22 43 22 17. UzoUwani 0 5 5 10 5 TOTAL 21 270 311 602 311 Source: ENSACA Strategic Knowledge/Monitoring & Evaluation Department .

2.1.16 GAP IN LITERATURE:

HIV/AIDS phenomenon came into global focus in the 80s’ and since then literature on the topic has been scanty. Materials that are readily available are in form of United Nations reports, reports prepared by National Agency for the Control of AIDS (NACA) or internal publications like Operational Manuals or Strategic Plans. Few textbooks or even Journals exist on the topic and the materials found dwelt more on clinical aspects of HIV/AIDS prevention, treatment, care and support. There is a gap in literature on HIV/AIDS in the area of administrative control.

2.2 HYPOTHESIS :

Following the research questions and the objectives proposed for this study, these hypotheses have also been proposed.

Hypothesis 1:

The provision of finance, human and infrastructural resources by the State has a positive impact on the control of HIV/AIDS in Enugu State.

Hypothesis 2

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Enugu State Agency for the Control of HIV/AIDS (ENSACA) has the capacity to intervene and control the scourge of HIV/AIDS in Enugu State.

2.3 OPERATIONALIZATION OF KEY CONCEPTS:

Within the context of this study, whenever ‘ State ’ is used, the researchermeans the functionaries of government within the boundaries of Enugu State which provide goods and services to the people of Enugu State. ‘Stakeholders’ here means any organisation that is involved in the fight against HIV/AIDS in the State.‘Control ’ within this context means any mechanism or activity employed to reduce the spread of HIV/AIDS. ‘Comprehensive Site’ here means the health facility that provides all the HIV/AIDS services like HCT, ART,

PMTCT etc. When ‘ resource’ is used in this work, it refers to financial, human and material resources like money, personnel, infrastructure, technical assistance and consumables. ‘Intervention ’used in this study means strategies or mechanisms used to reduce the spread of HIV/AIDS in the State.

2.4 METHODOLOGY:

This section will discuss the theoretical framework for this study, the research design, method of data collection, population of study, sampling size and technique, sources of data collection test of validity and reliability of research instruments and method of data analysis.

2.4.1 THEORETICAL FRAMEWORK:

The researcher made use of Scientific Management theory propounded by Frederick W. Taylor to support the study of the efficiency of Enugu State Agency for the Control of AIDS to deliver on its mandate of coordinating the multi sector response to HIV/AIDS in the State. Ezeani

(2006:103) said “that the bases of scientific management are efficiency and economy”.Kakar

(quoted in Ezeani 2006:104) explained that “there are two main aspects of Taylor’s theory: standardizing work, which meant finding the ‘one best way of working’ and ‘controlling so extensively and intensively as to provide for the maintenance of all these standards.” Ezeani

(2006:107) opined that “Scientific management contributed to greater specialization of

21 activities, with proper design of jobs, specification of methods, and set time and motion studies and establishment of standards of job performance. All these have contributed to greater efficiency in both public and private sectors.”

Application of this theory to the subject of study would mean that the researcher wants to use the principles of efficiency, economy and material welfare of staff to examine the performance of Enugu State Agency for the Control of AIDS in its task of controlling and coordinating efforts to stop the spread of HIV/AIDS in Enugu State.

2.4.2 RESEARCH DESIGN:

This study is a descriptive research and will involve a standardized instrument called ‘State and

HIV/AIDS Control Descriptive Questionnaire’which will be employed to get answers to the research questions posed. The Statistical Package for Social Sciences (SPSS) will be used to analyze the data collected. Simple statistical techniques of frequencies, percentages, Bar and

Pie charts including chi square will be used to test and accept or reject the hypotheses proposed and reach a conclusion while proffering recommendations. Apart from ENSACA, the researcher also targeted other Stakeholders in the study like Civil Society Organizations,

Networks, Local Action Committee on AIDS, Line Ministries and Development Partners, as they all work together to bring down the prevalence of HIV/AIDS in the State. The Taro

Yamane formula was used to arrive at the sample size and percentages used to distribute the questionnaire among the Stakeholders.

2.4.3 METHOD OF DATA COLLECTION :

This researcher made use of participant observation to gather information on the subject as the researcher is also a staff of the Enugu State Agency for the Control of AIDS. The in-depth interview technique or unstructured interview method, and answers from the questionnaire instrument usedwere employed to get primary information on the topic. Secondary sources of data like HIV/AIDS Policies, Standard Operational Manual, Strategic documents, Reports, textbooks and journals were also consulted to get more information on the subject.

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2.4.3.1 POPULATION OF THE STUDY

Since this research is a case study of Enugu State Agency for the Control of AIDS (ENSACA), the population of study will be the staff of ENSACA and a cross section of its stakeholders drawn from People Living with HIV/AIDS (PLWHA), Civil Society Organisations (CSOs),

Development Partners (DPs), Line Ministries (LMs), Local Action Committee on AIDS

(LACAs), and Networks which includes Non Governmental Organisations (NGOs) and Faith-

Based Organisations (FBOs).

ENSACA coordinates the activities of all these stakeholders in the State in order to control and stop the spread of HIV/AIDS. To deliver this mandate ENSACA has twenty-five staff in its employment and this includes Management, Programme Officers and Support staff. There are about 4,000 registered People living with HIV/AIDS under the Network of People Living with

HIV/AIDS (NEPWHAN) in the State. ENSACA has mapped 242 registered Civil Society

Organisations (CSOs) in Enugu State. There are 12 Development Partners in the State working in the area of HIV/AIDS response. ENSACA has 7 staff working in the area of HIV/AIDS in the 17 Local governments in the State (17x7 = 119). Closely working with ENSACA in the area of HIV/AIDS response in the State are 6 staff in 8 Line Ministries (8x6 = 48) in the State.

Finally, the registered Networks working in the area of HIV/AIDS in the State are 8 in number.

The population of study will be represented in a tabular format as follows:

Table 2.4.3.1 POPULATION DISTRIBUTION TABLE

S/NO STAKEHOLDER POPULATION PERCENT 1. ENSACA 25 0.57% 2. PLWHA 4000 89.8% 3. CIVIL SOCIETY 242 5.4% ORGANSATIONS 4. DEVELOPMENT PARTNERS 12 0.28% 5. LACAs 119 2.68% 6. LINE MINISTRIES 48 1.09% 7. NETWORKS 8 0.18% TOTAL 4454 100%

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2.4.3.2 SAMPLING TECHNIQUE:

The Taro Yamane formula will be employed to determine the sample size.

n = ____N______

1 + N (e)2

Where

n = Appropriate sample size

N = The population size

E = Allowable error or error margin = 6% or .06

1 = Constant

Therefore n = _____4454______1 + 4454 (0.06) 2 = ______4454______1 + (4454 x .0036) = ____4454_____ 1 + 16 = ____4454_____ 17 = 262

n = 262

From the above statistical calculation the total study sample size is 262. Since there are different stakeholders involved in HIV/AIDS response in the State, this population will have to be distributed and stratified among the stakeholders.

Table 2.4.3.2 SAMPLE SIZE DISTRIBUTION

S/NO STAKEHOLDER POPULATION SAMPLE PERCENT SIZE 1. ENSACA 25 2 0.57% 2. PLWHA 4000 234 89.8% 3. CSOs 242 14 5.4% 4. DPs 12 1 0.28% 5. LACAs 119 7 2.68% 6. LMs 48 3 1.09% 7. NETWORKS 8 1 0.18%

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TOTAL 4454 262 100%

The following technique was used to arrive at the sample size distribution among the stakeholders.

ENSACA

= 0.57 x 262 = 2 100 1 PEOPLE LIVING WITH HIV/AIDS (PLWHA) = 89.8 x 262 = 234 100 1 CIVIL SOCIETY ORGANIZATIONS (CSOs) = 5.4 x 262 = 14 100 1

DEVELOPMENT PARTNERS = 0.28% x 262 = 1 100 1 LACAs = 2.68 x 262 = 7 100 1 LINE MINISTRIES (LMs) = 1.09 x 262 = 3 100 1 NETWORKS = 0.18 x 262 = 1 100 1

n = 2+234+14+1+7+3+1 = 262

2.4.3.3 SOURCES OF DATA COLLECTION:

This research made use of primary source of data in form of observation of ENSACA as an organisation and personal interviews with ENSACA staff and some other stakeholders involved in HIV/AIDS intervention in the State. The primary source of data was also generated using an instrument called State and HIV/AIDS Control Descriptive Questionnaire (S.A.H.C.

D.Q).

This research made use of primary source of data in form of observation of ENSACA as an organisation and personal interviews with ENSACA staff and some other stakeholders

25 involved in HIV/AIDS intervention in the State. The primary source of data was also generated using an instrument called State and HIV/AIDS Control Descriptive Questionnaire

(S.A.H.C.D.Q).

The Secondary source of data employed were in form of HIV/AIDS manuals, reports, policies,

Journals, Bills (Legal documents), Plans and some other textbooks.

2.4.3.4 TESTS OF VALIDITY AND RELIABILITY OF RESEARCH INSTRUMENTS

Odo(1992:59) explained that “Validity is a process of finding out the degree to which a research or a test indeed measures what it purports to measure. While reliability of an instrument talks of using the same measuring objects to measure or to test or evaluate the same object at different period in time and at each time receiving the same or similar result.”

In order to establish the validity of the instrument, a pilot test was carried out by administering the questionnaire to a group of 15 people who have the same characteristics with the actual group.

When the questionnaire was collected, the respondents answered correctly and competently. It was then adjudged that the main study group would also answer competently.

To test the reliability of the instrument used, a reliable sample group different from the main study group and the pilot test group but who have the same characteristics as the main study and pilot test group was selected. They were given numbers from 1-15. The questionnaires were also numbered 1-15 and given to the reliable test group.

These questionnaires were collected and after three days another set of numbered questionnaires were administered to the numbered reliable sample group in such a way that each respondent received the number he/she answered before. The two answers for each respondent were then compared and found to be consistent for the majority of the respondents, proving that the instrument is reliable. The technique used here is the test-retest method.

2.4.3.5 METHOD OF DATA ANALYSIS:

26

At the completion of the distribution and return of the completed questionnaire exercise, frequencies, percentages, cross tabulation and Chi square statistical test will be used to analyze the data dealing with each research question and the hypothesis will be tested, accepted or rejected. The Statistical Package for Social Sciences (SPSS) will also be used to analyse data.

The National Harmonized Organizational Capacity Assessment Tool (NHOCAT) will also be used to test the capacity of ENSACA to deliver their mandate.

CHAPTER THREE THE STUDY AREA/GENERAL INFORMATION 3.1 STUDY AREA:

The area and location of this study is in Enugu State. According to 2006 population census, the total population of Enugu State is 3,267,837 (National Population Commission) and the

27 projected population by 2014 making use of the 3.2% growth rate of Nigeria, will be

3,372,408. Enugu State was created on 27 th August 1991 and occupies a surface area of about

8.000 sq. Km. Enugu State is located within the West African tropical rain forest region between latitude 5 o 55’ and 7 o 10’ North and longitudes 5 o 50’ and 7 o 55’ East. It is bounded in the East by Ebonyi State, in the West by Anambra State, in the North by Kogi and Benue

States and in the South by Abia State.

The population density is about 460 persons per square kilometre.

Enugu State has 17 Local government areas (LGAs). An additional 39 were created in 2003, but have not yet been given constitutional recognition and so remain development centres.

Fig. 3: Map of Enugu State showing 17 LGAs

Source: Enugu State Agency for the Control of AIDS (ENSACA) 2012 Fact Sheet

Enugu State as part of its health reform process operates the District Health System (DHS) framework. With the signing into law of the State Health Bill on the 28 th of July 2005 and its endorsement by the State Governor in August 2005, the law provides a legal framework for

DHS within the State. The model of DHS includes 7 District Health Boards (DHBs) for service delivery at District level and 56 Local Health Authorities (LHAs) which serves as local service delivery points at the local government level.

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Enugu State is made up of three Senatorial Zones namely: Enugu North, Enugu East and

Enugu West senatorial zones. Enugu State has a large deposit of coal and is popularly called the Coal City State. Enugu State was the seat of administrative government in the old Eastern

Region. Enugu is not a commercial town but is predominated by Civil Servants.

3.2 ENUGU STATE AGENCY FOR THE CONTROL OF HIV/AIDS (ENSACA) :

Enugu State Agency for the Control of AIDS was established by law in 2011 under the Office of the Executive Governor. Before becoming an agency in 2011, it had existed as State Action

Committee on AIDS (SACA).

ENSACA’s mandate:

Mission

“To coordinate the multi sector response to HIV/AIDS by facilitating the strengthening of stakeholders’ capacity, creating the necessary enabling environment, and mobilization of resources for effective delivery of State HIV/AIDS priorities.”

Vision

“A resourceful, efficient and responsive institution working towards an Enugu State without new HIV infections, where people infected and affected can live fulfilled lives with optimal mitigation of the impact of HIV & AIDS.”

To implement this mission and vision, ENSACA’s main funding sources are a World Bank

Loan and State Counterpart Funds. There is also indirect funding (through implementing partners) from DFID, Global Fund, USAID, PEPFAR, UNICEF and WHO.

Development/Implementing Partners working in the State include:

 Enhancing Nigeria’s Response to HIV/AIDS (ENR/DFID)  Centre for Clinical Case & Research Nigeria (CCCRN)  Catholic Relief Services (CRS)  John Snow International (JSI)  Excellence Community Educations Welfare Scheme (ECEWS)  Planned Parenthood Federation of Nigeria (PPFN)  Society for Family Health (SFH)  AIDS Prevention Initiative Nigeria (APIN)

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3.2.1 THE PRINCIPLE OF “THREE ONES” :

To achieve its mandate, ENSACA employs the “three ones” principle or concept as follows:

 One State Coordinating body

 One State Strategic Plan (SSP)

 One Monitoring and Evaluation system (District Health Information System –

DHIS)

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FIGURE 4: ORGANIZATIONAL CHART FOR THE STATE AGENCY FOR THE CONTROL OF AIDS

THE BOARD

DIRECTOR GENERAL/CEO

INTERNAL AUDIT

DEPARTMENT OF PARTNERSHIP DEPARTMENT OF DEPARTMENT OF DEPARTMENT OF DEPARTMENT OF COORDINATION (Responsible for FINANCE, ADMIN & POLICY, ADVOCACY STRATEGIC PROGRAMMES CSOs, LACAS, Private sector, Dev. Partner SUPPORT SERVICE & RESOURCE KNOWLEDGE MOBILISATION MANAGEMENT

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3.2.2 COORDINATING AUTHORITY AT THE STATE LEVEL

At the State level, the State Agency for the Control of AIDS (SACA) is the multi-sectoral coordinating entity for HIV/AIDS response and shall be located in the Office of Executive

Governor or Deputy Governor or the Secretary to the State Government but NOT in any particular Ministry.

3.2.3FUNCTIONS OF SACA

The functions of the State Agency for the Control of AIDS (SACA) are to:

• Design and coordinate intense multi-sectoral approaches and plans for HIV/AIDS prevention and control • Provide technical and financial support to the planning, implementation and management of HIV/AIDS interventions to line Ministries, CSOs, organized private sectors and LGAs • Support biennial sentinel survey on the incidence and prevalence of HIV/AIDS and promote operational research on intervention strategies • Promote and encourage multi-disciplinary collaboration and networking among all stakeholders including CSOs against HIV/AIDS. • Build capacity of personnel involved in the prevention and impact mitigation of HIV/AIDS at all the State and Local Government levels. • Undertake resource mobilization and other activities as are necessary or expedient for the performance of its functions under the law • Produce, document and disseminate quarterly, annual and special reports on HIV/AIDS interventions • Promote multi-sectoral and multi-disciplinary collaboration and networking among organizations working on HIV/AIDS interventions • Set and enforce standards on matters relating to HIV/AIDS intervention for all stakeholders. • Liaise with relevant agencies and establishments within and outside Nigeria pursuant to the functions of the Agency.

32

• Demand and obtain relevant information, data and reports from Government, Ministries, Departments and Agencies; LACAs; NGOs; FBOs; CBOs; and donor agencies on matters relating to the prevention and control of AIDS. • Promote and support research, consultancy, training and advocacy programme on the HIV/AIDS conducted by various institutions with a view to o Ascertaining their suitability

o Offering them such assistance either alone or in cooperation with other related

bodies as may improve the contents and quality of their work.

3.2.4FUNCTIONS AND COMPOSITION OF THE GOVERNING BOARD OF SACA

According to the Standard Operational Manual (SOP), SACA shall have a Governing Board whose membership and tenure shall be as stipulated in the law establishing it. The Governing

Board should have representatives of the following different constituencies/organizations with at least 40% females represented on the Board:

i. Civil Society on HIV/AIDS in Nigeria ii. Network of People Living With HIV/AIDS iii. National Youth Network on HIV/AIDS iv. Faith-Based Network v. Nigeria Medical Association (NMA) vi. Academia/Relevant Research Institution vii. Organized Private Sector viii. Ministry of Health ix. Ministry of Women Affairs x. Ministry of Education xi. Ministry of Information xii. Ministry of Local Government xiii. Ministry responsible for Youth Matters xiv. Three (3) Local Action Committee on AIDS (one for each senatorial district).

The Executive Secretary/ Director General shall be a member and serve as the Secretary of the

Board.

33

The functions of the Governing Board are to:

 Determine the overall policies of the agency including its financial operation

procedures and ensure their effective implementation

 Establish, appoint and constitute committees, which shall be charged with specific

functions

 Approve the State Action Plan for the prevention and control of HIV/AIDS and any

other plan that is complementary or part of the said action plan

 Ensure sustenance of funding and advocacy for HIV/AIDS at all levels

 Prosecute an intensive multi-sectoral approach to HIV/AIDS prevention and control

 Review from time to time the performance of the Agency in meeting targets set by the

State HIV/AIDS Strategic Plan.

The State Agency for the Control of AIDS (SACA) is the secretariat of the State HIV/AIDS response and it should be headed by the Director-General/Executive Secretary who is also the

Chief Executive Officer of the Agency. The Director-General/Executive Secretary shall be the

Head of the Secretariat and shall be responsible for the day-to-day running of the Agency secretariat.

3.2.5STRUCTURE AND FUNCTIONS OF THE DEPARTMENTS WITHIN SACA

According to the Standard Operational Manual (SOP), the responsibilities of the departments are as follows:

a) Partnership Coordination: responsible for coordinating activities of the LACAs,

CSOs, Private Sector and Development Partners

b) Policy, Advocacy and Resource Mobilization: responsible for all the issues relating

to advocacy, policy, plan and resource mobilization.

c) Strategic Knowledge Management: responsible for all data collection and

management, monitoring, evaluation, research and knowledge management issues.

34

d) Program: responsible for technical and programmatic issues relating to Prevention,

Treatment, Care and Support as well as coordinating the activities of the Line

Ministries.

e) Finance and Administration: responsible for managing the finances of the

organization including the payroll, personnel, office management, procurement, legal

and general administration issues.

Working closely with ENSACA is the Local Action Committee on AIDS (LACA) and they exist in all the 17 Local government areas.

3.3 ENUGU STATE HIV/AIDS EPIDEMIOLOGY

Enugu State has a prevalence rate of 5.1% (2010 ANC Survey) and has a projected HIV burden of 97,470. The following are the prevalence rates of HIV/AIDS for the past decade in Enugu State.

Fig. 5 : Trends in Enugu State HIV Sero Prevalence Rates from 1991– 2010

Source : 2010 National HIV SeroprevalenceSentinel Survey.

3.3.1 THE MOST AT RISK POPULATION (MARPs)

The most-at-risk populations are:  Youths  Female Sex Workers (FSW)  Injecting Drug Users (IDUs)  Men who have sex with Men (MSM)

35

 Vulnerable Children (VC)  People with Disabilities (PWDs)  Health Care Workers (HCW)  People Living with HIV and AIDS (PLWHA)  Transport Workers and men who travel often and  Women of Childbearing Age. The 2010 Mode of Transmission Study reported that 34.6% of new HIV infection occur among couples considered as engaging in ‘low-risk’ sex, (that is those in permanent relationships like marriage) while 23% occur among most-at-risk populations (MARPs). More than a third of all new infections were linked to female sex workers, their clients and partners, men who have sex with men and injecting drug users and their partners.

3.4 BASIC FACTS ABOUT HIV/AIDS:

HIV is an acronym for Human Immunodeficiency Virus, while AIDS means Acquired Immune

Deficiency Syndrome. AIDS is caused by HIV and is the terminal stage of the virus. The proven modes of transmission are through sexual contact whether male-to-female, male-to-male or female-to-female. It is also transmitted through blood transfusion, Injecting Drug Users (IDUs) through needle sharing, needle stick accidents, blood contacts during maternal deliveries, surgery or accidents.

Heterosexual transmission accounts for the majority of HIV transmission. The 2010 Mode of

Transmission (MOT) Study reported that 34.6 per cent of new HIV infections occur among couples considered as engaging in ‘low-risk’ sex, while 23 per cent occur among most at risk populations (MARPs). The Mode of Transmission (MOT) Study carried out in 2009, revealed that more than a third of all new infections were linked to female sex workers, their clients and partners, men who have sex with men (MSM) and injectin g drug users (IDUs) and their partners.

However HIV cannot be transmitted by body surface contact or insect bites, hugging, shaking

36 hands, eating together, swimming, sharing clothes, working in the same office or sleeping in the same bed. Studies of tran smission through body fluids like sweat or saliva are still inconclusive.

Globally, HIV/AIDS is no longer a myth but a reality which has claimed so many lives in the past few decades.

37

CHAPTER FOUR

DATA PRESENTATION, ANALYSIS AND FINDINGS

4.1 DATA PRESENTATION:

The data collected from the primary source of data using an instrument called State and HIV/AIDS Control Descriptive Questionnaire (S.A.H.C.D.Q), will be presented in this chapter and analysed using computer software called Statistical Package for Social Sciences (SPSS). Binomial Test of proportion using Z-approximations was used to test the research questions. The sample size is 262 and the corresponding number of questionnaires was distributed along the stratified groups. However, 250 questionnaires were returned giving a response rate of 95%. Only 12 or 5% of the questionnaires were unreturned.

Mogey, (2014) said that “Data from Likert scales are sometimes reduced to the nominal level by combining all agree and disagree responses into two categories of "Agree" and "Disagree".”. The chi- square , Cochran Q, Binomial test of proportion, or McNemar test is common statistical procedures used after this transformation. Also Conover, (1980) asserts that “Summarizing Likert items using the mode (not mean); is probably the most suitable for easy interpretation and expressing variability in terms of the range or inter quartile range (not the standard deviation)”. Distribution of observations of Likert can be represented with a dot plot or a bar chart (it can’t be a histogram, because the data are not continuous). Here we shall therefore analyze the research questions by • finding the consensus opinion and • by Statistical test analysis using the Binomial Test of proportion using Z- approximations.

Binomial test of proportion is a non-parametric test statistic used to analyze questions involving qualitative binomial mutually exclusive categorical e.g. (Yes/No), (Agree/Disagree), or (Strong/ Weak) responses. A non-parametric test is a distribution free test.

To do this, our data from Likert scales namely

1. “Strongly Agree ” , 2. “Agree”, 3. “Undecided” , 4. “Disagree” and 5. “Strongly Disagree”

38 are reduced to the nominal level by combining all four categories into two categories of "Agree" and "Disagree". Using Binomial Test of proportion using Z- approximation we shall look at the following A one sample binomial test allows us to test whether the proportion of successes on a two-level categorical dependent variable significantly differs from a hypothesized value.

The key to the decisions are guided by these equations:

If P<0.05 = Significant

If P<0.01 = Highly significant

If P>0.05 = NOT significant.

RESEARCH QUESTIONS:

i. Does the provision of financial, human and infrastructural resources by the State

have any impact on the control of HIV/AIDS in Enugu State?

ii. Has Enugu State Agency for the Control of AIDS (ENSACA) the capacity to

coordinate the HIV/AIDS response programmes in Enugu State?

iii. What are the factors that should be put in place to provide the way forward in the

response to HIV/AIDS in Enugu State?

39

4.2ANALYSIS AND INTERPRETATION OF RESEARCH QUESTIONS

4.2.1. RESEARCH QUESTION 1. DOES THE PROVISION OF FINANCIAL,

HUMAN AND INFRASTRUCTURAL RESOURCES BY THE STATE HAVE ANY

IMPACT ON THE CONTROL OF HIV/AIDS IN ENUGU STATE?

TABLE 4.2.1

To what extent do you agree to the assertion that the provision of financial, human and infrastructural resources by the State has positive impact on the control of HIV/AIDS in Enugu State?

Binomial Test of proportion using Research Z- approximations Question 1 SA A U D SD Mean Mode Range

Agree Disagree p-value To what extent do you Agree to the assertion that the provision of financial, human and 155 Test 92 0 3 0 n=247 infrastructural 62.00 1.40 1 3 n=3 prop. 36.8% 0.00% 1.20% 0.00% p=0.99 resources by % p=0.01 P=0.50 the state have (p-value) positive p=0.000 impact on the control of HIV/AIDS in Enugu state?

Conclusion: Mean = 1.40; Mode =1; Range=3. Decision /Consensus (Based on Mode Values) for this factor is “ Strongly Agree” Observed proportion =0.99; Test proportion =0.50. (p=0.000; p<0.01; Test is Highly significant) There is a strong perception at 99% statistical assurance that the provision of financial, human and infrastructural resources by the state has apositive impact on the control of HIV/AIDS in Enugu State?

40

BAR CHART 4.2 .1 Showing Respondents perception towards the provision of financial, human and infrastructural resources by the State having positive impact on the Control of HIV/AIDS.

155 160 140 120 92 100 80

Frequency 60 40

20 0 3 0 0 Strongly Agree Agree Undecided Disgree Strngly Decisions Disgree

41 4.2.2 RESEARCH QUESTION 2: HAS ENUGU STATE AGENCY FOR THE

CONTROL OF AIDS (ENSACA) THE CAPACITY TO COORDINATE THE HIV/AIDS

RESPONSE PROGRAMMES IN ENUGU STATE?

TABLE 4.2.2 To what extent do you agree to the assertion that Enugu State Agency for the Control of AIDS (ENSACA) has the capacity to coordinatate the HIV/AIDS response programmes in Enugu State? Binomial Test of Research Question proportion using Z- 2 approximations SA A U D SD Mean Mode Range Agree Disagree p-value To what extent do you Agree to the assertion that Enugu State Agency for the Control of AIDS 87 Test 125 17 17 4 n=212 (ENSACA) 34.80 1.90 2 4 prop. 50.00% 6.80% 6.80% 1.60% p=0.85 has the % P=0.50 capacity to n=38 p=0.15 (p-value) coordinate the p=0.000 HIV/AIDS response programmes in Enugu State?

Conclusion

Mean = 1.90; Mode =2; Range=4. Decision /Consensus (Based on Mode Values) for this factor is “ Agree” Observed proportion =0.85; Test proportion =0.50 . (p=0.000; p<0.01; Test is Highly significant) There is a strong perception at 99% statistical confidence. We therefore conclude at 99% statistical confidence that Enugu State Agency for the Control of AIDS (ENSACA) has the capacity to coordinate the HIV/AIDS response programmes in Enugu State.

42

PIE CHART 4.2.2: Showing Respondents' perception towards Enugu State Agency 's (ENSACA) Capacity for the Control of AIDS programmes in Enugu State.

17 4 17 87 Strongly Agree

Agree

Undecided

Disgree 125 Strngly Disgree

4.2 .3 RESEARCH QUESTION 3: WHAT ARE THE FACTORS THAT SHOULD BE

PUT IN PLACE TO PROVIDE THE WAY FORWARD IN THE RESPO NSE TO

HIV/AIDS IN ENUGU STATE?

Here we shall use Binomial Test of proportion using Z - approximations to test whether the proportion of respondents who indicated YES/NO or Agree/Disagree to the research questions or factorsdiffers significantly from 50%, i.e., from 0.5.

Observations or factors having the proportion of respondents who indicated “YES” in a YES/NO option , that differs significantly from 50%, i.e., from 0.5 (Statistically Significant) can be claimed to be those factors to be put in place to provide a way forward in response to HIV/AIDS in Enugu State .

Those with proportion of respondents who indicated “ YES” that do not differ significantly from 50% (Not Statistically Significant) are claimed to be adequately put in place.

43 The Test Statistic used is Binomial Test of proportion using Z- approximations

The Analyses Table is as follows:

In the tables below, the factors that should be put in place to provide the way forward in the response to HIV/AIDS in Enugu State are inferred from decisions underlined

TABLE 4.2.3

Factors that should be put in place to provide the way forward in the response to

HIV/AIDS in Enugu State.

Binomial Test of proportion using Z- approximations Factors that should be put in place to provide the way Observed Test forward in the response to HIV/AIDS in Enugu State . Category N Prop. Prop. Asymp. Sig. (2-tailed)

Is discipline and responsible Group 1 Yes 152 .61 .50 p=0.001 a dispatch of duties by staff at all Group 2 No 98 .39 levels your possible suggestion P<0.01 Test is Highly Significant. Total to ENSACA towards the control Therefore discipline and responsible dispatch of duties by staff at all of the scourge of HIV/AIDS in 250 1.00 levels should be put in place towards Enugu State? the control of the scourge of HIV/AIDS in Enugu State a. Based on Z Approximation.

44

Binomial Test of proportion using Z- approximations

Factors that should be put in place to provide the way Observed Test forward in the response to HIV/AIDS in Enugu State. Category N Prop. Prop. Asymp. Sig. (2-tailed)

Is resourcing and mobilizing Group 1 Yes 163 .65 .50 p=0.000 a P<0.05 Test is Highly Significant. alternate funding your possible Group 2 Therefore resourcing and mobilizing suggestion to ENSACA towards alternate funding should be put in No 87 .35 the control of the scourge of place to provide the way forward in the response to HIV/AIDS in Enugu HIV/AIDS in Enugu State? State.

Total 250 1.00

Is provision of sufficient Group 1 Yes 146 .58 .50 p=0.009 a P<0.01 Test is Highly Significant. vehicles your possible Group 2 Therefore provision of sufficient suggestion to ENSACA towards vehicles does not pose a challenge to No 104 .42 the control of the scourge of ENSACA towards the control of the scourge of HIV/AIDS in Enugu HIV/AIDS in Enugu State? State .

Total 250 1.00

Is aggressive media hype for Group 1 Yes 168 .67 .50 p=0.000 a P<0.01 Test is Highly Significant. PCT & PMTCT your possible Group 2 Therefore aggressive media hype for suggestion to ENSACA towards No 82 .33 PCT & PMTCT should be put in the control of the scourge of place towards the control of the scourge of HIV/AIDS in Enugu State HIV/AIDS in Enugu State?

Total 250 1.00

Is Capacity building of staff at Group 1 Yes 184 .74 .50 p=0.000 a P<0.01 Test is Highly Significant. all levels your possible Group 2 Therefore Capacity building of staff suggestion to ENSACA towards No 66 .26 at all levels should be put in place the control of the scourge of towards the control of the scourge of HIV/AIDS in Enugu State HIV/AIDS in Enugu State?

Total 250 1.00

Is proper motivation of staff for Group 1 Yes 135 .54 .50 p=0.229 a p>0.05 Test is NOT Significant. hard work your possible Group 2 Therefore proper motivation of staff suggestion to ENSACA towards for hard work does not pose a No 115 .46 the control of the scourge of challenge to ENSACA towards the control of the scourge of HIV/AIDS HIV/AIDS in Enugu State? in Enugu State

Total 250 1.00 a. Based on Z Approximation.

45

Binomial Test of proportion using Z- approximations Factors that should be put in place to provide the way Observed Test forward in the response to HIV/AIDS in Enugu State. Category N Prop. Prop. Asymp. Sig. (2-tailed)

Is more technical assistance and Group 1 Yes 171 .68 .50 p=0.000 a P<0.01 Test is Highly Significant. support from the government Group 2 Therefore more technical assistance your possible suggestion to and support from the government No 79 .32 ENSACA towards the control of should be put in place towards the control of the scourge of HIV/AIDS the scourge of HIV/AIDS in in Enugu State Enugu State? Total 250 1.00

Is transparency at all levels your Group 1 Yes 141 .56 .50 P=0.070 a p>0.05 Test is NOT Significant. possible suggestion to ENSACA Group 2 Therefore transparency at all levels towards the control of the No 109 .44 does not pose a challenge to scourge of HIV/AIDS in Enugu ENSACA towards the control of the scourge of HIV/AIDS in Enugu State State?

Total 250 1.00

Is more care and support to Group 1 Yes 169 .68 .50 p=0.000 a P<0.01 Test is Highly Significant. PLWHA your possible Group 2 Therefore more care and support to suggestion to ENSACA towards No 81 .32 PLWHA should be put in place the control of the scourge of towards the control of the scourge of HIV/AIDS in Enugu State HIV/AIDS in Enugu State?

Total 250 1.00

Is proper supply chain of ART Group 1 Yes 169 .68 .50 p=0.000 a P<0.01 Test is Highly Significant. and other consumables your Group 2 Therefore proper supply chain of possible suggestion to ENSACA ART and other consumables should No 81 .32 towards the control of the be put in place towards the control of the scourge of HIV/AIDS in Enugu scourge of HIV/AIDS in Enugu State State? Total 250 1.00

Is provision of more Group 1 Yes 133 .53 .50 p=0.343 a p>0.05 Test is NOT Significant. comprehensive sites your Group 2 Therefore provision of more possible suggestion to ENSACA comprehensive sites does not pose a No 117 .47 towards the control of the challenge to ENSACA towards the control of the scourge of HIV/AIDS scourge of HIV/AIDS in Enugu in Enugu State State? Total 250 1.00 a. Based on Z Approximation.

46

Binomial Test of proportion using Z- approximations Factors that should be put in place to provide the way Observed Test forward in the response to HIV/AIDS in Enugu State. Category N Prop. Prop. Asymp. Sig. (2-tailed)

Is developing proper referral Group 1 Yes 144 .58 .50 p=0.019 a P<0.05 Test is Significant. systems and follow up of Group 2 Therefore developing proper referral positive patients your possible systems and follow up of positive No 106 .42 suggestion to ENSACA towards patients does not pose a challenge to ENSACA towards the control of the the control of the scourge of scourge of HIV/AIDS in Enugu State HIV/AIDS in Enugu State? Total 250 1.00

Is provision of mobile HCT Group 1 Yes 143 .57 .50 p=0.027 a P<0.05 Test is Significant. Therefore vans your possible suggestion to Group 2 provision of mobile HCT vans does ENSACA towards the control of No 107 .43 not pose a challenge to ENSACA the scourge of HIV/AIDS in towards the control of the scourge of HIV/AIDS in Enugu State Enugu State?

Total 250 1.00

Is improving the HIV/AIDS Group 1 Yes 166 .66 .50 p=0.000 a P<0.01 Test is Highly Significant. database and monitoring and Group 2 Therefore improving the HIV/AIDS evaluation system your possible database and monitoring and No 84 .34 suggestion to ENSACA towards evaluation system should be put in place towards the control of the the control of the scourge of scourge of HIV/AIDS in Enugu State HIV/AIDS in Enugu State? Total 250 1.00

Is sensitization the anti- Group 1 Yes 145 .58 .50 p=0.013 a P<0.05 Test is Significant. discrimination and stigma law Group 2 Therefore sensitization the anti- your possible suggestion to discrimination and stigma law does No 105 .42 ENSACA towards the control of not pose a challenge to ENSACA towards the control of the scourge of the scourge of HIV/AIDS in HIV/AIDS in Enugu State Enugu State? Total 250 1.00 a. Based on Z Approximation.

47

Binomial Test of proportion using Z- approximations Factors that should be put in place to provide the way Observed Test forward in the response to HIV/AIDS in Enugu State. Category N Prop. Prop. Asymp. Sig. (2-tailed)

Is becoming a global Group 1 Yes 116 .46 .50 p=0.282 a p>0.05 Test is NOT Significant. stakeholder and reference point Group 2 Therefore becoming a global makers through website stakeholder and reference point information your possible No 134 .54 makers through website information does not pose a challenge to suggestion to ENSACA towards ENSACA towards the control of the the control of the scourge of scourge of HIV/AIDS in Enugu State

HIV/AIDS in Enugu State? Total 250 1.00

Is release of timely information Group 1 Yes 136 .54 .50 .184 a p>0.05 Test is NOT Significant. to policy makers through fact Group 2 Therefore release of timely sheets your possible suggestion information to policy makers through to ENSACA towards the control No 114 .46 fact sheets does not pose a challenge to ENSACA towards the control of of the scourge of HIV/AIDS in the scourge of HIV/AIDS in Enugu Enugu State? State

Total 250 1.00

Is qualitative and effective Group 1 Yes 156 .62 .50 p=0.000 a P<0.01 Test is Highly Significant. reporting at all levels your Group 2 Therefore qualitative and effective possible suggestion to ENSACA No 94 .38 reporting at all levels should be put towards the control of the in place towards the control of the scourge of HIV/AIDS in Enugu St ate scourge of HIV/AIDS in Enugu

State? Total 250 1.00

Is provision of office equipment Group 1 Yes 130 .52 .50 p=0.569 a p>0.05 Test is NOT Significant. and physical infrastructure for Group 2 Therefore provision of office the response your possible equipment and physical suggestion to ENSACA towards No 120 .48 infrastructure for the response does not pose a challenge to ENSACA the control of the scourge of towards the control of the scourge of HIV/AIDS in Enugu State? HIV/AIDS in Enugu State

Total 250 1.00 a. Based on Z Approximation.

48

Table 4.2.4 ShowingFactors that impact positively on the control of HIV/AIDS.

Factors are sorted in order of positive impact (i.e. most impactful) on the control of HIV/AIDS as shown below.

Factors that impact positively on the control of n frequency Percentage HIV/AIDS. frequency

1. Provision of ART 250 235 94.0

2. Prevention of mother to child transmission. 250 234 93.6

3. Proper education, awareness and sensitization 250 225 90.0

4. Provision of adequate and evenly distributed 250 215 86.0 comprehensive sites 5. Adequate finance 250 209 83.6

6. Proper use of condom/abstinence 250 190 76.0

7. Adequate trained Staff 250 190 76.0

8. Good referral system 250 180 72.0

9. Adequate HIV/AIDS database 250 177 70.8

10. Provision of infrastructure 250 175 70.0

11. Absence of stigma and discrimination 250 171 68.4

12. Discipline, responsible and cohesive workforce 250 170 68.0

13. Good leadership 250 165 66.0

14. Proper motivation of staff 250 163 65.2

Source: Feedback from questionnaire

49

BAR CHART 4.2.3 SHOWING DISTRIBUTION OF FACTORS THAT SHOULD BE PUT IN PLACE TO PROVIDE THE WAY FORWARD IN THE RESPONSE TO HIV/AIDSHIV/AIDS IN ENUGU STATE.

80 74 69 68 68 67 66 65 70 62 61 58 58 58 57 60 50 40 30 20 10

Percentage Response Frequency Response Percentage 0

Factors that should be put in place to provide the way forward in the response to HIV/AIDS in enugu state.

50 BAR CHART 4.2 .4 SHOWING RESPONSES ON SUGGESTED FACTORS THAT SHOULD BE PUT IN PLACE TO IMPROVE ENSACA’S CAPACITY FOR THE RESPONSE

60 56 54 54 53 52

50 46

40

30

20

10

0 Percentage Response Response Percentage

Suggested Factors that should be put in place.

51 BAR CHART 4.2.5 SHOWING DISTRIBUTION OF FACTORS THAT IMPA CT POSITIVELY ON THE CONTROL OF HIV/AIDS.

100.0 94.0 93.6 90.0 86.0 90.0 83.6 76.0 76.0 80.0 72.0 70.8 70.0 68.4 68.0 66.0 70.0 65.2

60.0

50.0

40.0

30.0

Percentage Response Percentage 20.0

10.0

0.0

Factors that impact positively on the control of HIV/AIDS.

52 4.2.6 FACTORS CHALLENGING THE RESPONSE TO HIV/AIDS RESPONSE IN THE STATE

The following factors have been identified to challenge the response to HIV/AIDS in the State.

ABLE 4.2.6 Challenges Hindering ENSACA from Delivering its mandate

Order Challenges hindering ENSACA from Percentage n frequency delivering its mandate frequency

Lack of financial resources 250 183 73.2 2 Inadequate staff 250 150 60.0 3 Lack of capacity building of staff at state and local government level 250 146 58.4 4 Insufficient motivation of staff 250 133 53.2 5 Insufficient vehicles 250 128 51.2 6 Inadequate referrals and follow up of positive patients 250 125 50.0 7 Stigma and discrimination of PLWHA 250 123 49.2 9 Inadequate database 250 123 49.2 9 Lack of technical assistance and support from the government 250 123 49.2 10 Inadequate education and awareness/sensitization 250 114 45.6 11 Insufficient IT support materials 250 113 45.2 12 Insufficient comprehensive sites in the state 250 111 44.4 13 Poor remuneration 250 107 42.8 14 Short supply of consumables 250 106 42.4 15 Lack of office space 250 97 38.8 16 Lack of proper understanding of roles and internal conflicts 250 86 34.4 17 Indifference to counseling and testing by the public 250 75 30.0 18 Lack of transparency by partners 250 65 26.0

53

BAR CHART 4.2 .6 Showing Challenges Hindering ENSACA from delivering its Mandate

80.0 70.0 60.0 50.0 40.0 30.0 20.0 10.0 0.0 … … … … … … Inadequate staff Inadequate Poor remuneration Poor Lack of office space office of Lack Insufficient vehicles vehicles Insufficient Percentage Frequency of Observational responses of Observational Frequency Percentage Inadequate database Inadequate Lack of financial resources financial of Lack Inadequate education and and education Inadequate Short supply of consumables of supply Short Insufficient motivation of staff of motivation Insufficient Insufficient IT support materials support IT Insufficient Lack of transparency by partners by transparency of Lack Stigma and discrimination of PLWHA of discrimination and Stigma Inadequate referrals and follow up ofup follow and referrals Inadequate Lack of technical assistance and support and assistance technical of Lack Lack of capacity building of staff at state at staff of building of capacity Lack Indifference to counseling and testing by by by testingtesting and and counseling counseling toto Indifference Lack of proper understanding of roles and rolesand of understanding proper of Lack

Challenges thestate in sites comprehensive Insufficient Challenges hindering ENSACA from delivering its mandatmandatee

54 Table 4.2.7Possible Suggestions to ENSACA towards the control of the Scourge of HIV/AIDS in Enugu State.

The Table below shows the Possible Suggestions to ENSACA towards the control of the Scourge of HIV/AIDS in Enugu State in order of priority with “Capacity building of staff at all levels’ being the top in the list of Possible Suggestions.

Possible Suggestions to ENSACA towards the control of n frequency Percentage the Scourge of HIV/AIDS in Enugu State. frequency 1. Capacity building of staff at all levels 250 184 73.6 2. More technical assistance and support from the government 250 171 68.4 3. More care and support to PLWHA 250 169 67.6 4. Proper supply chain of ART and other consumables 250 169 67.6 5. Aggressive media hype for HCT& PMTCT 250 168 67.2 6. Improving the HIV/AIDS database for monitoring and evaluation system 250 166 66.4 7. Release of timely information to policy makers 250 163 65.2 through fact sheets 8. Qualitative and effective reporting at all levels 250 156 62.4 9. Discipline and responsible dispatch of duties by staff 250 152 60.8 at all levels 10. Becoming a global stakeholder and reference point makers through website information 250 146 58.4 11. Provision of sufficient vehicles 250 145 58.0 12. Sensitization on the anti-discrimination and stigma law 250 145 58.0 13. Developing proper referral systems and follow up of positive patients 250 144 57.6 14. Provision of mobile HCT vans 250 143 57.2 15. Transparency at all levels 250 141 56.4 16. Proper motivation of staff for hard work 250 135 54.0 17. Provision of more Comprehensive sites 250 133 53.2 18. Provision of office equipment and physical 250 130 52.0 infrastructure for the response

55

4.3 TESTING OF HYPOTHESES:

The following hypotheses were proposed which will now be tested.

Hypothesis 1:

The provision of finance, human and infrastructural resources by the State has a positive impact on the control of HIV/AIDS in Enugu State.

Hypothesis 2:

Enugu State Agency for the Control of HIV/AIDS (ENSACA) has the capacity to intervene and control the scourge of HIV/AIDS in Enugu State.

4.3.1 TESTING HYPOTHESIS 1:

Hypothesis 1:

The provision of finance, human and infrastructural resources by the State has a positive impact on the control of HIV/AIDS in Enugu State.

Binomial Test of proportion using Z- approximations

Observed Asymp. Sig. Category N Prop. Test Prop. (2-tailed) Does the provision of Group 1 Yes 247 .99 .50 .000 a resources like finance, Group 2 No 3 .01 personnel and Total infrastructure impact positively on the control 250 1.00 of HIV/AIDS in the state?

a. Based on Z Approximation Observed proportion =0.99; Test proportion =0.50 . (p=0.000; p<0.01; Test is Highly significant)

56

Conclusion:

There is a strong perception at 99% statistical ass urance that the provision of finance, human and infrastructural resources by the State has a positive impact on the control of HIV/AIDS in Enugu State. (p=0.99 ; P=0.50; p=0.000; p<0.01). Therefore the hypothesis is accepted. The provision of finance, human and infrastr uctural resources by the State has a positive impact on the control of HIV/AIDS in Enugu State .

BAR CHART 4.3 .1 SHOWING THE DISTRIBUTION OF REPONDENTS ON WHETHER THE PROVISION OF FINANCIAL, HUMAN AND INFRASTRUCTURAL RESOURCES BY THE STATE HAS A POSITIVE IM PACT ON THE CONTROL OF HIV/AIDS IN ENUGU STATE.

0.7 62.0% 0.6

0.5 36.8% 0.4

0.3

0.2

Percentage Frequency Percentage 0.1 0.0% 1.2% 0.0% 0 Strongly Agree Uncertain Disagree Strngly Agree Disagree Extent Of Agreement Extent of agreement to the assertion that the provision of financial, human and infrastructural resources by the state have positive impact on the control of HIV/AIDS in Enugu state

57 4.3.2 TESTING HYPOTHESIS 2:

Hypothesis 2:

Enugu State Agency for the Control of HIV/AIDS (ENSACA) has the capacity to intervene and control the scourge of HIV/AIDS in Enugu State.

Binomial Test of proportion using Z- approximations Observed Asymp. Sig. Category N Prop. Test Prop. (2-tailed) Does ENSACAhave Group 1 Agree 212 .85 .50 .000 a the capacity to intervene Group 2 Disagree 38 .15 and control the scourge Total of HIV/AIDS in Enugu 250 1.00 State? a. Based on Z Approximation. Observed proportion =0.85; Test proportion =0.50 . (p=0.000; p<0.01; Test is highly significant) Conclusion:

There is a strong perception at 99% statistical assurance that ENSACA has the capacity to intervene and control the scourge of HIV/AIDS in Enugu State. (p=0.85 ; P=0.50; p=0.000; p<0.01). Therefore the hypothesis is accepted. Enugu State Agency for the Control of AIDS has the capacity to intervene and control the scourge of HIV/AIDS in Enugu State.

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BAR CHART 4.3.2 SHOWING THE DISTRIBUTION OF RESPONDENTS ON WHETHER ENSACA HAS THE CAPACITY TO COORDINATE THE HIV/AIDS RESPONSE PROGRAMMES IN THE STATE?

50.0% 0.5 0.45 0.4 34.8% 0.35 0.3 0.25 0.2 0.15 0.1 6.8% 6.8% Percentage Frequency Percentage 0.05 1.6% 0 Strongly Agree Uncertain Disagree Strngly Agree Extent Of Agreement Disagree

Extent of agreement to the assertion that Enugu State Agency for the Control of AIDS (ENSACA) has the capacity to coordinate the HIV/AIDS response programmes in Enugu State

4.4 NATIONAL HARMONIZED ORGANIZATIONAL CAPACITY ASSESSMENT TOOL(NHOCAT):

NHOCAT is a national organizational capacity assessment tool used to assess the capacity of organizations to deliver the HIV response both at t he National, State and Local government levels. It is also used to assess the capacity of Civil Societ y Organizations (CSOs), Line Ministries (LMs) and Local Action Committee on AIDS (LACAs) on their preparedness to deliver on the response to HIV/AIDS.

The capacity areas or domains assessed at ENSACA are:

1. Human resource management systems (Staffing, Personal Capacity and Workload Capacity)

2. Budget and Financial Management System 3. Procurement and Inventory Management 4. Planning

5. Physical Infrastructure Management

59 6. Supervision and Oversights Standards 7. Multi-Sectoral Coordination 8. Governance and Leadership 9. Monitoring and Evaluation Management System 10. Resource Mobilization and Accountability

4.4.1 ENSACA NHOCAT DASHBOARD: The questionnaire that was administered to the different departments in ENSACA that resulted in the scores on the dashboard below will be attached at the back of this study as an appendix. ENSACA DASHBOARD

Source: ENSACA

Key to Colour Weighting :

Black - not assessed

Red - weighted score >0 but <40%

Amber - weighted score ≥40% but <75%

Green - weighted score ≥75% but ≤100%

60 4.4 .2 BAR CHART REPRESENTING ENSACA’s NHOCAT SCORE

ENSACA NHOCA Weighted Scores 14 12.9 12 10 7.8 8 6.5 5.3 6 6 4 3 4 2 2.6 2.5 2 0

BAR CHART 4.4.2

Source: ENSACA NHOCAT ASSESSMENT

4.4.3 INTERPRETATION OF THE NHOCAT SCORES

From the Dashboard and Bar chart above it would be seen that ENSACA scored 2% in Human Resources Management out of the total domain score of 7% which was rated red colour or greater than 0% but less than 40%; ENSACA scored 7.8% in Bud get and Financial Management System out of 10% domain score, rating green which is greater than 75% but less than 100%; 5.3% in Procurement and Inventory Management out of 7% domain score which was rated green, or greater than 75% and less than 100% ; 4% in Planning out of 10% domain score which was rated amber or g reater than 45% and less than 75%; 2.6% in Physical Infrastructure Management out of 7% domain score which was rated red or greater than 0% but less than 40%; 2.5% in Supervision and Oversight Standard out of 10% domain score which was rated red or greate r than 0% but less than 40%; 12.9% in Multi-Sectoral Coordination out of 15% domain score rated green or above 75% but below 100%; 6.5% in Governance and Leadership out of 10% domain score and rated amber which is greater than 45% but less than 75%; 6% in Monitoring and Evaluation Management System out of 12% domain score rated amber which is greater than 45% but less than 75% finally, 3% in Resource Mobilization and Accountability out of 12% domain score and rated red or greater than 0% but less than 40 %.

61 4.4.4 PRESENTATION OFRAW DATAFROM ENSACA MONITORING AND EVALUATION DEPARTMENT:

The following are raw data on 10 Indicators collected by the Monitoring and Evaluation Department in the Sites where Development Partners are working.

TABLE 4.4.4 SHOWING HEALTH SECTOR HIV DATA FOR THE YEAR 2013

ENUGU STATE HIV/AIDS DATA, 2013 INDICATORS TOTAL

# of pregnant women tested with results 50705

# of pregnant women positive 1170

# of positive pregnant women on ARVs 2712 # of HIV PCR results 220

# of PCR results positive 15

Total # of individuals tested & received results 572916

Total # tested HIV Positive 17220 # of HIV positive newly started treatment (ART) 3363

# of individuals currently on ART 40394

# of HIV positive on TB treatment 198 SOURCE: M&E DEPARTMENT, ENSACA(District Health Information System)

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BAR CHART 4.4.4 SHOWING THE HEALTH SECTOR HIV/AIDS DATA FOR 2013

Enugu State HIV/AIDS Data, 2013

572916 1000000 50705 40394 100000 17220 2712 3363 10000 1170 1000 220 198

100 15 10 1

Source: ENSACA MONITORING & EVALUATION DEPARTMENT

4.5 DISCUSSION OF FINDINGS

From the data presented above it would be deduced that: i. There is a strong perception at 99% statistic al assurance that the provisions of resources like finance, personnel and infrastructure impact positively on the control of HIV/AIDS in the State. Enugu State Agency for the Control of AIDS is funded by World Bank with a resource envelope of $700,000 and State Counterpart fund of N15.9million which helps to fund all the HIV response interventions in the State . There is also indirect funding through donor and development assistance agencies. Th e Agency is headed by a Medical Doctor who is also a member of the Executive Council. The other staff were seconded from different ministries to ENSACA. The Agency is staffed by 26 Public Servants comprising of 1 Director, 3 Deputy Directors, 3 Chief Exe cutive Officers, 1 Assistant Chief Executive Officer, 1 Project Accountant, 3 Principal Administrative Officers, 1Cashier, 2 Drivers and about 10 support staff. ENSACA procured 4 new vehicles (2 Hilux Ford Rangers and Buses) to

63 facilitate transportation of staff to different intervention sites. In addition the key staff all have official Laptops or Desktop computers for generating their data and reports. ii. There is also a strong perception at 99% statistical confidence that Enugu State Agency for the Control of AIDS (ENSACA) has the capacity to coordinate the HIV/AIDS response programmes in Enugu State. The Agency is staffed by well trained personnel who deliver in their various thematic areas. The Agency coordinates all the HIV/AIDS related data in the State through monitoring and evaluation and keys in the data into the District Health Information System (DHIS). Most of the data presented in this research were sourced from the Monitoring and Evaluation department. In 2013 number of pregnant women tested with results were 50705, number of positive pregnant women were 1170, number of positive pregnant women on ARV were 2712, number of children born to positive women tested were 220, number of children born to positive mothers who tested positive were 15, total number of people tested with results were 572916, total number of women who tested positive were 17220, number of HIV positive newly started on treatment were 3363, number of individual currently on ART are 40394 and number of HIV positive on TB treatment are 198. iii. In Research question three the following factors were recommended to be put in place in order to move HIV/AIDS response in the State forward:  Capacity building of staff at all levels: Serious capacity gaps in the staff responsible for the response to HIV/AIDS in the State were identified especially at the Local government level. The staff working in the State response also need to be trained and re-trained.  More technical assistance and support from the government: It is recommended that the government sets aside at least 1% of its annual budget for HIV/AIDS. So far the response to HIV/AIDS in the State has been mostly donor driven. It is also recommended that government release the provision for HIV/AIDS in the annual budgets, many times little or nothing is released.  More care and support to People Living with HIV/AIDS:

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As we approach 2015 when the HIV/AIDS PROGRAM DEVELOPMENT PROJECT (HPDP-2) supported by World Bank will end, it is advocated that government should see to the sustainability and uptake of care to People living with HIV/AIDS.  Proper Supply Chain of ART and other consumables: Stock out of consumables should be nipped in the bud through a well coordinated supply chain of ART and other consumables.  Aggressive media hype for HCT & PMTCT: To address the ignorance of basic facts about HIV/AIDS, an aggressive media hype should be embarked upon to properly educate and sensitive the people on ways of contracting the virus and the evil of stigma and discrimination. The people also need to be sensitized on the existence of an Anti stigma and Discrimination law in the State.  Improving the HIV/AIDS database for monitoring and evaluation system: The Monitoring and Evaluation department is the information power house on HIV/AIDS for the State, as a result, they should be properly trained and equipped to generate reliable data for analysis and projections.  Release of timely information to policy makers through Fact Sheets: Timely release of HIV/AIDS response fact sheets in the State is highly recommended to facilitate decision making for Policy Makers.  Qualitative and effective reporting at all levels: The information flow is from CSOs to LACAs to SACA and to NACA. To achieve this, qualitative and effective reporting is required at all levels.  Discipline and responsible dispatch of duties by staff at all levels: To achieve the objectives of the State Strategic Plan on HIV/AIDS, staff at all levels should exhibit discipline and responsible dispatch of their duties.  Becoming a global stakeholder and reference point through website information:

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As the world has become a global village, the use of well informed and updated website will help ENSACA become a global stakeholder and a reference point.  Provision of sufficient vehicles: The Agency was operating with two old vehicles, but recently World Bank assisted the State to buy 4 new vehicles.  Sensitization on the anti-discrimination and stigma law: Many people do not know about the existence of the Anti- Discrimination and stigma law in the State. Efforts should be made to disseminate copies of this law as ignorance of the law is not an excuse.  Developing proper referral systems and follow up of positive patients: Patients who test positive should be followed up with proper referral systems to make sure that treatment is started to stop the spread of the virus.  Provision of Mobile HCT Vans: Provision of Mobile HCT Vans will avail many people of the opportunity to test and know their HIV status and start treatment if they test positive.  Transparency at all levels: There should be transparency and openness at all levels so that funds provided for HIV/AIDS is properly utilized for the response.  Proper Motivation of staff for hard work: Most of the staff that do the response are Civil Servants seconded from their parent Ministries. Despite the fact that they work round the clock and even write and send reports on weekends from their homes late at nights, yet they are not paid any allowance. They earn just the same as other Civil Servants who dismiss at 4.00pm. If thesestaff are well motivated, they will do more.  Provision of more Comprehensive sites: Some Local governments do not have Comprehensive sites, it is advocated that more comprehensive sites be provided and evenly distributed across the State.

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 Provision of Office equipment and physical infrastructure for the response: Provision of more office space, equipment and infrastructure will facilitate the response. A lot of renovation has been done in ENSACA recently but that should not replace the promised permanent site.

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CHAPTER FIVE

SUMMARY, CONCLUSION AND RECOMMENDATIONS

5.1 SUMMARY In summary, this study tried to find out whether the provisions of financial, human and infrastructural resources by the State have any impact on the control of HIV/AIDS in Enugu State and the result was that there is a strong perception at 99% statistical assurance that the provisions of resources like finance, personnel and infrastructure impact positively on the control of HIV/AIDS in the State. Whether Enugu State Agency for the Control of AIDS (ENSACA) has the capacity to coordinate the HIV/AIDS response programmes in Enugu State was also x-rayed and it was found out that there is a strong perception at 99% statistical confidence that Enugu State Agency for the Control of AIDS (ENSACA) has the capacity to coordinate the HIV/AIDS response programmes in Enugu State. Finally, the study probed for the factors that should be put in place to provide the way forward in the response to HIV/AIDS in Enugu State and found out the following:  Capacity building of staff at all levels: Serious capacity gaps in the staff responsible for the response to HIV/AIDS in the State were identified especially at the Local government level. The staff working in the State response also need to be trained and re-trained.  More technical assistance and support from the government: It is recommended that the government sets aside at least 1% of its annual budget for HIV/AIDS. So far the response to HIV/AIDS in the State has been mostly donor driven. It is also recommended that government release the provision for HIV/AIDS in the annual budgets, many times little or nothing is released.  More care and support to People Living with HIV/AIDS: As we approach 2015 when the HIV/AIDS PROGRAM DEVELOPMENT PROJECT (HPDP-2) supported by World Bank will end, it is advocated that government should see to the sustainability and uptake of care to People living with HIV/AIDS.  Proper Supply Chain of ART and other consumables: Stock out of consumables should be nipped in the bud through a well coordinated supply chain of ART and other consumables.

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 Aggressive media hype for HCT & PMTCT: To address the ignorance of basic facts about HIV/AIDS, an aggressive media hype should be embarked upon to properly educate and sensitive the people on ways of contracting the virus and the evil of stigma and discrimination. The people also need to be sensitized on the existence of an Anti stigma and Discrimination law in the State.  Improving the HIV/AIDS database for monitoring and evaluation system: The Monitoring and Evaluation department is the information power house on HIV/AIDS for the State, as a result, they should be properly trained and equipped to generate reliable data for analysis and projections.  Release of timely information to policy makers through Fact Sheets: Timely release of HIV/AIDS response fact sheets in the State is highly recommended to facilitate decision making for Policy Makers.  Qualitative and effective reporting at all levels: The information flow is from CSOs to LACAs to SACA and to NACA. To achieve this, qualitative and effective reporting is required at all levels.  Discipline and responsible dispatch of duties by staff at all levels: To achieve the objectives of the State Strategic Plan on HIV/AIDS, staff at all levels should exhibit discipline and responsible dispatch of their duties.  Becoming a global stakeholder and reference point through website information: As the world has become a global village, the use of well informed and updated website will help ENSACA become a global stakeholder and a reference point.  Provision of sufficient vehicles: The Agency was operating with two old vehicles, but recently World Bank assisted the State to buy 4 new vehicles.  Sensitization on the anti-discrimination and stigma law:

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Many people do not know about the existence of the Anti- Discrimination and stigma law in the State. Efforts should be made to disseminate copies of this law as ignorance of the law is not an excuse.  Developing proper referral systems and follow up of positive patients: Patients who test positive should be followed up with proper referral systems to make sure that treatment is started to stop the spread of the virus.  Provision of Mobile HCT Vans: Provision of Mobile HCT Vans will avail many people of the opportunity to test and know their HIV status and start treatment if they test positive.  Transparency at all levels: There should be transparency and openness at all levels so that funds provided for HIV/AIDS is properly utilized for the response.  Proper Motivation of staff for hard work: Most of the staff that do the response are Civil Servants seconded from their parent Ministries. Despite the fact that they work round the clock and even write and send reports on weekends from their homes late at nights, yet they are not paid any allowance. They earn just the same as other Civil Servants who dismiss at 4.00pm. If thesestaff are well motivated, they will do more.  Provision of more Comprehensive sites: Some Local governments do not have Comprehensive sites, it is advocated that more comprehensive sites be provided and evenly distributed across the State.  Provision of Office equipment and physical infrastructure for the response: Provision of more office space, equipment and infrastructure will facilitate the response. A lot of renovation has been done in ENSACA recently but that should not replace the promised permanent site.

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5.2 CONCLUSION Though statistical data and analysis has proven that ENSACA has the capacity to deliver the multi-sector response to HIV/AIDS in the State, however its performance is threatened by the following challenges:  Lack of financial resources as the HIV response in the State is mainly donor driven, a lot still needs to be done by the State in terms of budgetary allocations for HIV and AIDS and releasing the budgeted funds.  Inadequate staff: Each staff is multi-tasked, one person does many tasks.  Lack of capacity building of staff at State and Local government levels: The staff doing the response at all levels lack the capacity and need to be empowered more.  Insufficient motivation of staff: ENSACA staff work even from their homes and are not properly remunerated.  Inadequate referrals and follow up of positive patients: Lack of adequate referral and follow up of positive patients drives the epidemic as positive patients don’t receive treatment and care and they go on to infect others.  Stigma and discrimination of PLWHA: Stigma and discrimination is another driver of the epidemic as positive patients go underground and continue to infect others.  Inadequate database: Lack of adequate data on HIV/AIDS militates against policy making.  Lack of sufficient technical assistance and support from the government slows down the pace of the response in the State.  Inadequate education and awareness sensitization: Ignorance of the basic facts about HIV/AIDS and the mode of transmission fuels stigma and discrimination of positive people.  Insufficient IT support materials: There should be an upscale of IT materials as they are insufficient.  Insufficient Comprehensive sites in the State: Some Local governments in the State do not have Comprehensive sites where HCT, ART and PMTCT services are carried out.  Poor remuneration: the staff doing the response are poorly remunerated.  Short supply of consumables: Stock out of consumables and drugs is a serious challenge.

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 Lack of Office space: The office space is limited and not enough.  Lack of proper understanding of roles and internal conflicts: Multi-tasking sometimes breeds conflicts.  Indifference to counselling and testing by the public: the first step to curbing HIV/AIDS is by knowing one’s HIV status; but the public are indifferent to testing and knowing their HIV status.  Lack of transparency by partners: Partners hide their resource envelope and this militates against calculating the resource gap.

It would be pertinent to note that the above challenges facing ENSACA has been further exacerbated by the abrupt slashing of funds and support by the US government and other partners in the HIV/AIDS response nation-wide; hence the need for resource mobilization by looking inwards for increased government budgeting in HIV/AIDS response, increased private sector participation and contribution to the HIV/AIDS issue, improved allocative efficiency and good governance at all levels.The President’s Comprehensive Response Plan to HIV/AIDS, has set out key priority areas for the response and is setting up a HIV/AIDS Trust Fund in each of the States with a percentage of State government contribution, contribution from the Private Sector and Counterpart funding from the Federal government.

5.3 RECOMMENDATIONS

From the analysis in chapter four, the following are the factors that should be put in place to provide the way forward to the response to HIV/AIDS in Enugu State.

1. Resourcing and Mobilizing Alternate Funding Since World Bank fund credit will end by 2015, it is highly recommended that alternate funding should be sourced and mobilized for the sustainability of the HIV/AIDS response in the State.

2. Provision of Sufficient Vehicles To facilitate the operations of ENSACA vehicles are needed to transport staff to the various sites and facilities for supervision and collation of data. The World Bank has assisted the Agency to purchase 4 new vehicles which has boosted the intervention on HIV/AIDS in the State.

3. Aggressive Media Hype for HCT & PMTCT Many people are still ignorant of their HIV/AIDS status, aggressive media hype is recommended for testing and counselling and for the prevention of mother to child transmission.

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4. Capacity Building of Staff at All Levels Capacity gaps have been identified at all levels of the intervention, capacity building is therefore recommended to train staff on the latest technologies of the HIV/AIDS response.

5. More Technical Assistance and Support from The Government HIV/AIDS response in the State is more donorsdriven; it is recommended that government gives more technical and financial support to the Agency charged with the coordination of HIV/AIDS response in the State by releasing the budget for HIV/AIDS to Line Ministries.

6. More Care and Support to PLWHA More care and support to PLWHA is recommended. Many people in the State are ignorant of the existence of the anti-discrimination and stigma law. The citizens should be sensitized on this law in order to reduce stigmatization of PLWHA. Work place policy should also be developed to take care of the needs of PLWHA.

7. Proper Supply Chain of ART and other Consumables With the cessation of funds from Donor Agencies by 2015 it is forecasted that more AIDS related deaths will occur. This can be prevented by starting to plan now for that rainy day by instituting proper supply chain of ART and other consumables.

8. Developing Proper Referral Systems And Follow Up of Positive Patients. Proper referral systems and follow up mechanisms should be put in place to track the treatment of HIV positive patients to stop the spread of the virus.

9. Provision of Mobile HCT Vans. Provision of Mobile HCT Vans will bring testing and counselling to the door steps of the citizens of the State, as the first step of curbing the virus is to know one’s HIV status.

10. Improving the HIV/AIDS Database And Monitoring And Evaluation System Information from HIV/AIDS in the State is used by Policy Makers to make decisions concerted efforts should therefore be made to improve the HIV/AIDS database and the monitoring and evaluation systems.

11. Sensitization the Anti-Discrimination and Stigma Law People should be sensitized on the existence of the Anti-Discrimination and Stigma law as ignorance of the law is not an excuse.

12. Qualitative And Effective Reporting At All Levels Qualitative and effective reporting is expected from Civil Society Organizations, LACAs, and SACAs for onward transmission of the data to the national body – NACA.

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13. Discipline and Responsible Dispatch of Duties by Staff at All Levels Discipline and responsible dispatch of duties are expected from staff doing the response at all levels in the State.

Nevertheless, the Analysis suggests that the following factors be put in place.

1. Proper Motivation Of Staff For Hard Work The staff doing the response to HIV/AIDS in the State are Civil Servants seconded from their parent ministries to ENSACA. These staff work round the clock without receiving any extra allowance apart from their meagre salaries. Payment of allowances and stipends for the extra mile they go will motivate staff to work harder.

2. Transparency at All Levels. Transparency is recommended at all levels of the HIV/AIDS response in the State in order to utilize the available resources effectively and efficiently.

3. Provision of More Comprehensive Sites. More comprehensive sites should be provided and evenly distributed across the various Primary Health Centres in the State.

4. Becoming a Global Stakeholder and Reference Point Makers through Website Information. As the world has become a global village, developing an ENSACA website will position the Agency to become a global stakeholder and the uploading of current Fact Sheets will help the Agency to become a reference point.

5. Release of Timely Information to Policy Makers through Fact Sheets. Efforts should be made by all and especially the M&E department to release quarterly or yearly Fact Sheets on HIV/AIDS response in the State which will be used for decision making by Policy makers.

6. Provision of Office Equipment and Physical Infrastructure For The Response Obsolete office equipment and infrastructure should be replaced with the latest technology to boost the intervention on HIV/AIDS in the State.

It is believed that if these factors are put in place, ENSACA will be better positioned to deliver on its multi-sectoral response to HIV/AIDS in the State and it will also reduce the scourge of HIV /AIDS to its barest minimum.

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REFERENCES

Books Conover, W. J. (1980) ‘Practical Nonparametric Statistics’ 2nd ed. New York: John Wiley and Sons.

Ezeani, E.O. (2006) ‘Fundamentals of Public Administration’ , Enugu: SNAAP Press Ltd.

OdoO.M. (1992) ‘ Guide To Proposal Writing in Social and Behavioural Sciences ’ Enugu: SNAAP Press Ltd. Yamane,T. (1964) ‘ An Introductory Analysis’ , New York: Harper and Row Publications.

Government Publications All Africa (2010) ‘Nigeria: NACA Launches #756 billion National HIV/AIDS Strategic Framework 2010-2015’. ENSACA (2009) ‘ Enugu State HIV/AIDS Strategic Plan of Action (2010-2015)’

Enugu State Agency for the Control of AIDS (2012) Fact Sheet

Federal Ministry of Health (2008) ‘Antenatal Care Survey’ Abuja www.nigerianstat.gov.ng

Federal Ministry of Health (2009) ‘ Mode of Transmission Study ’, Abuja

Federal Ministry of Health (2010) ‘Mode of Transmission Study’ , Abuja

Federal Ministry of Health, Department of Public Health National AIDS/STI Control Programme (2010) ‘ National HIV Sero-Prevalence Sentinel Survey Technical Report’ Federal Republic of Nigeria (2007) Official Gazette

Federal Republic of Nigeria (2012) ‘Global AIDS Response Progress Report ’ www.unaids.org/.../knowyourresponse/countryprogressreport/ [Retrieved September 2013] National Agency for the Control of Aids (2009) ‘Project Implementation Manual forHIV/AIDS Program Development Project’ National Agency for the Control of Aids (2012) ‘President’s Comprehensive Response Plan for HIV/AIDS in Nigeria (2013-2015)’

National Agency for the Control of Aids (2012) ‘President’s Emergency Response Plan for HIV/AIDS in Nigeria (2013-2015)’

National Agency for the Control of Aids (2012) ‘Standard Operational Manual for NACA, SACA & LACAs Coordination Platforms and Technical Working Groups’

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National Agency for the Control of AIDS (2009) ‘National HIV/AIDS Strategic Framework 2010-2015’

National Bureau of Statistics [Online] http://www.nigerianstat.gov.ng

National Population Census (2006) www.population.gov.ng [Accessed September 2013]

Nigeria Demographic and Health Survey (2008) Abuja, Nigeria. www.nigerianstat.gov.ng [Accessed February 2014] UNAIDS (2008) ‘Report on the global AIDS epidemic’ www.unaids.org [Accessed September 2013]

UNAIDS (2010) ‘HIV Epidemic Update’ www.unaids.org [Retrieved August 2013]

United Nations Population Fund (UNFPA) (2008) ‘Report on HIV in Enugu State’ [Online] http:www.avert.org/aids.nigeria [Accessed August 2013].

United States Government (2007) ‘Nigeria Energy Profile’, Official Energy Statistics from the Energy Information Administration www.eia.gov/countries [Retrieved August 2013)

Internet Materials Global Health Observatory [Online] http://www.who.int/gho/hiv/epidemic_status/deaths/en/

Integrated Bio-Behavioural Surveillance Survey (2007) www.popcouncil.org/pdfs/2011HIV_IBBSS2010.pdf

Mogey, N. (2014). "So You Want to Use a Likert Scale?" .Learning Technology Dissemination Initiative.Heriot-Watt University.http://www.icbl.hw.ac.uk/ltdi/cookbook/info_likert_scale/index.html . Retrieved March 21, 2012.

Okoye C. [Online] http://cokoye.com/health/the-history-of-hiv-in-nigeria-you-should-know- and-statistics/ [Accessed August 2013]

[Online] www.unaids.org/documents/20101123_Global report_em.pdf [Retrieved September 2013]

[Online] http://www.unaids.org/en/dataanalysis [Retrieved August 2013]

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APPENDIX A

School of Post-Graduate Studies Department of Public Admin & Local Govt. University of Nigeria, Nsukka Campus

12 th February 2014

Dear Sir/Madam,

LETTER OF INTRODUCTION

I am a Post-graduate student of the University of Nigeria, Nsukka Campus. I am studying in the Department of Public Administration and Local Government. My dissertation is on ‘The State and HIV/AIDS Control in Nigeria: A Study of Enugu State Agency for the Control of AIDS’. As a result, I have developed a questionnaire called ‘State and HIV/AIDS Control Descriptive Questionnaire’.

You are requested to please answer the questionnaire truthfully to enable me achieve objective results. Your response will be treated with utmost confidence.

Thank you.

Yours faithfully

Aniagolu Josephine N.

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STATE AND HIV/AIDS CONTROL DESCRIPTIVE QUESTIONNAIRE (S.A.H.C.D.Q)

SECTION A – PERSONAL DATA

All information given in this research will be treated with utmost confidentiality and secrecy. Please answer truthfully to enable me achieve objective results.

Please tick as appropriate

1. What is your educational background? FSLC ______WASC/GCE ______NCE/OND ______B.Sc/HND ______M.SC/MBA ______PhD/Doctor ______2. Please indicate your age in years ______3. What is your occupation? ______4. Please state your LGA of origin ______5. Are you male _____ or female _____ 6. Please tick your marital status: Single ______Married ______Separated ______Divorced ______Widow ______

SECTION B

Please tick as appropriate.

7. Does the provision of resources like finance, personnel and infrastructure impact positively on the control of HIV/AIDS in the State? YES ____ NO _____ 8. Please rate accordingly To what extent do you agree to the assertion that theprovision of resources like finance, personnel and infrastructure impacts positively on the control of HIV/AIDS in the State? Agree ______Strongly Agree ______Undecided ______Disagree ______Strongly disagree ______9. Which of the following factors impact positively on the control of HIV/AIDS? i. Adequate Finance ______ii. Provision of ART ______

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iii. Provision of adequate and evenly distributed Comprehensive sites______iv. Prevention of Mother to Child Transmission ______v. Proper education, awareness and sensitization ______vi. Proper use of Condom/Abstinence ______vii. Provision of Infrastructure ______viii. Adequate trained staff ______ix. Good leadership ______x. Proper motivation of staff ______xi. Good referral system ______xii. Absence of stigma and discrimination ______xiii. Adequate HIV/AIDS data base ______xiv. Disciplined, responsible & cohesive workforce ______xv. All the above ______xvi. Others (specify) ______10. Does the mobilization of resources whether financial, technical assistance or material resources have an impact on the control of HIV/AIDS in Enugu State? YES ____ NO ____ 11. Please rate as appropriate To what extent do you agree to the assertion that the mobilization of resources like finance, technical assistance or material resources has an impact on the control of HIV/AIDS in the Enugu State.? Agree ______Strongly Agree ______Undecided ______Disagree ______Strongly disagree ______12. Does the provision of HCT, ART and PMTCT centres have any impact on the control of HIV/AIDS in the State? YES ____ NO_____ 13. Please rate accordingly To what extent do you agree to the assertion that the provision of HCT, ART and PMTCT centres has impact on the control of HIV/AIDS in the State? Agree ______Strongly Agree ______Undecided ______Disagree ______Strongly disagree ______14. Does the provision of an enabling environment for stakeholders have an impact on HIV/AIDS control in the State? YES ____ NO ____

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15. Please rate accordingly To what extent do you agree to the assertion that the provision of enabling environment for stakeholders has an impact on HIV/AIDS control in the State? Agree ______Strongly Agree ______Undecided ______Disagree ______Strongly disagree ______16. Does the motivation of ENSACA Staff and other Health workers have any impact on the control of HIV/AIDS in the State? YES ____ NO ___ 17. Please rate accordingly To what extent do you agree to the assertion that the motivation of ENSACA staff and other Health workers has an impact on the control of HIV/AIDS in the State? Agree ______Strongly Agree ______Undecided ______Disagree ______Strongly disagree ______18. Do you adjudge ENSACA as having the capacity to coordinate the HIV/AIDS response programmes in Enugu State? YES ____ NO ____ 19. Please rate accordingly To what extent do you agree to the assertion that ENSACA has the capacity to coordinate the HIV/AIDS response programmes in Enugu State? Agree ______Strongly Agree ______Undecided ______Disagree ______Strongly disagree ______20. Does ENSACA have enough personnel and the relevant capacity to deliver on its mandate of coordinating the multi-sector response to HIV/AIDS in the State? YES____ NO _____ 21. Please rate accordingly To what extent do you agree to the assertion that ENSACA has enough personnel and the relevant capacity to deliver on its mandate of coordinating the multi sector response to HIV/AIDS in the State? Agree ______Strongly Agree ______Undecided ______

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Disagree ______Strongly disagree ______22. Is ENSACA’s leadership and governance poised to deliver on its mandate? YES____ NO ___ 23. Please rate accordingly To what extent do you agree to the assertion that ENSACA’s leadership and governance is poised to deliver on its mandate? Agree ______Strongly Agree ______Undecided ______Disagree ______Strongly disagree ______24. Does ENSACA have a robust monitoring and evaluation system to implement the supervision and oversight function in the control of HIV/AIDS in the State? YES ___ NO ____ 25. Please rate accordingly To what extent do you agree to the assertion that ENSACA has a robust monitoring and evaluation system to implement the supervision and oversight function in the control of HIV/AIDS in the State? Agree ______Strongly Agree ______Undecided ______Disagree ______Strongly disagree ______26. Does ENSACA have enough networking to coordinate the multi-sector response to HIV/AIDS in the State? YES ___ NO ___ 27. Please rate accordingly To what extent do you agree to the assertion that ENSACA has enough networking and linkages to coordinate the multi sector response to HIV/AIDS in the State? Agree ______Strongly Agree ______Undecided ______Disagree ______Strongly disagree ______28. Does ENSACA have a robust budget and financial management system to document the financing of HIV/AIDS intervention activities in the State? YES ___ NO ____ 29. Please rate accordingly

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To what extent do you agree to the assertion that ENSACA has a robust budget and financial management system to document the financing of HIV/AIDS intervention activities in the State? Agree ______Strongly Agree ______Undecided ______Disagree ______Strongly disagree ______30. Are the resources available to ENSACA enough for implementing the activities of HIV/AIDS in the State? YES ____ NO _____ 31. Please rate accordingly To what extent do you agree to the assertion that the resources available to ENSACA are enough for implementing the activities of HIV/AIDS in the State? Agree ______Strongly Agree ______Undecided ______Disagree ______Strongly disagree ______32. Does ENSACA have enough physical infrastructure and equipment to carry out its mandate? YES ____ NO ____

Please rate accordingly

To what extent do you agree to the assertion that ENSACA has enough Physical infrastructure and equipment to carry out its mandate?

Agree ______Strongly Agree ______Undecided ______Disagree ______Strongly ______33. To what extent do you rate the planning and implementation of activities of ENSACA on HIV/AIDS? Excellent ______Good ______Fair ______Poor ______

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34. Please tick the challenges you think are hindering ENSACA from delivering its mandate. a. Lack of financial resources ______b. Inadequate education and awareness/sensitization ______c. Inadequate staff ______d. Poor remuneration ______e. Inadequate data base ______f. Lack of capacity building of staff at State and Local government levels ______g. Insufficient Comprehensive sites in the State ______h. Insufficient vehicles ______i. Insufficient IT support materials ______j. Lack of Office space ______k. Short supply of consumables ______l. Lack of transparency by Partners ______m. Indifference to counselling and testing by the public ______n. Stigma and discrimination of PLWHA ______o. Lack of technical assistance and support from the government ______p. Lack of proper understanding of roles and internal conflicts ______q. Insufficient motivation of staff ______r. Inadequate referrals and follow up of positive patients ______s. All the above ______t. Others (specify)______35. Indicate your possible suggestions to ENSACA towards the control of the scourge of HIV/AIDS in Enugu State. a. Resourcing and mobilizing alternate funding ______b. Provision of sufficient vehicles ______c. Aggressive media hype for HCT & PMTCT ______d. Capacity building of staff at all levels ______e. Proper motivation of staff for hard work ______f. More technical assistance and support from the government ______g. Transparency at all levels ______h. More care and support to PLWHA ______i. Proper supply chain of ART and other consumables ______j. Provision of more Comprehensive Sites ______k. Developing proper referral systems and follow up of positive patients ______l. Provision of Mobile HCT Vans ______m. Improving the HIV/AIDS data base and monitoring and evaluation system______n. Sensitization on the anti-discrimination and stigma law ______

83 o. Becoming a global stakeholder and reference point through website information___ p. Release of timely information to policy makers through fact sheets ______q. Qualitative and effective reporting at all levels ______r. Provision of office equipment and physical infrastructure for the response______s. Discipline and responsible dispatch of duties by staff at all levels ______t. All the above ______u. Others (specify) ______

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