Country Harmonization and Alignment in the National Response to HIV/AIDS and Sexually

Country Harmonization and Alignment in the national response to HIV/AIDS and Sexually transmitted infections

Report

Chisinau, 2009 CCM and UNAIDS Abreviations and acronims:

AFEW – AIDS Foundation East-West; APL/LPA –Local Public Authorities; Asdi/Sida – Sweden International Development Agency; BM/WB – World Bank; CHAT – Country Harmonization and Alignment Tool; CNAM/NCHI– National Company of Health Insurance; CNC TB/SIDA/CCM on TB/AIDS – Country Coordination Mechanism on National HIV/AIDS/STI Prophylaxis and Control and TB Control and Prophylaxis Programme; CNMS/NCHM – National Centre of Health Management; CNSPMP/NCPM – National Centre of Preventive Medicine; DDVR/RDVD – Republican Dermato-Venerologic Dispensary; DIP/DPI– Department of Penitentiary Institutions; DNR/RND – Republican Narcologic Dispensary; EMT/MTR – Mid Term Review of NP for the period 2006-2010; FSM/SMF –Soros-Moldova Foundation; GTZ – German Agency for Development; IDA – International Development Agency; IFP – Phtisiopneumological Institute; ILO – International Labour Organization; STI – sexually transmitted infections; MAI/MIA – Ministry of Internal Affairs; MEC – Ministry of Economy and Commerce; MET/MEY – Ministry of Education and Youth; MF – Ministry of Finance; MJ – Ministry of Justice; MNC/CCM – Country Coordination Mechanism; MPSFC/MSPFC– Ministry of Social Protection, Family and Child; MS/MH – Ministry of Health; M&E – monitoring and evaluation; OMS/WHO – World Health Organization; ONG/NGO – nongovernmental organizations; PNPCHS/NHAPCP– National HIV/AIDS/STI Prophylaxis and Control Programme; PNUD/UNDP – United Nations Development Programme; UCIMP/PCU – Project Coordination Unit; UNAIDS- United Nations Agency for HIV/AIDS; UNFPA – United Nations Fund for Population Development; USAID – United States Agency for International Development; Content:

Executive Summary Introduction Method of research Respondents’ description Mapping Key results and analyses Summary and recommendations Annexes: Annex 1 – List of reviewed reports Annex 2 – Analyses of collected information Annex 3 – Questionnaires for national partners Annex 4 - Questionnaires for international partners

INTRODUCTION What is CHAT and why should countries use it? The Country Harmonization and Alignment Tool (CHAT) was designed to help answer the following questions:  Do we have inclusive, participatory national responses to AIDS?  Do we have effective coordination and funding partnerships for the national AIDS  response?  How can we improve our partnerships to strengthen the response to AIDS?

The main purpose of CHAT is to invite dialogue about the strengths and weaknesses of the national AIDS response, leading to positive action for change. CHAT consists of a three-part process of mapping—or constructing a visual overview—of stakeholders in the national response, followed by structured interviews with national and international partners. The results will gauge national and international partner involvement in the AIDS response and their adherence to agreed good practice in harmonization and alignment, improve transparency and accountability, and help to catalyse a national dialogue to improve practice for a more effective national response. CHAT provides important contextual information relevant to national strategic planning, and is ideally carried out as part of the joint national AIDS programme review. The following diagram gives an overview of how the three CHAT components link to the joint review. CHAT is a way of assessing both the strengths and areas for improvement in these relationships. Additionally, CHAT is designed to highlight and reinforce the key role that civil society plays in the AIDS response.

It is important to emphasize that CHAT is not a standard survey tool. Rather, it is a multifaceted process based on action research principles and techniques. Therefore, CHAT is: This report has been compiled for the National Coordination on Prevention and Control of HIV/AIDS/STIs and TB. The survey on stakeholders’ harmonization and alignment in the national response to HIV/AIDS/STIs was accomplished in September 2008 – February 2009 within the process of Mid-term Review of the National AIDS Programme 2006-2010. It was complied with the principles pertaining to „Paris Declaration on Aid Effectiveness: strengthening the partnership between national and international actors to ensure a coordinated response (ownership, alignment, and harmonization)”. The ‘Three Ones” principle was respected. Its essence is to join the efforts in the field of programming and planning – one agreed National Programme, coordination – one National AIDS Coordinating Authority, monitoring and evaluating the national response to AIDS by managing one agreed National M&E System. One of the main principles of the survey pertains to the assessment of partners from the nongovernmental sector and identification of ways to improve their involvement in TB/AIDS Control and Prophylaxis.

The scheme below shows the relation between the CHAT tool and the process of Mid-term Review of the NAP. CHAT and MTR of the NAP

CHAT Mapping Provides basic data + shows key relationships for the national HIV response

CHAT CHAT National Partners All three components combined International Partners provide an overview of how Assessment Assessment partnership processes support the national HIV response M eas ures l part inte na ner rna tio n harm tion na tio an on al s pa d ali izati ure ici t gnm on as art en National AIDS ent Me r p em ne ag art ng Programme Review p d e an National AIDS Response Strategic Planning and Implementation Process

The application of this tool allows determining if the national AIDS response is a participative and inclusive one; if funding and coordination partnerships in the field of HIV are efficient. Also, it allows identifying ways to improve partnership and to strengthen the response to HIV/AIDS Control; inviting partners to participate in a dialogue while establishing the partnership’s strong and weak points; building a general visual framework of all the partners involved in the national response; identifying ways to improve transparency and partners engagement, including the role of NGOs; offering accurate answers in the process of strategic planning, including MTR; NCC reforming.

RESEARCH METHOD:

The Purpose of the Survey is to assess the strong and weak points of the national response to HIV/AIDS/STI Control, which would subsequently lead to positive actions for change. The Objective of the Research pertains to identifying strong and weak points of the national response to HIV/AIDS/STI Control, which would subsequently lead to positive actions for change.

TYPE OF STUDY: The study is a qualitative one, based on a questionnaire. The “face-to-face” and “self- administration” procedures have been used to interview the partners. The interviewees were mainly representatives from the national decision making level, partially local by including representatives from East and North regions of the Republic of Moldova.

COLLECTION TOOL: The CHAT questionnaire elaborated by UNAIDS Office from Geneva in 2007 was used throughout the survey. The questionnaires differ per category of respondents: national (which includes governmental and non-governmental sectors) and international (bilateral and multilateral development agencies). The questionnaire was adjusted to the national context in terms of terminology, and some content elements.

SELECTION OF RESPONDENTS: The respondents have been selected by combining two methods: purposeful and convenience selection. Both methods are non-probabilistic, specific for qualitative studies. The purposeful method of selection allows identifying various points of view and solutions coming directly from the persons involved in the assessment processes of the survey.

Convenience selection implies the selection of respondents who can be easier identified or those who have greater interest to participate in the survey.

DATA COLLECTION: Two consultants have been recruited for the data collection process. Some of the questionnaires have been used by applying the “face to face” procedure. The “self-administration” procedure was used for other questionnaires.

Data analyses were made in accordance with the 3 elements of the survey: mapping, national partners’ general assessment, with desegregation per national and international partners. The method of rapid revision of the existent reports and documents has been applied during the mapping process, and partners’ assessment. Annex 1 contains the list of the revised reports. 35 questionnaires have been validated for analyses: 18 questionnaires of representatives from governmental organizations, 9 – from non-governmental organizations and 8 – from international agencies. The data were introduced in a excel data base, verified by the consultants and several members of the Coordination Group. The database includes all the comments, opinions, and recommendations of the respondents. Annex 2. CHAT RESEARCH: The research was carried out during the process of Mid-term Review of the National AIDS Programme 2006-2010. During the workshop held on September 5-6 on MTR the CHAT tool was presented to all the partners and the technical aspects were established (objectives, collection tools, selection of respondents, plan on how to accomplish the survey, the person in charge of the survey). During the M&E workshop organized on November 13-15, the results of the mapping process on partners’ response to AIDS were presented and discussed. The final results have been coordinated with the Coordination Group and presented during the workshop on the final results of the MTR in February 2009.

Description of Respondents

35 stakeholders have been involved in the survey on the national response to HIV/AIDS/STI. 27 are national partners: 18 are from the governmental sector (central and local institutions) and 9 organizations represent the nongovernmental sector (6 NGOs, including umbrella institutions, such as NGOs Union active in the field of harm reduction and the League of People Living with HIV/AIDS, a representative from the private sector and 2 from various religious confessions). The governmental sector have been represented by respondents from ministries at the central level: the Ministry of Health (2), the Ministry of Social Protection, Family and Child (2), the Government Office (1), the Ministry of Internal Affairs (medical section - 1), the Ministry of Justice (Department of Penitentiary Institutions - 1); at the level of republican institutions: the AIDS Centre, the Republican Dermato-venerological Dispensary, the National Programme on TB Control, the National Centre of Health Management (3), UCIMP (1), the Guardian Service (1), local level – Balti and Tiraspol.

International agencies have been represented by 6 respondents on behalf of multilateral development organizations: UNAIDS, UNDP, WHO, UNFPA, ILO; and 2 on behalf of bilateral development organizations: - SIDA (Swedish International Cooperation and Development Agency) and USAID (United States Agency for International Cooperation and Development).

Respondenti per sector

20 18 16 14 12 10 8 6 4 2 0 1

Sect. GO Sect. ONG Sector Int.

Mapping

Mapping of stakeholders involved in the national response to HIV/AIDS/STI offers the possibility to identify basic data/ the general background about these stakeholders and the types of relations between them. The permanent updating of the map represents a solid tool in the process of coordination of the national response to AIDS. In order to accomplish the mapping process, all the previous reports/ documents pertaining to the review of the NAP have been revised, the NCC functionality, the management and coordination processes of the national AIDS response achieved both at national and international levels have been evaluated. Annex 1. The map of actors from the NCC central level and of all the stakeholders involved in the national response to AIDS has been presented and discussed at the workshop on the Evaluation of the M&E National System that took place between November 13-15, 2008. The final version was approved during the workshop held on February 27-28, 2009 on the final results of the Mid-term Evaluation of the National Programme on Control and Prophylaxis of HIV/AIDS.

The partnership framework of the national response to AIDS is incorporated in the activity of the National Coordination Council on the National Programme of Control and Prophylaxis of HIV/AIDS/STI and TB (NCC TB/AIDS). NCC is the only coordination body at the national level. Its establishment was determined by the awareness raising concerning the Tree One’s Principle, which proves a good functionality and efficiency of the national response in this field. The necessity to establish a unique coordination framework emerged as a result of the development and implementation of the second National Programme on Control and Prophylaxis of HIV/AIDS/STI for 2001-2005, which stipulates the need to strengthen the political engagement and to prioritize the HIV/AIDS issue on the country’s national agenda. Activities pertaining to the establishment and consolidation of the national multisectoral and interdepartmental Committee on HIV/AIDS/STI Prevention and Control, the promotion and facilitation of a more active involvement of actors from the nongovernmental sector and of donors have been formulated in the first strategy of the respective programme etc. Retrospectively, the National Interdepartmental Committee was created in October 2001, with the purpose to coordinate the activities of various ministries, departments, NGOs, and to evaluate these activities1. In 2002, when the Republic of Moldova accessed the financial resources from the first Grant of the Global Fund to Fight AIDS/TB and Malaria, the country solicited the establishment of a decision-making body – the National Coordination Mechanism (NCM). The

1 “Review of the National Programme on Prevention and Control of HIV/AIDS and STIs for 2001-2005”, Dr. Andrew J Amato-Gauci, UNAIDS Consultant, August 2004, p. 13 NCM was created simultaneously with the National Committee. The National Mechanism became a monitoring committee for the projects financed from the World Bank and IDA (International Development Agency). By that time, the NCM was considered by the greatest majority as being not functional enough – the NCM did not have systematic meetings2. In August 2005, once the Three One’s Principle stared to be promoted, the National Coordination Council was established to coordinate the National Programmes on Control and Prophylaxis of HIV/AIDS/STI and on TB Control and Prophylaxis by the Government Decision nr. 825. The existent reports relate that starting with 2005 the NCC improved its performance as a result of the development of a regulation/TOR which clearly stipulated the principles, the aim and objectives, the functions, the structure, and the ways of activity3. The national stakeholders and the international experts, involved in previous assessments of partnerships in Moldova, highly appreciated the active involvement of the nongovernmental sector, including people living with HIV/AIDS or affected by HIV/AIDS/STI, and representatives of the non-medical sector in the NCC processes and its technical mechanisms. Although the advantages of this appreciation and the evidence of the active involvement of the nongovernmental sector are quite evident, still there are restrictions regarding the direct financial support to NGOs, or any other kind of support from the state. In such a way, a recommendation was formulated to maintain advocacy among decision-making factors, for NGOs to receive appreciation and financial support and to be considered vital partners in the administration of these resources4. The National Coordination Council has three levels: the decision-making level, the coordination level and the technical level. The decision–making level consists of 22 members, representatives of the governmental sector (9), nongovernmental sector (5 or 23%) and international development agencies. The mapping exercise assessed both the NCC members’ level of influence and participation and the level of bilateral collaboration among NCC members, the

2 Idem, p. 13 3 „Report on progress, January 2006-December 2007”, Republic of Moldova, UNGASS, Chisinau 2008, p.21; „Situational analyses of National AIDS authority”, UNAIDS report, 2008. 4 “Review of the National Programme on Prevention and Control of HIV/AIDS and STIs for 2001-2005”, Dr. Andrew J Amato-Gauci, UNAIDS Consultant, August 2004, p. 13 Secretariat and other stakeholders. .

Relatii informare/ comunicare, participativitate&influenta

Legenda: Verde – influenta inalta Galben – mediu Guvern prin MS Oranj – scazut Cafeniu – lipsa - comunicare eficienta, inclusiv feedback

Secretariat comunicare dificila

CNSPMP UCIMP MJ UNAIDS OMS PAS LPTH FSM

Retea UNFPA UNICEF SIDA

Nivel BM ASDI USAID mediu Nivel Crucea PNUD Scazut MAI MinFin MET Rosie

APL Sec Actori Sector Com MPSFC MEC regiuni? acadmic lipsa privat relig

The level of participation and influence has been gauged by the periodicity of participation and interventions of the NCC members in the NCC processes, especially in meetings, and by the attitude towards national consultancy processes, these ones representing the main ways to influence policies and strategies in the field. Thus, the most active NCC members are representatives from the Ministry of Health, from the Ministry of Justice (within the governmental sector), UNAIDS, WHO, UNFPA, UNICEF (within international agencies) and PAS Centre, Soros Foundation Moldova, the League of People Living with HIV/AIDS, AIDS Network (within nongovernmental organizations). The respondents of the survey formulated the following recommendations regarding the active involvement of some partners, especially those from the governmental sector:  Implementation of an advocacy campaign among the high decision-making factors: the Presidency, the Parliament, the Government, the ministries to prioritize the HIV issue on the political agenda of the country and to take over responsibilities at the level of normative documents;  Development of clear mechanisms, approved and intermediated by the Government (for ex. by means of an operational manual) to make the participation mandatory; Mapping. National response. Influence and Financing  Cap GovernmentGuvern acit MH, MJ y UN Agencies AB:USAID, MIA, MEY, SAICD, GTZ MF, MEC, UCIMP MSPFC, AIDS Centre, MLPA, DVD, RND, FPI, CTrans MP, DIP, NCHM National NCC CNAM partners Secretariat International partners

NGOs: AFEW, EU TWG MSH, MSF APLcentru NGO, Balti, Religious, Gagauzia, Private, Tiraspol academic

Building of the persons designed for participation. It is necessary to make a national assessment of the needs to build the capacities, because at the moment this is done chaotically. A national assessment of various types of staff members would give the international donors the possibility to have a more qualitative approach to the subject.

The mapping exercise is useful for the identification of “missing” actors. Thus, the recommendation to involve the Ministry of Social Protection, Family and Child, the Ministry of Economy and Commerce, the Local Public Authorities representing governmental public organizations. Although these actors are missing from NCC, the indirect communication with them improved during 2008, the best proof being the active involvement of the Ministry of Social Protection, Family and Child in the process of GFTAM proposal development, round VIII and the creation of a intersectoral technical working group led by this ministry. The Ministry of Economy and Commerce demonstrated its engagement especially by facilitating and supporting the development of policies on HIV Prevention at work place. The civil society represented by the religious and academic sectors, and the private sector representatives are insufficiently involved. The same conclusion can be deducted for the “missing” actors representing the nongovernmental sector, which are not NCC members, but the collaboration with them has improved for 2007-2008. Both sectors are at the initial stage in dealing with these problems. However, the improvement of communication and collaboration with the religious sector was facilitated and coordinated with the financial and technical support of UNAIDS, a project dealing with capacity building in the field of prevention, care and support in the field of HIV/AIDS/STI and technical support to finalize a Strategy in this field for the religious community. As for the private sector, the communication was facilitated with the support of the International Labour Organization within the project on policy development on HIV/AIDS Prevention at workplace. Further, a map of all the stakeholders involved in the national response to AIDS is presented. Legend of the map: 1. Arrows represent the financial relation; 2. Abbreviations in green represent the active communication and participation; 3. Abbreviations in blue signify an average degree of communication and participation; 4. Abbreviations in red signify an inexistent and difficult communication. Further, the type of map made during the assessment process is presented: “Regional Capacity Assessment in the HIV/AIDS Area in Eastern Europe and the Commonwealth of Independent States - UNDP Regional Center, Bratislava, Slovak Republic Final Country Assessment Report for the Republic of Moldova, October 2006”. The map has been updated by the consultant. This map helps to visualize the information pertaining to the type of partnership, functions and the areas of responsibility:

Stakeholders’ Updated Map, February 2009, Republic of Moldova

Level Partner Functions Areas of responsibility National National Coordination Council (governmental Evaluation and Human Rights sector): development of National Health Government House; policies and strategies; Policies; Ministry of Health; Financing; Legislation in the Ministry of Finance; Legislation and its field; National Ministry of Education and implementation; Programme on Youth; HIV/AIDS/STI Ministry of Justice; Control and Ministry of Internal Affairs; Prophylaxis; Besides NCC: Capacity Building in Parliamentary Commission on the field; Health, Family and Social Protection; Ministry of Social Protection, Family and Child; Ministry of Economy and Commerce; Health authorities from, Transnistria Ministry of Local Public Authorities; National Scientific and Practical Centre of Preventive Medicine, AIDS Centre; National centre of Health Management; National Campaign of Health Insurance; Medicines Agency; Implementing NGOs: agencies NGOs activity is limited, Participation in the especially the one of the 3 NGO Legislation process of networks in the field: Legal support development and  AIDS network (protection against implementation of the (Approximately 40 discrimination) normative framework NGOs); Prevention in the field of  NGOs Alliance active in Counseling HIV/AIDS/STI. harm reduction (around Advocacy People Living with 20 NGOs); HIV/AIDS  League of people living General Population with HIV/AIDS (around Treatment Vulnerable groups: 10 NGOs); Care and support IDU CSW Several examples of NGOs MSM working in the field of HIV Youth individually: Detainees  CREDO; Migrants  Red Cross; Gipsy  Human Rights Institute; population

The religious community had Human rights meetings organized by the association “Moldavian Christian Aid”, assembling 4 churches:  Moldavian Metropolis;  Metropolis from Bessarabia; - care and support,  Lutheran Church; - prevention  Baptist Confession

Private Community: - Trade Union - National Confederation of Employers in Moldova; - prevention - Individual private - policies institutions and corporations Medical service providers: Republican Dermato- venerological Dispensary - policies (ARV treatment section), - diagnosis; Narcological Dispensary, - treatment; Blood Transfusion Centre; - medical surveillance; Ftizio-pneumological Institute ;

Mass-media: journalists network in the field of health; Beneficiaries Vulnerable groups Prevention; Youth, including those at high Care and support; risk of infection and vulnerable Advocacy; ones; People living with or affected by HIV/AIDS General Public

Monitoring Independent Body: and Evaluation MH, NCHM; M&E Unit; Monitoring and Epidemiological MH, GFTAM project – Evaluation monitoring; Coordination Unit, implementation Surveillance Use of funds; and monitoring of the project; Quality of services provided by the implementing agencies External International Organizations, UN Agencies Advocacy Assistance in the UNDP Technical assistance development of UNAIDS Financial assistance policies for the WHO governmental UNICEF institutions, UNFPA implementing agencies WB Prevention ILO M&E

Bilateral agencies: SIDA USAID GTZ

International nongovernmental organizations: AFEW; MSH; MSF

Recommendations: - Updating of the respective maps once in 2 years; - Insuring the involvement of both active actors and missing actors CHAT Report/Conclusions/ Specific conclusions for the first Field of Assessment -CCM and strategic national framework in HIV/AIDS

National partners

The first field of assessment refers to the level of participation and alignment of national partners to the National Programme of Control and Prophylaxis of HIV/AIDS/STI (Area 1.1) and the AIDS National Coordination Authority – the National Coordination Council of the National Programmes for the Control and Prophylaxis of HIV/AIDS/STI and Tuberculosis (Area 2). 19 respondents from governmental structures have been involved in the survey: 13 respondents represented the central and local levels, and the institutions within the Ministry of Health, and there were respondents from 6 other ministries: 2 from the Ministry of Social Protection, Family and Child, 1 from the Ministry of Education and Youth, 1 from the Ministry of Justice, 1 from the Ministry of Internal Affairs, and 1 from the Border Guard Service. 1) Area 1.1. Generally, the respondents from the governmental sector are satisfied with the degree of participation in the process of development, validation and evaluation both of the National Programme, and of other strategic documents on HIV/AIDS/STI. 72% of the respondents assigned the rating “much” and “very much”, while 28% appreciated it with “little”. The cross-sectional analysis within the sector determines that 90% of the respondents who assigned the rating by “little” are from other ministries. The choice of the representatives from the Ministry of Health and from its republican institutions to assign the rating “much” and “very much” was determined by the fact the they have been informed, i.e. each of the partners, especially the public institutions which have a certain role and interest in this issue, are invited to participate to give arguments or disagree and approve or disapprove subsequently. The National Programme is a typical example of such a document. Although the participants assigned a good rating to the degree of participation in the process of development of strategic documents, the majority of respondents asserted that public institutions (especially others than the Ministry of Health) are characterized by a type of participation which is aleatory, ad-hoc and less qualitative. The quality of participation of the national/governmental stakeholders is determined by the deficiency of human resources, by the multiple obligations referring to the plans and strategies specific for the organization, and to the plans and strategies specific for other ministries, to which each of the respective ministries contribute. Also, the respondents asserted that HIV/AIDS is not a priority. The prioritization depends more on the interests of the institutions, including those within the Ministry of Health, rather than on the national strategies of the National Programme. 2) Area 1.2. The majority of the respondents from the governmental sector assert that they have a strategy, and a working plan in line with the National Programme. Thus, 75% of the respondents appreciated the degree of alignment with the rating “much”, “good”, “very much”, “very good”. When giving arguments, the majority of the respondents asserted that the working plan/strategy on HIV/AIDS is not separate, but it is part of the general activity plan of the institution. 3) Area 1.3. As for the next question referring to the presentation and approval of these strategies/working plans within the mechanisms of the NCC, 50% of the respondents, both from institutions within the Ministry of Health and other ministries gave a negative answer. There are approvals and discussions at the level of technical working groups and activities pertaining to the implementation of the Global Fund project. The great rate of negative answers demonstrates the deficiency of some mechanisms and practices in which the NCC could be involved to approve plans and strategies on HIV/AIDS of various institutions, in the process of supervising the strategies developed and implemented by the national partners. 4) Area 1.4. As for the question referring to the degree of contentedness of the respondents regarding the participation of various relevant actors in the development, evaluation and validation of national strategic documents, and of the National Programme in particular, 70.5 % of the respondents assigned the rating “much” or “very much”. Representatives from other ministries appreciated negatively, or assigned the rating “little”, “very little” to the level of participation of all the actors. 5) Area 1.5. Representatives form the governmental sector (82%) appreciate the strategies developed and implemented by international organizations as being “much” or “very much” aligned to the strategies of the National Programme for Prevention and Control of HIV/AIDS, affirming that these ones represent “the engine moving everything forward”. Among the most strong points of the strategies developed and implemented by the international actors, the representatives of the governmental sector enumerated the following: ● The programmes are innovative and of high quality due to the fact that they represent best practices in the field of HIV/AIDS at the international level; ● They always have technical and financial support, which make them stable; ● Actors representing international agencies have new suggestions and tools, and they ensure a continuity from objectives to results in their strategies; Weaknesses pertain to: ● Deficiency of influence and real persuasive capacity of the proposed strategies; ● Very often, international agencies have regional mechanisms which are not always adjusted to the local situation and which do not cover all the activity areas; ● Because of the lack of a functional coordination mechanism, international organizations may deviate with their strategies from the national priorities.

rezultate Aria A .1

10 Nu 8 NS/NR f.puţin 6 puţin 4 mult f. Mult 2

0 Aria A 1.1 A 1.2 Aria A 1.3 Aria 1.4 Aria 1.5 optionale

International partners The evaluation of international partners allowed to have qualitative information about the collaboration of international partners both among them, and with national key –partners, including their active participation to the national strategic framework alignment and harmonization, as well as involvement in the Country Coordination Mechanism, National Programmes, and national M&E system.

Area 2/national partners refer to the degree of representation of national stakeholders within the NCC, the technical working groups and other coordination mechanisms. When referring to the representation of their organization in the NCC and TWG, half of the respondents gave affirmative answers, the other half – negative answers. Particularly, members of the NCC on TB/AIDS gave affirmative answers. One of the conclusions is that the members of the Council do not authenticate themselves as representatives of a constituent, while the subordinate institutions such as DVD, NCHM, PPI, local medical authorities, institutions subordinated to the Ministry of Internal Affairs, or to the Ministry of Education and Youth cannot consider themselves as represented in the Council. The majority of the respondents who gave negative answers consider that the only possibility to participate in the coordination mechanism is to be given the status of NCC member. Only two of the respondents affirmed that it is not necessary to have a direct representation, but it is advisable to ensure the access of the institutions by involving them in meetings, and national consultancy processes pertaining to the coordination of the national response in correspondence with the competency of each organization.

Additional questions from the questionnaire refer to the quality of representation and participation in the NCC and TWG of the governmental structures and their opinion about the quality of participation in the coordination process, including capacity building of the NCC ensured by international agencies. Thus, the majority of statements about the degree of representation of governmental agencies in the NCC and its mechanisms affirm that their representation is adequate, but the quality of their participation is low. Some mention that this is the cause of some objective factors such as: deficiency of human resources, lack of time, multiple obligations, and the fact that HIV/AIDS is not a priority of the governmental structures; others mention factors of attitude such as: indifference, insufficient comprehension of the problem. The coordination process is not adequate either because of the lack of a coordinator and institution that would have a clear coordination mandate. Representatives from the governmental structures affirm that the international agencies are characterized by consistency and they apply complex, multi-aspectual approaches; they ensure financial support, and quality in the coordination process of the National Response to HIV/AIDS. One of the weak points is the insufficient capacity building of the NCC members and those of the TWG, and the lower participation of the representatives from the highest level in comparison with 2004-2006. International partners It was mentioned by international partners the lack of a partner from private sector/sindicate from CCM. The additional questions of the questionnaire refers to the level of representation and participation in CCM and TWG of the respondents, as well as their opinion about the quality of participation at the coordination process, including the capacity building of CCM members supported by international agencies. Thus, the majority of the respondents considered the level of representation of international agencies in the CCM and TWG as appropriate. At the questions related to the capacity building by the international agencies the majority of the respondents declared that the support in this sense is being offered and they contribute at the capacity building process.

Summary of Conclusions for the first Assessment Field 1. Generally, respondents from the governmental sector are satisfied with the degree of participation both of their organizations and of other actors from this sector in the process of development, validation and evaluation of the National Programme and of other strategic documents on HIV/AIDS as well as their participation within the NCC mechanisms and technical working groups. Even if these ratings are rather high, the majority of respondents affirm that public institutions (especially others than the Ministry of Health) are characterized by a type of participation which is aleatory, ad-hoc and of low quality. The low quality of the national stakeholders’ participation in these processes and in the NCC mechanisms is determined by objective factors such as: deficiency of human resources, multiple obligations referring to plans and strategies of their own organizations, and to plans and strategies of other ministries, lack of time, and the fact that the HIV issue is not a priority of the governmental structures; factors of attitude such as: indifference, insufficient comprehension of the problem. 2. The degree of alignment of programmes and strategies developed and implemented by international partners is assigned the following ratings “much, moderate and sufficient”, the argument being that international agencies are characterized by consistency and they apply complex, multi-aspectual approaches; they ensure financial support, and quality in the coordination process of the National Response to HIV/AIDS. Representatives from the regional territories affirmed that the available financial resources are not sufficient and do not cover all the needs. At the same time, respondents have great expectations concerning international agencies in the sphere of technical assistance, monitoring and capacity building of NCC members. 3. The members of the Council do not authenticate themselves as representatives of a constituent, while the subordinate institutions such as DVD, NCHM, PPI, local medical authorities, institutions subordinated to the Ministry of Internal Affairs, or to the Ministry of Education and Youth cannot consider themselves as represented in the Council. This situation is a proof that the represented institutions do not take sufficiently enough upon themselves this obligation. 4. The majority of international partners affirm that they own a strategy, a working plan which is aligned, generally, to the National. They mention that there is a need of capacity building of CCM stakeholders in the field. More than half of the respondents that own specific strategies in the field declare that their strategies are not approved-presented at the CCM/TWG, especially due to the fact that a mechanism to solve this is missing.

Recommendations suggested by the respondents: 1. Appointment of an institution or a person with a national coordination mandate; 2. Development of an activity plan to accomplish the strategies of the National Programme and of an M&E National Plan; 3. Involvement of the following representatives within the NCC: MSPFC, MLPA, the Ministry of Defense, Transnistria. Ensuring of an active participation of governmental sector representatives. Several suggestions have been made in this respect: • Implementation of an advocacy campaign among decision making factors: Presidency, Parliament, Government, Ministries to prioritize the HIV issue in the political agenda and to take over responsibilities pertaining to normative documents; • Development of clear mechanisms endorsed and intermediated by the Government (by means of an operational manual) to make the participation mandatory; • Capacity building of the persons designated for participation. It is necessary to carry out a national assessment of the needs to build the capacities, because presently this is done chaotically. Thus, it is necessary to perform an assessment on the national level for various staff members, which would let the international donors treat this subject better. 4. At the level of technical working groups it is necessary to ensure the participation of all interested governmental institutions by identifying and inviting them, by permanently providing them information on national coordination processes, participation of representatives from Southern, Eastern and Northern regions of the Republic of Moldova; identification of mechanisms on how to make the decisions be operational within the technical working groups, decision-making between the decisional and operational levels of the NCC.

Conclusions specific for the second Assessment Field: Monitoring and Evaluation The second field includes 2 assessment areas (3 & 4) refers to monitoring and evaluation: • The degree of use of the national M&E system by the national partners (area 3); • The level of participation of national partners in the process of NAP review or other equivalent processes, such as UNGASS report elaboration (Assessment Field 4) The majority of respondents (90%) gave affirmative answers to the question if their organizations have a monitoring and evaluation plan to measure the effects and impact of their interventions and only 2 representatives of other ministries denied the existence of such a plan. A small rate of respondents (20%) do not know how the M&E plans of their organizations are aligned with or derive from the M&E National Plan, or the set of indicators established by the NPPCHA. The respondents affirmed that even if the National Programme contains measurable objectives, it does not have an M&E Plan; it includes only a set of indicators. Only the GFTAM project has a clear M&E Plan which derives from the National Programme and the reporting is made based on it. Many of the responding organizations, especially those representing other ministries, affirmed that: “They are at the incipient stage. Being partners in the process of Programme implementation, these organizations report quarterly and annually. The M&E Programme should be developed”. Only half of the respondents are members of the M&E technical working group on HIV/AIDS/STI and TB, while representatives of institutions that denied any kind of membership (RND, medical authorities from Balti and from the Eastern part of the Republic, MSPFC, Border Guard Service, and the Ministry of Education and Youth) expressed their wish to participate in TWG meetings, at least in those treating subjects of general interest and/or specific for these institutions (Area 3.2). Approximately half of the respondents did not appreciate the quality of the M&E system on HIV/AIDS. Those who know this aspect appreciated the system as a good one and only 15% of the respondents assigned the ratings “little”, or “underdeveloped”. International partners. At the question related to the existence of a M&E plan of the activities performed by these partners in HIV/AIDS field, the majority of the respondents (62,5%) offered affirmative responses. Thus, all those who gave an affirmative answer at the precedent question, affirm that their M&E plans are generally aligned to the national M&E system or to the existent set of national indicators. Some of the respondents affirmed the fact the NP does not have a national M&E plan, but only a set of indicators, the others mentioned that the national M&E plan is considered the one of the Global Fund. Another specific issue related into the interviews was the need to review the set of indicators and the use by the international partners of information obtained from indicators. Being asked about the degree of use of the offered information by the national M&E framework, the majority of the respondents answered it is being used in the planning process of the activities, and they also underlined that this information is obtained in a difficult way. The majority of interviewed persons recognize the importance of the need to have a national system of M&E and they support the development of the national and technical mechanisms of coordination of national M&E system in HIV/AIDS/STI. Evaluation area 4. The majority of respondents representing the international sector are satisfied with the degree of their involvement at the recent processes of UNGASS report elaboration and of MTR (62,5%). Referring themselves at the quality of participation of the representatives of national partners (governmental and nongovernmental) at these processes, 62,5% of answers were appreciated with „well” and „very well”, the others appreciating it as “little” or „insufficient”. In order to improve the quality of participation to these processes it was suggested to organize them in a planned manner and not on ad-hoc principles as used before.

The general conclusion is that the majority of respondents understand the importance and the necessity to have an M&E system; however this is a relatively new domain which needs to be improved and developed. The majority of respondents from the governmental and international sector are satisfied with the degree of participation in recent processes such as UNGASS report development and the Mid- term Evaluation of the National AIDS Programme (90%)

Area 4.1. Referring to the relevance and quality of participation in these processes of all the national partners, 52% of answers indicate the option “much”, while other respondents appreciate their involvement and participation as insufficient. Similar to other national processes, the participation of governmental sector representatives and of other ministries in the M&E system is insufficient and needs to be ensured. Recommendations suggested by the respondents: 1. To strengthen and improve the national M&E system by assigning a mandate 2. When approving the National Programme of Control and Prophylaxis of HIV/AIDS/STI it is necessary to approve the M&E Plan and the stakeholders should know their responsibilities. The M&E Plan should also contain a strategy for data dissemination and subsequent use of these data in the process of programming and planning. 3. To build the capacity of specialists from the M&E Unit and of the national partners working in the field of HIV/AIDS. Involving more actively of the partners from nongovernmental sector in the M&E group. 4. To ensure functionality of the M&E system by giving continuous financial support in the field of HIV/AIDS. 5. To realize the operational researches in the field in a similar way, in order to ensure the comparability of those. 6. Involving during the consultative processes and the evaluation ones more partners, especially those from nongovernmental sector.

The third Field of Assessment The third field of assessment incorporates 2 assessment areas: • The level of national partners’ equitable budgeting from the National AIDS Programme, including financial resources from international donors to support the NAP (area 5). • The degree of integration of national partners in the decision-making and financial reporting processes (area 6)

Area 5.1 In the current survey, the budget of the National Programme refers to both national and international financial resources, managed through national financial mechanisms, which are aimed to support the National Programme. Due to the fact that the budget of the National Programme incorporates the GFTAM grant resources, 47% of respondents state that they have sufficient financial resources to carry out the activities on HIV/AIDS/STI Control and Prophylaxis (Area 5.1). Among the respondents that do not benefit from financial resources, there are those from the central administrative level: ministries, including the Ministry of Health, because, according to the respondents, they do not provide services. Making reference to the strengths in the management of the NAP financial resources, the following view points have been shared: • The budget composed of resources that include those of the GFTAM make possible the implementation of NAP activities; • According to some respondents, lately financing has become adequate, rhythmic, consolidated and equitable, especially the one aimed to realize the National Programme of Control and Prophylaxis of HIV/AIDS/STI for 2006-2010. The following weaknesses of the process have been enumerated: • The realization of the National Programme of Control and Prophylaxis of HIV/AIDS/STI is greatly dependant on external financial resources (70%); • There are no capacities to adequately assess the needs and the correct and equitable budgeting in the field; • The national system of financial management is a complex and inflexible one; • The available financial resources are insufficient per strategies and per regions, for example for the Eastern part of the Republic; • The mechanisms of financing the services provided by the state are not finalized and concluded (for example: consultation services for patients, especially the ones without medical insurance); 75% of the respondents from international sector affirm that the organization they represent committed themselves for multi-years support (more than 3 years) in the national response to control HIV/AIDS to realize the control and prophylaxis activities. The majority of the respondents (62,5 %) mentioned that the volume and the period of the involvement in financing the HIV field depends on the existent background and the needs in the field. In the same time, 25% from the respondents mention that the finances are reduced or the organizations they represent stop the financing due to the present of GF financial resources.

The General Conclusion of this chapter is that there are sufficient financial resources to carry out the activities of the current NAP. The majority of representatives from the governmental sector are satisfied with the funding and they consider that the received sums are equitable. Financing is a relatively consolidated one, i.e. it includes both governmental resources and GFTAM grants. Very few organizations receive inconsistent resources directly from external donors. However, some strategies of the NAP are not covered enough, this situation being especially caused by the limited capacities of assessment of needs and correct and equitable budgeting as well as the existence of a complex and inflexible national system of financial management.

Area 6 Referring to the decision-making process regarding the resource allocation within the National Programme of Control and Prophylaxis of HIV/AIDS, the majority of respondents from the Ministry of Health and from its subordinate institutions assigned the rating “much” to the degree of involvement in this process. Respondents from the local health administration offices (Balti, Tiraspol, representatives of other ministries) affirmed that they are not involved in these processes, but still they are interested to participate. There are no unified mechanisms to report the financial resources and sometimes it is repeated two or three times for the governmental institutions. The majority of respondents indicate that they report the financial resources to the Government, the Ministry of Health, the Ministry of Finance, the National Centre of Medical Insurance, and the Global Fund monthly, quarterly or annually. It is already known that various financial resources are reported to various institutions. The respondents suggest the necessity to unify the reporting criteria of all the existent financial resources and the creation of a mechanism to ensure the information flow between various institutions that require this information. The respondents believe that the NASA tool and the development of the national health accounts will offer the possibility to solve these problems.

Recommendations suggested by the respondents: 1. Strengthening the external financing, by increasing periodically and constantly the financial proportion coming from the Government; 2. Capacity building at the national level in order to assess the needs, the correct budgeting, the cost efficiency and to prioritize financing to achieve the NAP objectives; the involvement of regional actors per various areas in this exercise; 3. Strengthening the coordination of financing and reporting processes by implementing the NASA tool and the national health accounts. 4. Ensuring the existence of financial resources from the Governmental ones or from the National Company of Health Insurance and of a mechanism of access to those resources for the members of nongovernmental sector.

The fourth Field of Assessment: Administration, Support and Communication This field incorporates 2 assessment areas: • The degree of participation of various national stakeholders in the development and assessment of the administration system of the national AIDS response; • The degree of transparency between the national stakeholders and their relation with the NCC on TB/AIDS. Aria A 7.1

f. Mult

puţin Aria A 7.1 f.puţin

0 1 2 3 4 5 6 7

In this diagram it is clearly seen that the majority of respondents (approximately 80%) asserted that they had participated in the process of development of administrative, management and coordination procedures in the national response to HIV/AIDS/STI. Among the respondents who gave negative answers there are representatives of the Border Guard Service within the Ministry of Internal Affairs. The majority of respondents did not appreciate the quality of procedures. The administration and coordination mechanisms have been appreciated as being at the incipient stage; there are tendencies for improvement, but the main impediment is the lack of a mandate for the national coordinator and for the coordinating institution. One of the administration/management procedures pertains to the reporting process, which is not unified and equitable. Some organizations report constantly to the NCC, others, including donor agencies, do not report. The most highly appreciated mechanism is the information sharing mechanism which is functional due to the NCC Secretariat which uses various channels: email, web, and informative bulletin, involvement in the NCC mechanisms: national consultancy processes, NCC and TWG meetings. Governmental sector representatives highly appreciate the level of information sharing between organizations and other national partners, and the level of transparency of the information sent by the Secretariat to the national stakeholders and the intercommunication between national partners. However, there were negative opinions such as those referring to communication between national partners which is partially ensured. The high appreciation of the intercommunication flow between national partners is due to the implementation of the existent normative framework “Petition Law”, even if some respondents affirmed that this is a relatively bureaucratic one. For the international partners the area of the research is different than those for the national ones, that is why they are presented below in a separate way. Assessment Area 7. According to the registered answers after questioning in relation to the procurement mechanisms alignment in HIV/AIDS field it can be affirmed that the majority of the respondents (75%) of the international sector use their own/internal rules/mechanisms of procurement, respecting the national law. The absence of unique national procurement procedures in HIV field was mentioned as a weak point. Assessment Area 8. Related to the degree of capacity building and harmonization of the strategies of offering technical assistance by the international partners it was affirmed by the majority of the respondents that their agencies had offered and continue offering the technical assistance to RM in HIV field. In the same time, all the respondents underline that a national strategy of technical assistance to rule the offer of the technical assistance in order to avoid the duplication is missing. Assessment Area 9. the degree of harmonization of the administrative reports, technical /financial reports and the approaches to the human resources in the national response to HIV/AIDS. Referring themselves to the reporting mechanisms, it can be mentioned that some of the organizations are constantly reporting to the CCM/TWG, while the others report at the request or spontaneously. Referring to the question of attracting human resources from the national sector into the international sector, there were no concluding answers. It was mentioned the fact that the human resources from the governmental sector which are trained and formed have to be a priority for the governmental sector, including the way of offering better salaries from donors resources, as well as using other motivation mechanisms. Assessment Area 10. analyses of the degree of openness, correctness and transparency among international organizations and in relation to the CCM members. In this assessment area it was mentioned that the best mechanism of information is the channels of CCM Secretariat, which uses different channels as email, web page, informative bulletin, involvement in CCM mechanisms: national consultancy processes, CCM and TWG meetings. 75 % of the respondents consider that the flux of information from the CCM secretariat id complete, correct and in useful time. 67,5 % from those questioned consider that the information exchange (a correct and in useful time one) exists between the international agencies and other national partners. The same number of respondents appreciates as „well” and „very well” the mechanism of information exchange between the CCM Secretariat and the questioned organizations. Only 50% of respondents appreciate as “well” the transparency and information exchange between international organizations and other national partners, especially when speaking about planning and finances. One of the causes mentioned by the respondents was the absence of a coordination structure of the main national partners of the programme, a management unit of the NP.

The general conclusion resulting from these information analyses is that the management/administrative and coordination procedures are not finalized yet. The information sharing procedures in this system are highly appreciated, including the communication between national partners. The information sharing process was appreciated as being transparent both between the NCC Secretariat and the national partners, and between the national partners.

Recommendations suggested by the respondents: 1. Designation of a mandate to the national coordinator and to the coordination institution; 2. Development of an operational manual to improve, harmonize and to render the management and administration requirements equitable; to inform about the mechanisms of a subsequent application, surveillance of grant surveillance, reporting and coordination of the national HIV/AIDS response. In connection with the above-mentioned, several recommendations have been given: • To make the reporting system official; • Taking over by the Secretariat of a pro-active role to make the administrative, coordination and management procedures operational; • Partners’ understanding of their roles and responsibilities; 3. Capacity building of national partners in the field of management, M&E. 4. Elaboration of a national strategy of technical assistance, which will rule the ofer of technical assistance. 5. The value of the human resources trained from national partners organizations have to become a national priority. 6. Organising in a permanent way (anually/one per two years) the national NGO froums to improive the experience and information change among national stakeholders in HIV/AIDS response.

National Partners Assessment (All respondents) 7 6 Very Poor f 5 o s

t Poor r 4 n e

e 3 Good b d 2 m n Very good u o 1 n p 0 s e e h

r A1 A2 A3 A4 A5 A6 A7 A8 t Area of Assessm ent

International Partners Assessment (All respondents)

Very Poor f 6 o s

t Poor r n

e Good b d

m 2 n Very Good u o n p 0

0 s 1 2 3 4 5 6 7 8 9 e 1 e B B B B B B B B B h r B t Area of Assessm ent

General conclusions As a result of this research several conclusions should be mentioned: 1. the Government commitment remains to be insufficient, especially when linked to the financial support of the activities from HIV/AIDS/STI field; the nongovernmental sector respondents consider that the financing of the activities is inequitable and not always transparent 2. There are important partners that are not sufficiently involved in the control of HIV/AIDS activities as the private sector, religious, academic, governmental 3. The involvement of national stakeholders in the national consultancy processes is better, but the coordination of the activities both on vertical as well as horizontal ways, at the level of service delivery: prevention, treatment, support and care are weak. 4. The M&E szstem is a functional one,. But it needs to be strengthened permanently. 5. Only at the level of informing the stakeholders a progress can be observed, but less in the coordination and management of the national response in HIV/AIDS/STI

General recommendations:

 Promoting the permanent capacity building of the partners involved in CCM activity, with an accent on the M&E system in HIV/AIDS/STI

 Involving new partners in CCM activities such as those from sindicates, religious organizations, private sector and others;

 Promoting collaboration relation with partners from Transnistria: including the representatives from Transnsitria in the taking decisions processes in the national response to HIV/AIDS

 Elaboration of a clear coordination and efficient management concept which would include clear definition of the responsibility of every national institution responsible for the general implementation of the activities in the framework of the national response, as well as links to other ministries, other governmental agencies and partners

 Adjusting and updating the existent legislative/ ruling framework subordinated to the National Programme to better reflect the new coordination and efficient management concept

 Assuring that the action plan of CCM promote the commitment of other ministries and state institutions and covers the needs of capacity building of these institutions .

 Development of quality systems to administrate the HIV/AUIDS activates based on performance results: the initiative has to come from ministries and to be integrated at all levels of management of the programmes and governmental services

 Development of the national capacities at the national level: to evaluate the human resources needs and to elaborate of a correct and equitable budget in HIV/AIDS field and promotion of the improvement of financing the NP from Government resources