WHO and UNODC Mission
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11.02.2011

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TERMS OF REFERENCE

Mid-term evaluation of the Latvian national programme

“Programme for limiting the spread of HIV infection 2009-2013”

Background:

Latvia operates in a framework of the national program/strategy for fighting HIV infection – “Programme for Limiting the spread of HIV infection 2009-2013” (accepted by Cabinet of Ministers on 30 Jun 2009, direction Nr.437). The main financial resources for implementing the Programme and the national program before (2003-2008) have been the state budget.

The 2008-2013 draft Programme document was reviewed by UNAIDS co-sponsors through the ASAP mechanism (ASAP, 2009). That review revealed relatively high costs of ART in Latvia, as well as obstacles for access to HIV treatment. In addition, UNODC had raised concerns about limited access to treatment in prison settings and for injecting drug users (IDU).

A previous evaluation “Evaluation of the Access to HIV/AIDS Treatment and Care in Latvia” (Kees de Joncheere at al., May, 2009) has taken place in March 2009 by WHO/EURO and UNODC. At this time problems of supply interruption of HIV treatment in Latvia had been observed. It had been agreed that a similar, but broader, mission will take place in 2010/11 to evaluate the mid-term progress of the implementation of the national HIV/AIDS strategy (Programme 2009-2013) in Latvia.

According to the previous national HIV infection control program (2008-2012, prepared by UNODC with foreign and local consultants) the proposed funding was 9.5 million LVL for 2009 and 10.2 million LVL for 2010 („Estimation of costs of HIV Strategy 2008-2012, Latvia” Anita Alban and Aigars Miezitis, World Bank, 2007).

The Programme implementation due to the economic situation in the state budget funds amounted to 3,266,140 LVL in 2009 (One third of the external experts’ recommendations), and remained in 2010 at 2009 levels, so it did not include measures/activities requiring additional financial resources. Also the HIV/AIDS care system of prisoners raises concerns.

The 2009-2013 Programme goal is to limit the spread of HIV infections and to decrease the number of new HIV cases.

The key tasks are:

1. Avert new HIV cases among selected target groups;

2. Implement comprehensive HIV prevention activities;

3. Improve access to health care services for PLWH and AIDS patients;

4. Promote evidence-based planning and management activities for HIV prevention;

5. Scale-up HIV prevention activities and improve national coordination.

Objectives and aim:

The objective is to evaluate the implementation of the 2008-2013 Programme and its cost effectiveness in the last 2 years and give a perspective until 2013 and beyond, considering that the budget for implementation remains at a level of 2010, excluding the budget for ART (ART will be provided from the state budget as budget of the state agency “Infectology Centre of Latvia” to all patients in need.

List of background data, reports available at the time of evaluation:

• The final report of the UNODC project "HIV/AIDS prevention and care among injecting drug users and in prison settings in Estonia, Latvia and Lithuania”

• Programme for limiting spread of HIV infection 2009-2013” (action plan included) (EN), (electronically)

• Monitoring report of implementation of the Programme for limiting spread of HIV infection (2009-2013) in 2009-2010 (EN), (electronically)

• Financing the Programme for limiting spread of HIV infection (2009-2013) in 2009-2010 (EN), (electronically)

• Respective documentation of the State agency “Infectology Center of Latvia” (LV) (hard copy) etc.

The aim of the evaluation is to give practical input for further development of effective HIV prevention (incl. resource allocation) in Latvia in conditions of restricted governmental budgeting. So, assessment (incl. cost effectiveness) and recommendations are expected in two main areas: structures and systems, and coverage and quality of services, as well as make proposals for the internal evaluation topic in 2012.

The evaluation is requested by the Ministry of Health as integral part of the collaborative agreement between the Government of the Republic of Latvia and the World Health Organization to support the scaling up the response to HIV/AIDS in Latvia.

Expertise needed:

- Structures and systems analyses (including financial systems)

- reaching and influencing target groups

- needed coverage and systems in HIV prevention and harm reduction

- health care systems (including infectious diseases related to HIV/AIDS)

- Coverage and quality of services (HIV prevention centres for IDUs)

- Management of Programme (2009-2013) implementation - organizational development

- NGO structures and capacity

- Institutional support for NGOs

Areas and key questions:

1) Structures and systems analyses and organizational development. The assessment of:

1.1. Management and coordination systems, including structures and systems for harm reduction;

1.2. Financial flow and NGO support systems (as providing financial support to service providers);

1.3. Monitoring, evaluation and quality assurance systems;

1.4. Healthcare systems connected with services for PLWH (including in prisons);

1.5. Organizational development and capacity building of coordinating institutions and service providers.

Questions to be answered when investigating each of the areas (1.1-1.5):

1. What is the capacity of the systems and organizations in place?

2. How has the capacity in the area developed in recent years?

3. Do present structures support the needs in fighting the epidemic in Latvia?

4. What are the strong and weak points of the developed systems?

5. Are there areas that need revision/restructuring, gaps to be filled or unnecessary practices that need to be removed?

6. What is needed to further scale up the national response?

1.6. Integration of services

Questions to be answered when investigating area 1.6:

1. To what extent HIV services are integrated to other services needed (TB, HCV, STIs, antenatal care, etc) and related to each-other?

2. What are the main gaps and positive developments in integrating different services?

The levels to look at under the section one:

− State and municipalities level

− Level of patients, NGOs and other service providers

2) Access to services, coverage and quality of services. The assessment of:

2.1. Prevention and health care services targeted at IDUs and prisoners;

2.2. Health care of PLWH – health monitoring, ARV, relation to TB, HCV and STIs, getting PLWH to the health care system;

2.3. Psychosocial support to PLWH and case management.

Questions to be answered when investigating each of the areas (2.1-2.4):

1. Is coverage of interventions sufficient for stopping the epidemic, increasing the quality of life of PLWH and achieving the targets set?

2. What are the main problems in achieving the sufficient coverage?

3. Are the services accessible to the target groups?

4. What are the hindering factors related to accessing the services?

5. Is the quality of interventions sufficient for stopping the epidemic and increasing the quality of life of PLWH?

6. What are the gaps in present quality assurance systems?

7. What is needed for improving the quality of services?

Methods

The evaluation mission will be organized with a focus on structures and systems in place and the coverage and quality of services for PLWH, on structures and services related to interventions targeted at IDUs and prisoners.

Methods of evaluation:

- Desk review of documents, reports and other materials related to HIV infection issues in Latvia. Materials will be provided by MOH before the in-country mission.

- Interviews with key informants in chosen organizations with visits to service provision sites in Riga. Key informants will be relevant government officials in different ministries (MoH, MoJ) and state agency “Infectology Center of Latvia”, representatives of NGOs (e.g. HIV/AIDS patient’s organizations). Institutions/organizations and key informants will be chosen in cooperation of evaluation experts and the state agency “Infectology Center of Latvia”.

Partnerships:

- World Health Organization Regional Office for Europe: HIV/AIDS, STI and Viral Hepatitis, Pharmaceuticals, Health Systems, Tuberculosis

- Independent consultant(s): e.g. drug use Jean Paul Grund, writer Roger Drew, prison Stöver?

- UNODC Signe Rotberga

- Civil society: AIDS Action Europe expert

- ECDC surveillance expert?

- Programme (2009-2013) - First contact: Inga Šmate, Director of department of Health policy planning, Head of Coordination commission for Limiting the spread of HIV infection, tuberculosis and sexually transmitted infection of Ministry of Health (MoH) (inga.smate@vm.gov.lv, phone +371 67876073)

- Ministry of Justice (MoJ) – Organizing meetings under the domain of the ministry. First contact: Kristīne Ķipēna, Head of Unit of Punishment Execution Policy of Sectoral Policy Department of Ministry of Justice, (Kristine.kipena@tm.gov.lv>, phone + 371 67046124).

Experts involved: TBA.

There will be a main report writer who will consolidate the reports of other experts to the overall report.

Timeframe:

All background materials sent until 15.Jan 2011.

Evaluation mission in country 15-18 Feb 2011.

Output

At the end of the mission in Latvia, a meeting will be organized for giving first feedback on evaluation findings. Meeting will find place in the Ministry of Health. Output of evaluation missions is a written report. Report should be structured according to all areas specified in the TOR. Under the section of one area answers should be given to the questions listed in TOR and recommendations given. The report has to contain a list of organizations and people interview and documents reviewed.

− Each of the evaluators involved write a 2-3 page long report on each area s/he has to cover after the mission in Latvia. When writing the report answers will be given to all questions listed in Terms of Reference and maximum 3 recommendations given for improving the situation.

− All evaluators will send their parts by 1 March 2011 to the writer who will integrate different parts to the overall report and send the first draft report to MOH by 09 March 2011.

− The deadline for the final consolidated report is 25 March 2011 (in EN).