Hiv Chai Evaluation Report
Hiv Chai Evaluation Report
EVALUATION REPORT
Alison Heywood
Health Systems Strengthening Specialist
UniQuest Pty Limited
July 2009
Aid Activity Summary
Total other $
Acknowledgments
The ET would like to thank all those with whom we have consulted. They have given us the opportunity to experience
their enthusiasm for the CHAI, and observe their commitment to this project. In particular we are grateful to the CHAI
team for the time they have spent with us, and their efforts to provide us with extensive documentation to support our
evaluation.
The ET would like to thank the Port Moresby AusAID office for the logistical support it has provided, for original
sourcing of key documents for review, and facilitating a smooth evaluation exercise. We do not underestimate the
demands of this task.
Please note that the views expressed in this report are those of the author and do not necessarily represent the views
of AusAID or the Government of Papua New Guinea
Author’s Details
Alison Heywood, Ph.D., is Director of Heywood Public Health Group, an international consulting company established
in 2002 providing services ranging from in-country situation analyses/needs assessments, health systems analysis,
program/project designs, study designs, to reviews and evaluations. These assignments have been undertaken in Fiji,
Tonga, Samoa, Solomon Islands, Kiribati, Vanuatu, Papua New Guinea, East Timor, Philippines, China, Laos,
Maldives, Thailand, Cambodia and Indonesia. Technical areas of focus have included health promotion and public
health, health systems strengthening, HIV and AIDS, immunisation, other non communicable diseases including
mental health, and disabilities. Alison has undertaken consultancies for AusAID, the Commonwealth Department of
Health and Ageing, NZAID, WHO and the World Bank, as well as for Australian universities, private companies and
NGOs. Alison comes with a behavioural science and research background, and lived in Papua New Guinea for 11
years, and eight of those were spent working in research at the PNG IMR in Madang. She currently serves on the
TRP of the Global Fund, and the IRC of the GAVI Alliance.
Rating scale: 6 = very high quality; 1 = very low quality. Below 4 is less than satisfactory.
________________________________________________
1 2007 Estimation Report on the HIV Epidemic in Papua New Guinea
2 AusAID HIV Annual Sector Performance Report 2009
3
IRG 2009. Independent Review Group on HIV/AIDS. Report from an assessment visit. 23 April – 6 May 2009.
At the time of the evaluation there was no documentation of the reasons for this transition from nine Areas of
Collaboration to six Program Areas. Explanations were provided by the CHAI Program Director during the evaluation:
“Training” was folded into program areas and not undertaken as a national program; “Clinical Support” became
“Clinical Mentoring”, and was undertaken at key project sites; and the “Hospital administration initiative” was never
initiated.
The ET uses the term Program Areas in its report. Each Program Area has a number of Sub-Programs:
3.1 Relevance
Key questions: Were the objectives relevant to Australian Government and partner government priorities? Were
the objectives relevant to the context/needs of beneficiaries? If not, what changes should have been made to the
activity or its objectives to ensure continued relevance?
3.2 Effectiveness
The evaluation is using the latest structure of the program and reporting on effectiveness of each of the Program
Areas, including Program Management
Key questions: Were the objectives achieved? To what extent has the activity contributed to achievement of
objectives?
“Effectiveness is a measure of the extent to which an aid activity attains its objectives”.4 As already stated the
overarching goal/purpose/objective of the CHAI was never clearly articulated, and thus no indicators to measure its
achievement have been presented in any project documentation. The ET consulted with the CHAI team to arrive at
possible indicators that might be used in the remaining six months of the program to indicate effectiveness of the
whole program.
In the absence of a clear statement of objectives at the overall project level, and objective statements without
indicators at the Program Area level it is not possible to say with any degree of confidence whether CHAI has been
effective. The only reports on progress are the Quarterly Reports (QRs) (and minimal reporting in the AAPs) and
these are limited to describing activities and outputs for each Program Area, and are not linked to indicators for the
Program Area.
Reporting on this is compromised by the lack of clear and consistent program logic that has indicators attached to
every level of the program. The overall objectives (not originally articulated) that are now stated for each Program
Area have been arrived at after discussion between the ET and the CHAI Country Director.
Six key programmatic areas are identified, and achievements against each of these are presented.
3.2.1 Laboratory infrastructure
Overall Objective: To support the government in the design and implementation of a rationalized laboratory
system for HIV care and treatment.
________________________________________________
4
OECD (2000). Glossary of Evaluation and Results Based Management (RBM) Terms
CHAI is working with NDoH, WHO and ADB to help improve the capacity of provincial hospitals and CPHL to provide
CD4 cell count testing to assist in the treatment and care of people living with HIV. CD4 operators have been
retrained and a new CD4 machine has been purchased by CHAI for Mendi to complement the six government-
funded machines (CPHL and provincial hospitals) and six ABD-funded machines soon to be in place in Rural
Enclaves locations. An external Canadian program of quality assurance for CD4 called QASI has been established,
demonstrating consistently excellent results in the PNG laboratories. CHAI has arranged repairs to CD4 machines
from an Australian technician and has recently identified two local candidates (Goroka, Port Moresby) to be trained in
Australia to provide regular maintenance to machines.
CHAI has made an assessment of laboratory/hospital capability now and planned for the future, with CHAI support.
This is found at Annex 7.
Discussion
In the absence of ART infants with HIV in PNG have a very short life expectancy (<1 year). Early diagnosis and
treatment is therefore critical. HIV positive infants were only able to be diagnosed at 18 months with the previous
test. The new PCR testing capability is therefore an important step in clinical management of infants.
Numerous centres are prepared to commence DBS collection, but unexplained delays in NDoH approving the
training curriculum is severely hampering efforts to rollout this service to other sites.
CD4 cell counts are an important tool in managing ART. Maintenance of CD4 machines is the major obstacle, with
machines regularly breaking down due to poor routine maintenance and power surges. Immediately prior to the ET
mission, just three of the seven government-owned machines were in working order. CHAI has been instrumental in
arranging their repair and is actively working to put in place a mechanism for their ongoing maintenance and repair.
PCR requires intensive laboratory staff training and QA, supported through strong supervision, as well as specialised
laboratory facilities which CHAI is supporting well. CHAI support at CPHL is therefore likely to be required for the
foreseeable future. In addition CHAI is in the process of establishing similar facilities at GPH to ensure the demand
for services is able to be met as more sites are able to provide DBS specimens.
Recommendation 6: Phase 2 of CHAI continues to support strengthening of laboratory services.
Objective: Expand quality HIV care, treatment and support including antiretroviral therapy to children in new and
existing paediatric treatment sites
Overall Objective: To design and implement a replicable model for HIV & AIDS testing, care and treatment for
the rural majority in Eastern Highlands Province (EHP) and Southern Highlands Province (SHP).
Overall Objective: To continue to serve the commodity and equipment needs of the national HIV program,
particularly in regards to paediatric care and treatment, and to encourage superior management of the distribution
system in-country through ongoing support to the HIV Logistics Unit
Overall Objective: To ensure a high level of quality of care at key ART treatment facilities and to build capacity of
local clinicians to manage HIV testing, care and treatment.
Overall Objective: To guide the development of a robust patient information management system which serves the
needs of patients, health workers and the national HIV program.
Overall Objective: To support and coordinate major program areas while providing strategic direction for the
Foundation’s activities in-country.
3.3 Efficiency
Key questions: Did the implementation of the activity make effective use of time and resources to achieve the
outcomes? Was a risk management approach applied to management of the activity (including anti-corruption)?
What were the risks to achievement of objectives? Were the risks managed appropriately?
The total budget for CHAI 2006-2009 is $11.08 million. All but one tranche has been paid to CHAI on time (see Table
below). The delay in payment of the fourth tranche was due to a lengthy discussion process on the AAP, focusing on
M&E weaknesses, and some issues that were raised by the NDoH. The issues were raised with CF Director for
Asia/Pacific in a meeting in Canberra. It must be noted that to date the M&E issues have not been addressed by
CHAI.
Tranche Date released
First tranche payment (Aug to Sept 2006) 14 Aug 2006
Second tranche (Oct to Dec 2006) 1 Oct 2006
Third tranche (Jan to Dec 2007) 1 Jan 2007
Fourth tranche (Jan to Dec 2008) 19 May 2008
Fifth tranche (Jan to Dec 2009) 16 February 2009
Detailed budgets are needed to assess efficiency adequately. Financial documentation available for the review for
the years 2007-2008 is found at Annex 10. Based on consultations and the information found in Section 3.1 of this
report it is the opinion of the ET that the model of having CHAI technical assistance (TA) that directly supports
capacity building in the Program Areas that have been identified as GoPNG priorities is working well, and constitutes
value for money. The model uses the CHAI TA to provide the continuing capacity building and mentoring that is so
necessary if ownership, confidence and skills are to be supported. Consultations with key stakeholders and ET
observations confirmed that this was being achieved in a way not often seen in PNG donor supported projects in the
health sector.
3.4 Impact
Impact examines the “long-term effects produced by a development intervention, directly or indirectly, intended or
unintended”.5 To do this the project would need to provide a statement of likely impact, with indicators to measure
this, and this has not been done. However, it is too early in the project to measure impact and will not be commented
upon in this evaluation.
3.5 Sustainability
Key questions: To what extent will the benefits of the project continue after donor funding ceases? What are the
major factors which might influence the achievement or non-achievement of sustainability of the project?
In the context of donor-funded development programs and projects, sustainability can be defined as measuring the
likelihood that there will be “continuation of benefits from a development intervention after major development
assistance has been completed”.6
This section of the report assesses the commitment and capacity of GoPNG to continue to implement each program
area, and should answer the question: To what extent are NDoH and EHP government able to take responsibility for
this work?
An important element of sustainability of the project is local ownership. This has been achieved in some (though not
all) key areas of CHAI nationally. At the national level there is outstanding individual leadership that persists and
achieves progress despite the absence of a “home” for some elements of the project in NDoH.
At the provincial level there is very clear evidence of local ownership and commitment to the RI. This is evident in
letters from key stakeholders, funding to facilities and staff positions, and has been confirmed through the ET’s
consultations. It has been evident from the top level of government (Governor), down through the provincial
administration to the leadership and health staff in the hospital and lower level health services.
At the request of the ET the project has provided an analysis of sustainability issues related to the overall program
and each Program Area specifically. The discussion below reflects the combined discussions of the ET and the CHAI
team. There are some key factors that will affect the sustainability of the overall program:
It is the view of the ET that the project is progressing well toward a sustainable situation. This is very largely due to
the GoPNG vision of health system reform, ownership, building capacity of health service providers for both
leadership and health service provision, and CHAI’s readiness to commit to this vision and provide support without
compromise. Long-term capacity building goes beyond simple training and must include close follow-up and
________________________________________________
5
OECD (2000). Glossary of Evaluation and Results Based Management (RBM) Terms
6
Ibid.
Key Question: To what extent has the project (i) advanced gender equality and (ii) promoted women, using the four
dimensions of access, decision-making, women’s rights and capacity building.
The CHAI AAPs describe the project approach to gender, and CHAI management reiterated to the ET that CHAI in
PNG is built upon the goal of equal access to treatment and care that need it. Within this broad vision are substantive
focal areas of work that at their core promote equity in HIV services, whether it is to ensure ARV supplies are
available throughout the country at all ART sites through supply chain management, provide women-appropriate
PPTCT services at ANC through the Rural Initiative, or implement integrated services for HIV positive mothers and
their babies at the Well Baby Centre through paediatrics.
However, there is no reporting in any QRs on achievement by CHAI describing what the project has actually done to
address gender issues, in particular those that are significant in HIV. Some training data made available to the ET
while in country was sex disaggregated, but most of it was not. A summary table provided to the ET as a result of
joint discussions during the evaluation process provided the following sex disaggregated training data, showing that
women dominate in training opportunities and thus opportunities for capacity building:
________________________________________________
7 OECD (2000). Glossary of Evaluation and Results Based Management (RBM) Terms.
3.8.2 Laboratory
________________________________________________
8 OECD (2000). Glossary of Evaluation and Results Based Management (RBM) Terms.
It is also evident that interventions put in place have been based on sound analysis of best practice nationally and
internationally. Some examples include:
• Detailed analysis of testing protocols in HIV/AIDS programs internationally;
• Researching SOPs for appropriate models for PNG;
• Sourcing of Australian laboratory expertise for quality assurance programs;
• University of Michigan Ross School of Business study into the supply management system for ARVs and
test kits;
• University of San Diego (CF care partner) contribution to sharing international practices in paediatric HIV;
• Identification of a Tanzanian patient information database to provide the basis for a PNG customised
database;
• Piloting implementation of the Ready-to-Use Therapeutic Food (RUTF) for malnourished and HIV-positive
children in PMGH and GPH;
• Assessment for establishing a model of Continuum of Prevention to Care to Treatment.
Rating scale:
Satisfactory Less that satisfactory
6 Very high quality 3 Less than adequate quality
5 Good quality 2 Poor quality
4 Adequate quality 1 Very poor quality
4.2 Recommendations
Recommendation 1: In Phase 2 of the project HIV prevention is mainstreamed into all service components.
Recommendation 2: A new phase of CHAI is guided by a design that includes a logical framework, uses recognized
project terminology and clearly identifies the project purpose, component/program areas and their objectives, and
activities that will contribute to achievement of each of the component objectives. The design should be preceded by
a concise needs assessment that clearly justifies the project content.
Recommendation 3: To support implementation of a new phase AusAID articulates a new agreement that is more
specific about reporting against all elements of the logical framework.
Recommendation 4: Areas of potential conflict are articulated in a risk management plan and GoPNG ensures that
all parties working in similar areas are collaborating and coordinating their activities.
Recommendation 5: As a matter of urgency NDoH precipitate the appointment of a permanent head to CPHL.
Recommendation 6: Phase 2 of CHAI continues to support strengthening of laboratory services.
Recommendation 7: Undertake a detailed assessment and cost-analysis within six months on those components of
the RI already in place to inform expansion of the model.
Recommendation 8: Establish criteria for selection of further provinces for implementation of the RI.
Recommendation 9: Efforts need to be made to maximise integration of HIV, including prevention, into other
services such as STIs, TB and maternal and child health.
Recommendation 10: AusAID, CHAI, Save the Children (and other relevant PASHIP implementing organisations),
FHI and GoPNG need to ensure that cooperation and synergies between projects are maximised. GoPNG must lead
this effort.
Recommendation 11: Leading into Phase 2 explore the feasibility of and alternative options for expanding
paediatric HIV services beyond the provincial hospitals.
Recommendation 12: At the national level institute strategies to improve training capacity to meet demand for staff
training.
9. Reading materials
a Responding to HIV/AIDS in PNG – Australia’s PNG specific HIV strategy
b Independent Review Group Reports 07 and 08
c AusAID/Clinton Foundation Agreement
d CF Workplans – 2007, 2008 and 2009
e AusAID’s new HIV Strategy (2009)
f NDoH 2009 – 2013 Corporate plan
g NDoH Strategic Plan (2006 – 2008)
h CF activity reports (2007, 2008 and 2009)
i PNG HIV/AIDS Strategic Plan 2008 – 2010
j PNG HIV Surveillance Plan 2008 – 2010
AusAID Canberra
Janet Donnelly Manager, Evaluation and Reviews, PQR, PNG Group
Jennifer Lean Manager, PNG Branch
Kirsty Dudgeon Program Manager, Program Quality & Review Section, PNG Branch
Mukii Gachugu Manager - Design Support, Program Quality & Review Section, PNG Branch
Sofia Erikson
AusAID Goroka
Moale Vagikapi Team Leader & Senior Program Officer
NDoH
Dr Clement Malau Secretary
Dr Esorom Daoni Principal Technical Adviser, HIV/AIDS/STI, CDB
NACS
Dr Romanus Pakure A/Director
FHI PNG
Nayer Kaviani Country Director
Tess Prombuth Senior Technical Officer
Goroka Hospital
Dr Joe Apa CEO
Dr Frank Dale Director Medical Services
Theresa Palau Laboratory Manager
Dr Paul Wari Paediatric Registrar
Simon Pekon Case Manager, Adult Care & Treatment
Sr Ulato Gebaro-Imara Sister-in-Charge, Michael Alpers Clinic
Mr Jani Wano 2nd OIC, Michael Alpers Clinic
Mary Drua Case Manager, PPTC/Paediatric HIV, Michael Alpers Clinic
AT Projects
Miriam Layton Co-Director
Steve Layton Co-Director
UNICEF
Carlos Baraka Assistant Programme Officer, Goroka
Cristi Morf HIV/AIDS Specialist, Port Moresby
Hamish Young Country Representative, Port Moresby
WHO
Dr Fabian Ndenzako HIV/AIDS Country Officer
AMS
Cathy Kemben Logistic Officer
Willie Aloitch CHAI Cadet, Career & Development Program
CPHL
Dr Evelyn Lavu a/Director
CBSC
Brendon Douglas Facility Manager
Shane Martin HIV Management Adviser
Heduru Clinic
Dr Jimbanao Medical Officer
Sr Gola Sawiya Senior Nursing Officer
Ns Po’o Mendi Community Health Worker
Miriam and Steve Layton Co-Directors AT Projects 1500 - 1630 AT Projects base
Thursday 28 May 2009
Dr Apa CEO Goroka Provincial 0830 - 1045 Goroka Provincial
Hospital Hospital
Dr Frank Dale Director Medical
Services
Carlos Baraka Assistant Program UNICEF Goroka 1100 - 1200
Officer
Field visit Asaro Health Centre, 1300 - 1600
Daulo District
Friday 29 May 2009
CF Goroka to organise Site visits to 0800 - 1600
Kainantu ( 1hour
drive) and
Henganofi
Dr Thomas Koimbo CEO Kainantu Hospital 9.00 - 1000 Kainantu Hospital
Chairman, EHP
PAC
Mr Malcolm Smith Governor EHP Provincial 1830 -2000 Working dinner
Government
Saturday 30 May 2009 - Return to Port Moresby (morning flight)
1. Laboratory Infrastructure
1.1 Early Infant Diagnosis (EID)
Objective: To support the government in the design and implementation of a
1.2 Rapid Test algorithm development
rationalized laboratory system for HIV care and treatment.
1.3 CD4 Testing
Indicators
1.4 Infrastructure, HR, mentoring & research
• None provided
2. Paediatric Care & Support 2.1 Provider Initiated Counselling & Testing (PICT)
Objective: Expand quality HIV care, treatment & support including antiretroviral
therapy to children in new & existing paediatric treatment sites 2.2 Early Infant Initiation
Indicators: 2.3 Retention & Case Management (Well Baby
• None provided Centre at PMGH)
5. Clinical Mentoring
Objective: To ensure high level of quality of care at key ART treatment facilities 5.1 Support to ART Sites
& to build capacity of local clinicians to manage HIV testing, care, & treatment.
Indicators:
• None provided
7. Program Management and Coordination 7.1 Support & Coordination of All Major Program Areas
Objective: To support & coordinate major program areas while providing 7.2 Budget Oversight
strategic direction for the Foundation’s activities in-country. 7.3 Safety & Security
Indicators:
7.4 Strategic Planning
• None provided
7.5 Reporting Support to NDOH Logistics Unit
Goroka Hospital
• HIV Serology Confirmatory Testing • IQC for VCT confirmatory testing in EHP
• CD4 Count • CD4 percentage upgrade and continuous CD4
• Haematology machine running with strengthened service,
• Biochemistry maintenance of machines
• Commence PCR testing
• Viral Load
Mendi Hospital • IQC for VCT confirmatory testing in EHP
• HIV Serology Confirmatory Testing • CD4 percentage upgrade and continuous CD4
• CD4 Count machine running with strengthened service,
• Haematology maintenance of machines
• Biochemistry
Adult Care & Treatment
January 2007 April 2009
Registered Care/Tx 169/78 946/521
Body Mass Index Increase 75% 87%
PPTCT
January 2007 April 2009
HIV Testing Uptake <50% 88%
Lost‐to‐Follow‐Up 74% 2%
Anti‐Retroviral Rx NVP 4 Protocols
Maternal Follow‐Up none 95%
Newborn Follow‐Up none 95%
District Level Testing none 14 sites
Projected Need Addressed 10% 39%
Paediatrics
January 2007 April 2009
Registered Care/Tx 1/1 69/19
Lost‐to‐Follow‐Up 34% 5%
Patients from PPTCT none 59
Projected Need Addressed 1.6% 55%
o Access to HIV testing has expanded dramatically. The efforts made in VCT training of Health Care Workers
as well as laypeople, followed up with ample opportunity to practice the skills learned, such as bringing newly
trained counsellors to Health Fairs featuring VCT to practice under supervision with higher numbers than
possible normally, has resulted in much higher numbers of VCT through the Hospital and Outreach,
answering a need of the community. Likewise, in-service training in PICT as distinct from VCT has led to far
better counselling skills and execution of PICT throughout the Hospital and affiliated clinics, namely the
Antenatal Clinic, Children’s Medical and Outpatient, Labour Ward, Medical Ward and STI/HIV clinic.
o expansion has been driven largely by existing Heath Care Providers. The first phase expansion of adult ART
to the District level was manned entirely by Provincial Health Services employees who had been trained in
ART prescribing but were since idle. Mentoring and supervising them as they undertake this new role has
given them greater job satisfaction. This approach also demonstrates how to optimize the existing human
resources within a Province through mentorship and supervision.
o Laboratory improvements have benefitted the people of the entire catchment area. Laboratory is the
backbone of health care service. Upgrades made to the Goroka General Hospital Pathology Lab in order to
provide adequate HIV treatment have benefitted the care of every patient.
Infrastructure, 347,848.00 ,
6%
Goroka Hospital, 251,221.00
, 5%
Southern Highlands, Salary, 1,240,823.00 , 23%
115,500.00 , 2%
Salary
Local Staff salary
Overhead
Rent
Local Staff salary, Meetings&Trainings
372,390.00 , 7% Program
Southern Highlands
Program, 2,048,179.00 , Goroka Hospital
36% Overhead, 341,836.00 , 6%
Infrastructure