Evaluation of the HIV and AIDS
program implemented by Hivos
in the period 2000-2009
Final evaluation report ACE Europe – ETC Crystal January 2011
Evaluation of the HIV and AIDS
program implemented by Hivos
in the period 2000-2009
Geert Phlix
Carolien Aantjes
Esther Jurgens
Renuka Motihar
Roberto Lopez
Preface
The evaluators would like to thank first of all the staff of the partners in
India and Peru: their cooperation, readiness to welcome the evaluators
and their willingness to share their perceptions, conclusions, hopes and
fears with the evaluators have made this report possible. The evaluators
would like to thank in particular the organisations for the time they have
invested in the collection of the Most Significant Change Stories.
The evaluators would also like to thank Hivos for the opportunity to
execute this evaluation and express their appreciation for the commitment
of the Hivos team to the results of the evaluation and their contribution to
the quality of this report. Finally, it is our hope that this report will
contribute to the further development of the HIV/AIDS policy to support
the effectiveness and sustainability of the interventions of all partners
involved. To respond to the HIV/AIDS epidemic long term social changes
are needed and Hivos and its partners play a key role in achieving these.
The evaluators wish all the activists a lot of success.
Geert Phlix
Coordinator of the evaluation
Executive summary
This program evaluation was initiated by Hivos and fits with the accountability requirements described in
the framework of the co financing system 2007-2010. This evaluation report concerns the evaluation of
the Hivos‘ HIV and AIDS program, covering the period between 2000-2009 and addressing the programs
in South America and India. The evaluation needs to provide evidence for the effectiveness and
sustainability of the Hivos‘ HIV/AIDS program in South America and India (accountability focus) and will
serve as input for the Hivos‘ 2010 HIV/AIDS policy, i.e. to inspire future development and implementation
(learning focus). The overall evaluation question reads as ‗What was the effectiveness of Hivos‘ HIV/AIDS
program: to what degree has Hivos‘ HIV/AIDS program in the period 2000-2009 been able to achieve its
objectives?‘. Five sub questions have been formulated by Hivos:
1) To what degree have/has …
human and sexual rights of key affected populations been strengthened?
access to equitable, non discriminatory HIV prevention improved?
access to sustained quality treatment and care improved?
2) Have targeted key affected populations been effectively reached?
3) How have gender dynamics been addressed?
4) Which major factors explain the observed level of results achievement?
5) How sustainable are the observed outcomes in the first question?
The evaluation was executed by a team of five international and national consultants in the period March
2010-October 2010 (with a final report in January 2010). The evaluation consisted out of four phases: (1)
an incentive phase within which the evaluation framework and methodologies for data collection were
elaborated, a policy reconstruction of the Hivos HIV/AIDS policies was done, countries and partners to be
visited were selected; (2) a phase of data collection with two field evaluations missions, visiting India and
Peru and a desk study analyzing documents of the 12 partners involved in the sample of selected
partners. 8 partners have been visited during field visits (4 in each country), 2 partners in Bolivia and 2 in
Ecuador were only analysed by desk study. 12 partners of a total of 24 partners in Latin America and
India have been involved in the evaluation, covering 78% of the total budget spent at the HIV/AIDS
program in the period 2000-2009 (and 54% of the co-financing budget spent in that period); (3) a phase of
analysis and (4) a phase of reporting. Conclusions have been presented and discussed in the internal
reference group that guided the evaluation. A workshop with program officers to discuss the conclusions
and to formulate in a participative way recommendations is planned to take place early 2011.
The methodology of the evaluation combined several instruments, such as analysis of documents,
collecting factual data by sending a questionnaire to the partners, interviews with staff, self assessment
workshops with staff including a timeline exercise, interviews with beneficiaries and external stakeholders,
focus group discussions with beneficiaries. The technique of Most Significant Change was used to collect
information on the changes that have occurred in the lives of the beneficiaries. External research reports
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and publications with official data (from partners or other agencies like publications of UNAIDS and the
UNGASS reports) were used to complete and assess the analysis of the data.
The program evaluation focuses on Latin America and India, involving countries that are dealing with a
concentrated epidemic. In India the estimated adult prevalence is 0,34% (between 0, 25% and 0,43%)
and is greater among male (44%) than among female (23%). The prevalence rate has stabilised over the
last years, 2002-2007. The HIV prevalence in Peru was in 2008 0,23%, with a prevalence rate of 13,9%
amongst MSM and 32% of the population of transgender. In both countries the prevalence rate is high
amongst key affected populations such as MSM, sex workers and transgender. These groups are also
the key target groups in the Hivos HIV/AIDS policy.
Since 2000, many developments have occurred in response to the HIV pandemic. One of the key
developments at the start of the 21st Century was the launch of the Millennium Development Goals
(MDGs). In this, the response to HIV/AIDS became part of a global action plan. In 2001, at the UN
General Assembly special meeting on AIDS (UNGASS), member states signed their declaration of
commitment to protect human rights and gender equality, through appropriate legal frameworks, in their
national response to HIV. One year later, the Global Fund for AIDS, Tuberculosis and Malaria was
established, presenting a new approach to international health financing. By 2003, WHO launched the
highly ambitious 3 by 5 initiative which aimed to provide 3 million people living with HIV/AIDS in low- and
middle income countries with ART by the end of 2005. Though this target was not reached in 2005, the
initiative did signal the start of an impressive scale-up of ART services in the years that followed. Many
international organisations entered the aid arena and availed major funding for HIV/AIDS. This provided a
boost to further target setting and in 2006, member states at the UNGASS meeting agreed to work
towards the goal of universal access to comprehensive prevention programs, treatment, care and support
by 2010. Over the past ten years, civil society organisations have increasingly been recognized as key
players in the national HIV response. This has resulted in their implication at national level in e.g. the
UNGASS reporting process as well as representation in formal governing bodies, such as National AIDS
Authorities and the County Coordinating Mechanisms (CCM) of the Global Fund.
Hivos was already responding to the HIV/AIDS epidemic since the nineties. Since then, relevant
HIV/AIDS policy formulations are found in 3 documents: the 2001 policy document, the 2006 Business
Plan for the MFS-period 2007-2010 and the recently reformulated HIV/Aids policy document. The
objectives of the Hivos‘ HIV/AIDS policy are increased access to prevention, treatment and care of key
affected populations (in particularly of PLHIV, MSM, sex workers and transgender) and a government that
assumes its responsibility for better service delivery. Hivos works from a rights based approach and aims
at strengthening human and sexual rights of key affected populations to fight stigma and discrimination.
Hivos prefers supporting advocacy and lobby activities and programs that strengthen the claim making
power of key affected populations above financing direct service delivery. When access to non
discriminatory and qualitative prevention, treatment and care will be guaranteed the HIV infection rate will
reduce as well as the socio-economic impact of HIV.
To achieve these objectives Hivos invests in following approaches: (1) healthcare providers need to
acknowledge their own discriminative attitudes towards the key affected populations, change their attitude
and behave accordingly; (2) key affected populations need to be able to claim their rights and to address
violations of their rights effectively, monitor policy implementation and put pressure on government and
other decision makers in the health system to improve the accessibility and quality of the services
provided to them; (3) good models for prevention, treatment and care that are not dominantly bio-medical
(giving attention to the psycho- and social support and the environment within which the key affected
populations are living) can be supported and need to be scaled up within the public health system in order
to improve the quality of the services provided by the health system; (4) auto-discrimination by key
affected population need to be decreased and self confidence increased, combined with a wider
acceptance of key affected populations by the society at large.
All partners implement in one way or another these approaches. The extent to which the partners have
contributed to improved human and sexual rights and to a sustained increased access to qualitative and
non discriminatory prevention, treatment and care reads as follows.
(1) Human and sexual rights of key affected populations strengthened
Hivos aims at strengthening human and sexual rights of key affected populations to fight stigma and
discrimination. All Hivos partners contribute to the strengthening of human and sexual rights of key
affected populations (1) by contributing to the debate on HIV and AIDS through participation at official
public structures and/or civil society forums/coalitions that discuss policies and programs to fight
HIV/AIDS, (2) by advocating for human and sexual rights of key affected populations, (3) by defending
individual cases of violation of human rights (cases of discrimination) of key affected population, (4) by
participating at networks that contribute to the debate, (5) by strengthening community based
organisations of key affected populations to make their voices heard.
Important results have been noticed by the evaluators. On the policy level legal frameworks started to
take into account the needs of key affected populations and several laws exist to fight stigma and
discrimination. Contribution of several Hivos‘partners was relevant to achieve these changes. Several
partners participate in formal governing bodies, such as National AIDS Authorities and the County
Coordinating Mechanisms (CCM) of the Global Fund to have a direct influence on the policy making
process. All partners monitor implementation of the policies and HIV/AIDS programs and take action
when needed. Many of the partners collaborate with health facilities and police stations at local level to
raise awareness on discriminative attitudes of their staff. Changes at local level (mainly in health facilities
and police stations) have been reported.
All Hivos‘ partners support and/or create community based organisations (CBOs) and federations of key
affected populations. These groups receive training and technical support in dealing with abuse cases,
communication with police and health workers, legal issues, how to access governments services and
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support schemes. The changes these groups are able to make are mostly localised and/or at individual
level (e.g. demanding a doctor to provide for better services or a police station to back off). Forming
groups of key affected populations and supporting them in claiming their rights collectively is at the core of
the strategy of the Hivos‘partners in India, not in Peru. However, the advocacy and lobby capacity of
these CBOs is limited. Most of the groups focus on their immediate needs. There is anecdotic evidence
(interviews, MSC stories) of a decrease of incidences of violations of human and sexual rights but this is
limited to the local level and differs from one group to another (ex. PLHIV - gay experiencing an improved
respect for their human rights compared to sex workers and trans gender in Peru). Overall stigma and
discrimination persists but at local level some changes have been reported after interventions of Hivos
partners and the CBOs supported by them. The most important changes as reported by the beneficiaries
involved in the programs of Hivos‘ partners are their increased understanding of the rights (and increased
understanding of discriminative attitudes) and how to claim their rights on the one hand and their
increased self esteem and self confidence on the other hand.
(2) Improved access to equitable, non discriminatory HIV prevention
In both countries a legal framework exists to develop and implement HIV prevention campaigns and
health preventive packages for vulnerable groups though implementation is hampered by prevailing
stigma and discrimination, the lack of sufficient means and the dominating bio medical approach not
taking into account the specific needs of key affected populations. HIV prevention is only marginally linked
to sexual and reproductive health and in both countries it is problematic for youth to seek confidential and
appropriate information on their sexual and reproductive health and HIV.
All Hivos partners are implementing HIV prevention activities targeting key affected populations and as
such complement government prevention initiatives to effectively reach key affected populations. Hivos
prefers to support innovative prevention approaches but it is not clear to what extent preference is given
to these ―innovative models‖ and what strategy is used to scale up these ―models‖. The annual reports of
the partners do not report on innovative approaches and in the interviews with the partners no information
was given on innovative approaches (two exceptions).
No evidence has been found of an elaborated advocacy and lobby strategy to hold governments
accountable for effective, equitable and non discriminatory HIV prevention. Most of the advocacy and
lobby is linked to addressing stigma and discrimination attitudes. Advocating for equitable and non
discriminatory prevention consists mainly in specific protest actions in cases of violation of rights to
access prevention (ex. actions against mandatory testing) and in monitoring availability of ARVs,
condoms, etc. in health care centres. In India the CBOs, supported by Hivos‘partners, have taken up an
important role in stimulating health seeking behaviour of their members (informing them on HIV and STI,
providing condoms, stimulating to go for testing, referring to the appropriate centres, etc.). In Peru these
activities have mainly been taken up by the partners themselves.
The role of Hivos‘ partners and the CBOs supported is important in reaching key affected populations with
appropriate HIV information. An improved access to information, VCT services and condoms for key
affected populations (through the public health system and civil society) has been reported by all
stakeholders interviewed, compared to the situation in 2000 and even 2004. Another important change
related to HIV education in the communities is related to the reduced fear by community members
because of gained knowledge on the disease and changed attitude of family and community members.
(3) Improved access to quality treatment and care
In both countries equitable and qualitative HIV/AIDS treatment and care are included in the national AIDS
programs (and in Peru regulated by several laws) to fight HIV/AIDS. In India and Peru, ARVs became
available at large scale since 2004. In Peru up to 85% of PLHIV is accessing ARVs. India, covering an
estimated 12% of PLHIV that need or will need ARVs, still has a long way to go.
Hivos‘ partners are active in a broad spectrum of care services such as VCT; palliative care; Home Based
Care (HBC); organisation of peer support groups (PLHIV support, post test (youth) clubs); and support to
groups active in income generating activities. Half of them effectively offer own treatment and/or care
services and all partners have counselors and/or health workers amongst their staff to support their target
groups with qualitative counseling. Apart from implementing own services, partners are above all
stimulating health seeking behaviour (giving information, informing target groups on their rights, referral to
ART centres, linking people up to nutritional support and support groups, accompanying when needed,
follow up of adherence to the program, etc).
in the period before 2004, all partners were very much involved in advocating for the right to access
treatment with considerable success. Since the roll out of the national ART campaigns, Hivos‘ partners
keep on monitoring the availability of ARVs and ART centres and take actions when access to ARVs for
key affected populations is denied. Partners‘ advocacy on the access and quality of care is limited to
addressing cases of stigma and discrimination. Holding governments accountable for improved quality of
care is not on the agenda of the Hivos‘ partners nor on the agenda of the networks they are involved in.
Little activism can be noticed addressing the quality of care in both countries and monitoring the
implementation of the quality standards as set out for HIV/AIDS health care services. According to the
interviewees (and confirmed in research) the overall quality level of health care services for PLHIV in
Peru has reached the same overall poor level of the public health services which seems to be accepted
by the key affected populations.
Beneficiaries interviewed and most significant change stories collected give evidence of better access to
treatment and care by beneficiaries of the partners‘ programs.
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(4) Sustainability of the outcome
Important changes at policy level have been realized; however sustainability of these changes is very
fragile. National AIDS programs exist but implementation and funding remain a challenge (HIV/AIDS
prevention, treatment and care not fully incorporated in the national budget). In both countries HIV/AIDS
services are organised vertically with limited convergence with other health services (ex. limited link
between HIV and sexual and reproductive health).This can be a threat for sustainability of these services
when the budgets will decrease.
Sustained access to prevention is hampered by several factors: stigma and discrimination of health care
staff and in IEC materials, staff turnover in health facilities (loosing well qualified staff that have been
trained by NGOs), lack of confidentiality, low level of self esteem and disinformation of key affected
populations. Hivos‘ partners are able to address these factors but only at local level (no structural change)
and primarily offering their own prevention services.
In both countries there is recognition of HIV requiring lifelong treatment, though it has not yet received
the status of a chronic disease. A strategy is lacking on how to integrate HIV/AIDS services in the public
health system.
India and Peru produce some patent free first generation ARVs. Purchase of ARVs is
funded through the Global Fund and by own public means. As the activism to access ARVs has been
very strong and the difference in health status of PLHIV is obvious, it will be politically very difficult to stop
delivering ARVs. The current challenge is to guarantee access to ARVs all over the countries, access to
second and third generation of ARVs and good management of purchase, stock and distribution of ARVs.
Then there are challenges that are not exclusive for the HIV/AIDS programs in both countries which relate
to the weaknesses in the overall health system to deliver (quality) services.
In both countries a strong civil society fighting for the rights of key affected populations has grown.
However, changes mainly happen to take place at local level. Partners and CBOs take up a role of a
―watch dog‖ in particularly by monitoring policy implementation and documenting cases. But there is little
follow up of these cases at political or juridical level: not many cases are brought to court; no much
pressure is put on policy makers, partners do not follow the agenda of the policy makers and there is no
pressure put on directors and management of health care centres. The influence of the Hivos‘partners on
decision makers and decision takers at government level and within the health system to speed up and
control implementation of laws and regulations is very limited. Civil society organisations did not succeed
in scaling up their good models because of a lack of a well developed strategy which takes into account
the risks and opportunities of the health system that are conducive for or hamper the swift implementation
of qualitative care. Advocacy and lobby is taken forward by a limited group of staff of Hivos‘ partners.
None of the partners have developed an advocacy and lobby strategy, invested in training lobbyist or in
creating networks with other experts to enhance lobby at policy level. Advocacy and lobby will depend on
the availability of these activists in the organisation and the room to maneuver when funds will become
more restricted.
Key affected populations and the HIV/AIDS NGOs have gained a lot of knowledge on HIV and AIDS (HIV
literacy) but do not automatically possess knowledge of the structural factors that hamper swift
implementation of government health policies. As a consequence key affected populations and the Hivos‘
partners are not very much capable in formulating alternative proposals in order to address in a structural
matter the underlying bottlenecks in the public health delivery system. Hivos‘ partners do not collaborate
with organisations that defend the rights of patients and that have expertise in lobbying the health sector
in general, though the solutions of the failing health system require systemic changes. They will keep on
documenting the problems (ex. lack of ARVs) without entering in a meaningful policy debate with policy
makers (as compared to their meaningful involvement in de the development of the HIV/AIDS laws and
programs).
Hivos collaborates with strong partners and the relevance and quality of the services provided have been
assessed by beneficiaries and external stakeholders as good. All of them are considered to be legitimate
experts regarding HIV/AIDS and the rights of key affected populations (by government, health care
workers, international agencies, colleagues and beneficiaries). Except for two partners, none of the
partners actually depends for more than 60% on Hivos funding. They succeeded to diversify their donors
though many of them depend a lot on Global Fund money. However most of the donors (also EU and
Global Fund) finance on a project bases something which may reduce the participation of partners at
networks and their involvement in advocacy and lobby activities. Institutional sustainability is at risk for
three partners who were confronted with financial problems.
Target group effectively reached
Hivos has clearly identified the target groups of its HIV/AIDS program and all partners visited are reaching
out to key affected populations as described in the Hivos policy. There are no reliable data on the amount
of people reached by all partners over the period 2000-2009. Partners use different strategies to reach
the specific key affected populations. Several partners deliver qualitative treatment and care services that
are easy accessible by PLHIV. Two organisations are organisations of PLHIV.
Gender
Hivos‘ HIV/AIDS policies describe three interventions regarding gender: gender mainstreaming,
addressing unequal power relations and enhancing understanding on different gender roles among MSM
and transgender. The evaluation shows that gender is not prominent in the strategies of the partners or
when it is, it is limited to implementing women projects. Discussion on gender roles amongst key affected
populations like MSM and transgender does not sound familiar for the partners visited. Some partners do
address unequal power relations, but mainly in their work with women, strengthening women and women
organisations. All partners set up specific projects to reach out to specific target groups (MSM, sew
workers, transgender and women) and take into account the characteristics of each specific group (mostly
female sex workers, MSM, transgender). The programs of the Indian partners (except one) are women-
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centred. The programs of the Indian partners are women-centred (except INP+) and put the vulnerability
of women at the core of their activities. In Peru, partners are more talking about sexual diversity instead of
gender diversity and as such have enlarged the concept of gender. When it comes to defending human
rights and addressing stigma and discrimination, the characteristics of the subgroups (target group of
each partner) are taken into account, rather than making a distinction between specific concerns of men
or women. Most of the partners make a link between HIV and Sexual rights, mostly focussing on sexual
and reproductive rights of women. This causes frictions between female transgender and women, each of
them having a different agenda when it comes to human rights.
Response to the overall evaluation question
Partners have contributed to an increased access to prevention, treatment and care for key affected
populations because of (1) their investment in HIV education and awareness raising of key affected
populations and their relatives, (2) training of peer educators, (3) actively referring beneficiaries to health
services delivered by the public health system or NGOs and (4) providing own counselling and support
services. Results on improving quality of prevention, treatment and care are less evident. Several
partners train health care workers from the public health system (including addressing attitudes of stigma
and discrimination) but the public systems keep on failing to deliver qualitative and integral heath care
packages. Most of the partners complement such gaps by offering qualitative and integral care and
counselling services themselves.
The focus on the empowerment of the key affected populations has equally contributed to increased
access to prevention, treatment and care. Increased knowledge on their rights and increased self esteem
are factors conducive for improved health seeking behaviour. Beneficiaries are trained on how to claim
their rights. Several cases of violations of rights have been reported with some of them resulting in an
improved situation. Collectives (claiming rights collectively) and leaders play an important role to that end.
Attitudes of stigma and discrimination continue to exist and in order to have a real impact on improved
access to prevention, treatment and care. Long term social change processes are needed. All partners
contribute to these change processes by addressing stigma and discrimination in their own information
material and trainings, documenting attitudes of stigma and discrimination and organising/participating in
demonstrations of LGTB and/or sex workers.
Results regarding changed attitudes at local level could be noticed (health care centres, police stations,
families and communities). However, results at a societal level are not clear and much is left to be done. It
seems that PLHIV experience less discrimination as compared to LGTB and sex workers who face
double stigmatization because of their sexual identity. Hivos‘ partners contribute only to a limited extent to
the strengthening of the LGTB movement and movement of sex workers. The success of these
movements differs from one country/state to another and from key population to key populations.
Explicative factors for the level of effectiveness and sustainability
The approaches described in the theory of change seem to be appropriate in the fight against stigma and
discrimination and to achieve improved access to services. However, in the theory of change (and as
such the HIV/AIDS policy) not enough attention is given to the structural bottlenecks that hamper
implementation of qualitative services by the government. A strategy to upscale good practices is lacking
and the policy is not clear on what kind of advocacy and lobby needs to be developed in order to bring
about structural change. Six groups of conclusions have been developed that explain the level of
effectiveness
The level of implementation of the Hivos’ HIV/AIDS strategy – the Hivos HIV/AIDS‘ policies are well
implemented into practice. However, the policies are of a rather general nature. Specific strategic
documents per region or country do not exist though countries are facing different challenges. By
consequence clear output and outcome indicators are lacking at regional, country and partner level what
complicates the monitoring process. Some approaches described in the policies are not well developed
which makes it difficult to have a critical dialogue with partners on the approaches chosen (ex. innovative
approaches, advocacy and lobby, strengthening of CBOs and networks, HIV and SRH convergence).
Advocacy and lobby – a well developed advocacy and lobby strategy is lacking and evidence of this
evaluation shows that the current strategies of the partners are not sufficiently to bring about structural
changes in the government system and the health system developing effective prevention campaigns,
ensuring sustained access to treatment and implementing qualitative integral health packages.
Rights holders and duty bearers – According to the Hivos HIV/AIDS policy the insufficient access to
prevention, treatment and care not only results from lack of political will but also from limited technical
capabilities. The answer from the Hivos policy and the partners is on training of health care professionals
in effective prevention and counselling to MSM, sex workers, transgender and youth and on the
development of innovative models. However, partners face a problem of scaling up good practices. By
consequence small successes have been noticed at local level but sustainability is at risk. Partners could
not intervene in a structural manner in curriculum development for counsellors and/or health workers,
influence quality control of the health facilities, change policies at level of health facilities to address
attitudes of stigma and discrimination or target oriented approaches. As the government keeps on failing
to reach key affected populations with non discriminatory and qualitative prevention, treatment and care,
all partners complement the public services with own services (prevention, treatment literacy, own VCT
services and involvement in treatment programs, own peer educators and counsellors, etc). A large part
of the Hivos programs funded is related to direct service delivery.
Stigma and discrimination – All partners have achieved considerable success in addressing stigma and
discrimination of key affected populations. The pattern of attitudes and behaviour of stigma and
discrimination is very diverse. Studying attitudes of stigma and discrimination –in order to develop
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appropriate strategies- seems very difficult because of (i) the discrepancy between own attitude and
behaviour of, for example, health care workers and (ii) the level of self-discrimination amongst key
affected populations. The evaluators have not seen much exchange on methodologies to this regard and
not much collaboration exists with human rights organisations that have experience in documenting and
studying stigma and discrimination.
Pro-active citizenship – Prominent in the Hivos strategy is the strengthening of the capacities of CBOs,
NGOs and networks to increase their claim making power and to provide qualitative HIV education and
support to their target groups. These CBOs and federations have been very effective in promoting health
seeking behaviour and in claiming rights collectively. However, their participation at advocacy and lobby
at local/regional level is limited to addressing cases of violation of rights or monitoring availability of
condoms and medicines in health care centres and sustainability of many of these CBOs is at stake.
All NGOs in the Hivos program are supported to participate at networks and coalitions. Partners visited
have stressed the importance of these coalitions and networks for information exchange and exchange of
good practices. A well articulated lobby strategy has not resulted yet from the networks mentioned.
Results of these networks on improved access of key affected populations to prevention treatment and
care are not clear as no data exists that provides evidence of their effectiveness.
Institutional strengthening of partners- The institutional funding of Hivos makes it possible for partners to
invest in endogenous capacity development projects when needed (ex. having time that is needed to
develop policies), to participate at networks and coalitions and to participate at international meetings with
other Hivos‘ partners. All partners visited are strong partners and with support from Hivos they could
further develop their organisation. However, Hivos‘ contribution to capacity development is not based on a
thorough analysis of the capacity of the partner in relation to the objectives of the partner organisations
and often takes place on an adhoc base. The HIV/AIDS policy pays specific attention to supporting
partners in developing gender policies and /or HIV/AIDS workplace policies. An example of the lack of a
capacity development strategy is the way partners are involved in gender mainstreaming. Many partners
have started to develop a gender policy upon request of Hivos. Although a lot of expertise on HIV and
gender exists within Hivos it seems that not much of this expertise has been shared with Hivos partners.
The notion of gender dynamics and gender roles taken up by MSM, lesbian or transgender as described
in the Hivos ‗policy, does not sound familiar to the Hivos ‗partners. By consequence, gender remains
limited to targeting women and women organisations and/or to linking HIV to sexual and reproductive
health.
List of abbreviations
ABC
Abstinence, Be faithful or Condomize
AfA
Aid for AIDs
AMP
Atencion Medica Periodica
ART
Anti Retroviral Treatment
BIRDS
Belgaum Integrated Rural Development Society
CBO
Community Based Organisation
CCM
Country Coordinating Mechanism
CERITS
Centres for STI treatment
CONAMUSA
Coordinadora Nacional Multisectorial en Salud
CSO
Civil Society Organisation
DLN
District Level Network
EU
European Union
FSW
Female Sex Worker
GAM
Grupo de Ayuda Mutua
GIPA
Greater Involvement of People Living with HIV/AIDS
HBC
Home Based Care
HRG
High Risk Groups
ICTC
Integrated Counseling and testing Centre
IEC
Information and Education Material
IESSDEH
Instituto de estudios en Salud, Sexualidad y Desarrollo
Humano
JC
Judgment Criteria
LGTB
Lesbian, Gay, Transgender and Bisexual
MINSA
Ministerio de Salud
MOHL
Movimiento para una Homosexualidad Libre
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MSC
Most Signifcant Change
MSM
Men having sex with Men
NACP
National AIDS Control Program
NACO
National AIDS Comission
NRHM
National Rural Health Mission
OSACS
PEP
Promotores Educadores de Pares
PHC
Public Health Clinic
PLHIV
People Living with HIV
PPTCT
Prevention of Parent to Child Transmission
PME
Planning Monitoring and Evaluation
PROSA
Programa de Soporte a la Autoayuda de personas
Seropositivas
SAATHI
Solidarity and Action against the HIV Infection in India
SANGRAM
Sampada Grameen Mahila Sanstha
SACS
State AIDS Counsil
SIAAP
South India AIDS Action Program
SRH
Sexual Rprodructive Health
STI
Sexual Transmitted Infection
TANSAC
Tamil Nadu State AIDS Prevention and Control Society
TARGA
Tratamiento Antiretroviral de Gran Actividad
ToR
Terms of Reference
UNGASS
UN General Assembly special meeting on AIDS
VAMP
Veshya AIDS Mukabala Parishad
VCT
Voluntary Counseling and Testing
WHO
World Health Organisation
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Table of content
1
2
Introduction
21
1.1
Objectives of the evaluation
21
1.2
Evaluation team
22
1.3.
The planning of the evaluation
22
1.4.
Structure of the report
23
Methodology
24
2.1.
Phase 1 - Inception phase
24
2.2.
Phase 2 – Field visits
37
2.3.
Phase 3 – Phase of Analysis and reporting
42
2.4.
Phase 4 – Restitution
44
2.5.
Limitations of the evaluation assignment and constraints faced during the
execution
44
3
The HIV and AIDS context in India and Peru within which Hivos
and its partners are operating
45
4
Hivos approach between 2000 and 2009
5
48
4.1.
The Hivos HIV and AIDS program
48
4.2.
Theory of change
54
Human and sexual rights of key affected populations
strengthened
5.1.
58
National recognition of the sexual and human rights of key affected populations 59
ACE Europe-ETC Crystal /Evaluation HIV and AIDS program of Hivos /Final evaluation report pag. 17/176
5.2.
Partners contribute to strengthening of human and sexual rights of key affected
populations
60
5.3.
Evidence of significant changes at the level of beneficiaries (positive changes
regarding their sexual and human rights)
70
Assessment of the achievements
73
5.4.
6
7
8
Improved access to equitable, non-discriminatory HIV
prevention
75
6.1. Nationwide coverage of equitable and non-discriminatory HIV prevention
76
6.2. Partners contribute to equitable and non-discriminatory HIV prevention
78
6.3. Significant changes at the level of the beneficiaries / increased access of key
affected population to equitable and non discriminatory HIV prevention
84
6.4.
86
Assessment of the achievements
Improved access to quality treatment and care
88
7.1.
Nationwide coverage of equitable and qualitative HIV/AIDS services (treatment
and care)
89
7.2.
Partners advocate for / implement equitable and qualitative HIV/AIDS services 91
7.3.
Secured access to quality HIV/AIDS services (treatment and care)
94
7.4.
Assessment of the achievements
96
To what degree are improvements with regard to the rights of
key affected populations and their access to non
discriminatory prevention and to quality treatment and care
sustainable?
97
8.1.
Sustainability of changes at policy level with regard to rights of key affected
populations, access to non discriminatory prevention and qualitative treatment
and care
98
8.2.
Sustainability of the output of partners
8.3.
Sustained access to non discriminatory prevention of key affected populations 101
8.4.
Sustained access to quality treatment and care
ACE Europe-ETC Crystal / evaluation HIV and AIDS program Hivos / Final evaluation report pag. 18/176
100
101
9
Support to capacity development of partners
103
10
Conclusions
105
10.1
10.2
Conclusion on the general evaluation question: To what degree has Hivos
HIV/AIDS program been able to achieve its objectives?
105
Level of implementation of the Strategy of Hivos
107
10.3. Advocacy and lobby
109
10.4
Rights holders and duty bearers
110
10.5
Stigma and discrimination
110
10.6
Pro-active citizenship
111
10.7. Institutional strengthening of partners
11. Annexes
112
114
11.1. Term of Reference
114
11.2. Evaluation framework
123
11.3. Overview of current partner portfolio in India
133
11.4. Planning of the field missions
137
11.5. Persons met
140
11.6. Documents consulted
147
11.7. Guidelines on most significant change
150
11.8. CV of consultants
155
ACE Europe-ETC Crystal /Evaluation HIV and AIDS program of Hivos /Final evaluation report pag. 19/176
1
Introduction
1.1
OBJECTIVES OF THE EVALUATION
The framework of the MFS 2007-2010 establishes that all recipient organisations will implement
a practice of Project Evaluations. In addition, the larger recipients (receiving > €
2,500,000/year) will also implement a series of Program Evaluations. This applies to Hivos.
Hivos has decided that each of its 7 sector programs will be the object of a Program Evaluation
in the period 2007-2010. Some of these Program Evaluations are implemented jointly with other
organisations (Cordaid-ICCO-Oxfam Novib-Plan). This evaluation report concerns the
evaluation of the Hivos‘ HIV and AIDS program, covering the period between 2000-2009 and
addressing programs in South America and India (see ToR in annexe 1). The purpose objective
of the evaluation is:

To provide evidence for the effectiveness and sustainability of the Hivos‘ HIV/AIDS
Program in South America and India (period 2000-2009). To this effect, a review of
programs and projects need to take place in selected countries.

To serve as input for the Hivos‘ 2010 HIV/AIDS policy, i.e. to inspire future
development and implementation. The evaluation will serve as a learning opportunity
for the organisation and a guiding tool in the formulation of recommendations for future
HIV/AIDS planning and programming.
The overall evaluation question reads as ‗What was the effectiveness of Hivos’ HIV/AIDS
program: to what degree has Hivos’ HIV/AIDS program in the period 2000-2009 been able to
achieve its objectives?‘.
The following questions have been formulated by Hivos (see ToR in annex 1):
1) To what degree have/has …

human and sexual rights of key affected populations been strengthened?

access to equitable, non discriminatory HIV prevention improved?

access to sustained quality treatment and care improved?
2) Have targeted key affected populations been effectively reached?
3) How have gender dynamics been addressed?
4) Which major factors explain the observed level of results achievement?
5) How sustainable are the observed outcomes in the first question?
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1.2
EVALUATION TEAM
The evaluation has been carried out by ACE Europe in collaboration with ETC Crystal. Geert
Phlix (ACE Europe) and Carolien Aantjes (ETC Crystal) were involved in all the phases of the
evaluation. Esther Jurgens (ETC Crystal) participated at the inception phase and phase of
analysis. She was also responsible for the document analysis of a selected number of partners
that could not be visited during the evaluation missions (see further under methodology). CVs of
consultants are added in annex 8.
Two missions were executed in the period June 2010-September 2010 by following teams:
-
India: Carolien Aantjes and Renuka Motihar (local consultant)
-
Peru: Geert Phlix and Roberto Lopez (local consultant)
At Hivos, an internal reference group was responsible for the quality control of the evaluation.
The internal reference group met twice, in June to discuss the inception report and in November
to discuss the finding and conclusions of the evaluation.
1.3.
THE PLANNING OF THE EVALUATION
The evaluation has been executed as planned. However, some adaptations were needed
because of following external factors.
(1) It was originally planned to organize two evaluation visits for each country selected
(India and Peru). This was done for purposes of a swift implementation of the Most
Significant Change methodology (MSC) (see further under methodology). Because of
problems with the VISA application with multiple entrances in India, the evaluator could
only enter once the country. Therefore, the design was slightly altered. The start up
workshop was held in Chennai and all partners were visited during the first mission
which took place from July 7 till 20, 2010. The restitution workshop was organised on
September 9, 2010 in Chennai and was only facilitated by the local consultant.
(2) Follow up of MSC and final restitution in India has been handed over to the
responsibility of the local consultant. Planning of the restitution meeting in India,
originally schedules for August 2010 had to be postponed because of internal
management problems of INP+.
(3) The process of analysis and drafting the evaluation report has been delayed because
of illness of the coordinator of the evaluation. A draft report initially planned to be
presented in October, could only be delivered at the beginning of December. The
evaluation team would like to thank Hivos for its comprehension and patience.
ACE Europe-ETC Crystal / evaluation HIV and AIDS program Hivos / Final evaluation report pag. 22/176
1.4.
STRUCTURE OF THE REPORT
Chapter two gives a description of the approach and methodologies applied. Application of the
MSC methodology is described and assessed and the process of selection of partners and
countries to be involved in the evaluation is documented. This chapter concludes with a
description of limitations and constraints faced during the evaluation.
Chapter three describes in which political and institutional context HIVOS has been
implementing its HIV and AIDS program. The Hivos approach between 200 and 2009 is
summarized in chapter four.
Chapters five to nine present the findings and assessments of the evaluation questions.
Conclusions and recommendations are described in chapter ten. Seven groups of conclusions
and recommendations have been developed.
Several boxes have been inserted in the report. They are only illustrative for the analysis done.
The evaluation team decided to use the term PLHIV, people living with HIV instead of PLWHA,
people living with HIV and AIDS to be coherent with the fact that the disease is evolving
towards a chronic disease with many people living long with HIV before developing AIDS.
ACE Europe-ETC Crystal /Evaluation HIV and AIDS program of Hivos /Final evaluation report pag. 23/176
2
Methodology
The evaluation has been executed in four phases:

Phase 1 – inception phase: study of documents and interviews at Hivos the Hague and
Hivos regional office in India, reconstruction of Hivos‘ policy on HIV/AIDS since 2000,
development of an evaluation framework, selection of partners to be visited,
identification of methods and tools for data collection. Meeting with the internal
reference group to discuss the draft inception report. Redaction of final inception
report.

Phase 2 – phase of field missions and data collection: field missions to India and Peru,
desk study of four additional partners. For each field mission a report has been made
for internal use (facilitating analysis of the data).

Phase 3 – phase of analysis and reporting: analysis of factual data, analysis of MSC
results, analysis of findings presented in the field reports and additional interviews with
Hivos officers. Internal meeting of the evaluation team to discuss findings and
formulate conclusions and recommendations. Draft evaluation report.

Phase 4 – restitution meeting at Hivos and workshop to discuss recommendations.
2.1.
PHASE 1 - INCEPTION PHASE
2.1.1.
EVALUATION FRAMEWORK
The logical framework for the Hivos‘ HIV/AIDS program (see table 9) as presented in the Hivos
business plan (2007- 2010) is of a rather general nature. It is an internal reference
framework/document helping to manage the whole program and partner portfolio but
insufficiently guiding to develop a program at country or regional level. The intervention logic
lacks some coherence (for example: the strategy to reduce stigma and discrimination consists
mainly in strengthening claim making power and pro active citizenship of partners and the
vulnerable groups. However several strategies are needed to contribute to reduced stigma and
discrimination. Hivos‘ partners are implementing a combination of strategies that contribute to a
reduction of stigma and discrimination but these interventions are not covered nor monitored by
the existing logical framework). The distinction between output level and outcome level is not
clear enough, in particular when looking at the indicators formulated that need to operationalise
ACE Europe-ETC Crystal / evaluation HIV and AIDS program Hivos / Final evaluation report pag. 24/176
the output and outcome. The link between the logical framework and the practice is weak. By
consequence, the logical framework and its monitoring data are not very helpful for this kind of
program evaluations and as such complicate the assessment of the HIV/AIDS program. The
evaluation team developed an evaluation framework with own specific indicators, approved by
the Hivos internal reference group that has been the guiding framework for the evaluation. The
evauation framework has been applied during the field visits to India and Peru, and during the
desk review of the Hivos‘ support to partners in Bolivia and Ecuador.
The evaluation framework consists of four evaluation questions, judgement criteria and
indicators, based on the four questions formulated in the Terms of Reference (see annex 2).
These four evaluation questions are linked to the strategic objectives as can be distinguished in
the several Hivos HIV/AIDS policies. These Evaluation Questions are too complex to be
answered directly. Therefore, the consultants have broken down the evaluation questions into
different criteria. The achievement of these criteria can be better practically observed and
assessed. The level of achievement of these criteria allows a judgement to be made on the
extent of the achievements, as asked in the overall evaluation questions. In this way, they are
judgement criteria (JC). These judgement criteria are linked to the intervention logic of the
program with a focus on the output of the partners and on the extent the outcome of the
partners contributed to the strategic objectives.
The first three evaluation questions address the analysis of the effectiveness of the
Hivos‘HIV/AIDS program. Effectiveness is ―the extent to which the development intervention’s
objectives were achieved, taking into account their relative importance”. Judgement criteria
have been formulated at three levels:

National level – focussing national policies and programs. The purpose is to describe
the context within which the partners operate, to assess to what extent the political
context is conducive for realising the rights of key affected populations and to gain
insight in the effects of advocacy and lobby of partners at policy level, addressing the
rights of key affected populations (outcome of partners particularly regarding advocacy
and lobby).

Partner level – focussing the output of the partner organisations. It looks to the extent
output has been realised. This output can be related to direct service delivery, to capacity
development of local NGOs, CBOs, peer groups, etc. and/or to advocacy and lobby.

The level of the beneficiaries – focussing changes in the lives of the beneficiaries
(assessment of the outcome of the partner).
The fourth evaluation question addresses sustainability issues. Sustainability is defined as ― the
continuation of benefits of development interventions after major development assistance has
been completed‖. Different dimensions of sustainability have been taken into account (like
institutional, socio-cultural, financial and political sustainability) and have been concretised
through four judgement criteria.
ACE Europe-ETC Crystal /Evaluation HIV and AIDS program of Hivos /Final evaluation report pag. 25/176
For each judgment criteria several indicators have been identified1. Taking into account the
diversity of the partners it could be possible that some indicators would not be relevant for a
particular partner. In that case, no evidence would be found on that indicator.
The evaluation question related to gender has been translated into an indicator for the
judgement criteria at partner level as the focus was on the extent gender dynamics have been
addressed by the partners. The evaluators tried to carry out gender sensitive analysis of data
at policy level and at beneficiary level to the extent possible (depending on the availability of
data). In the answers to each of the evaluation questions gender disaggregated data are
presented and an assessment is done of the effects of the program on women and men. In a
separate chapter nine, an overall assessment is done on the level of gender sensitivity of the
partners. The remaining evaluation questions from the ToR ―To what extent have targeted
populations been reached‖ and ―What factors explain the level of effectiveness‖ are addressed
in the analysis of the findings.
Indicators drawn from (ao): Hivos. Program CIVIL CHOICES: subprogram HIV/AIDS/Intervention logic 2006-2010 and UNAIDS.
National AIDS Programs. A Guide to Monitoring and Evaluation, 2000
1
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The following table gives a brief overview of the four evaluation questions and judgment criteria that have been developed. The complete evaluation
framework with indicators is added in annex 2.
Table 1: Overview evaluation questions and judgement criteria
EQ1: To what degree have human and sexual
EQ2:To what degree has
EQ3: To what degree has
EQ 4: To what degree are
rights of key affected populations been
access to equitable, non-
access to quality treatment and
improvements with regard to the
strengthened?
discriminatory HIV prevention
care improved?
right of key affected population
improved?
and their access to non
discriminatory prevention and to
qualitative treatment and care
sustainable?
National level
1.1. National AIDS programs, policies and laws in
2.1. Nationwide coverage of
3.1. National HIV/AIDS
4.1. Sustainability of changes at
place that address human and sexual rights of key
equitable and non
programs, policies and
policy level with regard to the
affected populations and/or laws in place to
discriminatory HIV prevention
guidelines in place to provide
rights of key affected
protect HIV affected populations against
HIV/AIDS treatment and
populations, access to non
discrimination.
qualitative care
discriminatory prevention and to
qualitative treatment and care
Partner level
1.2. Partners contribute to strengthening of human
2.2. Partners advocate/
3.2. Partners advocate/
4.2. Sustainability of the output
(output)
and sexual rights of key affected populations
implement equitable, non-
implement equitable and
of the partners
discriminatory HIV prevention
qualitative HIV/AIDS services
(treatment and care)
Level of
1.3. Evidence of significant changes at the level of
2.3. Evidence of increased
3.3. Secured access to
4.3. Sustained access to non
beneficiaries
the beneficiaries (positive changes regarding their
access of key affected
qualitative HIV/AIDS services
discriminatory prevention of key
(outcome)
sexual and human rights)
populations to equitable, non-
(treatment and care)
affected populations
discriminatory HIV prevention
4.4. Sustained access to
qualitative treatment and care
ACE Europe-ETC Crystal /Evaluation HIV and AIDS program of Hivos /Final evaluation report pag. 27/176
2.1.2.
SELECTION OF PARTNERS
During the period 2000-2009 Hivos supported 24 partner organisations in India and Latin
America combined. At least 14 of those partners had an ongoing relationship with Hivos in the
last year of the evaluation period (2009). In addition to this partner portfolio, Hivos (together
with Alliance 2015 partner Ibis) implements a large project as Principal Recipient of the Global
Fund in Bolivia (since 2007). A total of 16 small projects (Micro fund projects2 in Hivos) were
supported in the period under evaluation. Total funding (all funds, including MFS) from Hivos to
these partners/projects in the period 2000-2009 amounted to approx. € 17,700,000. MFS
funding from Hivos to these partners/projects in the period 2000-2009 amounted to €
6,900,000. The following tables show the geographical distribution of these partners and
projects, and of funds3.
Table 2 : Geographical distribution of partners and projects (2000-2009)
South
Total
Bolivia
Ecuador
Peru
America
India
Regional
Asia
Regional
Partner
organisation
supported (of
24(14)
4 (2)
1(1)
1(1)
16
3
3 (1)
3 (3)
3 (2)
10 (5)
1(1)
1
2
2
8
-
which in 2009)
Global Fund
Project
Small Projects
Table 3 : Distribution of funds (total in EUR for the period 2000-2009)
South
Total
Bolivia
Ecuador
Peru
America
India
Regional
Partner
organisations
Global Fund
Project
Small
Projects
10,462,000
1,127,000
7,063,000
7,063,000
129,000
13,000
Asia
Regional
2,190,000
2,146,000
578,000
4,213,000
207,000
10,000
20,000
20,000
66,000
-
2
Microfund projects are projects receiving a small and earmarked amount of money, for a limited period. Often used to start up a partner
relationship.
3
Annex 4 to the ToR PE Aids 2000-2009 (20 February, 2010): The portfolio HIV/Aids projects in South America & India – overview
ACE Europe-ETC Crystal / evaluation HIV and AIDS program Hivos / Final evaluation report pag. 28/176
Table 4: Distribution of funds in EUR (MFS/ 2000-2009)
South
Total
Bolivia
Ecuador
Peru
America
India
Regional
Partner
organisations
Global Fund
Project
Small
Projects
6,747,000
Asia
Regional
1,047,000
751,000
1,340,000
578,000
2,824,000
207,000
13,000
10,000
20,000
20,000
63,000
-
126,000
Most of the partners of Hivos receive institutional funding. Hivos was interested to gain more
insights in the effects of the programs of these partners, implemented over the period 20002009. The institutional financing contributes to all programs implemented by Hivos‘ partners
(funding overhead costs, funding salaries of management staff, also enabling staff to participate
at network activities and invest in advocacy and lobby that is not foreseen in concrete projects,
topping up funding of specific projects, etc.).
Selection of countries to be visited – This program evaluation concerns the HIV/AIDS
program in Latin America and India (see ToR), focussing on countries with a concentrated HIV
and AIDS epidemic. The ToR appointed India as the country to be visited in South Asia, taking
into account the amount of partners supported over the years and the strategic importance of
the regional office in the country. Peru had been selected by the evaluation team (and accepted
by the internal reference group) because of following reasons (1) the diversity of the partners as
compared to Bolivia and Ecuador (like targeted key affected populations, services delivered);
(2) innovative approaches of some the partners; (3) the duration of the partnership (with very
long partnerships in Peru) and (4) the higher amount of MFS funding in Peru as compared to
Bolivia and Ecuador.
Selection of partners4 - A total number of 12 partners have been involved in the evaluation. 8
partners have been visited during field visits and 4 partners have only been assessed based on
desk study.
In Peru all three partners have been visited + 1 regional partner that is based in Peru. As
Bolivia and Ecuador have not been visited, two partners in each of these countries have been
assessed during desk study only. In each country the two partners with the largest budget have
been selected to that end.
For the selection of partners to be visited in India (selection of 4 out of 10) following selection
criteria have been used: (1) Key populations covered: balance between organisations targeting
the general population and key target populations; (2) Features of the key organisations:
4
Small projects have not been taken into account for partner selection as these projects concern often start up partnerships or involve
limited amounts of funding which make them less relevant within the scope of this program evaluation.
ACE Europe-ETC Crystal /Evaluation HIV and AIDS program of Hivos /Final evaluation report pag. 29/176
balance between size and scope of the organisation; (3) Geographic coverage: balance
between urban – rural areas; (4) Duration of partnership with HIVOS: balance between longmedium-short period of partnering with Hivos; (5) Thematic focus: balance between focus on
human rights, sexuality, livelihoods, service oriented. As such, the diversity of partners in India
could be covered by the sample (a brief description of the whole India portfolio is added in
annex 4).
Table 5 : Geographical distribution of partners of the HIV/AIDS program and those
involved in the evaluation (2000-2009)
South
Total
Bolivia
Ecuador
Peru
America
India
Regional
Asia
Regional
Partner
organisation
supported (of
24(14)
4 (2)
3 (1)
3 (3)
3 (2)
10 (5)
1(1)
12(10)
2(1)
2(1)
3(3)
1(1)
4(4)
0
which in 2009)
Partners
involved in the
evaluation (of
which still
having a
relationship in
2009)
Italic = only involved in desk study
Comments on representativeness – Taking into account the total budget for partners in Latin
America and India (10.462.000 EUR) 81% of the budget is covered with the selected 12
partners (8.507.034 EUR - see also following table) and 53% of the budget is covered with the
partners visited during field missions, excluding the partners only studied based on desk work.
Regarding the MFS- co financing 78% of the budget is covered by the 12 partners and 54 %
covered through the field missions.
When we take a look at the activities of the partners visited and those only involved during desk
study, one can conclude that, although the partners are diverse in nature, there are many
similarities amongst the Hivos‘ partners (and the overall portfolio in Latin America and India5).
All address the needs of key affected populations. The scope of their interventions is a mix of
prevention activities (focus on HIV education), implementing own care services, being involved
in advocacy and lobby, strengthening capacities of leaders and CBOs of key affected
populations and of health care workers. All work from a rights based approach. With coverage
of 33% of the partners visited and taking these similar characteristics into account, the
evaluation team is convinced that conclusions are valid for the whole portfolio in Latin America
and India.
5
Based on interviews with Hivos program officers
ACE Europe-ETC Crystal / evaluation HIV and AIDS program Hivos / Final evaluation report pag. 30/176
The only difference that caught our attention was the stronger focus on integrating HIV and
sexual reproductive health (throughout all activities, from prevention to advocacy and lobby) as
could be noticed in the programs of the partners studied in Bolivia and Ecuador compared to
the partners visited. By consequence, the evaluation team is prudent in formulating conclusion
to this regard as the effectiveness of these programs could not be validated during field
missions. Only one regional partner (Aid for AIDS) has been visited which makes that the
evaluation will not be able to formulate conclusions on the regional programs supported by
Hivos.
ACE Europe-ETC Crystal /Evaluation HIV and AIDS program of Hivos /Final evaluation report pag. 31/176
Table 6 : overview of the selected partners
Partners in
Total Hivos budget 2000-2009 in
Peru
EUR (of which co financing)
Via Libre
1.611.421 (953.770)
Characteristics
Target groups: PLHIV with special focus to MSM, women, youth and transgender
Duration of partnership: Hivos partner since 1996, financing relation since 2003
Size: large organisation (45 staff and close to 30 volunteers).
Evolution from 32 % to 5 %,
Scope: Broad scala of services – VCT (at the centre and outreach), delivery of ARV (official distribution of ARV within the
Hivos contribution to the overall
global fund financed treatment campaign), prevention campaigns, advocacy and lobby, capacity building of CBOs of
budget
6
people affected/infected with HIV/AIDS and of health workers of the Ministry of Health.
Urban
Hivos facilitated EU financing (2007-2010)
Prosa
399.000 (250.000)
Target groups: PLHIV, MSM
Duration of partnership: Hivos partner since 2001
Evolution from 62 % to 22 %,
Size: relatively small organisation (7 staff and close to 14 volunteers).
Hivos contribution to the overall
Scope: organisation of PLHIV, empowerment of PLHIV and their organisations, prevention campaigns, advocacy and
budget
lobby, specific attention to care and positive living. Buddy Program is recognised by Ministry of Health (will be copied by
Kimirina, partner in Ecuador), and assist the Ministry of Health in setting up of PLHIV groups in hospitals.
Urban
Aid for AIDS
115.000 (115.000)
Target groups: PLHIV, youth, women
Duration of partnership: Hivos partner since 2007 (regional partner)
Evolution from 26 % to 66 %,
Size: small organisation (3 staff members in the office of Lima). Aid for Aids Lima is part of Aid for Aids international with
Hivos contribution to the overall
head office in New York. 5 regional offices in Latin America (Chile, Venezuela, Panama, Dominican republic en Peru).
budget
Hivos supports the Peru office.
Scope: access to treatment, advocacy and lobby (related to Global fund – AIDS observatory), prevention targeting youth
and women (observatorio de la mujer)
Urban
6
Evolution is based on the contribution of Hivos to the general budget in the first year of financing and the year 2009. For most of the partners there is a gradual decline in the Hivos contribution to
the overall partners‘ budget over the years.
ACE Europe-ETC Crystal / evaluation HIV and AIDS program Hivos / Final evaluation report pag. 32/176
IESSDEH
136.000 (136.000)
Target groups: MSM, transgender, lesbian, bisexual, sex workers, PLHIV
Duration of partnership: Hivos partner since 2007 (date of creation of the IESSDEH)
Evolution from 100 % to 23 %,
Size: relatively large organisation. The institute is a spin-off of the research unit on health, sexuality and human
Hivos contribution to the overall
development of the Cayetano university, faculty of public health and public administration (30 staff members at the unit of
budget
which ? are involved in IESSDEH).
Scope: research, advocacy and lobby, cultural ―civic‖ activism, capacity building of CBOs and of health workers of the
Ministry of Health
Urban
Partners in India
Total Hivos budget 2000-2009 in EUR (of which
Characteristics
co financing)
SIAAP
2.440.571 (1.538.956)
Target groups: FSW, MSM, PLHIV, youth, visually challenged
Duration of partnership: HIVOS partners since 1993
Evolution from 99% to 70% Hivos contribution
Size: large organisation (approx 48 staff)
to the overall budget, with again 90% in 2009
Scope: advocacy on human and sexual rights, capacity building and promotion of selforganisation and cooperatives, training of community counselors, programs on HIV prevention
and care in rural areas
Rural
Geographic area: Southern India
Hivos co-financed the Sarvojana coalition with the EU which was led by SIAAP (2006-2009)
Sangram
84.047 EUR (84.047)
Target groups: FSW, rural women, MSM
Duration of partnership: HIVOS partner since 2007
3% contribution to the overall budget in 2008
Size: very large organisation (192 staff)
and 8% in 2009
Scope: collectivization of FSW and MSM, raising awareness and addressing gender inequality,
provision of home based care, counseling, condoms and peer support, development of IEC
materials.
Rural
Geographic coverage: State of Maharashtra, Western India
ACE Europe-ETC Crystal /Evaluation HIV and AIDS program of Hivos /Final evaluation report pag. 33/176
Hivos facilitated EU financing (2007-2010)
Birds
642.953 (386.195)
Target groups: FSW, CBOs
Duration of partnership: HIVOS partnership since 1996
Evolution from 51 % to 5 %, Hivos contribution
Size: very large organisation with different sectoral programs under which HIV/AIDS
to the overall budget
Rural
Geographic coverage: State of Karnataka, Southern India
Scope: collectivization of FSW, capacity building in counseling and peer education, advocacy
INP+ Orissa
150.423 (150.423)
Target groups: PLHIV
Duration of partnership: INP+ Chennai since 2006, INP+ Orissa via Alliance 2015, since 2006
Evolution – no info7
(Joint funding HIVOS and Concern Worldwide)
Size: relatively small organisation (15-25 staff)
Scope: advocacy and lobby, capacity- and network building, service delivery in drop-in centres
Rural
Geographic coverage: State of Orissa, Eastern India
Alliance 2015 program receives EU financing (2009-2014)
Partners
Total Hivos budget 2000-2009 in
Desk study
EUR (of which co financing)
Sexsalud
833.655 (753.655)
Bolivia
Characteristics
Target groups: MSM, truckers, youth, PLHIV and transgender
Duration of partnership: Hivos partner since 2000, phasing out in 2009
Hivos contribution to the overall
Size: large organisation
budget8: 48% in 2006 and 42% in
Scope: Broad scala of services – VCT (own health centre), delivery of ARV, prevention campaigns (strong link between
2008
HIV and SRH). Advocacy and lobby
Urban
7
8
No financial data was given by the partner. The financial relationship concerns joint funding, channelled through Concern Worldwide.
Evolution is based on the contribution of Hivos to the general budget in the first year of financing and the year 2009. For most of the partners there is a gradual decline in the Hivos contribution to
the overall partners‘ budget over the years.
ACE Europe-ETC Crystal / evaluation HIV and AIDS program Hivos / Final evaluation report pag. 34/176
UNELDYS
108.936 (108.936)
Bolivia
Target groups: MSM, transgender
Duration of partnership: 2000-2005
Evolution – no info9
Size:. ?
Scope: advocacy and lobby, mainly on the rights of MSM and transgender, empowerment of MSM and transgender,
training of members and psychological support for members, HIV and AIDS education
Urban
Kimirina
260.000 (140.000)
Ecuador
Target groups: women with HIV
Duration of partnership: since 2005
Evolution – no info
Size: larger organisation
Scope: advocacy and lobby (focus on SRH and HIV), HIV prevention (strong link between HIV and SRH), implementation
of buddy program, strengthening support groups. Training of public health care workers and advocating health care
centres.
Urban
FEDAEPS
1.725.029 (642.203)
Target groups: PLHIV, LGTB, sex workers, youth, women
Duration of partnership: Hivos partner since 1998
Evolution from 84% in 2001 to
Size: 24 staff (small decline in last years because of financial problems)
65% in 2008, Hivos contribution
Scope: advocacy and lobby (focus on HIV and SRH, rights of LGTB, sexual diversity), HIV prevention (including a
to the overall budget
telephone helpline), sensitization on stigma and discriminations, collaboration with police, strengthening networks
Urban
9
Data only available in annual reports as additional data could not be asked for during a visit. Not all partners deliver the required financial data as asked for by Hivos such as information on the
overall budget of the organisation.
ACE Europe-ETC Crystal /Evaluation HIV and AIDS program of Hivos /Final evaluation report pag. 35/176
2.2.
PHASE 2 – FIELD VISITS
2.2.1.
APPROACH OF THE FIELD VISITS
Two evaluation missions have been planned for each country (total of four missions) with a time
delay of two months between the two missions in order to give the partner organisations
sufficient time to implement the Most Significant Change (MSC) technique (see further). At the
beginning of the first evaluation mission a start up workshop was organised to introduce the
evaluation, to inform the participants on the use of the MSC technique and to hold a
stakeholder mapping (to serve as base for selection of external stakeholders to be visited).
During the first mission two partners have been visited. After two months the evaluation team
returned to visit the other two partners and to organise a restitution workshop.
A two-day visit was foreseen for each partner. One day was spent at the organisation
(interviews with staff and timeline exercise). During the second day focus group discussions
with beneficiaries and interviews with external stakeholders were planned. When needed, the
evaluation team split up. Relevant documents (programs and budgets, annual reports,
organisational assessments, evaluation reports when available) had been consulted before
visiting the organisation.
In Peru the evaluation missions could be executed as planned. The first mission was organised
from 5 till 9 July 2010, the second mission took place from 13 till 20 September 2010.
Due to problems with the VISA application for India all partners in India have been visited
during the first mission which took place from 7 July till 20 July 2010. The restitution workshop
(including discussion the the results of MSC) was organised on September 9th 2010 and was
only facilitated by the local consultant.
In Peru all partners are based in Lima, with limited outreach activities in the regions. Partners
could easily attend the start up and restitution workshop. Jointly a stakeholder mapping had
been organised, identifying external stakeholders that could give information on the general
HIV/AIDS context and the evolutions since 2000, the changes with regard to the human and
sexual rights of the targeted populations and access to prevention, care and treatment. Some of
these stakeholders had been collaborating with the Hivos partners, others were considered to
be relevant information resources. The stakeholders identified during this start up workshop
were considered to be relevant for all the Hivos partners as they are operating in the same
context, targeting similar populations (organisations of PLHIV, organisations and networks
within the LGTB movement, Ministry of Health, Conamusa, other donors, members of the
congress, other NGOs, networks and coalitions. See annex 5). Additionally, every partner also
identified external stakeholders, specific for their own programs.
ACE Europe-ETC Crystal /Evaluation HIV and AIDS program of Hivos /Final evaluation report pag. 37/176
In India, partners are based all over the large and diverse country. The evaluation team visited
four different states in a period of two weeks. At the start up workshop a stakeholder mapping
was done. Unlike to the Peru case, most of the external stakeholders visited were only relevant
for one particular organisation what makes that less external information could be collected on
the context within which the partners operate, the changes in this context and the relatively
contribution of the partner to mentioned changes. The picture is evidently more fragmented as
is the situation in the different states.
2.2.2.
METHODOLOGY APPLIED
To gain insight in the effectiveness of the Hivos HIV/AIDS program it was necessary to assess
the effectiveness of the programs implemented by these partners. Focus of the evaluation is
above all on the changes at the level of the beneficiaries with regard to their access to
prevention, care and treatment and to the strengthening of their human and sexual rights
(mostly related to issues such as stigma and discrimination). To that end, a specific
methodology had been proposed by the valuators. Taking into account the long period under
evaluation and the often long lasting partnerships, a timeline perspective needed to be built in.
To be able to respond to these demands the consortium ACE Europe / ETC Crystal applied two
main methodologies: (1) workshop with the partner organisations (timeline exercise) and (2)
most significant change.
Workshop with the partner organisation - one day of the two-days visit to each partner was
spend for interviews with staff of the partners and a timeline exercise with a group of staff
members. With a relevant group of staff members a timeline was reconstructed starting from
the beginning of the existence of the organisation. Several milestones needed to be indicated,
related to successes and realisations of programs and to changes within the organisation.
Discussing these milestones, staff members were asked to describe factors that had an
influence on these milestones (internal and external factors that contributed to change, success
and failure). This exercise equipped the evaluators with a lot of relevant information to gain
insight in the main evolutions, successes and weaknesses of the organisation. For purposes of
triangulation, this information was further validated through additional individual or group
interviews with staff members and external stakeholders and through the study of the
documents (program proposals, annual reports, evaluation reports).
Most significant change technique – The evaluators were confronted with the fact that not
many evaluations of partners‘ programs, that assess the effectiveness of their programs up to
outcome level, were available (only three). Additionaly, are outcome data poorly presented in
the annual reports of the partners and reliability of these data remains a question. The outcome
data presented in this report (presented in tables that give an overview of output and outcome
achieved by the partners) can only be seen as indicative. As many program evauations face
this constraint, the evaluators proposed to use the technique of Most Significant Change to
collect information on the effects of the Partner‘s program on the level of the beneficiaries.
ACE Europe-ETC Crystal / evaluation HIV and AIDS program Hivos / Final evaluation report pag. 38/176
MSC10 is a form of participatory monitoring and evaluation based on recording stories amongst
all kind of stakeholders. Unlike conventional approaches to monitoring and evaluation, the MSC
approach does not employ quantitative indicators.
Essentially, the process involves the
collection of significant change stories emanating from the field level, and the systematic
selection of the most significant of these stories by panels of designated stakeholders or staff.
Once changes have been captured, various people sit down together, read the stories aloud
and have in depth discussions about the value of these reported changes. Necessary steps to
be taken are: collect stories of change; review the stories and select the most significant ones;
document reasons for choice; feedback results (see annex 7 for guidelines of MSC).
Experience of the evaluators with the technique has provided insights in the advantages and
appropriate use of this technique. Major advantage is the added value of the collection of
relevant qualitative data on the changes in the lives of the beneficiaries; provided the method is
introduced properly and sufficient time is taken to apply the technique. The latter implies a
careful organisation of the process, as described in the MSC manuals (including discussions on
the collected stories and process of selection of the most significant ones). This is the reason
why two missions have been planned to each country selected. In the first mission the partner
organisations have been informed on the use of the MSC technique, during the start up
workshop. Partner organisations received elaborated guidelines and reporting formats and
could rely on the support of the local consultant during collection phase. Partner organisations
received sufficient time to collect stories amongst their beneficiaries as the second missions
and the restitution had been planned two months after the first mission had taken place.
The evaluation team received, before the restitution meetings, all the stories collected and a
justification for the most significant stories that had been chosen by different panels of
beneficiaries and/or staff. The evaluators did a first qualitative analysis of the stories and the
result was discussed in the restitution workshop. After the mission the consultants did an
additional quantitative analysis of the stories. Results of the MSC stories have been compared
to the results of the focus group discussions with beneficiaries organised during the missions.
Table 7: Overview of amount of stories collected in India
Total stories collected
Stories recorderd amongst
Stories recorded amongst
men
women
SIAAP
30
16
14
INP+ Orissa
28
14
14
Sangram
32
?
?
Birds
25
/
25
Total
115
30 + ?
53 + ?
Remark: Sangram only sent the evaluation team five selected stories. The stories had been collected in local
language and only the five selected stories have been translated into English.
10
MSC technique was originally developed by Rick Davies (Davies, 1996, 2005) and later refined by Jess Dart (Dart, 1999)
ACE Europe-ETC Crystal /Evaluation HIV and AIDS program of Hivos /Final evaluation report pag. 39/176
Table 8: Overview of the amount of stories collected in Peru
Total stories collected
Stories recorderd amongst
Stories recorded amongst
men
women
Via Libre
10
5
5
Prosa
13
7
6
IESSDEH
17
8
9
Aid for Aids
9
3
6
Total
49
23
26
Comments on the MSC technique – the technique is a very interesting tool to collect stories
amongst beneficiaries and gain insight in the changes that occurred in their lives . However, the
evaluators can formulate following reflections, based on the application of the tool in this
evaluation:
(1) The output of this tool will be higher when the tool is an instrument of existing
monitoring and evaluation practice of the organisations. The collection of data and the
selection process demand a considerable input of time and staff. This explains the
lower number of stories collected as could be expected. All organisations did the effort
to collect stories, within their own implementation limitations (including financial
constraints). If the tool would be part of the M&E activities, this collection of stories
would not be an ―add on‖ activity. However, all partners testified they have appreciated
the approach (and the information resulting from the technique) and some of them are
considering integration of the tool in their M&E practice.
(2) Organisations were free to define domains of change in advance or to cluster reported
changes into certain domains of change after stories had been collected (according to
the official guidelines of R. Davies). All partners opted for the last possibility and
generally asked the question ―What has changed in your life since you have become
involved in programs of partner X‖. Interesting result of this choice is that it became
evident that most significant changes have been reported in relation to evaluation
question 1 (human rights). Fewer stories related to access to prevention, treatment and
care have been collected. Although changes have been reported in relation to these
objectives they have almost never been identified as most significant change (with
result that not more information was given as only the most significant change needed
to be further developed).
(3) The tool serves above all a learning objective. The arguments formulated during the
selection of the most significant stories give more insight in the approaches and
effectiveness of approaches implemented by the partners. The evaluators were not
part of these discussions and documentation of the arguments (as requested) was
limited.
ACE Europe-ETC Crystal / evaluation HIV and AIDS program Hivos / Final evaluation report pag. 40/176
(4) In India, stories needed to be recorded in local languages. Some partners translated
immediately during reporting, one organisation reported in the local language.
Evidently there is a loss of information during this translation process.
(5) Organisations that are not working with members nor collectives on a long term base
seem to have more difficulties to apply this technique and to involve their beneficiaries
in this kind of data collection. This can explain the fewer amount of stories collected in
Peru as compared to India.
(6) Definition and selection of groups of beneficiaries were the responsibility of the
partners. The partners had to explain why what groups of people had been involved.
Several partners also have programs directed to peer educators and healthcare
workers and evidently included these target groups in the story collection.
The
evaluators had no control on this selection. Taking into account the time the partners
needed to invest in this tool and the opportunity it created for each organisation to learn
from practice, the evaluators only can assume that beneficiaries have been carefully
selected. It is not possible to know to what extent the selected beneficiaries are
representative. Results of MSC have been validated in focus group discussions. It was
the evaluation team who decided what kind of focus groups needed to be organised
and in collaboration with the partner organisations these focus groups had been
organised.
The evaluation team thanks very much the partners for the time and energy they have invested
in the MSC technique and according to the reactions received afterwards several of the
partners are planning to integrate the MSC in their PME system. The challenge is to explore
further the usefulness of this technique for evaluation purposes with a strong accountability
focus. And to explore the applicability of the technique for evaluations that are organised in a
context characterised by rather weak existing PME systems and by an absence of a sound
practice of collecting data, in a systematic way, on the level of changes in the lives of
beneficiaries. The evaluation team would have liked to receive more stories from some of the
partners (that was the reason for creating sufficient time for the collection of the stories) and
would have liked to gain more insight in the selection process (including the discussions) of
these stories. The information received on this selection process was very limited. Nonetheless,
the information received is very valuable and was a good base for a qualitative analysis of
changes that have occurred in the lives of the beneficiaries. This data have been validated
through additional focus group discussions with beneficiaries during the evaluation missions.
The data from the MSC add more personal value to the insights gained through the focus group
discussions. The added value of the MSC is the fact that the stories collected indicated clearly
where the most significant changes can be situated.
ACE Europe-ETC Crystal /Evaluation HIV and AIDS program of Hivos /Final evaluation report pag. 41/176
2.2.3.
APPROACH OF THE DESK STUDY
Programs of four additional partners have been assessed based on desk work only. The
partners with the largest amount of funding and a broad scope of interventions had been
selected. The same reporting scheme as used during field missions (the one with all indicators
and the one for factual data) was used to look for appropriate information for all indicators
formulated. Desk study was based on the program and budget proposals, the contracts made,
the annual reports and organisational assessments.
This experience learns that it was only possible to collect reliable information on the factual data
and description of the output of the partners. No information was available in the documents
studied to assess the effectiveness neither of the activities nor on the contribution to policy
changes and changes in the lives of the beneficiaries. The evaluators could not invest in
documenting the political and institutional context within which these organisations are
operating, nor could they validate some of the findings from the analysis of the documents. By
consequence, contribution of the results of this desk work to answering the evaluation question
is limited.
2.3. PHASE 3 – PHASE OF ANALYSIS AND REPORTING
During the missions, the evaluators completed the evaluation forms, reporting according to the
indicators formulated per judgement criterion. Information on the indicators allowed the
evaluators to assess each judgement criterion. Through the analysis of each judgement
criterion an answer could be formulated to each evaluation question.
Additionally an
assessment of the HIVOS partnership relation was added for each partnership.
Analysis of the judgement criteria at national/policy level was based on review of most
important laws and policy documents and information collected from stakeholders at Ministries
of health, participants of CCM‘s, policy makers, health care workers and from the partner
organisations.
In order to analyse the judgment criteria at the level of the partner organisation, the evaluators
first described what kind of activities (and their respective target groups) the partners were
implementing over the years (based on study of documents and interviews), and listed the
most important achievements (output level), related to the improvements in access to
prevention, care and treatment and stigma and discrimination (based on the annual reports and
evaluation reports, interviews and timeline exercise). The partners were also asked to complete
a factual information format that was sent before the evaluation visit took place. This
information was validated through the interviews with staff and external stakeholders. As most
of the partners received institutional funding, all programs of the partners needed to be taken
into account.
ACE Europe-ETC Crystal / evaluation HIV and AIDS program Hivos / Final evaluation report pag. 42/176
For the analysis of the judgement criteria at the level of beneficiaries the evaluators described
the changes reported by the different target groups, via the focus group discussions and in the
MSC stories. Additional information was collected through interviews with the external
stakeholders and from additional studies when available (ex. UNGASS reports, specific
research reports. See list of literature in annex 6).
In the process of analysis the evaluators identified explicative factors for the level of
effectiveness and sustainability. Results of this analysis were presented and discussed during
the restitution workshops. All partners have participated at the start up workshop and the
restitution workshop.
Two DAC evaluation criteria were guiding the analysis:
Effectiveness – The effectiveness has been assessed on two levels. (1) Output-level: the
evaluators looked into the outputs of the interventions of the partners (JC 2 for each evaluation
question). The evaluators looked at the contribution of the partners to the debate on HIV/AIDS,
the results of capacity building of CSOs/CBOs/networks, involvement and results of advocacy
and lobby activities, results of direct service delivery with regard to prevention, treatment and
care. (2) Outcome-level: the evaluators tried to gain insight in the changes in the lives of the
beneficiaries regarding reduced stigma and discrimination, increased access to prevention,
treatment and care and the (improved) quality of these services (JC 3 for each evaluation
question). Where relevant, contribution to changes at policy level has been reported as well (JC
1 for each evaluation question).
Sustainability – As already indicated, a specific evaluation question was formulated to assess
sustainability at different levels (sustained policy changes, sustained output of partners,
sustained changes in the lives of the beneficiaries). See annex 2 for the list of indicators (#16).
Information was obtained through interviews with various stakeholders, partners and
beneficiaries and research reports.
During the analysis of the information obtained, the evaluators could assess to what extent the
key populations as described in the Hivos policy papers were reached. Additional questions
have been asked regarding gender. Apart from delivering gender disaggregated data and the
information on gender policies, the partners were questioned upon what they understand under
―gender dynamics‖ as described in the Hivos policy papers.
After the missions the team of evaluators met for sharing analyses and discussing the main
findings and conclusions and to prepare the recommendations. Specific attention was given to
the assessment of the extent the Hivos policy was implemented in the field. After the internal
meeting three additional interviews have been organised with Hivos‘staff to clarify some of the
findings.
ACE Europe-ETC Crystal /Evaluation HIV and AIDS program of Hivos /Final evaluation report pag. 43/176
2.4. PHASE 4 – RESTITUTION
Findings and conclusions have been presented and discussed in the internal reference group.
A draft report has been sent to all members of the internal reference group. Based on the
feedback, a final report has been drafted.
A workshop, involving Hivos program officers, is planned (after completion of the evaluation
report) to discuss further the analysis and conclusions and to formulate in a participatory
manner recommendation. This workshop will be facilitated by the team leader of the evaluation
team and is planned in the beginning of 2011.
2.5. LIMITATIONS OF THE EVALUATION AND CONSTRAINTS FACED DURING THE
EXECUTION
Several limitations and constraints have deen described in this chapter under the headings
2.1.1. Evaluation framework; 2.2.1. Approach of the field visits; 2.2.2. Methodologies applied
and 2.2.3. Desk study. Deviations from the original planning have been described under 1.3.
planning of the evaluation. These constraints and limitations concern:
(1) External factors that had an influence on the planning of the evaluation missions;
(2) The weak logical framework of the Hivos‘ HIV/AIDS program what has been dealt with
by developing a specific evaluation framework to guide the data collection for this
evaluation;
(3) The lack of reliable outcome data which has been compensated by applying a
combination of the MSC technique with focus group discussions and
(4) The limitations of the desk study, relying on incomplete annual reports and lack of
partner evaluations. Contribution of the results of this desk work to answering the
evaluation questions is limited. However all partners in Latin America show similar
characteritics in approach and intended target group. The evaluation team in convinced
that, with coverage of 33% of the partners visited and taking these similar
characteristics into account, conclusions of the evaluation are valid for the whole
portfolio in Latin America and India.
The evaluation team has managed the mentioned limitations in an appropriate manner and has
not been confronted with other constraints. The evaluation team is of the opinion that sufficient
reliable data could be collected in order to formulate conclusions that are valid for the whole
HIV/AIDS program as executed in Latin America and India.
ACE Europe-ETC Crystal / evaluation HIV and AIDS program Hivos / Final evaluation report pag. 44/176
3
The HIV and AIDS context in India and Peru within
which Hivos and its partners are operating
In the years under evaluation, many developments have occurred in response to HIV
pandemic. One of the key developments at the start of the 21st Century was the launch of the
Millennium Development Goals (MDGs). In this, the response to HIV/AIDS became part of a
global action plan. In 2001, at the UN General Assembly special meeting on AIDS (UNGASS),
member states signed their declaration of commitment to protect human rights and gender
equality, through appropriate legal frameworks, in their national response to HIV. One year
later, the Global Fund for AIDS, Tuberculosis and Malaria was established, presenting a new
approach to international health financing.
Concurrently, WHO, UNAIDS and others started to exert pressure on pharmaceutical
companies towards differential pricing of anti-retroviral treatment (ART). By 2003, WHO
launched the highly ambitious 3 by 5 initiative which aimed to provide 3 million people living
with HIV/AIDS in low- and middle income countries with ART by the end of 2005. Though this
target was not reached in 2005 (little less than half of the target), the initiative did signal the
start of an impressive scale-up of ART services in the years that followed, particularly in SubSaharan Africa.
Many international organisations entered the aid arena and availed major funding for HIV/AIDS.
This provided a boost to further target setting and in 2006, member states at the UNGASS
meeting agreed to work towards the goal of universal access to comprehensive prevention
programs, treatment, care and support by 2010. As the playing field of HIV became increasingly
complex with multiple actors and funding mechanisms, UNAIDS introduced three key principles
for country-level responses in 2003, notably partners involved in the response would have to
align to one agreed action framework, there should be one national AIDS authority with a broad
based multi-sectoral mandate as well as one agreed country level monitoring and evaluation
system. In 2000, UNAIDS and WHO developed a classification system for the variations found
in HIV epidemics across the globe. This classification took into account the groups that were
most affected by the epidemic. For Asia and Latin America, higher infection rates were found in
sub-populations such as men who have sex with men, transgender female sex workers and
injecting drug users. Such epidemic is also referred to as a concentrated HIV epidemic.
Upon the signing of the UNGASS declaration of commitment in 2001, member states
committed themselves to regularly report on their progress to the General Assembly. The
reports assist to get a clearer picture on the national responses worldwide to HIV. Despite the
massive scale-up in HIV testing and treatment services, the consolidated data from UNGASS
show limited progress on the targets. One example is that among youth aged 15-24 years, only
38% of females and 40% of males can demonstrate accurate and sufficient knowledge about
ways to protect themselves from acquiring HIV, while the UNGASS target is 90% by 2010.
Another example is new infections in infants born to HIV-positive mothers declined by 25% from
ACE Europe-ETC Crystal /Evaluation HIV and AIDS program of Hivos /Final evaluation report pag. 45/176
2001 levels in hyper-endemic countries in 2008, while the UNGASS target is a 50% reduction
by 2010. Then, several countries still have policies that interfere with the accessibility and
effectiveness of HIV interventions. Examples include laws criminalizing consensual sex
between men, prohibiting condom and needle access for prisoners and using residency status
to restrict access to prevention and treatment services. At the same time, laws and regulations
protecting people with HIV from discrimination are not enacted or fully implemented or
enforced.
Over the past ten years, civil society organisations have increasingly been recognised as key
players in the national HIV response. This has resulted in their implication at national level in
e.g. the UNGASS reporting process as well as representation in formal governing bodies, such
as National AIDS Authorities and the County Coordinating Mechanisms (CCM) of the Global
Fund. Nevertheless, the international council of AIDS service organisations (ICASO) pointed
out the necessity at UNGASS in 2008 to have a monitoring mechanism for assessing the
meaningful participation of civil society, particularly people living with HIV/AIDS and
marginalised groups, in country level and international processes.
In India, the national AIDS response is framed by the third National AIDS Control Program
Strategy and Implementation Plan (2007-2012). The main emphasis in the plan is on prevention
of new infections in high risk groups and the general population and on the provision of greater
care, support and treatment to a larger number of people living with HIV/AIDS. The public ART
program in India was launched in 2004, starting only in eight hospitals and expanding to 239
ART centres by 2010. Second line ART has become available since 2008, but is accessible in
only ten centres in the country. The NACP III refers to specific interventions for high risk
populations such as female sex workers, drug users, migrants and men who have sex with men
but does not link this to a human and sexual rights based approach. Civil society participates in
the implementation of the NACP III. They are represented in the CCM, while GIPA coordinators
(Greater Involvement of People living with HIV and AIDS) have been appointed in most State
AIDS Authorities. The major donors in the Indian HIV/AIDS response are the Global Fund,
World Bank, USAID, DFID and private foundations such as the Bill and Melinda Gates- and
Clinton Foundation. Pending the tabling of the HIV/AIDS bill, India does not currently have a
particular law that protects people living with HIV/AIDS from discrimination. A historic ruling did
take place in 2009, when the New Delhi High Court declared that the 149-year old colonial law
penalising gay sex violated fundamental human rights in the Indian constitution.
In Peru, the national response to the epidemic has been strengthened in the last seven years
due to several factor such as the pressure of the affected populations, new commitments of the
public sector (MoH), and the intervention of the Global Fund. In fact, before 2004
and
excluding those who could pay for their medicines, only those who were affiliated (public
servants) to the Social Security System (EsSALUD) received ART. After 2004, every person
living with HIV is receiving due treatment, most of them through Ministry of Health facilities. In
2007, through a participatory process, the country set up a Multisectoral and Strategic Plan for
2007-2011, which is now the official framework for all the activities around the epidemic at
national level; many of the 26 regions of the country have developed their own regional plan
officially approved by regional governments.
Since 2002 a National and Multisectoral
ACE Europe-ETC Crystal / evaluation HIV and AIDS program Hivos / Final evaluation report pag. 46/176
Coordinator on Health (CONAMUSA; the Country Coordination Mechanism
for the Global
Fund) is operating as well as similar bodies at the regional level (COREMUSAs). In these
bodies, participation of organisations of vulnerable populations (LGTB, Sex workers) , PLHIV,
and other organisations of civil society is relevant. Compared to the situation at the beginning
of the century, the investments of government to fight the epidemic is important; the public
expenses have been increased significantly. For example, up to day all the treatments for
PLHIV are financed by public funds. New challenges arise at present forecasting the end of the
projects financed by the Global Fund. National and Regional Governments have now the tools
to assure the continuity of the activities of an effective response to the epidemic. Old challenges
still remain such as the real respect and protection of the rights of vulnerable populations such
as the rights of people with a different sexual orientation, rights of sexual workers as well as the
right to access of young population to effective measures to prevent the HIV transmission.
Both countries are dealing with a concentrated epidemic. In India the estimated adult
prevalence is 0,34% (between 0, 25% and 0,43%) and is greater among male (44%) than
among female (23%). The prevalence rate has stabilised over the last years, 2002-2007 (Info
NACP). The HIV prevalence in Peru was in 2008 0,23%, with a prevalence rate of 13,9%
amongst MSM and 32% of the population of transgender (Ungass reports 2010).
ACE Europe-ETC Crystal /Evaluation HIV and AIDS program of Hivos /Final evaluation report pag. 47/176
4
Hivos approach between 2000 and 2009
4.1. THE HIVOS HIV AND AIDS PROGRAM
Hivos activities in the area of HIV/AIDS date back to 1989 when a first partner organisation
(Mexicanos contra el Sida) was financially supported. Hivos formulated its first HIV/AIDS policy
already in 1992. This policy document was reviewed and updated twice since then, in 2001and
most recently in 2010. Relevant HIV/Aids policy formulations are found in 3 documents: the
2001 policy document, the 2006 Business Plan for the MFS-period 2007-2010 and the recently
reformulated HIV/Aids policy document.
We further describe briefly the general objectives, target groups, strategies and implementation
guidelines as developed in the policies of 2001 and 2010.
General objectives
2001
Supporting processes that enable groups of people in developing countries to halt the
spread of AIDS and deal adequately with the disastrous impact that AIDS has on
their lives.
2010
Supporting social processes which enable groups in developing countries to claim
their rights; prevent the spread of HIV and deal effectively with the impact of AIDS on
their lives.
Both policies clearly stipulate the focus of Hivos, namely strengthening claim making power of
groups of people and not supporting organisations which provide direct services (though some
of the partners include service delivery within their scope of work). The 2010 policy more
specifically introduces a rights focus.
Target groups
2001
The Policy identifies the following target groups – each equally significant:

People living with HIV/AIDS

Women and young girls

Teens and young adults

Sexual minorities

(Labour) migrants and refugees

Poor urban and rural population
ACE Europe-ETC Crystal / evaluation HIV and AIDS program Hivos / Final evaluation report pag. 48/176
2010
The Policy distinguishes two categories of target groups:
11
Specific target groups, supported by Hivos own resources: PLWH, MSM ,
transgender, IDU, sex workers and their clients and sexual partners.
Target groups supported by Hivos with the support of external donors: focus on
women and youth and their sexual partners, particularly in Africa and Asia
Target populations according to Regions
Region
Nature of epidemic
Main target populations
Southern &
Generalised
Women, youth, PLWH, MSM, sex
Eastern Africa
Latin America &
workers; and their sexual partners.
Concentrated
South Asia (India
and sex workers; and their sexual
and Indonesia)
Central Asia and
Youth, PLWH, MSM, transgender
partners
Concentrated
PLWH, IDU
Indonesia
A central element in Hivos policy on HIV/AIDS is the focus on ―Key Affected Populations‖
(referred to as ―excluded groups‖ in the 2006 Business Plan). The 2010 draft policy document
specifies these Key Affected Populations. For the region under review, Latin America and South
Asia, main target populations identified are PLHIV, youth, MSM, transgender and sex workers
and their sexual partners. Women –as a general category - disappear as a main target group
for Latin America and India in the new policy.
The focus on minorities and vulnerable groups is similar in both policies. The 2010 Policy
however specifically mentions the particular groups such as MSM and sex workers. The 2010
Policy also specifies the target groups according to the region, and the nature of the epidemic.
This is a reflection of the recognition that there is not one ‗sweeping epidemic‘, but that the local
conditions and situation needs to be the determining factor in the selection of the response.
The 2010 Policy distinguishes between target groups which will be supported through Hivos‘
funds and those in conjunction with external/other donors. This distinction reflects Hivos‘
commitment to support key affected groups, often most excluded from society and with
limitations in accessing services because of discrimination, stigmatisation and violation of
human rights. Joining forces with external donors increases the opportunities to access funds
provided through international health initiatives such as the Global Fund and as such targeting
populations which could be considered more ‗mainstream‘, i.e. less controversial.
Strategies/Activities
2001
The Policy outlines 4 strategic areas:

Prevention, awareness and information

Lobbying, advocacy and influencing policy

Organisation building, network development and communication
11
The focus is on MSM compared to WSW (Women who have sex with WSW) because the overwhelming evidence
suggests that HIV/AIDS is a problem among MSM. Hivos will adapt its programs as more evidence emerges on the
extent of Hiv/aids among WSW. However, homophobia and violence against same sex are experienced by both MSM
and WSW.
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Strategies/Activities

Emancipation and sexuality
(1) The first area (prevention) is mainly geared towards teens and young adults. The
Policy indicates that the work in this area is not solely targeting AIDS organisations,
but that for strategic reasons activities will be covered by a broad spectrum of local
organisations – especially in regions where HIV/AIDS already impeded development
in general.
(2) Lobby and advocacy actions are aimed to influence policy, which in turn would
ensure optimal facilities for prevention, care and protection of human rights with
respect to HIV/AIDS. Therefore, Hivos‘ scope of work does not include direct support
for services. However, the Policy does identify exceptional circumstances which
allows for a deviation of this rule, such as the buddy care and counseling program (in
Latin America).
(3) At the time of the write up of the Policy it was recognised to enhance expertise in
the domain of HIV/AIDS, both internally in terms of organisational building, planning
and management, as well as externally through enhancing the position of civil society
and NGOs. The Policy identifies weaknesses in the linkages between local
organisations and the outside world (international lobby and support organisations)
and therefore underlines the need to support these processes, especially building
networks.
(4) The area of emancipation and sexuality is identified as a main challenge: ―Hivos
will need to meet to render prevention policy effective‖. Power relations and the
sensitivity of sexuality pose barriers to prevention and to overcome taboos. However,
for Hivos as a humanist organisation this is precisely the field where the organisation
sees its added value and its niche.
2010
Strategies are outlined under the different thematic priorities:
(1) promote the human and sexual rights of key affected populations, approaches:
- advocate for national and international policies
- break taboos and stigma on HIV, sex and drug use within the society
- strengthen women, youth, MSM, sex workers, PLHIV and IDU groups
(2) promote access to equitable, non-discriminatory HIV prevention, approaches:
- advocate governments and healthcare providers
- campaign against AIDS education on abstinence and faithfulness
- develop and systematise innovative HIV prevention tools and strategies
(3) promote access to sustained quality treatment and care
- advocate governments
- monitor the effectiveness of multilateral and bilateral agencies in terms of their
impact on access to treatment
- promote participatory processes and CS engagement
- pressure key actors to relax trips and promote access to AIDS medicines
(4) address gender dynamics of gender and HIV
- promote gender mainstreaming
- address unequal power relations
- enhance understanding on different gender roles among MSM and transgender
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Whereas the 2001 Policy outlines 4 categories of intervention strategies, the 2010 Policy
appears more detailed, specifying for each of the 4 thematic priorities the approaches to be
taken. The 2010 policy is a continuation of the 2001 policy however it places an increased
emphasis on following issues:

The 2010 policy keeps on promoting advocacy and lobby for effective national
HIV/AIDS policy over service delivery. Hivos continues to support organisations who
hold governements accountable, since it is ultimately their responsibility to provide care
and treatment. The new policy underlines more clearly the importance of participation
of target groups in advocacy and campaigns.

Hivos strengthens its rights based approach with a focus on fighting stigma and
discrimination, breaking taboos, and increasing the claiming capacity of the rights
holders;

The 2010 policy specifically addresses the global initiatives (Global Fund, WHO,
Pepfar, EU, World Bank) and bilateral initiatives. These players have emerged in the
international AID arena and took a leading role in providing access to care to PLHIV
but on the other hand paid less attention to the inclusion of key affected populations in
these processes. Hivos made the observation on the complexity of these processes
which may impede effective participation in decision making by key affected
populations. Hivos focusses on improving civil society particpation and invests in
monitoring the effectiveness of the interventions of these agencies.

.Whereas earlier international and national efforts in advocacy and lobby focused on
achieving universal access to prevention, care and treatment the focus has shifted to
issues around equitable access to qualitative prevention, treatment and care which is
clearly reflected in the 2010 policy.
Where the 2010 policy describes the importance of prevention, awareness and information not
solely implemented by HIV/AIDS organisations, the 2010 policy focusses rather on
interventions in the area of prevention that develop innovative prevention tools and strategies.
Gender becomes more prominent in the 2010 policy, describing several approaches as
compared to the general reference to ―unequal power relations‖ in the 2001 policy. Attention is
put to ―gender roles‖ referring to unequal power relations between men and women, men and
men, transgender and men/women.
Implementation
2001
Priorities and responses in HIV/AIDS require a cross-sectoral approach. The policy
describes areas where the HIV/AIDS sector overlaps with Hivos‘ other policy sectors:
human rights; gender, women and development; culture; economy and sustainable
development.
The implementation chapter in the 2001 Policy does not elaborate extensively on
implementation matters. It summarises the priority areas and expresses intentions to
increase resources (financially to programs in Africa and increases in human
resources for the Africa desk). Plans for increased alignment with networks and other
ACE Europe-ETC Crystal /Evaluation HIV and AIDS program of Hivos /Final evaluation report pag. 51/176
Implementation
development organisations active in the field of HIV/AIDS are mentioned. A short
section in this chapter is dedicated to monitoring and evaluation.
2010
The 2010 policy stipulates the following priorities:

promote the human and sexual rights of key affected [populations (e.g. women,
PLWH, MSM, transgender, sex workers and IDUs)

promote access to equitable, non-discriminatory HIV prevention

promote access to sustained, quality treatment and care

address the dynamics of gender and HIV
Its responses reflect a continued support to civil society and membership-based
groups; expanding this to alliances with knowledge and research centres,
international agencies and other donors to specifically invest in network development
in order to strengthen the position of civil society groups in advocacy.
The policy underlines the use of innovative tools and models in the empowerment of
key affected populations and HIV/AIDS prevention.
It also reaffirms Hivos‘ commitment to use its resources to address taboos, stigma
and discrimination faced by key affected populations.
The chapter on implementation specifies activities in the HIV/AIDS sector and within
the various sectors of Hivos. In addition to the responses under these thematic areas,
the Policy indicates implementation matters under:
- organisational building and networking
- knowledge development and dissemination
- engagement with strategic partnerships
- engagement with donors & multilateral agencies (such as GF, EU)
The chapter also guides on selecting partnerships (majority in the area of advocacy,
and fewer in direct HIV prevention services) and the role of partners (dialogue and
knowledge development).
The part on sustainability of HIV/AIDS work outlines how Hivos will prioritise at the
operational level (priority to projects with a broader, national, regional, global
outreach), and the exclusion of care programs from Hivos own resources. In terms of
building capacity, Hivos will establish such programs in the region (South-South
strengthening and leadership development). AIDS Workplace policies will be
stimulated. In terms of sustainability of the partners, Hivos will stimulate
diversification of funds.
The M&E part of the document is brief in outlining the actions ahead, such as training
of partners in M&E, and the challenges: to set baseline and benchmarks which are
needed to guide the implementation.
Clearly the Policy 2010 is more detailed on the implementation aspects of the policy and sets
out the boundaries of support to civil society organisations in the HIV sector. Both policies
indicate the importance of strategic alliances though the 2010 policy does so more in detail and
with more outward looking focus towards donors and multilateral agenda. The need for
knowledge development and dissemination is clearly defined in the new policy. The new policy
provides guidance on issues of sustainability, an area which is not explicitly mentioned in the
2010 policy.
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The following table describes how the HIV/AIDS policy is translated into the HIV/AIDS program, part of the civil choices program for the period 2007-2010.
Table 9: Description of the intended results of the evaluated interventions and the intended impact of these results (as formulated in the
business plan 2007-2010)
Impact level
- to reduce the HIV infection rate
- to reduce social-economic impact of HIV/AIDS
- to reduce stigmatisation and discrimination of PLWHAs
Effect level
Improved respect of HIV/AIDS-related rights, including access to services for excluded groups
Indicators:
- number of people with access to treatment
- sample evidence of free/open talk on HIV/AIDS
Outcome level –
Access to treatment and
result area 1
other specific rights
claimed, particularly for
Output level – Civil society building: rights of specific groups
Taboo-breaking organisations strengthened in campaigning for specific rights of excluded groups
excluded groups
Outcome level –
Improved HIV/AIDS
result area 2
education (quality,
Output level – Direct poverty reduction: HIV/AIDS education
access), particularly for
Civil society organisations strengthened in HIV/AIDS education, particularly for excluded people (youth, LBGT, sex workers, PLWHAs,
excluded people
poor women)
Outcome level –
Pro-active citizenship
Output level –Policy influencing: campaigning and lobbying
result area 3
promoted and policy
makers pressured
Civil society organisations strengthened in lobby and campaigning
Outcome level –
Workplace AIDS policies
Output level –Policy influencing and direct poverty reduction: workplace policies
result area 4
of partners implemented
Civil organisations strengthened in the design and implementation of workplace policies
ACE Europe-ETC Crystal /Evaluation HIV and AIDS program of Hivos /Final evaluation report pag. 53/176
4.2. THEORY OF CHANGE
No specific theory of change has been made explicit in the policy papers. Based on the policy
documents, the interviews with the Hivos program officers and the practice on the field the
evaluators have reconstructed a theory of change that explains the choices taken by Hivos. In
the overview below we have presented this theory of change in a schematic way.
The first column of boxes refers to the roles of Hivos. These are about institutional funding of
partner organisations, supporting capacity development at organisational level (including
attention to gender and the development of HIV/AIDS workplace policy papers) and stimulating
institutional development by enhancing networking and facilitating strategic partnerships (ex.
linking partners to larger donors or international programs).
The evaluators have distinguished four groups of operatonional strategies each contributing to
specific results. The operational strategies are presented in the second column of boxes, the
result chain in the third and fourth column.
The objectives of Hivos are on the one hand increased access to prevention, treatment and
care of key affected populations (in particularly of PLHIV, MSM, sex workers and transgender)
and on the other hand government that assumes its responsibility for better service delivery.
When access to non discriminatory and qualitative prevention, treatment and care will be
guaranteed the HIV infection rate will reduce as well as the socio-economic impact of HIV.
To achieve these objectives following results need to be achieved: (1) healthcare providers
need to acknowledge their own discriminative attitudes towards the key affected populations
and need to act accordingly; (2) key affected populations need to be able to claim their rights
and to address violations of their rights effectively, monitor policy implementation and put
pressure on government and other decision makers in the health system to improve the
accessibility and quality of the services provided to them; (3) good models for prevention,
treatment and care that are not dominantly bio-medical (giving attention to the psycho- and
social support and the environment within which the key affected populations are living) can be
developed and need to be scaled up within the public health system in order to improve the
quality of the services provided by the health system; (4) auto-discrimination by key affected
population need to be decreased and self confidence increased, combined with a wider
acceptance of key affected populations by the society at large.
For each of these results operational strategies can be distinguished:
(1) Acknowledgment of healthcare providers of their own discriminative attitudes
Specific anti-discrimination measures need to be taken, for example targeted training of health
care providers, awareness raising of health care providers (but also policy e officers, a.o.) on
ACE Europe-ETC Crystal / evaluation HIV and AIDS program Hivos / Final evaluation report pag. 54/176
their own discriminative attitudes, followed up by targeted actions to improve the attitude and
behaviour of staff in health care centres (police stations). Training and awareness raising are
not sufficient. These need to be followed up by actions on management and policy level in order
to change practice in a structural way.
Several partners are involved in these type of actions (Siaap, Sangram, Via Libre, Prosa and
IESSDEH). Worth mentioning is the innovative approach through cultural activism to raise
awareness on discrimination against MSM, PLHIV or sex workers as executed by IESSDEH.
Other anti-discriminative actions entail redressing violations of rights, bringing cases of
discrimination to court. The later is more present in the programs of the Indian partners but
rather absent in the Peru program. In all programs studied it looks difficult to put pressure on
the health system in order to change practice in a structural manner.
(2) Key affected populations are able to claim their rights
This operational strategy is key in the approach of Hivos and can entail several approaches.
Key affected population are being trained/informed on issues related to stigma and
discrimination in order to identify discriminative behaviour. They need to be informed on their
rights in order to motivate them to become involved in advocacy and lobby activities.
Involvement in advocacy and lobby can be articulated by a coalition or collectives (established
groups of people). To that end, groups of key affected populations are being formed and
strengthened or partners collaborate with existing groups or movements of key affected
populations. The participation of these groups in decision making processes will be enhanced.
Partners themselves are also active in advocacy and lobby, involving key affected populations
in this advocacy and lobby.
All partners are implementing these approaches. These seem to be better developed in the
India programs as strengthening of community based groups of key affected populations is at
the core of their programs.
(3) Scaling up of good models in the health system
Hivos does not intend to be too much involved in direct service delivery. However, relevant is
the support to the development of appropriate models for prevention, care and treatment. This
justifies the involvement of partners in direct service delivery. Essential in these models is the
taboo breaking nature and the attention given to unequal power relations, sexual diversity,
stigma and discrimination. These models need to be introduced in the public health system.
And being involved in prevention, treatment and care enables the partners to have first hand
information on what works and what does not, information that can be used in advocacy and
lobby.
All partners do implement prevention activities and/or are involvement in delivery of ARVs and
counselling and/or offer a variety of care and support services. The Hivos policy is not clear to
what extent Hivos wants to continue supporting this. Taking into account the advantage of their
partners in having easier access to key affected populations compared to the government, it
ACE Europe-ETC Crystal /Evaluation HIV and AIDS program of Hivos /Final evaluation report pag. 55/176
looks pertinent to keep on offering services. However, eventually Hivos is of the opinion that the
government needs to take responsibility for organising effective and qualitative prevention, care
and treatment. In practice not much strategies have been developed to scale up good and
innovative models developed by some of the partners.
.(4) Reduced (auto)-stigma and increased acceptance of key affected populations
A fourth set of approaches has been observed in practice which has not been clearly included
in the Hivos policies. It looked to be very important to help key affected populations to recognize
attitudes of auto-stigma and discrimination and to increase their self confidence. Information
sessions, training and being involved in support groups plaid a significant role to that end.
Important is the improvement of the socio-economic situation of the key affected populations
what influences directly their self confidence but also enhances the acceptance of the key
affected populations by the wider community. Programs that are not exclusive targeting key
affected populations but also addressing the wider community (ex. income generating activities
and/or referring people to welfare schemes; prevention activities, community counsellors) have
a positive influence on the acceptance of PLHIV and other key affected populations by the
wider community.
Several partners support community based groups of key affected populations and integrate
economic activities in their programs, in particularly in India. This strategy is less developed in
the Peru programs.
Hivos implements the operational strategies through their partners (who often support CBOs
and collectives to implement some of the operational strategies) but Hivos itself is also actively
involved in advocacy and lobby at international level. The latter was not part of this evaluation.
ACE Europe-ETC Crystal / evaluation HIV and AIDS program Hivos / Final evaluation report pag. 56/176
Institutional funding of
partners
Operational strategies
Specific anti-discrimination measures, targetted
interventions (training of health care workers,
redressing cases, awareness raising on stigma
and discrimination)
Put pressure on decision makers within the health
Support to
capacity
development,
organizational
building and
networking
Health care providers, peer
educators, police etc.
acknowledge own
discriminative attitudes and are
able to implement changed
behaviour
Increased access to
information, VCT,
treatment and care
system
Training of key affected population on stigma and
discrimination
Informing key affected population on their rights
Engagement
with strategic
partnerships,
donors and
multilateral
agencies
Results chain
Involving key affected populations in monitoring
policy implementation, advocacy and lobby
Key affected populations
claim their rights (adressing
violations of rights, monitoring
policy implementation and
putting pressure on policy
makers)
Government assume better
their responsibilities to secure
equitable, non discriminative
and qualitative prevention,
treatment and care services
Setting up CBOs, support groups, collectives and
strengthening them
Increasing participation of CBOs, collectives, key
affected populations at Global Fund and other
larger porgrammes
Supporting gender
mainstreaming and
development of
HIV/AIDS workplace
policies
Developing appropriate and qualitative models for
prevention, treatment and care taking into
account the specific needs of key affected
populations
Developing strategies to scale up innovative
models
Improving socio-economic situation of key
affected populations
Involving the larger communities in implementing
activities for PLHIV
Good models for prevention,
treatment and care are taken
over by government and
health care providers and civil
society organizations are
recongnized as relevant
partners in prevention
campaigns targeting specific
key affected populations
Increased access to qualitative
prevention, care and treatment
Increased self confidence and
increased acceptance of key
affected population by the
larger community
ACE Europe-ETC Crystal /Evaluation HIV and AIDS program of Hivos /Final evaluation report pag. 57/176
Reduced infection rate and reduced socio-economic impact of HIV/AIDS
Roles of Hivos
5
Human and sexual rights of key affected
populations strengthened
Hivos approaches HIV/AIDS from a human rights and development perspective, and refers to
social exclusion faced by vulnerable groups as a key underlying factor to the spread of HIV.
Crucial in the fight against HIV/AIDS is therefore defending the rights of key affected
populations and advocating for their access to treatment and information. The human rights and
development perspectives on HIV/AIDS provide a framework for: (a) holding governments
accountable for their actions; (b) enabling activists to engage in a wide range of advocacy
aimed at securing the human rights and the protection of key affected populations; (c)
addressing social and gender inequalities amongst the population12 .
This evaluation focuses on the extent to which the HIV/AIDS program of Hivos has contributed
to the strengthening of human and sexual rights of key affected populations. Focus here is on
the level of stigma and discrimination of key affected populations hampering their access to
prevention, care and treatment. The human rights program of Hivos is also collaborating with
organisations within the LGTB movement to strengthen the rights of LGTB. Their achievements
have not been assessed in this evaluation.
Evaluation results are described for the three judgement criteria followed by an assessment of
the results.
Judgement criteria
Indicators
1. National recognition of the sexual and human
1.1. National AIDS programs and policies and laws
rights of key affected populations
in place (and / or national AIDS commission
established) that address human and sexual rights
of key affected populations (MSM, sex workers,
etc) and / or evidence of laws in place to protect
the HIV affected against discrimination
2. Partners contribute to strengthening of human
2.1. Partners contribute to the debate on HIV and
and sexual rights of key affected populations
AIDS from a rights based approach
2.2. Partners are meaningful involved in networks
and coalitions that defend the rights of key affected
populations
2.3. Partners involved in capacity building of civil
society organisations /movements /networks in
lobbying and campaigning, that address the rights
of specific target groups
2.4. Gender dynamics of key affected populations
12
HIvos HIV/AIDS policy 2010
ACE Europe-ETC Crystal / evaluation HIV and AIDS program Hivos / Final evaluation report pag. 58/176
have been taken into account while advocating for
their rights
3. Evidence of significant changes at the level of
3.1. Involvement of PLWHA in campaigning / lobby
beneficiaries (positive changes regarding their
and advocacy (local/national levels) / establishment
sexual and human rights)
of networks of PLWHA (support groups)
3.2. Decrease in incidences of violations of human
and sexual rights of key affected populations
3.3. Cases of defending human and sexual rights
of key affected population
5.1. NATIONAL RECOGNITION OF THE SEXUAL AND HUMAN RIGHTS OF KEY
AFFECTED POPULATIONS
The extent to which the legal frameworks to fight HIV/AIDS and to address stigma and
discrimination pay attention to the rights of key affected population is very different in India as
compared to Peru. Peru has a legal framework to protect the rights of MSM, sex workers,
transgender and PLHIV and to protect them against discrimination. This legal framework does
not exist in India.
In India, the legal framework on HIV/AIDS is still weak as the HIV/AIDS bill has not yet been
tabled. This bill is supposed to address human rights of key affected populations, including a
chapter on stigma and discrimination. India does not have particular laws that protect PLWHA
from discrimination. In 2009, the Delhi High Court decriminalised homosexuality (section 377,
the 149-year-old colonial law that banned gay sex, had been deemed to be a violation of
fundamental human rights protected by India‘s constitution).
In Peru, a law on HIV/AIDS was already in place since 1997 (Ley 26626 Contrasida) and has
been modified in 2004 (Ley 28243). With this modification, specific attention was given to the
rights of key affected populations (like the right to integral care that include access to free
treatment). On the negative side, the obligation of pregnant women to be tested on HIV became
part of the modified law. The national health plan 2007-2020 (resolución ministerial 589/2007
MINSA) includes the rights of vulnerable groups to access prevention, treatment and qualitative
care. The national plan on human rights 2006-2010 (Decreto supremo 017-2005) defines eight
vulnerable groups, amongst them people with different sexual orientation and PLHIV. Specific
reference is made to their right to access integral care in the health centres. A specific law
against discrimination includes, since 2006 (Ley 28867), specific articles referring to the non
discrimination based on, of amongst other, sexual identity.
The law on sex work is ambiguous in the sense that sex work is permitted in brothels (not in the
street) and under the condition that sex workers attend at regular base health control services
(Atención Médica Periódica) delivered in specific established health centres (CERITS, centro
de control de ITS). A specific ministerial resolution has been adopted in 2006 (Resolución
Ministrerial 1452-2006-IN) leading to the development of a manual on respecting human rights
ACE Europe-ETC Crystal /Evaluation HIV and AIDS program of Hivos /Final evaluation report pag. 59/176
in police activities. In this manual also specific attention is given to vulnerable groups, amongst
them LGTB and PLHIV. Though the legal framework to protect the human rights of the
vulnerable groups exists, implementation remains a challenge (see further).
In both countries a decentralisation process is ongoing. At state (India) and regional (Peru)
level, several regulations are being developed that defend the human rights of the key affected
populations, like the government order which ruled the police should punish the trafficker and
not the sex worker (Tamil Nadu) and the regional laws (ordonanzas in several regions) to
protect vulnerable groups against discrimination in Peru.
The national AIDS programs in both countries recognize key affected populations as important
target groups (currently NACPIII in India and the multi-sectoral national plan to fight HIV and
AIDS in Peru), in Peru since the modification of the HIV/AIDS law in 2004, in India since 2007.
Both countries have a legal framework on sexual and reproductive rights, however, no link is
made between HIV and sexual and reproductive rights and no specific attention is given to
vulnerable groups in these frameworks. India has a reproductive and child health program and
the government is trying to converge with the HIV/AIDS program which has been very vertical
till recently.
5.2. PARTNERS CONTRIBUTE TO STRENGTHENING OF HUMAN AND SEXUAL RIGHTS
OF KEY AFFECTED POPULATIONS
Hivos aims at strengthening civil society organisations to promote pro-active citizenship and
pressure policy makers in order to increase the respect of human and sexual rights of key
affected populations.
All Hivos partners contribute to the strengthening of human and sexual rights of key affected
populations (1) by contributing to the debate on HIV and AIDS through participation at official
public structures and/or civil society forums/coalitions that discuss policies and programs to
fight HIV/AIDS, (2) by advocating for human and sexual rights of key affected populations, (3)
by defending individual cases of violation of human rights of key affected population, (4) by
participating at networks that contribute to the debate, (5) by strengthening community based
organisations of key affected populations to make their voices heard. Following we describe the
output of the different partners and their respective achievements.
Contribution to the debate on HIV and AIDS from a rights based approach -
Staff
members of the Hivos partners have been activists for long and some of them are considered to
be legitimate experts on the rights of PLHIV and key affected populations by decision makers
and staff at health facilities (in particular the Directors of Via Libre, Prosa, SIAAP and
Sangram). The founder of SIAAP has been recognized for her work with the marginalized
populations and HIV/AIDS. The general secretary of Sangram has been awarded a global
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human rights prize in 2004 and she has also been recognised and invited to panel discussions
at global HIV/AIDS conferences on issues of Human Rights and HIV/AIDS.
Four partners participate at the country coordinating mechanisms of the Global Fund to develop
proposals, monitor and evaluate implementation of these proposals (Sangram and INP+
ORISSA in India and Via Libre (till 2010) and Prosa13 in Peru). )14. In India and Peru these
structures have quite some influence on national policy development (whereas the influence of
the CCM is much weaker in countries like Ecuador and Bolivia)15.
India – SIAAP and INP+ ORISSA have participated at forums at national, state and district level
to push the development of the HIV/AIDS bill and in this also collaborated with the Lawyers
collective16. Additionally, SIAAP has developed guidelines and helped take models to scale at the
national level eg. PPTCT (Prevention of Parent to Child transmission), counselling guidelines for
VCT (Voluntary Counselling and Testing) and ICTC (Integrated Counselling and testing Centre) that
were taken from state to national level. SIAAP was also a member of the national steering committee
and task group so were able to flag issues. Sangram is member of the UN reference group on
HIV/AIDS and sex work policy and facilitates sex workers and MSM to voice their opinions at
NACO meetings. Both Birds and the sex workers collective (one of the collectives formed and
supported by Birds) participate at District AIDS committees in the state of Karnataka where
state programs are being discussed. They were able to secure funding through the State AIDS
control program for a number of the collectives.
Peru – Via Libre and Prosa have contributed to the debate on the modification of the national
HIV/AIDS bill (2004) and the development of the national multi sectoral plan to fight HIV/AIDS
(2007-2011), through several advocacy and lobby campaigns and through participation at the
CCM and their working groups. Via Libre also participates at the consultative committee of the
Ministry of Health (though no meetings have been organised in 200617). The HIV/AIDS law and
the national plan pay specific attention to the rights of the key affected populations. All partners
(except IESSDEH) have participated in the ―Colectivo Para la Vida‖ to fight for free access to
treatment what resulted in the launch of the TARGA campaign in 2004 (free access to
treatment for all). All partners have good collaboration with the ombudsman and all of them
have access to several members of parliament.
Advocacy and lobby for human and sexual rights of key affected populations – All
partners fight for respecting the human rights of the key affected populations, usually focussing
issues of stigma and discrimination. Partners lobby for specific anti-discrimination laws at
national and regional level, they monitor implementation of these laws and collaborate with
health facilities and police stations18 at local level to raise awareness on discriminative attitudes
13
Indirectly through one of their members
In India, another partner (not visited) Sangama that works with sexual minorities is also on the CCM.
15
Based on interviews with various stakeholders and partners in Peru, during and after the evaluation mission.
16
The Lawyers Collective is an indian NGO that works on legal and rights issues.
17
From annual report 2006 Via Libre
18
Mainly in India. In Peru only RUNA, the Hivos partner from the human rights program, is involved in activities with
police.
14
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and the rights of key affected populations (through documenting cases, sensitization and
training).
India – The partners visited have been involved in lobbying aspects of human rights at the state
level and to a limited extent at the national level. SIAAP, Sangram and the NAZ foundation (not
visited) contributed to the law on decriminalisation of homosexuality (section 377, the 149-yearold colonial law that banned gay sex). Partners are mainly involved in awareness campaigns
targeting health facilities and police stations. The programs of Sangram are worth mentioning.
Sangram has implemented several larger advocacy campaigns with government functionaries
at state, local and district level and with schools to raise awareness on sexuality, gender based
violence, human rights and HIV/AIDS. Sangram‘s advocacy efforts have been on promoting sex
work as work and as a viable livelihood option. Sangram is member of the UN reference group
on HIV/AIDS and sex work policy and participate at the sex workers group of UNFPA.
Peru – Involvement of Hivos‘ partners in lobbying for respect of human rights at national level is
very diverse and depends a lot on specific projects funded. Via Libre and Prosa participated
(directly or via CBOs supported) at forums organised at regional level (mesas de concertación),
to discuss the regional laws regarding stigma and discrimination and to monitor implementation
of these laws. In several regions, regional laws (ordenanzas) to address discrimination of key
affected populations in health centres have been adopted. Via Libre and Prosa were also
actively involved (in collaboration with the ombudsman) in advocating for the rights of PLHIV to
get married (forbidden according to the ―codigo civil‖ (with no success so far). IESSDEH, being
a research institute and as such different in nature from the other partners, has a strong rights
based approach and contributes to the debate on human and sexual rights through its research
and publications and the organisation of conferences. IESSDEH is part of a university with a
certain prestige and is recognised by all stakeholders interviewed by the solidness of their
research19. Worth to be mentioned is the innovative project regarding cultural activism that
addresses stigma and discrimination of PLWHA (Vivo con VIH), of MSM (homophobia mata)
and sex workers, including transgender (Bochinche). Activists, health care workers and
community members involved in these campaigns reported recognition of their own attitude of
discrimination20 as one of the results.
Most of the partners make a link between HIV and Sexual rights. Sangram is contributing to the
debate on sexual rights via the national network of sex workers and the rainbow planet coalition
promoting sex work as a viable livelihood option. INP+ Orissa is member of the coalition on
sexual and reproductive rights of sexual minorities and PLHIV. In Peru Via Libre implements a
specific project on advocating convergence of HIV and Sexual and Reproductive Health
(participation at fora, executing research, distributing publications). IESSDEH is advocating for
the sexual rights of sexual minorities (for example, through research and the organisation of
conferences). Aid for AIDS has started an ―observatorio de la mujer‖ to raise awareness
amongst women on their sexual and reproductive rights and to study the integration of HIV in
19
20
These research activities are (not yet) financed by Hivos
However, changed attitude does not result immediately in changed behaviour. Interviewees mentioned that health
workers might say that they do not discriminate although evidence shows the contrary.
ACE Europe-ETC Crystal / evaluation HIV and AIDS program Hivos / Final evaluation report pag. 62/176
sexual and reproductive health services in health facilities. A report recently has finalised and
will be presented in Congress.
Defending individual cases of violations of human rights – one of the strategies to enforce
respect for existing laws is bringing cases to court and /or to advocate individual cases through
actions in the media, the congress or the Ministry of health. All partners are involved in this kind
of activities. In India, all partners also support particular cases with legal advice and assist
individuals or groups to bring their cases to court. In Peru, this legal support is limited to
supporting key affected populations to bring their cases to the ombudsman (at regional or
national level). Only Prosa has been involved in assisting victims of violation of human rights in
court.
Participation at networks - All partners participate in networks and coalitions, that defend the
rights of key affected populations at state, national level and international level.
The
effectiveness of these networks is not known as there are no evaluations of its results (only one
evaluation of the Sarvojana network, see box).
Table 10: Participation in or collaboration with networks and coalitions, partners India
Partner
Network/coalition
SIAAP

Member of Sarvojana (lead agency)

Collaboration with the Lawyers collective
Sangram
At national level:

One of the collectives (Muskaan) is linked to various national networks of MSM

Action Plus, a network of 15 organisations working to prevent the spread of
HIV/AIDS in India

National Network of Sex Workers, of which VAMP is a member

Rainbow Planet, a diverse coalition of progressive groups working for the rights of
sexuality minorities, sex workers and PLHA (People Living with HIV/AIDS) in India

Network of Sex Work Projects - A global network of projects around the world that
advocate for the human rights of people in sex work irrespective of their legal
status.

Vimochana, Bangalore, an autonomous women's group that works on issues
related to violence against women and women's rights

Point of View, a Mumbai-based non-profit organisation that mainstreams women's
rights through media, art and culture
At international level

UNAIDS reference group on HIV/AIDS and Human Rights, Geneva

Asian Women's Human Rights Council, an organisation that speaks of a new
generation of women's human rights through the voices of women

With Women Worldwide, a coalition of women‘s groups worldwide

International Women‘s Health Coalition, New York

FEIM, Argentina and INCREASE, Nigeria – Strategies of the South

Asia Pacific Network of Sex Workers, Bangkok

Network of Sex Work Projects, New York

Research for Sex Work, Amsterdam
ACE Europe-ETC Crystal /Evaluation HIV and AIDS program of Hivos /Final evaluation report pag. 63/176
INP+ Orissa

Member of the coalition on sexual and reproductive health rights of sexual
minorities and PLHIV in the state of Orissa
Birds

Collaboration with Human rights Law Network

Collaboration with SAATHI
Not specifically
Sarvojana network
The Sarvojana Coalition has been an effective platform for national level collective advocacy and lobbying
for key affected populations. The partners felt that collective advocacy was more effective than individual
organisation advocacy. The coalition has been effective in influencing the nature of services in the local
communities to the key affected populations, yet the evaluation brought out that this work remains
unfinished. The evaluators found that the work of the coalition had largely focused on the establishment of
seven community based voluntary counselling, testing, support and care centres and that the attention
given to improving the quality of services from other service providers was less clear. They were trying to
take this further up but it was dependent on future funding.
Table 11 : Overview of national networks in which Hivos partners participate in (P) or
collaborate (C) with, Peru
Via Libre
Prosa
La Red SIDA Peru
P
P
Movimiento para una
C
C
AfA
IESSDEH
P
C
Homosexualidad Libre (MOHL)
Peruanos Positivos
C
Red de GaMs (Grupos de Auto
C
Mutua)
Red Peruana de Mujeres viviendo
C
C
con VIH
Red LGTB
P
Red nacional de patientes
P
Foro Salud
Movement of sex workers
P
C
C
C
Table 12: Overview of international networks in which Hivos partners participate in (P) or
collaborates (C) with, Peru
Via Libre
Global network of PLHIV
International AIDS alliance
Prosa
AfA
IESSDEH
P
P
P
IASSCS International Association for the Study of
P
Sexuality, Culture and Society
Coase, coordinadora de ONG de las Americas
HIV/AIDS Horizontal Technical Cooperation in
P
P
P
Latin America and the Caribbean.
LACASSO, Latin American and the Caribbean
P
Council of AIDS service organisations
ACE Europe-ETC Crystal / evaluation HIV and AIDS program Hivos / Final evaluation report pag. 64/176
P
P
It is mainly through the ―Red SIDA‖ that joint advocacy and lobby takes place in Peru. In
contrast with the joint advocacy and lobby within the ―Colectivo Para la Vida‖ (a coalition that
does not exist anymore) to fight for the right to access ARVs, all partners develop their own
advocacy and lobby activities separately (except collaboration within Red SIDA, now focussing
on advocating for a law that improves access of minors to sexual and reproductive information
and care (including HIV). The partners visited collaborate with networks and coalitions of key
affected populations in order to have access to key affected populations rather than to prepare
joint advocacy and lobby (exception IESSDEH). Participation in networks at international level
serves in particular the exchange of information and experience. A well developed lobby
strategy is often lacking (example see box on the Latin American forum)
IV Foro Comunitario de America Latina y del Caribe sobre VIH/SIDA e ITS
In November 2009 the fourth community forum on HIV/AIDS and STI was organised in Lima (with technical
support from Via Libre). Organisations from Latin America and the Carribean participated and debated
during three days issues related to stigma and discrimination, human rights, access to treatment and
advocacy and lobby. The gathering appears to be very relevant for purposes of exchange. The list of
conclusions recommendations however remains rather general and concrete proposals are lacking.
Recommendations are not linked to a concrete advocacy and lobby strategy. One of the lessons
formulated was ―“Los foros regionales deben tener resultados concretos. Mas alla de la publicacion de un
resumen deben llevar a asumir compromisos de alto nivel politico, por ejemplo, la compra a nivel regional,
tratamiento del VIH y prevencion en fronteras, movilizacion de la agenda regional en espacios globales,
etc “. (Reporte del IV foro comunitario de America Latina y del Caribe sobre VIH/SIDA e ITS, p.28).
Strengthening
the
lobby
and
campaigning
capacity
of
civil
society
organisations/movements/networks - All Hivos‘ partners support and/or create community
based organisations and federations of key affected populations. These groups receive training
and technical support in dealing with abuse cases, communication with police and health
workers, legal issues, how to access governments services and support schemes. Entry point is
informing beneficiaries on their rights and how to defend them. Hivos partners assist them in
filing for abuse cases (in India to the court, in Peru to the ombudsman), organise
demonstrations and working groups. The rights based approach is prominent in all partners‘
approaches, less so in INP+ Orissa and Birds where activities tended to be initiated more from
a needs based approach. This observation emerged from the discussions with both the field
staff and beneficiaries
The changes these groups are able to make are mostly localised and/or at individual level (e.g.
demanding a doctor to provide for better services or a police station to back off). Results of
these groups are not systematically documented. In the table below we report results as
described in annual reports and evaluation reports of the partners. In point 5.3. more concrete
results at the level of the beneficiaries are described as reported in focus group discussions and
the most significant change stories.
ACE Europe-ETC Crystal /Evaluation HIV and AIDS program of Hivos /Final evaluation report pag. 65/176
Table 13 : Overview of output regarding capacity building of CBOs21
Partner
output
Results reported regarding claiming
rights

SIAAP

Formation of PLHIV support groups
The Sangams are actively pursuing
(incl. MSM)
cases on harassment, stigma and
Formation of 30 sangams (collectives)
discrimination
for MSM and FSW

Formation of coalitions, e.g. the
One example was the sudden mass
Federation of MSM and the Federation
testing for HIV going on in the Tamil
of FSW in Tamil Nadu State
Nadu State. The coalition members
These Federations in turn represent the
of Tamil Nadu immediately joint
State at National level and the Federations
hands and collected stories from
engage with similar groups in other States
individuals over a course of three
-
Sangram
22



Formation of joint action
days and presented these to
committees to deal with advocacy
TANSACS. TANSACS stopped this
and rights issues
testing drive.
Formation of collective of sex workers -
Members of collectives participate,
VAMP;
for example, in crisis intervention
Formation of collective of MSM-
committees23 and managed to get
MUSKAN,
these committees to also address
Formation of collective of rural women
cases of violence against women.
who are living with HIV – SANGRAM
Plus
Members become engaged in
rallies at local or state level. For
example, the collective VAMP went
in to assist the affected women,
fight for their rights, even up to the
national level for the raids in 2002.
In 2003, the collective VAMP also
assisted the protests when FSW
houses were demolished in the
State of Goa.
INP+ Orissa
Birds


Formation and strengthening the
The DLNs reported that they take
capacity of four district level networks
up issues around rights of PLHIV
(DLN).
with the district collectors24
Formation of 18 Female Sex Workers
The collectives with initial training
(FSW) collectives (Some collectives
and support from BIRDS now
have up to 9500 members)
understand the legal process, how
21
Data have been taken from the annual reports. Almost no info is available on the activities of the CBOs involved and
the results achieved. The information in the table is indicative and has been collected during the evaluation missions
(timeline exercises, interviews and focus group discussion). The evaluators have only consulted the annual reports
since 2006.
22
No numbers of members are available in annual reports
23
The crisis intervention committee is a formal body in each village of elected members of the Gram Panchayat. Their
mandate is to arbitrate in local disputes.
24
This is the highest position in the government structure within a district.
ACE Europe-ETC Crystal / evaluation HIV and AIDS program Hivos / Final evaluation report pag. 66/176

Formation of Federation of FSW
collectives, called Sahabagini.
to deal with the police, how to deal
with the media and have lawyers on
Each collective has associated with it two
their panel who support them in
lawyers. They are also linked to a State
moments of crisis25.
lawyer‘s network, of which the establishment
was facilitated by BIRDS.
One of the (stronger) collectives
reported to have fought 120 legal
cases in court and all of them were
acquitted.
12 of the 18 collectives are
empanelled by JAT committee of
Karnataka State AIDS Prevention
Society
Via Libre

Organisation of workshops for CBOs of
- 2006-2008: interventions in 6
key affected population on advocacy and
regions. Results not documented in
lobby (depending on specific projects,
Hivos annual reports.
amongst others ―proyecto incidencia
politica para poblaciones claves 20062008‖ financed by the AIDS alliance)


4 CBOs (3 trans, 1 trans and MSM)
- Results not documented. The
strengthened through the EU funded
ombudsman testified that several
SOMOS project
cases of violations have been
Technical assistance to two CBOs (one
reported by CBOs that had been
of Women with HIV and one of sex
trained by Via Libre.
workers), EU-SOMOS project
Manual has been developed to support key
26
- In 200828, 16 cases of violations of
affected populations in documenting cases
rights have been reported to the
and develop a lobby strategy. Training has
Ministry of health (attitudes of
been organised for CBOs
discrimination, insufficient ARVs,
technical norms that have not been

Specific trainings organised for leaders
respected)
of CBOs of MSM and transgender on
- increased knowledge reported
organisational development (ex.
(based on evaluation after the
developing an annual plan, strategic
training), results of CBOs not
planning) and human rights: reaching
documented
out to 307 MSM and 112 sex workers
(2008)27
Prosa

9 GAMS strengthened (2007-2009)
PROSA is taking the lead in

Annually several workshops for PLHIV
monitoring the provision of ARVs, in
and separate workshops for women
collaboration with the GAMS
25
Based on focus group discussion organized during evaluation mission
Example ―Actuemos ya! ―Guía de incidencia política pzrz personas trans. Via Libre. Developed in 2010 in the EU
funded SOMOS project.
27
Only participants of the trainings have been counted. It is possible that one participants attend several training.
28
Only since 2008 most of the partners start monitoring systematically on these cases
26
ACE Europe-ETC Crystal /Evaluation HIV and AIDS program of Hivos /Final evaluation report pag. 67/176
living with HIV (participation of 15 person

average (89 person reached in 2006,
No info available on the results of
130 in 2007)
the GAMS and the LGTB platform
strengthening plataforma LGTB Callao
Development of a manual ―Liderando
nuestra GAMS (2006), including
guidelines for advocacy and lobby
IESSDEH

Ciudadaniax – some CBOs of MSM,
Start of marches of MSM and sex
transgender and sexworkers have learnt
workers. Multiplication of the action
how to advocate for their rights in a
model is hampered by a lack of
different, more attractive way.
resources of the respective CBOs.
Not with Hivos funds (but involved in a
UNFPA project to strengthen CBOs of sex
workers)
AfA



Observatorio de la mujer – training of

58 leaders trained that are
leaders of women organisations in
conducting monitoring activities
advocacy and lobby, in particular
at health care centres in 13
monitoring SRH services at health care
regions, installment of ―mesas
facilities
de vigilancia‖ in the regions
Technical support to 4 women

Four women groups have
organisations, to include HIV in their
become actively engaged in
sensitization activities
HIV education
Seed money for the set up meeting of
the sex workers movement

Observatorio latino – AfA gives

Start up with 10 focal point to
information and technical support to
disseminate info (with limited
NGOs and CBOs of key affected
success);
populations to increase their

participation at Global Fund.
7 alerts distributed informing
CBOs in Latin America on
GF(2008); 10.000 persons on
the mailing list

3 CBOs received TA (2008)
(Paraguay, Nicaragua, Bolivia)
Collectivisation29, establishing and strengthening CBOs is core in the strategy of the Indian
partners. In Peru this strengthening of CBOs is not their core business and no strategy has
been developed to strengthen these CBOs in a systematic way. However, several partners in
Peru are involved in strengthening CBOs due to specific project funding received to that end
(example Global Fund money, EU project). The number of CBOs formed is limited and support
to strengthening networks is almost absent.
At the restitution meeting the Hivos partners
explained this as follows: (1) many of the networks of key affected populations are in the
formation phase and as such very much inward looking. CBOs that are being formed are
29
Collectivisation is the formation of collectives or groups. This was especially used for marginalised groups (female sex
workers, Men having Sex with men) so that they formed groups for advocacy and fighting for their rights together
instead of being isolated as individuals.
ACE Europe-ETC Crystal / evaluation HIV and AIDS program Hivos / Final evaluation report pag. 68/176
initially focussing on immediate needs rather than on taking position and becoming engaged in
networks. It is only recently that several networks start positioning themselves and as such
start looking for partners or facilitators30. (2) Another issue is the fact that networks of key
affected people like sex workers and transgender do not want to be associated with HIV and as
such do not seek collaboration with the Hivos partners. They prefer to focus on human and
sexual rights31. This looks like a pertinent explanation, according to the evaluators. However,
this issue does not seem to be discussed thoroughly between Hivos and its partners. The policy
of Hivos is not clear about this strategy. The evaluators notice that the formation and
strengthening of CBOs of key affected populations is part of its human rights program (with a
focus on human rights and not on HIV and with no linkages to the HIV/AIDS partners) and that
Hivos facilitated the EU Somos project executed by Via Libre which included the formation and
strengthening of CBOs as one of the main intervention strategies.
The movement of key affected populations, in particular of sex workers and transgender but
also the PLHIV, in Peru is very much fragmented, partly because of their participation (and
competition) in projects funded by the Global Fund (Cáceres, C. 200932) and confirmed by all
stakeholders interviewed33). Based on research mentioned and interviews with external
stakeholders the evaluators gained the impression that most of the networks, movements or
coalitions in Peru are not very effective nor strong (except the MOHL, movement of MSM). Most
of these movements and coalitions/networks depend on one strong leader and there is a lack of
democratised structures34.
Gender – none of the partners is familiar with the concept of ―gender dynamics‖ as introduced
in the Hivos HIV/AIDS policy. All partners develop programs that are targeting specific groups
and take into account the characteristics of each specific group (mostly female sex workers,
MSM, transgender35).
The programs of the Indian partners are women-centred (except INP+). Siaap, Sangram and
Birds take the vulnerability of women as an important factor into their programs. For example,
Sangram takes into account gender differences and biases in sexuality in their sex education
program. Siaap has drawn attention to the abuse of women, particularly female sex workers
30
PROSA sees some similarities with the evolution of the network of PLWHA.
PROMSEX, a partner of Hivos program on …. is focussing more on sexual rights of key affected populations and
collaborates with CBOs of sex workers.
32
Caceres, C. et all (2009) Lecciones Aprendidas de la Colaboración con el Fondo Mundial en VIH y SIDA en el Perú.
Efectos en el Sector Publico, Sociedad Civil y Comunidades Afectadas. Hallzagos de la primera fase del studio. Lima,
IESSDEH.
33
According to the research and the stakeholders interviewed, the criteria to access Global Fund money had a negative
influence on the movement of key affected populations. To access Global Fund money NGOs or CBOs needed to
collaborate with CBOs of key affected populations. Consortia that have been built up had to compete against each
other for the available funds. Some consortia and by consequence also CBOs of key affected populations received
funding, others not what caused a climate of jealousy and critics and weakened collaboration between them.
34
The movements and networks of TLGB lack a common agenda (ex. one group of transgender advocates for their right
of identity whether another group of transgender advocates for the gay wedding).
31
35
During the evaluation no information has been given by partners on their specific work with lesbian and bisexual
people nor could representatives of these sub groups be interviewed. Most of the partners target gay and transgender
people within the TLGB group.
ACE Europe-ETC Crystal /Evaluation HIV and AIDS program of Hivos /Final evaluation report pag. 69/176
and started to invest in a PPTCT program (prevention of parent to Child Transmission) when
they realised that married women seemed to be particularly vulnerable for HIV infection.
In Peru, partners are more talking about sexual diversity instead of gender diversity and as
such have enlarged the concept of gender. However unequal power relationships are not
systematically addressed. Specific projects are developed targeting men or women.
When it comes to defending human rights and addressing stigma and discrimination, the
characteristics of the subgroups (target group of each partner) are taken into account, rather
than making a distinction between specific concerns of men or women. Most of the partners
make a link between HIV and Sexual rights, mostly focussing on sexual and reproductive rights
of women. This causes frictions between female transgender and women, each of them having
a different agenda when it comes to human rights.
Apart from the specific target groups of key affected people, several partners implement
programs to reach out to women living with HIV although partners in Peru mentioned that this
group is often neglected by donors as HIV/AIDS programs dealing with a concentrated
epidemic usually do not focus on women. Prosa and INP+ being organisations of PLHIV do
include women living with HIV in their programs. However, at INP+ the majority of presidents of
the District Level Networks are male while the majority of the support group members are
female. At Prosa where most of the members are gay, the women support groups usually leave
the organisation once they have been established and capable to work independently.
5.3. EVIDENCE OF SIGNIFICANT CHANGES AT THE LEVEL OF BENEFICIARIES
(POSITIVE CHANGES REGARDING THEIR SEXUAL AND HUMAN RIGHTS)
Increased participation of PLHIV and key affected populations in advocacy and lobby –
all partners (IESSDEH to a limited extent) collaborate with CBOs of PLHIV and key affected
populations. As shown in table 13 partners in India and Peru have invested in informing their
target groups upon their rights and assisted them in claiming their rights. In the period 20002009 this resulted in an increased participation of PLHIV and key affected populations in
advocacy and lobby activities. At local level specific cases of rights abuse have been supported
and action has been taken by some of the collectives/CBOs with or without support of the Hivos
partners. However, the advocacy and lobby capacity of these CBOs is limited. Most of the
groups focus on their immediate needs36 (ex. to start income generating activities, to promote
health seeking behaviour). But examples have been seen of CBOs that do work from a rights
based approach and that collectively react on violations of rights (see example in table 13).
36
The evaluation of the EU-SOMOS project implemented by Via Libre concludes that the advocacy power of CBOs of
vulnerable groups is hampered by the fact that these groups often focus on immediate needs. As such these group rarely
take action to advocate for their rights. These CBOs do not use the ―rights language‖. The same observation could be
made by the evaluation team visiting Birds and INP+ ORISSA.
ACE Europe-ETC Crystal / evaluation HIV and AIDS program Hivos / Final evaluation report pag. 70/176
Decrease in incidences of violations of human and sexual rights of key affected
populations37 – not many official reports are available. There is anecdotic evidence (interviews,
MSC stories) of a decrease of incidences of violations of human and sexual rights but this is
limited to the local level and differs from one group to another (ex. PLHIV - gay experiencing an
improved respect for their human rights compared to sex workers and trans gender in Peru).
Overall stigma and discrimination persists but at local level some changes have been reported
after interventions of Hivos partners and the CBOs supported by them (see box on Sangram).
Sangram – decrease in violence against Female Sex Workers (FSW)
In India, staff of Sangram indicated that there is a decrease in violence against FSW. Since SANGRAM
has started to broaden the scope of its work to include issues around domestic violence in their District
campaign (HIVOS funded), the number of cases getting to them is on the increase. There are about 40-50
cases a month and SANGRAM tries to first address/solve the case at family- or village level and in cases
of serious harm, the police and lawyers are involved.
In Peru research has been done on the level of stigma and discrimination of key affected
populations by society in general and health facilities in particular. The most relevant studies
are executed by IESDDEH and RUNA38 (also Hivos partner, targeting in particular transgender,
training of police to prevent violence).The study of IESSDEH concludes that stigma and
discrimination attitude still exists at the health services and that specific needs of vulnerable
groups are not taken into account (Cáceres, 2009). Studies executed by Prosa39 (USAID
financed project, 2005) and Via libre40 (EU-SOMOS project, 2009) confirm these conclusions
and describe how stigma and discrimination is happening within families, communities and at
health centres. All studies show differences in level of stigma and discrimination according to
age, sex and region of the health workers. The evaluation team could not access similar reports
in India.
In both countries more cases of violations of rights seem to be reported41. An increase of cases
can be explained by the fact that knowledge of the vulnerable groups regarding their rights and
how to claim their rights has been improved (see box on the Ombudsman in Peru).
Ombudsman - Via Libre informing their target groups on their human rights
In Peru only 30 cases regarding discrimination of key affected populations were reported to the
ombudsman in the period 2002-2006. In 2007, the ombudsman started a project 42 to increase its own
capacity to address stigma and discrimination of HIV affected populations and started to promote its
services in the regions. They collaborate with NGOs, amongst them Via Libre, to inform key affected
populations on their rights and the role of the ombudsman in protecting them. As a result, the
Ombudsman did receive more than 100 cases only in 2007 (mostly cases on discrimination by health care
workers).
37
Violations of human and sexual rights are linked to stigma and discrimination and to violence against key affected
populations (by Hivos program and their partners).
38
RUNA is patrner of the Hivos Human Rights program
39
Diez Canseco Montero, F. (2005) Estigma y discriminación: la mirada de las personas viviendo con VIH/SIDA en el
Perú. Lima, USAID (proyecto Policy).
40
Ccapa Quispe, A. & Lescano Morales, A. (2009) Estudio exploratorio sobre estigma y discriminación en poblaciones
claves. Lima, Via Libre.
41
This is not an indicator for increased violence of human rights but an indicator of increased claim making power of the
vulnerable groups.
42
Funded by UNDP and UNAIDS
ACE Europe-ETC Crystal /Evaluation HIV and AIDS program of Hivos /Final evaluation report pag. 71/176
Target groups feel their rights respected – based on the focus group discussions and the
most significant change stories collected, target groups of the Hivos‘ partners have reported an
improvement of the respect of their rights at family and community level, health facilities and
police.
India – The majority of the significant change stories collected by the Hivos‘ partners in India
mention the importance of the formation of groups and the ability to fight for their rights
collectively as the most significant changes that occurred in the lives of the key affected
populations.
Throughout all stories the evaluation team reads that beneficiaries have gained understanding
of their rights (leading to increased self confidence), understand better the legal process, how to
deal with police harassment and how to deal with the media. With the support of their
collectives, actions have been taken towards police stations, local governments and/or health
centres to fight violence, stigma and discrimination. Successes of these actions have been
reported. Some examples: the FSWs and collectives (Sangram) reported a past where there
was a lot of harassment by the police, raids against the FSW, arrests, violence while
imprisoned (verbal abuse, stealing their money and jewellery), forced testing. The police raids
have reduced (example see box Siaap).
SIAAP successfully lobbied for a government order which ruled that the police should punish the trafficker,
not the sex worker. With this government order in hand, many of the FSW now feel empowered to go to the
police station and get their fellow FSW out. SIAAP also helped file a petition against rowdies (gangsters)
who used to harass the FSW, rape and steal from them and sensitised the police on this problem. FSW
indicated that the harassment of such men decreased accordingly.
Further, the most significant changes reported by the beneficiaries are related to increased self
confidence and self-dignity (SIAAP and
INP+ Orissa), the collectivisation (Sangram) and
improved living conditions (Birds). Most important changes are situated at the family and
community level. Through participation at services of the Hivos partners and at the collectives,
the economic independence of beneficiaries has made significant changes to their social status
and recognition. This resulted in increased respect from their families and the larger
communities and less stigma and discrimination.
Peru – the culture of collectivisation as exists in India does not exist in Peru. For example,
PLHIV do not attend the GAMS (support groups at the health facilities) any more as compared
to the period before the TARGA program. By consequence claiming rights collectively is limited.
According to Prosa43 there is also a fear amongst PLHIV that their situation will become worse if
they advocate for their rights towards politicians or directors of health facilities.
Although limited, the importance of setting up and strengthening CBOs and the role they have
in collectively defending their rights have been mentioned several times as important changes
in the lives of the people that recorded their stories. Not much evidence regarding human rights
43
PLHIV fear that if they claim for better attention, staff of health facilities will treat them worse in the future.
ACE Europe-ETC Crystal / evaluation HIV and AIDS program Hivos / Final evaluation report pag. 72/176
respected came out of the analysis of the stories. However, many stories collected refer to
increased insight in own discriminative attitudes (by activists and peer educators), increased
understanding of discrimination and increased respect for sex workers and PLHIV. Youth,
PLHIV and sex workers reached learnt about their human and sexual rights, how to defend
them, how to demonstrate and advocate the Ministry. Changes regarding increased self esteem
and confidence have been reported by members of Prosa.
5.4.
ASSESSMENT OF THE ACHIEVEMENTS
A UNAIDS publication44 describing case studies of successful programs on HIV related stigma,
discrimination and human rights violations describes that programs that have addressed AIDS
related stigma and discrimination tend to have been of three broad types: (1) stigma reduction
approaches (frequently consisting of community based prevention and care programs); (2)
specific antidiscrimination measures (often focused initiatives in institutional settings such as
health care centres and workplaces) and (3) redress mechanisms (using legal means to
challenge discrimination). Often these three approaches are combined, which is proven by the
practice of the partners visited. The UNAIDS publication describes several key principles of
success. We highlight some of them as they explain the level of effectiveness of the programs
of the Hivos‘ partners.
Redress mechanisms – A rights based AIDS approach offers powerful instruments with which
to combat discrimination in institutional settings. Hivos‘ partners have effectively contributed to
the development of such rights based approaches. However, antidiscrimination laws, policies
and codes of professional ethics will remain ineffective in the absence of mechanisms for
redress in circumstances where violations occur. Legal AID institutions and lawyers‘ collectives
specializing in AIDS (such as the lawyers‘ collective45 in India) have a critical role to play in
ensuring the enforcement of human rights and in tackling instances of discrimination and
human rights violations. Support is also needed to establish community based legal services to
tackle discrimination and human rights violations. As the UNAIDS report states ―training
schemes to develop the capacity of such organisations to provide in house para legal
counselling and advice is likely to increase the access of PLHIV to legal protection.‖ Evidence
of such an approach has been noticed in India but is absent in the HIV/AIDS program in Peru
(leading to a situation of impunity).
Cross-sectoral approach - Individuals experience stigma in many different settings. Multi
sectoral programs which target multiple contexts of stigma and discrimination and create
alliances across different sectors of civil society may increase the sustainability of the response
to discrimination. Stigma and discrimination need to be tackled not only in relation to AIDS as
AIDS related stigma reinforces existing inequalities. All Hivos partners address inequalities of
44
UNAIDS (2005) HIV related stigma, discrimination and human rights violations. Case studies of successful programs.
UNAIDS best practice collection. Switzerland.
45
Not a partners of Hivos
ACE Europe-ETC Crystal /Evaluation HIV and AIDS program of Hivos /Final evaluation report pag. 73/176
sexuality but the link between social inequality, gender inequality and inequalities in wealth is
weak and not much cross-sectoral alliances are formed (ex; human rights, health, education,
etc). The stories collected amongst the beneficiaries of the Hivos‘ partners show that improved
economic independence of PLHIV contributed to reduced stigma and discrimination at family
and community level as this improved economic situation contributes to significant changes to
their social status and recognition. However, no strong links could be noticed with economic
empowerment programs and organisations of Hivos or other NGOs in the region.
Training - Participatory training (on human rights, stigma and discrimination, HIV literacy, etc.)
at community level can encourage people to challenge the accumulated and often
unquestioned beliefs that reinforce stigma. All partners implement successfully training
programs targeting key affected populations and their relatives at community level, peer
educators and health care workers in order to question their own attitudes of stigma and
discrimination. Research suggests that people do not always know they are behaving in a
stigmatizing way. This has been experienced by Via Libre while conducting a study on stigma
and discrimination resulting in a conclusion that there was no discrimination. Via Libre
acknowledges the importance of appropriate methodologies to study attitudes of stigma and
discrimination. However, not much exchange of tools, methodologies and experiences between
Hivos partners and between Hivos partners and human rights organisations could be noticed.
All partners conduct separately studies on stigma and discrimination. The study of UNAIDS
emphazises also the importance of participatory awareness-raising to bring unintended effects
of people‘s practice to their attention.
The project of the IESSDEH (cuidadaniasX) gives
evidence for this statement though their outreach still is limited (pilot project).
Specific anti-discrimination measures – several Hivos partners try to have influence on the
policy of health care centres and police stations. Apart from bringing cases to court,
participatory approaches have been developed to install anti-discriminative measures at health
facilities and police stations, supported by investing in training of health care workers and police
officers. Here mixed results have been reported. The focus of the partners‘ intervention is often
on low level management and practitioners. It seems difficult to access higher level
management and to bring about structural change in the policy and practice regarding stigma
and discrimination of these health facilities and police stations.
Stigma reduction approaches in community based prevention and care programs – all partners
involve PLHIV and peers in their programs. The active involvement of PLHIV in prevention and
care programs can encourage greater community acceptance of PLHIV by promoting a better
understanding of their situations; reduce self-stigma by increasing the confidence of PLHIV and
encourage further disclosure of a seropositive status by promoting openness and discussion
around HIV/AIDS. In particular the MSC stories give evidence of such an approach.
ACE Europe-ETC Crystal / evaluation HIV and AIDS program Hivos / Final evaluation report pag. 74/176
6
Improved access to equitable, non-discriminatory
HIV prevention
Prevention is considered key in halting the spread of the disease among the population and in
diverting trends in the epidemic. Becoming aware of the risks of HIV transmission is as
important as understanding the consequences of HIV/AIDS.46 In the 2001 Hivos HIV/AIDS
policy ―prevention, awareness and information‖ is one of the four strategic areas. In countries
with a concentrated epidemic focus is on targeting prevention to key affected populations,
including PLHIV, MSM, transgender, sex workers, women, teens and young adults. Women
disappeared as a specific target group in the 2010 policy. To improve access to HIV prevention
partners are supported in providing HIV education and in advocacy and lobby activities to hold
governments and health care providers accountable for effective HIV/AIDS prevention.
A review held in preparation for the new Hivos policy (2010) indicated the need for increased
involvement of PLHIV and youth in prevention activities. The focus on advocacy and lobby and
not on implementing HIV prevention activities) is more prominent in the 2010 HIV/AIDS policy. It
is stressed that implementing HIV/AIDS prevention preferably is supported when it is about
developing and systematising innovative HIV prevention tools and strategies and about
campaigning against AIDS education on abstinence and faithfulness.
The following judgement criteria have been assessed.
Judgement criteria
Indicators
1. Nationwide coverage of equitable and non-
1.1. National HIV prevention programs and policies
discriminatory HIV prevention
in place, and campaigns adapted to specific target
groups / Agenda setting regarding equitable and
non-discriminatory HIV prevention services
1.2. Equitable access to non-discriminatory
HIV/AIDS prevention services / SRH services
which take into account special needs of key
affected populations (# key affected populations
reached by quality, non-discriminatory HIV/AIDS
education, including VCT services for sex workers,
youth and LGBT)
2. Partners advocate for/implement equitable, non
2.1. Partners provide/advocate for equitable, non-
discriminatory HIV prevention
discriminatory HIV prevention (agenda setting of
equitable/non-discriminatory HIV prevention)
2.2. Partners strengthen CSOs in HIV/AIDS
education (and the use of evidence based
prevention models and /or innovative IEC models),
particularly for excluded groups
46
Hivos Policy Document on AIDS and Development Cooperation 2001
ACE Europe-ETC Crystal /Evaluation HIV and AIDS program of Hivos /Final evaluation report pag. 75/176
2.3. Gender dynamics of key affected populations
have been taken into account while implementing
equitable, non-discriminatory HIV prevention
3. Significant changes/increased access of key
3.1. Key affected populations experience improved
affected populations to equitable, non
access to non-discriminatory HIV prevention
discriminatory HIV prevention
3.2. Target groups involved in the development of
non-discriminatory HIV prevention information and
services
6.1. NATIONWIDE COVERAGE OF EQUITABLE AND NON-DISCRIMINATORY HIV
PREVENTION
In both countries a legal framework exists to develop and implement HIV prevention campaigns
and health preventive packages for vulnerable groups (including VCT services, availability of
condoms, PMTC, etc).
The policy framework for the National AIDS Control Program in India is anchored in the National
AIDS Prevention and Control Policy (NAPCP) of 2002. The focus of the earlier rounds of the
government national AIDS control program and the current one is on HIV prevention. The
subsequent national AIDS Control programs have become more decentralized with improved
surveillance and reach across the country. Newer data has also affected the response. The
primary goal of NACP-III (2007-2012) is to halt and reverse the epidemic in India over the next
5 years by integrating programs for prevention, care, support and treatment. This will be
achieved through (1) saturation of coverage of high risk groups (including sex workers and their
clients, long distance truckers, migrant workers, IDU) with targeted interventions and (2) scaled
up interventions in the general public with a focus on young people, women and children
affected by HIV/AIDS. The emphasis of NACP-III is on raising awareness amongst key
populations and the general public through media campaigns in different states and through
interpersonal communication (ex. peer education).
The national AIDS control program is being implemented in the country but confronted with
several bottlenecks as mentioned by the stakeholders interviewed: (1)
Stigma and
discrimination by health care providers continues at health facilities hampering vulnerable
groups to attend health services; (2) Turnover of health staff hampers the proper capacity in
provision of SRH and HIV related services; (3) equipment for STI screening in MSM is available
at the clinics but not being used by all doctors, etc. NACP-III includes a strategy to have
community counseling and testing centres in each district with the aim of bringing such facilities
closer to all section of the population. The latest UNGASS progress report for India (2010)
indicated that in 2009 alone, 9 million HIV tests were carried out. Yet, it does not specify
whether it has been able to reach the key affected populations with this strategy.
ACE Europe-ETC Crystal / evaluation HIV and AIDS program Hivos / Final evaluation report pag. 76/176
The number of people tested has increased from 4 million in 2006 to 7,3 million in 200747. By
2008, 10,1 million were tested which was further scaled up by 3 million to reach a total of 13.4
million in 2009. This significant increase was possible due to the concerted efforts of NACP III
to address certain barriers such as timing of ICTC, staff attitudes towards high risk groups,
inconvenient location of testing facilities. Counseling and testing services are expanded to 578
Primary Health care Centres through integration with NRHM (national Rural Health Missions) in
rural areas of the high prevalence districts.
In Peru, several laws regulate HIV prevention activities (since the nineties), in particular
targeting MSM and sex workers. Transgender (within that group focus on sex workers) have
only been included as a risk group since the last 5 years.
Sex workers have to attend regular
medical care (Atención Médica Periódica) which include STI and HIV prevention. A system of
peer educators was set up, attaching peer educators from within the specific target groups at
the health centres. Several laws and ministerial resolutions have been adopted since then, to
regulate the right of key affected populations to HIV prevention (Ley 28243 contrasida (1997
and 2004), Plan nacional concertado de salud 2007-2020; Norma tecnica para la prevención de
la transmission vertical de VIH 2007, Plan Estrategico Multisectorial 2007-2011). A specific
ministerial resolution (rm 242-2009) regulates the distribution of condoms in the health centres.
With the revision of the AIDS law in 2004, HIV testing became obligatory for pregnant women.
The ―Plan Nacional de Acción por la Infancia y la Adolescencia 2002-2010‖ plans to reduce HIV
infection amongst adolescents with 50% and target that 100% of adolescents in secondary
schools need to have gained knowledge on HIV/AIDS and STI prevention through sexual
education.
The approach to prevention is very bio-medical and focuses on peer educators, condom
distribution, prevention of vertical transmission and VCT. Specific centres (CERITS) have been
created all over the country to manage STI and HIV prevention and treatment.
No large
prevention campaigns are planned and as such HIV prevention is hardly visible in the street
and media. Since 2004 most of the prevention activities are funded through the Global Fund
with several civil society organisation implementing prevention campaigns targeting specific key
affected populations.
According to the study on the impact of Global Fund in Peru, executed by IESSDEH, several
bottlenecks regarding access to and quality of prevention persist. Amongst others the following
problems have been described (Cáceres, 2009, p.90): (1) Specific needs of key affected
populations (MSM, transgender or other groups) are not always taken into account. Services do
not take sufficiently into account socio-cultural characteristics; (2) level of discrimination in
health centres, (3) prevention materials developed by government and civil society targeting
key affected populations still include messages that stigmatize PLHIV and are often desinforming. The quality of the specific service ―Atencion Medica Periodica‖ (including distribution
of condoms) targeting sex workers has been assessed by the sex workers interviewed as of
good quality in Lima and Chimbote and bad in Iquitos. However in the three cities there still
exists barriers to access AMP: (1) the focus of AMP is on sex workers and not on the whole
47
UNGASS country progress report on India 2010
ACE Europe-ETC Crystal /Evaluation HIV and AIDS program of Hivos /Final evaluation report pag. 77/176
population of MSM and bisexual people; (2) no uniform costs; (3) quality of service depends
very much on the personality of the health worker and is better for sex workers as compared to
transgender (4) the attending hours are not adequate, (5) not accessible by minors, (6) though
the costs to access AMP is low, several sex workers do not manage to pay these costs, (7) a
barrier accessing AMP is also the low level of self esteem and des - information of the sex
worker herself.
In India and Peru HIV prevention is marginally linked to sexual and reproductive health and in
both countries it is problematic for youth to seek confidential and appropriate information
regarding their sexual and reproductive health and HIV. In India, there is a national program on
adolescence education which covers sexual health and HIV but there does not appear to be a
linked intervention to the provision of sexual and reproductive health services especially for the
unmarried young population. There was a backlash on this program and there was a ban in a
few states because of the ―graphic material‖. This has been re-worked and toned down for
wider acceptance. The program is in the process of trying to overcome these obstacles. In
Peru access to sexual and reproductive health services by minors is hampered by the fact that
they need to be accompanied by an adult48.
6.2. PARTNERS CONTRIBUTE TO EQUITABLE AND NON-DISCRIMINATORY HIV
PREVENTION
Partners implement equitable, non discriminatory HIV prevention – all partners visited
implement prevention activities (partially with Hivos funds, partially with funds from Global Fund
and other donors). HIV prevention constitutes an important part of the programs of the Hivos
partners. None of the partners use the ABC strategy. They speak openly about condom use
and break taboos in their information materials.
All partners develop IEC materials (Information, Education and Communication materials). Four
organisations (Via Libre, Prosa, Siaap and Birds) train HIV counsellors (volunteers, own staff
and public health care workers). In the case of India, Siaap (and Birds being part of the Siaap
counselling training program) managed to put these trained counsellors in the public health
facilities. All partners (except IESSDEH) invest in training of peer educators who give HIV and
STI information and who refer people to testing centres. In India peer educators are formed
within the collectives. Via Libre organises own VCT services (in house and mobile). Stimulating
people to go for testing has increased since the ART roll out programs (around 2004).
Sangram, INP+ Orissa, Via Libre and Aid for Aids implement larger school and/or youth
programs.
The Hivos HIV/AIDS policy paper does not explain what is meant by ―innovation‖. The annual
reports of the partners do not report on innovative approaches and in the interviews with the
48
In 2009 the regional governments of Ucayali and lambayeque have adopted regional laws that tackle this national law
and permit minors to attend SRH services without an adult.
ACE Europe-ETC Crystal / evaluation HIV and AIDS program Hivos / Final evaluation report pag. 78/176
partners no information was given on innovative approaches. All Hivos partners are
implementing HIV prevention activities targeting key affected populations and as such
complement government prevention initiatives to effectively reach key affected populations.
Table 14: Overview of the prevention activities of the partners and their coverage
Partner
output
Coverage and results49
SIAAP

Training module on counseling for HIV
500 counsellors trained
testing, including sections on HIV
Trained counsellors mainstreamed
prevention and non-discriminatory
into the public health system
messages


Certified as an a-grade training
institution
No data on number of people
Support to SMIS (Selvi Memorial) which
making use of the SMIS
is a centre in Chennai where people can
stay while being prepared for HIV testing
at a nearby hospital (need for a place to
stay because of long distances and
travelling).

52 youth friendly counselling centres set
up in rural areas across 13 districts of
Tamil Nadu
Sangram

Promotion of VCT (since 2004)
VAMP and MUSKAN (collectives of

use of a variety of IEC materials such as
sex workers) –
posters for exhibitions at weekly
reached
markets, community video‘s, flipbooks,
SANGRAM Plus – Through regular
cards with pictures and brochures.
follow up visits 1640 including male,
sexuality education and sharing HIV
female and orphaned children

prevention information with adolescent
girls and boys at youth festivals and
other forums.

5500 members
SANGRAM Plus – Women‘s
support group – 463 women
Theatrical project entitled – The struggle
to be Human (2008-2009, specifically
with Hivos support)
INP+ Orissa

school programs

media activities (incl. radio station)

various types of events

No data easily available
positive speaker‘s bureau (speakers can
be called in to speak at various venues
such as schools, banks, etc.)

outreach workers at DLN provide
counselling and refer people to ICTC for
testing
49
Data in the annual reports are not complete and lacking for several years. The data in the table are above all
indications. One or two years are taken as example.
ACE Europe-ETC Crystal /Evaluation HIV and AIDS program of Hivos /Final evaluation report pag. 79/176
Birds

trained counsellors (SIAAP program)

support to collectives (see further)
Number of direct beneficiaries per
year (FSW)
2000 – 4168
2001 – 4431
2002 – 4585
2003 – 10090
2004 – 13155
2005 – 14620
2006 – 18987
2007 – 25795
2008 – 34163
2009 - 36414
Via Libre

VCT services (in house) and mobile

VCT (since 2007, financed by the EU
Referrals: 30.567 MSM (incl.
transgender) and 28.242 sex
project)
workers (2008)

VCT: 879 (2007) – 26.119
(2008)

Training of peer educators

Peer educators: 176 MSM and
64 sex workers (2008)


Production of information materials
- 40.897 persons reached with IEC
(leaflets, brochures, video, posters, etc)
materials (including website) (2007-
Condom use demonstrations (in streets,
2009)
disco‘s, sauna, etc) and condom

Prosa
distribution
- HIV/AIDS education for 500
Specific projects targeting women and
teachers, 100 educationalists, 150
youth (other donors)
parents and 100 youngsters (2008)

Training of peer educators
Since 2000 PROSA collaborates

Production of information materials
and trains a group of 6 peer
(leaflets, brochures, video, posters, etc)
educators and an average of 10

Condom distribution
peer counsellors per year.

Observatorio de la mujer (since 2008):
58 women trained, leaders of
development of information materials on
organisations
Focus on PLHIV (MSM, women)
AfA
HIV and SRH

Youth project (since 2006): training of
# schools with 10 to 15 peer
peer educators, development of
educators in each school (no info
information materials and video,
on number of schools participating)
activities in schools and at public events
According to the annual reports, the partners reach their target groups and realized the targets
set. No information is available on the results of the prevention activities (apart from people that
come for testing) such as condom use, increased HIV knowledge and changed behavior. Some
partners started to collect these kind of data since 2008 (see further under 6.3.).
ACE Europe-ETC Crystal / evaluation HIV and AIDS program Hivos / Final evaluation report pag. 80/176
Partners advocate for equitable, non discriminatory HIV prevention – No evidence has
been found of an elaborated advocacy and lobby strategy to hold governments accountable for
effective, equitable and non discriminatory HIV prevention. Lobby activities are usually done
through participation of partners at fora of civil society and (regional) governments to give input
into law development and development of national HIV/AIDS programs, addressing the rights of
key affected populations. Most of the advocacy and lobby is linked to addressing stigma and
discrimination attitudes (see also EQ. 1). To that end, partners (Siaap, Sangram, INP+ Orissa,
Via Libre and Prosa) also invest in raising awareness of health care workers on stigma and
discrimination and in training them how to take into account the specific needs of the key
affected populations, including needs related to HIV and STI prevention (see example Siaap‘s
counselling program in box).
SIAAP – advocating for improved qualitative counselling services in public health facilities
SIAAP‘s focus on making counselling services available in India facilitated the access to testing for both
key affected populations as well as the general public. SIAAP saw this as the vehicle to introducing HIV
testing to the population. In this, they have positively influenced the government‘s prevention program in
India, both in quality of services as well as towards the inclusion of key affected populations. The
placement of community counsellors has also assisted in improving access of preventive services for key
affected populations. These counsellors are the bridge between the community and the available services.
In our discussions with the former director of SIAAP, her disappointment (even calling it a failed
intervention) of sustaining the quality level of counselling in the public system was evident. The quantitative
targets imposed since by government are prohibiting the trained counsellors to do a proper job.
Advocating for equitable and non discriminatory prevention consists mainly in specific protest
actions in cases of violation of rights to access prevention (ex. actions against mandatory
testing) and in monitoring availability of ARVs, condoms, etc. in health care centres (in Peru
called vigilancia social).
Table 15: Overview of the output of the partners and results reported regarding
advocacy and lobby
Partner
output
SIAAP

Results
Sensitization of health facilities to open
up preventive services for key affected
populations

Advocating against mass testing in
TANSACS
health facilities and violations of opting-
testing
stopped
this
mass
out method in PPTCT settings

Several advocacy and lobby campaigns
Filing of 39 cases of violence

Formation of National forum for sex
against sex workers with evidence
worker

Formation of Joint Action Committee to
stop unethical testing
Public hearing on violence against
sex workers
ACE Europe-ETC Crystal /Evaluation HIV and AIDS program of Hivos /Final evaluation report pag. 81/176

Studies on lubrication for condoms for
MSM, Condom quality, Discrimination of
PLHA in government hospitals,
Sangram

Placing own health workers in PHC
Beneficiaries interviewed testified
clinics to influence the government to
that quality of service has increased
stop mandatory testing and pressing
in those hospitals that were
women to abort their child once HIV+.
targeted by Sangram.
These health workers also provide
information to the women and do follow
up visits in their homes

District Advocacy Campaign for
District
prevention of HIV and reducing violence
people in 713 villages
Campaign
–
2.500.000
against women
INP+ Orissa

Advocating with OSACS on needs of
No data on results
PLHIV

Reduction of Stigma and Discrimination,
Interface conducted with Governor of
Orissa

District Level Sensitization programs
conducted for Doctors and Paramedics
of District Head quarter Hospitals in
Orissa on HIV

District Level Sensitization programs
conducted for employees of the 13
District Health Hospitals, 3 Medical
Colleges and Capital Hospital

―Standing Right Next to You‖ Case
studies documented and published in
collaboration with the partners

Advocacy on GIPA – State level
Consultation on GIPA organized
Overview of all campaigns not complete,
several campaigns have been organised
Birds

Advocacy with health department to get

permission for placement of counselors

Counsellors placed in the
health departments
Advocacy with Karnataka state AIDS
Prevention Society to appoint project

counsellors as counsellors in VCT
Counsellors appointed in
VCTCs
centres

Advocacy with health department for
constant and uninterrupted supply of

Condom supply improved
condoms for women in sex work and
their CBOs

Advocacy with medias and lawyers to
provide support services for activities of

Media and lawyers support
FSWs collectives increased
sex workers collectives
ACE Europe-ETC Crystal / evaluation HIV and AIDS program Hivos / Final evaluation report pag. 82/176
Via Libre


Advocating for the right of youth to have
Proposal of law taken up by Red
access to information about their SRH
Sida. Not much room for
and HIV (formulation of a proposal of
manoeuvre at the national level
law, organisation of mesa de niñez y
(conservative congress) but taken
VIH), in collaboration with Red SIDA
up at regional level (with success in
(ongoing)
two states)
Project on co-infection TB and HIV
(2007): organisation of a conference with
participation of politicians
Prosa


Monitoring availability of condoms
Follow up given by health centres
(continuously)
or MINSA (individual cases)
Participation at the Red Sida (right on
See Via Libre
SRH services for youth)
IESSDEH

Study on the effect of Global Fund that
Report published and discussed
includes prevention activities addressing
with policy makers
the needs of key affected populations by
state and civil society (2007)
AfA

Peer educators in school monitor the
Just started
implementation of the law on SR
education (since 2010)


―Observatorio de la mujer‖, monitoring
- report drafted that analysis the
the implementation of laws that address
quality of sexual and reproductive
the vulnerability of women towards HIV
health services and the attention
and STI (including prevention and
given to HIV. Report just finalised.
control of STI and HIV), since 2008
Will be presented at policy makers.
Participation at the Red Sida (right on
SRH services for youth)
- See Via Libre
Partners strengthen CSOs in HIV/AIDS education, particularly for excluded groups –
Hivos‘ partners mainly reach the key affected populations through the CSOs formed and/or
strengthened. These CSOs are supported with IEC materials, received training on HIV
education and/or peer educators and counsellors are trained. Particularly in India these CSOs
have taken up an important role in stimulating health seeking behaviour of their members
(informing them on HIV and STI, providing condoms, stimulating to go for testing, referring
people to the appropriate centres, etc). Peer educators interviewed confirmed that during the
training received power relations, sexual diversity and taboos were openly debated.
In Peru, all partners (except IESSDEH) mainly organise workshops on HIV education for
leaders and members of CBOs and their families. All of them support CBOs with organisational
development and strategic planning but only AfA has a strong focus on stimulating women
organisations to include HIV prevention in their activities. Via Libre and Prosa supported CBOs
to develop their own annual plans but focus of these plans seem to be rather on looking for
solutions for immediate needs than on implementing prevention activities.
This has been
explained during restitution as follows: (1) Hivos‘ partners do not want to impose an agenda on
ACE Europe-ETC Crystal /Evaluation HIV and AIDS program of Hivos /Final evaluation report pag. 83/176
the CBOs; (2) Key affected populations (sex workers, transgender) seem not to recognize their
vulnerability for HIV/or have other priorities (confirmed by leaders of these CSOs that have
been interviewed); (3) CBOs of transgender and sex workers do not want to be linked to HIV.
Gender – In all the prevention activities (from developing IEC materials to organising VCT,
training counsellors or promoting health seeking behaviour) characteristics of each specific
target group the partners are addressing, are taken into account. For example, Via Libre has
analysed its education material in focus groups and adapted according to the recommendations
formulated. In its education programs toward youth, partners address unequal power relations
and sexual diversity (ex. Sangram, Aid for AIDS, Via Libre).
Specific measures have been taken to address the needs of women in particular. Several
partners are promoting the female condom (ex. Via Libre, Aid for Aids, Sangram). In India, the
concept of ―prevention of mother to child transmission‖ changed towards ―prevention of parent
to child transmission‖ acknowledging the responsibility of both men and women. The Hivos
partners use the same concept. Siaap started to integrate broader sexual and reproductive
health issues in the training program of the (community) counsellors. Sangram took specific
action to reach out to wives of clients of sex workers. In Peru the law foresees mandatory
testing of pregnant women, the same exist in some states in India. Partners have not taken
action yet to address this issue. The evaluators explain this by the fact that the general group of
women is not part of the partners‘ core target groups.
6.3. SIGNIFICANT CHANGES AT THE LEVEL OF THE BENEFICIARIES / INCREASED
ACCESS OF KEY AFFECTED POPULATION TO EQUITABLE AND NON DISCRIMINATORY
HIV PREVENTION
Target groups involved in the development of non discriminatory HIV prevention
information and services – All partners involve – in varying degrees- affected and infected
populations in the design of prevention materials (sometimes also in the design of programs).
The Global Fund has taken up a leading role by imposing involvement of PLHIV in coalitions
that apply for GF funding. In Peru for example, the Global Fund implementers took the initiative
to involve the most affected populations in the design of prevention materials and to test the
materials with them (ex. through focus group discussions). Via Libre has executed a specific
research on the use of videos and lessons learned have been incorporated in the development
of new IEC materials. In India, much information and awareness raising materials are being
developed by the collectives of PLHIV themselves. As described above, all partners train peer
educators and peer counsellors, peers selected from within the vulnerable groups.
Key affected populations experience improved access to non discriminatory HIV
prevention – The figures presented in 6.1. show an improved general access to prevention
services. Regarding VCT Hivos ‗partners contributed, in particular, by referring (informing,
stimulating, supporting people to go for testing) their target groups to the public health centres
(see results described in the above). The role of Hivos‘ partners is important in reaching key
ACE Europe-ETC Crystal / evaluation HIV and AIDS program Hivos / Final evaluation report pag. 84/176
affected populations with appropriate HIV information. All people interviewed underlined the
added value of civil society in reaching these specific groups, including youth. Groups that are
difficult to reach by government as government is not implementing adapted prevention
campaign for each of the specific target groups and prevention activities remain very biomedical (focus on testing, STI screening and PMTC). Quality of the public services however
remains questionable (long waiting lists, problems with confidentiality, etc) .
Results regarding increased access to prevention are not reported in the annual reports (except
numbers of beneficiaries reached) nor have results of HIV prevention been documented
(attitude and behaviours change). The MSC stories give evidence of increased knowledge but
only a few mention behavioural change. Based on focus group discussions and results of most
significant change stories the following changes can be listed.
India – The FSW and MSM, the evaluation team talked to, did indicate that there is now greater
access for them to health care. The SIAAP counsellors in the community as well as those
placed in the health facility have accommodated this to a great extent and assisted them to
access testing services. The number of places where testing facilities are available have
increased in several states (like in Orissa), yet bottlenecks such as absence of counsellors and
lab technicians prohibit the full functioning of these centres, according to the DLNs (INP+
Orissa). PLHIV indicated that the presence of a SANGRAM health worker in PHC clinics as well
as the civil hospital has facilitated access for them to information, voluntary counselling and
testing.
The youth programs of Sangram seem not yet to have been able to make major changes. One
PHC doctor interviewed indicated she did have few boys (not girls) coming to the clinic for
condoms and/or screening, which was more than before, but still very limited. The youth itself
indicated there are still many inhibitions among them to seek services.
Several changes related to improved access to prevention have been mentioned by the story
tellers involved in the MSC exercise. However, these changes have never been selected as
being the most significant ones. Most significant changes are increased self confidence, gained
respect and the importance of the support received within the collectives. When analysing the
changes related to access to prevention, more than 50% of the story tellers indicated that they
have gained more knowledge on HIV and safe sex. Two story tellers also mentioned the fact
that men started to use condoms. The importance of being referred to clinics was also
mentioned. Another important change related to HIV education in the communities is related to
the reduced fear by community members because of gained knowledge on the disease,
changed attitude of family and community members.
Peru – an improved access to information, VCT services and condoms for key affected
populations has been reported by all stakeholders interviewed (through the public health
system and civil society) as compared to the situation in 2000 and even 2004. This change
seems to be obvious for MSM. Problems of stigma and discrimination of transgender and sex
workers hamper their access to health facilities (confirmed by Caceres, C. 2009). According to
PROSA, access to appropriate information and condoms is not officially monitored. Accessing
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condoms is forbidden for youth (not allowed without adult accompaniment) and sex workers
only receive a limited amount of condoms a month via the CERITS.
The system of PEP (Promotores Educadores de Pares) makes peer educators available who
are linked to a hospital but who also reach out and visit key affected people at home, giving
information and stimulating them to come for testing and counselling. These peer educators are
selected from within the key affected populations. The study of
IESSDEH mentions that
indeed the older system of PEP has been revitalized but that the problems that have existed
since long, keep on existing, like inability to adapt the system to the needs of specific vulnerable
groups, biomedical focus, lack of an information and educational component. This has been
confirmed in a focus group with transgender and MSM who informed us on the challenges of
the PEP system: (1) in some hospitals the system of PEP is not introduced. Management do
not see the need for additional staff as they have already psycho-social workers in the centre.
(2) in some regions PEPs are not selected from within the community hampering a swift access
for key affected populations in that particular community (geographically linked).
The most significant change stories collected by the partners in Peru indicate some changes
regarding HIV prevention. As three organisations train peer educators, stories also have been
collected from peer educators. They all told that they had gained knowledge on HIV, STI,
sexual and reproductive health and how to protect against STI and HIV. All peer educators
mentioned how important their work as peer educator has been for their personal development.
Peer educators feel satisfied being able to give appropriate information and in helping others.
Some of them have gained self confidence because of the skills learned in the training for peer
educators. Via Libre and PROSA also collected stories from PLHIV. The changes reported in
the Via libre stories are about increased access to testing (service provided by Via Libre). Half
of the stories collected by Prosa describe the importance of increased knowledge on HIV and
above all increased knowledge how to live with a positive diagnosis.
6.4.
ASSESSMENT OF THE ACHIEVEMENTS
The advocacy and lobby activities have contributed to the development of proposals of laws
and national plans that include the specific needs of key affected populations, including needs
regarding prevention. Implementation of these laws remains a challenge and several
bottlenecks in accessing equitable and non discriminatory prevention services continue to exist.
Hivos‘ partners are mainly documenting the gaps in implementation and respond to filling in the
gaps in the public system by providing qualitative HIV prevention themselves. Doing so, they
facilitate an increased access to qualitative and non-discriminatory access to prevention.
Specific advocacy and lobby targets regarding HIV prevention are hardly included in program
objectives, results and indicators of the partners‘ programs.
Effective lobby at national level is rather difficult in both countries. In India all major decisions
are centralized in New Delhi which makes it difficult for Hivos partners who are based in other
states, to have an influence on the central decision making process. Lobby is evidently
ACE Europe-ETC Crystal / evaluation HIV and AIDS program Hivos / Final evaluation report pag. 86/176
channeled through networks Hivos‘ partners participate in (see EQ 1). In Peru, the conservative
government makes it difficult to have a break through, for example in improving access of youth
to sexual and reproductive health services. Hivos‘ partners invest more time and energy in
lobbying regional governments (with some successes).
It is not clear to what extent innovative prevention approaches have been developed as these
are not documented. SIAAP has an experience with the training of counsellors (to increase the
quality of counseling that takes into account specific needs of key affected populations) that
have been absorbed by the public system. However, the counsellors feel that what they have
learnt cannot be implemented as there is a targeted approach (focus on quantity) for the
government as well as a lack of confidentiality.
As evidenced by several studies (UNAIDS, HIV related Stigma, Discrimination and Human
Rights Violations, case studies of successful programs, 2005) decreased stigma and
discrimination have an influence on effective HIV prevention. All partners address issues of
stigma and discrimination, amongst their own staff and volunteers (peer educators) and in their
training activities of health care workers and counsellors. However, results are limited taking
into account the limited outreach and staff turnover at health facilities (problems with scaling up
training of counsellors). Hivos‘ partners succeed in delivering own equitable, non discriminative
and qualitative prevention activities improving access of key affected populations within their
intervention zone. They have also contributed
to the increased access of key affected
populations to prevention services organised by government by referring them to these services
and stimulating health seeking behaviour.
Access to information, condoms and VCT services by key affected populations is hardly
monitored, nor is there information on results of behaviour change. The MSC stories collected
did not give insight in changes at the level of responsible behaviour as most of the changes
reported by beneficiaries were not related to HIV prevention but more to empowerment.
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7
Improved access to quality treatment and care
Only 30 percent of the people who need AIDS medicines in developing countries receive them,
resulting in 5,700 AIDS deaths daily50. Although the majority of PLHIV do not receive medicines
and treatment, those who are MSM, sex workers or IDUs often have even more restricted
access due to discrimination and stigma. Over the past decade the notion to improve the
access to quality HIV/AIDS treatment and care has increased, however there is still a long way
to go towards universal access to such services. Under international pressures, an increase in
national responses is visible, given an increased public spending on HIV/AIDS and the
development of National AIDS Strategies and Policies, albeit their implementation is often
lacking because of weak systems to implement the actions.
Hivos is particularly alerted by the observed effect of increased access to treatment and care on
a decline in the willingness to continue the fight for inclusive services and non-discrimination.
As stated in the 2010 Policy document: ―the irony is that in some countries, as people obtain
treatment (e.g. Bolivia and Peru), they seem to relax their activism despite the constraints which
affect the sustainability and quality of the services and the pervasive homophobia which limits
their rights‖. Treatment becomes increasingly available; PLHIV live longer which in turn will
place increased demand on the existing services. The Hivos HIV/AIDS policy did not (2001) –
and does not (2010) – foresee partnering with organisations providing direct HIV/AIDS
(medical) services. Its focus has been on lobbying and advocacy for quality treatment and
services and increased access to them by key affected populations. As such Hivos has
supported organisations that are instrumental in reaching out to service providers to increase
their knowledge on key affected groups and their specific needs. In practice however, the
evaluation team could notice that several partners are involved in direct service delivery.
The evaluation questions have been assessed according to the following judgement criteria.
Judgement criteria
Indicators
1. Nationwide coverage of equitable
1.1. National HIV/AIDS programs, policies and guidelines to
and qualitative HIV/AIDS services
provide HIV/AIDS treatment and qualitative 51 care in place
(treatment and care)
1.2. Equitable access to quality HIV/AIDS services (treatment
and care) which take into account the special needs of key
affected populations (# key affected populations reached by
quality treatment and care)
2. Partners advocate for / implement
2.1. Partners advocate for / implement accessible52 and quality53
equitable and qualitative HIV/AIDS
HIV/AIDS services (treatment and care)
services
2.2. Partners strengthen local NGOs, CBOs and other relevant
50
Number of PLWHA receiving treatment in developing countries rose from 240,000 in 2001 to 3 million in 2008, but
nearly 70% of the people still do not have treatment (Hivos, 2010)
51 Meeting quality standards set by the government/national AIDS commission), accessible for key affected populations
52 Accessible: taking into account specific characteristics of a target group in particular like location, hours service is
offered, cost of the service, kind of service offered like combination of mobile VCT, Home based VCT, diagnostic VCT
53 According to the official quality standards
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service providers to take into account issues related to access of
key affected populations to care and treatment and issues
related to quality in their service delivery or advocacy activities.
2.3. Gender dynamics of key affected populations have been
taken into account while implementing specific HIV/AIDS
services
3. Secured and sustained access to
3.1. Key affected populations experience improved access to
quality HIV/AIDS services (treatment
qualitative HIV/AIDS services (treatment and care)
and care)
3.2. Participation of key affected populations in development of
(advocacy for) inclusive qualitative HIV/AIDS services
(treatment and care)
7.1.
NATIONWIDE COVERAGE OF EQUITABLE AND QUALITATIVE HIV/AIDS
SERVICES (TREATMENT AND CARE)
In both countries equitable and qualitative HIV/AIDS treatment and care are included in the
national AIDS programs (and in Peru regulated by several laws) to fight HIV/AIDS. Access to
treatment has substantially increased since the WHO launched the 3 by 5 initiative in 2003
which aimed to provide 3 million people living with HIV/AIDS in low- and middle income
countries with ART by the end of 2005. The initiative did signal the start of an impressive scaleup of ART services in the years that followed. In India and Peru, ARVs became available at
large scale since 2004.
India- the primary goal of NACP–III is to halt and reverse the epidemic in India over the 5 years
(2007-2012) by integrating programs for prevention, care, support and treatment. This will be
achieved through (apart from prevention) providing greater care, support and treatment to a
larger number of people living with HIV/AIDS. The Government has rolled out first line ART
drugs in some states and few states have access to the second line ART. ART for eligible
PLHIV was launched on April 1 2004 in 8 government hospitals located in 6 high prevalence
states. Since then, the program is scaled up both in terms of facilities for treatment and number
of beneficiaries seeking ART — especially in districts with a high number of PLHIV. First line
ART drugs are provided to PLHIV as per the WHO-NACO guidelines. Under NACP-III the
number of ART centres has expanded in the high prevalence states and districts to increase
outreach, where PLHIV can access ART services. As of January 2010, there were 239 fully
functional ART Centres against the target of 250 by March 2012. However, based on need and
demand for ART, the actual number of ART centres may reach 300 by the end of 2010. Also,
ART centres are supposed to be linked with Community care centres (CCC) established with
the mandate of providing a comprehensive package of CST services including psycho-social
support, ensuring drug adherence and providing home-based care.
NACO has developed various guidelines for standards of care with the support of its partner
organisations (like WHO and Pepfar). The guidelines include ART guidelines, guidelines for
prevention and care of opportunistic infections, HIV care and treatment in infants and children
ACE Europe-ETC Crystal /Evaluation HIV and AIDS program of Hivos /Final evaluation report pag. 89/176
etc. According to the UNGASS report on India, about 90.000 patients were on treatment in
March 2007 and 290.000 patients in November 2009. A lot needs to be done, taking into
account the estimate number of 2,4 million people living with HIV in 2009.
Peru – Before 2004 ARVs were only available in the health centres affiliated to the EsSalud
(accessible by public public servants, and the military and police health centres. A limited
number of HIV infected children were treated. The modification of the HIV/AIDS law in 2004
regulated the treatment of PLHIV. Several technical norms have been developed to regulate the
distribution of ARV. In 2005 the TARGA program, Tratamiento Antiretroviral de Gran Actividad,
was launched, resulting in the establishment of TARGA points all over the country. At the
beginning TARGA was concentrated in Lima, however in a short period other hospitals in cities
with high prevalence were included in the program.
This has resulted in an increase in uptake of ARVs. Up to 85% of PLHIV that need treatment
have access to ARVs (official numbers given by MINSA, 2007). The gap of the 20% can be
explained by (1) PLHIV not having somebody who accompanies him/her and support the
adherence to the program ; (2) ARVs are not given to alcohol addicts or drug users. Via Libre
participates in this TARGA program. Civil society organisations claim that the % is not correct
as monitoring capacity of the government is weak and the CSOs are convinced that there is a
group of unknown PLHIV that might need treatment.
Several technical norms regulate the quality of care. Integral health packages are foreseen in
the national guidelines that accompany the TARGA program. Quality standards are set out for
qualitative and integral care of PLHIV and specific manuals for peer educators in the health
centres have been developed by the government. However a debate is ongoing regarding the
notion of ―integral care‖ for PLHIV. Issues such as treatment of opportunistic infections,
treatment of side effects of ART, the need for additional nutritional support are not taken
forward yet by the government.
64 health facilities54 of the Ministry of Health are involved in the TARGA program (73% of the
total TARGA points). EsSalud covers 25 % and the remaining 2% is provided via NGO and
prisons. According to the UNGASS report on Peru of 2010 there following number of PLHIV
was on treatment: 3.216 in 2005 (34% female, 66% male); 6.298 in 2006; 10.367 in 2008 and
14.780 in 2009.
54
UNGASS report 2010 - Peru
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7.2.
PARTNERS ADVOCATE FOR / IMPLEMENT EQUITABLE AND QUALITATIVE
HIV/AIDS SERVICES
Partners implement HIV/AIDS treatment and care services – All partners (except IESSDEH
and INP+ Orissa) implement treatment and/or care services. Hivos‘ partners are active in a
broad spectrum of care services such as VCT; palliative care; Home Based Care (HBC);
organisation of peer support groups (PLHIV support, post test (youth) clubs); and support to
groups active in income generating activities. Half of them effectively offer own treatment and/or
care services and all partners have counselors and/or health workers amongst their staff to
support their target groups with qualitative counseling.
Apart from implementing own services, partners are above all stimulating health seeking
behaviour (giving information, informing target groups on their rights, referral to ART centres,
linking people up to nutritional support and support groups, accompanying when needed, follow
up of adherence to the program, etc). In India this is done via own health workers and the
collectives formed and strengthened; in Peru by the health workers within the staff and the peer
counselors and volunteers trained.
Table 15: Overview of the treatment and care activities of the partners and their coverage
Partner
output
Coverage
SIAAP


Not involved in implementing care and
Sarvojana project 2008-9: Result 1:
treatment programs (except training of
Mobilization of community to access
counsellors)
services of VCT
Total outreach done: 86.085
Total visitors to the centres who
availed various services
:16.688
Care and treatment activities
implemented by the Sarvojana project
Result 2 : Improved quality of
services in the project areas
Number underwent testing: 5.970
Number identified positive: 545
(9.13%)
Number referred to ART:566
Number referred for others:1354
Sangram

own counselling centre since 2001

mobile health clinic for truckers since
No data available
2003
INP+ ORISSA
Peer counselling supported in DLN
No data available
Birds
- training of community counsellors
Referrals to ART centres, not data
on numbers
Via Libre (since

1993)
Several services:
TARGA program since 2005

Consult HIV and STI

Nutricionist

Psychologist

Nurses

Social support
-
811 patients in treatment
(5% of TARGA population)
Several services:
-
1846 beneficiaries all
projects in 2007
-
304 beneficiaries (SOMOS
project, 2008)
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
STI counseling

Training of peer counselors55
Prosa (since 1991)
Numbers of PLHIV attending the
services, 2007 and 200856

Bio medical services (gynaecologist,
-
23-50;57-130
infectologist)

Nutritionist
-
196-142

Gym
-
37-913

Group therapy
-
196-604

Tai-chi and yoga
-
73-152

Massage
-
98-126

Psychologist
-
105-110

Social services
-
0-44
of which 30% women

Training of peer counsellors

Home based care
About 8 volunteers are attending 34
patients (20 men and 14 women) in
2006 and 31 clients in 2007
AfA

Import of ARVs that are not available in

the country (via the New York office)

Counselling of individuals and families
100 patients in treatment
actually

268 women and 309 men
benefitted from counseling
services
IESSDEH
Not involved in implementing care and
/
treatment programs
It appears that partners in Latin America (i.e. in Peru, Ecuador and Bolivia) are much more
involved in implementing treatment and care services than partners in India. Several of the
Latin American partners manage own health centres, give medical services and additional
support services like a nutritionist and psychologist.
Partners advocate for HIV/AIDS treatment and care services –in the period before 2004, all
partners were very much involved in advocating for the right to access treatment with
considerable success. Since the roll out of the national ART campaigns, Hivos‘ partners keep
on monitoring the availability of ARVs and ART centres and take actions when access to ARVs
for key affected populations is denied.
In Peru, civil society was organized in the ―Colectivo para la vida‖ (with participation of Via
Libre, Prosa and AfA and a lot of PLWHA). This coalition of activist seems to have been very
strong and according to all stakeholders interviewed their activism was crucial in the
government taking up its responsibility for the ART roll out program since 2004. Via Libre,
Prosa and AfA are currently preparing a new coalition to monitor the continuous availability of
55
56
No consolidated numbers. Training of peer educators is part of several projects.
Fernandez, A. & Pait Sara (2008) Evaluación externa del Programa de Soporte a la Auto ayuda de personas
seropositivas.
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ARVs (vigilancia farmacologia). Several bottlenecks keep on existing related to the purchase,
stock and disbursement of the medicines. Problems that are not exclusively linked to the ART
roll out.
In India, partners collaborate with networks when required for setting up of ART centres and
monitoring availability of ARVs. Partners take action when needed to hold government
accountable for setting up sufficient ART centres eg. Sangram.
Sangram - After heavy floods in Sangli in 2005, the government did nothing to transfer the ART centre,
which was in a basement, to a better place. SANGRAM protested against this and raised funds for a new
ART centre but waited for the government to put things in place, like allocating land etc. That process took
about two years but SANGRAM insisted on shifting this responsibility to the government, whereas it could
have easily built a new centre itself.
INP+ ORISSA-Orissa - Despite the roll-out of ART in India, access to quality treatment continues to be a
point of concern. INP+ Orissa is currently advocating for the availability of second line treatment in the
State. At the moment, a person needing such treatment has to travel to another State in order to access
this. This is the result of the bias in the national policy on ART access towards high prevalence states. This
leaves a low prevalence state as Orissa, with some of the highest HIV prevalence districts, with restricted
access to ART (even to first line treatment at lower levels of service provision). The national umbrella of
INP+ ORISSA is involved in pushing for the patent to produce second line treatment in the country, as
NACO pays for such drugs (Pepfar does not support this line of drugs).
Partners‘ advocacy on the access and quality of care is limited to addressing cases of stigma
and discrimination. Holding governments accountable for improved quality of care is not on the
agenda of the Hivos‘ partners nor on the agenda of the networks they are involved in. Little
activism can be noticed addressing the quality of care in both countries and monitoring the
implementation of the quality standards as set out for HIV/AIDS health care services. According
to the interviewees (and confirmed in research executed by the IESSDEH) the overall quality
level of health care services for PLHIV in Peru has reached the same overall poor level of the
public health services which seems to be accepted by the key affected populations.
Partners strengthen local NGOs, CBOs and other relevant service providers to take into
account issues related to access of key affected populations to qualitative treatment and
care – several bottlenecks regarding treatment and care continue to exist, like issues related to
stigma and discrimination, the quality of the services and the lack of confidentiality. Several
organisations invest in training of health care workers and counsellors in order to increase the
quality of their services (Siaap and Birds, Via libre and Prosa). For example, in the EU-SOMOS
project 653 professionals have been trained by Via Libre in 37 workshops (2007-2009). Focus
is on reducing stigma and discrimination, informing them on the specific needs of key affected
populations. Several manuals have been developed to that end. Partners have also developed
innovative models regarding qualitative counseling. Siaap brought in the counseling approach
as a minimum standard for HIV testing and launched the approach of working with community
counselors. These community counselors are not only accessible by PLHIV but also by the
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wider community who seek their advice. Prosa has developed a buddy program which is taken
over by the public health system. However, scaling up of these initiatives and maintaining the
quality as set out in these approaches when handing over to the public systems remain a
challenge. Kimirina, the Hivos partner in Ecuador will be supported by Prosa in the further
development of their buddy program.
CBOs are not specifically strengthened with the aim to provide HIV/AIDS services for their
members. The CBOs are above all stimulating health seeking behaviour of their members
(referring to ART centres, health clinics, etc). To that end, a number of their members have
been trained as counselor. Some of the CBOs set up support groups for PLHIV or are
institutionalized support groups of PLHIV.
Gender – No additional specific observations could be made.
7.3.
SECURED ACCESS TO QUALITY HIV/AIDS SERVICES (TREATMENT AND CARE)
Participation of key affected populations in development of (advocacy for) inclusive
qualitative HIV/AIDS services – representatives of key affected populations participate in the
national CCM that has influence on the national HIV/AIDS program (see EQ1). In India, GIPA
coordinators have been appointed in the State AIDS Control Societies, since 2009 (after lobby
of INP+ Orissa GIPA coordinators have been installed in 11 out of the 28 SACS in Chennai.)
These GIPA coordinators can have influence on the HIV/AIDS service provision in the state.
Peru did install already before 2000 peer educators in the health clinics to reach out to key
affected populations more easily. However, their presence is sometimes contested by the
health staff in these centres and they are not involved in decision making processes.
At the level of the partners, key affected populations are involved in the development and
provision of care services (participating at training, evaluating quality of care offered, needs
assessments have been conducted).
Regarding advocacy and lobby, key affected populations have been involved in actions and
demonstrations. Specific individual cases have been used to address bottlenecks in the
provision of HIV/AIDS services. Actions are usually linked to specific individual cases and at
local level. (ex. lack of ARV, discrimination attitude –see EQ1)
Key affected populations experience improved access to qualitative HIV/AIDS services –
Since 2004 there is an increase in key affected populations taking up medicines as shown in
7.1.
In India the instalment of ART centres, also in rural areas contributed to an increased access to
treatment. However, ARVs are not available in all centres and there is a need for second and
third generation medicines. In Peru, the launch of the TARGA program resulted in a take up of
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ARVs by 80% of the target group in 2009. Improved access to HIV/AIDS services is closely
linked to attitudes of stigma and discrimination (see EQ1).
IESSDEH evaluated the quality57 of care and treatment as part of the larger studies on the
effects of the Global Fund in Peru. Main bottlenecks mentioned by sex workers, MSM and
transgender interviewed are: (1) the costs of the services, (2) the hours are not appropriate, (3)
lack of sufficient qualified personal, (4) quality depends on the individual health care worker and
there is a difference between ―nombrados y contratados‖, (5) key affected populations criticise
the rigid culture at the health centres not creating a conducive environment for health care
workers to take into account the specific needs of the key affected populations, (6) health
workers still try to convince MSM to change their sexual orientation, (7) bad infrastructure and
bad hygiene, (8)problems with respect of confidentiality. Treatment received has been
assessed as excellent to good by 70% of the PLHIV and the same amount of PLHIV was
satisfied with the solutions received for their problems. The researchers attribute this positive
result to the level of auto-stigma of the PLHIV and the fact that overall quality of health care is
bad. PLHIV assessed the quality of care as ―normal‖.
The study examined also the quality of the counselling on positive prevention. Though the
quality of the counselling in the public health facilities is assessed as good by the interviewees,
PLHIV would prefer a PLHIV giving counselling which is not always the case. PLWHA would
like to receive not only medical information but also information regarding self esteem,
emotional support, and the need to have continuous access to psychological support.
Regarding improved access to treatment and care, beneficiaries interviewed and most
significant change stories collected give evidence of better access to treatment and care by
beneficiaries of the partners‘ programs.
India – all stories revealed that community counsellors and staff of Hivos‘ partners have been
instrumental in facilitating access to treatment and care services. This included access to ART
initiation at the public hospital, psycho-social support and assistance in accessing government
welfare schemes. Beneficiaries report an improved quality of their lives. Beneficiaries also
highlighted the importance of belonging to support groups. Several of the stories collected
came from peer educators for whom their involvement in helping PLHIV changed their lives
considerably.
During a focus group discussion with support group members in Bhubaneshwar, the members
said that for them the support group had helped them be in contact with others, feeling of
solidarity, that there were others like them. They felt that the support group provided most
significantly emotional and psychosocial support which gave them hope, belief in the self.
57
The study (executed in four cities in 2007) assessed the quality of treatment and care amongst others on following
criteria: waiting hours, time between two appointments, satisfaction degree of the patient, daily access to ARV. The
average waiting time is 1,73 hrs (ranging from 1 minute to 6 hours). The average time between two appointments is 0,
54 month.
ACE Europe-ETC Crystal /Evaluation HIV and AIDS program of Hivos /Final evaluation report pag. 95/176
Peru – PLHIV interviewed confirmed the importance of having access to treatment, which
changed the quality of their lives considerably. PLHIV and MSM seem to experience the best
access to treatment and care whereas stigma and discrimination hamper above all the access
of transgender and sex workers to treatment and care. In Peru, only Prosa managed to collect
stories of PLHIV accessing treatment and care services. The stories give evidence for the
importance of the services delivered by Prosa. The added value of the group therapy organised
at Prosa has been mentioned. Members of Prosa increased their knowledge on how to live
positively with HIV, learned to accept their diagnosis, felt supported by others.
7.4.
ASSESSMENT OF THE ACHIEVEMENTS
As the quality of the integral health care packages delivered by the public health facilities is
neither sufficient nor adequate, all partners (except IESSDEH) complement these packages by
implementing their own treatment and/or care services. In India, partners invest in training
community counselors and own health workers in order to provide qualitative counseling to the
members of their collectives and stimulate health seeking behaviour of their target groups. In
Peru, two partners offer themselves services with higher quality as compared to what is offered
through the public health system (also partners in Bolivia and Ecuador). These strategies
improve access of key affected populations to quality treatment and care but it is evident that
their coverage is limited.
Partners do not develop an appropriate strategy to scale up good practices nor have influence
on structural change within the health system. Advocating and lobbying on the quality of care is
not included in the strategy and programs of the partners. Advocacy and lobby in India is limited
to addressing individual cases at local level, in Peru it is limited to monitoring the availability of
ARVs. Partners did not enter into a policy debate on how to realize the implementation of
qualitative integral health care packages and it appears difficult to exert influence on the policy
of health care facilities (In India the government is reluctant in seeking for collaboration between
civil society and public services. In Peru the centralized management and decision making
system of the health facilities is hampering change process at the level of specific health
centres).
The level of quality of HIV/AIDS services has reached a comparable level to the health sector in
general. Partners are confronted with challenges beyond the specific HIV/AIDS problems.
However, partners did not develop a comprehensive advocacy and lobby strategy and as such
do not include ‗allies‘ in their advocacy and lobby work, such as patient organisations or
organisations and networks that advocate for a better health system in general (only Prosa but
to a limited extent).
With PLHIV becoming healthier, new challenges appear such as the need to improve their
economic situation. This is a concern that is addressed by the CBOs supported. However, only
a few partners support CBOs with economic and livelihood interventions. Other challenges
ACE Europe-ETC Crystal / evaluation HIV and AIDS program Hivos / Final evaluation report pag. 96/176
include – the need for family planning services as PLHIV are sexually active, marrying again,
having children and also need to understand the PMTCT programs.
8
To what degree are improvements with regard to the
rights of key affected populations and their access
to non discriminatory prevention and to quality
treatment and care sustainable?
The fourth evaluation question is different in kind and addresses sustainability issues. Different
dimensions of sustainability have been taken into account: institutional, socio-cultural, financial
and political sustainability. The sustainability of the benefits of the Hivos financed programs has
been assessed based on following judgement criteria and indicators.
Judgement criteria
Indicators
1. Sustainability of changes at policy level with
1.1. Level of implementation of national policies
regard to rights of key affected populations, access
and laws that take into account the rights of key
to non discriminatory prevention and qualitative
affected populations
treatment and care
1.2. Partners or other relevant civil society
organisations take up the role of a watch dog for
national policy development and implementation
1.3. Key affected populations are empowered to
express their opinions and know how to make their
voices heard
1.4. Governance structures of health facilities are
adapted to include voices of key affected
populations
1.5. Resource implications to guarantee access to
non discriminatory prevention, quality treatment
and care are taken into account by private and
public services
2. Sustainability of the output of partners
2.1. Partners have developed an appropriate
advocacy and lobby strategy (setting targets,
planning, etc.)
2.2. Partners are perceived as legitimate advocates
for the rights of key affected populations (incl.
access to prevention, treatment and care) by
external stakeholders
2.3. Partners are aware of social and cultural
patterns that enhance stigmatization and
discrimination of key affected populations and take
them into account
2.4. Partners have developed an effective strategy
ACE Europe-ETC Crystal /Evaluation HIV and AIDS program of Hivos /Final evaluation report pag. 97/176
to build the capacity of the CSOs (with regard to
lobby and/or delivering non discriminatory and
qualitative prevention, treatment and care services)
2.5. Bottlenecks to access non discriminatory HIV
prevention and to qualitative treatment and care by
key affected populations are known by the partners
and partners have taken action to deal with these
bottlenecks
2.6. Partners are capable to attract sufficient
funding from different donors
3. Sustained access to non discriminatory
3.1. Level of stigma and discrimination within the
prevention of key affected populations
society (openness to address sensitive issues and
acceptance of LGBT)
3.2. Evidence of specific needs of key affected
populations with regard to prevention, being
addressed by the health system through the private
and public services
4. Sustained access to quality treatment and care
4.1. AIDS is recognized as a chronic disease and
treatment and care are included in the basic health
care system
4.2. Evidence of specific needs of key affected
populations with regard to treatment and care
being addressed by the health system through the
private and public services
4.3. There do not exist financial bottlenecks to
access treatment and care by key affected
populations
8.1.
SUSTAINABILITY OF CHANGES AT POLICY LEVEL WITH REGARD TO RIGHTS
OF KEY AFFECTED POPULATIONS, ACCESS TO NON DISCRIMINATORY PREVENTION
AND QUALITATIVE TREATMENT AND CARE
Important changes at policy level have been realized; however sustainability of these changes
is very fragile.
The human rights of key affected populations in Peru are protected by law which is not the case
yet in India (a legal framework on HIV/AIDS still needs to be voted and not many laws and
regulations exist to fight discrimination). National AIDS programs exist but implementation and
funding remain a challenge (HIV/AIDS prevention, treatment and care not fully incorporated in
the national budget).
In both countries HIV/AIDS services set up by the government can be seen as a parallel
structure (Cerits in Peru as a separate service for STI and HIV screening and treatment, NACO
with its own ART centres alongside the National Rural Health Mission in India). They work
ACE Europe-ETC Crystal / evaluation HIV and AIDS program Hivos / Final evaluation report pag. 98/176
vertically with limited convergence (ex. limited link between HIV and sexual and reproductive
health).This can be a threat for sustainability of these services when the budgets will decrease.
In both countries a strong civil society fighting for the rights of key affected populations has
grown. Actually, according to the evaluators and confirmed in several interviews with partners,
these civil society organisations tend to be more collaborative than critical to the government. In
India there is fear of reprisal. To avoid repressive actions against individuals the partners have
started to advocate collectively (with reported results at local level). In Peru CSOs take up the
role of a ―watch dog‖ by monitoring policy implementation and documenting cases (vigilancia).
The evaluators received evidence on these monitoring activities and cases addressed (see
evaluation questions in the above) but there is little follow up of these cases at political or
juridical level: not many cases are brought to court; no much pressure is put on policy makers,
partners do not follow the agenda of the policy makers and there is no pressure put on directors
and management of health care centres. Their influence on decision makers and decision
takers at government level and within the health system to speed up and control
implementation of laws and regulations is very limited. During the restitution meeting in Peru
several explicative factors have been formulated, amongst them (1) the fragmentation of and
internal conflicts within the LGTB movement and movement of sex workers, not arriving to
lobby a common agenda and (2) the lack of communication between NGOs working in the field
of HIV/AIDS even when they work with the same population and achieve similar objectives.
Key affected populations are slowly beginning to express their opinions and they are learning
how to approach the media, the parliament and health facilities. Some of the leaders participate
at national and international conferences. With the wide reach and expansion of the media
across the countries, there is more visibility of key affected populations. However, there is a
tendency to sensationalise and there is still a taboo and inhibition to discuss issues of sexuality
and sexual orientation given the conservative environment in India and Peru and the
discriminative culture that is dominant in both countries. A little break through has been
reported by several stakeholders interviewed in both countries, indicating that it has become
possible to discuss issues such as sexual diversity more openly (in media, conferences, etc) as
compared to 5 years ago. There seems to be more widespread acceptance of the key affected
populations. It is however not possible to cast a verdict whether this is a sustainable trend or
not. It seems to be the domain of CSOs mostly to bring out the rights issue of these key
affected populations.
PLHIV are involved in national AIDS commissions (and at regional/state level) in both countries
(representation of PLHIV in the NACO and CCM in India and in the Conamusa in Peru) but it is
not clear to how meaningful their involvement is. The Ministry of health and the health facilities
do not seem to include the voices of PLHIV in its decision making process or design of
services. To a certain extent they collaborate with peer educators and counsellors and HIV
support groups but these are not involved in the policy making process and often received
marginalised attention within the health centre.
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8.2.
SUSTAINABILITY OF THE OUTPUT OF PARTNERS
Hivos collaborates with strong partners and the relevance and quality of the services provided
have been assessed by beneficiaries and external stakeholders as good. All of them are
considered to be legitimate experts regarding HIV/AIDS and the rights of key affected
populations (by government, health care workers, international agencies, colleagues and
beneficiaries). They have a good knowledge of the needs of the target groups and those not
being membership organisations collaborate meaningfully with organisations of key affected
populations.
Institutional sustainability is at risk for three partners who were confronted with financial
problems. Except for two partners, none of the partners actually depends for more than 60% on
Hivos funding58 . The other partners succeeded to diversify their donors though many of them
depend a lot on Global Fund money. Hivos contributed, through its institutional funding, to the
further development of the partner organisations. All of them are strong organisations with a
good track record which will facilitate access to different donors, including larger donors (like
EU, AIDS alliance, UNAIDS). However most of the donors (also EU and Global Fund) finance
on a project bases something which may reduce the participation of partners at networks and
their involvement in advocacy and lobby activities. Hivos supports its partners in linking them to
other donors or to larger international programs and alliances to support them diversifying
financial means. Hivos could improve its communication regarding the phasing out time frame
for its partners as this is not always clear to the partners. Besides linking partners to other
donors, fundraising capacity of some partners could be enhanced.
The risk of depending on several donors financing projects only is the disruption in consistency
of strategy and approach. In particular the sustainability of CBOs of key affected populations
created or strengthened is at risk when (project) funding stops. The evaluators did not find
evidence of a strategy enhancing sustainability of these CBOs.
Advocacy and lobby is taken forward by a limited group of staff of Hivos‘ partners. None of the
partners have developed an advocacy and lobby strategy, invested in training lobbyist or in
creating networks with other experts to enhance lobby at policy level. Advocacy and lobby will
depend on the availability of these activists in the organisation and the room to maneuver when
funds will become more restricted.
58
But information is not complete. For three partners (2 of the desk study and INP+ Orissachapter) no information on the
overall budget and other partners was available.
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8.3.
SUSTAINED ACCESS TO NON DISCRIMINATORY PREVENTION OF KEY
AFFECTED POPULATIONS
HIV prevention, targeting key affected populations is included in the HIV/AIDS national
programs (and in laws in Peru). There is a general knowledge and acceptance of the specific
needs of key affected populations by policy makers and health care staff related to quality and
access to HIV prevention (ex. specific instruments for STI screening, such as a proctoscope,
are foreseen at health centres, availability of condoms). At policy level the needs for specific
targeted interventions is acknowledged. However, putting this into practice is not evident (see
EQ 2).
Sustained access to prevention is hampered by several factors: stigma and discrimination of
health care staff and in IEC materials, staff turnover in health facilities (loosing well qualified
staff that have been trained by NGOs), lack of confidentiality, low level of self esteem and
disinformation of key affected populations. Access is hampered by the lack of uniform or too
high costs, inadequate attending hours and exclusion of specific target groups like minors
(Peru) and IDU‘s (Peru). Hivos‘ partners are able to address these factors but only at local level
(no structural change) and primarily offering their own prevention services.
Most of the prevention campaigns targeting vulnerable groups have the Global Fund as main
donor. It is not clear yet to what extent the Indian and Peruvian governments will finance
prevention campaigns if Global Fund money is not awarded.
The study executed by the
IESSDEH on the effect of the Global Fund on the public sector reveals that the Peruvian
government is not yet prepared to take over the responsibility to implement targeted prevention
campaigns.
8.4.
SUSTAINED ACCESS TO QUALITY TREATMENT AND CARE
In both countries there is a recognition of HIV requiring lifelong treatment, though it has not yet
received the status of a chronic disease. A strategy is lacking on how to integrate HIV/AIDS
services in the public health system. In India, there is an initial attempt to converge the NACP III
with the National Rural Health Mission especially for areas such as ICTC; PMTCT; Blood safety;
STI/RTI; Condom programming; and ART.
Right to access ART is part of the HIV/AIDS bills and national HIV/AIDS programs. India and
Peru produce some patent free first generation ARVs. Purchase of ARVs is funded through the
Global Fund and by own public means. As the activism to access ARVs has been very strong
and the difference in health status of PLHIV is obvious, it will be politically very difficult to stop
delivering ARVs. The current challenge is to guarantee access to ARVs all over the countries,
access to second and third generation of ARVs and good management of purchase, stock and
ACE Europe-ETC Crystal /Evaluation HIV and AIDS program of Hivos /Final evaluation report pag. 101/176
distribution of ARVs. Then there are challenges that are not exclusive for the HIV/AIDS
programs in both countries which relate to the weaknesses in the overall health system to
deliver (quality) services.
Key affected populations will need to continue advocating for universal and sustained access to
treatment. However, several factors hamper a strong and effective ART activism. (1) Because
of the increased access to ARVs, in particular in Peru, activism has gone down. (2) Key
affected populations and the HIV/AIDS NGOs have gained a lot of knowledge on HIV and AIDS
(HIV literacy) but do not automatically possess knowledge of the structural factors that hamper
swift implementation of government health policies. As a consequence key affected populations
and the Hivos‘ partners are not very much capable in formulating alternative proposals in order
to address in a structural matter the underlying bottlenecks in the public health delivery system.
They will keep on documenting the problems (ex. lack of ARVs) without entering in a
meaningful policy debate with policy makers (as compared to their meaningful involvement in
de the development of the HIV/AIDS laws and programs).
As already described, qualitative standards for integral health care exist in both countries but
implementation and control remain limited. The focus on health care is very bio-medical
oriented and other needs (ex. nutrition, socio-emotional support, psychological support) of key
affected populations are not given sufficiently attention. Civil society organisations did not
succeed in scaling up their good models because of a lack of a well developed strategy which
takes into account the risks and opportunities of the health system that are conducive for or
hamper the swift implementation of qualitative care (ex. cases of Siaap (counselling) and Prosa
(budy program59)). Secondly, the quality level of the public health system is generally poor and
key affected populations have accepted this general poor level of service delivery. Hivos‘
partners do not collaborate with organisations that defend the rights of patients and that have
expertise in lobbying the health sector in general, though the solutions of the failing health
system require systemic changes.
Finally, the financial implications of the ART roll out programs and care services may be limited
(free access to ARVs) , some studies (IESSDEH, Prosa, Via Libre) show that even a small
financial contribution can exclude some groups of key affected populations. The question is
how long ARVs will be delivered for free (compared to medicines of other chronic diseases that
are not at all for free). Only a better economic situation of the key affected populations can
secure sustained access to ARVs at the long term. Several collectives (India) and CBOs (Peru)
are addressing ―immediate needs‖ of their members, often linked to setting up income
generating activities. In India are Siaap, INP+, Birds linking their members to welfare schemes
or supporting them in setting up income generating activities. Support to income generating
activities is not the core business of the Hivos‘partners visited in Peru. The evaluators did not
receive evidence of efforts to link these collectives/CBOs to other economic programs.
59
It was beyond the timeframe of this program evaluation to analyse in depth the factors that hampered effective
implementation of the models developed by Prosa and Siaap. Some explanations had been given for the limited
results achieved but it would be interesting to study these cases, draw lessons from it and develop recommendations
to adapt the strategy.
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9
Support to capacity development of partners
Apart from financial support to its partners, Hivos intends to strengthen its partners (see logical
framework: strengthening partners as main output). At the beginning of a partnership or a new
program period, Hivos makes an organisational assessment of the partner that includes the
formulation of recommendations to improve certain organisational or institutional aspects of the
partner concerned. These are shared and discussed with the partners and when relevant,
specific institutional strengthening components are integrated in the funding proposal. This
support to capacity development entails usually support to PME, financial management and/or
financial sustainability, gender mainstreaming and HIV/AIDS workplace policies. Apart from
support to capacity development at organisational level, Hivos also invests in linking their
partners to regional and international networks, facilitates linking and learning and organises
joint workshops or training.
These efforts are very much appreciated by Hivos‘partners. The initial and continuous support
in the form of institutional funding has been crucial for several organisations to establish and
position themselves in the civil society (like for Siaap, Via Libre and IESSDEH). It was not part
of the ToR to analyse in depth the quality and effectiveness of this support to capacity
development. We will only enter more into detail regarding the Hivos support to gender
mainstreaming and development of HIV/AIDS workplace policies as these are part of
the
HIV/AIDS policies.
Gender - Hivos‘ HIV/AIDS policies describe three interventions regarding gender: gender
mainstreaming, addressing unequal power relations and enhancing understanding on different
gender roles among MSM and transgender. Assessment of gender sensitivity is part of the
organisational assessment done by Hivos‘ program officers. When this gender sensitivity is
weak, Hivos proposes to include in the Hivos funded program the strengthening of the gender
policy of the partner organisation. Following table gives an overview of the level of gender
mainstreaming by the partners visited.
Table 16 : Overview of the level of gender mainstreaming by the partners visited
Partner
Level of gender mainstreaming
SIAAP
No gender policy, no focus on gender roles of key affected population
Gender sensitivity related to addressing female sex workers, PMTC, including SRH in HIV
education of counsellors and reaching out to rural young women
Sangram
Gender policy
Women‘s vulnerability at the centre of their work, gender differences part of education
programs, questioning prevailing norms in Indian society on sexuality, introduction of
female condom
INP+ Orissa
A gender policy at the Chennai office but not actively implemented in the Orissa office.
No specific actions in the Orissa programs. For example, majority of DLN presidents are
ACE Europe-ETC Crystal /Evaluation HIV and AIDS program of Hivos /Final evaluation report pag. 103/176
male while the majority of support groups are female
Birds
No specific gender policy
The program is women-centred
Via Libre
Gender policy under development (support from Hivos)
Specific projects targeting vulnerable women.
Evolution from a focus on ―quota‖ to broadening gender concept to sexual diversity.
Prosa
Gender policy under development (support from Hivos)
Specific projects targeting CBOs and support groups of women. Practice has shown that
women groups eventually continue working independently from Prosa whereas support
groups of men stay at Prosa.
Increased understanding that gender is more than delivering sex disaggregated data.
IESSDEH
Gender policy under development (support from Hivos)
Focus of the program of IESSDEH is on sexuality, sexual diversity and human rights
Aid for Aids
No specific gender policy
Specific projects targeting women and women organisations (observatorio de la mujer),
working on HIV-SRH convergence
Resources: interviews with partners, organisational assessments and annual reports of the partners
From this overview and the interviews held with program staff of partners it is clear that gender
is not prominent in their strategies or when it is, it is limited to implementing women projects.
Discussion on gender roles amongst key affected populations like MSM and transgender does
not sound familiar for the partners visited. Some partners do address unequal power relations,
but mainly in their work with women, strengthening women and women organisations.
Partners in Peru have been stimulated recently (since 2007) to develop a gender
mainstreaming policy. According to the interviews with partners, it appears that they have not
received much support from Hivos to that end. It does not seem that Hivos program officers and
staff of the partners has become engaged in a structural dialogue on how to develop such a
mainstreaming policy. Interviewees said never have discussed with Hivos different gender roles
amongst MSM and transgender. However, Via Libre and Prosa appreciated the incentive of
Hivos to develop a gender policy.
In the Hivos HIV/AIDS policy a specific target is set regarding support to HIV/AIDS workplace
policies (ex. 40% of all Hivos‘partners will have a workplace policy by 2010). Such a target is
not set for the countries facing a concentrated epidemic. From the sample visited and studies
during desk phase 12 partners) 3 partners (Birds, Prosa and IESSDEH) received support from
Hivos to develop a HIV/AIDS workplace policy paper. The other partners do not have such a
policy. It is not clear why certain partners were asked to develop such a policy and others not.
However, the development of a HIV/AIDS workplace policy was not felt as being very relevant
by the partners in Peru and it looks a donor driven approach.
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10 Conclusions
We will first formulate an answer to the general evaluation question. Following we describe
several main conclusions that explain the level of effectiveness. Six groups of conclusions have
been developed, regarding: the level of implementation of the Hivos‘ HIV/AIDS strategy;
advocacy and lobby; rights holders and duty bearers; stigma and discrimination; pro-active
citizenship; institutional strengthening of partners.
10.1
CONCLUSION ON THE GENERAL EVALUATION QUESTION: TO WHAT DEGREE
HAS HIVOS HIV/AIDS PROGRAM BEEN ABLE TO ACHIEVE ITS OBJECTIVES?
Partners have contributed to an increased access to prevention, treatment and care for key
affected populations because of (1) their investment in HIV education and awareness raising of
key affected populations and their relatives, (2) training of peer educators, (3) actively referring
beneficiaries to health services delivered by the public health system or NGOs and (4) providing
own counselling and support services. Results on improving quality of prevention, treatment
and care are less evident. Several partners train health care workers from the public health
system (including addressing attitudes of stigma and discrimination) but the public systems
keep on failing to deliver qualitative and integral heath care packages. Most of the partners
complement such gaps by offering qualitative and integral care and counselling services
themselves.
The focus on the empowerment of the key affected populations has equally contributed to
increased access to prevention, treatment and care. Increased knowledge on their rights and
increased self esteem are factors conducive for improved health seeking behaviour.
Beneficiaries are trained on how to claim their rights. Several cases of violations of rights have
been reported with some of them resulting in an improved situation. Collectives (claiming rights
collectively) and leaders play an important role to that end.
Attitudes of stigma and discrimination continue to exist and in order to have a real impact on
improved access to prevention, treatment and care, long term social change processes are
needed. All partners contribute to these change processes by addressing stigma and
discrimination in their own information material and trainings, documenting attitudes of stigma
and discrimination and organising/participating in demonstrations of LGTB and/or sex workers.
Results regarding changed attitudes at local level could be noticed (health care centres, police
stations, families and communities). However, results at a societal level are not clear and much
is left to be done. It seems that PLHIV experience less discrimination as compared to LGTB
ACE Europe-ETC Crystal /Evaluation HIV and AIDS program of Hivos /Final evaluation report pag. 105/176
and sex workers who face double stigmatization because of their sexual identity. Hivos‘
partners contribute only to a limited extent to the strengthening of the LGTB movement and
movement of sex workers. The success of these movements differs from one country/state to
another and from key population to key populations.
The assumptions as described in the theory of change seem to be valid when dealing with
stigma and discrimination and improving access to services. However, in the theory of change
(and as such the HIV/AIDS policy) not enough attention is given to the structural bottlenecks
that hamper implementation of qualitative services by the government. A strategy to upscale
good practices is lacking and the policy is not clear on what kind of advocacy and lobby needs
to be developed in order to bring about structural change.
Hivos has clearly identified the target groups of its HIV/AIDS program and all partners visited
are reaching out to key affected populations as described in the Hivos policy. There are no
reliable data on the amount of people reached by all partners over the period 2000-2009. In the
previous tables we have presented some indications. Partners use different strategies to reach
the specific key affected populations. Several partners deliver qualitative treatment and care
services that are easy accessible by PLHIV. Two organisations are organisations of PLHIV. All
partners set up specific projects to reach out to specific target groups.
Table 17: Overview of target groups effectively reached by the Hivos’ partners
SIAAP
PLHIV
Aid For AIDS
PLHIV
Female sex workers
Special projects targeting women
MSM
and youth
youth
Birds
Female sex workers
IESSDEH
PLHIV
MSM
Transgender
Sex workers
INP+Orissa
PLHIV
Kimirina
PLHIV - women
Sangram
PLHIV
Fedaeps
PLHIV
Female sex workers
Sex workers
MSM
LGTB
Rural women
Youth
women
Via Libre
PLHIV
Sex Salud
PLHIV
Special projects targeting
MSM
transgender, MSM, women, youth
Transgender
and prisoners
Truckers
youth
Prosa
PLHIV – gay
PLHIV – trans
Uneldys
MSM
transgender
PLHIV - women
ACE Europe-ETC Crystal / evaluation HIV and AIDS program Hivos / Final evaluation report pag. 106/176
10.2
LEVEL OF IMPLEMENTATION OF THE STRATEGY OF HIVOS
In a program evaluation, evaluators are supposed to assess the extent to which the policy has
been implemented in practice. Further we describe the main conclusions to that end.
Both HIV/AIDS policy papers (2001 and 2010) clearly stipulate the focus of Hivos namely
holding governments accountable for stopping the spread of the AIDS epidemic and for creating
a social and political environment conducive for an effective AIDS response (including
prevention, treatment and care). The 2010 policy is more explicit in priorities and strategies, in
part this is a reflection of the fact that in 2005 a specific sector has been established within the
Hivos programs responsible for implementing HIV/AIDS (as part of the civil choice program).
Both policies clearly distinguish between target groups and reflect Hivos‘ commitment to
support key affected populations. The 2010 policy is more detailed on the implementation
aspects of the policy.
The evaluation of the partners in India and Peru shows evidence of the correct implementation
of the policy into practice. Hivos has been able to identify key players in the sector of HIV and
AIDS in both countries. All partners work from a rights based approach and reach out to key
affected populations. All of them are involved in activities related to increasing access to
prevention, treatment and care as been described in the policies. All partners are successful in
their programs and reach most of their goals. All partners contribute to the results as have been
described in the Hivos Civil choices program (and related monitoring protocol) and specific
target groups effectively have been reached.
The Hivos policies are of a rather general nature. There is an overall policy and strategy for all
countries Hivos is involved in. Specific strategic papers per continent/region or country do not
exist though countries are facing different challenges and experiencing differences in the HIV
epidemic. The policy and HIV/AIDS strategy have a limited ―guiding‖ function, for both Hivos
program officers and partners. There is a lack of strategic thinking at country or regional level.
Hivos has clearly identified the target groups of its HIV/AIDS program and all partners visited
are reaching out to key affected populations as described in the Hivos policy. This identification
became even more focussed in the 2010 policy whereby for Latin-America and India women,
migrant workers and refugees disappeared as main target group. In both countries visited the
discussion, between partners and Hivos, on reaching out to women is ongoing with several
partners insisting on developing HIV prevention programs for women (while this group is not a
target group anymore in the 2010 policy). The programs supported in Peru are very much urban
based and centred in Lima whereas in several regions and in more rural regions, the need to
fight stigma and discrimination and to advocate for an effective AIDS response by regional
government is relevant. In India, partners tend to move more towards reaching out to rural
women. In some programs (like Via Libre) prisoners have become part of the target group.
ACE Europe-ETC Crystal /Evaluation HIV and AIDS program of Hivos /Final evaluation report pag. 107/176
The 2001 and 2010 policies are cross-sectoral, emphasising the need to link up with the human
rights program, gender program and ICT program (and even the economic program) of Hivos.
This cross –sectoral approach is however not very visible in the countries visited.
Evidently the indicators as described in the monitoring protocol are very general. However clear
targets at country or regional level are not set out which makes it difficult to follow up the
achievements. Also at partner level, clear indicators at output level but above all at outcome
level are lacking. Annual reports are mainly informing on the level of activities. Targets
regarding advocacy and lobby do not go beyond a description of activities. Targets regarding
HIV prevention are usually linked to improved knowledge. No specific targets have been found
on changed attitude and behaviour. One needs innovative methodological approaches to really
measure the impact of HIV/AIDS prevention on knowledge, attitude and behaviour change.
Some attempts of partners developing such measuring methods to deliver these data have
been noticed but the reliability of the data is unclear.
Some approaches or choices described in the policies are not very well developed or explained
and as such they are not very helpful in guiding program officers in selecting partners or
discussing these strategies with partners. Some examples:

Innovative approaches – the way how partners are stimulated to develop innovative
approaches and how to upscale these approaches is not further developed.

Advocacy and lobby strategy - the policy only stresses the role of advocacy and lobby.
However, in programs of partners a clear strategy and targets are missing. Although
advocacy and lobby is difficult to plan in advance, some strategic position could be
taken (see further).

Strengthening movements / networks – the policy is very general regarding
development of CBOs and networks, in particular on how to take measures to improve
sustainability of these CBOs; how to strengthen the democratization process within the
LGTB movements and organisations.

HIV and SRH convergence – the policy does not elaborate a strategy how to contribute
to HIV and SRH convergence.

Participation at Global Fund – in the HIVOS policy 2010 it is foreseen to link partners
with larger donors such as global fund and EU. Hivos is directly participating in the
implementation of Global Fund by assuming the role of principal recipient, like in
Bolivia. By doing so, Hivos aims (1) to increase participation of CBOs of key affected
populations to Global Fund money and (2) to have direct influence on increased
access to treatment. The evaluators are of the opinion that initiatives such as the
―observatorio America Latino‖ (Aid for AIDS) and the Civil Society Action Team (a
global initiative that gives technical assistance to CBOs to participate at the Global
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Fund. Aid For AIDS is involved in this program) are more appropriate instruments to
increase civil society participation at Global Fund. The role of Hivos as a principal
recipient puts Hivos more in the role of an implementer and evidently doing so Hivos
will directly contribute to increased access to treatment. There exist different opinions
amongst Hivos partners, external stakeholders and Hivos staff about the positive &
negative effect this role of principal recipient can have on the advocacy and lobby
position of Hivos. At the moment it is too early to assess the effects of this kind of
involvement but it will be necessary to document carefully the advantages and
disadvantages of this strategic choice, in particular on the advocacy and lobby side.
10.3.
ADVOCACY AND LOBBY
All partners are involved in advocacy and lobby activities however a well developed strategy is
often lacking. Advocacy and lobby is limited to the directors of the NGOs and leaders of the
CBOs who are considered to be real activists and acknowledged by decision makers for their
knowledge and expertise.
Lobby is mainly done through participation of partners and CBOs at civil society fora, at
commissions installed by the government and/or national AIDS programs to discuss the
national laws and plans to fight HIV/AIDS. Partners contributed to the increased attention to the
rights of key affected populations and civil society has been very successful in advocating for
the right on treatment.
In both countries the main bottlenecks nowadays are situated in the implementation of the
existing laws and plans. Advocacy and lobby is done through research, documenting the ―bad‖
practice and monitoring attitudes of stigma and discrimination and/or availability of condoms
and medicines. This research and documentation of cases have been executed in a qualitative
way but did not bring about structural changes. Partners are also stimulated by Hivos to
participate at regional and international networks that advocate for the rights of key affected
populations. Results of participation at these networks are not clear.
Evidence shows that the current strategy is not sufficient to bring about structural change in the
government system developing effective prevention campaigns, ensuring sustained access to
treatment and implementing qualitative integral heath packages. As HIV is evolving towards
becoming a chronic disease, its management is confronted with the same bottlenecks as can
be found in the overall health system (problems with corruption, with financing, planning,
purchasing, distributing medicines; problems with controlling quality standards of health
packages, problems with bringing services to all regions, etc.) Most partners and key affected
populations are not involved in a meaningful debate with policy makers and decision makers
within the (larger) health system to address these challenges and there is not much
collaboration with civil society organisations that are active in the health sector.
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10.4
RIGHTS HOLDERS AND DUTY BEARERS
According to the Hivos HIV/AIDS policy the insufficient access to prevention, treatment and
care not only results from lack of political will but also from limited technical capabilities. The
answer from the Hivos policy and the partners is on training of health care professionals in
effective prevention and counselling to MSM, sex workers, transgender and youth. Several
partners have effectively invested in training health care workers and/or have developed
innovative models (counselling, buddy program) which have been handed over to the public
health system, however with limited success. Several bottlenecks hamper implementation of
good practices (rigid culture in health facilities to change practice, centralised decision making
system, turnover of staff, etc). The partners face a problem of scaling up good practices. By
consequence small successes have been noticed at local level but sustainability is at risk.
Partners could not intervene in a structural manner in curriculum development for counsellors
and/or health workers, influence quality control of the health facilities, change policies at level of
health facilities to address attitudes of stigma and discrimination or target oriented approaches.
As the government keeps on failing to reach key affected populations with non discriminatory
and qualitative prevention, treatment and care, all partners complement the public services with
own services (prevention, treatment literacy, own VCT services and involvement in treatment
programs, own peer educators and counsellors, etc). These activities improve the access of key
affected populations to qualitative prevention, treatment and care but have evidently limited
outreach. A large part of the Hivos programs funded is related to direct service delivery.
The rights holders (being the key affected populations) have gained more knowledge on their
rights and how to claim for their rights, have gained knowledge on the disease and how to
manage a positive diagnosis and health seeking behaviour has been stimulated. This has
resulted in an increase in cases of violations of rights that have been reported and in an
increased participation at VCT and treatment programs offered by the state. However, key
affected populations seem to accept the overall poor level of the health system. Knowledge of
the key affected populations of the factors contributing to a failing health system is limited and
by consequence, their involvement in advocacy and lobby still is limited to documenting cases
of violations or participation at demonstrations.
10.5
STIGMA AND DISCRIMINATION
All partners have achieved considerable success in addressing stigma and discrimination of key
affected populations. Three strategies are dominant, (a) informing key affected populations on
their rights and supporting them to claim their rights (collectively), (b) raising awareness
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amongst health care workers, community counsellors and peer educators stimulating reflection
on their own attitudes of stigma and discrimination and (3) bringing cases of stigma and
discrimination to court. Addressing stigma and discrimination is prominent in the programs of all
partners visited. All partners speak openly about sexual diversity and confront taboos in their
information material and campaigns. Their actions have contributed to an increased openness
in society for sexual diversity (ex. it is possible to organise hearings, conferences and debates
on issues related to sexual diversity). The HIV epidemic has made, in one way or another,
specific key populations visible, like MSM and transgender. In the most significant change
stories, key affected populations testify of reduced levels of stigma and discrimination by family
members and/or health care workers. Informing family and community members on HIV and
AIDS, improved health situation of PLHIV and improved economic situation of PLHIV all
contributed to increased acceptance of PLHIV by family, community members and health care
workers.
The pattern of attitudes and behaviour of stigma and discrimination is very diverse and depends
of (1) the group of people who discriminate (family members, community members, health care
worker and society in general) and (2) the group that is discriminated (ex. more stigma and
discrimination of transgender and sex workers). Studies executed by several partners still show
attitudes of stigma and discrimination by society in general and health care workers in
particular. A study of Via Libre60 showed that more than 50% of people interviewed still do not
sufficiently know their rights. By consequence, there is a lot of self-discrimination amongst key
affected populations. A study of Prosa indicated how difficult it is for key affected populations to
claim their rights (1) often people do not know their rights and (2) often people do not want to
disclose their status nor their sexual identity.
Studying attitudes of stigma and discrimination seems very difficult because of (1) the
discrepancy between own attitude and behaviour of, for example, health care workers and (2)
the level of self-discrimination amongst key affected populations. The evaluators have not seen
much exchange on methodologies to this regard and not much collaboration exists with human
rights organisations that have experience in documenting and studying stigma and
discrimination.
10.6
PRO-ACTIVE CITIZENSHIP
Prominent in the Hivos strategy is the strengthening of the capacities of CBOs, NGOs and
networks to increase their claim making power and to provide qualitative HIV education and
support to their target groups. Hivos also intends to enhance participatory processes by
stimulating civil society organisations to participate at country coordinating mechanisms and the
national coordinating bodies.
60
Ccapa Quispe, A. And Lescano Morales, A. (2009) Estudio exploratorio sobre stigma y discriminación en
poblaciones claves. Via Libre. Lima
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Community based organisations of key affected populations have been formed and
strengthened (support to organisational development, strategic planning, development of
advocacy and lobby activities, etc.). In India this ―collectivisation‖ formed the main strategy of
the programs of the partners which resulted in several strong CBOs and federations of key
affected populations. In Peru this strategy was less prominent and depended a lot on project
funding. These CBOs and federations have been very effective in promoting health seeking
behaviour and in claiming rights collectively. However, their participation at advocacy and lobby
at local/regional level is limited to addressing cases of violation of rights or monitoring
availability of condoms and medicines in health care centres.
The CBOs of key affected populations are confronted with several bottlenecks: (1) one can
hardly speak of a LGTB movement. The movement is very fragmented which makes a
concerted action to tackle stigma and discrimination difficult. Different groups also have a
different agenda. This fragmentation hampers democratic representation of key affected
populations at the country coordinating mechanisms; (2) the level of democratisation within
these movements is rather low with a lot of information and power concentration in the leaders;
(3) many CBOs of key affected population focus on their immediate needs and it appears
difficult to effectively take action or participate in advocacy and lobby activities; (4) the
management of these CBOs is too fragile to effectively manage global fund programs what
makes it difficult to participate at global fund programs; (5) CBO are sometimes linked to
national federations and international networks but mostly in the person of the leader (see also
lack of democratization). This can cause tensions within the movement.
All NGOs in the Hivos program are supported to participate at networks and coalitions. Partners
visited have stressed the importance of these coalitions and networks for information exchange
and exchange of good practices. A well articulated lobby strategy has not resulted yet from the
networks mentioned. Results of these networks on improved access of key affected populations
to prevention treatment and care are not clear as no data exists that provides evidence of their
effectiveness. Hivos has limited its task in bringing partners in contact with these networks or
facilitating meetings of these networks or making time available for staff to participate at these
networks (via the institutional funding).
10.7. INSTITUTIONAL STRENGTHENING OF PARTNERS
Most of the partners receive institutional funding from Hivos. This institutional funding makes it
possible for directors to invest in endogenous capacity development projects, when needed (ex.
having time that is needed to develop policies), to participate at networks and coalitions and to
participate at international meetings with other Hivos‘ partners. At the start of a specific
program, every partner organisation is assessed by Hivos program officer and points for
improvement are indicated. These points of improvement are usually linked to improving the
implementation capacity of the organisation. These points of improvements are discussed
during a dialogue between the Hivos program officers and the partners, which is highly
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appreciated by Hivos‘ partners. When needed, specific activities have been planned to improve
identified weaknesses (mostly focussing improvements in financial management and financial
sustainability, improvement of M&E systems, etc). On ad-hoc base specific technical support
has been provided by Hivos officers (or other capacity builders) to deal with organisational
challenges (ex. leadership crisis).
All partners visited are strong partners and with support from Hivos they could further develop
their organisation. However, this contribution to capacity development is not based on a
thorough analysis of the capacity of the partner in relation to the objectives of the partner
organisations. Some challenges partners are facing have not been taken up/identified by Hivos
nor have been addressed by the partner self (ex. weak advocacy and lobby strategy, problems
with sustainability of CBOs formed or strengthened, problems with studying attitudes of
discrimination, response to the fragmented LGTB movement, etc.). Regarding the added value
of international meetings with Hivos‘ partners, it was not possible to assess to what extent these
meetings effectively have contributed to organisational strengthening61. No specific targets had
been set in advance.
The HIV/AIDS policy pays specific attention to supporting partners in developing gender
policies and /or HIV/AIDS workplace policies. An example of the lack of a capacity development
strategy is the way partners are involved in gender mainstreaming. Many partners have started
to develop a gender policy upon request of Hivos. Although there exists a lot of expertise on
HIV and gender within Hivos (amongst others through its participation at Stop AIDS now!) it
seems that not much of this expertise has been shared with Hivos partners. The notion of
gender dynamics and gender roles taken up by MSM, lesbian or transgender as described in
the Hivos ‗policy, does not sound familiar to the Hivos ‗partners. By consequence, gender
remains limited to targeting women and women organisations and to linking HIV to sexual and
reproductive health (by a limited number of partners). The evaluators have not found evidence
for addressing biased gender concepts amongst men and MSM.
61
Effective assessment of support to capacity development of the partners was not part of the ToR as no specific
capacity development programs had been developed in the HIV/AIDS program.
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11.
Annexes
11.1. TERM OF REFERENCE
Project title
Programme Evaluation ―Hivos‘ HIV/Aids Programme in South America &
India‖
Project number
QZ…..
Commissioned by
Hivos
Evaluation Team
…………….
Sector
HIV/Aids
Partner Organisations and
other Hivos support involved in
See annexes 3, 4 and 5
this evaluation
Financial support concerned
€ 6,900,000 (MFS/Cofinancing funds)/ € 17,700,000 (all funds)
Period to be evaluated
2000-2009
Type of evaluation
ex-post
Level of results
Outcome
Available budget
Max. € 90,000
To be financed from
Hivos Programme Evaluation Fund
Evaluation from-until
01/04/10– 31/10/10
Terms of Reference
Programme Evaluation (PE)
Hivos’ HIV/Aids Programme
2000-2009
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1. Introduction
1. 1. Hivos
Hivos –the Humanistic Institute for Development Cooperation -is a secular Dutch development
organisation, founded in 1968. Hivos works to contribute to a free, fair and sustainable world, in
which women and men have equal access to resources, opportunities and markets, so that they
can actively participate in decision-making processes that determine their lives, society and
future. Hivos commits itself to poor and marginalised people and their organisations in the
South and East. Hivos‘ core activities are funding and political support to civil society
organisations and initiatives with shared goals, networking, lobbying, and knowledge sharing at
international as well as national level. The main activity is financial support and advice to local
NGOs. Hivos does not implement projects or programmes itself. The NGOs supported carry out
various activities at different levels of society and play a role in the development of their
societies. Hivos always looks for partners that are willing to point the way, are not dogmatic and
welcome innovation.
Hivos takes an institutional approach in supporting organisations. This entails support to the
organisation as a whole: organisational and policy development, management, financial control,
internal democracy and public accountability.
Hivos is currently active in seven sectors: 1) Financial Services & Enterprise Development, 2)
Sustainable Production, 3) Arts & Culture, 4) ICT & Media , 5) Gender, Women & Development,
6) HIV/Aids and 7) Human rights & Democratisation.
The largest part of Hivos‘ budget is funded through the Co-Financing System (MFS) of the
Dutch Ministry for Development Co-operation. The MFS is part of the national budget for
development co-operation and is open to Dutch development organisations working towards
poverty alleviation and civil society building.
Hivos operates from its head office in The Hague (The Netherlands) and four Regional Offices
in Harare (Zimbabwe), Bangalore (India), San Jose (Costa Rica) and Jakarta (Indonesia).
1.2. Program Evaluations
The framework of the MFS 2007-2010 establishes that all recipient organisations will implement
a practice of Project Evaluations.
In addition, the larger recipients (receiving > € 2,500,000/year) will also implement a series of
Programme Evaluations. This applies to Hivos.
A Programme Evaluation assesses the effectiveness of a set of related activities & programmes
(geographically, thematically or both), which distinguishes it from a ‗project evaluation‘, which
only looks at one single project, programme or organisation.
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Whereas project evaluations have ―partner organisations‖ as their central object, in the case of
program evaluations this is ―Hivos‖.
Hivos has decided that each of its 7 sector programmes will be the object of a Programme
Evaluation in the period 2007-2010. Some of these Programme Evaluations are implemented
jointly with other organisations (Cordaid-Icco-Oxfam Novib- Plan).
All Programme Evaluation reports are submitted to the Ministry of Foreign Affairs and their
quality is assessed by the independent Evaluation Unit of this Ministry (IOB), using a standard
assessment framework (see annex 7)
In 2010 Hivos will implement this present Evaluation of its HIV/Aids Programme. In addition –
jointly with Cordaid-Icco-Oxfam Novib-PLAN it will undertake a Programme Evaluation in the
sector Gender, Women & Development.
2. Hivos and HIV/Aids
Hivos activities in the area of HIV/Aids date back to 1989 when a first partner organisation
(Mexicanos contra el Sida) was financially supported. The year 1992 saw the first formulation of
Hivos‘ policy on HIV/Aids. This policy document was reviewed and update twice since then, in
2001(annex 1) and most recently in 2010 (draft - annex 3)
In relation to this forthcoming Program Evaluation, which covers a 10-year period 2000-2009,
the relevant HIV/Aids policy formulations are to be found in 3 documents: the 2001 policy
document,
the 2006 Business Plan for the period 2007-2010 (annex 2) and the recently
reformulated HIV/Aids policy document.
Analysis of these three documents reveals a fair degree of continuity in policy during these past
10 years. For this reason it is possible to use the formulations of the most recent policy
document as the basis for these Terms of Reference (see para 3.4.)
A central element in Hivos policy on HIV/Aids is the focus on ―Key Affected Populations‖.
(referred to as ―excluded groups‖ in the 2006 Business Plan). The 2010 draft policy document
specifies these Key Affected Populations as follows, differentiating between 3 geographical
regions:
Region
Nature of epidemic
Main target populations
Southern &
Generalised
Women, youth, PLWH, MSM, sex workers; and
Eastern Africa
Latin America &
their sexual partners.
Concentrated
South Asia (India and
Youth, PLWH, MSM, transgender and sex
workers; and their sexual partners
Indonesia)
Central Asia and
Concentrated
PLWH, IDU
Indonesia
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The 2010 draft policy document (pages 9-11), distinguishes 4 thematic priorities:
-Human and Sexual Rights of key affected populations,
-Access to equitable, non discriminatory HIV Prevention,
-Access to sustained quality Treatment and Care,
-Dynamics of Gender and HIV.
3. Evaluation: Purpose – Scope - Objective & Evaluation Questions- Research
Questions
3.1. Purpose – what do we want this evaluation for ?
Hivos will use the findings of this program evaluation:
-To show and account for the results of its activities in the area of HIV/Aids
-To critically review these activities
-To inspire future policy development & implementation.
3.2. Scope of the evaluation
Region: the evaluation will cover Hivos portfolio in South America and India. For more details
on the portfolio see annexes 4,5 and 6. The South America portfolio is managed by Hivos Head
Office in The Hague, the Netherlands. The India portfolio is managed by Hivos Regional Office
in Bangalore, India.
Period: the evaluation will cover the period from 2000 -2009.
Funds spent on HIV/Aids :in the period under review Hivos spent a total of approx. €
17,700,000 in these 2 regions, of which € 6,900,000 from the MFS/ Cofinancing.
Result level: Outcome
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3.3. Objective – Evaluation Question
The objective of this evaluation is to answer the following Evaluation Question:
What was the effectiveness of Hivos HIV/Aids program : (to what degree) has Hivos Hiv/Aids
program, in the period 2000-2009 been able to achieve its objectives ?
Definitions: As this is a program evaluation in which Hivos is the evaluation object, it is
important to specify what is meant by ―Hivos‘ HIV/Aids Program‖ .
For the purpose of this evaluation the ―Hivos I&M Program‖ includes
a) the Hivos HIV/Aids portfolio of projects (being) implemented
-by partner organisations,
-by Hivos itself,
b) Hivos‘ support interventions towards these partners/projects. These interventions include
financial support and other support (advice, linking & networking, knowledge sharing),
c) Hivos‘ identification and selection of the project/partner portfolio,
d) Hivos policy.
The evaluation criteria to be applied by this evaluation are ―Effectiveness‖ and ―Sustainability‖.
Following the OECD-DAC Glossary,
-effectiveness is defined as ―the extent to which the development intervention‘s objectives were
achieved, taking into account their relative importance,
-sustainability is de fined as ― the continuation of benefits of a development interventions after
major development assistance has been completed‖.
3. 4. Research Questions
To achieve its objective, the evaluation must provide explicit answers to the research questions
below. The following formulation of these questions are explicitly derived from the formulations
in the 2010 policy document:
1. To what degree have/has:
-human & sexual rights of key affected populations been strengthened ?
-access to equitable, non discriminatory HIV prevention improved ?
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-access to sustained quality treatment and care improved ?
2. Have targeted key affected populations been effectively reached?
3.How have gender dynamics been addressed ?
4. Which major factors explain the observed level of result achievement?
5. How sustainable are the observed outcomes in research question 1. ?
4. Methodology
The evaluation will proceed in three phases:
-phase 1: Inception > inception report
-phase 2: Data collection & analysis > evaluation report
-phase 3: Formulation of recommendations
4.1. Inception
This phase leads to an inception report in which the evaluators explain how they will
proceed to answer the research questions and the evaluation question.
In the inception report the evaluation team will present a clear description/reconstruction of the
intervention logic of the program, and its various components, as it applies in the countries &
regions selected for the evaluation,
-the project portfolio,
-the operationalisation of the research questions & concepts,
-the judgement criteria,
-the indicators,
-the data sources to be used,
-the data collection techniques to be applied,
-the –justification of the –sample/ selection of cases for the field study.
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In the inception phase the evaluation team will interact intensively with the Hivos staff involved
in the program, through interviews and meetings.
In addition, the evaluation team will base its inception report upon a desk study of documents
available in Hivos. Data sources will include (reports from) a number of project evaluations
which have been carried out in years 2000 – 2009.
Hivos will have to approve the inception report.
4.2. Data collection & analysis
This phase can start after Hivos has approved the inception report. It includes the field work in
to-be selected countries , and the writing of the final report in which the evaluators fully answer
the research questions and the evaluation question (conclusions).
4.3. Recommendations
After the evaluation report has been finalised, the Evaluation Team and Hivos will engage in a
participatory exercise to jointly formulate the recommendations that follow from this evaluation.
5. Evaluation Team
The evaluation team will cover the following expertise:
-Result-oriented Evaluation research/ Analysis of programs (Team Leader),
-HIV/Aids in the context of Concentrated Epidemic,
-particular conditions of relevant Key Affected Populations, including self-organisation,
-gender dynamics of HIV/Aids,
-Policy influencing & lobby,
6. Budget
6.1. A maximum amount of max. € 90,000 is available for this evaluation. This includes VAT
(BTW).
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6.2. Disbursement
-An amount of € 25,000 will be disbursed upon signing of the contract
-An amount of € 25,000 will be disbursed after approval of the inception report
-Final disbursement will take place after the declaration of expenses with supporting documents
has been received , the evaluation report has been accepted by Hivos and recommendations
have been formulated.
7. Time Frame
-The evaluation will start early April 1st, 2010,
-Inception phase will be in April and May 2010; the final inception report will be presented midMay 15th,
-The Data Collection and Analysis phase will start as soon as Hivos has approved the inception
report. The draft final report will be presented not later than September 30th, 2010 and the final
report will be presented not later than October 31st, 2010.
-The formulation of recommendations will take place in the first half of November 2010.
8. Reports
The required outline of the final report will be defined in the contract.
9. Hivos staff involved
9.1. Head Audit & Evaluation
-Jappe Kok – commissions the evaluation
9.2. Evaluation Manager - Chairperson of Internal Reference Group
-Karel Chambille
9.3. Members Internal Reference group
-Kwasi Boahene, Hivos Programme Manager HIV/Aids
-Miriam Musch, Hivos Programme Officer HIV/Aids- South America
-Bishwadeep Ghose, Hivos Programme Officer HIV/Aids - India
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10. Annexes
1)
Policy Document HIV/Aids (2001)
2)
Program Logic HIV/Aids , taken from the Hivos Business Plan 2007-2010 (2006),
3)
Policy Document HIV/Aids (draft, 2010)
4)
Portfolio HIV/Aids projects in South America & India 2000/2009 – overview
5)
Portfolio HIV/Aids partners & projects in South America & India 2000/2009 – details
6)
Portfolio HIV/Aids in South America & India– summary project descriptions of the most
recent projects with each of the 24 organisations in the portfolio + description of the
Global Fund project
7)
IOB assessment framework
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11.2. EVALUATION FRAMEWORK
The evaluation framework serves as the guiding framework for the evaluation of Hivos‘
HIV/AIDS programs in Latin America and India. It will be applied during the field visits to India
and Peru, and during the desk review of the Hivos‘ support to partners in Bolivia and Ecuador.
Answers to the research questions on the effectiveness of the interventions (have key affected
populations been effectively reached), and major factors explaining the observed levels of
results will be addressed in the analysis phase of the evaluation, based on the results as
obtained by the desk study and the field visits. Indicators for the effectiveness 62 of the
interventions are included in evaluation framework as part of questions 1 to 463 .
Four evaluation questions have been formulated with judgement criteria and indicators. Taking
into account the diversity of the partners it will be possible that some indicators will not be
relevant for that particular partner. In that case, no evidence will be found on that indicator.
The first three evaluation questions are related to the specific questions on results achieved by
the HIV and AIDS program, as formulated in the ToR. The fourth evaluation question addresses
sustainability matters.
For the first three evaluation questions, judgement criteria have been formulated at three levels:

National level – focussing national policies and programs. The purpose is to describe
the context within which the partners operate, to assess to what extent the political
context is conducive for realising the rights of key affected populations and to gain
insight in the effects of advocacy and lobby of partners in addressing the rights of key
affected populations.

Partner level – focussing the output of partner organisations. To what extent output has
been realised. This output can be related to service delivery, to capacity development
of local NGOs, CBOs, peer groups, etc. and/or to advocacy and lobby.

The level of the beneficiaries – focussing changes in the lives of the beneficiaries.
The fourth evaluation question addresses sustainability issues. Sustainability is defined as ― the
continuation of benefits of a development interventions after major development assistance has
been completed‖. Different dimensions of sustainability can be taken into account: institutional,
socio-cultural, financial and political sustainability.
Effectiveness is the extent to to which the development intervention’s objectives were achieved, taking into account their relative
importance
62
63
Indicators drawn from (ao): Hivos. Program CIVIL CHOICES: subprogram HIV/AIDS (HA)/Intervention logic 20062010; UNAIDS.
National AIDS Programs. A Guide to Monitoring and Evaluation, 2000
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Evaluation question 1: To what degree have human and sexual rights of key affected populations
been strengthened?
Justification of the question
Hivos approaches HIV/AIDS from a human rights and development perspective, and refers to social
exclusion faced by vulnerable groups as key underlying factors to the spread of HIV. Crucial in the fight
against HIV/AIDS is therefore defending the rights of key affected populations and advocating for their
access to treatment and information. The human rights and development perspectives on HIV/AIDS
provide a framework for:
(a) holding governments accountable for their actions;
(b) enabling activists to engage in a wide range of advocacy aimed at securing the human rights and the
protection of key affected populations;
12
(c) addressing social and gender inequalities amongst the population . In light of the vision above, Hivos
promotes and supports organisations in developing countries that defend the rights of PLWHA and
enhance their full participation in society. Particular attention is given to organisations active in lobby and
advocacy for optimal dissemination of information, prevention and care in developing countries. This vision
and approach has continued to be the building blocks of Hivos‘ work between 2000 and 2010. To this
extent partner organisations have been strengthened and supported to carry out their core business in the
domain of HIV/AIDS, whether as a generalist or as a specialised organisation.
Since the Hivos‘ HIV/AIDS policy of 2001, there have been some new trends but also persistent obstacles
in the response to HIV/AIDS64 . Many countries witnessed a trend towards increased criminalisation of HIV
infection, same sex and sex work as well as rampant violations of the privacy of MSM, sex workers and
PLWH in seeking HIV/AIDS related services and treatment. Regional differences in the spread of the
disease have influenced national and international responses in dealing with its consequences, as well as
societal perceptions on the disease and the stigmatisation of key affected populations. In contrast to subSaharan Africa, where the epidemic is characterised as generalised, in India and Latin America the
epidemic is concentrated in MSM, transgender and sex workers.
For evaluation purposes the level of analysis will be twofold:
1) which was the national context in which Hivos and their partners operated in the period between 2000
and 2010, and in turn, how has this influenced their ‗space‘ for implementing actions in advocacy and
service delivery?
2) how capable where the partners to execute their work, and take up new/emerging challenges in sexual
and human rights strengthening?
National: The national context of the countries included in the evaluation (India, Bolivia, Ecuador, Peru) will
be assessed specifically looking at the ‗readiness‘ to address HIV/AIDS as a human rights and
development issue include. To this extent the evaluation criteria include: national policies in place;
proportion of budget allocation to HIV/AIDS and proportion of funding allocated to HIV/AIDS. In addition,
cultural and societal factors impeding the sexual and human rights of key affected populations will be
addressed by assessing the freedom to address sensitive issues and levels of stigma and discrimination in
the country, among others.
Partners: Indicators to ascertain the ‗readiness‘ of partners to address HIV/AIDS as a human rights and
development issue include assessing the level of embedding of partners‘ actions and work within the wider
country context, rather than focusing on the sustainability of the partner. Their internal growth and
development (organisational strengthening) may illustrate their capacity to seize opportunities within the
national and international environment (i.e. tapping into funding opportunities, linking to international
networks, etc.), as well as ability to mobilise increased attention for sexual and human rights of key
64
Hivos’ HIV/AIDS policy 2010
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Evaluation question 1: To what degree have human and sexual rights of key affected populations
been strengthened?
affected populations, such as: initiation of political debate and media attention; strengthening and
facilitation of civil movement/organisations; capacity building of key affected populations; participation in
policy making processes.
Beneficiaries: Changes at the level of beneficiaries is assessed by looking at their involvement in change
processes; their capacity to mobilise and advocate, etc.
Judgement criteria
Indicators
Sources of verification
JC1. National
JC1.1. National AIDS programs and policies and
Policy documents
recognition of the sexual
laws in place (and / or national AIDS commission
Researches, surveys
and human rights of key
established) that address human and sexual
(DHS, others)
affected populations
rights of key affected populations (MSM, sex
Routine monitoring /
workers, etc) and / or evidence of laws in place to
assessments of health
protect the HIV affected against discrimination
facilities
JC2. Partners contribute
JC2.1. Partners contribute to the debate on HIV
Reports partners and
to strengthening of
and AIDS from a rights based approach
other project documents
human and sexual rights
Annual reports to MFA
of key affected
JC 2.2. Partners are meaningful involved in
Reports on capacity
populations
networks and coalitions that defend the rights of
building initiatives (training
key affected populations
reports, feedback,
JC2.3. Partners involved in capacity building of
evaluation forms, pre/post
civil society organisations /movements /networks
tests)
in lobbying and campaigning, that address the
Evaluations Interview with
rights of specific target groups
staff Interviews, FGD with
relevant stakeholders
Field visits Hivos staff
Field visits evaluators
JC 2.4. Gender dynamics of key affected
populations have been taken into account while
advocating for their rights
JC3. Evidence of
JC3.1. Involvement of PLWHA in campaigning /
(official statistics and
significant changes at
lobby and advocacy (local/national levels) /
statistics of the partner)
the level of beneficiaries
establishment of networks of PLWHA (support
MSC Reports partners
(positive changes
groups)
and other project related
regarding their sexual
JC3.2. Decrease in incidences of violations of
documents
and human rights)
human and sexual rights of key affected
Evaluations
populations / Cases of defending human and
Interviews
sexual rights of key affected population
partners/relevant
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Evaluation question 1: To what degree have human and sexual rights of key affected populations
been strengthened?
JC3.3. Target groups feel their rights respected
stakeholders
(own perception), i.e. experience decrease in
Field visits Hivos staff
discrimination and stigmatisation at the
Field visits evaluators
workplace, in social life, in health care systems
Evaluation question 2: To what degree has access to equitable, non-discriminatory HIV prevention
improved?
Justification of the question
Prevention is considered key in halting the spread of the disease among the population and in diverting
trends in the epidemic. Hivos programmatic responses in the area of HIV/AIDS therefore, besides
advocacy and lobby, included prevention, awareness and information, aiming to empower people in the
South running the greatest risk of HIV infection65.
Hivos doen not focus on providing direct care and treatment but rather on advocacy because it believes
that it is the responsibility of governments to provide care and treatment. Therefore, more attention is given
to supporting partners in their advocacy for access to prevention and treatment and the rights of key
affected populations. To this entent Hivos‘ partners range from grass roots organisations to intermediary
organisations, including specific AIDS service organisations and a growing number of organisations that
have taken up AIDS prevention as a secondary responsibility. This latter is considered important in
expanding opportunities to reach out to women. Around 2005 programs targeting young adults increased
because of their vulnerability and generally deprived situation in accessing information, advice and
services. In countries with low prevalence rates (such as in Latin America) there is also ample reason to
support programs geared towards prevention, awareness and information. Becoming aware of the risks of
HIV transmission is as important as understanding the consequences of HIV/AIDS. 66 A review held in
preparation for the new Hivos policy (2010) indicated the need for increased involvement of PLWHA and
youth.
Given the crucial role of unprotected sex in most HIV epidemic, many AIDS programs have focused
actively on increasing people‘s knowlegde about sexual and transmission and promoting safer sex.
Knowlegde is an important prerequisite for prevention in other areas of HIV transmission (among IUDs and
mother to child transmission. Increased knowlegde however does not aloways guarantee behaviour
change. Measuring knowlegde and condom use/safer sex practices combined allow for a better
understanding of behaviour change dynamics.
The evaluation focuses on national trends in prevention programs, and on partners‘ inventions in among
others: creating awareness; VCT; prevention targeting youth, and affected populations; training of ‗role‘
models like traditional healers, religious leaders etc.; dissemination of information; life skills programs; peer
education; and advocacy for increased access to quality and non-discriminatory HIV prevention, including
prevention measures such as condoms. Sustainability of the actions are measured at the level of partner
organisations (availability, quality of prevention programs, especially for key affected populations), and at
national level: effects of lobby and advocacy for equitable, quality, non-discriminatory AIDS education and
Next to the following categories: Lobbying, advocacy and influencing policy; Organisation building, network development and
communication; Emancipation and sexuality
66 Hivos Policy Document on AIDS and Development Cooperation 2001
65
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Evaluation question 2: To what degree has access to equitable, non-discriminatory HIV prevention
improved?
prevention in India, Bolivia, Ecuador, Peru.
Judgement criteria
Indicators
Sources of
verification
JC1. Nationwide
JC1.1. National HIV prevention programs and policies
Policy documents
coverage of equitable
in place, and campaigns adapted to specific target
Researches, surveys
and non-discriminatory
groups / Agenda setting regarding equitable and non-
(DHS, others)
HIV prevention
discriminatory HIV prevention services
Routine monitoring /
assessments of
health facilities
JC1.2. Equitable access to non-discriminatory
HIV/AIDS prevention services / SRH services which
take into account special needs of key affected
populations (# key affected populations reached by
quality, non-discriminatory HIV/AIDS education,
including VCT services for sex workers, youth and
LGBT)
JC2. Partners
JC2.1. Partners provide/advocate67 for (depending the
Reports partners and
advocate for /
nature of the organisation) equitable, non-discriminatory
other project
implement equitable,
HIV prevention68 (agenda setting of equitable/non-
documents
non-discriminatory HIV
discriminatory HIV prevention)
Annual reports to
prevention
JC2.2. Partners strengthen CSOs in HIV/AIDS
MFA
education (and the use of evidence based prevention
Evaluations
models and /or innovative IEC models), particularly for
Interview with staff,
excluded groups
relevant stakeholders
Field visits Hivos staff
Field visits evaluators
JC 2.3. Gender dynamics of key affected populations
have been taken into account while implementing
equitable, non-discriminatory HIV prevention.
JC3. Significant
JC3.1. Key affected populations experience improved
Official statistics
changes / increased
access to non-discriminatory HIV prevention
MSC
access of key affected
FGD
populations to
Field visits evaluators
equitable, nondiscriminatory HIV
prevention
JC3.2. Target groups involved in the development of
non-discriminatory HIV prevention information and
services
67
68
Depending the nature of the organisation (directly service delivery or advocacy/lobby)
In particular reaching out to key affected populations (not reached by national programs or by other stakeholders through quality
prevention services = appropriate and accessible messages and materials (look at: language used, collaboration with appropriate
stakeholders, involvement of target groups in the design etc.)
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Evaluation question 3: To what degree has access to quality treatment and care improved?
Justification of the question
Only 30 percent of the people who need AIDS medicines in developing countries receive them, resulting in
5,700 AIDS deaths daily69. Although the majority of PLWH do not receive medicines and treatment, those
who are MSM, sex workers or IDUs often have limited access due to discrimination and stigma. Over the
past decade the notion to better access to quality HIV/AIDS treatment and care has increased, however
there is still a long walk ahead towards universal access to such services. In surge of international
pressures, an increase in national responses is visible, given an increased public spending on HIV/AIDS
and the development of National AIDS Strategies and Policies, albeit their implementation is often lacking
because of weak systems to implement the actions.
Hivos has supported civil society groups in setting the agency for treatment and care, and stimulated the
development of innovative responses to the epidemic, whether generalised or concentrated. In the early
years of the epidemic, the response to AIDS came from people with HIV and their families, who organised
themselves to care for those in need and carry out advocacy for better care. In the 1990s, networks
emerged which sought to unite HIV positive people from different countries and provided the opportunity to
pursue advocacy. Over the years, civil society has become an important stakeholder in promoting the
rights of key affected populations such as MSM, sex workers and IDU, and access to treatment and
effective national Aids policies.
With the establishment of Country Coordinating Mechanisms (CCMs) and the Global Fund Board, came
the need to involve PLWHA and partners in these processes at national level, to shape their agenda
towards inclusive equitable and non-discriminatory HIV/AIDS services and towards addressing more
specifically the needs of previously neglected groups and the most vulnerable.
Hivos is particularly alerted by the effect of increased access to treatment and care on a decline in the
willingness to continue the fight for inclusive services and non-discrimination. As stated in the 2010 Policy
document: ―the irony is that in some countries, as people obtain treatment (e.g. Bolivia and Peru), they
seem to relax their activism despite the constraints which affect the sustainability and quality of the
services and the pervasive homophobia which limits their rights‖. This trend is not seen in Africa, where
lack of treatment stimulated activism. In any case, as treatment becomes more available, PLWH live longer
which in turn will place increased demand on the existing services. Hivos did not – and does not – foresee
partnering with organisations providing direct services HIV/AIDS (medical) services. Its focus has been on
lobbying and advocacy for quality treatment and services and increased access to them by key affected
populations. As such Hivos has supported organisations that are instrumental in reaching out to service
providers to increase their knowledge on key affected groups and their specific needs. Hivos‘ partners are
active in a broad spectrum of care services such as VCT; palliative care; Home Based Care (HBC);
organisation of peer support groups (PLWHA support, post test (youth) clubs); and support to groups
active in income generating activities. In the evaluation focus is placed on the national scenarios in terms
of access to HIV/AIDS quality treatment and care, with particular attention to key affected groups, as well
as on partners‘ interventions to strive for such services (lobby and advocacy) and in providing care for their
target populations.
69
Number of PLWHA receiving treatment in developing countries rose from 240,000 in 2001 to 3 million in 2008, but nearly 70% of the
people still do not have treatment (Hivos, 2010)
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Evaluation question 3: To what degree has access to quality treatment and care improved?
Judgement criteria
Indicators
Sources of verification
JC1. Nationwide
JC1.1. National HIV/AIDS programs, policies and
Policy documents
coverage of equitable
guidelines to provide HIV/AIDS treatment and
Evaluations Research
70
and qualitative
qualitative care in place
and surveys Research,
HIV/AIDS services
JC1.2. Equitable access to quality HIV/AIDS
surveys (DHS) Facility
(treatment and care)
services (treatment and care) which take into
records Policy
account the special needs of key affected
documents
populations (# key affected populations reached by
quality treatment and care)
JC2. Partners advocate
JC2.1. Partners advocate for (implement)
Reports partners and
for / implement
accessible71 and quality72 HIV/AIDS services
other project documents
equitable and qualitative
(treatment and care)
Interviews with staff
HIV/AIDS services
(treatment and care)
Field visits Hivos staff
JC2.2. Partners strengthen local NGOs, CBOs and
Field visits evaluators
other relevant service providers to take into account
issues related to access of key affected populations
to care and treatment and issues related to quality
in their service delivery or advocacy activities.
JC 2.3. Gender dynamics of key affected
populations have been taken into account while
implementing specific HIV/AIDS services
JC3. Secured and
JC3.1. Key affected populations experience
MSC
sustained access to
improved access to qualitative HIV/AIDS services
Evaluations, research,
quality HIV/AIDS
(treatment and care)
surveys
services (treatment and
FGD
care)
Field visits evaluators
JC3.2. Participation of key affected populations in
development of (advocacy for) inclusive qualitative
HIV/AIDS services (treatment and care)
70
Meeting quality standards set by the government/national AIDS commission), accessible for key affected populations
Accessible: taking into account specific characteristics of a target group in particular like location, hours service is offered, cost of the
service, kind of service offered like combination of mobile VCT, Home based VCT, diagnostic VCT
72 According to the official quality standards
71
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Evaluation question 4: To what degree are improvements with regard to the rights of key affected
populations and their access to non discriminatory prevention and to quality treatment and care
sustainable?
Judgement criteria
Indicators
Sources of verification
JC1 Sustainability of changes at
JC1.1. Level of implementation of national
Interviews with partners
policy level with regard to rights
policies and laws that take into account
and external
of key affected population,
the rights of key affected populations
stakeholders
access to non discriminatory
JC 1.2. Partners or other relevant civil
prevention and to quality
society organisations take up the role of a
Focus group discussions
treatment and care
watch dog for national policy
with beneficiaries
development and implementation
JC 1.3. Key affected populations are
empowered to express their opinions and
know how to make their voices heard
JC 1.4. Governance structures of health
facilities are adapted to include voices of
key affected populations
JC 1.5. resource implications to guarantee
access to non discriminatory prevention,
quality treatment and care are taken into
account by private and public services
JC 2 Sustainability of the output
JC 2.1. Partners have developed an
of partners
appropriate advocacy and lobby strategy
(setting targets, planning, etc.)
JC 2.2. Partners are perceived as
legitimate advocates for the rights of key
affected populations (incl. access to
prevention, treatment and care) by
external stakeholders
JC 2.3. partners are aware of social and
cultural patterns that enhance
stigmatization and discrimination of key
affected populations and take them into
account
JC 2.4. Partners have developed an
effective strategy to build the capacity of
the CSOs (with regard to lobby and/or
delivering non discriminatory and
qualitative prevention, treatment and care
services)
JC 2.5. Bottlenecks to access non
discriminatory HIV prevention and to
qualitative treatment and care by key
affected populations are known by the
partners and partners have taken action to
deal with these bottlenecks
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Evaluation question 4: To what degree are improvements with regard to the rights of key affected
populations and their access to non discriminatory prevention and to quality treatment and care
sustainable?
Judgement criteria
Indicators
Sources of verification
JC 2.6. Partners are capable to attract
sufficient funding from different donors
JC3 Sustained access to non
JC3.1. Level of stigma and discrimination
discriminatory prevention of key
within the society (openness to address
affected populations
sensitive issues and acceptance of LGBT)
JC 3.2. Evidence of specific needs of key
affected populations with regard to
prevention, being addressed by the health
system through the private and public
services
JC 4 Sustained access to quality
JC4.1. AIDS is recognized as a chronic
treatment and care
disease and treatment and care are
included in the basic health care system
JC 4.2. Evidence of specific needs of key
affected populations with regard to
treatment and care being addressed by
the health system through the private and
public services
JC4.3. There do not exist financial
bottlenecks to access treatment and care
by key affected populations
Some factual data will also be collected. The whole partner portfolio in Latin America and India
will be described with regard to:
1)
Number of partners involved in advocacy and lobby on a rights based approach, in
particular regarding key affected populations;
2)
Participation of partners in Global Funds CCM;
3)
Number of campaigns in which partners have involved in focussing on respect for the
rights of LGBT, MSM, sex workers and PLWH.
4)
Number of partners involved in advocacy and lobby on equitable and nondiscriminatory HIV prevention;
5)
Number of partners involved in implementation of on equitable and non-discriminatory
HIV prevention;
6)
Number of volunteers and peer educators trained;
ACE Europe-ETC Crystal /Evaluation HIV and AIDS program of Hivos /Final evaluation report pag. 131/176
7)
Number of partners involved in WWP programs supported by Hivos.
8)
Number of partners involved in advocacy and lobby on accessible and qualitative
treatment and care for key affected populations;
9)
Number of partners involved in implementation of accessible and qualitative treatment
and care for key affected populations.
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11.3.
OVERVIEW OF CURRENT PARTNER PORTFOLIO IN INDIA
Partners in India + regional73
South India
SIAAP, works with the most marginalized sections of the society affected by HIV/AIDS
AIDS Action
(PLWHA, sex workers, truckers, sexual minorities). Now promotes, develops and
Program
strengthens CBOs / training and supervision/ supported over 100 NGOs in the three
(SIAAP)*
southern states of Andhra Pradesh, Tamil Nadu and Karnataka/ training of VCT
counsellors/ advocacy / established lawyers network/ sensitization of HWs / promoted
Sangams (groups) of Female Sex Workers (FSWs) and MSM / forged a coalition of 8
partner NGOs across 5 south Indian states to implement a common program on halting
Aids related poverty (EU funded). Now: program to reduce HIV prevalence in 13 high
prevalence districts of Tamil Nadu, directed to young and newly married women,
female sex worker (FSWs) and MSM, interventions in line with the priorities set in the
National Aids Control Program (NACP III).
Since 1992 supported by Hivos (co-financing, HIV/AIDS program development for
NGOs/CBOs; CBO initiatives in STD/HIV). In 2006 EU (until 2009 and SAN!) funding:
‗Challenging AIDS related poverty, interventions with ownership, diversity, innovations
for poor and marginalised communities in South India). Since 2001: funding for
proposal for 2001-2005). 2008-2012, co-financing, addressing broader sex health
issues around HIV prevention and care; and 2009: co-financing, improving HIV
prevention and care among young women, FSW, and MSM in rural Tamil Nadu.
Positive People
PP largest NGO working in the field of HIV/ AIDS in Goa (since 1991) / Services
(PP)
include prevention, care and support services (includes counseling, home based care,
referral services, medical updates, advocacy, publicity of the issue and promotion of
HIV/ AIDS self help groups). PP‘s prevention projects focus on different sections of
society like industries, educational institutions, sex workers, nurses and paramedics,
women, youth, construction workers, truckers, migrant labourers, religious leaders, the
population living and working in and around beach areas. Though PP‘s projects relate
mainly to HIV/ AIDS, some projects like the Educational Institutions involve issues like
sexuality and the women‘s project covers issues of reproductive health.
Partner since 1995, beginning co-financing, educational campaigns on HIV/AIDS; later
(1999-2007): co-financing ‗Positive living‘.
AIRTDS
AIRTDS is a counterpart of Hivos from 1996. Works for the overall development of dalit
and tribal communities. Providing health care for women and children, environment
awareness, trainings, income generating activities, and HIV/ AIDS intervention among
commercial sex workers. In 1994, an issue based Network of 10 NGOs emerged to
work on the issue of HIV/ AIDS in Andhra Pradesh. The ground work for this was done
by Interaid, a French donor agency, and Hivos-partner SIAAP. Interaid and SIAAP
have jointly worked out the strategy to rapidly increase the outreach of HIV/ AIDS
intervention programs in South India by involving NGOs to take up HIV intervention
work. AIRTDS acts as nodal agency and channelizes funds for the NGOs in the
73
* included in the field visits
ACE Europe-ETC Crystal /Evaluation HIV and AIDS program of Hivos /Final evaluation report pag. 133/176
Partners in India + regional73
Network. In 1996, AIRTDS approached Hivos to extend funding for HIV/ AIDS
intervention in the 10 districts of Andhra Pradesh on behalf of the Network. Hivos
supported the network since 1996.
Belgaum
BIRDS (established in 1980) is active in organizing the rural poor in the remote
Integrated Rural
northern parts of Karnataka. BIRDS target groups women in sex work in Belgaum
Development
district in 1993 as one of the NGO partners of Karnataka Network of NGOs working
Society
with women in sex work promoted by SIAAP - Chennai. Later BIRDS took over as the
(BIRDS)*
nodal agency of the network and expanded its operation to different districts of
Karnataka state in 1996 with support from HIVOS. BIRDS promoted and strengthened
the district collectives comprising women in sex work as a strategy to counter the HIV
AIDS epidemic in the state. The district collectives federated themselves under
SAHBHAGINI (a registered federation of women in sex work-Karnataka) which is a
partner in program management.
Vision: empower women in sex work to access and demand their rights/ counsellors
trained by BIRDS have been inducted into the Government run VCTCs.
BIRDS has established synergistic links with organisations having technical skills in the
sector at the local, national and international level such as NACO (National AIDS
Control Organisation), SIAAP, Chennai, INP+ ORISSA, Karnataka State AIDS Control
Society (KSACS), Indo-Canada HIV-AIDS Prevention Program (ICHAP), UNICEF, and
the AIDS Prevention and Control Society (APAC), Karnataka Health Promotion Team
(KHPT), International Institute for Population Science (IIPS), Mumbai among others.
Hivos‘ partner since 2000 (co-financing: program impact assessment; NGO PT
network HIV international; strengthening of collectives of women in sex work to
address issues of HIV/AIDS – until 2010/SAN! funded).
IDEAL
IDA (1992) – target groups marginalised communities (women, poor tribals, dalits, HIV
DEVELOPMENT
affected persons, and farmers of Keonjhar District of Orissa State). IDA plays a
AGENCY (IDA)
significant role in advocacy and lobby for the development of policies that are
supportive of women, HIV/AIDS, tribals and dalits. IDA has a strong base at the
community level and strong in influencing policy at state level.
Partner, 2004-2006, SAN!, IDA-community based STD/HIV/AIDS in Northern Orissa
South Orissa
Since 1993 works with communities that are marginalized, such as migrant labourers,
Voluntary Action
poor tribals and women of Koraput District of Orissa State. Empowerment / prevent
(SOVA)
HIV/AIDS among the vulnerable population and support the PLWHAs in the Boriguma
Block and SEWA Paper Mill and its peripheries, situated adjacent to the Boriguma
Block in Koraput District of Orissa. / training / awareness / IEC campaigns
Partner, 2004-2006, SAN, SOVA: prevetinion and care: intevrtions in HIV/AIDS
UTKAL SEVAK
Since 1985 - main target group for USS is the communities that are marginalised
SAMAJ (USS)
including tribals, dalits, migrant labourers, and women of Cuttack District of Orissa
State. Creation of community grain/seed bank/community centre establish/ The main
target group for USS is the communities that are marginalised including tribals, dalits,
migrant labourers, and women of Cuttack District of Orissa State. / capacity building/
training / sensitisation of CBOs and small NGOs / establishment of health care centre
ACE Europe-ETC Crystal / evaluation HIV and AIDS program Hivos / Final evaluation report pag. 134/176
Partners in India + regional73
with full time STD staff with treatment for STI/RTI and counseling services.
Partner, 2004-2004, SAN, USS: prevention and control of HIV/AIDS and rights of
PLWHA
INP+ ORISSA
Since 1997, membership organisation of PLHAs, has 22 state and 235 district level
Indian Network
networks in India with a membership of 1, 29,000 PLHAs. Mission: improve the quality
for People Living
of life of the PLHAs in India and provide a sense of belonging to PLHAs and their
with HIV/AIDS
families for their active participation in the society and also prevent further HIV
(INP+ ORISSA)
transmission. INP+ ORISSA focuses on three critical areas: Advocacy, Network
Building and Services for PLHAs.
Hivos: building
Members: sex workers, MSM, Intravenous Drug Users (IDUs), Trans Genders (TG),
strong networks
and affected people from the general population
of positive
Primary emphasis ensuring that ART is available on a continuous basis / Positive
people at
Speakers bureau/ consistently pushed for Greater Involvement of Positive People
district, state
(GIPA) with the State and Civil Society at all levels which has contributed to the
and national
National Aids Control Organisation (NACO) adopting the GIPA policy.
level
INP+ ORISSA nominated as member of UN theme group CCM for GF. affiliated to
Global Network of Positive People (GNP+), International Community of Women Living
with Aids (ICW) and Asia Pacific Network of Positive People (APN+). INP+ ORISSA
formed a National Women‘s Forum (NWF) / INP+ ORISSA has aligned its work within
the larger framework of National Aids Control Organisation (NACO) which under
National Aids Control Program (NACP III) aims to provide prevention, treatment and
care & support through Community Based Organisations (CBOs). Hivos supports INP+
ORISSA because promoting and strengthening membership organisations and CBOs
especially from the semi rural areas are central to Hivos‘ institutional policies.
Partner, 2005, Microfunds, INP+ ORISSA: capacity building of positive people
Partner, 2006-2008, co-financing, INP+ ORISSA: to strengthen the capacity of state
level network
Partner, 2009 – co-financing, INP: building strong network of positive people at
national, state and district level
Concern*
Concern Worldwide is international, humanitarian NGO dedicated to the reduction of
suffering and working towards the ultimate elimination of extreme poverty in the world's
poorest countries. Concern Worldwide is one of the seven European donors (including
Hivos) that constitute the Alliance 2015 Donor Consortium. The achievement of the
MDGs is the primary focus of Alliance 2015.
Hivos and Concern have jointly been implementing a program on HIV and Aids in
Orissa since 2006 with four implementing partners- South Orissa Voluntary Action
(SOVA), Utkal Sevak Sangh (USS), Ruchika Social Service Organisation (RSSO) and
the Orissa state network of positive people (OSNP+/ INP+ ORISSA). The next phase
of the program beginning January 2009 is also supported by the European Union. The
overall objective of the program is to respond effectively to the HIV and AIDS
pandemic in Orissa; reducing risk and vulnerability to HIV infection and ensuring that
those People Living with HIV (PLHIV) or affected by it have an improved quality of life.
Specific: strengthen capacity of CBOs and population and local implementing partners;
ACE Europe-ETC Crystal /Evaluation HIV and AIDS program of Hivos /Final evaluation report pag. 135/176
Partners in India + regional73
increase access to PMTCT services in Orissa; reduce stigma of vulnerable
communities. The target groups for this program are youth - rural and tribal; college
students and young professionals; and slum and street adolescents. Apart from these
core populations the program would also look at mobile populations such as mini truck
and long distance taxi drivers, auto/taxi drivers and coolies and the high risk
populations of sex workers, IDUs, MSMs, women, People Living with HIV.
Partner, 2006-2009, private, Concern: strengthening local responses to HIV/AIDS
Partner, 2006-2009, co-fainancing, Concer: strengthening local response to HIV/AIDS
Partner, 2009- co-financing, Concern: HIV and AIDS program in Orissa Phase 2 (20092013)
SAMPADA
Since 1992 in Sangli district of Maharashtra which has the highest incidence of HIV,
GRAMEEN
after Mumbai in Maharashtra. It believes that people should believe that they can
MAHILA
change things. It works with a philosophy that is not about a few activists fighting for
SANSTHA
other people's rights. It concurs that anybody who has imbibed this understanding
(SANGRAM)*
should be able to go and fight for their rights. SANGRAM responds to HIV/AIDS
through a comprehensive strategy of prevention, care and support. It reaches sex
workers and married women, clients, husbands and lovers, teenagers and truck
drivers, orphans and widows, panchayat heads and policemen. Gender project:
address the relationship between violence against women and HIV/AIDS /
empowerment / girls
XXX
NAZ Foundation
Naz Foundation International (NFI) is an international non-governmental organisation
International
that advocates to improve the sexual health, welfare and human rights for men who
(NFI) / UK
have sex with men (MSM) and their partners. With a primary focus on MSM, NFI's
mission is to empower socially excluded and disadvantaged males to secure for
themselves, social justice, equity, health and well-being.
NFI provides technical, financial and institutional support to MSM networks, groups and
organisations in India. It ensures that issues of male sexualities and sexual practices
are appropriately and adequately addressed in the provision of HIV/AIDS and sexual
health services. Wherever possible it provides technical assistance, capacity building
and support to local self-help sexual networks, groups and organisations for the
development of community-based and beneficiary-led HIV/AIDS and sexual health
services and advocate on their behalf. Since 2006, NAZ Foundation has supported the
setting up of APCOM (Asian Pacific Coalition on Male Sexual Health) to promote HIV &
AIDS prevention among MSM in the Asia Pacific Region.
APCOM: lobby / advocacy
XXX
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11.4. PLANNING OF THE FIELD MISSIONS
11.4.1. PLANNING INDIA MISSION
Dates
Activities
July 6
Arrival Carolien Aantjes in Chennai
July 7
MSC start-up workshop
July 8
Evaluation visit to South India AIDS Action Program (SIAAP)
July 9
Evaluation visit to SIAAP continued
July 10
Meeting with the consultants, data analysis
July 11
Travel by air to Pune, by road to Sangli
July 12
Evaluation visit to Sampada Grameen Mahila Sanstha (SANGRAM)
July 13
Evaluation visit to SANGRAM continued
July 14
AM: Travel to Belgaum
PM: Evaluation visit to Belgaum Integrated Rural Development Society (BIRDS)
July 15
Evaluation visit to BIRDS continued
July 16
AM: Evaluation visit to BIRDS continued
PM: Travel to Hubli by road, travel to Bangalore by air
July 17
AM: Meeting with Biswhadeep Ghoose, HIVOS Regional Office
PM: Meeting with the consultants , data analysis
July 18
Travel to Bhubaneswar
July 19
Evaluation visit to Orissa Network of people living with HIV/AIDS (INP+ Orissa )
July 20
Evaluation visit to INP+ Orissa continued
Evening: fly out to Delhi and onwards to Amsterdam
ACE Europe-ETC Crystal /Evaluation HIV and AIDS program of Hivos /Final evaluation report pag. 137/176
11.4.2. PLANNING PERU MISSION
Date
Activities
Stakeholders involved
Saturday, 3-07-2010
Arrival in Lima
International consultant
Sunday, 4 -07-2010
Desk study and briefing local
Evaluation team
consultant
Monday, 5 – 07-2010

preparation workshop


Start up workshop

Local consultant
Two staff members from Via
LIbre, Prosa, IESSDEH and
one from AfA
Tuesday, 6-07-2010

Visit to Via Libre
Meeting with staff (#8) +
discussing timeline developed for
EU evaluation (2009)

Participation conference
IESSDEH on sexual
diversity

Wednesday, 8-07-2010

Study of documents
Interviews external

stakeholders (general)

Thursday, 9-07-2010

Study of documents

Visit to Prosa
Representante de las PVVS
en la Conamusa

ICW
Meeting with staff (#5) +
timeline exercise
Friday, 9-07-2010

Intevriews external
-
Cepesju
-
mother of a child with
stakeholders (general)

beneficiaries Prosa
HIV, supoprted tob ring
her case to court

PVVS Callao
Return to Belgium
Date
Activities
Stakeholders involved
Saturday, 11-09-2010
Arrival in Lima
International consultant
Sunday, 12 -09-2010
Desk study and meeting local
Evaluation team
consultant
Monday, 13 – 09-2010
Tuesday, 14-09-2010
Interviews external stakeholders

Defensoria del Pueblo

Promsex

Red perunos Positivos

UNFPA

Plataforma LGTB de Calloa

Visit AfA – interviews staff

All staff of AfA (#3)

Interviews beneficiaries

CBO observatorio de la
ACE Europe-ETC Crystal / evaluation HIV and AIDS program Hivos / Final evaluation report pag. 138/176
mujer

Red national de mujeres
con VIH (participa al
observatorio de la mujer)


Focus group peer educators

Movimiento de TS del Peru
Peer eduactors youth
projects

Interviews external

stakeholders (general) (team
has split up)
Secretaria tecnica de la
CONAMUSA

Jefe de la estrategia
nacional de ITS y VIH/SIDA

Abogado y activista en
DDHH

Coordinadora nacional de
los DDHH
Wednesday, 15-07-2010

Visit to IESSDEH – meeting

group interview staff (#5)
with staff

Interview beneficiaries

Movimiento de TS del Peru

Focus group participants

Focus group with
cuidadaniasX
representatives of TS de
Callao (#2), red peruana de
mujeres con VIH,
coordinadora peruanos
positivos

Thursday, 16-07-2010


Interview director IESSDEH
Focus group participants

Focus group with artists that
ciudadaniasX
participated in the cultural
Additional interview
activism actions
coordinator project
CuidadaniasX

Interview external

Director Prosa

Red Sida
stakeholders IESSDEH

Interviews external
stakeholders general
Friday, 17-07-2010

Visit to Via Libre

Interviews external
stakeholders
-
director and 2 project
managers
-
priest
Saturday, 18-07-2010
Reporting
Evaluation team
Sunday, 19-07-2010
Reporting and preparation
Evaluation team
restitution
Monday, 20-07-2010

Restitution
Two staff members from Via

Return to Belgium
LIbre, Prosa, IESSDEH and one

Interview external
from AfA
After the mission, in NOvember
MOHL
stakeholders
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11.5. PERSONS MET
6.5.1. HIVOS
Kwasi Boahene
Miriam Musch
Corina Straatsma
Artien Utrecht
Bishwedeep Ghose
Hivos Program
Hivos Program
Hivos Program
Hivos Program
Hivos Program
Manager HIV/AIDS
Officer HIV/AIDS South America
Officer HIV/AIDS Bolivia
officer Human Rights South America
Officer HIV/AIDS India
6.5.2. MISSION PERU
VIA LIBRE - STAF
Robinson Cabello
Ada Meija
Jimmy Carreazo
Manuel Rouillon
Julio Lata
Sulay
Alfonso
José Luis Castro
Alfonso Lescano
Executive Director
Director programs
Director health services
Director HR and administration
Project coordinator
M&E officer
Project coordinator (SOMOS)
Project coordinator (SOMOS)
PROSA – STAF
Julio Cesar Cruz
Flora
Oscar
Luis Malon
Director
Administration
President
Communication
AID FOR AIDS – STAFF
Teresa Ayala
Lidice Lopez
Ethel
Director
Program officer Observatorio Latino
Program officer Observatorio de la mujer and youth
project
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IEESSDH – STAFF
Carlos Cáceres
Ruth Iguiñiz
Ximena Gutiérrez
Ximena Salazar
Fernando Olivos
Jorge Martínez
Director
Coordinadora del área de estudios político
programáticos-coordinadora del secretariado de
la IASSCS
Administradora
Coordinadora Ejecutiva
Coordinador del Proyecto Ciudadaniasx y del
área de comunicación abogacía y derechos
humanos
Punto Focal del Monitoreo y Evaluación del
Proyecto Ciudadaniasx
EXTERNAL STAKEHOLDERS
Ender Allain
Luisa Córdona
José Luis Sebastián
Susel Paredes
Jorge Liendo y Suzana Chavez
Guisselly Flores
Marina Soto
Maria Luz
Anna Maria Rosasco
Ercilio Moura
Julia Campos
Sonia Parodi
Carmen Murguía
José Fedora
Pablo Anamaria
Carmen Guevara
Christian Pacheco
Delma
Lita Aurca
Christian Olivera
Secretaria Técnica de la CONAMUSA
Defensoría del peublo
Ministerio de salud. Jefe de la estrategia nacional
de ITS y VIH/SIDA
Abogada y activista por los derechos humanos
Promsex
Red peruanos de mujeres viviendo con VIH
ICW
ICW
Cepesju (antes de Via Libre y del IESSDEH)
Coordinadora nacional de los derechos humanos
Red SIDA
Red PVVS - coornidara de la red National
Peruanos positivos
UNFPA
Iglesia
ex personal de Prosa, miembro de la Conamusa,
Madre de niño viviendo con VIH a cause de
transfusión de sangre infectado (caso de
incidencia politica)
PVVS Callao
Red nacional de las mujeres (AfA)
CBO, participante del observatorio de la mujer
(AfA)
Coordinador del MoHL
FOCUS GROUP DISCUSSIONS
Aid for




Aids – Peer educators youth project
Corina Milagro Mosquida Faipe
Raúl Eduardo García Barrientos
John Pomari Huiman
Pamela Navarro Flores
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Prosa - Plataforma LGTB Callao





E. Gomeja
Carlos Alfonso Sarmiento Piacencia
Kapla Lino Heredia
Carlos Huamanchumo Villamonte
Takaki Robles Ganno
IESSDEH – Ciudadaniax – gruop of PLHIV and sex workers that have particpated in
the project
 Hayde Flores
 Pablo Anamaria
 Guiselly Flores
 Leyda Portal
 Karina Quispe
IESSDEH – Ciudadaniax – group of artists and activist that have particpated in the
project
 Alfonso Silva Sansisteban
 Javier Vargas
 Rocio Gomez
 Alberick Garcia
 Fedora Martinez
6.5.3. MISSION INDIA
SIAAP
 Group interview management:
Swaminathan, Anand Kumar, Chitra, Selvi, Raju, Selvakumar
 Group interview field officers:
Robin, Manickam, Sivakumar, Tirupathi, Hamsa, Suresh, Seethalakshmi, Saroja
 Group interview office staff:
Sundararaj, Tharani, Prabakar, Maya, Triloga Chandran, Lalitha Rajmohan, Lavanya,
Saraswathi
 Group interview rural youth project – STI and YFC counsellors
Sermakani – Kovilpatti; Rajakumari – Kovilpatti; Semmalar - Gudiyatham; Karunakaran –
Gudiyatham; Dhanalakshmi – Krishnagiri ; Bagyalakshmi – Kanyakumari; Vijayalakshmi –
Kanyakumari; Angayarkani – Tenkasi;Lakshmi – Tenkasi; Pandeeswari – Theni; Ilayraja –
Madurai; Sarojini – Sirkazhi; Karthik – Sirkazhi; Sudhakar – Tanjore; Murgesh Kannan –
Pudukkotai ;Vairamani – Salem;;Gunasekaran – Erode; Munnusamy – Tiruvannamalai
 Group interview counsellors trained by SIAAP
Kayalvizhi, Palanivel, Ezhilmurugan, NSP Chitra, Mohammed Rafique, Sridhar, Saravana
Muthu (visually challenged), Kaliammal (visually challenged), Selvam (community
counsellor), Sanjeev – SANGAMA, Bangalore, Michael– SANGAMA, Bangalore
ACE Europe-ETC Crystal / evaluation HIV and AIDS program Hivos / Final evaluation report pag. 142/176
 Focus group discussion FSW Federation
Shanthi, Kokila, Nazima, Vimala, Vijaya, Shanthi, Rosammal, Puyal Rani, Parvathi,
 Focus group discussion MSM federation
Sumathi, Kannadasan, Raman, Arumugam, Nataraj, C.A. Das
 Group interview Theni (Sarvojana)
Alagathai, Tamil Rani, Shankara Lingam, Pushpa
 Group interview TC
Saraswathi, Roselet, Palani, Krishnan, Indira
Interviews member of collectives



Anbukkarangal – 2 Members: Chitra & Rani
SMIS – 4 Members: Mary Thomas, Sarvanan, Soundar & Saraswathy
SWAM – 3 Members: Sekar, Jacob & Srinivasan
Interviews external stakeholders
 Lalitha Rajaram
 Dr. Shantha

Dr. Kuganantham

Mr. Perumal & Mr. Ravikumar

Angeline

Dr. Usman
Retainer Consultant
Ward Councillors - Periyakulam
INP+ ORISSA
Group interview staff Concern Worldwide



S. Gomathi
Aparajita Dhar
George Kerketta
Senior Program Officer
Program Manager
Assistent Program Officer
List of people of INP+ Orissa that participated in the orientation session







Suryamanta Behera
Sanjib Kumar Sahu
Rakesh Mahapatra
K. Santosh Kumar
Subrat Maharana
Lousie Creber
Sarita Hota
AAC- Brahamapur
MIS & Documentation Associate
Network Support Associate
GIPA Coordinator
DRA-Khurda
VSO Volunteer
Accountant
List of staff that participated in the timeline workshop





Suryamanta Behera
Sanjib Kumar Sahu
Rakesh Mahapatra
K. Santosh Kumar
Subrat Maharana
AAC- Brahamapur
MIS & Documentation Associate
Network Support Associate
GIPA Coordinator
DRA-Khurda
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



Lousie Creber
Manoj Ranajan Das
Laxmidhar Das
Banmali Nayak
VSO Volunteer
DRA- Angul
DRA-Balasore
DRA- Ganjam
Group interview DLN leaders
Gitanjali Pattanaik, Papu Singh, Manishankar Bag, Biswamitra Harpal, Ripu Chandra
Khura, Manjulata Nayak, Pushpalata Mohanta, A Dillip Kumar Rao, Dheeraj Nayak,
Jayakrushna Sahoo, Panchu Bhola, Sarita Hota
Overview of interactions with several support staff at Khurda Hospital
Badrinath Mohanty (attendant); Satyananda Sahoo (security guard); Purna Chandra
Sahoo (attendant); Jadunath Sahoo (sweeper); Harichandan (attendant); Sahoo Babu
(security guard)
Interview with two counsellors, an ICTC counsellor and a STD counsellor
Interview with members of a support group meeting
Bideshini Tripathy (Support Staff INP+), Manorama Maharana (Field Worker), Laxmi Rana
(House wife), D. Sudha Rao (BNP+ Pressident)
Interviews external stakeholders





Anuja Behera
Mitali Mohanty
Subhalaxmi Mohanty
Sashiprabha Bindani
Ms. Pranati
OSCAS official - CMS Consultant
SAATHII official - Training and Coalition Coordinator
SAATHII official - Helpline Advisor
Director HRLN
Project Coordinator HRLN
BIRDS STAFF
Group interview with staff
 BK Barlaya
 Jeevankumar
 Bhagya BK
 Ambika
 Gangawwa
 Shivagami
 Shama
 Jyothi
 Drakshayanamma
Group interview CBO leaders
 Lalitha
 Shama
 Suntha
 Yashoda
 Kamarunnisa
 Drakshayanamma
 Shivagami
 Rathna
Executive officer Birds Naganur
Staff Birds
Liaison officer, Birds HIVOS project
Accountant Birds
Peer coordinator Birds
Peer coordinator Birds
Peer coordinator Birds
Peer coordinator Birds
Peer coordinator Birds
Shakthi Sangha
Srusti Sangha
Durbar Sangha
AIDS Jagruthi
Malenadu Sangha
Sanjeevini Sangha
Hassan Sangha
Chetana Sangha
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

Renukamma
Bhagya BK
Sadhana Sangha
Liaison officer Birds
Group interview CBO members Shakthi Sangha
Lalitha Hosmani
President
Laxmi Kamble
Vice president
Nagamma Sangolli
Secretary
Gangawwa Teli
Peer coordinator
Prakash Kurubet
Technical Staff
Gangadhar
M&E officer
RB Patil
Taluk coordinator
IP Bannibhagi
Taluk coordinator
Yamanawwa kamble
Taluk peer coordinator
Shoba Chalawadi
Taluk peer coordinator
Prabhavathi
Taluk peer coordinator
Uma
Taluk peer coordinator
+ staff members: Sunitha Jayale, Gangawwa Madhur, Durgawwa Mestri, Savitri Madhur,
Anjana Gudaj, Suvarna Sutar, Jyothi Kadam, Roshni, Mangala, Reshma, Renuka, Staish
Focus group discussion with community members at Mudalagi
 Deavakka Kanski
 Vidya Pujeri
 Manjula Parsannavar
 Rajashree Gasti
 Soniya Nagannavar
 Shoba Gasti
 Akkamma Shanwale
 Yamanavva Mellegri
 Yamanavva Bhangennavar
 Laxmi Hadimani
 Vidyashree Metri
Interviews external stakeholders
Ravikittur
ART Counselor, Bijapur
Guru Hiremath
ICTC Counselor, Gulburga
Kiran Bhagoji
ART Counselor, Belgaum
DV Mutnal
Lawyer Belgaum
AS Anikindi
Lawyer Gokak
MS Putani
Social welfare Officer Gokak
6.5.3.
SANGRAM
Group interview staff
Sangita Tadakhe, Sima Patil, Sushila Kunde, Shantilal Kale, Sashikala Surve, Alka
Waichal, Sindhutai Pawar, Jayashree Pakhare, Sangita Kore, Mr. Sunil Gade
Focus Group with Group of Sangram plus
Suerkha Kale, Shalan Pawar, Sangita Sutar, Alka Patil, Lata Lakan, Yashoda Khot,
Reshma Khot, Savguni Kale, Chandbi Mulla
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Interviews external stakeholders





Dr. Mrs. Nandrekar - Medical officer at the Publich Health Clinic Kavathe Piran
Pandurang Jaganath Kamble - Principal college Vinaee Ashram Shala
Mrs. Sujata Madane (chairperson) , Mr. Madane (member), Dr. Ashok Sutar
(Taluka health officer) – Block Development office, Islampur
Mr. Hanmantrao Patil – Block Development officer Shirala Block
Somnath Gharge (sub divisional police officer) and Prashant Mahadik (police
officer) – Police station Islampur
Group interview collective Kurlup Grmpancahayt
Prakash Shivaji Patil (sarpanch), Prakas B. Pawar (deputy), Namdev Devkar (ex
sarpanch), Tukaram Gaikwad (gramsevak), Dinkar Pawar (member)
Focus group youth group “Youth Mandal, Maitrin” at Kurlup
Sashikant Maruti Shingare (supervisor public health clinic), A.A. Patil supervisor public
health clinic),Satish Balasaheb Patil (teacher), Aparna Tanaji Satpute (maitrin) , Lata
Uttam Wategaonkas (maitrin), Vaibhav Dhanwade (member), Sandip Pawar (member),
Sagar Satpute (member), Suhas Devkar (member), Rahul Mali (member), Amol (member)
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11.6. DOCUMENTS CONSULTED
GENERAL

HIVOS, HIV and AIDS policy 2001

HIVOS HIV and AIDS policy 2010

Hivos, annual plan 2010 Civil choices program

De Bruyn, Maria (October 2005) Women, gender and HIV/AIDS. Where are we now
and where are we going? Hivos paper.

Policy brief on gender mainstreaming, HIVOS 2010

For all partners, following documents have been consulted:
o
Kenschetsen
o
Program proposals, logical frameworks and budgets of the programs
presented for Hivos financing
o
Annual reports
o
Organisation assessments
o
Communication between Hivos and the partners
o
To the extent available, evaluation reports
o
Websites of the partners
SPECIFIC ADDITIONAL DOCUMENTS CONSULTED DURING INDIA MISSION

Aggleton, P. et all (April 2005) HIV-related Stigma, Discrimination and Human Rights
Violations. Case studies of successful programs. UNAIDS Best Practice Collection,
Geneva.

Banerjee, P. (July 2009) Strategic and programmatic review of Alliance 2015 HIV
program in Orissa.
ACE Europe-ETC Crystal /Evaluation HIV and AIDS program of Hivos /Final evaluation report pag. 147/176

Program for appropriate Technology in Health (March 2007) HIV-SRH Convergence.
Policy and Practice update 2. PATH, New Dehli.

Reid.E. (September 2009) End of project evaluation report, Sarvojana Coalition.

UNGASS Progress report 2010 India

Websites of UNAIDS and NACO India
SPECIFIC ADDITIONAL DOCUMENTS CONSULTED DURING PERU MISSION

Cardens, P. (2009) Reporte del IV foro comunitario de America Latina y del caribe sobre
VIH/SIDA e ITS. Lima. Via Libre

Caceres, C. (2009) Lecciones Aprendidas de la Colaboración con el Fondo Mundial en VIH
y SIDA en el Perú. Efectos en el Sector Publico, Sociedad Civil y Comunidades Afectadas.
Hallzagos de la primera fase del estudio. Lima, IESSDEH

Ccapa Quispe, A. And Lescano Morales, A. (2009) Estudio exploratorio sobre stigma y
discriminación en poblaciones claves. Via Libre. Lima.

Defensoria Del Pueblo. Legislación sobre VIH. Normas nacionales. En:
http://sistemavih.defensoria.gob.pe:8081/nlvih/seacrchnl.do

Diez F. (2005) Estigma y Discriminación: La mirada de las personas viviendo con VIH/SIDA
en el Perú. Proyecto Policy (USAID), Lima.

Fernández A. And Pait, S. (2008) Evaluación Externa del Programa de soporte a la Auto
ayuda de personas seropositivos. Certum, Lima.

Informe nacional sobre los progresos realizados en la aplicación del UNGASS. Periodo
enero 2008-diciembre 2009.

Ministerio de educación (julio 2008) Lineamientos educativos y orientaciones pedagógicas
para la educación sexual integral república del Perú. Manual para profesores y tutores de
la educación básica regular. Perú, Lima.

Ministerio de jusitica. Plan nacional de derechos humanos 2006-2010

Ministerio del interior. Policia nacional del Perú. (mayo 2006) Manual de derechos humanos
aplicados a la función policial. Resolución ministerial no.1452-2006-IN.

Ministerio de Salud Perú: Informe sobre los progresos realizados en la aplicación del
UNGASS. Periodo Enero 2008-Diciembre 2009, 2010

MINSA. Plan estratégico multisectorial 2007-2011 para la prevención y control de las ITS y
ACE Europe-ETC Crystal / evaluation HIV and AIDS program Hivos / Final evaluation report pag. 148/176
VIH/SIDA en el Perú.

Olivos, F. (2009) Arte, activismo y cambio cultural: nuevas sinergias para la accion.
En:Cáceres, C. et all (2009) Promoción de la salud sexual : aportes para la investigación y
la acción. IESSDH. Universidad Peruana Cayetano Heredia. Lima.

Proyecto de ley general de salud sexual y reproductiva. Presentatdo por un grupo de
congresistas en 2007.

Promudeh. Plan nacional de acción por la infancia y la adolescencia 2002-2010

Ramirez, J. B. and Castro Chuquillanqui, J.L. (2010) Actuemos ya ! Guía de incidencia
polítca para personas trans. Via Libre, Lima.

Salazar, X. Santisteban, S. Et al. (2010) Las personas trans y la epidemia del VIH/SIDA en
el Perú: Aspectos sociales y epidemiológicos. IESSDEH, Lima.
ACE Europe-ETC Crystal /Evaluation HIV and AIDS program of Hivos /Final evaluation report pag. 149/176
11.7.
GUIDELINES ON MOST SIGNIFICANT CHANGE
THE “MOST SIGNIFICANT CHANGE” TECHNIQUE AS AN EVALUATION TOOL
The objectives of this evaluation are to know to what degree have/has

Human and sexual rights of key affected populations been strengthened?

Access to equitable, non discriminatory HIV prevention improved?

Access to sustained quality treatment and care improved?
Official data and data from the evaluation and annual reports will be collected. This information
will be completed by the perception of the beneficiaries with regard to their rights (respect of
human and sexual rights, access to prevention and access to treatment and care). To that end,
we would like to make use of the technique ―Most Significant Change‖. To implement this
technique, we need your collaboration. We would like to ask you to invest some of your time
implementing the Most Significant Change technique. We think this technique can also come up
with interesting information that is relevant for your own monitoring and evaluation activities and
could become a monitoring tool for your own M&E system.
Following we describe briefly the most significant change technique and give you some
guidelines for implementation.
MOST SIGNIFICANT CHANGE (MSC)
MSC74 is a form of participatory monitoring and evaluation based on recording stories amongst
all kind of stakeholders. Unlike conventional approaches to monitoring and evaluation, the MSC
approach does not employ quantitative indicators.
Essentially, the process involves the
collection of significant change stories emanating from the field level, and the systematic
selection of the most significant of these stories by panels of designated stakeholders or staff.
Once changes have been captured, various people sit down together, read the stories aloud
and have in depth discussions about the value of these reported changes. Necessary steps to
be taken are :
74
MSC technique was originally developed by Rick Davies (Davies, 1996, 2005) and later refined by Jess Dart
(Dart, 1999)
ACE Europe-ETC Crystal / evaluation HIV and AIDS program Hivos / Final evaluation report pag. 150/176

Collect stories of change

Review the stories and select most significant

Document reasons for choice

Feedback results
Following we‘ll describe how this technique should be implemented in the perspective of this
evaluation.
GUIDELINES TO IMPLEMENT THE MSC TECHNIQUE
We describe five phase (when MSC is used as a monitoring tool, 9 phases are foreseen).
1. Identification of “domains of change”
Depending on the nature of the programs you are implementing, several domains of change
can be identified. These domains of change concern the spheres of influence that are most
relevant to your program. Domains are broad and often fuzzy categories of possible changes.
For example: changes in health, changes in income, changes in the quality of people‘s lives,
changes in the nature of people‘s participation in development activities, changes in the
sustainability of people‘s organisations and activities, etc. A domain of change is NOT an
indicator.
Three to five domains of change can be identified. It is also possible to identify only one domain
of change. We suggest that these domains of change will be identified by the staff.
2. Starting
You have to decide what stakeholders and staff you will involve in MSC. Look for people and
sections of your organisation that will be most interested and enthusiastic about the potential of
MSC.
-
Staff has to collect the stories and organise discussions on the recorded stories.
-
Stakeholders – identify amongst your beneficiaries who are the best people to capture
the MSC stories from.
ACE Europe-ETC Crystal /Evaluation HIV and AIDS program of Hivos /Final evaluation report pag. 151/176
3. Collect the stories
There are many ways to collect significant change stories such as by interview or through group
discussion. Beneficiaries can also write down themselves some stories. Ideally the significant
change stories will be 1-2 pages long.
The main questions to be asked are:

― From your point of view, describe changes that has resulted from your involvement
with the … project/program, with regards to (domain of change)?‖

―Select the MOST significant change of all changes that you have mentioned‖ Try to
describe this change in the form of a story.

― Why was this change significant for you?‖
Staff will have to record the stories and ask the interviewee for permission to use these stories
for reporting to donors (can be anonymous). We propose a format to be used for recording the
stories (see annex 1). We ask you to collect minimum 30 stories (the more the better).
4. Selection process
The selection process will be organised at beneficiary level and at staff level. Organise group
discussions and foresee a facilitator.
The purpose of this phase is to reduce the pile of stories down to one (or two) stories per
domain of change. So if there are four domains, in each domain the participants will select a
story that they believe represents the most significant change of all. It might be possible that
you did not identify a domain of change beforehand. If this is the case, the first job to be done
after collecting the stories is to identify some domains of change (based on the stories
collected).
The selection process begins with reading some or all of the SC stories out loud or individually.
The facilitator can help the beneficiaries/staff to decide which the most significant stories are.
Whatever process you use to select the stories, it is most important to document the
reasons why certain stories were selected over the others.
Various discussion processes and techniques can be used, however the key ingredients to
story selection are:

Every-body reads the SC stories

Hold an in-depth conversation about which ones should be chosen
ACE Europe-ETC Crystal / evaluation HIV and AIDS program Hivos / Final evaluation report pag. 152/176

Come to a decision with regard to which stories everyone feels to be most significant
(choose if necessary 2 or 3)

Document the reasons for the choice
It is up to you to decide who will be involved in the story selection. This can be various groups
of beneficiaries and staff (when relevant, staff at different level). You can discuss the stories
recorded in one or several groups of beneficiaries, than followed by a discussion on the same
stories collected with staff.
For the evaluators, it is important that somebody is responsible for recording the reasons for
choosing the story. A format is proposed in annex 2.
5. Verification
During our visit we will ask you to give feedback on the application of the MSC technique and to
present the results. The evaluation team will also have some focus group discussions with
beneficiaries to verify the stories and changes mentioned (but other people than have been
involved in recording and discussing the stories). Results of the MSC will be discussed with
them. In the case focus group discussions will be organised before the collection of the stories,
a similar technique will be used to facilitate the focus group discussion (asking for changes,
prioritize these changes).
FORMAT FOR RECORDING THE STORIES
Name of the organisation
Name of the storyteller:
Name of the person recording the story:
Location:
Date of recording
From your point of view, describe changes that has resulted from your involvement with the …
project/program, with regards to (domain of change)
Change 1:
Change 2
Change 3:
Etc.
ACE Europe-ETC Crystal /Evaluation HIV and AIDS program of Hivos /Final evaluation report pag. 153/176
Select the MOST significant change of all changes that you have mentioned
Try to describe this change in the form of a story.
Why was this change significant for you
FORMAT FOR RECORDING THE REASONS FOR CHOOSING THE MOST SIGNIFICANT
STORY
Name of the organisation
Names of participants of the
workshop/group discussion to select the
MSC
Date of selection the MSC
What significant story (stories) has (have) been selected to be the MOST significant ones
What are the reasons for selecting this Most Significant Change Story?
ACE Europe-ETC Crystal / evaluation HIV and AIDS program Hivos / Final evaluation report pag. 154/176
11.8.
CV OF CONSULTANTS
CURRICULUM VITAE
1. Family name:
2. First names:
3. Date of birth:
4. Nationality:
5. Civil status:
6. Education:
Institution
Date: from (month/year):
to (month/year)
Degree(s) or Diploma(s) obtained:
PHLIX
Geertrui
04.12.1969
Belgian
Married, three children (°95, °97, °04)
Institution
Date: from (month/year):
to (month/year)
Degree(s) or Diploma(s) obtained:
Universitat de Barcelona
January 1992- March 1992
Catholic University of Leuven
September 1987- September 1992
Master in Educational Sciences, option Adult
education
International Erasmus Program on Adult
Education
7. Language skills: (Mark 1 to 5 for competence)
Language
Reading
Speaking
Dutch (mother tongue)
5
5
French
5
5
English
5
5
Spanish
5
4
Writing
5
4
5
3
8. Present position: Consultant and manager of ACE Europe bvba
9. Years within the firm:
10
10. Key qualifications:
 Evaluator of programs of NGO‟s and local authorities concerning local
development, capacity building of organisations, gender, municipal
international cooperation and joint action, development education
 Trainer (technical issues) on project and process management
 Trainer (specific topics) on gender and development, HIV and AIDS
mainstreaming, international cooperation at a municipal level
 Facilitator of awareness-raising and learning processes (on development issues
and the European integration)
 Project formulation and - management
ACE Europe-ETC Crystal /Evaluation HIV and AIDS program of Hivos /Final evaluation report pag. 155/176


Facilitating gender and HIV/AIDS mainstreaming processes
Policy preparatory work (development of concepts and methodology in the area
of development cooperation)
 Organisation of international seminars and exchange programs
11. Specific experience:
Kenya, Ethiopia, March 2009Team leader of the PSO program evaluation, part of the
October 2010
South Sudan
larger study on “Dutch support to capacity
development, evidence based case studies”.
Assignment for the IOB, The Netherlands. General
coordination and team leader of the case studies in
Kenya, Ethiopia and Southern Sudan.
DR Congo
January 2009 Coordination of the evaluation on partnerships and
December 2009
capacity development involving partnerships between
Belgian NGOs and their partners in the South.
Methodological support, coordination of the missions
to DR Congo, India and Peru. Team leader of the field
mission to Kinshasa and Kisangani. Assignment for the
service of the specific evaluator of the Ministry of
Foreign Affairs Belgium.
Belgium
March 2009 –
Evaluation of the awareness raising programs
December 2009
(development education) implemented by FOS,
Socialist Solidarity Belgium in the period 2008-2009.
An assignment for FOS.
Belgium
March 2009Evaluation of the campaign on decent work,
December 2009
implemented by a coalition of Belgian NGOs and the
trade unions, under coordination of 11.11.11. An
assignment for 11.11.11.
The Netherlands December 2008- Limited policy review of the cofinancing system 2008March 2009
2010. An assignment for the IOB, The Netherlands
Bolivia
July 2008Evaluation of the quality of the performance of the
December 2008
Belgian Technical Cooperation. General coordination
and management of the evaluation, involving five field
missions (Maroc, Algeria, Ecuador, Bolivia, Peru).
Team leader of the mission to Bolivia. An assignment
for the Directorate General for Development
Cooperation.
Belgium
January 2008Formulation of the new awareness raising program
October 2008
“Kleur bekennen/Annoncer la couleur” taregtting youth
in Belgium. An assignment for the Belgian Technical
Cooperation.
Albania
May 2007 –
Evaluation of the Technical and vocational education
February 2008
and training program, implemented by the ICCO
alliance in the period 2003-2006. General coordination
ACE Europe-ETC Crystal / evaluation HIV and AIDS program Hivos / Final evaluation report pag. 156/176
and management of the evaluation, involving four
missions (India, Albania, Kenya and Ethiopia). Team
leader of the mission to Albania. An assignment for
ICCO.
DR Congo
July 2007
Facilitating an international seminar “We can end all
violence against women”, an assignment for Oxfam
Novib.
Rwanda
June 2007
Training on HIV/AIDS mainstreaming targeting HIV
focal points of Oxfam Novib in Rwanda, Burundi and
DR Congo. An assignment for Oxfam Novib.
The Netherlands
March 2007October 2007
Evaluation of the financing system of the programs
executed by the Royal Tropical Institute in Amsterdam
and financed by the Dutch Ministry of Foreign Affairs.
General coordination and management of the
evaluation.
South Africa
January 2007April 2007
Evaluation of the city to city cooperation between
Maasmechelen (Belguim) and Tshwane (South Africa)
Burundi
January 2007March 2007
Documenting good practices on HIV and AIDS
mainstreaming of Oxfam Novib partners in Burundi
Belgium
September –
December 2006
Development of monitoring and evaluation system for
the program on development education of the NGO
Trias (Belgium), including a baseline study.
Burundi
June September 2006
Try-out of toolbox en training manual for HIV/AIDS
and gender mainstreaming, case Burundi. For the NGO
Oxfam-Novib (The Netherlands)
Belgium
March – July
2006
Evaluation of the educational and cultural program of
the Royal Museum for Central Africa. An assignment
for the museum.
Belgium
March–
September 2006
Impact evaluation of the Fair Trade school project,
from Oxfam Fair Trade shops, for Oxfam Fair Trade.
South-Africa,
The Netherlands
September 2005
-February 2006
Guinée Gonakry
Belgium
Ecuador
MBN HIV/AIDS evaluation: evaluation of relevance,
efficiency and effectiveness of the strategy and the
projects in the field of HIV/AIDS executed by 5
development NGOs, co-financed by the Dutch
government: HIVOS, ICCO, Novib, Cordaid and Plan
the Netherlands.
June 2005-july
Mid-term evaluation of the project for food security of
2005
the NGO TRIAS. An assignment for the Belgian
Survival Fund.
April 2005-June Action Aid: evaluation of the lobby activities of the
2005
European lobby office.
December
Evaluation of the programs “migration and
ACE Europe-ETC Crystal /Evaluation HIV and AIDS program of Hivos /Final evaluation report pag. 157/176
2004-April
2005
Belgium
development”, financed by the Belgian development
cooperation and executed by organisations working
with refugees and migrant. General coordination and
management of the evaluation, involving missions to
Burundi, DRCongo and Ecuador. Team leader of the
mission to Ecuador.
Redaction of a gender policy kit for the (Belgian)
Commission Women and Development.
September
2004-December
2004
For a complete list, please contact the consultant: geert.phlix@ace-europe.be
12. Professional Experience Record:
Date:
Location
Company
Position
Description
2000Belgium
ACE Europe
Manager and senior consultant
European Affairs and International co-operation
Date:
1997-2000
Location
Company
Position
Belgium
Belgian development NGO, Fund for Development Cooperation
Gender coordinator and head of the department development
education
Different tasks within the field of education and gender
Folow-up of the gendermainstreaming within the organisation and its
partners (Bolivia, Peru, Chili, Nicaragua, Honduras, Zimbabwe,
Mozambique, Angola, South- Africa, Vietnam, Cambodge and
Palestine)
Description
Date:
Location
Company
Position
Description
September 1995-June 1997
Belgium
Coopibo (NGO)
Volunteer
Volunteer for the development educational program of Coopibo
(Vredeseilanden)
Date:
Location
Company
July 1995-August 1995
Belgium
Flemish Association of Development Cooperation and Technical
Assistance (VVOB)
Educational and logistics staff member
Facilitator of the program for capacity building of the international
staff of the VVOB. Editor of a manual
Position
Description
ACE Europe-ETC Crystal / evaluation HIV and AIDS program Hivos / Final evaluation report pag. 158/176
Date:
Location
Company
Position
Description
1993-1994
Belgium
Catholic University of Leuven
Scientific research assistant
Scientific assistant of the research project: „Regional educational
networks‟, Supervisor: Prof. Dr. W. Leirman
ACE Europe-ETC Crystal /Evaluation HIV and AIDS program of Hivos /Final evaluation report pag. 159/176
CURRICULUM VITAE
1.
2.
3.
4.
5.
6.
Family name:
First name:
Date of birth:
Nationality:
Civil status:
Address:
7. Education:
Institution:
Date:
Degree(s) or Diploma(s)
Aantjes
Carolien
12-09-1974
Dutch
Married
ETC Crystal, P.O. Box 64, NL-3830 AB LEUSDEN, The Netherlands
033-4326030 (office)
e-mail: crystal@etcnl.nl
Free University (VU), Athena Institute, Amsterdam
Ongoing
PhD candidate
Research on the long term response of the health sector to HIV as a chronically manageable
disease (Sub-Saharan Africa)
Institution:
Date:
Degree(s) or Diploma(s)
Royal Tropical Institute, Amsterdam
2004 – 2005
Master degree in Public Health
Thesis: ‘HIV/AIDS threatening civil society. A study on the response of nine NGOs in Ethiopia’
Institution:
Date:
Degree(s) or Diploma(s)
Leidse Hogeschool, Leiden
1998 – 1999
Post Graduate in Community Health for Developing Countries
Paper: ‘Sustainability in Community Health Projects’
Institution:
Date:
Degree(s) or Diploma(s)
Hogeschool West-Brabant, HBO-Verpleegkunde, Breda
1992 – 1996
BA Degree in Nursing
Paper: ‘Women and AIDS in the Netherlands’
8. Languages:
Language
Dutch
English
French
Afrikaans
Spanish
German
Reading
5
4
4
2 to 3
3
Speaking
Mother tongue
5
4
4
2 to 3
3
Writing
5
3
3
2
2
*score 1 –5; 1= not aware, 2= poor, 3=moderate, 4= good, 5= excellent
9. Membership of
professional bodies:
2008 – ongoing: steering group member of the Netherlands Network on Sexual
Reproductive Health and AIDS (share-net).
10. Present Position:
Consultant with ETC Crystal, The Netherlands. HIV/AIDS programming and
mainstreaming.
Activities:
 Identification, evaluations and reviews of (national) HIV/AIDS programs
 HIV/AIDS capacity building, organisational and institutional development
 Technical support to HIV/AIDS program design & planning of sectoral and
multi-sectoral responses, and external mainstreaming activities
ACE Europe-ETC Crystal / evaluation HIV and AIDS program Hivos / Final evaluation report pag. 160/176

11. Years of professional
experience:
Years of service
current position:
12. Key qualifications:
Technical support to organisations wishing to develop a HIV/AIDS and/or
Health & Safety workplace policy and workplace needs- and risk
assessments on HIV/AIDS
 Operational research in the field of HIV/AIDS
Over 13 years
Since December 2005






Over ten years of professional experience in the field of health and
HIV/AIDS prevention and control policies;
Monitoring and evaluation of HIV/AIDS programs, ranging from multi-donor
programs to localised NGO programs with specific interventions & target
groups;
HIV/AIDS program identification, design and formulation according to
logical framework approach (LFA), strategic planning processes;
Training and capacity building in HIV/AIDS;
Formulation of multi-sectoral responses (mainstreaming);
Design and review of workplace policies.
13. Employment record (long –term employment):
Date:
2005 – present
Location:
Leusden (the Netherlands)
Company:
ETC Crystal
Position:
Consultant
Description:
Consultant with a special focus on HIV/AIDS programming and mainstreaming.
Date:
2002-2004
Location:
Amsterdam (The Netherlands).
Company:
Municipal Health Services (GGD)
Position:
Public health nurse
Description:
Testing and treatment of STI's, HIV testing and pre- and post test counseling, partner
notification, outreach prevention activities and training, support to clinical research.
Date:
2003
Location:
Amsterdam (The Netherlands)
Company:
Netherlands Network on Sexual and Reproductive Health & AIDS (Share-net)
Position:
Research-assistant
Description:
Conducting a research assignment on managing HIV/AIDS in the workplace, covering
eleven Dutch NGOs.
Date:
2002
Location:
Amsterdam (The Netherlands)
Company:
Share-net
Position:
Assistant AIDS Coordinator
Description:
Organising the logistics for the share-net workshop ‘stigma & discrimination’ held at the
National AIDS Conference 2002.
Date:
2002
Location:
Amsterdam (The Netherlands)
Company:
Royal Tropical Institute (KIT)
Position:
Project Officer
Description:
Development of the UNAIDS local response toolkit by collecting and documenting
practices and techniques used in HIV/AIDS programs worldwide.
Date:
2002
Location:
Leusden (The Netherlands)
Company:
ETC Crystal
Position:
Junior Consultant
Description:
Exploration phase in HIV/AIDS staff policy development for SNV Development
ACE Europe-ETC Crystal /Evaluation HIV and AIDS program of Hivos /Final evaluation report pag. 161/176
Date:
Location:
Company:
Position:
Description:
organisation (sequel in 2003/2004 – consultancy record).
1999-2001
Keetmanshoop (Namibia)
Ministry of Health and Social Services / Ministry of Local Government and Housing
Regional HIV/AIDS Coordinator, Karas RACOC
Coordination and management of the (Karas-) regional AIDS response. Mobilising
government departments, civil society and private sector in the multi-sectoral response
to HIV/AIDS; forging partnerships in prevention and awareness campaigns, capacity
building and coaching of professional staff and volunteers in district HIV/AIDS programs,
establishing home based care programs and channels for condom distribution
throughout the region, including duties in (financial) administration and reporting to the
National AIDS Coordination Program and donors (EC, UNAIDS, WHO).
Consultancy record (short-term assignments):
Country
Year
Company; description of mission
Ethiopia
2010
Cordaid; team leader in country study on trends in Home Based Care policies, service
delivery and demands of people living with HIV, in light of the introduction of antiretroviral treatment.
The Netherlands
2010
Oxfam International; desk study on HIV mainstreaming models to inform strategic
planning for Oxfam’s mainstreaming program in East-, Central and the Horn of Africa.
Uganda
2009
Cesvi Uganda & HIVOS; formulation of a sexual and reproductive health and rights (incl.
HIV/AIDS and SGBV) program implemented by multiple actors and in a post-conflict
setting.
Kenya
2009
International Child Support; team leader of a mid-term review of a Civic Driven Child
Development program in West-Kenya.
The Netherlands
2009
ICCO; Policy advice towards the development of a HIV workplace policy for ICCO headand field offices, activity framework and budget.
Ethiopia
2009
ICCO; development of a roadmap (strategic direction for second phase program), with
NGO partner IIRR, in the provision of ongoing capacity building services in HIV/AIDS
mainstreaming to civil society, public and private institutions in Ethiopia.
The Netherlands
2009
HIVOS; produce internal memo for senior management on HIV/AIDS mainstreaming,
linkages between HIV and all HIVOS’ sectors, and strategic choices for the organisation.
Niger, Senegal,
Burkina Faso
20082009
Oxfam Novib; technical backstopping and capacity building of local consultant, joint
monitoring visits, facilitation of exchange workshops as part of a follow-up project,
supporting HIV/AIDS mainstreaming efforts of 22 Oxfam Novib partner organisations
from a range of sectors (e.g education, agriculture, health, finance and markets). New
initiatives also include partners from Cote d’Ivoire.
Malawi
2008
Malawi National AIDS Commission (through ITAD); team member/public health expert in
National AIDS review, responsible for reviewing the health sector response to HIV/AIDS.
The Netherlands
2008
Royal Tropical Institute (KIT); develop a Policy and Guidance note on HIV for the
development department of KIT. The note targets KIT employees, KIT students (e.g.
MPH), scholars, visitors and sub contracted expertise.
Zambia
2008
Zambian Ministry of Health; team member in the Mid term review of the Zambian health
sector, responsible for reviewing the service delivery for HIV/AIDS/STI and TB.
Indonesia
2008
Netherlands
(South-Africa)
2008 2009
Cordaid; team leader of an identification/mapping mission for the expansion of Cordaid’s
support to HIV/AIDS programs on Java and Papua.
ETC Compas; provide advice to Compas partners on the linkages between endogenous
development and HIV/AIDS, publication of innovative community responses and
preparation of a paper on traditional medicine and HIV/AIDS for traditional healers
conference in India.
ACE Europe-ETC Crystal / evaluation HIV and AIDS program Hivos / Final evaluation report pag. 162/176
Indonesia
2008
The Netherlands
(Ghana, South
Africa,
Mozambique)
Niger
2008 2009
Zimbabwe
2007
Burkina Faso &
Senegal
Ethiopia
2007
Netherlands
2007
Netherlands
2007
Netherlands
2006
Netherlands/
Nigeria
Netherlands
2006/
2007
2006
Netherlands
2006
South Africa &
Tanzania
2006
Netherlands
Nigeria
2006
2006
Netherlands
2006
Netherlands
2006
Malawi, Zimbabwe,
India
20052006
Ethiopia
20042005
2008
2007
Oxfam Novib; facilitate the training of trainers (pool of consultants) in the area of
mainstreaming and workplace program development and conduct training on internal and
external mainstreaming of HIV/AIDS for partner organisations on Java.
ETC Ecoculture; provide advice and general guidance* to country studies on the
implications of HIV/AIDS on ETC Ecoculture’s core business - participatory innovation
development in Agriculture and Natural resource management - and publication of
innovative community responses (* study design, implementation and study outputs).
Oxfam Novib; conduct three day training on internal and external mainstreaming of
HIV/AIDS for partner organisations of Oxfam Novib.
Plan Netherlands & Plan Zimbabwe; team leader of an end of term evaluation (PCM
methodology) of a three-year program for Children Affected by HIV/AIDS, implemented
by five partners and managed by Plan.
Oxfam Novib; conduct three day trainings on HIV/AIDS mainstreaming for partner
organisations of Oxfam Novib, incl. formulation of follow-up project.
Cordaid; team leader of an identification mission for the expansion of Cordaid’s support
to HIV/AIDS programs in the country
SNV; technical advice in policy revisions and action planning for SNV’s HIV/AIDS
workplace program, following the policy review late 2006
Ministry of Foreign Affairs (evaluation department IOB); desk study on the effectiveness
of the Ministry’s policymaking and allocation of funding to INGOs in the domain of Sexual
and Reproductive Health & Rights and HIV/AIDS.
HIV Foundation Nederland; presenting the research outcomes on STD care for HIVpositive people at the National AIDS Conference in Amsterdam, 4-12-2006
Oxfam Novib; technical backstopping, capacity building of Nigerian lead NGO and
conducting joint monitoring visits. (Follow-up project).
Consortium of Cordaid, ICCO, NOVIB and Plan; resource person and co-reader.
Formulation of a three year action plan for an NGO (IIRR) to become an advisory institute
for HIV/AIDS workplace policy and program development in Ethiopia.
Netherlands Institute for Southern Africa (NiZA); developing a Health and Safety policy
(including HIV/AIDS) for NiZA employees in close collaboration with senior management,
human resource- and selected program officers and NiZA’s workers council.
Ministry of Foreign Affairs (personnel department); evaluation (PCM methodology) of the
Ministry’s HIV/AIDS personnel policy, prevention and treatment program as implemented
in Dutch embassies in Africa.
SNV; review of the SNV corporate HIV/AIDS workplace policy and program.
Oxfam Novib; conduct a three day training HIV/AIDS mainstreaming for partner organisations of Oxfam Novib, working in a range of sectors, incl. formulation of follow-up project.
HIV Foundation, The Netherlands; research on (the requirements of) STD care for HIVpositive people in the Netherlands and development of a concept note, incl. policy
recommendations.
Netherlands Institute for Southern Africa (NiZA); technical advice on the integration of
HIV/AIDS in personnel documents and insurances and designing an information brochure
for travelling personnel on health and safety with regard to HIV/AIDS.
ACE-Europe (Belgium); team member & HIV expert in a multi-country/multi-donor
evaluation on HIV/AIDS. The evaluation (PCM methodology) reviewed evolutions in
policy-making on HIV/AIDS, positioning and partner- and funding choices to direct and
indirect HIV/AIDS programs of five Dutch donors: Cordaid, ICCO, NOVIB, HIVOS and
Plan Netherlands.
Cordaid, ICCO, NOVIB and Plan Netherlands; project coordinator (as an external
consultant) of a pilot project on internal mainstreaming of HIV/AIDS among eleven
partner organisations, funded by STOP AIDS NOW! and PSO, incl. thesis research.
ACE Europe-ETC Crystal /Evaluation HIV and AIDS program of Hivos /Final evaluation report pag. 163/176
Netherlands
20032004
Netherlands
2003
ETC Crystal; developing a corporate HIV/AIDS policy for SNV Developing organisation,
in close collaboration with the SNV human resource department and field offices from
four continents.
NOVIB; developing an HIV/AIDS Question & Answer document in support to the
HIV/AIDS mainstreaming process within Head office.
14. List of publications upon request.
ACE Europe-ETC Crystal / evaluation HIV and AIDS program Hivos / Final evaluation report pag. 164/176
CURRICULUM VITAE
Name
Date of birth
Nationality
Present position
Jurgens, Esther Maureen Jane
1st of November 1964
Dutch
Consultant International Health
Policy Advisor: Netherlands Society for Tropical Medicine and International Health
Key qualifications
- Master‟s degree in medical sociology
- Additional training in research, program management and planning
- Specific focus: sexual and reproductive health and rights, adolescents, gender
- Extensive experience in policy preparation, strategic and operational planning and
management in health, both in Europe and overseas
- Research expertise: sexual and reproductive health and rights, child health, gender, health
financing, literacy
- Provision of training and teaching in health policy, sociology, gender issues
Other skills
Excellent communication, reporting and editing skills, good team player, training and
facilitation
Education & courses
1990
Medical Sociology, Nijmegen University, the Netherlands (diploma)
2005
International Advisory Trail, MDF, the Netherlands
2004
Proposal writing, ZonMW, the Netherlands (certificate)
2000
Policy, Program and Planning, UNICEF, Colombia (certificate)
2000
Multi Indicators Cluster Survey, UNICEF, Dominican Republic (certificate)
1999
Project Management / Logical Framework, MDF, the Netherlands (certificate)
1999
Human Rights Programming, UNICEF, USA (certificate)
1992
Sentinel Sites Research Methodology, Universidad de Guerrero, Mexico (certifícate)
Dutch (Mother language), English (fluent), Spanish (fluent), German (good), French
(basic)
Languages
Selection of consultancy assignments – specific experience
Country, year
Company; description of work
Nicaragua, 2010
For: IOB / Ministry of Foreign Affairs
Preparation of research protocol for the conduct of an impact study in SRHR (planned
2011) (team member).
Netherlands, 2010
For: Share-Net
Conduct of stock-taking assessment
Netherlands, 2010
For: AMREF NL
Support to the Program Department (several assignments, including support to the
development of the funding proposal in the context of MFS-2)
Georgia, 2008 -
For: ETC Foundation
Technical advisor to the project „Enhancing the Quality of Care: Improving Knowledge and
Skills of Midwives in Georgia‟ (2008-2011). Focus areas: sexual and reproductive health
and rights, curriculum development and support to development of professional association
Netherlands, 2009
For: IOB / Ministry of Foreign Affairs
ACE Europe-ETC Crystal /Evaluation HIV and AIDS program of Hivos /Final evaluation report pag. 165/176
Selection of consultancy assignments – specific experience
Research and writing of publication on impact evaluations in sexual and reproductive health
and rights: ‘Synthesis of impact evaluations in sexual and reproductive health and rights.
Evidence from developing countries’
Netherlands, 2008
For: IOB / Ministry of Foreign Affairs
Literature review and preparation of inventory of impact evaluations in sexual and
reproductive health and rights (SRHR); formulation of options for impact studies in SRHR
Netherlands
2008/09
For: Wemos
Research and writing of series of briefing papers on Human Resources for Health
Netherlands,
2008/09
For: AMREF NL
Several assignments (Paper on Capacity Building; Development of funding proposals)
Netherlands, 2006
- ongoing
For: Maastricht University
Lecturer Master Public Health (area: health policy; Human Resources for Health)
Netherlands,
2007/08
For: AMREF NL
Interim project management
Netherlands, 2007
For: IOB / Ministry of Foreign Affairs
Policy review in the field of sexual and reproductive health and rights
Tajikistan,
2006/07
For: CARE Tajikistan
Sexual and Reproductive Health Advisor to Youth SRHR project
Netherlands, 2006
For: Wemos
Preparation of design for impact study on global initiatives on HRH (team member)
Netherlands, 2006
For: Oxfam Novib
Assessment of the use of power analysis for hiv/aids programming and development of tool
to incorporate a power approach to planning and programming for hiv/aids
Ethiopia, 2006
For: Federal Ministry of Health Ethiopia, Central Joint Steering Committee
Participation in the evaluation of the second phase of the Health Sector Development
Program (2002/2005), specific focus on management and finance
Netherlands, 2005
For: Netherlands Ministry of Foreign Affairs
Part of research team conducting a literature study on health care financing & co-author of
position paper: „The Role of User Fees and Health Insurance in Health Care Financing‟
Netherlands,
2004/05
For: GEO (standing committee for Health and Development of the NVTG)
Reports of conferences: „The Agenda for Primary Health Care, 25 years after Alma Ata‟;
„Expert meeting on MDGs: 5 years down, 10 to go‟; „Priority Programs: Synergy or
Antagonism‟
Netherlands,
2004 – ongoing
For: Federation of European Societies of Tropical Medicine and International Health
Development of workplan, advice to the European Board of FESTMIH
Netherlands, 2002
For: Mondriaan Zorg Groep (mental health institution)
Development of plan of action for the Division of Short-Term-Stay patients
Netherlands,
2001/02
For: UNICEF-the Netherlands
Workshops for Primary Schools; articles on teenage pregnancy, reduction of maternal
mortality, parenting and adolescents
ACE Europe-ETC Crystal / evaluation HIV and AIDS program Hivos / Final evaluation report pag. 166/176
Selection of consultancy assignments – specific experience
Belize, 2001
For: the Ambassador of Cultural Affairs of the Government of Belize, based in Merida,
Mexico
Draft project and funding proposals
Colombia, 2001
For: Colectivo de Abogados José Alvear Restrepo (Lawyers collective, Bogotá)
Draft plan of action 2001/2002; analysis of organisational policies and projects; preparation
of training material on gender issues; conduct of workshops on gender from a rights based
approach
Employment record – long term employment
Date
November 2007 – present
Free lance consultant – see: Selection of consultancy assignments
Date
April 2003 – present
Location
Wageningen, the Netherlands
Company
Dutch Society for Tropical Medicine and International Health (NVTG)
Position
Policy advisor (part-time)
Description
Policy advisor to the board; drafting of policy documents and implementation of work
plans; development of funding proposals
Date
2005 – November 2007
Company
ETC Crystal (Leusden, the Netherlands)
Description
Consultant, providing short-term consultancy in health policy planning and development
and health systems analysis, research/monitoring & evaluation, health sector reforms
Date
2002 – 2005
Location
Maastricht, the Netherlands
Company
GKZ/GGD-zzl: public health care institution
Position
Policy advisor / project management
Description
Management of the Integrated Youth Health Care Project
Date
1999 – 2001
Location
Bogotá, Colombia
Company
UNICEF, The Americas and Caribbean Regional Office (TACRO)
Position
Assistant Program Officer
Description
Drafting of project proposals, plans of action; advice UNICEF offices and partners
organisations on issues related to gender, health and adolescents; development of a
regional strategy on the reduction of maternal mortality based on experiences in Peru,
Bolivia, Nicaragua, Cuba and Chile; assessment of civil society organisations in
Guatemala; M&E activities related to adolescents, participation, health and gender issues
Date
1997- 1998
Location
Utrecht, the Netherlands
Company
Stimezo NL (umbrella organisation of abortion clinics)
Position
Policy advisor
Description
Project development and management; monitoring of quality control projects in 14 clinics
Date
1996 – 1998
Location
Heerlen, the Netherlands
Company
PC Welterhof (mental health institution)
Position
Staff member
Description
Project development and implementation; drafting policy papers; M&E
Date
1996
Location
Amsterdam, the Netherlands
Company
HealthNet International
Position
Consultant
Description
Systematisation of world-wide private sector health initiatives for MSF-Holland;
exploration of private health initiatives in developing countries and implications for MSF
Date
1995
ACE Europe-ETC Crystal /Evaluation HIV and AIDS program of Hivos /Final evaluation report pag. 167/176
Employment record – long term employment
Location
Deventer, the Netherlands
Company
IZO/MSO - Institute for Health Research
Position
Researcher
Description
Research on employment opportunities for health care personnel in the Netherlands
Date
1991-1994
Location
Belize
Company
UNICEF-Belize
Position
Project manager / researcher
Description
Project management in two areas: social planning & monitoring, women & development;
collection of baseline data for UNICEF/Situation Analysis; research on infant mortality;
research on literacy; research on adolescents and gender issues; implementation of
research method (Sentinel Sites Surveillance method); development of a research unit at
the Department of Women‟s Affairs; training; development of materials
Date
1994
Location
Belize
Company
University College of Belize
Position
Part-time teacher
Description
Teaching of sociology (undergraduate program)
Publications – upon request
ACE Europe-ETC Crystal / evaluation HIV and AIDS program Hivos / Final evaluation report pag. 168/176
CURRICULUM VITAE
1.
2.
3.
4.
5.
6.
Family name:
First names:
Date of birth:
Nationality:
Civil status:
Education:
Motihar
Renuka
Indian
Married, three children (°95, °97, °04)
Institution
Date:
Degree(s) or Diploma(s) obtained:
Lady Irwin College, Delhi University, New Delhi
1988 - 1990
Masters degree in Child Development (now called
Human Development and Childhood Studies with a
focus on psychology, sociology and anthropology
looking at the child and family)
12. Language skills: (Mark 1 to 5 for competence)
Language
? (mother tongue)
English
Reading
5
5
Speaking
5
5
Writing
5
5
13. Present position: Independent Social Development Consultant
14. Years of professional experience:
19
15. Key qualifications: Independent consultant working for non-government,
bilateral and multilateral agencies in the social development sector. 19 years
experience in the fields of reproductive health, HIV/AIDS (prevention, care and
support), broader social issues affecting children, youth and women in India
and Asia. Program development and strategy planning; situational assessments;
program management; NGO appraisals; monitoring, review assessments and
evaluations; research, documentation; and training.
16. Specific experience:
USA and India
January 2010 –
to date
India
February 2009 –
Developing a global strategy and framework on life skills
education for the Room to Read‟s Global program on Girls
Education. Capacity building of the RtR staff in S.Asia,
S.E.Asia and Africa on life skills education within an
education context.
Centre for Development and Population Activities (CEDPA)
ACE Europe-ETC Crystal /Evaluation HIV and AIDS program of Hivos /Final evaluation report pag. 169/176
to date
India - Analytical documentation of the Child Maternal
Health project, an integrated health project targeting
women and children, implemented in Barmer,
Rajasthan in collaboration with the oil company Cairn
India and IFC. Analytical documentation of the Pahel
project in Bihar – empowering elected women‟s
representatives to take action on sexual and
reproductive health.
Bangladesh
May 2009December 2009
International Planned Parenthood Federation (IPPF), South
Asia Regional - Writing a Best practice document on a Safe
Motherhood project supported by EU and implemented by
the Family Planning Association of Bangladesh.
India
February 2009September 2009
Project Concern International (PCI), India - Developing
operational guidelines on Community and Home based HIV
care and support for a CDC supported Pathway project
being implemented by PCI to be utilized for scaling up.
India
July 2009
Participation in the Belgian study on partnerships and
capacity development. Consultant participating in the
evaluation mission to India. An evaluation coordinated
by ACE Europe Belgium.
Myanmar
June 2009
Bangladesh
May 2009
Technical Support Hub. Asia; International HIV/AIDS
Alliance, India - technical support to the International
HIV/AIDS Alliance Myanmar office for a period of 2.5 weeks
on a new European Commission funded project on
children infected and affected by HIV/AIDS. Supporting the
Alliance team on a project design workshop with their
partner organisations.
White Ribbon Alliance, Global - Assist WRA Global in
assessing the capacity of WRA Bangladesh and providing
input and guidance to strengthen the alliance. Support
WRA Global in creating a project implementation plan for a
DFID-Bangladesh funded project.
July 2008-April
2009
India
Seven
assignments in
the period 20012008
White Ribbon Alliance for Safe Motherhood, Global
and India - Program design for a 3-year India program
on safe motherhood as part of a DFID UK funded
WRA Global project. Review and best practice
document for White Ribbon Alliance of India (WRAI)
tracing the history, key achievements, processes, key
strategies, challenges and lessons learned.
Family Health International (FHI), New Delhi – Several
assignments, amongst others : Developing the draft
Tamil Nadu Operational Plan for Children and AIDS;
Proposal development for a project on sex workers and
their children to The Abbott Fund; Developing
National Operational guidelines for National AIDS
Control Organisation (NACO) and Ministry for
Women and Child Development for children affected
ACE Europe-ETC Crystal / evaluation HIV and AIDS program Hivos / Final evaluation report pag. 170/176
by HIV/AIDS in collaboration with Unicef, USAID
and India HIV/AIDS Alliance; Developing a protocol
on detoxification and rehabilitation for substance-using
children and adolescents; Facilitating and conducting
the participatory evaluation and review assessment for
FHI‟s partner organisations on HIV/AIDS
India
July 2007
Cordaid, SKN and Bernard van Leer Foundation,
Netherlands - Mid-term review of a pioneering street
children, sexual health and HIV prevention
intervention (APSA) funded by the three agencies in
Bangalore, Karnataka
India, Sri Lanka,
Thailand,
Indonesia and
Pakistan
2005-2007
Global Fund for Children (GFC), Washington D.C. -
Identifying organisations, NGO appraisals, facilitating
project proposal development, monitoring grantmaking to local organisations in a) tsunami-affected
countries - Sri Lanka, Thailand and Indonesia, b)
Earthquake hit regions of Pakistan, and c) India focused on children and youth –learning, safety,
enterprise, healthy minds and bodies, and creative
opportunities
India
March 2005-June UNICEF, India - Reviewing proposals on youth,
2005
children and HIV/AIDS submitted to NACO for the
Global Fund to fight AIDS, TB and Malaria
For a complete list, please contact the consultant: renuka.motihar@gmail.com
17. Other information
 Member of the Ford Foundation International Fellowship India Program Selection
panel, July 2005
 Member of the Packard Foundation Technical Advisory Group for IMRB‟s external
evaluation of their supported reproductive health and adolescent projects in Bihar and
Jharkhand, 2004-2005
 Member of Population Council‟s Working Group on Adolescents
 Founder and Board member of PRAVAH, an organisation working on youth
citizenship and leadership issues, Delhi
 Guest lecturer at Department of Human Development and Childhood Studies, Lady
Irwin College, Delhi University
 Travel writer – articles with photographs published in Mail Today newspaper, August,
September and December 2009
 WRAI representative at the Global White Ribbon Alliance for Safe Motherhood
annual meeting in Tanzania, November 2009
ACE Europe-ETC Crystal /Evaluation HIV and AIDS program of Hivos /Final evaluation report pag. 171/176
Curriculum Vitae JESUS ROBERTO LOPEZ LINARES
Sociologist. I have participated in health programs based on communities; in
several studies and assessment of health programs and in activities of dissemination
of medicine information with the approach of rational use of medicines and
universal access to essential medicines. I have a good knowledge on the field of
pharmaceutical policies in Latin American countries; long experience in advocacy
with national and international organisations
As a representative of Acción Internacional para la Salud I have been one of the
founders of the Peruvian Country Coordinating Mechanisms (CONAMUSA) for
the Global Fund to fight AIDS, TB and Malaria. Active participant in national and
international processes related with the HIV AIDS epidemic, particularly on access
to ARV medication. I have performed several tasks for the Joint Program of the
United Nations to fight against the HIV AIDS epidemic.
PROFESSIONAL EXPERIENCE (last 7 years)
De 2002 a la actualidad
Acción Internacional para la Salud
Coordinator of projects related to access to essential medicines and rational use of
medicines. Adviser for studies on prices of medicines applying the methodology set up
by HAI-WHO. Active participant in processes related to access to medicines; in those
linked to trade agreements and their impact over access to medicines. Adviser in studies
on several areas of medicines: policy and regulations, use of medicines, promotion of
medicines.
UNAIDS. PERU
2009 (ongoing)
Consultant
Peru
International consultant for the elaboration of a Plan of Technical Support for the
HIV AIDS Program.
Health Policy Initiatives
2008
Consultant
Peru
Elaboration of a diagnosis of the Peruvian pharmaceutical area with emphasis on
access to Essential medicines and rational use.
Health Policy Initiatives
2007
Consultant
Peru
Peru: case study on contraceptive public purchasing.
UNAIDS
2007
ACE Europe-ETC Crystal / evaluation HIV and AIDS program Hivos / Final evaluation report pag. 172/176
Perú
Consultant
Elaboration of a Joint Plan for United Nations agencies in Peru to support the
national response to the HIV AIDS epidemic. (Co author: Dr. José Pajuelo)
UNAIDS
2006
Consultant
Peru
Elaboration of a proposal for articulation and harmonization of plans and programs of
UN agencies in Peru to respond to the HIV AIDS epidemic (Co author Dr. Carlos
Cáceres).
POLICY Project
Consultant
a.
b.
2006-2007
Peru
Elaboration of a proposal for a National Policy on HIV AIDS (Perú)
Diagnosis: purchasing options of contraceptives in El Salvador, Guatemala y
Honduras. Exploring possibilities of regional or sub regional purchasing.
Universidad Peruana Cayetano Heredia
Consultant
2006-2008
Peru
Participation in the Study Team on the effects of the Project funded by Global Fund over
the national response to HIV AIDS epidemic, particularly in the area of relationships
among the stake holders involved in the response. Second phase of the study examined
the efforts for decentralizing the response to the epidemic.
POLICY Project
2005
Consultant
Peru
Assessment of legislation and regulations related to the options to purchase
contraceptives in El Salvador, Nicaragua, Dominican Republic, Paraguay and
Peru.
Universidad Peruana Cayetano Heredia
Consultant
2002-2003
Peru
Member of the study team on “Analysis of alternatives for the implementation of
ARV therapy for HIV infection in Peru: medical, legal, economical, social and
political consequences.” Consortium: Universidad Cayetano Heredia - Universidad
del Pacífico - Acción Internacional para la Salud
POLICY Project
2002
Consultant
Peru
Diagnosis: stake holders involved in the national response to HIV AIDS epidemic
RED SIDA PERU
2003
Consultant
Perú
Study for the identification of best practices in HIV AIDS. (Contract with Red SIDA
Peru)
ACE Europe-ETC Crystal /Evaluation HIV and AIDS program of Hivos /Final evaluation report pag. 173/176
GTZ PERU
Consultant
Elaboration of modules on HIV/AIDS in the areas of GTZ‟s
projects
(Collaboration with other consultants). Elaboration of document on Mainstreaming
HIV AIDS
ACE Europe-ETC Crystal / evaluation HIV and AIDS program Hivos / Final evaluation report pag. 174/176
2003-2004
Perú
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