Joint Assessment - Moldova

1. Joint Assessment - Moldova Draft Final Presentation JAOB 7 July

2. Joint Assessment – what and why? Joint assessment A process whereby country stakeholders and international partners come together… … to carry out an independent assessment of a national strategy and its accompanying documentation… … that is seen as valuable and is accepted by multiple stakeholders (including within the country) Purpose of joint assessment To provide country with constructive feedback on the national strategy that could be used to further strengthen it To inform decisions on funding or technical support by the government and international agencies

4. Methodology (1) • Independent team of 5 internationally recognized experts • Team of 7 National Facilitators • Supported by NCC Secretariat, AIDS Centre, UN Joint Team • JASG Observers – 2 • Reporting to JAOB

5. Methodology (2) • Extensive review of documentation: over 150 reports, reviews, plans, official documents, brochures, studies… • Interviews with stakeholders • Field visits • Assessment according to the JANS tool (IHP+)

6. Methodology (3) The JANS tool – attributes of a ‘sound ‘ strategic plan 5 categories of attributes: • Situation analysis • Process • Finance and Audit • Implementation and management • Results, monitoring and evaluation Added 2: • Strategic Planning • Procurement and supply management

7. Stakeholders interviewed • More than 40 organizations in public sector ministries, local government, hospitals and clinics, civil society including the private sector, churches and academia • More than 200 individuals • In Chisinau, Balti and Teraspol

9. Findings • Presented according to the 7 categories • Strengths, weaknesses, critical issues • Conclusions • Not a ‘pass/fail’; rather a menu of strengths to build on, weaknesses to be addressed, critical issues to be considered.

10. Strategic Planning Strengths: • Fully integrated into national processes and procedures/regulations • Aligned with and draws on NDP, National Health Plan and National Health strategies • Fully overseen by National Coordination Council • Broad scope and scale, forward-looking; comprehensive response to HIV and AIDS in Moldova (prevention, VCCT, treatment and care, impact mitigation, M&E, etc) • Model for other programmes in MoH • Heavy collective investment (intellectual, political, etc) • Comprehensive, coherent statement of the national response • Major step forward – building on proven successes • Important platform for participating in and contributing towards health reform processes and programmes

11. Strategic Planning Weaknesses: • Not a strong strategic formulation of priorities • Not results-based; remains activity-based • Does not fully correct previous weaknesses identified in the response analysis and programme evaluation (esp. IEC, BCC, etc) • Need to find a way to more coherently engage with the programme on the left bank (Transdniestria)

12. Strategic Planning Critical issues: • Need to move towards results-based planning and management (RBM); bring strategic coherence to the programme; allow for evidence-based correction and adjustment; ensure attributable reporting towards programme impact. • Need to make more specific and explicit prioritization and resource allocation.

13. Situation Analysis Strengths: • An elaborated evidence base (integrated bio-behavioural studies, case registration reports, intervention assessments, data on risk behaviours among youth). Sometimes, breakdown for the Right and the Left bank of the Dniester river. • Evidence and its implications for interventions discussed and agreed on in participatory manner by representatives from GO, NGO and international partners within the framework of TWGs and other forums. During this process the central role of injecting drug users in promoting the epidemic was acknowledged. • International agencies are actively involved in providing technical assistance to establish empirical evidence on the trends of HIV epidemic and its determinants. • The objectives of the NSP tend to be supported by evidence and to some extent meet the SMART criteria. • A number of specific objectives included in the NSP respond to the needs of vulnerable groups.

14. Situation Analysis Weaknesses: • The results of the detailed situational and response analysis conducted prior to the development of the NSP are not fully reflected in the priorities of the National Programme. • Specifically, the role of injecting drug users and their sexual partnersin the epidemic is not highlighted even though the available evidence points to their currently being the primary driving force of the epidemic. • The rationale behind prioritizing objectives and activities contained in the NSP is not always clear. Some of them should be reconsidered based on the available evidence. • The evidence is not sufficient to support present prioritizations. • The objectives of the NSP are not clearly differentiated as output-, outcome- and impact-related. Specific objectives tend to be process-oriented while the impact of activities on the HIV epidemic not clearly defined. • There is limited availability of data reflecting the epidemiological situation on the Left Bank. • Some of the conclusions in the migrant study are of preliminary nature or not fully supported by the respective data and need to be re-examined.

15. Situation Analysis Critical issues: • The evidence base with respect to the driving forces of the HIV epidemic in Moldova needs to strengthened (especially with respect to migrants). • Presently available evidence needs to be re-examined. • The priorities of the national HIV/AIDS response need to be more closely guided by the epidemiological evidence. This evidence should determine the scale and the amount of funding allocated to respective activities. • There is limited availability of data reflecting the epidemiological situation on the Left bank. Bio-behavioural studies among all risk groups and behavioural in general population are required.

16. Multi-stakeholder involvement (MSI) Strengths: • Exemplary model of MSI • Robust engagement of wide range of stakeholders (other sectors, advocacy groups, AIDS service organizations, external partners) • Strong structures: NCC, Secretariat, TWGs, MoH structures – both programme development and implementation • Innovative programming from civil society incorporated in National Strategy – significantly strengthening and deepening the national strategy • Government led – wide ‘ownership’ • Responsive to global norms (UN) • Joint programming, joint planning, joint implementation, joint monitoring

17. Multi-stakeholder involvement Weaknesses: • Overly dependent on UN for TA? • Make more use of local resources – academia, private sector? • More explicit capacity building for national stakeholders, including civil society • Possible other donor TA providers? EC?

18. Multi-stakeholder involvement Critical issues: • Strengthen technical base for programme management, results-based planning & management, costing, etc • Look for additional sources of TA.

19. Finance and audit Strengths: • Costing: detailed activities and price estimations • HIV/AIDS case increase forecasts • Per capita cost for HIV/AIDS is in the range US$4-5; good compared with international available data • Donor funding for HIV/AIDS integrated with the Government budget, but channeled separately • Organizations involved in HIV/AIDS, follow different regulations issued by Government, routinely report to different organizations monthly, quarterly and annually bases. • Information which is not confidential is available from different organizations

20. Finance and audit Strengths (cont): • Auditing mechanisms are in place, both International and local audit companies. • Audit activities in Republic of Moldova are regulated by Law on Audit • Different control mechanisms are in place; • Count of auditors which controls public funding and reports to Parliament • Different control groups under Ministry of Finance control public funding • Compulsory Insurance Fund has special division controlling different contracted medical facilities • Functions, qualification and terms of reference of the people working in Auditing and Controlling organizations clearly defined

21. Finance and audit Weaknesses: • The National Strategy costing does not have a common classification for costing according to different functional categories (eg staff costs, materials, etc). This lack of expenditure structure creates inconsistencies in the way different objective/activity lines are costed • Treatment costing uses government approved prices which do not reflect real costs • In budgeting, economical factors for price adjusting not included. Despite the per capita budget in absolute figures increasing, the real purchasing power parity is decreasing for the plan period • For year 2013, Governmental financing share decreases 3-5 times compared with other years and falls to 5.2%. • For some activitiesGovernment financing is zero in contrast to previous and future years

22. Finance and audit Weaknesses (cont): • According 2008-2009 UNGASS report, the HIV/AIDS expenditure structure according to different functions, showed that expenditure on prevention is too high by international comparisons (70%). This is carried on into new strategy. • In national strategy budget, public financing does not correspond with Government middle term expenditure framework for 2009-2011, and draft for NSP duration. The figures in MTEF are three times lower than strategy budget allocations.

23. Procurement and Supply Management : Strengths: • Legislation in procurement corresponds to international standards and recommendations by international partners. • The procurement of goods including medicines is institutionalized through the Agency for Public Procurements and National Medicines Agency . They are equipped, staffed and mandated to implement the law. • The PSM policies guarantee access to safe , effective and good quality pharmaceuticals and commodities: • There is a system (database) to monitor the prices of the manufacturers to follow the price formation on the local market • There is a quality control system that specifies minimum quality standards ( based on GMP ) and National Quality Control Laboratory to follow the quality of medicines on the market. • There is a compulsory registration mechanism for the medicines to be accepted on the local market. • Transparency is ensured by the publication of procurement plans, opportunities, public bid opening , publication of results in the Public Procurements Bulletin. The law does not discriminate foreign bidders. Tenders above 2.5 mln. MDL have to be published in international press. • Agency for Public Procurements monitors the adherence of Contract Authorities to the procedures and examines the bid protests against the Contract Authorities. • There is an oversight committee to whom the APP reports quarterly; this committee reports to the government semiannually. Procurements are verified by the Court of Accounts. • The procurement of medicines is centralized and performed by t he Medicines Agency . This is best practice in Moldova.

24. Procurement and Supply Management Weaknesses: • In some instances the legislation is too rigid for example is ceilings for the procurement methods. • The registration process makes difficult the access of generic ARV and TB medicines supplied by international non-profit organizations like IDA, UNICEF, GDF, GTZ at very competitive prices. • Procurement plans are not published in separated editions of the Public Procurements Bulletin that makes difficult to find this information. • The quality of specifications do not correspond all the time to the requirements in law because they may not be based on performance parameters. For example the correlation between performance parameters and maintenance costs. • The documentation required from bidders under government regulation are difficult and numerous; often leading administrative rejection. The documentation requirements should be simplified.

25. Procurement and Supply Management Critical Issues: • Medicines Agency can examine the possibility to recognize the quality control system of the WHO Prequalification Project to be able to import generic ARV or to Fast track their registration • The ceilings for procurement methods could be removed from the law and included in the regulations (eg, inflation). • For a better Procurement and Supply Management it is necessary to accelerate the establishment of the central ARV store and the computerized informational system based on patient evidence. • Establishment of a set or a database of generic specifications is needed that will be taken as a base by the beneficiaries.

26. Implementation and Management Strengths: • Operational and sectoral action plans regularly developed • Indicators measured annually • Organization of service delivery defined • Governance, management and coordination mechanismsdescribed

27. Implementation and Management Weaknesses: • Unclear description of responsibilities for Public Health leadership and programme linkages • Inconsistency of some targets and budget allocations • Unnecessarily bureaucratic management systems • Taking-over prevention and NGO activities from public sources not described • Special requirements of Left Bank (Transdneistra)

28. Implementation and Management Critical issues: Longer term need for efficiency gains: • increased community mobilisation (NGO sector) • Early treatment as prevention • Alignment with regional and global strategies • Better prioritisation • Elimination of structural barriers • Synergies (integration) with other Public Health services (TB, mental health, SRH)

29. Results, Monitoring and Review • Strengths: • Comprehensive, national M&E plan with practical manual • Strong human resources available centrally for M&E • Data sources clearly identified and described • Well-established mechanisms for data collection, validation and reporting • Electronic databases aid data management • Evidence of some data analysis at multiple levels • Many opportunities to review both programme and M&E system • Examples of data being used to make adjustments to national programme

30. Results, Monitoring and Review • Weaknesses: • Identified weaknesses of M&E system are supportive supervision; data quality assurance; availability/ capacity of human resources; and operationalisation of the national database • Multiple results frameworks and M&E plans – some differences, e.g. in time frame, definitions and figures • Many indicators – unclear priorities • Main intended results unclear/not used for planning • Multiple problems with the programme’s specific objectives– some inappropriate, some unmeasurable • Some reporting focused on donor/international requirements • Ways to use data relatively unclear • Monitoring systems in Transnistria not yet well-developed

31. Results, Monitoring and Review • Critical Issues: • M&E data does not appear to be being used to drive and shape the national HIV response to match the epidemic pattern • The main results to be achieved by the programme need to be identified and prioritised, and used for planning purposes. Progress towards these results needs to be tracked. • M&E data needs to be used to ensure value for money of both donor and domestic funds. This means prioritising the most needed and most effective interventions.

32. Conclusions • Strong NSP, representing significant financial, human, intellectual, political and community investment in strategic planning for the national response in Moldova • Operating in a fragile/vulnerable economic and political context • Represents a clear and realistic description of the national response • Potentially significant contribution to public health architecture in Moldova • Brings into coherent focus a wide range of effective interventions being implemented in a coordinated programme with a transparent financial and management system support

33. However there are some significant weaknesses that need to be addressed: • The team feels the NSP is not particularly strategic in the identification of priorities and the allocation of resources • It does not have an underlying results framework – simply a set of ‘specific objectives’ • This is reflected in the identified weaknesses in identifying strategic priorities, weaknesses in the costing and budgeting, and M&E and reporting • Overall management systems need to be strengthened, learning lessons from the GF management system • These weaknesses need to be addressed quickly if the intended impact of the NSP is to be achieved • This is critical if the enormous investment in the NSP is to be realized.