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Uganda develops a new HIV/AIDS Strategic Plan, 2007/8-2011/12

By Joyce Kalumba, Uganda AIDS Commission

Uganda fully recognizes HIV/AIDS as a real and serious threat to socio-economic development and national security. Efforts have been made to translate this conviction into programs and actions at various levels guided by the Poverty Eradication Action Plan (PEAP) and the Multisectoral Approach to the Control of AIDS (MACA). The MACA is a policy strategy that has guided the response since 1992 through consecutive national planning frameworks.

Uganda AIDS Commission (UAC), the central coordinating body of the AIDS response, has so far coordinated the development of three such frameworks since 1993 including the National Strategic Framework (NSF) Activities (2000/1 to 2005/6) whose implementation was concluded in June 2006. This article highlights the country's extensive consultation process to develop a new National Strategic Plan (NSP) for 2007/8-2011/12 hinging it on evidence about the epidemic and the response in the country and elsewhere in the world.

The NSP development process

The process of developing the NSP features among best practices for involving all stakeholders in identifying needs, assessing capacity to respond and shaping priorities for further action. The process was initiated in 2005 during the November Joint Annual AIDS Review (JAR) that among other issues, highlighted the evidence needs to inform the new planning frame. The JAR also identified national priorities for the period January 2006 to June 2007 to bridge the gap between the two long-term national planning frameworks. The NSP development process was formally launched in August 2006 with stakeholder consensus on the various major phases and their outputs. The process featured technical working groups (TWGs) at the analysis stage that assisted in collection and validation of data. TWG outputs were further discussed in an appointed National Task Force, which handled the exercise on behalf of the HIV/AIDS Partnership Committee that received regular reports.

Documentation of evidence : Phase one, running from August to December 2006, featured the establishment of evidence in various areas. This was building on the 2004/5 National HIV Sero and Behavioural Survey by the Ministry of Health, and the rapid assessment of drivers of the epidemic and effectiveness of the prevention response since the late 1980s conducted April to July 2006.

The phase featured a deep analysis of the performance of the response as guided by the NSF, identifying strengths, weakness, opportunities and threats to the country's efforts under each of the goals, objectives and strategies. This exercise involved stakeholders at national and lower levels through eight technical working groups (TWGs) on issues of HIV prevention, care and treatment, social support, resources, infrastructure, institutional arrangements and human resources, research, and monitoring and evaluation. TWG members, facilitated by thematic consultants, greatly enriched this process through identification of information resources, validating the findings and developing strategic direction in the various areas.

Outcomes from the NSF review process were further discussed through meetings in selected districts for validation and input of stakeholders at decentralized levels into recommendations for future action.

During the same phase, a number of issue papers were generated on key gaps areas identified during the 2005 JAR that required deeper analysis to promote understanding of dynamics and contexts. These included an assessment of sector spending on HIV/AIDS and funding mechanisms for the civil society stakeholders at various levels; studies on HIV/AIDS and nutrition; gender and HIV/AIDS; children and AIDS; and an assessment of the implementation of the greater involvement of people living with HIV/AIDS (GIPA) principle. Outcomes and recommendations from these processes fed into the development of the 1 st outline of the National Strategic Plan (NSP). Cost projections for the identified intervention areas were also developed presenting stakeholders with several costing scenarios to inform decisions.

District and constituency Consultations : Running from January to March 2007, this phase featured intensive stakeholder consultation processes to seek input into identified goals, objectives and strategies in areas of prevention of HIV transmission, treatment and care, social support and the various systems supporting the response. The phase involved regional fora bringing together stakeholders from all districts at various levels to interface with findings, make input into recommendations for further actions, assess the country's capacity to deliver identified services according to proposed targets and also make input into the prioritization process.

More national fora brought together members of the various Self Coordinating Entities of the Uganda HIV/AIDS Partnership including AIDS Development Partners, Government Line Ministries, all the 8 civil society Self-coordinating Entities (SCEs), and Parliament to discuss and make input into identified priority areas, resource and other capacity needs and implementation arrangements.

Over 1000 stakeholders at national and district level from the public and non-public sectors were involved in NSP discussions during this phase. Recommendations from the various consensus fora fed into a national technical level retreat that made final suggestions on priorities and targets for the next 5 years and the most suitable costing scenario to achieve the targets. These were presented and discussed in the National NSP Task Force. Drafting of the National Strategic Plan: The consensus process resulted into the drafting of the 2 nd outline of the NSP with more concrete consensus on priorities.

The 5 th HIV/AIDS Partnership Forum of May 2007 provided an opportunity for all stakeholders to discuss and agree on the final set of identified priority areas. While the second NSP outline has been shared as a working document since end of May, as the document entered the writing phase. Besides shaping the document into a simple easy to understand national document, the writing process also strengthened aspects of integrating HIV/AIDS and reproductive health, gender and human rights. Besides an agreed NSP, two outputs are expected from the NSP development process namely a Performance Management and Measurement Plan (PMMP) and an NSP implementation guideline. Monitoring and evaluation is critical for the success of the NSP. In line with the global “Three Ones” principles for coordination and management of national responses, the NSP relies on establishment of a national M&E Framework to track the overall performance and impact of the national response. All partners involved in the implementation of the NSP shall be required to align to agreed priorities and the PMMP to report progress in their specific areas of action. The PMMP will guide the collection, analysis, use and provision of information to enable tracking progress of the response and enhance informed decision-making.

The implementation guidelines will serve as a checklist to assist implementers from public and non-public sectors at national, district and lower levels to align to NSP priorities and harmonize their actions as they all contribute to common goals and objectives. The guidelines will specify stakeholders to take lead in implementing key areas of the strategy, working together with other identified strategic partners. The essence of the NSP The NSP represents a framework and context within which Government in partnership with development partners, civil and private sectors will formulate specific strategies, plans and budgets forthe next 5 years. It focuses on three goals on HIV Prevention, Care and Treatment and Social Support providing a more functional decision-making platform that articulates a set of priority objectives, activities, outputs and outcomes as well as input requirements and critical assumptions for the national response. The NSP translates international frameworks and guidelines and national commitments within the current environments and is aligned to country development targets. It is intended to contribute to improved planning; advocacy; harmonization of funding mechanisms and sources; mutual accountability; and to the extent possible to eliminate duplications and therefore enhance effective use of resources. All Ugandans are called upon, individually and collectively, to draw from the NSP to intensify the response at various.

Challenges to the priority setting process

Uganda is at crossroads in the AIDS response. There is a large and growing pool of those infected that requires immediate and substantial investment into appropriate care including life-long antiretroviral therapy. At the same time, there is need to step-up prevention efforts targeting all the drivers of the epidemic to break the cycle of new infections so as to drastically reduce on numbers of those who will need care in the long-term, and gradually alleviate the impact of the epidemic.

However, initial cost projections basing on a total universal access package revealed an enormous resource need of over $2.5 billion over the next five years. This was regarded as unfeasible considering factors such as of fiscal space within which to expend the resources, focus on other development aspects and capacity for ensuring resource effectiveness. This resulted into a challenging prioritization process especially acknowledging the need to invest in expanding HIV treatment to those eligible to reduce mortality while significantly increasing investment into prevention to reduce on HIV incidence rate. Basing on several assumptions, the costing scenarios considered included: sustaining current funding levels and allocations between the three service goals, moderate funding, and full funding for universal access with logical allocations based on projections for impact on HIV incidence and mortality.

The agreed costing scenario is within the moderate range focusing on cost effective prevention interventions particularly targeting drivers of the epidemic and major sources of new infections. The decision-making process considered the limitations to universal access but also the feasibility of mobilizing the resourcesand ensuring optimal utilization. It is however emphasized that priority setting in the AIDS world should appropriately evolve to match the dynamics of the epidemic.

NSP dissemination process

In the past, many stakeholders have decried the lack of access to this programmatic policy tool. Beyond distributing copies of the NSP therefore UAC is planning a systematic rollout of the NSP together with other existing supporting documents to stakeholders at national district and lower levels. Targeted stakeholder meetings will be organized to allow for interaction on priorities and implementation approaches, to promote buy-in into the NSP implementation process and ownership for the response.

Uganda AIDS Commission calls upon all Ugandans to get informed and utilize the NSP to address HIV at individual, household, community and national levels.

Relevant documentation to inform the NSP development process

1. Declarations and resolutions

a. Global and regional

i. UNGASS Declaration 2001

ii. UNGASS Political Declaration 2006

iii. African Union Heads of State Resolution 2006

iv. Paris Declaration

v. Global Task Team Report

vi. Brazzaville resolution on universal access

vii. GLIA Declaration

b. National

i. Declaration of Commitment 2004

ii. Aide Memoire 2004

iii. Aide Memoire 2006

2. Policies and Policy guidelines

a. AIDS specific

i. Draft National AIDS Policy

ii. Revised PMTCT Policy

iii. HCT Policy

iv. ART Policy

v. OVC Policy

vi. National Policy guidelines for Cotrimoxazole prophylaxis 2005

vii. Home-based Care Policy Guidelines

viii. TB/HIV Policy

ix.

b. Related

i. Universal Primary/Secondary Education

ii. Gender Policy

3. Planning/M&E Frameworks and guidelines

a. AIDS specific - national

i. National Strategic Framework for HIV/AIDS Activities 2000/4-2005/6

ii. National HIV/AIDS M&E Framework

iii. National Priority Action Plan

iv. Country Road Map for Accelerating HIV Prevention 2006

v. Conceptual Framework for Communicating to Young People

b. AIDS Specific – thematic/sector level

i. Health Sector HIV Strategic Plan

ii. HIV/TB Communication strategy

iii. ART Communication strategy

iv. Guidelines on Nutrition, care and support for PHAs

v. Draft Guidelines for early diagnosis and care for infants and young children

vi. Peer educators Handbook

c. Related – global, regional and national

i. Millennium Development goals

ii. Poverty Eradication Action Plan

iii. HSSP

iv. Social Sector Strategic Plan

4. Response Coordination and management approaches

a. Global

i. The 3 Ones Principles

b. National

i. UAC coordination approaches

ii. SCE Self-Assessment report 2005

iii. Report on harmonization of funding mechanisms 2005

5. Programme reporting

a. AIDS specific - national

i. NSF Mid-term report 2003

ii. UNGASS Country report 2003

iii. UNGASS Country report 2005

iv. HIV/AIDS Status Report 2004

v. HIV/AIDS Status Report 2005

b. Sector reports

i. Health Sector Performance report 2003/4

ii. Health Sector Performance report 2004/5

iii. Sector issues papers 2005

c. Programme reports

i. AIM end of programme

ii. Academic Alliance End of project

iii. PEPFAR annual report

6. Survey reports

a.       National HIV Sero-and Behavioural Survey (NHSBS)

b.      NHSBS secondary data analysis report

c.       UDHS2001

d.      UDHS 2005

e.       LQAs report

f.        DRI report

g.       HIV/AIDS Rapid Assessment Synthesis Report August 2006

h.       Rapid Assessment Paper I: A Review of the Trends and Projections of HIV/AIDS Prevalence and Incidence in Uganda

i.         Rapid Assessment Paper II: A Review of the Cultural, Behavioural and Socio-Economic Factors Driving the HIV/AIDS Epidemic in Uganda