National HIV and AIDS Strategic Framework 2006-2010

Objectives

Zambia’s National HIV and AIDS Strategic Framework 2006–2010 provides a common multisectoral direction for controlling HIV and AIDS, integrating the response into national development and partners’ work, and scaling up prioritised, locally responsive action. Its vision is a Zambia free from the threat of HIV and AIDS, and its goal is to prevent, halt and begin reversing the spread and impact of HIV and AIDS by 2010.[1][2][3]The framework responds to an epidemic with estimated adult prevalence of about 16%, marked by gender, age, geographic and socio-economic inequalities.[4][5]

• Intensify HIV prevention, including safer sexual practices, prevention of mother-to-child transmission, blood safety, infection prevention in care settings, confidential counselling and testing, reduction of stigma and discrimination, and prevention of transmission through intravenous drug use.[2][6][7]
• Expand treatment, care and support, including universal access to antiretroviral therapy, treatment for tuberculosis, sexually transmitted infections and other opportunistic infections, home and community-based care, palliative care, nutrition and positive living.[1][8][9][10]
• Mitigate social and economic impacts through protection and support for orphans and vulnerable children, people living with HIV and AIDS, caregivers and affected households, alongside food security, livelihood support and social protection.[1][11][12]
• Strengthen decentralised and mainstreamed responses by integrating HIV and AIDS into sectoral, district and organisational policies, plans and budgets, including workplace programmes and workforce strategies.[1][13][14]
• Improve monitoring, evaluation, research, advocacy, leadership and coordination across the multisectoral response.[1][15][16]

The framework is guided by human rights, meaningful involvement of people living with HIV and AIDS, gender equity, pro-poor programming, cultural sensitivity, decentralisation, multisectoral partnership, ethical and evidence-based practice, and prioritisation of affordable, sustainable and cost-effective interventions.[1][17][3]Prevention is especially intended to reach young people, women, populations exposed to high-risk behaviours and communities affected by poverty, gender inequity, stigma and limited access to services.[18][19][7]

Implementation

Implementation uses a coordinated, decentralised and multisectoral model under the National AIDS Council, aligning government, civil society, communities, private businesses, cooperating partners and programme implementers around the “Three Ones”: one national coordinating authority, one strategic framework and one monitoring and evaluation framework.[18][17][3]The framework complements partners’ own plans while seeking harmonised scale-up, practical partnerships, resource management and accountability.[18][1]

• Coordinate national leadership through the National AIDS Council and its Secretariat, supported by Cabinet-level oversight, while using annual joint reviews and an operations manual to clarify roles, implementation arrangements and reporting responsibilities.[20][21][22]
• Decentralise planning and delivery through Provincial and District HIV and AIDS Task Forces within development-coordination structures, District Development Coordination Committees, District Health Management Teams and local authorities, in line with the National Decentralisation Policy.[17][13][23]
• Mainstream HIV and AIDS into national development instruments, sector policies, district plans, organisational budgets and workplace programmes, including the Poverty Reduction Strategy, National Development Plan and Medium Term Expenditure Framework.[1][17][3]
• Deliver prevention through behaviour-change communication, life-skills education, condom promotion, voluntary counselling and testing, prevention of mother-to-child transmission, blood screening and targeted outreach to vulnerable populations.[6][24][7]
• Provide integrated services through public, private, community, home-based and hospice settings, linking HIV testing, prevention of mother-to-child transmission, antiretroviral therapy, tuberculosis and opportunistic-infection care, palliative care, referrals, commodity systems and rural mobile services.[9][10]
• Engage civil-society organisations, faith-based and community-based organisations, the media, trade unions, traditional healers, youth structures, private employers and development partners in culturally sensitive outreach, service delivery, advocacy and grant-supported community action.[23][25][26]

Monitoring is intended to draw routinely on data from all sectors and levels, including health-management information, behavioural and demographic surveys, sentinel surveillance, cohort studies, facility surveys, workplace surveys and financial resource-flow monitoring.[27][15][21]The national monitoring framework includes impact, outcome and output indicators, while operational priorities include strengthening local data use, surveillance, research, information flows, implementing-partner capacity and integration of financial management with programme monitoring.[15][21][28]Selected scale-up targets include increasing clients tested and receiving results from 400,000 in 2005 to 1,000,000 in 2010, pregnant women receiving a complete antiretroviral course from 25,000 to 50,000, and eligible people accessing antiretroviral drugs from 50,000 to 160,000.[29]

Approximately US$273 million annually had been mobilised by government and cooperating partners for the multisectoral response up to 2008, while communities, civil society and the private sector contributed additional unquantified resources.[18]Resource management focuses on mobilisation, allocation to priority cost-effective actions and disbursement to providers and communities; however, the supplied material does not provide a complete framework budget, theme-specific allocations or quantified funding gap.[29][18]

Monitoring & Evaluation

The framework establishes a national, multisectoral monitoring and evaluation system intended to track progress towards HIV and AIDS goals, strengthen partners’ use of evidence for decision-making, improve service effectiveness and efficiency, support operational research, and demonstrate value for money.[14][21]Monitoring the multisectoral response is one of the six priority themes, operating through the “Three Ones” model of one national coordinating authority, one strategic framework and one national monitoring and evaluation framework.[1][3]

• Coordinate monitoring through the National AIDS Council, which is mandated to coordinate, monitor and evaluate programme inputs, activities, outputs and impacts, while the Cabinet Committee of Ministers provides policy oversight and supervision of implementation.[20][16]
• Use a national framework with 55 performance indicators, comprising four impact, 17 outcome and 34 output indicators, supported by defined data sources and data-flow arrangements.[15]
• Track epidemiological impact through HIV infection among infants born to mothers living with HIV, pregnant women aged 15-19 years, adults aged 15-49 years, and young people aged 15-24 years.[27]The 2015 impact indicator is HIV prevalence among pregnant women aged 15-19 years, used as an estimate of HIV incidence.[30]
• Monitor prevention, treatment and social-support outcomes, including HIV knowledge, condom use, sexual debut, life-skills education, receipt of HIV test results, antiretroviral prophylaxis for pregnant women, tuberculosis cure, antiretroviral therapy coverage, workplace policies, support for orphans and vulnerable children, and school attendance among orphans.[27][31][30]
• Use surveillance and information sources including cohort studies, sentinel surveillance, demographic and health surveys, the Health Management Information System, education censuses, the Zambia Sexual Behaviour Survey, health-facility surveys, workplace surveys and resource-flow surveys.[27][31][32]
• Institutionalise routine data collection across sectors and levels, improve information flows and geographic mapping, integrate financial-management monitoring with programme monitoring, and align annual programme review with planning and budgeting cycles.[21]
• Use National AIDS Council Activity Reporting Forms to collect programme-monitoring data from provincial and district levels, and use Joint Annual Programme Reviews for strategic monitoring, coordination, best-practice sharing and assessment of value for money.[28]
• Strengthen district monitoring and evaluation systems and databases, with coverage targeted to increase from no baseline coverage to 40% in 2007 and 60% thereafter.[33][34]
• Assign indicator-specific responsibilities principally to the Ministry of Health, Central Board of Health and Central Statistical Office, alongside civil-society, local-management and specialist bodies for relevant programme areas.[35][36][37]

Selected service targets provide a quantified accountability basis. Clients tested for HIV and receiving results were targeted to rise from 400,000 in 2005 to 1,000,000 in 2010; pregnant women receiving a complete antiretroviral course to prevent mother-to-child transmission from 25,000 to 50,000; and eligible people accessing antiretroviral drugs from 50,000 to 160,000.[29]The framework also sets prevention targets, including reducing HIV infection among pregnant women aged 15-19 years to 12% and infant infection following maternal HIV infection to 20% by 2009/10.[38][39]

Accountability is linked to political leadership, transparency, annual joint reviews, reporting mechanisms and clarified stakeholder roles, including district reporting aligned with the National Monitoring and Evaluation Framework.[1][22][40]Important implementation weaknesses include fragmented partner systems, limited information-sharing, lack of a national management information system capable of tracking programme activities, difficulty tracking resources by geography and partner, inadequate equipment and skills, and weak links between national, provincial, district and data-provider structures.[15][21]The supplied material does not specify sanctions for non-performance, a complete reporting timetable, or a single consolidated surveillance and data-quality protocol.[21][16]

Costing & Financing

Financing is framed as a core function of the coordinated multisectoral HIV and AIDS response, with emphasis on mobilising resources, allocating them to prioritised and cost-effective interventions, disbursing funds to providers and communities, and improving value for money.[28][29]Approximately US$273 million annually had been mobilised by government and cooperating partners for the response up to 2008, while contributions by communities, civil society and the private sector were significant but not quantified.[18]

• Mainstream HIV and AIDS into national development instruments, sector policies, plans and budgets, including the Poverty Reduction Strategy, National Development Plan and Medium Term Expenditure Framework, to support sustainability.[1][17]
• Prioritise affordable, sustainable and cost-effective interventions through evidence-based public-health approaches, particularly because prevention is presented as necessary to sustain expanded antiretroviral treatment economically and socially.[18][30]
• Provide antiretroviral treatment, medicines and related laboratory services free of charge under a government decision made in September 2005.[8]
• Address affordability barriers arising from patient assessment charges and monthly service fees, and pursue price negotiations, revolving procurement funds, stronger commodity systems, infrastructure, equipment, medicines, training and staffing.[41][9][10]
• Align external financial support with national strategies and progressively shift from project-based to programme financing, while harmonising donor programming and reporting at district level.[14]
• Harmonise financing involving the Global Fund, World Bank, bilateral institutions and other partners; develop a Resource Management Strategy; assess a National HIV/AIDS/STI/TB Trust Fund; and provide specific budgetary allocations for HIV/AIDS/STI/TB interventions.[22][40]
• Strengthen costed district annual workplans, targeted for 80% district coverage in 2005 and full coverage in 2007 and 2009/10.[33]

Resource constraints include insufficient financing for technical support despite increased programme activity financing, fragmented financial and technical assistance, limited public-expenditure capacity to add service-delivery staff, and inadequate financial resources for monitoring and evaluation.[23][25][26][15]The framework does not provide a complete 2006-2010 budget, allocations by theme, quantified funding gap, unit costs, expenditure ceilings or a detailed costing methodology in the supplied material.[18][22][40]