Post Title:International consultant for evaluation of the Youth Friendly Health Services (YFHS) programme in Tajikistan

Duration of contract: Feb. – May 2014 (40 w/d)

Office location: Dushanbe, Tajikistan

Closing date: 26 Jan. 2014

TERMS OF REFERENCE:

COUNTRY:TAJIKISTAN

UNICEF COUNTRY PROGRAMME: 2010-2015

PROGRAMME TIME PERIOD:2006-2013

PERIOD OF EVALUATION PROCESS: JANUARY 2014–MAY 2014

1.CONTEXT

1.1 HIV Situation:

In Tajikistan, as of end2012, a cumulative total of 4,674 HIV cases (MoH, 2012) had been registered since the beginning of the epidemic in 1991, while, according to WHO/UNAIDS estimates,the number of HIV-infected people nationwide was12,759 in 2011. According to the National AIDS Center data, approximately 800-1,000 new cases are registered annually in recent years (2010-2012) and the number is increasing. The number of deaths from the total reported HIV cases is764 (16% of officially reported cases). About 6% (277 cases) and 27% (1272 cases) of total HIV cases were registered among children under the age of 18 years and young people aged 19-29 respectively. Out of all HIV cases, 74.6% were reported among men and 25.4% among women.

The HIV epidemic in itscurrent “concentrated”[1]stage in Tajikistan is driven by injecting drug use (IDU) along with other factors such as growth of commercial sex workandpregnant women with heterosexual partners who are drug users.Prevalence rates among injecting drug users and sex workers are 16.3% and 4.4%, respectively. The injection route of transmission was responsible for 50.4% of the total number of registered HIV cases.Sexual transmission was reported in 31.0% of cases and mother-to-child transmission in 2.1% of cases, while, for HIV cases among women, the sexual route of HIV transmission was responsible for 66.5%, according to the National AIDS Center data in 2012.

However, the following recent trendsrequirespecial attention:

  • The proportionof people infected with HIV through sexual intercourse has increased significantly from 8.2% in 2003 to 30.96% in 2012.
  • The proportion of HIV-infected women in the total number of HIV reported cases increasedfrom 8.5% in 2005 to 25.4% in 2012[2],in conjunction with an annual increase in new HIV infection among women (from 83 in 2008 to 289 in 2012), including pregnant women[3].
  • Almost one third of HIV cases were reported among people aged 15-29 years.[4]

1.2 Young people in Tajikistan:

In Tajikistan, young people aged 10-24 years make up one third of the total population. They have endured the consequences of economic and political transitions after the dramatic breakup of the Union of Soviet Socialist Republics (USSR) andcivil war as well as changing and conflicting value systems (Soviet, traditional Tajik, Islamic). Despite being potentially the driving force of the country’s development, they have limited opportunities for economic and political participation. Access to appropriate and quality information and services, including those on sexual and reproductive health and HIV is another constraint faced by young people in Tajikistan: Discussing sex within the family is taboo. Life-skills based education to provide appropriate knowledge and skills related to prevention of HIV and AIDS, sexually transmitted infections, and drug use is not widely available and meets with resistance in education establishments. Access to voluntary, anonymous counselling and testing of HIV services for young people is also limited.

In this context, less than half (43%) of the women aged 15-19 have ever heard of AIDS, compared to 70% of the women aged over 30 (DHS 2012). Only about 13% of young women and men aged 15-24could both correctly identify ways of preventing the sexual transmission of HIV and reject major misconceptions about HIV transmission (UNGASS report 2012). Moreover, the DHS data clearly shows that knowledge and awareness regarding HIV/AIDS is much lower among those who are unmarried, younger, rural, or less educated. This highlights the issue of inequity in terms of access to information. It is also evident that young people in Tajikistan engage in risky behavior. According to the Global School Based Health Survey 2007, overall, 3% of students aged 13-15 had their first sexual intercourse before age 13, and 2.1% of students had had sexual intercourse with two and more partners. Among all students who had sexual intercourse in the past 12 months, 56% said they used a condom during their most recent sexual relation. According to the non-government organization (NGO), “Mekhrubon”, ninety percent of unwanted teenage pregnancies ended up with abortion; and the majority of teenage girls involved in sex work were from poor families in rural areas. In Tajikistan, through which drugs from Afghanistan are transported, drug use is a problem, especially among young people, with more than 1% of students aged 13-15 saying they had used illicit drugs – e.g., marijuana, hashish, opium or heroin once or more. The same survey also indicated that 1.6% of all students had shared a needle or syringe for drug injection once or more times.[5]

1.3 Health system:

The health systemin Tajikistan generally lacks confidentiality. The law enforcement and public health authorities can easily access an individual’s medical records. Lack of confidentiality and registration policies are important barriers to service utilization. Parental consent is required for people below 18 years old to access sexual and reproductive health services, which is another barrier specific to young people’s service utilization.The national criminal code of the Republic of Tajikistan, Articles 138-141, the national policy on administrative misconduct and the national reproductive health law, Article 13, 20, along with the existing discrimination and stigma towards at-risk young people are among the key factors limiting free access to confidential services. The “Soviet” strategy of treating Sexually Transmitted Infections (STI) in in-patient beds remained in place up to 2010, resulting in the irrational distribution and expenditure of already limited resources within the health sector.Moreover, according to the STI prevention and treatment protocol,the “Soviet” style of epidemiological investigation of all sexual partners of the patient with STIs is still used.

Combating HIV/AIDS is a priority of the National Development Strategy and the Living Standards Improvement Strategy (LSIS) of the Republic of Tajikistan for 2013-2015. The Comprehensive National Health Strategy of Tajikistan for the period of 2010 – 2020 also contains provisions of quality services to women, children and adolescents, including prevention of HIV/AIDS as one of the priority goals of Mother and Child Health. The National HIV/AIDS Programme for the period of 2011-2015 is based on the principles of providing universal access to prevention, treatment, care and support not only to high risk groups, but also to the population in general, including children. It aims to hold the HIV epidemic in its ‘concentrated’ stage with its target that HIV prevalence among IDUs, Men who have sex with Men (MSM) and Sex Workers will not exceed 20% by 2015. For young people’s health and development specifically, there is aNational Programmeon Young People’sHealthy Development for 2011-2014; and the National Strategy for Development of Health of Children and Adolescents in Tajikistan for 2010-2015, which facilitatedthe creation of Youth-Friendly Health Services (YFHS) in health settings and access by young people and adolescents to those services.

2.YOUTH FRIENDLY HEALTH SERVICES (YFHS) PROGRAMME

Since 2006, UNICEF has been assisting the Ministry of Health (MoH) of the Republic of Tajikistan to establish, scale up and integrate YFHS into the extensive network of reproductive health and dermato-venerologycenters across Tajikistan.

The YFHS programme in Tajikistan evolved in two phases since UNICEFassisted the Committee for Youth, Sports and Tourismto develop the policy framework on YHFS delivery under the National Young People’s Healthy Development Programme for 2006-2010. Initially, the pilot projectintroduced the concept of YFHS through establishment of youth-friendly ‘cabinets’ in three sites – Dushanbe, Tursun-zade and Isfara. The project implementation was led by the Civil Society Organization (CSO) Association ofDermato-Venerologists “Zukhra”.Its results as well as the cost and benefit for further scale up were analysed and documented, which helped the MoH to integrate the YHFS in the health system. The second phase of the YFHS programme started with the implementation of the current UNICEF country programme 2010-2015.

2.1 Goal, Outcome and Outputs:

The overall goalof the programme isto:

  • Reduce behavioral risks amongst vulnerable and at risk young people in terms of susceptibility to HIV/AIDS, STIs, substance (drug) abuse, and unwanted pregnancies by improving access to quality and friendly services within the health system.

The keyprogrammeoutcomes are:

  • The package of YFH services in the area of HIV, STIs and reproductive health for vulnerable young people and most-at-risk adolescents (MARA)aged 10-18 and up to 24is institutionalized.
  • By 2015, outreach services and STI/HIV voluntary counseling, testing and treatment for vulnerable and most at risk young adolescents (MARA)are provided in all 21 YFHS clinics nationwide.[6]

There are four outputs, which contribute to these two outcomes:

  • The legal frameworktointegrate and scale up YFHS inthe health systemis endorsed and used to increase sustained access by vulnerable young people, with a special focus on its risk group;
  • All YFHS centresare providing servicesand essential supplies in line with quality standards and the needs of young people and at risk group;
  • All YFHS clinicians[7]are knowledgeable, skilled and certified in STI screening, treatment, voluntary counseling and confidential testing on HIV (VCT), and referral to AIDS centers for HIV testing and ART, if required; and
  • High coverage of vulnerable young people, andMARA[8], in particular, by YFHS achieved through outreach support and referral system (involving peer to peer approach, health facilities, educational settings, and youth clubs, etc.).

The programme model adopted the behavior change communication (BCC) strategy in the context of HIV/AIDS, developed by sociologists Fisher & Fisher in 1992. The model uses a variety of targeted entry points, such as communication through peer/outreach support, hot-line, mass media, voucher and referral system, and facility-based confidential health services.The project's basic operating model is to ensure that vulnerable young people, particularly MARA,receive STI, HIV, and reproductive health services through: i) making YFH services available at both YHFS facilities and outreach; and ii) using outreach support to channel young peopletowards YFHS clinics for counseling, testing and treatment. The minimum and optimal package of YFH services defined as per the needs of vulnerable and at risks young people includes:

  • Information on HIV/AIDS, STIs and reproductive health.
  • Access to condoms and other contraceptives.
  • STI screening, STI syndrome treatment, support and care.
  • HIV confidential counseling and testing, ART.
  • Prevention of unwanted pregnancies and other reproductive health services.
  • Basic psychological and legal support.

2.2 Interventions:

With a view to achieving the above-mentioned outputs and outcomes, the following interventions were designed and have been supported in line with WHO adolescent health services quality standards[9] in terms of availability, accessibility,equity, and appropriateness.

Outputs / Interventions
  1. The legal frameworktointegrate and scale up YFHS in the health systemis endorsed and used to increase sustained access by vulnerable young people, with a special focus on its risk group
/ Corresponding WHO standard –“availability”:
  • Support to the development of the National Programme on Young People’s Healthy Development 2006-2010 and 2011-2014; the National HIV/AIDS Programme 2011-2015; the National Strategy for Child and Adolescent Health 2010-2015.
  • Support to the development of instructions for YFHS budgeting and its integration into health sector financing based on the cost-benefit analysis conducted in 2008.
  • Support to the development of the national regulation to institutionalizeYFHS within the national health system, which adopted WHO 5 standards for the quality of services provided to young people.
  • Support to a fiscal space analysis of the budget of the health sector at national and district level for sustainable scale up of YFHS, which resulted in the reform of STI services and rationalization of PHC expenditure.
Corresponding WHO standard –“appropriateness”:
  • Support to the ongoing Tajik health sector reform, especially to introduce the “Confidential” services for young people.
  • Support to revision of the national protocol on STI syndrome management to include “confidential” clinical examination of patients and treatment of STIs.
Corresponding WHO standard –“accessibility” and “appropriateness”:
  • Support to the review process of two laws: “Reproductive Rights and Reproductive Health”; and “Prevention of HIV/AIDS” in order to take into account the findings of the “National Assessment on Sexual and Reproductive Health and Rights of Adolescents in Tajikistan” as well as analysis on health trends among young people who used YFHScentres during the period of 2011-2013.

  1. All YFHS centresare providing services and essential supplies in line with quality standards and the needs of young people and at risk group
/ Corresponding WHO standard –“availability”:
  • Ensuring availability of basic equipment and supplies such as condoms, contraceptives, IEC materials, and STI drugs at all 21 YFHS centres / clinics.
  • Renovation of 20 YFHS centres / clinics.
  • Provision of HIV rapid testing by YFHS certified staff and referral of positive cases to AIDS centers for ELISA testing.
  • Provision of counseling sessions for at-risk groups, including people living with HIV and AIDS by a group of specialists in law and psychology on a quarterly basis, addressing the issues that are faced by clients such as violence, stigma and discrimination, and suicidal ideation, etc.
  • Provision of leaflets and booklets for young people.
Corresponding WHO standard –“accessibility”:
  • Establishment of a telephone hotline (‘Trust Telephone’) with the related national legislation and regulations, enabling young people to anonymously receive counseling and referral to the YFHScentres. In addition, mobile numbers of service providers were provided so the (potential) clients can make contacts prior to the visit of the centres.
Corresponding WHO standard –“appropriateness”:
  • Implementation of the Universal Identification Coding (UIC) system to ensure confidentiality.
  • Provision of legal support by a team of lawyers to YFHS managers and specialists in order to prevent conflict with law enforcement authorities and to ensure confidentiality of services provided to at-risk teenagers.
Corresponding WHO standard –“equity”:
  • Provision of services as per the demands of clients – e.g., different focus in different geographical areas, such as the emphasis on harm reduction and prevention of HIV/STI/HCV in GBAO where there is high concentration of drug addicts; and the emphasis on psychological counseling in Sougd where suicide rate is high, etc.

  1. All YFHS cliniciansare knowledgeable, skilled and certified in STI screening, treatment, voluntary counseling and confidential testing on HIV (VCT), and referral to AIDS centers for HIV testing and ART, if required
/ Corresponding WHO standard –“accessibility” and “appropriateness”:
  • Development of training modules for YHFS staff and teachers on different subjects.
  • Training of YFHS centrestaff on the new national clinical protocol on STI management (MoH Order #3 dated 10-Jan-2012).
  • Training and certification of YHFS centre staff on VCT and HIV testing.
  • Training of YHFS centre staff on motivational interview process and psychological counseling for vulnerable young people.

  1. High coverage of vulnerable young people, andMARA, in particular, by YFHS achieved through outreach support and referral system
/ Corresponding WHO standard –“accessibility”:
  • Implementation of outreach communication component by youth NGOs: “NasliSolim”, “Reproductive Health and Adolescents”, “Young Generation of Tajikistan”, and “Tagribot”, in order to attract young people
Corresponding WHO standard –“equity”:
  • Implementation of a ‘voucher’ system by outreach workers, which guarantees free services for young people at YFHS clinics

2.3 Geographical areas:

Currently, 21 YFHS centres are operational in 12 districts.

2.4 Partners:

In the past 7 years, UNICEF leveraged resources (financial, in-kind, and technical - more than USD 6 million equivalent) for the national scale up of YFHS from different partners, including GFATM (Round 8 grant), CARE International, WHO, UNFPA, PSI and GIZ.

Implementing partners include:

MoH, MCH and Sanitary Epidemiological Stations (SES),local hukumats and health departments implement all activities related to YFHS, including provision of services in the clinics.

MoF, local financial departments support budget allocation and expenditure.

Youth–led NGOs(“Young Generation of Tajikistan”, “NasliSolim”, “Reproductive Health and Adolescents”, and “Tagribot”)support to enhance the outreach network, and provide legal assistance to health service providers and YFHS clients.

Other collaborating partners include:

GFATM, as a main donor, has contributed about USD 3.5 million to the programme.

CARE International has contributed about USD 2.5 million to the programme.

WHOhas provided technical assistance forYFHSnational policy development, quality and coverage standards, and evidence-based advocacy.

UNFPA has contributed tocapacity building of YFHS staff along with in-kind contribution of commodities (contraceptives and HIV rapid test kits).

PSI has contributed to the outreach network and voucher system approach in 3 YFHS centres.

GIZhas contributed through its work on policy and advocacy related to youth participation and access to quality services.

2.5 Programme monitoring mechanism:

The implementation of the YFHS programme is periodically monitored by UNICEF jointly with the national partners within the scope of the national commitment to reporting on progress achieved by the country to halt the HIV epidemic. UNICEF constantly provides technical support to national partners in preparation of national progress reports through the UN Joint Advocacy Programme (UNJAP) and as the sub-recipient of the GFATM 8R grant.

UNICEF through the Project Cooperation Agreement (PCA)with Association of Dermato-Venerologists “Zukhra” provided support to the Republican Health Statistics and Information Centre of the MoHin establishing the national analytical unit where all YFHS data are collected and analysed. It resulted in the integration of the UIC database into the Health MIS, enabling the MoH decision makers to access trend analyses, including STI/HIV prevalence among those clients who used YFHS.Each quarter the YFHS centremanagers submit the report generated from the UIC database.The data is analysedat national level every six monthsbytheMoH working group and UNICEF officer.The bottlenecks are discussed with YFHS centremanagers annually.