e discusison on NACP III: What did we do in NACP II

[Guest guest]

National AIDS Control Programme Phase - II (1999 - 2006)

The Phase II of the National AIDS Control Programme has become

effective from 9th November, 1999. It is a 100% Centrally sponsored

scheme implemented in 32 States/UTs and 3 Municipal Corporations

namely Ahmedabad, Chennai and Mumbai through AIDS Control Societies.

Project formulation for Phase II, National AIDS Control Programme

followed a truly participatory process at the State and Municipal

Corporation levels. Between April and June 1998, the Technical

Liaison Officers(TLOs) of NACO, in collaboration with State AIDS

Control Programme Officers, conducted State Level Planning Workshops

in all the States and the cites of Mumbai, Chennai and Ahmedabad.

Each of these workshops was conducted for 2 days in which all major

stakeholders such as senior officials of the Government departments,

NGOs, private sector, medical professionals and district level

officials participated. On an average around 100 stakeholders

participated in each of these workshops. In addition to serving as a

tool preparation, these workshops also turned out to be a major

advocacy effort. In the formulation of the State Implementation Plan

(Ips) the following steps were taken :

Step 1 : Holding of State level workshops in which

participants from Government departments, NGOs etc. discussed the

various issues under several components and came out with

recommendations

Step 2 : Constitution of Core Team to finalise the specific

programmes for AIDS Control Project II based on the recommendations

made under seven components.

Step 3 : Core Team held three sittings in June-July, 1998,

examined the recommendation to identify and select

programmes/activities which needed to be given priority and focus.

Step 4 : The activities suggested were listed and prioritized

by the Core Team based on the recommendations at the workshop.

Step 5 : In end July, 1998, the World Bank prescribed cost

codes were received. A special Task Force was constituted and the

activities were regrouped under five components as per the revised

guidelines from NACO and World Bank

Step 6 : The various activities were divided into sub-

activities, cost codes were assigned for each sub-activity. The

implementation plan was prepared indicating the process, sub-

process, activities, implementing agency, assessment parameters and

risk.

Step 7 : The unit cost and the number of units under each

activity were finalised by the Special Task Force and the outlay was

worked out. Discussions were held with officials of USAID and VHS-

APAC to assess the extent of the bilaternal's involvement in Tamil

Nadu.

Step 8 : The Technical Liaison Officers, World Bank

Consultants and the PD, NACO, reviewed the draft Project

Implementation Plan(PIP) prepared and suggest scaling down of

outlay, taking into account the past and current expenditure and the

absorptive capacity funds in the future. At this state, the

Procurement Plan and the Training Action Plan were prepared

simultaneously.

Step 9 : The special task of force held several sittings to

review the no. of interventions and units of various activities.

After the southern states PIP workshop at Bangalore in the first

week of Sept.,1998, it was decided to restrict the interventions and

the no. of other units/activities and the outlay was revised. The

procurement plan was finalised after excluding the cost of equipment

to be procured and supplied by NACO. The training action plan was

also revised and finalised based on the modified outlay.

In the month of September-October, 1998, National AIDS Control

Organisation organised regional workshops for State ADS Programme

Officers for finalisation of the State PIP. On the basis of the

State PIPs, the National Project Implementation Plan was prepared

The Mission of the International Development Association(IDA)

visited during December 14-22, 1998 and appraised the project in

collaboration with officials of the Government of India. The Mission

recommended an overall assistance of US $ 191 million with

Government of India's contribution of US $ 38.8 million. The total

project cost was estimated at US $ 229.8 million (Rs.1155 crores).

The detailed project document was considered by the Expenditure

Finance Committee(EFC) in its meeting held on 29th April, 1999 along

with USAID and DFID assisted projects. The EFC recommended 3

projects for approval - NACP II (National AIDS Control Project) for

Rs.1155 crores, US assisted AVERT project in Maharashtra for Rs.166

crores and DFID project for AP, Orissa, Kerala and Gujarat for

Rs.104 crores for the period of 5 years from 1999-2004 except US

assisted AVERT Project which will be for a period of 7 years.

The World Bank and DFID projects are for a period of 5 years (1999-

2004), while US assisted AVERT project for 7 years (1999-2006).

The negotiations for an IDA Project NACP II were held between the

representatives of the Government of India and IDA in Washington

from 7-12th May, 1999. The AIDS II project was approved by IDA Board

in its meeting dated June 15, 1999. The NACP II project was approved

by the Cabinet on 26th August, 1999.

The National AIDS Control Project, Phase II is aimed at

To shift the focus from raising awareness to changing behaviour

through interventions, particularly for groups at high risk of

contracting and spreading HIV;

To support decentralisation of service delivery to the States and

Municipalities and a new facilitating role for National AIDS Control

Organisation. Program delivery would be flexible, evidence-based,

participatory and to rely on local programme implementation plans;

To protect human rights by encouraging voluntary counselling and

testing and discouraging mandatory testing;

To support structured and evidence-based annual reviews and ongoing

operational research ; and

To encourage management reforms, such as better managed State level

AIDS Control Societies and improved drug and equipment procurement

practices. These reforms are proposed with a view to bring about a

sense of 'ownership' of the programme among the States, Municipal

Corporations, NGOs and other implementing agencies.

The National AIDS Control Project has two key objectives namely

To reduce the spread f HIV infection in India; and

Strengthen India's capacity to respond to HIV/AIDS on a long term

basis.

Operationally, the project interventions would seek to achieve the

following by the end of the project:

To keep HIV prevalence rate below 5% of adult population in

Maharashtra, below 3% in Andhra Pradesh, Karnataka, Manipur, Tamil

Nadu where the HIV prevalence is moderate and below 1% in remaining

States, where the epidemic is still at a nascent stage;

to reduce blood borne transmission of HIV to less than 1%

to attain awareness level of not less than 90% among the youth and

others in the reproductive age group

To achieve condom use of not less than 90% among high risk

categories like Commercial Sex Workers.

Project Description and Strategy

The project would adopt a multi- pronged approach that would focus

on the most critical intervention to begin limiting HIV

transmission. Project activities are grouped into two components and

five sub-components. Both components reflect activities at National,

State and Municipal levels.

A. Delivery of Cost-effective interventions Against HIV/AIDS

1. Priority Targeted Intervention For Groups At High Risk

The project aims to reduce the spread of HIV in groups at high risk

by identifying target populations and providing peer counselling,

condom promotion, treatment of STIs and enabling environment. These

would be locally modified and delivered largely through Non-

Governmental Organisations, community based organisatins (CBOs) and

the public sector using generic protocols.

Identify those groups at higher risk – This would involve

- participatory approaches;

- locating groups at highest risk, chiefly commercial sex trade

workers, truck drivers, injecting drug users, migrant labourers, men

having sex with men;

- determining the access and demand for health services among the

groups of high risk; and

- developing strategies based on outreach, peer education and

partnerships.

Provide integrated peer counselling, condoms, and treatment for STIs

for those at high risk. Representatives of groups at high risk would

be trained to provide peer education aimed at changing high risk

behaviours. In addition, these interventions would

- train Primary Health Care providers in syndromic case management

and counselling in condom use;

- strengthening STIs clinics in each district hospital and medical

college hospitals; and

- improve referral services for STIs treatment. In addition client

programme would aim to deliver targeted IEC, condom promotion and

STI treatment and counselling to clients of commercial sex workers.

2. Preventive Intervention For the General Community

This includes the following activities:-

IEC and awareness campaigns.

Activities include

- conducting mass media campaign at the State and municipal levels;

- conducting local IEC campaign, use traditional media such as folk

arts and street theatre;

- promoting advocacy campaigns;

- conducting awareness programme geared towards youth and college

students; and

- organising Family Health Awareness Campaigns on a regular basis to

generate awareness and provide service delivery for control of STI

and RTI infections.

Providing voluntary testing and counselling.

This involves

- increasing availability of and demand for voluntary testing,

especially joint testing of couples

- training grass root level health care workers in HIV/AIDS

counselling;

- providing counselling services through all blood banks in India

and through STI clinics. It is envisaged that one voluntary testing

centre would be established in each district.

Reduce transmission by blood transfusion and occupational exposure.

This activity would include

- setting up of 10 new modern blood banks, upgrading 20 existing

major blood banks and setting of 80 new district level blood banks;

- establishing another 40 components separation units;

- establishing mandatory screening of all blood units for Hepatitis

C Virus;

- mobilising voluntary blood donation;

- training providers in the rational use of blood products;

- facilitating communications among blood banking services;

- providing trained counsellers for blood banks in public and

private sectors; and

- training health care workers at all levels in universal

precautions, including provision of post exposure prophylaxis drugs.

3. Low Cost AIDS Care

These activities would provide funding for home based and community

based care, including increasing the availability of cost effective

interventions for common opportunistic infections. Specific activity

would include

- establishing best practice guidelines and providing appropriate

drugs for treating common opportunistic infections (OIs) at district

hospitals;

- training at selected State level hospitals for the provision of

referral services.

improve the quality and cost effectiveness of interventions offered

by existing procedures.

establish new support services for care for persons with AIDS in

partnership with NGOs and CBOs by establishing small community based

hospitals, hospice programmes, drop-in-centres and home based care

would be taken up.

B. STRENGTHEN CAPACITY

1. Institutional strengthening :

This component aims to strengthen effectiveness and technical,

managerial and financial sustainability at National, State and

Municipal levels.

Building implementation capacity at the States and Municipal levels

by :

- ensuring adequate staff and skills in AIDS Control Societies;

- transferring implementation responsibilities to the State and

Municipal levels;

- emphasizing management and implementation capacity at all levels.

There would be an enhanced emphasis in the second project, on

establishment of blood banking services, blood testing centres and

STD clinics in all district hospitals.

Accounts and Finance Unit: The World Bank has decided that for all

IDA assisted projects starting after July, 1998, a " Loan

Administration Change Initiative " (LACI) is to be established. The

main objectives of LACI is to assist the project to perform better

by reducing delays and financial bottlenecks through speedy

disbursement and facilitating project monitoring and control by

linking expenditure with actual physical progress. This system

visualises a Project Financial Management System at NACO and an

Accounts and Finance Unit in each State and Municipal Corporation.

Strengthening leadership capacity of NACO:

NACO would enhance

- strategic planning skills;

- focus on disseminating best practices for targeted interventions;

- establish and manage network of technical expertise through

Technical Resource Groups (TRGs) in STI/HIV/AIDS and other important

issues;

- conduct operation research; and v) oversee research and

development activities nation-wise. NACO would be in overall charge

of the Financial Management of the Project and would be responsible

for effective and efficient use of financial and other resources for

the project.

Expand and improve nation-wide STI/HIV/AIDS sentinel surveillance:

Specific activities include

- sentinel surveillance in every State;

- STI surveillance through specific surveys;

- behaviour surveillance surveys; and

- AIDS cases surveillance.

Training

A training Action Plan has been finalised after convening four

regional and one national workshop of various States with twin

objectives of

- preventing the spread of epidemic and strengthening the local

capacity to respond to the epidemic in future and

- to address the training needs identified in the various components

of the project. Keeping in view the overall objectives of the

proposed project, a two pronged approach have been adopted for

training activities under the proposed project; at the national

level, the activities are of generic nature addressing the technical

needs - development of curriculum and training/training materials,

continual review of the ongoing training activities and

incorporating the local best practices, orientation/training of

trainers/training co-ordinators, periodic evaluation of impact of

the training project activities and inputs for completing training

infrastructure.

At the state level the activities focus on implementation -

development of training phase/calendars as part of the State Project

Implementation Plan, organising training programmes, evaluation of

the training activity to improve their quality and training for the

NGOs.

Build capacity for monitoring and evaluation programme activities

An independent National M & E agency would be selected in the first

year of the project. Each AIDS Control Society would have a M & E

officer. M & E would be conducted by an outside agency at baseline,

interim, and final year. The Performance and Expenditure Annual

Review (PEAR) would involve NACO, AIDS Control Societies and IDA

jointly reviewing project expenditure, financial flows, annual

action plans, PMRs and project input, output and outcome and process

indicators.

Increase India's capacity for research on HIV/AIDS

Most operational research, policy development studies, research and

development (R & D) and cause of death and other studies would be

organised by NACO, States and Municipal Corporations keeping in view

the guidelines from an expert working group composed of NACO, State

and related officials.

A Research Advisory Committee has been constituted to determine

research needs of the country in the field of HIV/AIDS, to promote

research capability of Indian Scientist/Institutions. Initiative

will be taken to develop a HIV vaccine programme in our country.

Mother to child transmission prevention programme has been

introduced as an operation research.

2. Intersectoral Collaboration

This component would promote collaboration among the public ,

private and voluntary sectors. Activities would be coordinated with

other programmes within the Ministry of Health and Family Welfare

and other Central Ministries and Departments. Collaboration would

focus on :-

- learning form the innovative HIV/AIDS programmes that exist in

other sectors; and

- sharing in the work of generating awareness, advocacy at

delivering interventions.

Several Central Ministries and some public sector organisation with

very large work force have developed their own programme and have

funded under the NACP II. Some of these are, Ministry of Sports and

Youth Affairs, Ministry of Labour (Employees State Insurance

Corporation), the Indian Railways, the Ministry of Defence and the

Steel Industry. Similarly, the private sector has also shown

interest in getting actually involved in the fight against HIV/AIDS

in India.

Procurement Arrangements: NACO would be responsible for procurement

of HIV test kits, equipment and certain drugs as central component

through the National Thermal Power Corporation Limited (NTPC), the

procurement agent appointed under the project.

Project Targets

The programme has the following firm targets to be achieved during

project period

To reduce blood-borne transmission of HIV to less than one percent

of the total transmissions.

To introduce Hepatitis C as the fifth mandatory test for blood

screening.

To set up 10 new modern blood banks in uncovered areas, upgrading of

20 major blood banks, setting up of 80 new district level blood

banks in uncovered districts, establishing another 40 blood

component separation units, promotion of voluntary blood donation

and increase its share in total blood collected to at least 60%. The

total blood collection in the county which is now around 3-3.5

million units is sought to be raised to 5-5.5 million units by the

end of the project.

To attain awareness level of not less than 90% among the youth and

those in the reproductive age group.

To train up at least 600 NGOs in the country in conducting targeted

intervention programmes among high-risk groups and through them

promote condom use of not less than 90% among these groups and

control of STDs.

To conduct annual Family Health Awareness Campaigns among the

general population and provide service-delivery in terms of medical

advice and provision of drugs for control of STDs and Reproductive

Tract Infections (RTIs). These campaigns will be conducted jointly

by NACO and RHC programme managers at the State level..

Promotion of voluntary testing facilities across the country at the

end of the project. It is visualised that every district in the

country would have at least one voluntary testing facility.

Awareness campaigns will now be more interactive and use of

traditional media such as folk arts and street theatre will be given

greater priority in the rural areas. It is proposed to cover all the

schools in the country targeting students studying in Class IX and

Class XI through school education programmes and all the

universities through the " Universities Talk AIDS " programme during

the project period.

Promotion of Organisations of people living with HIV/AIDS and giving

them financial support to form self-help groups.

Monitoring and Evaluation of the Programme

For the effective monitoring and evaluation to assess the

implementation of the Phase-II of the National AIDS Control Project

at National and State level, the following mechanism has been

envisaged.

Creating a Computerised Management Information System (CMIS) at the

National and State levels

Training NACO Staff and Health specialists in evidence based health

programme management.

Conducting base line, mid term and final evaluation

Conducting the Annual Performance and Expenditure Review (APER)

Conducting the National Performance Review (NPR) under the National

AIDS Control Board.

A National level independent outside agency is being identified who

would be assigned the responsibility of development of CMIS, conduct

of base line, mid-term and end term evaluation.

Financial Management System

It is envisaged to maintain an adequate project financial management

system to provide accurate and timely information regarding project

resources and expenditure to facilitate efficient project

management. For this purpose an consultancy agency is being selected

for developing a Project Financial Management System for NACP-II.

The financial management system would be integrated one for the

whole project. A common set of policies and procedures would apply

to the entire project and a consolidated set of financial reports

for the project would be prepared from the FMS.

Outlay for National AIDS Control Programme - II

There are three funding agencies for Phase II of National AIDS

Control Programme. These are :

International Development Agency (IDA): World Bank has provided an

account of US $191.00 million as soft loan for the project and the

domestic budgetary support is US $ 38.8 million. The total outlay is

US $ 229.8 million (Rs. 11550.00 million).

United States Agency for International Development (USAID): United

States Agency for International Development has extended its

assistance to the Govt. of Maharashtra for implementation of 'AVERT'

Project based on their earlier experience of working in the State of

Tamil Nadu under the AIDS Prevention and AIDS Control (APAC)

project. The outlay for USAID assisted `AVERT' project is Rs.

1660.00 million.

Department For International Development (DFID) of U.K. Government:

Department For International Development has extended its assistance

for implementation of Sexual Health Projects in the States of Andhra

Pradesh, Gujarat, Kerala and Orissa in continuation of their earlier

projects in West Bengal. The outlay for this project is Rs. 1040.00

million.

Outlay for National AIDS Control Project Phase -II Rupess in

Million

IDA credit (1999-2004) 11550

USAID assistance for AVERT Project in Maharashtra. 1660

DFID assistance for Sexual Health projects for the States of Andhra

Pradesh, Gujarat, Kerala and Orissa. 1040

Total 14250

http://www.nacoonline.org/abt_phase2.htm