HIV/AIDS and Sexual Reproductive Health Among University Students in Ethiopia: A Policy Intervention Framework

Publication date: 2013

HEALTH POL ICY P R O J E C T In Ethiopia, the HIV prevalence rate among people ages 15−49 is 1.5 percent, according to the country’s 2011 Demographic and Health Survey. However, youth, a sub-group of this population, tend to be very sexually active and have more sexual partners, thus placing them at greater risk of HIV infection. Further, students of higher education institutions (HEIs), the majority of whom fall into the 15–49 age group, are often financially insecure and therefore susceptible to economic incentives that can lead to higher risk sexual behavior. For example, young women at HEIs may form relationships with men outside the HEI environment to help meet their financial needs. It is of note that, in Ethiopia, prevalence among women is higher than among men in most age groups (e.g., 1.9% versus 1.0% for women and men ages 15–49, respectively). Other factors contributing to increased risk of HIV among youth, particularly young women, include a lack of comprehensive knowledge about HIV/AIDS, poor access to health services and commodities, early sexual debut, early marriage, and sexual coercion or violence. HIV/AIDS AND SEXUAL REPRODUCTIVE HEALTH AMONG UNIVERSITY STUDENTS IN ETHIOPIA A POLICY INTERVENTION FRAMEWORK November 2013 Brief Aragaw Lamesgin, Futures Group “Why are women more vulnerable to HIV infection? They are not the ones with more sexual partners, and they are less likely than men to use substances and inject drugs, so they should be safer. However, social inequalities and poverty place them at an elevated risk, and they have limited access to HIV or sexual reproductive health education, so they become more vulnerable to HIV and SRH-related problems.” —Ergogie Tesfaye, Instructor and Head of Gender and HIV/AIDS Prevention and Control Office at St. Mary’s University College, Ethiopia 2 November 2013 Students of HEIs in Ethiopia are considered to have adequate knowledge about HIV/AIDS and sexual and reproductive health (SRH) issues, as well as their elevated risk of becoming infected with HIV. However, most related interventions targeting the general public do not directly respond to these students’ needs and expectations, making actual coverage of behavioral and biomedical interventions extremely low. The Ethiopian government is working with universities and other higher education institutions to prioritize and target interventions in HEI settings. The Health Policy Project (HPP), in collaboration with the Federal HIV/AIDS Prevention and Control Office (FHAPCO), has been supporting this effort by establishing and strengthening planning, monitoring, and evaluation functions at HEIs. HEIs’ PARTNERSHIP SUB- FORUM AGAINST HIV/AIDS A supportive policy environment exists for improved HIV prevention among HEIs. The Policy on HIV/AIDS of the Federal Democratic Republic of Ethiopia (1998) emphasizes the need to reduce HIV among all sectors of the population; and the Second Strategic Plan for Intensifying Multisectoral HIV and AIDS Response in Ethiopia (SPM-II 2009–2014)— developed by FHAPCO—promotes mainstreaming HIV/AIDS prevention and control into all sectors to help achieve universal access to services. In support of the SPM-II, in 2010, FHAPCO and the Ministry of Education led the establishment of the Higher Education Institutions’ Partnership sub-Forum against HIV/AIDS (HEI-PSFAHA). The forum now has more than 70 member institutions, including public and private universities. Its key objectives, as outlined in its first strategic plan (SPM 2013–2015), include the following: ƒ Create an enabling environment for a scaled-up and comprehensive HIV/AIDS response in HEIs ƒ Intensify prevention to reduce the rate of new infection within HEI communities ƒ Provide treatment, care, and support to mitigate the health and socioeconomic impacts of HIV/AIDS ƒ Collect evidence to address existing and emerging HIV/AIDS challenges in HEIs and the country at large ƒ Monitor and evaluate interventions to ensure the timely generation and use of information to enhance evidence-based decision making In achieving these objectives, the forum seeks to promote leadership, good governance, partnership and coordination, capacity building, and community involvement. THE PME FRAMEWORK The number of HEI-PSFAHA member institutions and other partners implementing or supporting different HIV/AIDS and SRH interventions has increased during the last few years. Similarly, the scope and diversity of Risk factors that can leave students of higher education institutions vulnerable to HIV infection include: ƒ Lack of comprehensive knowledge about HIV/AIDS and sexual reproductive health issues ƒ Financial insecurity ƒ Lack of proper counseling ƒ Absence of discussion about HIV/AIDS and sexual and reproductive health between students and parents before joining university ƒ Gender-based violence ƒ Low level of perceived risk of HIV ƒ Peer pressure Members of the HEIs’ PME Framework Taskforce. 3 HIV/AIDS and Sexual and Reproductive Health Among University Students in Ethiopia interventions being implemented have also increased. To ensure the effectiveness of interventions and gauge progress under the SPM 2013–2015, the HEI- PSFAHA has developed a Planning, Monitoring, and Evaluation (PME) Framework for HIV/AIDS and SRH interventions in HEIs. Rationale and Development Establishing a standardized system for planning, monitoring, and evaluation will promote coordination of efforts from different actors and boost the effectiveness of interventions by facilitating the generation and use of high-quality, program-related data to inform decision making. Many HEIs use divergent templates for reporting and have weak systems for documenting lessons and best practices. Effective implementation of the HEI- PSFAHA strategy, including developing the capacity of HEIs to track their interventions, will require a strong monitoring and evaluation (M&E) system across different levels of the education sector. HEI-PSFAHA, in collaboration with HPP in Ethiopia, developed and endorsed the PME framework and its training manual. In addition, training on the framework was provided to all HIV and SRH program coordinators and gender experts at all public and private HEIs. Guiding Principles The framework reflects the guiding principles described in the forum’s various policy and strategy documents. The principles focus on the following: ƒ Evidence-based decision making during planning and implementation of interventions ƒ Comprehensive understanding of complex social processes underlying HIV- and other SRH-related problems ƒ Harmonization and alignment of interventions to reduce duplication of efforts ƒ Efficient information use to ensure data are captured, collected, and reported only if there is an explicitly-defined intended use ƒ Results to see if intended changes are being achieved among target beneficiaries ƒ Standardization so all HEIs follow the same procedures and use the same tools ƒ Simplification to minimize the reporting burden on HEIs ƒ Participation so all relevant stakeholders are involved ƒ Gender-sensitivity to allow disaggregated monitoring and ensure targeted effectiveness Photo credit: Aragaw Lamesgin, HPP 4 Integration of HIV and Sexual and Reproductive Health Prior to the establishment of HEI-PSFAHA, interventions on HIV/AIDS and SRH issues in most HEIs had been implemented separately—either by universities or in collaboration with different development partners, with little continuity or synergy. When fully implemented, the framework will ensure the generation and use of program data for decision making during the design and implementation of interventions. It will create an enabling environment among all HEIs to work together in responding to HIV/AIDS and SRH issues facing the HEI population, using strategic documents such as the SPM 2013−2015 as a guide. Intended Users The framework is primarily intended for the forum’s members, other universities and colleges, and other government and nongovernmental organizations involved in the design, implementation, and M&E of HIV/AIDS and SRH interventions in HEI communities. PLANNING, MONITORING, AND EVALUATION APPROACHES The PME Framework is designed with the understanding that planning, monitoring, and evaluation are interrelated functions. Planning Operationalizing a broad set of interventions requires the development of annual plans at all levels and an appropriate follow-up mechanism to assess progress toward set targets. The planning process involves top- down communication of priorities and major strategies and bottom-up aggregation of plans of action from major actors in interventions. The process occurs in three steps. Step 1: Indicative plan development The major purpose of the indicative annual plan for HIV/AIDS and SRH interventions is to communicate agreed-on priorities for HEIs and provide guidance on how to address those priorities. The development process includes priority setting, resource mapping, indicative target setting, and identification of major strategies at the forum level. The indicative plan is communicated to member HEIs so that they can prepare their own indicative plan for aggregation during joint planning. Step 2: Annual planning at HEIs Annual planning at the institutional level will occur in six essential steps: 1. Situation analysis 2. Setting of priorities 3. Setting of goals and objectives 4. Activity planning 5. Budget planning 6. Planning for M&E The resulting annual plan of the HEI is then submitted to university management for approval. November 2013 “It has been one of the best trainings ever for me—to acquire new knowledge and skills on project and program planning, monitoring, and evaluation. [It] will help HEIs to standardize HIV and SRH intervention programs across different institutions in the country and builds the technical capacity of coordinators to enable, effectively design, plan, monitor, and evaluate programs at HEIs.” —Lemma Kessaye, instructor at Bahir Dar University, member of PME training program 5 Step 3: Final compilation of HEIs’ plan at the forum level The plan of HEI-PSFAHA should reflect what the forum is going to accomplish during the fiscal year through its coordination office and an aggregated plan of all member HEIs. During this step, the HEI-PSFAHA coordination office aggregates the annual plans of all member HEIs. The coordination office’s draft plan of action is also finalized during this step. These two components make up the annual plan of HEIs for the fiscal year. Monitoring Monitoring HEIs’ HIV/AIDS and SRH interventions involves routine oversight of inputs, outputs, outcomes, and impacts. Inputs and outputs Input and output monitoring is the routine tracking of information about the availability and quality of resources and the volume of services and products produced. This information need can be met if there is a routine management information system that captures, collects, and shares data generated during service delivery. Instruments for data capture and compilation at the HEI level and indicators for reporting HIV/AIDS and SRH performance data can be used to create more accountability. Data and reports should be checked for accuracy, completeness, and timeliness. The executive committee of the forum will conduct regular review meetings to evaluate the performance of the forum and its member HEIs. Outcomes and impacts Unlike inputs and outputs, where data are captured during implementation of interventions, outcomes and impacts are characteristics of the target population. Students of HEIs experience different vulnerability factors in relation to HIV/AIDS and SRH than the rest of the population, creating a clear need to monitor priority behavioral and biomedical indicators in HEIs. Discussion among major stakeholders shows that establishing a system of regular surveys representative of the HEI community is not feasible. Potential alternatives for outcome and impact monitoring include the following: ƒ Student research and thesis reports ƒ Data from student clinics ƒ Data on youth from the Demographic and Health Survey and the Behavioral Surveillance Survey HEI-PSFAHA and its partners can also provide technical support to member HEIs through joint supervision. This supervision must be jointly implemented to support existing HEI activity so offices can more effectively address the needs of their community. Evaluation While monitoring provides most of the information that decisionmakers need, evaluations may offer more detailed information not revealed in the monitoring stage. Evaluation on HIV/AIDS and SRH interventions in HEIs could be designed to answer two categories of questions: 1. How well are interventions implemented and what organizational, user-related, or contextual factors explain observed levels of implementation? 2. How much did HIV/AIDS and SRH issues change because of interventions in place? How much did the intervention(s) under evaluation contribute to the observed changes? Unlike monitoring, evaluations are expected only periodically. Evaluations should be initiated only when there is a clear information need that existing sources cannot fulfill. Programs that may require evaluation include those with innovative approaches, suboptimal results as revealed by routine output monitoring, or low levels of change in outcome indicators. Evaluations should consider four widely accepted standards of program evaluation: utility, propriety, feasibility, and accuracy. HIV/AIDS and Sexual and Reproductive Health Among University Students in Ethiopia 6 HIV/AIDS and Sexual and Reproductive Health Among University Students in Ethiopia NEXT STEPS HPP and the HEI-PSFAHA will continue to oversee the framework’s implementation in selected universities in the Amhara region. It will be important to assess the effectiveness of the PME training manual and extent of the skills and knowledge gained after the training. Equally important will be ensuring that a standardized planning, monitoring, and evaluation system across HEIs is established. ACKNOWLEDGMENTS The PME Framework was developed with generous funding support from Ethiopia’s Federal HIV/AIDS Prevention and Control Office. As part of a task force, numerous institutions reviewed the framework and provided valuable input, including the United Nations Population Fund, the Ministry of Education, the HEI Partnership sub-Forum Against HIV/AIDS, Addis Ababa University, Jimma University, and St. Mary’s University College in Ethiopia. The Health Policy Project is a five-year cooperative agreement funded by the U.S. Agency for International Development under Agreement No. AID-OAA-A-10-00067, beginning September 30, 2010. It is implemented by Futures Group, in collaboration with CEDPA (part of Plan International USA), Futures Institute, Partners in Population and Development, Africa Regional Office (PPD ARO), Population Reference Bureau (PRB), RTI International, and the White Ribbon Alliance for Safe Motherhood (WRA). The information provided in this document is not official U.S. Government information and does not necessarily represent the views or positions of the U.S. Agency for International Development. Health Policy Project One Thomas Circle NW, Suite 200 Washington, DC 20005 www.healthpolicyproject.com policyinfo@futuresgroup.com Contact Us

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