Terminal evaluation - Increasing Access to HIV/AIDS Prevention and Care for Vulnerable People

Report Cover Image
Evaluation Plan:
2013-2017, India
Evaluation Type:
Final Project
Planned End Date:
06/2017
Completion Date:
11/2017
Status:
Completed
Management Response:
Yes
Evaluation Budget(US $):
20,000

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Title Terminal evaluation - Increasing Access to HIV/AIDS Prevention and Care for Vulnerable People
Atlas Project Number: 00076037
Evaluation Plan: 2013-2017, India
Evaluation Type: Final Project
Status: Completed
Completion Date: 11/2017
Planned End Date: 06/2017
Management Response: Yes
Focus Area:
  • 1. Others
Corporate Outcome and Output (UNDP Strategic Plan 2014-2017)
  • 1. Output 1.2. Options enabled and facilitated for inclusive and sustainable social protection
Evaluation Budget(US $): 20,000
Source of Funding:
Evaluation Expenditure(US $): 10,000
Joint Programme: No
Joint Evaluation: No
Evaluation Team members:
Name Title Email Nationality
Mr. Pradeep Sharma Independent Consultant pradeepsharma0329@gmail.com INDIA
Mr. Pradeep Sharma Independent Development Consultant pradeepsharma0329@gmail.com INDIA
GEF Evaluation: No
Key Stakeholders: National Aids Control Organisation (NACO)
Countries: INDIA
Comments:

The Project is rated very highly for leveraging government and non-government partnerships in the most outstanding manner. It tapped into social protection champions and sympathetic civil servants, networks of positive persons, civil society and staff in DAPCU. The Project also made full use of innovative approaches like social protection camps to create demand for services and awareness. 
 

Overall, the Project was a timely and relevant initiative that provided support to NACO in the operationalization of mainstreaming activities under NACP-IV. The outcomes have been remarkable – the Project created enabling legal and policy environment, contributed to understanding and reducing stigma, worked towards equal rights for the sexual minorities especially transgender, improved uptake of social protection schemes, and positioned social protection at a higher level as a means to mitigate HIV impact. With the rolling out of the HIV/AIDS (Prevention and Control) Act, 2017 and the Transgender Bill, which will eventually be enacted as an Act, there is further work to be done till the PLHIV and high-risk groups are mainstreamed in the society.

Lessons
Findings
1.

3.1 Relevance

The Project is strategically very important and relevant as it directly supports mainstreaming strategies and activities under NACO’s National AIDS Control Programme-IV. The Project contributes to the enabling legal, policy and living environment to make it conducive for the PLHIV and HRGs to access services. Strong advocacy by UNDP and civil society has led to the Supreme Court recognizing transgenders as the “third sex”. It is remarkable that the Supreme Court in their judgement have cited and acknowledged UNDP’s technical inputs on the subject. Furthering its work on TG and MSM, UNDP helped NACO in preparing Operational Guidelines for Implementing HIV Target Interventions among Hijras and Transgender People and Operational Guidelines for Implementing HIV Target Interventions for Men who have Sex with Men (MSM). UNDP’s contribution and technical support in the formulation of these Guidelines was duly recognized and acknowledged.


Tag: Relevance HIV / AIDS Policies & Procedures Advocacy

2.

Stigma is a major barrier to infected and affected communities accessing social protection services and living a life of dignity. Under the Project, UNDP worked with ICRW to analyze the root causes of stigma (lack of awareness, social judgement, fear of infection) and adapt the global stigma reduction framework to Indian context. In particular, note must be made of the inclusion of ‘intersecting stigmas’ (occupation and caste) given the social stratification in India and also focus on family, rather than individual, as a target group, while working on the 18stigma reduction framework in India. UNDP provided technical support to NACO to integrate stigma reduction framework under NACP IV (2012-2017).


Tag: Relevance HIV / AIDS Technical Support

3.

UNDP also assisted in formulation of the “Guidelines for Prevention and Management of Stigma and Discrimination associated with HIV/AIDS” to facilitate implementation of the HIV/AIDS (Prevention and Control) Act 2017. These Guidelines once approved and adopted will be a major contribution under this project to the mainstreaming efforts.

The UNDP-supported National Survey on HIV-related Stigma and Discrimination in urban India (2014)6, covering 18 states, is a significant knowledge product in understanding the various types of stigma. The survey showed that HIV-related stigma persists and, more importantly, PLHIV continue to face stigma and discrimination, mostly covert, within health care settings. This was also confirmed by a number of HIV positive respondents this consultant interviewed who alleged that they were refused treatment under one pretext or another.


Tag: Relevance HIV / AIDS Knowledge management

4.

The Project design is holistic in approach and takes into account concerns around prevention, impact mitigation and creating enabling environment. It comprehensively addresses mainstreaming and stigma by engaging non-health ministries and signing MOUs with them for HIV risk reduction, addressing stigma and mitigating HIV impact. This has been a major initiative to sensitize the Ministries and encourage them to be more inclusive in providing services to infected and affected communities.


Tag: Relevance HIV / AIDS Programme/Project Design National Institutions

5.

At the central level, a Joint Working Group, representing signatories to the MOUs, is constituted that meets regularly to develop a plan of action and monitor progress. At the state level too, MOUs are implemented by the state level Joint Working Groups comprising representatives from various government departments and chaired by PD-SACS. Such meetings are helpful in modifying schemes of relevant departments to make them HIV sensitive. Action plan for each ministry typically includes capacity building of staff on HIV/AIDS within the ministry and of institutions affiliated with the ministry; implementation of awareness programme; and review of schemes and modifications to make them HIV sensitive by changing, if needed, eligibility criteria.


Tag: HIV / AIDS Awareness raising Capacity Building National Institutions Regional Institutions

6.

A key mainstreaming strategy is the provision of appropriate social protection schemes, by largely modifying existing schemes to make them more PLHIV and HRG friendly. Under NACP-IV, social protection appears as a priority area as a means to mitigate the impact of HIV on infected and affected persons. The Project is strategically aligned to the NACO’s National AIDS Control Programme-IV the strategy document of which aims at “Ensuring social protection schemes for people infected and affected with HIV/AIDS through mainstreaming of HIV/AIDS with other ministries”. The activities under this Project also directly contribute to the state level policies on social protection and HIV/AIDS strategies.

The “single window” social protection interventions are well aligned with the UNDP Strategic Plan (2014-2017), India UNDAF (2013-2017) and Country Programme Outcome 4 that reads: “Vulnerable and marginalized populations have equitable access to and use quality basic services in selected states (i.e. health, education, sanitation, HIV and AIDS, safe drinking water)”. The “single window” model is also in harmony with the operationalization of provisions on social welfare under recently enacted HIV/AIDS (Prevention and Control) Act 2017 (Chapter VII, Section 15).


Tag: Relevance HIV / AIDS Results-Based Management Social Protection Vulnerable

7.

The overall Project design is appropriate as it addresses exclusion by focusing on some of the most vulnerable groups namely HIV positive persons, HIV affected children and MARPs and also has appropriate geographical focus as it concentrates its activities in high prevalence districts. The Project thus contributes strongly to inclusiveness so that people with HIV/AIDS could live with dignity and without stigma. It also demonstrates scalable social protection models which could potentially become the “best practice”.

The Project builds on past experience of UNDP’s interventions in this area which received very positive review in the India Assessment of Development Results (ADR) Report 2012. UNDP is well positioned, trusted and valued by government for its thought leadership, regional / international experience and innovative approaches. Operational flexibility, civil society partnerships and capacity building (rather than capacity substitution) are other strengths of UNDP.


Tag: Relevance HIV / AIDS Programme/Project Design Strategic Positioning Social Protection Vulnerable

8.

3.2 Effectiveness

Based on the desk review, interviews with a wide range of partners and field visits, it is our assessment that the Project has made significant contribution to the achievement of all the outputs and to overall outcome. A key instrument of mainstreaming has been the signing of MOUs between NACO and non-health ministries / departments with technical assistance from UNDP. This was preceded by the first ever National Mainstreaming Conference in 2011 organized by NACO in partnership with UNDP highlighting the need for non-health ministries to engage in addressing the epidemic.

So far, 15 such MOUs have been signed with as many Ministries / Departments listed at Annexure 5. A review of status on roll out of these MOUs at national and state level done in August 2017 shows some progress. Besides action on operational front like constituting Joint Working Group, designating nodal officers and preparing action plans, ground actions have also been taken by some states.


Tag: Effectiveness National Institutions Regional Institutions

9.

To cite a few examples, HIV is incorporated in the SIRD training programme in 5 states; messages on HIV/AIDS published in Common Service Centres (set up under e-governance programme) in Himachal Pradesh; free SMS sent by private telecom companies in Punjab and Mumbai; BSNL officials trained in Andhra Pradesh and Telangana; an ICTC started by BEST Mumbai; hoardings near toll gates installed in Tamilnadu; training for medical and paramedics conducted by Tamilnadu SACS; training for port workers conducted at 7 ports and FITC set up at Haldia; all coal PSUs have set up HIV and STI services in central hospitals; ICTCs are functional in many coal field PSUs; HIV/AIDS awareness programme conducted for NSS and NYKS; training conducted at many sports universities / institutions; and hoardings installed at petrol pumps in Odisha among others.


Tag: Effectiveness Health Sector HIV / AIDS Capacity Building

10.

Gujarat recently reported setting up of F-ICTC in 23 out of 26 district jails and initiating sensitization and prevention programme for Gujarat State Road Transport Corporation staff in all their 125 depots as a follow up to MOUs reviewed in JWG meetings which needs to be captured.

State-wise progress of the implementation of MOUs is however uneven and sporadic. Even though nodal officers have been designated and JWGs set up, not all states have reported concrete actions on the ground. Mid-Term Review of NACP-IV confirm this and cites shortage of human and financial resources for mainstreaming as a reason besides inadequate communication efforts to generate awareness about mainstreaming notably social protection schemes.

Not enough time has lapsed since the signing of MOUs and it is expected that with further push from NACO and advocacy from civil society, the process of operationalization of MOUs will gather momentum. It is important that state-specific reports on the progress under MOUs are prepared and disseminated.


Tag: Effectiveness Regional Human and Financial resources Social Protection

11.

One of the most effective contributions made by UNDP has been advocacy to get transgender recognized as “third sex”. In a landmark judgement, the Supreme Court not only recognized TG as third sex but also issued directions to the central and state governments to take steps for the welfare of TG community. It was extraordinary for the Supreme Court to cite technical studies conducted by UNDP in their judgement. In continuation of its work on TG, recognized as High Risk Group by NACO under NACP-IV, UNDP worked closely with NACO and provided technical support for the issue of ‘Operational Guidelines for Implementing HIV Target Interventions among Hijras and Transgender People’. The guidelines provide information to CBOs/NGOs and the TI implementation staff as well as to NACO and SACS officials. Similar guidelines were issued by NACO for MSM with the technical support from UNDP. In both cases, UNDP’s contribution was recognized and acknowledged.


Tag: Effectiveness Knowledge management Technical Support Vulnerable

12.

Much before the Supreme Court judgement, UNDP commissioned a study of the Tamilnadu Transgender Welfare Board to develop practical models of social protection programmes for transgender people in India. UNDP also continued to provide inputs and technical support as well as advocate along with civil society in the drafting of the Transgender Bill in accordance with the spirit and letter of the Supreme Court judgement. So far following states have set up TG Welfare Boards: Rajasthan, Maharashtra, Chhattisgarh, Tamilnadu, Manipur and West Bengal. Besides, Kerala has a TG Policy in place and Odisha a draft policy on TG. Kerala has also set up a TG Justice Board to monitor and oversee the implementation of TG Policy, ensure convergence of existing schemes across departments for a more targeted approach towards welfare of TG community, among others.

The study of TG Welfare Board in Tamilnadu reported a screening process to screen self-identified TG to certify them as aravani (transgender). The screening involves presence of psychological, medical and TG community representative and has been perceived as humiliating apart from the fact that ambiguity about who is a TG has led to tensions. During the fieldwork in Karnataka, this consultant was informed that many TG people did not come back to claim benefits to avoid screening procedure which they find demeaning. All other states which have set up TG Welfare Boards or have TG policies in place similarly provide for elaborate screening process. Further advocacy may be needed to ensure that this screening respects the rights of TG people to privacy and dignity or altogether dropped and self-identification accepted as valid proof of identity for providing social protection benefits


Tag: Effectiveness Regional Oversight Social Protection Advocacy Technical Support Civil Societies and NGOs Vulnerable

13.

A significant study by UNDP-NACO on the “Uptake of Social Protection Schemes by Transgender Population in India” (2014) lists different social protection schemes that benefit transgender population (either directly or through general schemes), assesses current utilization pattern availed by them and the barriers for accessing the schemes. The study also identifies priority schemes that would need to be modified to benefit transgender population. Most of the schemes benefiting TG relate to identity documents but housing and employment stand out as other priorities. It is pertinent to note that many states have exclusive housing schemes for the third gender (Bihar, Chhattisgarh and Rajasthan). Stigma and discrimination, lack of proof of residence and other identity documents and lack of awareness are the major barriers to accessing social protection benefits by transgender population.

The Project also provided a compendium of laws that impede or enable HIV response which was used for the enactment of HIV/AIDS Act 2017 of which Chapter VII and Section 15 makes provisions for welfare of HIV affected and infected persons.


Tag: Effectiveness HIV / AIDS Social Protection Vulnerable

14.

UNDP was equally effective in addressing the issue of stigma and discrimination. The setting up of the Technical Resource Group (in October 2014) by NACO with UNDP’s efforts was a major initiative for providing necessary guidance to develop and implement HIV stigma framework in NACP to ensure zero stigma in all settings. The TRG is a platform that provides voice to representatives of sexual minorities and PLHIV who are members on this Group.

The UNDP-supported National Survey on HIV-related Stigma and Discrimination in urban India (2014), cited above, is perhaps the first such comprehensive survey, covering 18 states, trying to understand the sources and types of stigma, both from the perspectives of the stigmatized and the perpetrators, and makes recommendations on addressing misconceptions, trainings, campaigns, and sensitization involving PLHIV. The persistence of HIV-related stigma acts as a major barrier in accessing social protection services. The fieldwork in four states by this consultant shows that stigma varies from state to state and depends on the prevalence and location. Karnataka (Bangalore Urban) reported less cases of stigma than Rajasthan.


Tag: HIV / AIDS Country Support Platform Awareness raising Capacity Building Vulnerable

15.

Fear of breach of confidentiality has not completely disappeared and was one of the reasons for target groups not accessing certain social protection services. It was observed that the schemes that offered highest confidentiality were the most popular schemes (Palanhar and AAY in urban areas in Rajasthan, Jatan and Tabibi Sahay in Gujarat for example) while the least popular schemes were the more “open” ones like NREGA which had no takers.


Tag: Effectiveness Social Protection

16.

The PLHIV respondents were also averse to any schemes that required certification by a sarpanch. They would rather forgo the benefit than run the risk of their status being disclosed to the whole village. As mentioned above, stigma did not appear to be much of concern in Bangalore Urban and people are coming out very openly. In Manipur as well, stigma is not a major factor as many families are affected by the IDU-related HIV. No discrimination against children with HIV positive status or HIV positive parents was reported in Manipur.

Another significant report that helps in understanding stigma is the report on “Global HIV stigma reduction framework adapted to and implemented in five settings in India” namely: educational setting, multiple layers of stigma faced by rural FSW living with HIV, to combat negative attitudes towards PLHIV through engagement of local governance systems (panchayats), to capture stigma in health settings and among MSM, and stigma at workplaces. This report was prepared by ICRW and UNDP.


Tag: Effectiveness Regional Urban Local Governance HIV / AIDS Knowledge management

17.

The social protection aims at reducing vulnerabilities and to mitigate the impact of HIV. Social protection includes access to rights and entitlements including health, nutrition, shelter, legal aid, transport support, pension etc. The DAPCU-led “Single Window” model of social protection for People Living with HIV/AIDS (PLHIV), Children Affected by HIV/AIDS (CABA) and Most-at-Risk Populations (MARPs) is one of the outputs under the Project. The Project has been able to reach out to cumulatively increasing number of infected and affected persons reaching 1,000,000 benefits in 2016.

The Project directly influenced the guidelines on HIV-sensitive social protection delivery. UNDP’s technical assistance to NACO resulted in the latter issuing the Guidance Note for the Implementation of the DAPCU-led Single Window on Social Protection for PLHIV, CABA and MARPs. Working closely with civil society and the networks, UNDP Project led to significant modifications in various schemes, including relaxed eligibility criteria or treating PLHIV at par with BPL, making the same more HIV sensitive.


Tag: Effectiveness Human rights HIV / AIDS Knowledge management Social Protection Technical Support

18.

It is interesting that the submission of applications for various schemes for PLHIV in Gujarat (Jatan, Tabibi Sahay, Scholarships) is done directly to the relevant departments by CSC and other help desks and not through DAPCU. In Rajasthan, DAPCU has no role in Palanhar scheme which is online. In Manipur as well, with the exception of AAY, DAPCU is not the routing agency and all applications are made directly by Care and Support Centres (or Vihaan Centres)7 to concerned departments. In all such cases, DAPCU receives a copy of the forwarding letter through which CSC / help desks submit the applications. DAPCU and CSC then jointly follow up with the relevant departments.

DAPCUs are not equally effective in all states. In Gujarat, these are headed by District TB and HIV Officer (DTHO) who, as the name suggests, also has TB as his / her responsibility. The day-to-day monitoring is done by a relatively junior District Supervisor, who is of late also given additional charge of a neighbouring district. In Karnataka, DAPCU head is also Medical Officer of a PHC with DAPCU being one of the many responsibilities. In all the states visited, DAPCU was not adequately staffed or funded to perform their role. DAPCU’s data systems were weak in Rajasthan but much better in other states (Gujarat and Karnataka). In Rajasthan, DAPCU does not sign the forwarding letter - it is the CMHO who does and is critical in this scheme. DAPCU DPO relies on CMHO for advocacy and support.


Tag: Effectiveness HIV / AIDS Social Protection Awareness raising National Institutions Regional Institutions Vulnerable

19.

Though rejection rate has declined, there is huge gap in Rajasthan and Manipur between the number of people registered with ART Centres and the number that finally applies for schemes. Even smaller number finally benefits. For example, in Rajasthan, out of 13,892 PLHIV who agreed with ART / CSC only 3491 applied and 3234 benefited. Reasons are many: sometimes old patients dissuade the new ones at ART Centres against such schemes citing their own experience of delays, corruption, breach of confidentiality, and unnecessary paperwork, among others. Only a small percentage of cases come back to CSC / DAPCU with necessary documents for further processing. Complaints of excessive requirement of documents are still being reported from all states. In Manipur, applications were pending for 2-3 years with no response from the government which frustrated the PLHIV and they became suspicious of the motive behind these applications. However, success in terms of entitlement benefits (Aadhar card, ration card, birth certificate, BPL card, etc) is much higher uniformly in all states and practically all those who apply get the benefit.


Tag: Effectiveness Local Governance Vulnerable

20.

In terms of capacity building, the Project specifically engaged with key implementers and worked with staff in CSCs, TIs, DAPCU and others. It developed guidelines on increasing access to social protection by HIV affected populations; web-based portal on social protection which is an important source of information; a module on social protection that was used for training of key stakeholders; and built capacity of CBOs who have taken social protection seriously as part of their mandate. SACS was more active in Gujarat and has formed a core team of trainers that is called upon to build capacity of DAPCU and help desks. Under the prevention area, the UNDP Project developed the capacity of the project staff working for the Targeted Interventions projects that resulted in effective support to the sexual minorities.


Tag: Social Protection Capacity Building Effectiveness Knowledge management

21.

Manipur made good use of non-conventional sources of social protection. Under the District Innovation Fund, created under the 13th Finance Commission, benefits were provided to 200 HIV positive women of which 5 received loans under MUDRA Yojana. Similarly, one time financial assistance of Rs 40,000 for HIV widows was provided to six widows under the Indian Red Cross Society‘s livelihoods programme. Many PLHIV also received benefit through a local philanthropist, Marup Loi Foundation and World Vision.

The roles of DAPCU, SACS and NACO are well defined in the Guidance Note on DAPCU-led Single Window Model issued by NACO. The DAPCU office acts as a single window for provision of social protection services to infected and affected communities. DAPCU officer collects applications from various service centres (designated as “help desks”), submits to concerned departments and follows up as necessary. The role of SACS is to issue directives to DAPCU for implementation of” single window model of social protection and also to all facilities at district level to establish social protection helpdesks. SACS also advocates for amendments in existing schemes to further make these HIV sensitive. The help desks generate demand and facilitate access to social protection by helping applicants complete their applications with required documents (Aadhar card, voter Id, BPL card).


Tag: Effectiveness Regional HIV / AIDS Human and Financial resources Social Protection

22.

The DAPCU-led social protection aims at creating enabling environment where PLHIV, CABA and MARPs are able to access social protection without stigma or discrimination. Its objective is also to increase the enrolment of infected and affected communities in the social protection schemes by modifying the schemes to make them more HIV sensitive.

Even though “single window” approach itself may not be innovative, as there are several examples in India of successful single window e-governance initiatives, the approach and the processes leading up to “single window” were innovative. In particular, we must mention the campaign approach used to generate demand, which brought together target groups along with departments and community members. The filling up of applications and submission to the concerned departments took place simultaneously thus saving time and giving more confidence to field staff. These camps were not only for conventional social protection schemes but also offered help in developing business plans as part of self-employment placements. Overall, the camp approach is more effective (at least in initial phases) in aggregating demand. However, once all partners are sensitized, its repeat may not be necessary and standard procedures may just be as effective.


Tag: Effectiveness e-Governance HIV / AIDS Social Protection

23.

The overall effectiveness of the Project is rated exceptional as it aimed to mainstream HIV, worked to secure justice for sexual minorities and, through social protection schemes, strived to reduce vulnerabilities and mitigate the impact of HIV. UNDP’s work in the area of TG is particularly noteworthy as also work in support of the HIV Bill which is now an Act. Over one million benefits have been provided the infected and affected people. All these show to demonstrate strong partnership between UNDP and NACO.


Tag: Effectiveness HIV / AIDS Social Protection Coordination Technical Support Vulnerable

24.

3.3 Efficiency

The overall assessment is that the Project was being implemented in an efficient manner and both financial and human resources were put to most efficient use. No duplications were found. The strategy of embedding technical experts in NACO (working closely with state governments) to provide prototyping support, technical assistance in determining the feasibility of scaling up, developing the social protection portal has not only been cost-effective but also ensured national ownership and enhanced development outcomes. Being part of the system helped these experts move things quickly. Five experts housed within the Mainstreaming Unit of NACO assisted NACO throughout the process of formulation of HIV Bill – preparing notes, making presentations, holding consultations, framing rules, among others. The HIV Bill had 50 clauses making references to various guidelines. It was the UNDP experts in NACO who identified the relevant guidelines and ensured these were up-to-date and aligned with the Bill.


Tag: Efficiency Human and Financial resources Oversight Technical Support

25.

For the budget under this Project, the achievements have been significant thanks to the national implementation and committed partnerships which avoided the need for creating parallel structures (like a PIU) for implementation. This Project demonstrates that the strength of ideas and commitment far outweighs the budgetary allocation.


Tag: Efficiency Partnership National Institutions

26.

The absence of a sound Results and Resources Framework, made comparisons over time difficult and measurement of progress with any sense of precision challenging. The AWPs for 2013, 2014, and 2015 had no baselines, indicators or means of verification. The targets were subsumed in the outputs. However, baselines, indicators and targets appear for the first time in AWP 2016. The Multi-Year Project Strategy Description is also not appropriately designed, as it does not have any baselines or indicators. It has targets but in the absence of indicators it is difficult to say what do these targets refer to. It would have been good to mention baselines even if these were zero. Though the Project is very sound on substance, on monitoring framework it is somewhat weak. There was no clear articulation of what would determine the success, or otherwise, of the Project.


Tag: Efficiency Results-Based Management

27.

The target of number of persons accessing HIV sensitive social protection services (part of the output formulation) kept changing in every AWP. In 2014, the target was to benefit 600,000 PLHIV, in 2015 it was 800,000 and in 2016 1,000,000 PLHIV. A better approach would have been to keep the target fixed and report achievement against these targets. However, there was a recent transition by NACO to measure progress in terms of benefits rather than number of persons. As of now, we are informed that more than 1 million benefits have been provided.


Tag: Efficiency HIV / AIDS

28.

Two PSC meetings took place during the Project implementation - one in October 2015 and another in October 2016. At the time of writing this (November 2017) the third PSC meeting for 2017 was yet to take place. Delays in approval of AWPs were also reported. The QPRs are skimpy and quality of Annual Progress Reports variable (2014 much more detailed than 2015).

Finally, even though the Project was entirely funded out of UNDP core resources, it catalyzed resources in terms of the government funding of the DAPCUs. Use of MOUs as a strategy also leveraged resources in non-health Ministries to set up ICTC, ART centres etc. One of our recommendations is to quantify these resources. With reported decline in UNDP core resources, the Project must continue to catalyze parallel funding from government for future interventions in this important area. UNDP should remain engaged, as new opportunities will open up once implementation of the HIV/AIDS Act 2017 is rolled out.


Tag: Efficiency Human and Financial resources

29.

3.4 Impact

The Project has positioned mainstreaming efforts to a higher level making it central to multisectoral response to HIV/AIDS. Working with NACO and other stakeholders, the Project has placed HIV/AIDS as a development challenge that goes beyond the realm of bio-medical interventions and needs non-health interventions especially in a country like India with low prevalence and low visibility.

Signing of MOUs with non-health ministries has led to greater awareness amongst the staff, strengthening of internal health care facilities making these HIV sensitive, and modifications in social protection schemes of various ministries. It is encouraging that there was not only no resistance from ministries to change their schemes but greater understanding and readiness to modify eligibility criteria and conditions to make the schemes more inclusive of HIV. Even at the district level, government officials were inclined to be more inclusive if they were informed of the specific needs of infected and affected people. However, it must be added that it required persistent dialogue and hard work by UNDP and NACO at multiple levels to achieve this.


Tag: Impact Health Sector HIV / AIDS Social Protection National Institutions Regional Institutions Vulnerable

30.

The mainstreaming efforts required systems to be put in place and make them robust and functional as well as issuing of formal guidelines. This has been another impact of the Project. Technical support in setting up of TG Welfare Boards and inter-ministerial Joint Working Group to monitor the MOUs and issuing of operational guidelines on TG and MSM have been significant contributions of the Project


Tag: Impact Operational Efficiency Technical Support

31.

Another major impact has been the modifications that various state governments and line ministries carried out in their social protection schemes to make them HIV sensitive. Many schemes saw their eligibility criteria relaxed or the scheme itself extended to cover infected and affected people as vulnerable groups eligible for benefits. Relaxation of age limit for HIV widow pension, provisional BPL status conferred on HIV positive people, taking out HIV from the exclusion list of RSBY, and use of more sensitive / camouflaged language in the government communications and identity cards issued to beneficiaries are good examples of how general social protection schemes can be made HIV sensitive. This offers huge potential for invigorating general (non-HIV) social protection schemes and making them sensitive to specific needs of other groups as well (such as persons with disabilities).


Tag: Impact Local Governance HIV / AIDS Social Protection Regional Institutions Vulnerable

32.

The overall uptake improved significantly in last three years and so did the number of benefits. As of now, more than 1 million benefits have been availed by people infected or affected by HIV/AIDS. Between 2012 and 2017, the number of AAY beneficiaries in Karnataka, for example, went up from 15063 to 34786. There is huge demand for making identity documents (Aadhar card, ration card, BPL card etc), which enables the applicants to apply for other social benefits and reduce their vulnerability. In fact, number of applications for this service is nearly at the same level as the actual social protection schemes.


Tag: Impact HIV / AIDS Service delivery

33.

The most significant impact of the mainstreaming and anti-stigma activities under the Project has been, as noted earlier, recognition of transgenders as a third sex by the Supreme Court paving the way for further action for the welfare of this community including setting up of welfare boards where UNDP is already actively supporting the government including help in drafting TG policy at state level. It is a recognition of UNDP’s technical assistance to the government that in Rajasthan UNDP is a member on the TG Welfare Board. The passage of HIV/AIDS (Prevention and Control) Act, 2017 drafting of which was also supported by UNDP through NACO, creates enabling legal and social environment to fight stigma, provide social protection without discrimination and affords PLHIV, CABA and MARPs a life of dignity.

The “single window” initiative on social protection was showcased at the UNAIDS Programme Coordination Board (PCB) meeting in Geneva (2014) which encouraged Cambodia, Myanmar, Thailand and Vietnam to have south-to-south exchange with India on this issue.


Tag: Impact Justice system HIV / AIDS Oversight Policies & Procedures Social Protection South-South Cooperation Technical Support Vulnerable

34.

3.5 Sustainability

The sustainability of the mainstreaming initiatives under the Project can be gauged from the fact that as many as 15 non-health ministries are on board to collaborate with NACO on mainstreaming activities. The “single window” model of social protection that was prototyped by UNDP in 2013 was scaled up and operationalized in 100 priority districts in 2014 and later scaled up to all 189 districts under DAPCU. That this scaling up was funded by the government out of their own resources and without additional staffing shows the effectiveness of the model as well as strong national commitment to providing HIV sensitive social protection.


Tag: Sustainability National Regional Human and Financial resources Social Protection National Institutions

35.

The Project has also built adequate capacities with facilitators at the help desks and staff at DAPCUs to carry on the activities on their own without any external support. However, the staff turnover, new interventions and need to advocate and stay engaged with partners and communities necessitate continuous capacity building of service providers. Also the success in future of mainstreaming activities requires active involvement of non-health ministries in capacity building. That this needs to come about without additional financial or human resources makes it challenging but should trigger more creative and cost-effective capacity building strategies.


Tag: Sustainability Human and Financial resources Capacity Building

36.

The single most important factor that contributed to the sustainability of the “single window” model was the strong partnerships the Project forged. The convergence of networks of positive persons, sensitive officials in line departments and DAPCU staff all worked towards making single window model an effective way of delivering social protection to infected and affected people. Each partner within the government (NACO, SACS and DAPCU) had clearly defined roles as documented in the Guidance Note.


Tag: Sustainability Partnership

37.

The Project also identified champions of social protection within the government not least NACO whose positive attitude towards social protection, willingness to issue directions to (and coordination with) SACS and close work with line departments, that modified the schemes to address the specific needs of key populations, led to the improved uptake and scaling up of the single window model. DAPCU support was instrumental in training counselors on social protection to reach hard-to-reach communities.


Tag: Sustainability Social Protection

38.

Interviews with line departments were clear that they value their partnership with the networks of positive people. This not only potentially expands the coverage, it also reduces time, effort and costs in identifying and reaching out to larger number of similarly placed people. This approach can be fruitfully utilized for providing benefits to other vulnerable groups such as PWDs.


Tag: Sustainability Partnership Vulnerable

39.

The Project acquits itself very well in knowledge management, a key contributor to sustainability. A number of products and documents have been prepared to support NACO in their mainstreaming efforts. Mapping and Size Estimation of Hijras and other Transgender Populations in 17 States of India, Operational Guidelines on TG and MSM, the National Survey on Stigma, the Compendium on Social Protection Schemes, the Guidance Note on the DAPCU-led Single Window Model, the Study on TG Welfare Board Models, among others, are first-of-its-kind knowledge products of great practical import.

Social protection portal that was a product of this Project is up and running. It is a useful resource providing state-wise and gender-wise (including separately for transgender) information on various social protection schemes available to key populations. The portal is already transferred to NACO who keep it updated.


Tag: Sustainability Knowledge management Social Protection

40.

A key factor that will contribute to sustainability is the need to provide social protection as mandated within the recent HIV/AIDS (Prevention and Control) Act 2017. Governments at the centre and states will need to put a more robust social protection system in place and formulate an HIV sensitive social protection policy.


Tag: Sustainability HIV / AIDS Country Government Social Protection

41.

3.6 Value addition

The Project added value to the functioning of NACO by providing technical support to their mainstreaming activities and thus enabling realization of the relevant goals under NACP-IV. UNDP has been in the forefront in mapping TG population, building capacities of partners from national to district level, piloting initiatives, providing technical papers, advocating, presenting evidence and so on. These activities encompassing legal, social, policy dimensions strengthened NACO’s hands in effectively mainstreaming HIV and engaging non-health players.


Tag: Oversight Partnership Capacity Building Coordination Technical Support

42.

The single window model of social protection brought together various partners for a common cause. The partnership of government, networks and civil society was exceptional. DAPCU’s interface resulted in lower rejection rate for applications as DAPCU pre-screens all applications against criteria and supporting documents required. The applicants do not have to run around and chase the departments. This saves time which they can use for care and work.


Tag: Partnership Country Government Social Protection Civil Societies and NGOs

43.

Another significant value addition of the model is the advocacy role played by DAPCU and networks. This led to many changes in the schemes at district level although modifications in schemes can only happen at the state level. In Dahod (Gujarat) for example, we were informed that following DAPCU advocacy, the district collector relaxed the income criteria for HIV positive tribal population to access benefits. Similarly, in Mehsana the district collector included all positive persons in BPL category to grant coverage under AAY. In Imphal East, the District Supply Officer covered all HIV positive persons under AAY regardless of their BPL status. Yet, these are exceptions rather than rules and very specific to the individual officials. Most changes require state level intervention.


Tag: Regional HIV / AIDS Advocacy

44.

Sending applications through DAPCU also means that the PLHIV can seek social protection with relative confidentiality although complete confidentiality appears difficult to achieve. The applicants see if the benefits outweigh the cost in terms of breach of confidentiality. With more and more schemes being launched, the stigma is breaking down as the Karnataka experience shows and balance tilting towards coming out in the open to claim the benefits. In Manipur, stigma is not the issue but the lack of HIV-sensitive policy and programmes is. The strength of belonging to a network enables members to raise their voice and be more assertive to claim their rights. There are also complaint mechanisms to take action against people who discriminate against PLHIV.


Tag: Regional HIV / AIDS Policies & Procedures Social Protection

45.

The “single window” model has made government officials more sensitive and flexible to the needs of the infected and affected people. From a pure practical point of view, since all applications come from a single point where information, needs and priorities of infected and affected people are available, for the government this lowers the transaction cost and expands the coverage.

With the ‘test and treat’ policy, all persons tested HIV positive will be put on ARV treatment regardless of CD4 count. This will also increase the numbers wanting to access social protection. With the SW model in place, it should be possible to deal with enhanced numbers.


Tag: HIV / AIDS Service delivery

46.

3.7 Gender equality

The Project is rated highly for its gender sensitivity, defined broadly to include transgender and children, as it promoted availability in a stigma-free environment of social protection services for women living with HIV, HIV widow and women as guardians of children affected by HIV. Besides, positive children themselves, children of positive parent(s), transgenders, FSW were also specifically addressed by various social protection schemes.

By and large, social protection schemes are biased in favour of women with few schemes that target MARPs, even though transgender have lately started to benefit from specially designed schemes. Low access to social protection services by MARPs is for various reasons: unwillingness to come out openly; high mobility leading to lack of residence proof and other identity documents; and relatively better off employment / economic status hence no pressing need for social protection. However, there is need to design HIV sensitive schemes for MARPs, as distinct from HIV specific, and create awareness so that MARPs can access alternative income generation schemes


Tag: Gender Equality HIV / AIDS Social Protection Vulnerable Women and gilrs

47.

Although DAPCU does not keep gender-disaggregated data, visibly it did not appear that women were in any way hesitant to come forward to avail of social benefits. On the contrary, perhaps women overcome and handle stigma much better than men. In all the network meetings this consultant attended, women far outnumbered men and were more vocal in expressing themselves on social protection issues. This was true across all states (somewhat less in Rajasthan though). In Gujarat, during the dissemination of HIV issues through nukkad nataks(street theatre), young women in rural areas were more active in asking questions.


Tag: Rural HIV / AIDS Social Protection Women and gilrs Youth

48.

With the recognition of transgender as third sex, there is hope that they will be able to lead a life of dignity. Many states have exclusive schemes for them. For example, Karnataka has the Maitri scheme under which DAPCU receives the list of TGs from Revenue Department. DAPCU then verifies the TG status of the persons in the list. For this purpose, the TGs are subjected to biological and psychological tests in a hospital to verify if they are indeed TGs. This is found to be humiliating by many TGs who refuse to go to the hospital and prefer to forgo the benefit.


Tag: Gender Equality Vulnerable

49.

Notwithstanding many schemes that benefit CABA (Palanhar in Rajasthan; and Palak Mata Pita in Gujarat), most states (except Manipur) reported that children in school face discrimination with parents of general children threatening to withdraw their wards from school. Strong district administration that protected the rights of CABA (Gujarat), change in requirements from school principal issuing a certificate to online certification (Shala Darpan in Rajasthan), dropping of question on HIV status from school form, direct transfer of benefits to children and not disclosing the identity of children to banks (Karnataka, Gujarat) have gone a long way in protecting children against discrimination.

In Manipur, the Pediatric Centre of Excellence was receiving nutrition packages from the Department of Social Welfare under the Double Nutrition to Children scheme. But the Department discontinued this in 2014, on the ground that children are already receiving benefits under ICDS. This was raised with the Department who were more than wiling to resume supplies of nutrition packages to the Centre. This again proves that advocacy is a continuous process and the concerned partners must keep the pressure on.


Tag: HIV / AIDS Service delivery Advocacy Women and gilrs

Recommendations
1

The MOUs with non-health ministries is a key instrument of mainstreaming and it is important that the Joint Working Groups (JWGs) meet regularly and robust monitoring system is put in place at the state level to gauge progress and to prevent disjointed response by line ministries

2

With growing digitization, there is need to find online solutions to link DAPCU, networks and line departments and promote greater use of Common Service Centres. This will promote efficiency, reduce corruption, ensure confidentiality and strengthen monitoring and database in the delivery of social protection services

3

As DAPCUs are likely to remain the lynchpin of the “single window” model they need to be strengthened and empowered with more funds at their disposal for training, monitoring and outreach so that they can perform their mandate as envisaged in the Guidance Note

4

The “single window” model of social protection that was prototyped by UNDP in 2013 was scaled up and operationalized in 100 priority districts in 2014 and later scaled up to all 189 districts under DAPCU. That this scaling up was funded by the government out of their own resources and without additional staffing shows the effectiveness of the model as well as strong national commitment to providing HIV sensitive social protection. The Project has also built adequate capacities to sustain activities without external support but staff turnover, new interventions and need to stay engaged with partners and communities necessitate continuous capacity building of service providers and communities

5

For the future interventions, UNDP should strengthen its results and resources framework with clearly defined baselines, indicators, targets and means of verification

1. Recommendation:

The MOUs with non-health ministries is a key instrument of mainstreaming and it is important that the Joint Working Groups (JWGs) meet regularly and robust monitoring system is put in place at the state level to gauge progress and to prevent disjointed response by line ministries

Management Response: [Added: 2017/12/07] [Last Updated: 2021/01/10]

The project built sufficient capacities at the central and state levels and established a Joint Working Group (JWG), representing signatories to the MOUs to meet regularly and monitor the progress. The  JWG meetings have proved helpful in bringing modification in schemes of relevant departments to make them HIV sensitive

Key Actions:

Key Action Responsible DueDate Status Comments Documents
No action required
[Added: 2017/12/07]
NA 2017/12 No Longer Applicable [Justification: The project is ending by 31st Dec'17]
2. Recommendation:

With growing digitization, there is need to find online solutions to link DAPCU, networks and line departments and promote greater use of Common Service Centres. This will promote efficiency, reduce corruption, ensure confidentiality and strengthen monitoring and database in the delivery of social protection services

Management Response: [Added: 2017/12/07] [Last Updated: 2021/01/10]

The project developed a portal for Social Protection Schemes anchored in NACO. The project also proposed a Social Protection model that combines the State led digitized initiative called E- Mitra with an increased outreach of CBOs and NGOs

Key Actions:

Key Action Responsible DueDate Status Comments Documents
Given the UNDP’s next country programme 2018-22 is unlikely to have a focused HIV /AIDS programme, it is expected that NACO will scale up the model as required
[Added: 2017/12/07]
NACO 2017/12 Completed
3. Recommendation:

As DAPCUs are likely to remain the lynchpin of the “single window” model they need to be strengthened and empowered with more funds at their disposal for training, monitoring and outreach so that they can perform their mandate as envisaged in the Guidance Note

Management Response: [Added: 2017/12/07] [Last Updated: 2021/01/10]

The “single window” model of social protection that was prototyped by UNDP in 2013 was scaled up and operationalized in 100 priority districts in 2014 and later scaled up to all 189 districts under DAPCU. That this scaling up was funded by the government out of their own resources and without additional staffing shows the effectiveness of the model as well as strong national commitment to providing HIV sensitive social protection. The Project has also built adequate capacities to sustain activities without external support but staff turnover, new interventions and need to stay engaged with partners and communities necessitate continuous capacity building of service providers and communities

Key Actions:

Key Action Responsible DueDate Status Comments Documents
NACO to monitor
[Added: 2017/12/07]
NACO 2017/12 Completed
4. Recommendation:

The “single window” model of social protection that was prototyped by UNDP in 2013 was scaled up and operationalized in 100 priority districts in 2014 and later scaled up to all 189 districts under DAPCU. That this scaling up was funded by the government out of their own resources and without additional staffing shows the effectiveness of the model as well as strong national commitment to providing HIV sensitive social protection. The Project has also built adequate capacities to sustain activities without external support but staff turnover, new interventions and need to stay engaged with partners and communities necessitate continuous capacity building of service providers and communities

Management Response: [Added: 2017/12/07] [Last Updated: 2021/01/10]

With the historic Supreme Court judgment and constitutional recognition of transgender population as third gender, the government is expected to identify alternative livelihood opportunities treated with dignity. The TG welfare board have played a strong advocacy role in recognizing the rights of the transgender population

Key Actions:

Key Action Responsible DueDate Status Comments Documents
No action required
[Added: 2017/12/07]
NA 2017/12 Completed The project ends by 31st Dec'17
5. Recommendation:

For the future interventions, UNDP should strengthen its results and resources framework with clearly defined baselines, indicators, targets and means of verification

Management Response: [Added: 2017/12/07] [Last Updated: 2021/01/10]

The management acknowledges the recommendation.

Key Actions:

Key Action Responsible DueDate Status Comments Documents
The recommendation has been considered in the new country programme document 2018-22.
[Added: 2017/12/07]
UNDP 2017/12 Completed

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