41622 HIV/AIDS M&E - Getting Results These reports describe activities, challenges and lessons learned during the World Bank Global Global AIDS Monitoring and Evaluation Team's (GAMET) work with countries and other partners. HIV/AIDS Program Decentralising HIV M&E in Africa Country Experiences and Implementation Options in Building and Sustaining Sub-National HIV M&E Systems, in the context of Local Government Reforms and Decentralised HIV Responses Global AIDS Monitoring & Evaluation Team (GAMET) In operationalising the 3rd of the Three Ones -- One HIV Education transfers responsibility for school M&E system, a growing number of countries in Africa management to a district council) (Winkler, 20072). are opting to decentralise their national HIV monitoring and evaluation (M&E) systems. This decentralization is "It is important to note that decentralization can be best viewed not as a single intervention, carried out at one primarily driven by other decentralisation processes point in time, but rather as a bundle of interventions ­ happening within government, and by the fact that the shifts in responsibility; creation of new managerial, HIV response itself is changing towards less centralized supervisory, and participatory bodies; capacity building; intervention and increased community ownership. etc. ­ that often occur in stages over many years. This Decentralisation of national HIV M&E systems is an increases the complexity of monitoring and evaluation, arduous and resource intensive process, but experience largely because of the sheer number of changes that has shown that it is essential to decentralise M&E must be noted (monitoring) and of impacts that must be functions as HIV services are rolled out. assessed (evaluation)." (Hutchinson & La Fond, 2004) This note summarizes the experience of countries that are decentralizing their national HIV M&E systems and describes how it can be done. It defines decentralization, Why decentralize? discusses the rationale and benefits of decentralizing the HIV response, and key factors to take into account when Decentralization aims to remove inefficient levels of doing so. Decentralizing the HIV M&E system is linked to bureaucracy, enabling decision making that is faster and decentralizing the HIV response. The note describes more appropriate for local circumstances. Economic how each of the 12 components of a HIV M&E system rationales for decentralization are to improve efficiency can be decentralized, with country examples. and better take account of diverse user preferences. Decentralization may allow efficiency gains by reducing the costs to the central governments of coordinating What is decentralization? activities across large populations or geographic areas. Also, local officials may have greater knowledge of the The concept of `decentralization' refers, broadly, to local situation. However, decentralization does not enabling a relatively large number of decisions to be guarantee improved efficiency, more equitable access to taken lower down the organization in particular operating care or improved outcomes. units.1 Two broad types of decentralization can be distinguished: administrative decentralization, the Numerous conditions influence the success of decentralization of power to lower levels within an decentralization processes, including local managerial organization (e.g. transferring responsibility for and technical capacity, systems of accountability, clear purchasing textbooks from ministries of education to and transparent legal frameworks that delineate the schools); and devolution, or giving powers to general- division of responsibilities, and sufficient funding to fulfill purpose local government units (e.g. the Ministry of mandates and to meet local priorities. 1 Pearson Education glossary, accessed 25 July 2007: 2Accessed on 25 July 2007 from wps.prenhall.com/wps/media/objects/213/218150/glossary.ht http://education.stateuniversity.com/pages/1903/Decentralizati ml on-Education.html 1 Decentralization context for HIV M&E systems media, as in the story on decentralized action in a Swaziland newspaper. Decentralization of HIV M&E systems is affected by ongoing decentralization of many government functions, Why decentralize the HIV response? especially health systems and the HIV response. There is an increased call for decentralized HIV Decentralization of Government Functions: State responses, for the following key reasons: decentralization in developing countries has been supported by the World Bank and others as a means to 1. Decentralization of the HIV response fits into wider enhance transparency, pursue efficiency and policy reforms in many countries aimed at building competitiveness gains, and strengthen democracy. The a stronger health sector and stronger local World Bank has been careful to support fiscal responsiveness and accountability. sustainability during transitions from centralized to decentralized public management, understanding that 2. National HIV/AIDS responses cannot reach the the process needs legal and constitutional reforms, cuts necessary scale through centrally operated across sector ministries, involves many stakeholders, programs. For example, centralized programs entails adjustment at the central or federal level and typically do not reach enough people in rural areas. requires strengthening of sub-national government capacity.3 3. A participatory approach that involves all relevant sectors (i.e. multisectoral approach) leads to wider Decentralization of health systems: The move to coverage and ownership of the response - decentralize HIV responses fits into the wider context of decentralization thus links with an essential process health sector reform. The World Health Organization in scaling up the response to HIV/AIDS: community (1978) and World Bank (1987) are among those who involvement and community empowerment. have argued that decentralization can (a) make health systems function more efficiently; and (b) can increase 4. Policy-makers and planners need the input of local community involvement in oversight and locally relevant people to understand the particular socio-economic decision making. conditions affecting the epidemic locally ­ there are enormous variations in needs and capabilities Decentralization of HIV responses: When countries across communities, and only local stakeholders will created National AIDS Coordinating Authorities (NACs), be able to advise on programs required. most also planned for multisectoral AIDS Coordinating Authorities at decentralized government levels, linked to 5. Coordination functions must be localized in order the NAC. These regional, provincial, district, and/or local to be effective in responding to day-to-day needs committees generally struggled to become operational. arising from community activities. In cases where they were operational, they focused 6. Decentralization brings stakeholders together, which mostly on implementing HIV services, rather than on can improve the flow of information to support coordinating planning and implementation of HIV service delivery and on M&E of the HIV response at the informed decision making and performance decentralized level. evaluation. 7. Accountability of service providers and contractors Health sector decentralization in general, and HIV to local populations is easier to achieve than with response decentralization in particular, are part of larger distant centralized agencies. democratization and good governance efforts, which are expected to promote more effective service delivery and 8. Active engagement of people at the "grass roots" local government responsiveness and accountability. level is a prerequisite for wide-ranging behavior change ­ people have to trust and buy into the As government decentralization has picked up pace, the thinking behind the need for changing their behavior need has grown to strengthen decentralized AIDS in order to change. Coordinating Authorities so they can become operational and fulfill their mandate. This view goes well beyond the Decentralization of the HIV response is, however, a NACs, for example, the clear need to coordinate the double-edged sword: whilst it can ensure greater scale, national response at a local level has been noted in the coverage and impact, it also relies on more skilled human resources at all levels ­ human resources that are often already over-stretched, and may be being eroded by AIDS. 3 World Bank website, accessed on 27 July 2007: http://web.worldbank.org/WBSITE/EXTERNAL/COUNTRIES/LAC EXT/EXTLACREGTOPPUBSECGOV/0,,contentMDK:20830786~p agePK:34004173~piPK:34003707~theSitePK:832592,00.html 2 Issues to consider when decentralizing the HIV Decentralizing the HIV response and M&E are response linked ˇ Decentralization alters patterns of authority and Should HIV M&E be decentralized if the HIV response is accountability, vesting decision making power in decentralized? Yes. The purpose of HIV M&E is to those who have informational advantages, and provide data to enable data-informed decision making strengthening linkages between local officials, about the HIV response. So if the HIV response is service providers, clients and other stakeholders. planned and coordinated at decentralized levels, data should be available at these levels too. ˇ Making results-based information public can change the dynamics of institutional relations, budgeting and Local government and local organizations may resource allocations, personal political agendas, and successfully implement programs or policies, but have public perceptions of governmental effectiveness. they produced the intended results? Introducing a results-based M&E system takes local decision makers ˇ The need for strong central coordination does not one step further in assessing whether and how goals are disappear with decentralization, but the center's role being achieved over time. shifts to policy creation, facilitation, financing and supporting local efforts. How to decentralize a national HIV M&E system ˇ Decentralization generally leads to a diminished central government role in direct service delivery, What does an HIV M&E system consist of? Based on but calls for strong central capacity for monitoring collected country level experience, GAMET has the efficiency and equity of services delivered by identified critical components which combine to make a others, and for enforcing regulations and standards. national HIV M&E system (Gorgens-Albino & Nzima, 2006). These components have been accepted by all ˇ Decentralization of planning and decision-making development partners as defining a functional HIV M&E must be accompanied by decentralization of funding. system ­ the implication is: if the performance objectives This requires that standards and procedures for of all 12 components are being achieved, then the M&E disbursing funds be developed. Financial system is functional. administration must provide safeguards through consistent monitoring. The central level may be Figure 1. The twelve components of an M&E system instrumental in developing manuals and databases. ˇ Certain functions are likely to be most efficiently undertaken at the central level, such as research and dissemination of research findings, establishing standards, regulations and accreditation, and publishing health information. ˇ Local capacity of facilitators, trainers, service providers, etc. in the private, non-profit and public sectors is needed to sustain the decentralized response, and must be developed. Central government's role is to facilitate and fund skills development at the local level according to needs. ˇ Individual and organizational responsibilities at different levels should be delineated, and a clear "line of sight" established ­ meaning that staff and organizations should understand their connections to common goals and the country strategy. ˇ Systematic collection, analysis, and reporting of Source: MERG M&E Assessments TWG, 2007 information are critical elements of decentralization - uses of this information include verifying compliance with policy goals, analyzing outcomes, and guiding decision-making. 3 How will the M&E system link project, program, b) Focal points for M&E in sub-national HIV committees sector, and national goals? When starting the process (e.g. Burkina Faso) of system decentralization, it is important to determine the opportunities for and risks in trying to link information c) Technical sub-committee for supervising, monitoring across the government in an aligned fashion (Kusek & and reporting. Rist, 2004). In an ideal situation, project performance data are fed into and linked to program assessments Guinea plans to use the Ministry of Health Surveillance that, in turn, are linked to sectoral, regional, and national Officer (Médecin chargé des maladies) to carry out the goals and targets. Each level helps inform the next level monitoring and reporting tasks of the Regional AIDS to achieve the desired results. The goal is to create an Committee. This person already deals with data and M&E system that is transparent and aligned from one statistics, and carries out regular supervision visits to level to the next. A good flow of information can help lower level health facilities and community projects ensure that policies, programs, and projects are linked working with the Ministry of Health (MOH). This option and coordinated. will also improve communication between the MOH and Regional AIDS Commission. In Anglophone Africa, there Staff at each level should have a clear "line of sight" into, is a strong trend towards integrating Regional AIDS or understand each of the other levels and how they Committees (RACs) with local government services, with relate to one another. In addition, it is necessary to the RACs becoming standing committees of the district ensure that there is commitment within each level to councils (or equivalent). horizontally use and share the information that is collected and analysed. In this way, each level becomes Human resources a producer and consumer of results-based information. Ensuring the availability of skilled monitoring staff has been a challenge both at coordination level and at How should the HIV M&E system be decentralized? implementer level. Countries have used various Decentralizing the HIV M&E system means, in practice, approaches to improve human M&E capacity at decentralizing each of the 12 components of a national decentralized levels: HIV M&E system. A summary description of the 12 M&E system components at central and decentralized levels At coordination level: is presented in Table 1. a) Part time M&E staff reporting to District Councils and paid by District Councils, using Local Government's The rest of this paper provides options and examples of database (Tanzania) how each of the 12 components has been decentralized in different countries. b) Full time M&E staff reporting to the Ministry of Regional Government and paid by the National Emergency Response Committee on HIV and AIDS Country experiences in decentralizing HIV M&E (NERCHA), using a separate database as District systems Councils do not yet have databases (Swaziland) c) Full time M&E staff reporting to the HIV M&E unit Countries have chosen to decentralize the 12 M&E and paid by the Response Monitoring and components in different ways. Decentralization has often Evaluation (RM&E) sub-division in Namibia happened under considerable resource constraints and pressure to avoid creating new structures and d) Full time M&E staff for all government functions at bureaucratic layers. NACs have tried to be innovative district level, paid for and reporting to district and have generally focused on building on existing well- councils (Malawi). working structures and systems. New linkages have been forged with existing structures within regional At implementer level: administrations, the MOH and other institutions. a) Designated M&E focal person in each implementing organization whose M&E training is 1. Decentralizing Organizational Structures with part of the M&E system development process. This M&E Functions and Posts capacity building often uses a Training of Trainers (ToT) approach for increased efficiency. Organizational structures b) Networks of implementers who share M&E skills Most countries set up structures at lower government during coordination meetings ­ this happened levels early in the epidemic, in order to coordinate, plan, spontaneously in Senegal when implementing monitor, evaluate and supervise local AIDS response organizations realized that there is existing M&E efforts. M&E responsibilities have been dealt with in capacity within some implementers and that training several ways: funds are very limited (the network was seen as a "palliative"). a) Multisectoral AIDS committees at decentralized levels with broad M&E functions (most countries) 4 Table 1: Summary description of the 12 HIV M&E system components, central and decentralized levels Component Central level Decentralized government level (e.g. district council or regional council) 1- Organizational Fulltime M&E unit at the NAC Fulltime HIV M&E officers, or fulltime AIDS coordinators at structures with M&E HIV Focal Persons in government ministries decentralized government offices with HIV M&E responsibilities, or with M&E responsibilities fulltime M&E officers Umbrella organizations have M&E officers, or At least one staff member responsible for HIV M&E at every HIV HIV focal points with M&E responsibilities implementer in public sector, private sector and civil society 2- Human capacity for Capacity of all persons involved in coordinating Build capacity of all HIV implementers, and all persons involved in M&E HIV activities to be built on M&E concepts and coordinating HIV at decentralized level on M&E concepts and system specific tasks system specific tasks 3- M&E partnerships National technical working group on HIV M&E Decentralized government staff are part of national technical working group, and HIV implementers are represented on the national M&E technical working group Regional AIDS Committees work as partnership forum with general monitoring functions 4- M&E framework National M&E framework linked to the National Decentralized HIV Action Plans (which are based on the national HIV Strategic Plan framework) linked to guidelines for routine programme monitoring 5-Costed M&E work National costed HIV M&E work plan, that Decentralized costed M&E work plan plan includes all regional M&E work plan costs HIV M&E included as a separate line item in the budgets of HIV implementers 6- Advocacy, National level advocacy and communication Decentralized level advocacy and communication efforts to build communications and efforts to build M&E culture at national level M&E culture at decentralized levels culture for HIV M&E Identification of highly placed champions Identification of champions at sub-national level advocating results- advocating results-based M&E based M&E 7- Routine programme National guidelines for routine programme Submission of routine programme monitoring data at the monitoring monitoring of HIV services ­ at health facilities decentralized levels, aggregated, and submitted to the national and in the communities level 8- Surveys and National level surveys Sample frame to be stratified by decentralized administrative units surveillance (e.g. regions, provinces), where possible and if funding allows 9- HIV Information National HIV information system to capture data Decentralized data capture system ­ either paper-based or system about all 12 components of a functional HIV electronic. Where possible, this should be integrated in the national M&E system HIV M&E system. 10- HIV learning & National level HIV research strategy and Inputs from decentralized levels as to specific issues to be added to research agenda the national HIV research agenda 11- Supervision & dataNational guidelines for supportive supervision Supportive supervision and data auditing carried out by auditing and data auditing for 3 types of visits: National decentralized staff; reports on supportive supervision visits and HIV M&E unit at NAC to decentralized levels, data auditing visits sent to national level staff at decentralized levels to HIV implementers and umbrella organizations to HIV implementers 12- Data use Use of data from all levels for national policy Use of local level data for program decision making at local level formulation and program decision making, as (with consideration of national level data and strategic information) well as to measure overall performance and Measure performance and track progress in achieving desired track progress in achieving desired national goals at sub-national level goals. Creation and dissemination of national level Decentralized level information products created at regional level or information products, where possible data in by national level, and decentralized workshops arranged to information products should be disaggregated disseminate data by decentralized administrative units 5 2. Decentralizing Human Capacity for M&E work plans. This makes it very important that the a) Umbrella organizations of civil society groups have national M&E framework is well disseminated and played an important role in human resource available to all coordination and implementation development for M&E at implementer level structures. (Zanzibar) In some large or federal countries, M&E frameworks b) Training of Trainers approach used to train M&E have been developed for the decentralized level (e.g. staff in implementing agencies (Swaziland) Ethiopia, Malawi). c) Pool of M&E facilitators at decentralized level, who are available in a certain region or district for 5. Decentralizing Costed HIV M&E Work Plans coaching M&E staff of implementing organizations (Guinea, Uganda) Countries increasingly tend to avoid a "top down" approach to planning, since it is not conducive to appropriate planning for the different types of AIDS 3. Decentralizing M&E Partnerships epidemics in a country. In addition, the approach does One of the most powerful ways to forge M&E not strengthen ownership of the response in the way a partnerships at sub-national (and indeed national) level "bottom up" approach does. is through multisectoral committees. For these committees to work, the following issues have been Developing annual sub-national work plans with an identified during country-based work: integrated M&E plan has therefore become the norm in many countries including Guinea, Senegal, Zanzibar and Multisectoral committees: Swaziland. Plans are sometimes guided by planning orientation papers from the NAC, as in Burkina Faso, ˇ Must have terms of reference and specific in order to give strategic direction to the sub-national responsibilities allocated to individuals (president, plans. If well done, this approach raises the probability of secretary, monitoring & reporting, finance) sub-national levels taking into account current available ˇ Must have premises and basic office equipment evidence and national data from surveillance and ˇ Must have an operating budget and access to a research, and may increase intervention effectiveness. vehicle Annual sub-national work plans are usually consolidated into an annual national plan of action. ˇ Must meet at least once monthly even in the absence of NAC funding, in order to monitor all AIDS activities One of the major challenges encountered by sub- in their geographic area national authorities in the annual cycle of planning and ˇ Must receive endorsement by the highest authority in implementation is timing. Planning, harmonization and their area of work and be actively promoted as the approval of their plans and budgets, consolidation of all AIDS coordinating authority in the locality sub-national plans into a national plan, mobilization and ˇ Must have monthly or quarterly reporting requirements then disbursement of funds usually take several months, to the superior level and annual plans are often only implemented after serious delays, frustrations and interruption of activities ˇ Must include review or evaluation activities in their at community level. Part of the solution lies in ensuring annual work plan. that the monitoring time frame and planning time period are staggered by six months. Compiling monitoring data Other forms of M&E partnerships can be interest groups six months earlier allows the data to be available when (NGOs in Senegal, email listservs in Zanzibar), umbrella planning takes place (e.g. the Great Lakes Initiative on organizations, networks, etc. AIDS, Zanzibar) At the local level, M&E partnerships are important too. A few countries have gone a step further and produced Decentralized M&E multisectoral committees are often district plans, which are consolidated into regional and formed; these committees need to have a dedicated then national plans. While this approach increases M&E function. further the ownership and the specificity of interventions to each local epidemic situation, it also complicates the 4. Decentralizing M&E Frameworks process and increases the likely time between planning of activities and availability of funds for implementation. M&E frameworks are usually elaborated at national level as part of longer-term planning (e.g. a five-year Strategic Guinea is starting to use M&E software in producing Plan). People working at decentralized levels participate, work plans (Sidapes system developed within the and the M&E framework is a key document for the whole Backup Initiative). This will make it easier to harmonize country. This is important for harmonization in that the individual plans and to consolidate lower level plans into national document declares which M&E indicators summary plans. should be used nation-wide. The national framework is an essential guide for the development of sub-national 6 6. Decentralizing Advocacy and Communications to stressed more, and GAMET and others have focused on Create a Culture for HIV M&E strengthening capacity for activity monitoring. Reporting Countries have realized that if the local level is not requirements, both financial and technical, increasingly convinced that M&E is important, then the M&E system have been laid down in detail in contracts between will never be operational. At the national level, strategies implementing organizations and funding agencies. The for communicating about and advocating for HIV M&E "results based disbursement" introduced by the Global need to be built into the national HIV communications Fund to Fight AIDS, TB and Malaria and others is an and advocacy strategy (as done in Zanzibar and incentive to strengthen activity monitoring. Without Tanzania Mainland.). High level champions, ideally activity monitoring, results cannot be documented and located in the centre of policy-making, are important reported ­ and funds will not be received. advocates for results-based M&E. Their support is crucial to the success and sustainability of the M&E Activity monitoring must be prepared for at the planning system. Equally, at sub-national level, political stage, so countries have tried to communicate the champions are key to ensuring that results-based M&E national output indicators to implementers who are systems are institutionalized and sustainable. applying for NAC funding. For instance, project proposals for NAC funding in Senegal had to include an Several tools can support advocacy efforts at local level: M&E plan, which was based on a template and a list of national indicators for program activity monitoring. a) Sub-national participatory (or joint) reviews and Activity monitoring costs should be budgeted for by evaluations can show data gaps and needs. For implementers and funding agencies should expect a instance, the realization by local people that important certain percentage of the total budget to be used for data are completely lacking advocated in a powerful monitoring. way for better decentralized M&E in Senegal. b) Informed leaders and champions at decentralized In most countries, reporting of monitoring results is done level have been indispensable in M&E advocacy in a standardized way so that data can be aggregated activities. For instance, the Governors and Prefects of and summarized easily. Pre-formatted monthly or Senegal have played a key role in demanding data on quarterly reporting forms facilitate this. Some countries the local response and promoting use of the data. (Guinea, Swaziland and Zanzibar) have printed books of They can be powerful advocates for the M&E system. auto-carbonated forms with different color pages for transmission to different structures, e.g. red for the NAC, c) Pamphlets and flyers have been produced and blue for RACs, yellow for NGO umbrella organizations/ disseminated at decentralized levels to advocate for supervising ministerial departments, and white to keep at the use of program activity monitoring systems implementer level. This method allows several structures (SHAPMoS in Swaziland, TOMSHA in Tanzania, etc). to receive the same information in the absence of a d) Road Maps for operationalising the national M&E photocopier or computers. It also helps prevent double- system have been developed in a participatory way by entry of data in the national data base, since only one several countries including Swaziland, Tanzania form (e.g. the blue one at RAC level) is used to enter Mainland and Zanzibar (GAMET, 2006). A good Road information into the data base. Map, (i.e. one which plans for all levels), galvanizes the actors at all levels and provides an important tool A major hurdle in activity reporting is the lack of an for advocacy. incentive for implementers to do it well and at the agreed intervals. If disbursement to implementers is suspended if reports are not submitted, the target populations do not 7. Decentralizing Routine Program Monitoring receive the planned services, and disbursement at Routine program monitoring is at the heart of an central level slows down ­ two effects which are not operational M&E system. It involves collecting data desired. However, with considerable advocacy, training about HIV services from all actors involved in the HIV and publicizing efforts, coordinating authorities can response. It is the most complex component of the M&E obtain significant reporting percentages (Malawi 85%, system. At the national level, uniform guidelines for Zanzibar 72%). Malawi, when introducing the activity activity monitoring or programme monitoring should be monitoring forms, decided to "name and shame" non- available. complying organizations at the end of quarterly service coverage reports to encourage organizations to comply with reporting requirements. At the decentralized level: Monitoring functions are naturally decentralized since they are commonly carried out by implementers and their direct supervisory 8. Decentralizing Surveys and Surveillance authorities. Until a few years ago, the emphasis was on financial monitoring and reporting in HIV activities. Some surveys and surveillance clearly need to be Activity (technical) monitoring and reporting was weak conducted at the national level (such as DHS, MICS) and undervalued in many countries. This has changed; with stratified sampling frames that will ensure that the importance of technical accountability is now survey results are also representative at decentralized 7 levels. Others can and should be implemented more evaluations of key programs and interventions are frequently by the decentralized level. The AIDS epidemic needed to scale-up HIV programming sensibly and is diverse even within a country, and smaller scale effectively. Important evaluation areas in which sub- surveys can be an indispensable data source for national levels need to contribute are epidemiological & evidence-based planning. Capacity to conduct survey response syntheses, cost-effectiveness evaluations, activities, and even more so to analyze data, still needs surveillance and strategic information, program to be strengthened. evaluation, and expenditure tracking evaluation. National surveys need to be planned and analyzed with Regarding research, it is necessary to develop a national the interests of the decentralized level in mind. Sample research strategy and agenda. This requires strong sizes need to be large enough, if practical and financially participation from sub-national and community levels, in feasible, to allow region-specific analysis.4 This also order to ensure that the research agenda includes their implies that the regions need to receive the raw data, the needs appropriately. At sub-national levels, the results of the analysis, as well as the final report, in a coordination authority must plan evaluation, learning and form which is useful at regional level. research activities as part of the annual work plan, in line with national research priorities laid down in the national strategy. For implementation of research studies, 9. Decentralizing HIV Information Systems specific capacity strengthening activities may be required, particularly at sub-national and local levels, The national HIV/AIDS information system relies on a and appropriate ethical procedures need to be in place. national M&E database. The database is a repository of all relevant M&E data and information for a country. A populated national M&E database that is actually used 11. Decentralizing Supervision & Data Auditing indicates that a functional national M&E system has been established successfully. Supervision activities take place between hierarchical levels (see table 1, component 11) and procedures for Decentralization of the information system is best data auditing should be defined in guidelines for data achieved by decentralizing the M&E database, or by auditing and supportive supervision. Supervision needs creating links between an existing decentralized to be budgeted for in all M&E work plans, and intervals database and the national HIV database. The central and extent need to be consistent with the defined norms. level usually spearheads development of the database, Specific tools to conduct and document supervision and the country might in a first phase operate one need to be developed to achieve a standardized centralized national database. Decentralization of this approach to supervision, and a mechanism should be database must follow, to equip sub-national coordinating established to act on supervision results. Supervision bodies to be fully functional. Decentralization of the should always be supportive and be used as a capacity database frees the central level from massive data entry building instrument. tasks and empowers the regions to manage the project planning cycle in relative autonomy. Data auditing is an independent, objective activity designed to check and improve data quality. Internal In Tanzania Mainland, routine monitoring data will be data auditing provides an assessment undertaken by a captured at the decentralized level into an existing local unit reporting to management; external data auditing is government database system and then exported into the conducted by an independent organization. national HIV database. In Zanzibar, a new module has been created for the national HIV database to capture Whilst linking data auditing processes to financial data at the decentralized levels and in Botswana and auditing processes may save costs, data auditing is Namibia, the UNAIDS CRIS system version 3 will be quite different from financial auditing. Data auditing is the used to capture data at the decentralized levels. process of verifying the validity of data by tracking all the steps in the data collection and recording process. 10. Decentralizing HIV Evaluation, Learning & Good data auditing and supervision helps to improve Research monitoring systems. In Swaziland, data auditing revealed that one organization submitted summary In a results-based M&E system, evaluation, learning and reports based on `information that they remembered research need to happen at all levels. Evaluation from memory'. The Officer conducting the audit then supports a learning agenda on what is working and what helped the organization to develop standard forms to is not working, and assesses whether changes expected use to record all their data. from program and policy interventions are actually happening. It is now recognized that systematic 4 "Region" indicates the first decentralized level. 8 12. Decentralizing Data Dissemination and Data Use ˇ Where possible, existing government structures Data dissemination and data use rely on information should be used and followed, and HIV M&E products such as reports and news bulletins. Some functions integrated with other local government information products need to be created at the national functions. This avoids inefficient duplicating of local level; others can and should be created at decentralized government functions levels. In Swaziland, for example, it was recently decided that the decentralized levels would create a ˇ The Ministry of Local Government needs to be a key quarterly `dashboard' of standardized and clearly partner in the decentralized HIV M&E system, presented programme monitoring data, to submit to the otherwise the system will always be seen as regional management structures. In Senegal, the something `outside' local government functions Presidents of the Regional AIDS Committees requested regular summary tables on the level of attainment of key ˇ There is no one correct way to build results-based service delivery indicators. This illustrates the M&E systems, and they are continuous works in importance of data demand and use to encourage data progress, and can be built in different ways supply. ˇ Sustainability considerations are important when A good vehicle for sub-national data communication and building a decentralized HIV M&E system, but it use are regular dissemination seminars. They should be might not always be possible to fully integrate it into linked to planning activities to promote data-based local existing structures and have them run the M&E planning and results-based management. system in the early stages of system development. Other considerations may be equally important, such For information products to be created and interpreted as achieving high system performance quickly, well, capacity in data analysis, report writing and data responsiveness to stakeholder varying information interpretation are necessary. These skills should be a needs, preparation of information products based on major focus of support in the future. the information needs of stakeholders, and instilling pride into the operational system. Integration may When implemented properly, results-based M&E take place in a second phase only systems provide a continuous flow of information feedback into the system, which can help guide ˇ Capacity, capacity and more capacity are needed at policymakers and implementers toward achieving the decentralized levels desired results and gain insight into the performance of their organizations. "Decentralization requires considerable shifts in thinking and doing. It also requires some humility; the Viability of HIV M&E systems at sub-national level is ability to listen to people at local level and understand dependent upon the information being viewed as that they have much to offer at all levels". relevant, trustworthy, useable, and timely by local and decentralized governments, enabling them to manage (African Development Forum, 2000) the HIV epidemic at the local level and make better decisions for more effective interventions. References Key lessons in decentralizing national HIV M&E systems African Development Forum, 2000. AIDS: The greatest leadership challenge. Building on lessons learnt from ˇ It is possible and necessary to decentralize HIV intensified responses to HIV/AIDS. www.uneca.org/ADF2000/theme3.htm M&E systems as HIV control efforts are decentralized GAMET & Country Partners (2006). "If it's not on the Road Map, we're not going there". Getting Results ˇ Building and sustaining results-based M&E systems series, World Bank. is not easy; it requires continuous commitment, time, effort, resources and champions at all levels Gorgens-Albino M & Nzima M (2006). Eleven components of a fully functional HIV M&E system. ˇ Central M&E functions change in the course of Getting Results series, World Bank. decentralization, and necessary capacity and procedures need to be developed at central level so Hutchinson PL & LaFond AK (2004). Monitoring and that it can support the decentralized level to perform Evaluation of decentralization reforms in developing and add value within the national M&E system country health sectors. Bethesda, MD: The Partners for Health Reformplus Project, Abt Associates Inc. 9 Kasheeka EB, Bicego G, Gorgens-Albino M, Kemerer V Authors: & Nzima M (2006). Strengthening partnerships in HIV monitoring and evaluation. Getting Results series, World Nicole Fraser is a Monitoring and Evaluation Specialist with the Bank. Global AIDS M&E Team (GAMET) at the World Bank Global HIV/AIDS Program. Kusek JZ & Rist RC (2004). Ten steps to a results-based monitoring and evaluation system: a handbook for Adjaratou Ndiaye is an M&E Specialist with GAMET and main development practitioners. The World Bank, Washington architect of the Senegalese National M&E System. DC. ISBN 0-8213-5823-5 Marelize Görgens-Albino is a Monitoring and Evaluation Litvack JJA & Bird R (1998). "Rethinking decentralization Specialist with GAMET at the World Bank Global HIV/AIDS in developing countries". Washington, D.C.: World Bank. Program. Mbengue C & Kelley A (2001). Funding and implementing HIV/AIDS activities in the context of For more information or feedback, please contact: decentralization Ethiopia and Senegal. Special Initiatives Report No. 34, 2001. Bethesda, MD: Partnerships for Jody Zall Kusek (jkusek@worldbank.org) Health Reform Project, Abt Associates, 2001. Lead: Global AIDS Monitoring and Evaluation Team The World Bank Global HIV/AIDS Program World Bank (1987). Financing health services in developing countries: An agenda for reform. Washington, D.C. World Bank (2007). GAMET HIV monitoring and evaluation Resource Library CD. The World Bank: Washington DC World Health Organization (1978). The Declaration of Alma-Ata, International Conference on Primary Health Care. Alma-Ata, USSR, 6-12 September 1978. August 2007 10