Introduction

A W4GF webinar on Tuesday 17 April 2018 provided space for 13 W4GF advocates and partners to engage with the Global Fund Secretariat (GFS), Stop TB Partnership and Eastern Africa National Networks of AIDS Service Organisations (EANNASO) around TB gender assessments. The TB gender assessment tool was adapted from the 2010 UNAIDS Gender Assessment tool and is a collaborative effort between UNAIDS and the Stop TB Partnership. The webinar reviewed the TB gender assessment tool and key findings from countries that have conducted assessments, and the ways those processes have informed countries’ national TB responses (and Global Fund investments). The Global Fund CRG Strategic Initiative (SI) shared information on how they are supporting TB gender assessments and EANNASO shared lessons from the process to conduct a TB gender assessment in Tanzania. The presentations delivered during this webinar are available here and the recording is accessible here.

Presentations

Update from Stop TB Partnership – Mr James Malar, Project Officer working on Community, rights and gender (CRG) at the Stop TB Partnership. Slide 3 – 13.

CRG is a relatively recent development within the TB response compared to the HIV response. Tools such as the TB Gender Assessment, The Legal Environment Assessment, Key Population Data for action Framework Assessment and Stigma Measurement Tool will be able to advance relevant TB discussions.

  • The Stop TB Partnership strives to include CRG in the TB response at a national level. The challenge has been shifting mindsets allowing CRG to inform policies, decision-making and national programmes instead of TB being addressed in a silo, which separates CRG interventions.
  • The main response in TB has consisted of advocacy and service delivery in countries most affected whilst community monitoring has been neglected. The purpose of the assessment tool provides an opportunity to enhance the work of civil society and to implement leanings from the gender assessment more practically in countries.
  • The STOP TB Partnership has tried to integrate human rights and gender sensitive approaches in their advocacy at the country level.
  • The Global Plan to End TB has been integral in guiding CRG and the TB response. The Global Plan to End TB is a strategy aligned to the WHO Strategy and calls for human rights and gender to be at the core of the TB response.
  • The Legal Environment Assessments, the Key Population Data for Action Framework, the TB and Gender assessment tool and the Stigma Assessment tool are all important. Having such a diverse package highlight the full scope of a CRG response to TB. Although these tools deal with unique themes they overlap and complement each other, as they identify different indicators of marginalisation underlying vulnerability to TB.
  • The importance of these tools is to identify how gender impacts health seeking behaviour and treatment outcomes. The assessments also place emphasis on how gender is relevant in the TB response and highlights barriers that exist as a result of gender.
  • Implementation of assessments is often carried out through national civil society entities or partners – for example The Kenya legal and Ethical Issues Network on HIV and AIDS (KELIN) in Kenya an EANNASO in Tanzania. The implementation phase consists of a five steps, which consists of securing high-level support, understanding the country context, developing recommendations and gaining political and stakeholder support at the national level.
  • CRG has identified specific countries for the roll out of the assessments. Countries in final stages of the roll out stage include (Cambodia, Kenya, Ukraine and Tanzania). Those in the preliminary stages of the assessment or in the process of implementing training are (Bangladesh, South Africa, Nigeria, Pakistan, Philippines, Mozambique, Myanmar, Indonesia, DRC, India). By December most countries should have rolled out gender assessments and hopefully incorporate commitments into the National TB Programme (NTP).
  • Lessons learned: Partnerships are integral to successful implementation of assessments. TB responses must be sensitive to gender and tools used in the assessments must assist to build links between gender and TB.   TB responses must be adapted to the needs of key/vulnerable populations e.g. people who use drugs, migrants, people living with HIV, miners, the urban poor, and their families.   Adapting to the needs of those most vulnerable is key to finding missing populations and those who need the most assistance.

Updates from the Global Fund Secretariat. Ms Heather Doyle, Gender Senior Coordinator in the Community Rights and Gender Department at the Global Fund. Heathers presentation starts from slide 14-20 and Uliane Appolinario, Program Officer, Strategic Initiative, Community Rights and Gender Department slide 21

  • The Technical Review Panel (TRP) is an important structure to influence countries on issues concerning gender and human rights. TRP recent findings highlight, “Gender and legal assessments are guiding sets of detailed comprehensive contextualised interventions addressing barriers to access to services.” Within the recommendations the TRP looked at supporting applicants for gender and legal and environmental assessments.
  • Positive responses emerged from the TRP when countries that had conducted the assessments had integrated the findings into their funding request, improving interventions. Ethiopia was one example of how female health extension workers had a positive impact on diagnostic and treatment outcomes. This enabled them to reach those currently at risk as well as those often missed – in this instance women were missing from diagnosis and treatment.
  • Currently there is an initiative geared to reduce human rights related barriers to services in 20 countries. Part of this initiative is to conduct human rights related baseline assessments on TB. Some of the 20 countries overlap with countries implementing the Stop TB Partnership CRG Tool. A multi-stakeholder convening will be held for the baseline assessment, which seeks to include participation from those already implementing gender assessments.
  • Examples of TRP feedback for an application from West Africa placed emphasis on the development of action plans and the intensification of case findings on communities that were traditionally not focused on women, the elderly, children, people living with HIV and key and vulnerable populations and miners. The TRP further reflected the importance of capturing sex and age disaggregated data to identify those who are being missed in the treatment and diagnosis process as well as to reduce the barriers for those who are at risk.
  • In a Central African country application the TRP made recommendations for a mid-term program assessment and for gender analysis to be conducted based on the realization that gender related barriers constrain progress within national programs.
  • Within the scope of CRG SI, TB has been given priority and attention in the new implementation cycle. It is an investment initiative and there is a move towards engaging civil society organisations (CSOs) and seeing how the CRG team can contribute to gender assessments. Technical Assistance (TA) support is key to enabling the assessments to take place via the regional platforms, which are an important vehicle in driving awareness amongst civil society and the TB community, on the opportunities to conduct gender assessments. During the last week of April a Gender TB Assessment meeting will be held in Ghana at the Anglophone Africa regional Civil Society Forum to bring CSOs together on the using the gender assessment tool.
  • The CRG TA program has provided support for assessments, which focuses on the assessment process. Civil society and governments need to own the process to ensure success. Technical assistance is being provided in Chad – where a key challenge has been to ensure all stakeholders are engaged. Countries that have already conducted the assessment are working toward creating an accountability framework to guarantee political commitment.

Country experience in Tanzania, Presented by Ms Olive Mumba, Executive Director at EANNASO Olive’s presentation starts from slide 22 – 29.

  • The TB gender assessment took place from April – December 2017. Tanzania has no existing TB policy, no gender operational plan for TB and lacks other gender responsive policies and plans, with links to SRHR.

Recommendations

  • The NTP has an advocacy communication and social mobilization unit, but it requires a technical working group to support coordination of these policies.
  • Data recorded by NTP is neither age nor sex disaggregated more especially amongst vulnerable groups and those in the private sector such as miners. Operational research is essential.
  • High levels of stigma and discrimination and violence against women still prevail. A stigma index should be conducted to promote a better understanding of the reality for people living with TB and their families.

What worked well?

  • The TB gender assessment tool was adaptable to Tanzanian context and the process was owned by the NTP
  • Inclusion of community and support groups and identification of key populations such as people who use drugs and miners were also identified.
  • Interviews with key informants, community and development partners took place.
  • A strong technical team worked well and met deadlines.
  • The gender assessment, Legal Environment Assessment and the Data Framework for Action (looks at identifying the Key Populations affected by TB) were conducted altogether at the same time and there was great flexibility in the process.
  • The gender assessment consultant provided key questions, which were incorporate in focus group discussions.

What didn’t go well?

  • Not all key informants could attend interview.
  • Data for vulnerable groups could be retrieved and analysed and challenges with ethical clearance but was retrieved at a later point.
  • There was a delayed release of funds to support the process
  • The report template for the assessment tool was not available so we created our own.
  • A desk review was conducted but there was a need to gather more data.

What could have been improved?

  • It emerged that implementing partners were collecting data, which was crucial for the assessment and it would have been helpful to have included this at the beginning of the process
  • Utilizing a multi-stakeholder task team comprising of CBOs, government departments, international organizations and the private sector.
  • Reviewing the report and ensuring a validation at the end of the process.

Tips for successful roll out

  • Ensure NTP ownership throughout the process, not merely the result but also the process matters.
  • Ensure the political by in of stakeholders
  • Feeding the recommendations into the national system.
  • Identifying resources at country level to support the process.
  • Wide dissemination of findings and recommendations.

Discussion: Questions and Answers

KELIN shared their experience in Kenya to conduct three assessments, including the Gender Assessment, Data for Key Population, and the Legal Environmental Assessment from October 2017-January 2018. The assessment process was similar to the EANNASO experience. Civil society participated in a meeting in Bangkok and then connected with stakeholders at the national level.

EANNASO acknowledged the positive contribution and support by members of the NTP who owned the process and actually used the outcomes of the assessment to inform their TB national strategic plans. An implementation task force was then formed made up of NTP members and CBOs. The recommendations were key in highlighting the importance of fast tracking implementation to improve outcomes in TB programming. One of the key recommendations is for organisations and the NTP to mobilise resources that sustain programming.

Q: Were the gender assessment recommendations in Tanzania costed?

A: The recommendations were not costed. There are plans to meet with the multi stakeholder team and cost the recommendations.

Q: What process was used to identify countries for the Stop TB Partnership CRG assessments? Botswana is missing given its high TB HIV co infection rate.

A: Catalytic funding from the Global Funding to Stop TB Partnership has enabled support for the CRG to conduct TB gender assessment and KP framework.  The selection criterion was based on countries with the highest burden, and the largest number of the missing cases.

Q: Is there an opportunity to request support from the Global Fund CRG to provide oversight for CCM proposal development committees to integrate recommendations from the TB Assessments creating stronger awareness of the kind of interventions that are required?

A: The CRG TA is dedicated towards general technical assistance. Civil society on the CCM, are key to influence funding request drafting and focusing priorities. TB is a key area for the Global Fund and TA can support civil society on the CCM to leverage the gender assessments.

Q: What are the plans for EANNASO around advocacy given that nationally data is not being disaggregated against gender and key populations? Is there any awareness and capacity building that will take place to deal with these concerns?

A: Through the Data Framework for Action assessment, EANNASO was able to identify an area where TB is rampant in the mines. From that data collected they were able to lobby for interventions in that particular area.

Q: Stop TB Partnership will focus on community monitoring. What tools will be used for community to monitor TB?

A: A community-monitoring tool known as One Impact is currently in use to monitor TB. It is an online platform, created by an organization based in Tajikistan. Monitoring is conducted through a community support group for people living with TB. The support group is made up of people affected by TB and now provide support and information for those on treatment. The platform is a collaborative effort between the NTP and civil society.

Comment: There may further scope to expand and use this tool particularly where TB violations and stigma may occur. Tanzania will also do this.

Comment: In Francophone Africa, specifically Chad, assessments were conducted for a month. Stakeholders struggled to collaborate and form partnerships – this in contrast to many partnerships and government engagement that owned the process in Tanzania. Support from various stakeholders remains low at a national level in Chad. There is a need to standardised support in each context to conduct systematic assessments and support linkages to the NSP

Response from the GFS: A lot of the questions were integrated in the Key Population Action Assessment process. One of the things being discussed by the CRG is the possibility of adding additional tools to the Gender Assessment that would be qualitative in nature, such as key focus interviews and focus group discussions. It will be useful to add a qualitative guide to add to the assessment which currently isn’t included. In Tanzania the TB gender assessment was simultaneous happening with several processes which all fed into the process.

Processes were different in Tanzania compared to Chad. Training was beneficial for the implementation process in Tanzania . Linking efforts with the national strategic plan is key. In Tanzania the next step is to follow up and look at tools for screening and treatment with the inclusion of Key Populations in data collection. One of the most important lessons learned in this context was of how NTPs can be flexible but also coming to terms with the fact that the process of advocating and influencing national processes is lengthy.

13 people attended this webinar: three colleagues from the Global Fund Secretariat including Heather Dole, Rukia Manniko and Uliane Appolinario. James Malar from the Stop TB Partnership, Olive Mumba from EANNASO and six W4GF advocates and partners: (Lucy Wanjiku, Bertran Kampoe, Gemma Oberth, Lucy, Roderick Wilbroad, Nana Gleeson). Sophie Dilmitis and Matipa Ndoro represented the W4GF Secretariat.