A Systems Approach to the Design of Comprehensive HIV/AIDS programs

1. Systems Approach

2. A Systems Approach to the Design of Comprehensive HIV/AIDS programs Malcolm Bryant, MB.BS., MPH Systems Approach

3. Format of the Presentation • A framework for national AIDS programming • Personal and community behavior change • Tailoring services to behavior change needs • Establishing systems to support services • Summary Systems Approach

4. DISTRICT Effective systems COMMUNITY Mobilized for action FAMILY Support INDIVIDUAL Healthy behaviors Implementors across sectors Resource Inputs External Investors Global Fund Grants, loans Donations Ultimate Customers and what Supports Them National AIDS Commissions Outcomes Global Fund Multi lateral banks Multi lateral donors Bilateral donors Foundations Private Business Private Philanthropy Associations NGO donors Civil Society Voluntary (NGOs) Networks Businesses Community Faith-based Traditional health Activities Intermediate Outcomes COUNTRY Policy, resources, leadership Advocacy Protecting human rights Building human capacity Systems strengthening Community mobilization Technology Quality of life of those affected by HIV/AIDS Advocacy Prevention Care & Support Treatment Impact Mitigation Government Sectors Health, Education Community Development Agriculture, Trade Water, Labor use of improved, effective, sustainable responses to HIV  Incidence of HIV  Prevalence of HIV/AIDS Political Institutions Parliament Political Parties Legal Traditional UNAIDS, WHO, UNICEF, ILO, Consulting Firms, NGOs, Activists, Universities External Technical Assistance Technical Inputs Systems Approach

5. Understanding the whole picture • What are the outcomes we desire? • Who is the customer? • What are we doing to serve the customer? • Who is doing this? • Who takes the lead? • Who are they responsible to? • How do they relate to the rest of the world? Systems Approach

6. Outcomes  Incidence of HIV ( prevalence of HIV/AIDS) • Quality of life of those affected by HIV/AIDS • Survival times for people with HIV/AIDS Systems Approach

7. Outcomes  incidence of HIV ( prevalence of HIV/AIDS) Quality of life of those affected by HIV/AIDS survival times for people with HIV/AIDS Systems Approach

8. Ultimate Customers (and their role) Individuals (Health Behaviors) Family (Support) Community (Enabling Actions) Province (Effective Systems) Country (Context and Leadership) Systems Approach

9. COUNTRY Context and Leadership PROVINCE Effective systems COMMUNITY Enabling actions FAMILY Support INDIVIDUAL Healthy behaviors Ultimate Customers (and their role) Outcomes  incidence of HIV ( prevalence of HIV/AIDS) Quality of life of those affected by HIV/AIDS survival times for people with HIV/AIDS Systems Approach

10. Intermediate Outcomes •  Condom use •  Risky sexual encounters •  Injection drug use • Number receiving VCT • Treatment of STI Expanded Management of Opportunistic Infections PMTCT Expand Home-based Care (Including ARV) • Established Community Partnership for Community Care Systems Approach

11. COUNTRY Context and Leadership PROVINCE Effective systems COMMUNITY Enabling actions FAMILY Support INDIVIDUAL Healthy behaviors Ultimate Customers (and their role) Intermediate Outcomes Outcomes  Condom use  Risky Sexual encounters • Number receiving VCT  incidence of HIV ( prevalence of HIV/AIDS) • Treatment of STI  Injection Drug Use Quality of life of those affected by HIV/AIDS Expanded Management of Opportunistic Infections • PMTCT Equitable use of ARV survival times for people with HIV/AIDS Expand Home- Based Care Established Community Partnership for Community Care Systems Approach

12. Technical Activities Advocacy Prevention IEC/BCC Community Mobilization Systems Strengthening Care and Support Treatment Impact Mitigation Systems Approach

13. COUNTRY Context and Leadership PROVINCE Effective systems COMMUNITY Enabling actions FAMILY Support INDIVIDUAL Healthy behaviors Ultimate Customers (and their role) Intermediate Outcomes Technical Activities Outcomes  Condom use Advocacy  Risky Sexual encounters Prevention • Number receiving VCT  incidence of HIV ( prevalence of HIV/AIDS) • Treatment of STI IEC/BCC  Injection Drug Use Community Mobilization Quality of life of those affected by HIV/AIDS Expanded Management of Opportunistic Infections Systems Strengthening • PMTCT Equitable use of ARV survival times for people with HIV/AIDS Care & Support Expand Home- Based Care Established Community Partnership for Community Care Treatment Impact Mitigation Systems Approach

14. In-country Implementing Organizations • National Government • Local Government • Private Practitioners • Traditional Practitioners • Non Governmental Organizations • Religious Associations • Community-Based Organizations (PLWA) • International Private Voluntary Organizations • Private business Systems Approach

15. COUNTRY Context and Leadership PROVINCE Effective systems COMMUNITY Enabling actions FAMILY Support INDIVIDUAL Healthy behaviors Technical Activities Ultimate Customers (and their role) In-country Implementing Organizations Intermediate Outcomes  Condom use Advocacy Outcomes  Risky Sexual encounters Prevention • Number receiving VCT National Government  incidence of HIV ( prevalence of HIV/AIDS) • Treatment of STI IEC/BCC Religious Associations  Injection Drug Use Local Government Community Mobilization Quality of life of those affected by HIV/AIDS Private Practitioners Expanded Management of Opportunistic Infections Systems Strengthening Traditional Practitioners • PMTCT NGO Equitable use of ARV survival times for people with HIV/AIDS Care & Support PLWA Intl. PVO Expand Home- Based Care Private business Established Community Partnership for Community Care Treatment Impact Mitigation Systems Approach

16. Government Sectors Health, Education Agriculture, Trade Com. Dev. Water, + Political Institutions Parliament Political Party Legal Traditional Civil Society Voluntary Private Community Faith-based Traditional Commercial Systems Approach

17. COUNTRY Context and Leadership PROVINCE Effective systems COMMUNITY Enabling actions FAMILY Support INDIVIDUAL Healthy behaviors Internal Multi-Sectoral Players Actions that take place within the country Actions outside the country In-country Implementing Organizations Ultimate Customers (and their role) Intermediate Outcomes INTERNATIONAL INVESTORS Multi lateral banks Multi lateral donors Bilateral donors Foundations Private Business Private Philanthropy Associations NGO donors Technical Activities Flow of Financing Government Sectors Health, Education Agriculture, Trade Com. Dev. Water, + Outcomes  Condom use Advocacy  Risky Sexual encounters Prevention • Number receiving VCT National Government  incidence of HIV ( prevalence of HIV/AIDS) National AIDS Commission Global Agenda • Treatment of STI IEC/BCC Religious Associations Political Institutions Parliament Political Party Legal Traditional  Injection Drug Use Local Government Community Mobilization Quality of life of those affected by HIV/AIDS Private Practitioners Expanded Management of Opportunistic Infections Systems Strengthening Traditional Practitioners • PMTCT Civil Society Voluntary Private Community Faith-based Traditional Commercial NGO TECHNICAL COOPERATION AGENCIES UNAIDS WHO UNICEF ILO Bilateral agencies NGOs Private Business Foundations Universities Activists PVO Networks Professional. Associations Equitable use of ARV survival times for people with HIV/AIDS Care & Support PLWA Intl. PVO Expand Home- Based Care Private business Established Community Partnership for Community Care Treatment Impact Mitigation Flow of Technical Assistance Systems Approach

18. Test Negative Behaviors to Prevent self infection Maintain HIV negative status IN THE COMMUNITY HEALTHY Stigma free environment supportive to Behavior Change Behaviors to prevent infection of others Test Positive Prophylactic treatment INSIDE THE HOME Early treatment of O.I. Early recognition of illness Optimized health and survival Optimized health and survival PROGRESSION TO AIDS SICK Informal community services Formal community services Traditional healer services Western health services Palliative care Treatment of opportunistic infections Family, social, financial and orphan support & high quality curative health services Responds Fails to respond Treatment with Anti-Retro Viral agents Systems Approach

19. Personal and Community Behavior Change Systems Approach

20. Tailoring Services to Behavior Change needs Defined need • Knowledge of HIV status with no fear of repercussions and expectation of care and support Individual service required • Testing of status, with counseling and appropriate referral Community service required • Information and action to reduce misconceptions and stigma. • Education services through schools, community organizations, social service center, etc. • Community leadership from local authorities, NGOs, religious associations • Community service and demonstration through NGOs, community organizations, etc. Systems Approach

21. Establishing Functional Services CLIENT LEVEL • Access to information that enables them to identify their own needs • Skills to interpret that information • Capacity to act on the information • The expectation of a response to their actions SERVICE PROVIDER LEVEL • Competent and motivated staff • Appropriate medications, equipment, and supplies • Information to make locally appropriate decisions • Adequate facilities • Clearly delineated referral mechanisms Systems Approach

22. Establishing a Functional Support System • Must be multi-sectoral bridging public, private, social, and cultural boundaries • Essential elements • Information gathering, interpretation, planning, decision-making evaluation, and action • Skill development, maintenance, and motivation to ensure quality • Procurement, management, and logistics of drugs, supplies and equipment • Financing to ensure continued and equitable access to quality services • Laboratory services to make essential clinical management decisions • Referral mechanisms to ensure continuity of care Systems Approach

23. Establishing a Functional Support System (2) • Characteristics of a functioning system • Individual elements complement each other to create a whole that is larger than the sum of the parts • Each element relates to every other element in a similar fashion • Constant feedback results in continuous adjustment • Rules are consistent and adhered to Systems Approach

24. Establishing a Functional Support System (3) • Prioritizing the elements in a resource poor environment • Cannot focus exclusively on any single element • At earlier stages of programmatic development, the emphasis is more towards information, drugs and supplies, and human resources • At later stages of programmatic development, the emphasis can shift more towards financing, laboratory, and referral mechanisms • Different organizations may be at very different stages of development and capacity and should be used to reinforce each other Systems Approach

25. Four Stages of Programmatic Development Systems Approach

26. Summary • Understand the whole picture before developing effective responses • Begin with the desired outcomes • Focus on the ultimate customers • Services are multi-sectoral and must follow actual needs • Systems must be only those required to support the services needed, and must reflect the stage of development of the program Systems Approach