1. Program Science: Opportunities, Challenges and Impact Program Components and Issues James Blanchard, MD, MPH, PhD Professor and Director, Centre for Global Public Health University of Manitoba

2. What is a “Program” in the context of STI/HIV Prevention and Control? Drawing on the public health concept: –“science and art of preventing disease” (Winslow, 1923) –“organized efforts of society to protect, promote, and restore the peoples’ health” (Last) Focusing on the population level, and population-level impacts Coherent planning, implementation and management processes and structures

3. Intervention vs. Program Program –Multiple components (interventions) –Resource allocation between components, and sharing across components –Emphasis on optimizing population level impact Program –Multiple components (interventions) –Resource allocation between components, and sharing across components –Emphasis on optimizing population level impact Intervention –Specific technological or behavioural modality –Particular target group(s) –Focus on effectiveness, fidelity, coverage Intervention –Specific technological or behavioural modality –Particular target group(s) –Focus on effectiveness, fidelity, coverage

4. “Program Science” for HIV/STI Prevention: A Component Framework Strategic Planning Policy Development Program Implementation Program Management Choose: The best strategy… The right populations… The right time… Do: The right things… The right way… Ensure: Appropriate scale… Efficiency… Change when needed… Epidemiology Transmission dynamics Policy analysis Health systems research Efficacy / effectiveness Operations research Surveillance Monitoring/evaluation Operations research Health systems research Spheres of KnowledgeSpheres of PracticeIntended Outcomes

5. Program Components Strategic Planning –How will prevention be achieved and epidemics controlled? Implementation System –What interventions will be deployed and how will they be delivered? Program Management –How will the program be managed, monitored and evaluated?

6. Strategic Plan – Program Design Setting prevention priorities and objectives: –Based on epidemiology and transmission dynamics to have population-level prevention impact –Specifies sub-population focus Organized based on epidemic heterogeneity and/or health system structure –National program design –State / Provincial –District / Local

7. Issues in Strategic Planning Epidemic appraisal and understanding the transmission dynamics Balancing short, medium and longer term prevention objectives Matching strategies to the level of implementation

8. Epidemic Appraisal and Transmission Dynamics Recent upheaval in methodological approaches –The “numerical proxy” approach (1% / 5% rules) are being replaced by the “Modes of Transmission” methodology Unclear link between typifying the epidemic and strategic plans –Previous blurring of response to “generalized” epidemics at 2-3% prevalence and >15-20% –Replaced by MOT with usual estimates that most new HIV infections occur in “low risk heterosexual partnerships”, regardless of HIV prevalence –Unclear approaches to “mixed epidemics”

9. Epidemic Appraisal and Transmission Dynamics (cont) Inadequacy of data at all levels –Behavioural data are inconsistent, and often clearly inaccurate –Credible size estimation of different key populations often absent –Inconsistent coverage and methodology for biological surveys Understanding epidemic phase and the trade- offs between short, medium and long term prevention objectives –In most mature epidemics a large % of new infections occur in the context of stable, low risk partnerships, but how much should prevention be focused there?

10. Epidemic Typology – 3 Districts in India District HIV prevalence in antenatal females % of new infections in low activity GP (MOT) Likely Epidemic Typology Bagalkot2.1%38.4% Mostly driven by large FSW-client networks Shimoga1.0%57.9% Highly concentrated, FSW- clients Varanasi0.25%77.2% Quite truncated, with substantial transmission from migrant men

11. Examples of Key Strategic Planning Issues – India How are the transmission dynamics different in the regions with persistently high prevalence, and what additional interventions might need to be used? –This includes strategies for the rural areas with high prevalence What are the objectives and strategic options for the very large migrant population? What are the future risks of emerging epidemics? –IDU?

12. Examples of Key Strategic Planning Issues – Kenya Beyond circumcision, what are the differences in transmission dynamics in different regions? –General sexual structure, key populations What is the relative contribution of key populations (FSW, MSM, IDU) to the epidemics in different regions? –What would be the impact of interventions in key populations? To what extent should “general population” interventions be targeted? –Geographic? Socio-demographic?

13. Examples of Key Strategic Planning Issues – Nigeria How should prevention resources and strategies be tailored to the high levels of epidemic heterogeneity? What should be the population focus for preventive interventions in different contexts? –General population? –High risk subsets or locales? –Most at risk key populations?

14. Issues in Program Strategies – Levels of Application Global / Regional –Prone to using “broad-brush” approaches or “campaigns” –Influences lower level strategy and policy, often through funding choices –Large international funders and NGOs sometimes focus on “most highly favoured” interventions Country –Challenges include lack of specificity and complex processes for regional resource distribution –Often dealing with multiple donors with competing priorities

15. Issues in Program Strategies – Levels of Application (cont) State / Province –Often influenced by “top down” approaches –Technical capacity constraints District / Local –Often lack sufficient data and/or technical capacity for planning –Generally highly dependent on State / Provincial resources and decision-making

16. Issues in Implementation Knowing what works Tailoring interventions to local contexts Horizontal programs and vertical interventions Building capacity

17. Knowing What Works Evidence for the efficacy and effectiveness of many behavioural interventions is lacking –When does that mean it won’t work? Lack of knowledge about why some interventions appear effective in some contexts, and not others What is the effect of combining interventions? –Addition, synergy or antagonism

18. Tailoring implementation to local contexts Tension between standardized intervention packages and local adaptation –Flexibility in components –Flexibility in resources –Who decides, and on what basis? What are the implications of a results-based approach (as opposed to common packages)? –Defining outputs and outcomes and indicators How can intervention results be compared if there is variability?

19. Horizontal programs and vertical interventions How can the tensions between scaling up vertical interventions across wide areas and establishing local implementation processes be managed? How do you avoid the “cookbook” approach to implementation, while maintaining consistent standards and quality of implementation?

20. Building Capacity Capacity for implementation is a key constraint at all levels, including: –Lack of trained managers at the implementation level –Paucity of good implementation resource material –Limited skills in using data to optimize performance Most capacity building includes either extensive academic training or short workshops: –Lack of opportunities for “hands on” learning –Lack of mentoring and peer learning mechanisms

21. Examples of Key Implementation Issues – India How will existing targeted intervention programs be maintained, and for how long? How will targeted interventions adapt to changing risk environments: –Changing patterns of sex work –Emerging IDU? How can program implementation address persistent gaps? –E.g. new/young sex workers

22. Examples of Key Implementation Issues – Kenya What are effective methods for HIV prevention in the context of “general population” transmission? –Population wide approaches –Hotspot approaches How can prevention programs for at risk key populations be scaled up rapidly and effectively? What is the role for “combination prevention”, and how will the “combinations” be selected and prioritized for local contexts?

23. Examples of Key Implementation Issues – Nigeria How will states and local areas design and prioritize prevention packages? How will scaling up be achieved in light of competing priorities and limited implementation capacity? How will implementation funded by different funders be harmonized at the state and local level?

24. Issues on Program Management Establishing effective monitoring systems and responsive program management Segmentation vs. integration with existing health programs and systems Impact evaluation of programs and interventions

25. Issues in Program Monitoring Purpose of the monitoring: –Program delivery? (field level) –Funding models? –UNGASS indicators? Performance measurement frameworks –Often not reflected at all relevant levels of program implementation Poor capacity and limited latitude for using monitoring data at field level

26. Overarching Issues What are the preferred “models” for planning, implementing, managing and scaling up? What are the systemic constraints on robust and responsive program design and delivery? How is responsibility shared among key actors and stakeholders? –Global normative bodies –Country, State / Provincial, Local

27. Conceptual Approaches to Scaling Up… (from David Peters et al.) DomainScaling up to reach the MDGs Scaling up small scale innovations Validity of strategies Assumption of external validity of strategies. Search for standardized approaches that can be generalized within and across countries. Assumption that approaches should be determined contextually. Value on internal validity. What works best depends on the context. Planning perspective Create better blueprints and targets that can be locally adapted. Learn by doing. Plan with key stakeholders, and link knowledge with action. Implementation perspectives Focus on “accelerating” implementation to meet well- defined goals and deadlines. Slower, phased implementation… incremental expansion based on concurrent, participatory research and adaptation. Monitoring and evaluation methodologies Focus on status of the problem.Focus on problem solving.

28. Structure of this Meeting – An Overview A.Examination of key Program and Science issues related to the program components: –Strategic Planning and Program Design –Implementation –Monitoring and Evaluation B.Review and discussion of the scope for “program science” initiatives C.Discussion of future opportunities for learning and applying “program science” principles

29. Thank You