1. Systems Approach1

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

3. Systems Approach3 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

4. Systems Approach4 COUNTRY Policy, resources, leadership Ultimate Customers and what Supports Them DISTRICT Effective systems COMMUNITY Mobilized for action FAMILY Support INDIVIDUAL Healthy behaviors Outcomes  Quality of life of those affected by HIV/AIDS  Incidence of HIV  Prevalence of HIV/AIDS  use of improved, effective, sustainable responses to HIV Implementors across sectors Advocacy Prevention Care & Support Treatment Impact Mitigation Intermediate Outcomes Political Institutions Parliament Political Parties Legal Traditional Government Sectors Health, Education Community Development Agriculture, Trade Water, Labor Civil Society Voluntary (NGOs) Networks Businesses Community Faith-based Traditional health Global Fund Multi lateral banks Multi lateral donors Bilateral donors Foundations Private Business Private Philanthropy Associations NGO donors External Investors UNAIDS, WHO, UNICEF, ILO, Consulting Firms, NGOs, Activists, Universities External Technical Assistance Global Fund Grants, loans Donations Advocacy Protecting human rights Building human capacity Systems strengthening Community mobilization Technology Activities Resource Inputs Technical Inputs National AIDS Commissions

5. Systems Approach5 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?

6. Systems Approach6 Outcomes  Incidence of HIV (  prevalence of HIV/AIDS)  Quality of life of those affected by HIV/AIDS  Survival times for people with HIV/AIDS

7. Systems Approach7  Quality of life of those affected by HIV/AIDS  incidence of HIV (  prevalence of HIV/AIDS)  survival times for people with HIV/AIDS Outcomes

8. Systems Approach8 Ultimate Customers (and their role) Individuals (Health Behaviors) Family (Support) Community (Enabling Actions) Province (Effective Systems) Country (Context and Leadership)

9. Systems Approach9 COUNTRY Context and Leadership PROVINCE Effective systems COMMUNITY Enabling actions FAMILY Support INDIVIDUAL Healthy behaviors  Quality of life of those affected by HIV/AIDS  incidence of HIV (  prevalence of HIV/AIDS)  survival times for people with HIV/AIDS Outcomes Ultimate Customers (and their role)

10. Systems Approach10 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

11. Systems Approach11 COUNTRY Context and Leadership PROVINCE Effective systems COMMUNITY Enabling actions FAMILY Support INDIVIDUAL Healthy behaviors  Quality of life of those affected by HIV/AIDS  incidence of HIV (  prevalence of HIV/AIDS)  survival times for people with HIV/AIDS Outcomes Ultimate Customers (and their role) Intermediat e Outcomes  Condom use  Risky Sexual encounters  Number receiving VCT  Treatment of STI Expanded Management of Opportunistic Infections  PMTCT Expand Home- Based Care Established Community Partnership for Community Care  Injection Drug Use Equitable use of ARV

12. Systems Approach12 Technical Activities Advocacy Prevention IEC/BCC Community Mobilization Systems Strengthening Care and Support Treatment Impact Mitigation

13. Systems Approach13 Technical Activities Care & Support Systems Strengthening IEC/BCC Prevention Advocacy Community Mobilization Impact Mitigation Treatment COUNTRY Context and Leadership PROVINCE Effective systems COMMUNITY Enabling actions FAMILY Support INDIVIDUAL Healthy behaviors  Quality of life of those affected by HIV/AIDS  incidence of HIV (  prevalence of HIV/AIDS)  survival times for people with HIV/AIDS Outcomes Ultimate Customers (and their role) Intermediat e Outcomes  Condom use  Risky Sexual encounters  Number receiving VCT  Treatment of STI Expanded Management of Opportunistic Infections  PMTCT Expand Home- Based Care Established Community Partnership for Community Care  Injection Drug Use Equitable use of ARV

14. Systems Approach14 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

15. Systems Approach15 National Government Religious Associations Private Practitioners Traditional Practitioners PLWA NGO Local Government Intl. PVO Private business In-country Implementing Organizations Technical Activities Care & Support Systems Strengthening IEC/BCC Prevention Advocacy Community Mobilization Impact Mitigation Treatment COUNTRY Context and Leadership PROVINCE Effective systems COMMUNITY Enabling actions FAMILY Support INDIVIDUAL Healthy behaviors  Quality of life of those affected by HIV/AIDS  incidence of HIV (  prevalence of HIV/AIDS)  survival times for people with HIV/AIDS Outcomes Ultimate Customers (and their role) Intermediat e Outcomes  Condom use  Risky Sexual encounters  Number receiving VCT  Treatment of STI Expanded Management of Opportunistic Infections  PMTCT Expand Home- Based Care Established Community Partnership for Community Care  Injection Drug Use Equitable use of ARV

16. Systems Approach16 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

17. Systems Approach17 Technical Activities Care & Support Systems Strengthening IEC/BCC Prevention Advocacy Community Mobilization Impact Mitigation Treatment COUNTRY Context and Leadership PROVINCE Effective systems COMMUNITY Enabling actions FAMILY Support INDIVIDUAL Healthy behaviors  Quality of life of those affected by HIV/AIDS  incidence of HIV (  prevalence of HIV/AIDS)  survival times for people with HIV/AIDS Outcomes Ultimate Customers (and their role) Intermediat e Outcomes National Government Religious Associations Private Practitioners Traditional Practitioners PLWA NGO Local Government Intl. PVO Private business 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 National AIDS Commission Internal Multi-Sectoral Players Actions that take place within the country Global Agend a Actions outside the country Flow of Financing Flow of Technical Assistance  Condom use  Risky Sexual encounters  Number receiving VCT  Treatment of STI Expanded Management of Opportunistic Infections  PMTCT Expand Home- Based Care Established Community Partnership for Community Care  Injection Drug Use Equitable use of ARV INTERNATIONAL INVESTORS Multi lateral banks Multi lateral donors Bilateral donors Foundations Private Business Private Philanthropy Associations NGO donors TECHNICAL COOPERATION AGENCIES UNAIDSWHO UNICEF ILO Bilateral agenciesNGOs Private BusinessFoundations Universities Activists PVO Networks Professional. Associations In-country Implementing Organizations

18. Systems Approach18 Optimized health and survival Maintain HIV negative status Behaviors to Prevent self infection Test Negativ e INSIDE THE HOME IN THE COMMUNITY SICK HEALTHY Treatment of opportunistic infections Respon ds Palliativ e care Western health services Traditional healer services Formal community services Informal community services PROGRESSION TO AIDS Early treatment of O.I. Early recognition of illness Prophylactic treatment Behaviors to prevent infection of others Test Positive Treatment with Anti-Retro Viral agents Fails to respond Family, social, financial and orphan support & high quality curative health services Stigma free environment supportive to Behavior Change Optimized health and survival

19. Systems Approach19 Personal and Community Behavior Change

20. Systems Approach20 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.

21. Systems Approach21 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

22. Systems Approach22 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

23. Systems Approach23 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

24. Systems Approach24 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

25. Systems Approach25 Four Stages of Programmatic Development

26. Systems Approach26 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