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A Systems Approach to the Design of Comprehensive HIV/AIDS programs. Malcolm Bryant, MB.BS., MPH. 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 - PowerPoint PPT Presentation
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Systems Approach 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
COUNTRY Policy, resources, leadership
Ultimate Customers and what Supports Them
DISTRICTEffective systems
COMMUNITY
Mobilized for action
FAMILYSupport
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 acrosssectors
Advocacy
Prevention
Care & Support
Treatment
Impact Mitigation
Intermediate Outcomes
Political InstitutionsParliament
Political PartiesLegal
Traditional
GovernmentSectors
Health, EducationCommunity Development
Agriculture, TradeWater, Labor
Civil SocietyVoluntary (NGOs)
NetworksBusinessesCommunityFaith-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
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
Quality of life of those affected by HIV/AIDS
incidence of HIV
( prevalence of HIV/AIDS)
survival times
for people with
HIV/AIDS
Outcomes
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
FAMILYSupport
INDIVIDUALHealthy 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)
Systems Approach 10
Intermediate Outcomes Condom use
Risky sexual encounters
Injection drug useNumber receiving VCTTreatment 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
FAMILYSupport
INDIVIDUALHealthy behaviors
Quality of life of those affected by HIV/AIDS
incidence of HIV
( prevalence of HIV/AIDS)
survival times
for people with
HIV/AIDS
OutcomesUltimate Customers
(and their role)Intermediate Outcomes
Condom use
Risky Sexual encounters
Number receiving VCT
Treatment of STI
ExpandedManagement ofOpportunisticInfections
PMTCT
Expand Home-Based Care
Established CommunityPartnership forCommunityCare
Injection Drug Use
Equitable use of ARV
Systems Approach 12
Technical Activities
Advocacy
Prevention
IEC/BCC
Community Mobilization
Systems Strengthening
Care and Support
Treatment
Impact Mitigation
Systems Approach 13
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
FAMILYSupport
INDIVIDUALHealthy 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
ExpandedManagement ofOpportunisticInfections
PMTCT
Expand Home-Based Care
Established CommunityPartnership forCommunityCare
Injection Drug Use
Equitable use of ARV
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
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
FAMILYSupport
INDIVIDUALHealthy 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)
Intermediate Outcomes
Condom use
Risky Sexual encounters
Number receiving VCT
Treatment of STI
ExpandedManagement ofOpportunisticInfections
PMTCT
Expand Home-Based Care
Established CommunityPartnership forCommunityCare
Injection Drug Use
Equitable use of ARV
Systems Approach 16
GovernmentSectors
Health, EducationAgriculture, Trade
Com. Dev.Water, +
Political InstitutionsParliament
Political PartyLegal
Traditional
Civil SocietyVoluntary
PrivateCommunityFaith-basedTraditionalCommercial
Systems Approach 17
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
FAMILYSupport
INDIVIDUALHealthy 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
GovernmentSectors
Health, EducationAgriculture, Trade
Com. Dev.Water, +
Political InstitutionsParliament
Political PartyLegal
Traditional
Civil SocietyVoluntary
PrivateCommunityFaith-basedTraditionalCommercial
National A
IDS C
omm
ission
Internal Multi-SectoralPlayers
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
ExpandedManagement ofOpportunisticInfections
PMTCT
Expand Home-Based Care
Established CommunityPartnership forCommunityCare
Injection Drug Use
Equitable use of ARV
INTERNATIONAL INVESTORSMulti lateral banksMulti lateral donors
Bilateral donorsFoundations
Private BusinessPrivate Philanthropy
AssociationsNGO donors
TECHNICAL COOPERATION AGENCIES
UNAIDS WHOUNICEF ILO
Bilateral agencies NGOsPrivate Business FoundationsUniversities ActivistsPVO NetworksProfessional.Associations
In-country Implementing Organizations
18Systems Approach
Optimized health and
survival
MaintainHIV
negative status
Behaviors to Prevent self infectionTest
Negative
INS
IDE
TH
E H
OM
E
IN THE COMMUNITY
SIC
K H
EA
LT
HY
Treatment of opportunistic infections
Responds
Palliative 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
TestPositive
Treatment with Anti-Retro Viral agentsFails to respond
Family, social, financial and orphan
support&
high quality curative health services
Stigma free environment supportive to
Behavior Change
Optimized health and survival
Systems Approach 19
Personal and Community Behavior Change
Phase Community Response Individual at Home
Healthy, Uninfected Decreasing stigma; care of orphans; prevention ofdisease through education of youth, addressingparenting, sexual values and behavior; Promotingwomen’s rights; outreach to HTA and high-riskgroups.
Awareness of status; Practice of healthylifestyle; Activities to prevent infection of self -Safe sex, Clean needles, single partner.
Asymptomatic HIV (Stage 1) Above and: protection from persecution; advocacywith employers; support from other PLWA;encouragement of preventive practices.
Above and: Testing of family for HIV and TB;Dual protection for contraception; MTCT+;Good nutrition; Prophylaxis of OIs; Recognitionof symptoms of progression and OIs; Hometreatment for OIs; Periodic laboratory tests
Symptomatic HIV/Transition to AIDS(Stage 2)
Above and: Care and support to families; Provision ofsocial and financial security; Provision oftransportation for referral services.
Above and: Assessment at an AIDS treatmentUnit; Decision about use of ARVs.
Acute AIDS with opportunistic infections(Stage 3)
Above and: Support for adherence to ARV and otherdrug regimens; Financial support to families toaddress employment/income problems, includingchild support
Above and: Access to home care as needed;Access to inpatient care as needed; Nutritionsupport as needed; Rehydration strategy; ARVtherapy; Family support.
Terminally ill (Stage 4) Above and: Family support (help with workload, griefcounseling, etc.)
Above and: Regular home visiting; Transport tohome/village; Special nutritional care; Paincontrol
Death, survivors Care and support of orphans and remaining family Handling of body to prevent infection; Burialand funeral social support;Counseling/prevention for sero-positve familymembers
Systems Approach 20
Tailoring Services to Behavior Change needsDefined 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 DevelopmentI: Start up II: Growth III: Maturity IV: Sustainability
Acc
ess
Limited # of service deliverychannels
Huge barriers to access
Multiple service deliverychannels
Still many barriers to access
Multiple service deliverychannels, effectivepublic/private collaboration
Few remaining barriers toaccess
Widespread network ofservice delivery channels
Virtually no barriers toaccess
Qu
alit
y
Focus on provider training Little monitoring of quality
Increasing attention to qualityof care (specifically norms andstandards), supervision,monitoring of quality
Quality concerns expand toinclude choice, convenience,client focus
More attention to monitoring ofquality
Services perceived to be ofhigh quality and client-focused
Ongoing quality assuranceprogram in place
Dem
and
Awareness limited to urban,more educated populations
IEC messages/materialsbroadly focused
Expanded awareness Nascent community
involvement BCC/IEC messages and
materials more targeted,exploring alternative media
Widespread awareness, harderto reach populations beginningto express demand
Growing communityinvolvement
BCC/IEC messages welltargeted, using multimediaapproaches
Widespread awareness Widespread expression of
demand Active community
involvement Demonstrated behavior
change
Inst
itu
tion
alS
tren
gth
enin
g Basic systems for planning,training, logistics,management information,financial management
Increased attention to strategicplanning, coordination
New focus on data for decisionmaking, some cost recovery
Management systemsstrengthened
Expanded focus on strategicplanning, data for decision-making, control over resources
Management systems moreflexible and efficient
Management systemsrobust, able to adapt tochanges int eh environment
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