systems approach1. 2 a systems approach to the design of comprehensive hiv/aids programs malcolm...

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)


Survival times for people with HIV/AIDS

Systems Approach 7


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


incidence of HIV


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



incidence of HIV


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


Care &

Support

Systems

Strengthening

IEC/BCC

Prevention

Advocacy

Community

Mobilization

Impact

Mitigation

Treatment

COUNTRY

Context and

Leadership

PROVINCE

Effective systems

COMMUNITY

Enabling actions

FAMILYSupport



incidence of HIV


survival times

for people with

HIV/AIDS

Outcomes

Ultimate Customers(and their role) Intermediat

e Outcomes

Condom use



Treatment of STI


PMTCT



Injection Drug Use


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



Care &

Support

Systems

Strengthening

IEC/BCC

Prevention

Advocacy

Community

Mobilization

Impact

Mitigation

Treatment

COUNTRY

Context and

Leadership

PROVINCE

Effective systems

COMMUNITY

Enabling actions

FAMILYSupport



incidence of HIV


survival times

for people with

HIV/AIDS

Outcomes

Ultimate Customers(and their role)

Intermediate Outcomes

Condom use



Treatment of STI


PMTCT



Injection Drug Use


Systems Approach 16

GovernmentSectors

Health, EducationAgriculture, Trade

Com. Dev.Water, +


Political PartyLegal

Traditional

Civil SocietyVoluntary

PrivateCommunityFaith-basedTraditionalCommercial

Systems Approach 17


Care &

Support

Systems

Strengthening

IEC/BCC

Prevention

Advocacy

Community

Mobilization

Impact

Mitigation

Treatment

COUNTRY

Context and

Leadership

PROVINCE

Effective systems

COMMUNITY

Enabling actions

FAMILYSupport



incidence of HIV


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 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



Treatment of STI


PMTCT



Injection Drug Use


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


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

systems approach1. 2 a systems approach to the design of comprehensive hiv/aids programs malcolm...

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