Program Science:Opportunities, Challenges and

Impact

Program Components and Issues

James Blanchard, MD, MPH, PhDProfessor and Director,

Centre for Global Public HealthUniversity of Manitoba

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

Intervention vs. Program

• 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

“Program Science” for HIV/STI Prevention:

A Component Framework

Strategic PlanningPolicy Development

ProgramImplementation

ProgramManagement

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 Knowledge Spheres of Practice Intended Outcomes

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?

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

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

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”

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?

Epidemic Typology –3 Districts in India

DistrictHIV

prevalence in antenatal

females

% of new infections in low activity GP (MOT)

Likely Epidemic Typology

Bagalkot 2.1% 38.4% Mostly driven by large FSW-client

networks

Shimoga 1.0% 57.9% Highly concentrated, FSW-clients

Varanasi 0.25% 77.2% Quite truncated, with substantial

transmission from migrant

men

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?

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?

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?

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

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

Issues in Implementation

• Knowing what works

• Tailoring interventions to local contexts

• Horizontal programs and vertical interventions

• Building capacity

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

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?

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?

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

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

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?

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?

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

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

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

Conceptual Approaches to Scaling Up…

(from David Peters et al.)Domain Scaling up to reach the

MDGsScaling 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.

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

Thank You