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
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
• Intervention
– Specific technological
or behavioural modality
– Particular target
group(s)
– Focus on effectiveness,
fidelity, coverage
• Program
– Multiple components
(interventions)
– Resource allocation
between components,
and sharing across
components
– Emphasis on optimizing
population level impact
“Program Science” for HIV/STI Prevention:
A Component Framework
Spheres of Knowledge
• Epidemiology
• Transmission dynamics
• Policy analysis
• Health systems research
• Efficacy / effectiveness
• Operations research
• Surveillance
• Monitoring/evaluation
• Operations research
• Health systems research
Spheres of Practice
Strategic Planning
Policy Development
Program
Implementation
Program
Management
Intended Outcomes
Choose:
• The best strategy…
• The right populations…
• The right time…
Do:
• The right things…
• The right way…
Ensure:
• Appropriate scale…
• Efficiency…
• Change when needed…
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 tradeoffs 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
HIV
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, FSWclients
Varanasi
0.25%
77.2%
Quite truncated,
with substantial
transmission from
migrant men
District
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
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 welldefined 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