Colonel Juan Luis Sierra, the leading military officer in the Dominican Republic's Dajabon Province, did not want to spend three-and-a-half days at a planning workshop about HIV/AIDS. He didn't believe AIDS was a problem in the Dominican Republic and saw no reason for an officer of the National Police to work with doctors and nurses on a health issue. But he had his orders, so he went.
As the national AIDS program staff presented the results of an analysis of HIV/AIDS in Dajabon and workshop participants added their own observations, Col. Sierra became interested. He had seen many of the things they described: young adults suddenly falling ill and dying, police contracting sexually transmitted infections (STIs), women suddenly disappearing, rumored to have returned home to die. But he had never connected these things with AIDS.
The colonel quickly became one of the most active participants in the workshop, organized for the National AIDS Council (CONASIDA) by the national AIDS and STI program (Programa de Control de Enfermedades de Transmisión Sexual y SIDA, or PROCETS) and the provincial health department to develop a plan for HIV/AIDS activities in the province. At the end of the workshop, Col. Sierra announced that he would be the first to ask his troops to change their behavior and he would lead them by his own example.
Later that year, at a national health forum on HIV/AIDS, Col. Sierra told hundreds of people about his conversion to the cause of HIV/AIDS prevention as an individual and a military leader.
Today, Col. Sierra leads the effort to carry out his province's plan, which has brought together the provincial health department, the military, the private sector, religious groups and many community members to improve HIV/AIDS prevention and care in Dajabon.
The strategic planning workshop where Dajabon's plan was produced is one of 34 such workshops being held in the Dominican Republic's 29 provinces and five municipal districts as part of a national strategic planning process. By the second week of May 2000, 21 action plans had been developed.
People from many different sectors of society are working together to carry out those plans, according to Maria de Carmen Wiese of Family Health International (FHI), which has provided technical assistance to PROCETS throughout the strategic planning process.
"So many groups in the community are involved in implementation, from Boy Scouts to business owners," said Wiese, who coordinates HIV/AIDS activities in the Dominican Republic for FHI's Implementing AIDS Prevention and Care (IMPACT) Project, which is funded by the United States Agency for International Development (USAID). "The participation that this process has generated is remarkable."
A National Response
Strategic planning for HIV/AIDS prevention and care in the Dominican Republican began at the national level, with the participation of more than 100 people from throughout the country. They represented a wide range of individuals and organizations with a stake in the future direction of HIV/AIDS programs, including the central and provincial levels of the Ministry of Health, the ministries of labor, education, tourism and immigration, the armed forces, nongovernmental organizations (NGOs), businesses, religious groups, national and international donor institutions, people living with HIV/AIDS, and healthcare providers from the private and public sectors.
All of these "stakeholders" took at least one opportunity to contribute to the process by participating in workshops, focus group discussions or interviews. Most were engaged in several days of intensive discussions during two national strategic planning workshops. The result was consensus on a comprehensive, multisectoral national strategic plan for preventing and controlling HIV and other STIs from the year 2000 to 2003.
Perhaps even more important were some of the less tangible benefits of the participatory process that produced the plan. These include better information about the needs and abilities of those implementing local projects, increased use of local resources, more efficient use of resources overall, improved donor coordination and greater potential for sustaining HIV/AIDS prevention and care efforts.
And the most important result of this participatory approach to strategic planning was the sustained commitment it inspired among stakeholders to making the plan work, according to PROCETS Director Martha Butler de Lister.
"Once people commit through a process like this, they remain committed, which is something I had not seen before," she said.
The Process
The first national stakeholders' workshop in February 1999 brought together about 70 people from a range of public and private sector organizations throughout the Dominican Republic. This two-and-a-half-day workshop began with presentations and a discussion on the results of a CONASIDA-commissioned analysis of the HIV/AIDS situation in the country and the Dominican response.
The analysis showed that an estimated 2 percent of the sexually active adult population of the Dominican Republic were living with HIV/AIDS. Conducted by the research arm of the Dominican national family planning organization, with support from the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the USAID-funded AcciónSIDA Project of the Academy for Educational Development, the analysis also highlighted the lack of a coordinated response to date. Donor priorities drove the response, in part because of the weak leadership provided by the national AIDS program and the National AIDS Council. The analysis noted that Dominicans living with HIV/AIDS often suffered from discrimination and lack of access to quality care.
During the workshop and the entire strategic planning process, PROCETS worked with a design team of five national and international HIV/AIDS experts and two facilitators. One facilitator from the U.S.-based consulting firm Social Impact was paired with a second facilitator from the local consulting company ALEPH (Agencia Latinoamericana de Expertos en Planificación H.) to transfer a thorough understanding of Social Impact's approach to strategic planning for future application in the Dominican Republic.
The facilitators engaged participants in a process called "appreciative inquiry." Unlike most planning processes, which tend to emphasize how to overcome obstacles and challenges, this "assets-based" approach begins by looking at what is working well.
"Traditional approaches are problem-based, "explained Social Impact Vice President Pat Hanscom. "Appreciative inquiry is empowering because it focuses on opportunities to be embraced."
Workshop participants met in small groups to identify the strengths of current HIV/AIDS plans and programs in the Dominican Republic and to develop a vision of how they could build on those strengths to make the country's response to HIV/AIDS more effective.
During the next week, design team members and PROCETS staff conducted focus group discussions and in-depth interviews with some of the workshop participants and other stakeholders. Then they synthesized all the information gathered during the focus group discussions, interviews and the first workshop into a conceptual framework for the initial strategic plan. This framework included three strategic areas -- policy, prevention, and care -- one area of special concern for strengthening (counseling), and 13 lines of action for achieving progress in the three priority areas.
In a final Synthesis Planning Workshop, the stakeholders returned to review and refine the conceptual framework. Working in small groups again, they discussed the potential challenges, constraints and opportunities in each strategic area and developed lists of specific activities that could be undertaken.
Participants were impressed with the spirit of solidarity and collaboration fostered by the workshops. "United we looked for solutions," one observed.
The Plan
The national plan drafted by the design team at the end of the strategic planning process and embraced by CONASIDA reflects the collective vision of a broad spectrum of Dominican society for improving HIV/AIDS prevention, treatment and policies. It includes specific activities designed to achieve the objectives identified by stakeholders.
True to the appreciative inquiry approach, the plan begins by recognizing what HIV/AIDS programs have achieved in the Dominican Republic. Among the successes noted are reports of significant behavior change to reduce HIV risk -- including reductions in unprotected sex -- relatively high condom use among sex workers, adoption of a national AIDS law, and a system that screens 98 percent of the blood supply for HIV. As a result, there are preliminary indications that HIV prevalence may have stabilized within some populations in parts of the country.
Emphasizing the need to maintain successful interventions and continue targeting groups at high risk, the plan also describes how Dominicans can build on earlier progress. For example, the national AIDS law passed in 1993 provides important protections against discrimination for people living with HIV/AIDS, but further work is needed to ensure that the law is actually followed.
The plan calls for innovative interventions and research to address the changing nature of the Dominican Republic's HIV/AIDS and STI epidemics. New challenges include providing high-quality HIV counseling and testing, exploring innovative ways to improve treatment of common STIs, increasing access to antiretroviral treatment, and evaluating interventions to prevent mother-to-child transmission of HIV.
The 13 lines of action identified by stakeholders include their three top priorities: (1) behavior change interventions, particularly sex education for young people in and out of school, (2) preventing and treating STIs, and (3) ensuring access to HIV/AIDS care.
Involving Communities
In April 1999 the strategic planning process moved to the provinces, where responsibility for HIV/AIDS and other health programs is being shifted under a government decentralization effort. A team composed of PROCETS staff members, three staff members from the provincial health directorate, one facilitator from ALEPH and one facilitator from Social Impact spent four days in Monseñor Nouel Province working with stakeholders to develop a provincial operational plan under the framework of the national strategy.
First the team members interviewed key stakeholders and prepared for a workshop in the city of Bonao that involved about 30 health workers, government officials, business and religious leaders, NGO staff and people living with HIV/AIDS. Through the same process of appreciative inquiry and small group discussions used at the national level, participants were able to develop a three-year vision for HIV/AIDS programs and a specific one-year action plan.
Using the knowledge and skills they had gained through their partnership with FHI and Social Impact and the lessons learned from this pilot effort in Monseñor Nouel, ALEPH and PROCETS staff continued to facilitate the strategic planning process in the Dominican Republic's 29 provinces and five municipal districts. These provincial workshops are cosponsored by the IMPACT Project with funding from the USAID mission in the Dominican Republic and by the European Union's Proyecto de Apoyo al Programa Nacional de VIH SIDA (PREVIHSA) Project.
PROCETS staff members, who have gradually assumed most of the responsibility for facilitating the workshops, hope to complete the design of all 34 operating plans in 2000.
Like the national strategic plan, these provincial plans have drawn together diverse groups of people, many of whom had never worked together before. In Peravia Province, for example, firefighters, civil defense groups, Boy Scouts, neighborhood associations, groups of housewives and farmers are all involved in carrying out the provincial plan.
In one province, a physician from the health department of one of the Dominican Republic's largest corporations was -- like Col. Sierra -- transformed from a reluctant participant into the energetic leader of the follow-up committee established to coordinate implementation of the provincial plan. In another, a Catholic nun successfully argued that condoms should be moved to the top of the list of the province's HIV/AIDS priorities.
Dr. Butler attributes the broad base of interest in HIV/AIDS to its increasingly visible presence in Dominican society.
"Ten years ago planning for AIDS was very difficult because no one could see it, but now it's there," she said. "People are dying. They know what we're talking about. And they also know that they can do something about it."
Visions and Goals
The three-and-a-half-day planning workshops in the provinces begin with a brief discussion of the situation analysis developed for each province with support from the PREVIHSA Project.
"People usually discuss how accurate the diagnosis is," Wiese said. "Most of the provinces have more information than was available when the situation analysis was done. And the provinces are not that big, so they all know where the problems are."
Then participants move to the "discovery" phase of appreciative inquiry, when they identify what they have been able to accomplish in the past and how they have succeeded in working together as a community, whether it was to organize a city celebration or respond to natural disaster.
"What appreciative inquiry does is get everybody thinking about how to build on the good," Dr. Butler said. "We try to get them to think about the success stories where they're good at being one single community working towards a goal."
After that participants work in small groups to envision what they would like to accomplish in HIV/AIDS prevention during the next three years.
Like the national strategic plan, the provincial plans include three-year strategic plans. But the provincial operating plans go a step further, laying out specific activities to be carried out in the first year and identifying partners to be involved.
Grassroots Action
FHI/Brazil Program Officer Valmir Costa recently observed a provincial planning workshop in the Dominican Republic's Boca Chica Province in order to identify aspects of the process that might be relevant in designing a strategic planning methodology for Brazilian states and municipalities. He was impressed with how well-organized and goal-oriented the workshop was.
"By the end of the third or fourth day, they already had their plan prepared," he said. "It was a quick, simple process, and they got the results they needed by the end."
Wiese agrees that this systematic approach is one of the strengths of the methodology. "We have tools for each step in the process, so the plan is ready at the end of the workshop," she said.
Juliana Martinez, PROCETS' head coordinator for the provincial planning process, has seen just how important that it is to participants. "They go home with a real plan in their hands that's ready to be applied, and that empowers them," she said.
PROCETS plans to work with FHI to design a system for monitoring the implementation of the national and provincial plans. In the meantime, one indication of progress in the provinces is the assistance that the provincial health directorates seek from the national HIV/AIDS and STI program to carry out their plans.
"What we're finding at the central level is that we're sometimes overwhelmed with requests for technical guidance," Dr. Butler said.
PROCETS' solution is to train health professionals in the provinces so that they can help fill the need for technical assistance at the local level. Some provinces are taking advantage of another source of technical expertise -- the NGOs such as Coordinadora de Animación Socio-Cultural (CASCO), Centro de Orientación e Investigación Integral (COIN), Patronato de Solidaridad (PASO), and Comité de Vigilancia y Control del SIDA (COVICOSIDA) that have worked with PROCETS and FHI for more than a decade -- to tap their experience in working with groups such as youth and sex workers.
The provinces are also doing much of the implementation on their own. Many provincial health directorates and operating plan committees are even beginning to do their own fundraising -- a first in the Dominican Republic, according to Dr. Butler. One provincial committee, for example, secured a large donation of condoms. And some of the committees have asked local business for donations so that they can reproduce T-shirts and other materials that PROCETS can afford to give them only in limited quantities.
Mobilizing Resources
Observing what has been happening in the provinces has made Dr. Butler a firm believer in appreciative inquiry. She compares it favorably with more traditional methodologies for strategic planning, which she says tend to take problems and try -- usually unsuccessfully -- to "turn them into opportunities."
"We really want people to concentrate on opportunity -- just opportunity -- and on the strengths of the community," she added.
Some people are less enthusiastic about the appreciative approach, believing that it puts too much emphasis on the positive at the expense of confronting the real challenges of implementation. "The process was really good for generating a commitment and will and a feeling of inclusiveness, but after you've established that, you've got to make the hard decisions," said Tito Coleman, director of AcciónSIDA. "It's a great start, but we need to look hard at what can be done with the resources at hand."
Everyone agrees that mobilizing resources for implementation is one of the most important challenges ahead. These efforts were galvanized by the launch of the national strategic plan at the National Health Forum organized by the Dominican public health association, Instituto Nacional de Salud (INSALUD), in November 1999.
The decision to dedicate this annual meeting to HIV/AIDS in 2000 was seen as a chance to mobilize additional political and financial support for the national response, and PROCETS and INSALUD seized the opportunity.
The forum drew about 700 people, including key policymakers and community leaders from different sectors and representatives of international donors. During the opening ceremony, the Minister of Health gave a speech in which he pledged his support for ensuring compliance with the national AIDS law -- legislation he had coauthored as a senator.
Knowing that senior government and NGO officials would not be able to stay for the entire two-and-a-half-day meeting, INSALUD AND PROCETS worked with ALEPH to arrange a morning session for them to discuss specific responses to HIV/AIDS in each of their sectors.
"What we got out of that morning was a commitment to develop sectoral plans and a committee within themselves to actually follow through with them," Dr. Butler reported.
Since then, work has begun on developing sectoral HIV/AIDS plans for tourism, labor, religious organizations and the military. The Dominican Republic's attorney general has also organized a committee to begin designing an HIV/AIDS plan for prisons.
These plans will give people working in the different sectors authorization and support for getting involved in HIV/AIDS prevention and care, Dr. Butler explained. "The sectoral plans will endorse what they've been doing at the provincial level, and funding may follow," she said.
Before the forum a Dominican researcher, Rolando Perez Uribe, had calculated the cost of carrying out the strategic and provincial plans. The estimate -- 100 million pesos a year (about US$ 6.3 million) -- has become the advocates' rallying cry.
PROCETS budget was increased by 10 percent for 2000, and provincial budgets for HIV/AIDS are rising as well. Although total contributions are not likely to reach 100 million pesos, Dr. Butler is encouraged by the growing financial support from the national government and donors.
For example, USAID has committed additional funding for technical assistance through FHI. UNAIDS has added US$ 50,000 for efforts to prevent mother-to-child HIV transmission (using supplies of the antiretroviral drug nevirapine donated by the community of La Rioje in Spain) in two maternity hospitals in Santo Domingo and one in the coastal city of Puerto Plata.
UNAIDS Director Peter Piot, who was the featured speaker at the opening of the National Health Forum, believes that the Dominican Republic's experience "provides an excellent example of a strategic planning process based on principles of ample consultation and participation from all sectors of society."
Strategic planning for HIV/AIDS, sustained by strong political commitment, is key to an effective national response to the epidemic," Dr. Piot added. "The challenge ahead is to take advantage of the momentum created and intensify our efforts against the epidemic."
Learning From Each Other
The strategic planning process so far has been a rewarding experience for participants and facilitators alike. Dr. Butler says she has learned so much from the communities.
"For example, in one province people talked about kids riding mopeds and going out of the town limits to the woods to have sex," she said. "I would never think about that sitting in Santo Domingo! Nobody know those realities better than the people who live there."
At the same time, many participants come away from the workshops with new information about HIV. In response to requests from participants, PROCETS has added a session that includes a presentation and questions and answers on the basic facts about HIV transmission, prevention and care.
"When they hear the word 'workshop,' people have this expectation that they're going to learn something about AIDS, so we've compromised a little bit by adding this session," Dr. Butler explained. "And it's good because then everyone is on the same wavelength."
There is no accommodation, however, for another common expectation -- that participants are invited to the provincial workshops simply to approve a plan that has been developed by experts.
"Most of the people who come to the workshops think that they are called to validate the process," Wiese said. "They come thinking that they've been asked in order to make believe that they've been consulted, because that's the traditional way of doing things."
Participants quickly learn that they are expected to develop their own plan, and most are pleased at the opportunity to contribute.
"People really work at making the plan real and realistic," Wiese said. "They discover that they are able to do planning, that they are able to work at actually making the plan possible, and that is very empowering."
-- Kathleen Henry
