Module 1: Strategic Planning

Overview

Many countries already have comprehensive national strategic plans for HIV/AIDS. The purpose of Module 1 is not to replace these national strategic plans, but to build on them by establishing an ongoing strategic planning process that mobilizes additional partners to support ECR implementation.

Module 1, Strategic Planning:

• Identifies the core principles for ECR strategic planning.
• Discusses expanding partnerships, ensuring participation and involving communities in planning.
• Outlines stakeholder roles in planning.
• Describes the steps involved in strategic planning, including priority setting.
• Lists key implementation questions stakeholders can address when conducting strategic planning for ECR.
• Provides a case study for ECR strategic planning.
• Provides references and resources for further reading.

Core Principles for ECR Strategic Planning

The five core principles to guide ECR strategic planning are:

• Respect for human rights to ensure that proposed programming does not stigmatize, debilitate or otherwise negatively affect the dignity of the very people the programs serve, including persons living with HIV/AIDS (PLHAs).
• Evidence-based decision making that allows planners and program implementers to learn from successes and from areas that need improvements.
• Accountability for program decisions and funding allocations.
• Openness to stating objectives and expected results clearly and reporting back to the public regularly.
• The shift from an expert-driven to a broadly participatory process.

Expanding Partnerships for Strategic Planning
Developing an effective ECR requires participation by a broad range of public and private sectors in the strategic planning process. For many countries, partnerships likely will be expanded and new partnerships developed to ensure appropriate input into ECR strategic planning. Key sector areas for inclusion involve health, education and agriculture. It is important to fully engage these and other identified key sectors in planning to ensure the effective delivery of programs and interventions. Three sectors are critical to successful strategic planning for ECR:

• NGO sector. Identify partners that are able to implement programs, receive resources and be accountable. Planners may need to assist non-governmental organizations (NGOs) in strengthening their capacity; civil accountability mechanisms may need to be established or strengthened; and PLHAs must be included in all aspects of strategic planning and implementation.
• Private sector. HIV/AIDS business coalitions can be established or strengthened.
• Public sector. HIV/AIDS programs can be mainstreamed into public sectors, along with infrastructure development.

This describes the types of partners to target for involvement in planning in each of these key sectors.

Ensuring Participation In ECR Strategic Planning
The importance of ensuring broad participation in HIV/AIDS program planning and implementation is one of the most critical lessons learned worldwide during two decades of fighting the pandemic. The core team responsible for developing strategic plans can aim to include as many key stakeholders as possible. Comprehensive representation from all sectors of society includes:

• PLHAs
• Political leaders
• Religious leaders
• Cultural/traditional leaders/rulers
• Key population groups
• Gatekeepers to key population groups
• Other influential community members such as musicians, athletes, spokespersons, business leaders, media representatives
• "Worker bees" – for example, those who lay the groundwork and do the daily implementation
• Current and future implementers of programs
• Technical advisors

It is important to create workable, balanced community representation to promote different aspects of strategic planning conducted by the core team. The core team must especially ensure the participation of:

• PLHAs and others whose voices may not be heard otherwise, such as stigmatized subpopulations of young women, commercial sex workers (CSWs), refugees and internally displaced persons (IDPs).
• Those likely to hold dissenting opinions and those likely to support HIV/AIDS programming. Including both of these voices will promote greater understanding of all positions and facilitate all parties' broader appreciation of the complexities of the epidemic.
• Diverse sectors within government, NGOs and for-profit institutions.

Involving Communities in ECR Strategic Planning
Opportunities for involving communities in the strategic planning process exist:

• in the initial pre-planning stage to define the strategic planning process.
• throughout implementation of the planning process.
• to launch and provide ongoing support for the plan.

The table below illustrates the roles communities can play in the ECR strategic planning process.

The Role of National and Local/Sectoral-Level Leaders in ECR Strategic Planning
As a component of HIV/AIDS programming, strategic planning has undergone valuable changes over time. In the early years of the epidemic, strategic planning was conducted largely in a top-down fashion, which over the course of the epidemic has proved to be unworkable. Community involvement is key to successful planning, and the strategic planning process has begun to involve the community in all aspects of planning, implementation and evaluation. This involvement has strengthened the process greatly by ensuring participation and input at all levels.

The planning process has a somewhat different focus on the national versus the local/sectoral (regional, provincial, district, municipal) level. On a national level, the planning process establishes broad goals and objectives; articulates specific national-level program roles (such as policies and national-level system support); demonstrates leadership in defining HIV/AIDS as a national priority; facilitates multi-sectoral coordination; and mobilizes domestic and external resources. At the local/sectoral level, planning becomes a function of assessing the local situation and environment.

The roles of national and community managers in supporting ECR strategic planning are described in this table.

Steps in ECR Strategic Planning

ECR strategic planning uses a four-step approach. These basic steps, designed to guide both national and local/sectoral levels in their planning process, are described below.

ECR Strategic Planning
Step 1: Situation Assessment
The purpose of the situation assessment is to gather information about HIV/AIDS in the population(s) under consideration. This information includes:

• Epidemiological data, including HIV and sexually transmitted infection (STI) prevalence and most vulnerable key groups.
• Major risk behaviors that are driving the epidemic.
• Socioeconomic, political, cultural, legal and health factors that contribute to vulnerability to HIV infection – for example, accessibility of health services, gender issues, migration, property rights, educational opportunities and workplace/employment issues.
• Present and projected impact of HIV on the community.

The situation assessment will produce a map of who is at risk, how they are at risk, the size of the population(s), and how and where they interact in ways that increase vulnerability to HIV infection. The situation assessment is important for ECR strategic planning in three areas:

• Estimating the size of key population groups to present a realistic picture of total need.
• Prioritizing needs.
• Exploring in more detail the interactions between key population groups and their contacts to better understand the dynamics of how the epidemic is growing.

ECR Strategic Planning Step 2: Response Assessment
Response assessment is used to:

• Inventory (or list) current efforts to address the epidemic.
• Assess these efforts for adequacy, acceptability and relevance.
• Identify critical gaps in programs and other efforts.

Response assessment provides planners with an opportunity to hear directly from frontline workers and the clients they serve. The planning team must maintain a positive perspective during this process so that program implementers and clients feel comfortable providing honest input about successes and limitations. Gathering information about what works, what needs improvement and where gaps exist is critical to the strategic planning process.

Response assessment identifies:

• Current program coverage levels and gaps. Using mapping techniques, response assessment provides a baseline of information about current program efforts. When studied with the situation assessment, the response assessment also can provide insights into priority areas not being served and identify potential "staging" areas for increasing current coverage.

• Useful models. Response assessment can identify successful program models, along with the essential elements that can be used to replicate and/or adapt programs in other settings.

• Technical resources. Response assessment also identifies potential implementing agencies and technical expertise that can be deployed quickly. This expertise also represents valuable country-specific institutional memory. Sharing information about successes and failures will result in more efficient use of time and will help minimize the use of culturally inappropriate strategies.

• Partner gaps. Trends and gaps in partners are identified with response assessment and current partners. Planners can look at whether current programs involve multiple sectors (for example, faith-based organizations, women's groups, private sectors, schools) versus primarily the ministry of health and HIV/AIDS NGOs. It is critical for planners to assess whether PLHAs have been included sufficiently.

• Response capacity. The response assessment provides information on the capacity to respond in terms of the infrastructure, skills and systems available and identifies areas that need to be developed to fully mobilize ECR.

To facilitate response assessment at the local/sectoral level, the planning team must explore the impact of HIV/AIDS on the:

• quality and quantity of services provided within the sector
• ability to supply the required services
• organization of the sector
• role of the service providers
• human resource policy and management practices
• planning and management of sector resources
• availability of public and private resources for the sector
• donor support to the sector

ECR Strategic Planning Step 3: Strategic Plan Development
The results of the situation and response assessments will provide planners with most of the information needed to prepare an appropriate ECR strategic plan. This information must be analyzed carefully to determine priorities (see "Determinants for Choosing ECR Priorities" below).

ECR strategic plans can include:

• priority areas
• clear objectives for each priority area
• major action strategies to address the objectives for each priority area
• overall achievement targets, including aggregate indicators (or benchmarks) and how they will be measured
• definitions of the planning partners and their roles
• definitions of the roles and involvement of PLHAs
• estimates of the program costs and funding sources

Step 3: Strategic Plan Development – Determinants for Choosing ECR Priorities
As planners consider the complex issues and options for implementing ECR in their locales and establish realistic time frames, the following determinants can be used to select ECR priorities:

• state of the epidemic
• behavior targeting
• geographical focus
• level of resources
• leadership capacity for implementation
• community readiness

The current state of the epidemic in a country, region or locale often determines the availability of resources and the time frame for expanding interventions and programs. The table above reviews three different states of the HIV epidemic.

Determining community readiness, or what UNAIDS defines as AIDS competence, is particularly important in the ECR priority-setting process. Factors to examine when determining community readiness include:

• Accurate knowledge of the HIV/AIDS situation in the community
• Perception of the current and potential impact of HIV/AIDS on the community
• Attitudes toward PLHAs
• Openness to discussing HIV/AIDS with youth
• Attitudes toward HIV/AIDS programming in the community
• Priority placed on HIV/AIDS, compared with other community needs
• Immediate familiarity with HIV/AIDS; for example, having an HIV-positive family member or friend

Step 3: Strategic Plan Development in Summary – Action to Resources to Results
Developing realistic and effective strategic plans requires priority-setting that takes into account the stage of the epidemic, the level and adequacy of the current response, the absorptive capacity of systems and infrastructure to respond further, and especially the level of response that will help slow the spread of the epidemic. Program planners can factor into the strategic planning process lessons learned and best practices from international and regional responses to HIV/AIDS. These factors can inform the development of innovations and make improvements in current programming.

One extremely critical component of strategic planning is developing budget scenarios. Program planners must prioritize the plans (and the plans' components) according to available funds and resources. This type of prioritization will ensure a consensus on the priority interventions and on the funding and resources available to implement them.

Along with developing budgets, designing a monitoring and evaluation plan is essential. Monitoring and evaluation allows for important periodic reviews of critical benchmark indicators and design of a strategy for updating the plan as needed.

The national strategic plan will serve as the overarching framework for local/sectoral plans. While the categories for the local plans can be similar to the national plan, the amount of detail will increase at the local/sectoral level because implementation planning becomes more specific. Local/sectoral plans will include clear activities, have definite time constraints, identify the specific actors and their roles and delineate concrete budgets and funding sources.

ECR Strategic Planning Step 4: Resource Mobilization
There seems to be a clear consensus that the resources available to date for HIV/AIDS programming have been grossly inadequate to produce an effective response. Greater budgetary allocations for HIV/AIDS must be provided by all national governments at all levels. In addition, each country's private sector must be organized to support and fund HIV/AIDS programs.

Important initiatives have been introduced since 2000 to increase funds available for HIV/AIDS programming. These include:

• International multilateral donor programs; for example, the International Partnership for AIDS in Africa
• Significant increases in the level of support from bilateral donors such as USAID
• Private sector initiatives, such as the Melinda and Bill Gates Foundation and international pharmaceutical companies, to make antiretrovirals (ARVs) available at significantly reduced costs
• Debt relief schemes such as Jubilee 2000 and the World Bank's Heavily-Indebted Poor Countries Debt Reduction Program

Recently, African country budgetary commitments to HIV/AIDS have been increasing. In April 2001, at the Abuja Summit on HIV/AIDS, African leaders committed to spending 15 percent of their gross national product (GNP) for health care and a response to HIV/AIDS. Multilateral and bilateral donors are now requiring greater political and budgetary commitment from developing-country partners themselves, which can happen through various means. Debt-relief programs, for example, free up countries to commit their own resources previously allocated to debt servicing to education, health and social services, including HIV/AIDS. As more countries decentralize health planning and management, local-level governments are charged with allocating budgetary resources for HIV/AIDS and exploring cost-recovery mechanisms for relevant services, such as HIV testing, condom distribution and delivery of palliative care drugs. Countries are turning increasingly to the private sector for financial support and program partnerships.

Key Questions for Implementing ECR Strategic Planning

Planning teams can use their existing HIV/AIDS strategic plans for ECR strategic planning. Planners can review the ECR strategic planning steps described above and compare them to their current plans. The following box lists key questions to consider when developing and implementing an ECR strategic planning process. These questions are relevant for both national and local/sectoral planning.

Further Reading

1. African Development Forum. Lessons Africa Has Learnt in 15 Years of Responding to HIV/AIDS. Working paper. Unpublished report of the African Development Forum, 3—7 December 2000. Addis Ababa, Ethiopia.
2. African Development Forum. The African Consensus and Plan of Action: Leadership to Overcome HIV/AIDS. Unpublished report of the African Development Forum. 3—7 December 2000. Addis Ababa, Ethiopia.
3. African Development Forum. Theme 3: Scaling Up to Reponses to HIV/AIDS. Unpublished report of the African Development Forum, 3—7 December 2000. Addis Ababa, Ethiopia.
4. Bonnel R. 2000. Costs of Scaling HIV/AIDS Program Activities to a National Level in Sub-Saharan Africa. Unpublished report. London, England: World Bank.
5. Chan C, Moodie R, Goodridge G. HIV/AIDS Prevention and Care in Resource Constrained Settings: A Handbook for the Design and Management of Programs (expected publication date December 2001). Arlington, VA: Family Health International.
6. Community Mobilization and AIDS: UNAIDS Technical Update (UNAIDS Best Practice Collection: Technical Update). April 1997. Geneva: UNAIDS.
7. HIV and Development Program, UNDP. Mainstreaming the Policy and Programming Response to the HIV Epidemic. Issues Paper No. 33, 2000.
8. Kelly MJ. September 1999. The impact of HIV/AIDS on schooling in Zambia. ICASA.
9. Lamboray JD. Local Responses to HIV/AIDS: The global agenda: UNAIDS Local Response – Key Note. Geneva: UNAIDS.
10. Local Responses to HIV/AIDS. Technical Note No. 1. A Strategic Approach Toward an AIDS-Competent Society. Geneva: UNAIDS. (Adapted from Kelley MJ, The impact of HIV/AIDS on schooling in Zambia. ICASA, September 1999.)
11. Management Development and Governance Division, Bureau for Development Policy, UNDP. 1998 Capacity Assessment and Development in a Systems and Strategic Management Context. Technical Advisory Paper No. 3.
12. UNAIDS. November 2000. The International Partnership on AIDS in Africa. Update. Geneva: UNAIDS.

Case Study

Case Study: Jump Start in Nigeria: Strategic Planning for ECR
Over the past year, donor funding for HIV prevention and care programs in Nigeria has increased rapidly, creating pressure on implementing agencies to scale-up programs and build implementation capacity. Because Nigeria is Africa's most populous country, the fate of its battle with HIV is of special interest to global and African regional AIDS programs. In 2000, Nigeria's HIV prevalence rate was about 5 percent, and the risk of an epidemic spinning out of control, as it had in southern Africa, seemed great.

In that same year, FHI was commissioned by USAID to intensify prevention and care work in four priority states and expand coverage in the most vulnerable communities in those states. An annual commitment of $1 million (US) per state was provided for field costs. FHI determined that it could not use a business-as-usual approach to project development, which might cost the program more than a year in developing the dozens of projects required for a comprehensive prevention and care response.

A jump-start model was developed to accelerate the process. In only six months, four state programs were developed and 52 subprojects were launched, based on a sequence of rapid and in-depth assessments, workshops for stakeholders, and proposal development training for local implementing partners. The jump-start approach was conceived as a way to:

• Ensure consistency and quality control at the project development phase.
• Build the capacity and networking of implementing partners.
• Rapidly inject momentum into a program by simultaneously launching a set of mutually reinforcing projects.

The Nigeria model is a process of progressive prioritization of populations and sites, gradually building up local participation and ownership of the process and products of strategic planning. There were six sequential elements to this process:

• Desk review at the national level.
• Rapid assessment at the state (or provincial) level.
• In-depth assessment at the local government level.
• Stakeholders' workshop.
• Strategic planning workshop.
• Sub-project development workshop.

A certain amount of risk was involved with this rapid project development because of several factors: inadequate screening of the implementing partners' capability; limited time to build capacity of NGOs for managing finances and activities; and the possibility of strategic errors in the rush to select priority geographic areas and populations. FHI was able to reassure the donor that adequate precautions would be taken to minimize risk, including onsite pre-award audits of the local agencies' financial systems.