53371 Improving HIV/AIDS Strategic and Action Planning -- Lessons Learned from Lead Consultants AIDS Strategy and Action Plan Program (ASAP) A small number of ASAP lead consultants and other AIDS Strategy and Action Plan (ASAP) program lead experts met in Washington in July 2008 to discuss consultants and other experts distilled their experiences challenges and good practices in guiding strategic and in supporting national strategic planning for HIV/AIDS operational planning processes in countries, and to around the world, and made recommendations for consider ways in which ASAP can offer greater support enhancing the effectiveness of that support. to its consultants. This note presents findings and conclusions from the meeting, with a focus on the lead consultant role including: ASAP experiences in supporting national ƒ Elements of a good strategic plan HIV/AIDS strategic planning ƒ The process of strategic planning Over the last two years, the AIDS Strategy and Action ƒ Moving from strategic to operational planning Plan (ASAP) program, a service of UNAIDS, has assisted over 50 countries to enhance their HIV/AIDS ƒ The essential skills of lead consultants strategic and action planning by providing: ƒ How ASAP can enhance its support to lead ƒ Technical and financial support for the planning consultants and strategic planning in general. process The note also looks at other areas, including: ƒ Confidential peer reviews of draft strategic and ƒ The major challenges for strategic planning action plans consultants ƒ Tools and lessons learned ƒ Designing an HIV/AIDS strategy with insufficient ƒ Capacity building for countries, UNAIDS Technical data on drivers of the epidemic Support Facility consultants, and UN partners ƒ Dealing with stakeholder views which may not be Two important findings from the 2007 external evaluation based on evidence. of ASAP’s first year of operation were that ASAP should ƒ Prioritizing activities in operational plans broaden its support beyond HIV/AIDS strategies to offer: (i) a continuum of support from strategic through ƒ The prerequisites for a productive strategic planning operational planning, and provide support over a longer exercise period to accomplish this; and (ii) support for organizing The audiences for this report are consultants and and managing the planning process, both with regard to others who assist countries to prepare good strategic the content of strategies and action plans and the and action plans. The findings may also be useful for process of preparing them. national authorities engaged in strategic and operational The evaluation suggested that an important element of planning, providers of technical support and donors. 2 future ASAP assistance should be the provision of high- level “lead” consultants 1 who have the skills to advise and facilitate the strategic planning process (in addition 2 Other relevant documents available on the ASAP to advising on the strategy content and substance), as website (www.worldbank.org/ASAP) on strategic well as the skills to help countries move forward on planning include: (i) HIV/AIDS Strategy Self-Assessment detailed operational planning. Tool and Guidelines; (ii) Key Steps in Preparing a National Strategic Plan; and (iii) Preparing National 1 HIV/AIDS Strategies and Action Plans – Lessons of Consultants with other specialized skills and expertise Experience. could also be provided. Lessons learned spending scarce resources with little chance of having a measurable impact. In such cases, the first year or two of the strategy should support a process 1. Elements of a Good Strategic Plan of gathering evidence on the epidemic and on ASAP was established by the 2006 Global Task Team to program effectiveness, and then using this evidence assist countries to make their strategic plans more to design a longer-term strategy. evidence-informed, prioritized, costed and linked to implementation realities. The experience of the lead ƒ The response analysis strengthens the consultants produced a consensus on the foundation provided by the evidence. It describes objectives/elements of a good strategic plan. the national response to the epidemic to date, and relates it to the epidemic situation analysis (were the ƒ Strategies should serve to guide the response. right things being done?), presents the results of A strategy should be a guide for a country, not a previous programs/projects, indicating areas found blueprint for implementation. It should be short, to be particularly challenging. Ideally it also provides focused, easily readable and understandable by information on the status of the M&E plan and on decision makers and the general population, 3 and human and financial resource availability and/or reflect the actual thinking of decisions makers. It constraints that will help shape the new strategy. 4 should present the evidence, define the key results, and identify – at a general level – the interventions ƒ Linkages. HIV/AIDS is multi-sectoral and needs to most likely to have an impact on the epidemic. The be seen in a wide context, especially in high strategy should not go into details on activities -- prevalence countries. Thus the response needs to those belong in operational plans. be coordinated with other areas of the health sector (e.g., sexual and reproductive health, TB) and with Lessons from ASAP Peer Review Experience other sectors/actors beyond the ministry of health, especially those that deal directly with high risk At the request of countries, ASAP has conducted groups (e.g., prison and legal systems, transport, more than twenty peer reviews of draft strategies and mines) and mindful of the broader concerns around action plans. The strategies and plans have many health system strengthening generally. strengths, but also contain weaknesses, and many would benefit from: ƒ Focus on Results. There should be a strong and • A stronger evidence base clear internal logic moving from evidence of the • Better linkage between the evidence on the drivers of the HIV/AIDS epidemic to identification of epidemic and the proposed strategy results to be achieved over the strategic plan period, which requires program prioritization. 5 For each • A focus on results rather than on advocacy result, a relatively small number of targets and • More attention to gender and to marginalized indicators need to be identified, with data groups requirements that are reasonable and feasible • Improved operational and human resource without assuming major improvements in M&E. planning ƒ The benefits and challenges of stakeholder consultation. Stake-holders have valuable ƒ The situation analysis provides the evidence on knowledge and experience to contribute to the which the strategy is built. This section should lay strategic planning process. And consultation out the main facts emerging from the available encourages ownership and healthy debate, and epidemiological and behavioral data, along with an allows a wide range of views and positions to be indication of the cultural and socio-economic understood. At the same time, both national and realities that relate to HIV transmission. Countries international stakeholders (including donors and that have a sufficient evidence base need to assess providers of technical support) sometimes advocate it critically and use it as the basis for deciding the for inclusion of views/activities that might not reflect size and structure of their response. the evidence of the epidemic. The challenge then is to strike a balance between reflecting stakeholder Countries without solid evidence on the size and views and focusing on the drivers of the epidemic. In drivers of the epidemic should make getting this evidence the primary focus of their strategy. If not, 4 they risk making unsupported assumptions and One important added value of lead consultants should be to help rationalize evidence to clarify priorities and help national authorities to make choices. 3 5 The formatting of the strategy, the use of graphs and UNAIDS guidance on prevention planning provides a text boxes (where relevant), and a very short, concise good starting point for prioritization within the strategic executive summary are all essential. planning process. 2 the final analysis, while some compromises will be staff, prioritizing the response – all of which are critical to inevitable, the programs chosen and the budgets a successful outcome. Thus many national AIDS allocated should reflect the realities of the epidemic authorities choose to contract out important parts of the and not just stakeholder interests and “the loudest strategic planning process to specialized voices”. A good strategy is based on the evidence – experts/institutions, while retaining overall supervision. it is not a summary of consultation meetings. Over the past two years, ASAP and the lead consultants ƒ Facilitation. Having an experienced facilitator to with whom it has worked have provided advice to guide participation of stakeholder groups and to countries on the process of strategic planning. A suggest mechanisms for resolving differences and number of valuable lessons have been learned about the mitigating institutional self-interest is very helpful, process, many of which apply broadly, regardless of especially given the substantial amounts of funding specific country situations. involved. “We need to ‘land’ the strategic plan ƒ Coordination and Implementation Challenges. so that it comes down to earth” Overcoming these challenges is critical for a successful national response to the epidemic, and (Latin American AIDS official) thus an assessment of past experience should be included in the Situation Analysis. Further, while the ƒ Planning the Process. Strategic planning should be details are best left to operational plans, the key kept short and focused and organized well in principles and practices of coordination and advance of starting the process. A realistic timetable implementation are also relevant for a strategy, is imperative. The fact that the major sources of including establishing overarching coordinating funding – a country’s ministery of finance, the Global mechanisms such as joint country-led annual Fund, and the U.S. Government – have different reviews, and defining how funds will move to procedures is a fact of life that complicates implementing organizations, especially those outside developing one strategy. However, maintaining the the public sector and at decentralized levels. international community’s commitment to supporting “one national strategy” remains important. ƒ Strategic Flexibility. As the epidemic changes over time, it is useful to update strategic plans to Using a “road map”, such as the one developed by reflect new evidence. One approach to ensuring that ASAP, indicating the various steps and options the strategy is appropriate in changing involved in strategic planning, can be an effective circumstances is to organize joint country-led approach and can keep all those involved focused reviews every year or two. Such reassessment on where they are and where they are going in the needs to be built into the strategy. process. It is important that there is sufficient time to analyze the epidemiological evidence and consult ƒ Costing and Financing. It is important to present a stakeholders, and that responsibility for tasks in the picture of the current and expected sources and process are clear, especially if a lead consultant is levels of finance, and to estimate the resources being used. needed to implement the five-year strategy. 6 It is also important to indicate how much of available ƒ Managing the Process. Process management, resources has been spent and to give an indication which might involve enhancing local capacity, is as of historic capacity to absorb funds. However, few important as the technical skills involved in strategies today have a financing section and many producing the substance of the strategy. do not yet include a cost estimate. ƒ Coordination and Supervision. One danger to the process is having a team of staff and consultants, 2. The Process of Strategic Planning funded by and reporting to different masters, with insufficient supervision and guidance, resulting in a Countries usually develop HIV/AIDS strategic plans “cut and paste” strategy without internal coherence. every four to five years. It is common for country Coordinating the stakeholders, especially those program managers, therefore, to have limited experience representing external agencies, is especially with the process of strategic planning – leading the important. The ability of the UNAIDS Country process, assembling the evidence, organizing the Coordinator to assist with coordination varies and participation of stakeholders, managing consultants and needs to be enhanced along with the participation of the main external funders, the Global Fund and PEPFAR. 6 There are several existing models currently used (Resources Needs and Goals, for example) for the kind ƒ Local Champions. An important asset is having of aggregate costing that is appropriate for a strategy. local champions with authority to guide the process 3 and ensure local ownership, regardless of the nationality or affiliation of those who do the work. A When Stakeholders Hold Views Not Based on corollary to this is having a steering group and Evidence technical working groups with consistent The strategic planning process encourages membership, active involvement and effective participation by large numbers of stakeholders, many leadership. Funding needs to be provided to ensure of whom hold views based not on evidence of the the consistent participation of local champions and epidemic but rather on their own understanding of the experts as well as the facilitation process for epidemic or on their institutional mandates. How stakeholder consultations. does one deal with this situation without alienating stakeholders? Some suggestions: ƒ Assembling Evidence on the Epidemic Drivers. This is often challenging, even in countries with • Start the stakeholder consultations with an good data, unless all relevant documents are well examination of the evidence of the epidemic known and readily available. Still, putting together a provided in user-friendly formats picture of the epidemic -- including addressing • Give prominent roles to stakeholders who focus sensitive issues of high risk groups in a way that can on evidence be discussed objectively with stakeholders – is critical to overcome vested interests or entrenched • Consider bringing in epidemiological experts who (but perhaps outdated) views and ultimately produce are good communicators and facilitators an evidence-informed and prioritized response. One • Search out small-scale studies or operational approach is to use visuals showing transmission research that might have been conducted by routes and groups whose behavior puts them at 7 NGOs, academics and others risk. • Propose a peer review or another form of quality enhancement early in the drafting of the strategy 3. Moving from Strategic to Operational as another opportunity to focus on evidence Planning • Provide token support to stakeholders who can advance the overall response but who do not Since 1995 the amount of money available for HIV/AIDS work with high risk or most affected groups programs has increased from about $250 million to more than $10 billion in 2008. This has been a tremendous • In the medium term, provide more resources for success for the international community, enabling reinforcing the evidence base countries to scale up prevention, care and treatment, and mitigation programs. The over-riding challenge today is to spend this money effectively and efficiently, to ƒ Integrating Operational Planning into Strategic Planning. The key decision is how to move from achieve demonstrated results. This makes the role of the general level of program identification operational plans – which allow countries and appropriate for a strategy to the very specific stakeholder organizations to implement the response – activities needed in an operational plan. Identifying critical. The challenge is for strategic planning to move specific program activities may well involve a more directly into operational planning to ensure timely detailed process of prioritization within the implementation. The objective is to have a time-bound framework of available/feasible human and financial operational plan as part of the overall strategic planning resources, including a gap identification exercise. In process. The lead consultants had a number of the situation where an operational plan is being observations on how to integrate strategic and prepared on the basis of an old national strategy, operational planning: revisiting and updating the national strategy – including identification of key results – is important. ƒ Time Frame. The realities of budgeting and In any case, the format of the operational plan disbursing funds suggest that a two-year rolling should reflect the results and programmatic areas operational plan is more useful than a one-year plan. identified in the strategic plan. ƒ Content. Operational plans should include: 7 The more we learn about epidemic drivers, the fewer → Agreed results to be achieved, with appropriate countries are judged to have “generalized” epidemics. indicators and arrangements for monitoring program Still, many strategies program activities as if their effectiveness and efficiency. This should include epidemics were generalized, when often they are both program indicators and other indicators that actually concentrated in specific groups with risky relate to improved management of financial and behaviors. Such countries are more likely than those human resources. Objectives should be grounded in with generalized epidemics to be able to make a reality and not be expressions of advocacy. ‘strategic shift’ based on analysis of the evidence. 4 → A description of activities: what is to be done, diversity as well as for aggregating hundreds of where, when, by whom, and at what cost. individual costing exercises into one operational framework at the national level. Other important information on plan implementation: ƒ Capacity for Operational Planning. It will be a → Most HIV/AIDS operational plans will include a major challenge for countries, especially those with considerable scaling up of institutional activities that hundreds of implementing partners, to develop cannot, in reality, be achieved without a special operational plans. Agreeing on formats and costing effort. A SUFI (Scaling Up For Impact) assessment details is essential. The same investment in including the investment needed by implementing instruments and capacity that countries, supported organizations in order to scale up, can be helpful. by UNAIDS and bilateral partners, made for → A narrative on operational experience, especially strategies should be done for operational planning. areas of challenge that can be addressed by The costing exercise, in particular, requires an external actors, including capacity building and important initial investment of time and money but technical support once a country and implementing partners do it once, successive years will become easier if the → Policies, procedures and practices, including from costing instrument remains the same. donors, that impede operational efficiency – the “implementation barriers” - including elements of the fiduciary framework – monitoring and evaluation, financial management and disbursement, and The Major Challenges for Strategic Planning procurement Consultants → The essential requirements (and expected Lead consultants are often asked by countries to play results) of the main funders, in particular a both an advisory and operational role in the process country’s ministry of finance, the Global Fund, and of developing an HIV/AIDS strategy. In addition, the PEPFAR task requires dealing with multiple clients who often → Plans for capacity building, technical support, have very different interests and responsibilities. and M&E From their experiences, lead consultants list a number of other challenges: Prioritizing Activities in Operational Plans • Mobilizing stakeholders (especially people living At the start of most operational planning exercises, with HIV) to participate effectively in the process there may be hundreds of potential activities and then keeping them on track competing for resources. The challenge is to decide • Determining the reliability and relevance of on a process to prioritize activities in order to ahieve available data the results identified in the strategic plan. A number of methods have been tried: • Obtaining consensus on prioritized programs on the basis of the reality of the epidemic rather • “Informed judgment” – the team developing the than the interests of some stakeholders – i.e., operational plan uses its judgment on an “urgent “keeping the strategic plan strategic” and priority agenda” after consulting with a wide range of stakeholders. • Agreeing on key results and achievable targets • Explicit criteria, with rating and weighting. Criteria • Integrating the plans of sectors with national are developed such as: (i) capacity to implement; priorities (ii) immediate benefits; and (iii) long-term • Deciding on the appropriate level of costing benefits, with different weights assigned to reflect strategic plans relative importance. • Balancing the need for consultation with • Explicit criteria (impact and feasibility) with yes or completing the strategy no decisions. Priority activities must satisfy two • Differentiating between major and minor criteria: (i) quick impact on the epidemic; and (ii) stakeholders, especially in the donor community capacity to implement exists. • Assessing the key factors in scaling up programs • Balancing ambitious objectives with implementation capacity and available resources ƒ Costing. Costing at different levels – community, district and national – for each significant • Focusing on spending available resources implementation organization can be done by using effectively rather than on fundraising actual costs and through budgeting instruments, such as the Activity Based Costing (ABC) approach developed by ASAP, that allow for organizational 5 4. Essential Skills for a Lead Consultant ƒ In collaboration with the requesting country, the UCC and the UNAIDS Regional Support Team, The general terms of reference for a lead consultant are provide all key documents and arrange critical early to: (i) advise national authorities on the process of meetings prior to the consultant’s arrival in country strategic and operational planning; (ii) facilitate the planning process as requested; and (iii) manage/ ƒ Set up a strategic planning help desk for immediate implement aspects of developing the strategy in “on demand” assistance accordance with recognized standards and practices. In small countries with low-level epidemics, the lead ƒ Provide comments and advice on draft documents consultant may be asked to do much of the work within 72 hours herself/himself. In larger countries with more serious epidemics, the lead consultant may play an important ƒ Provide more quality assurance to lead consultants role in managing other consultants and integrating inputs at the beginning of consultant assignments by: into the final product. It is also understood that the → organizing a briefing teleconference before the process and expected products in countries with more assignment serious epidemics will be more complex. Recognizing these differences among country situations, some of the → providing tools and instruments, examples of good generic skills identified in the meeting are: strategies and action plans, and lessons learned from other assignments Essential skills (in order of importance): → discussing the assignment regularly when the consultant is in the field • Process management with a focus on results • Team management → clarifying the respective roles of ASAP, the requesting government partners, and UNAIDS so • Strategic thinking that ASAP’s collaborative approach is fully • HIV/AIDS expertise understood • Ability to listen ƒ Hold an annual workshop of high level consultants to • Communication/facilitation exchange lessons learned, to improve support to • Experience in strategic planning in HIV/AIDS countries and other sectors • Ability to work with multiple interest groups ƒ Give even more priority to improving coordination on strategic and action planning to reduce duplication • Ability to write clearly and succinctly within the UN system, especially with co-sponsors, UNAIDS regional support teams, UNAIDS country Desirable skills (not in order of importance); coordinators and Technical Support Facilities • Pragmatism • Flexibility • Experience in the region • Respect for different cultures References, further information • Budgeting skills • A sense of humor ƒ Information on the AIDS Strategy and Action Plan (ASAP) program: www.worldbank.org/asap ƒ HIV/AIDS Strategy Self-Assessment Tool and Guidelines; Available on-line at 5. How ASAP Can Enhance its Support to Lead www.worldbank.org/asap > Tools for Strategic Consultants and Strategic Planning Generally Planning The meeting participants and ASAP Secretariat ƒ Key Steps in Preparing a National Strategic Plan discussed how to better support the work on the ground. Available on-line at www.worldbank.org/asap > It was suggested that the ASAP Secretariat undertakes Roadmap to implement as many of the following suggestions as ƒ Preparing National HIV/AIDS Strategies and Action possible: Plans – Lessons of Experience. Available on-line at ƒ Establish a network of high-level strategic planning www.worldbank.org/asap > Publications. consultants to share information, raise questions and offer answers 6 www.worldbank.org/asap Prerequisites for a Productive Strategic Planning Process The ASAP lead consultants offered a number of suggestions for the ASAP Secretariat, ASAP partners, and national AIDS authorities, to enable countries to get the most benefit from the consultants’ support: Country Actions • Ensure that main stakeholders inside and outside of government are informed and support undertaking the process (especially the UNAIDS country coordinator and UN partners) • Agree with local stakeholders the manner in which the process will be led and managed (e.g., establishment of a steering committee and technical working groups) • Identify the individual who will have overall responsibility for managing the process, and who will be the person to whom the consultants will report in the country • Draft TOR for consultants and others involved in the process, with clear lines of responsibility and ‘deliverables’ • Insist that important criteria are met when appointing national consultants, for example: availability (being free of other tasks), capacity for intensive work, commitment to the HIV response, etc. • Draft a ‘road map’ or timeline for the process (this can be modified as time goes on, but is important to help keep all partners focused). Take into account potential schedule conflicts (e.g., international conferences, donor proposal deadlines, elections, annual leave of key local stakeholders, national holidays) • Secure local funding for workshops and other local expenses • Once consultants are identified, help them to quickly understand the situation in which they will be working by: o Assembling and sharing all available evidence at the earliest possible date (before the arrival of any outside consultants), in collaboration with the NAC and UNAIDS Country Coordinator o Providing a ‘map’ of the main stakeholders o Discussing by phone with all partners (in particular government and UNAIDS) how the visit will be organized, and in particular arranging initial meetings before the consultant’s arrival o Mobilizing stakeholders to ensure they will be available once the consultants and working groups begin their work ASAP Actions • Organize an initial teleconference with the country partners (including Government, UNAIDS and others) and ASAP-supported consultants to clarify the task, expectations and the timing of the work • Organize a ‘pre-visit’ by the consultant to the country if this is agreed to be useful • Provide access to ASAP tools and general technical backstopping and guidance throughout the process UN/Bilateral Actions • Briefings from UN system stakeholders • Commit to participate in consultations • Explicit role for UN stakeholders as champions and as rapporteurs • Coordinate strategy work with other external and internal tasks (like GFATM proposal submission.) September 29, 2008 7 Addendum Since the July meeting, ASAP has received useful comments from participants highlighting issues on which further discussion would be helpful. Some of the comments relate to the fact that the participants’ country experience with ASAP has been largely in concentrated and low-level epidemic situations. 8 • The identification of drivers of the epidemic is likely to be more helpful in shaping an appropriate response in countries with concentrated epidemics and a history of a relatively unfocused response than in generalized epidemic situations. Examples of countries in the first category that have recently demonstrated success in making a ‘strategic shift’ include Madagascar, Mauritius and Zanzibar. However, thus far there has been less success in hyper-epidemic or generalized epidemic situations to translate evidence on the drivers into sound strategic priorities. • More attention needs to be given to the challenges of prioritizing and tailoring a response to the epidemic based upon the evidence in each country, and guidance in this area needs to be strengthened. In particular it was suggested that guidance on prevention planning is crucial, and that a number of UNAIDS tools and approaches should be used as a helpful starting point. • Although the principles on the use of evidence, prioritization, identification of results, costing and the need for participation are applicable across country situations, the processes and products are likely to be different in different situations. It was suggested that guidance should be explicit in acknowledging this and applying it in different country contexts. • The nuts and bolts (the ‘what and how’) of results-based planning merit greater discussion and rationalization. A rapid review of language used by planners in the Eastern and Southern Africa (ESA), undertaken by the UNAIDS Regional Support Team for ESA, found that an enormous number of terms and concepts are currently in use, without sufficient definition or common understanding. In addition, concepts are sometimes used improperly (e.g., using the term ‘outcome’ for something that is in fact an activity or an objective). Further, the notion of a ‘logic chain’, while common, is not applied systematically. Lastly, M&E frameworks are too often developed long after the strategy has been produced, and not well aligned to the strategy. • Questions were raised regarding the comprehensiveness of operational plans. It is clear that in complex response situations (in which the number of partners and levels of decentralized response are many) the challenge of bringing this all together into a single document is enormous. Further, the issue of how to link the national operational plan with the plans of main partners (e.g., PEPFAR, GF, MAP, international NGOs) requires further work. 8 Africa: Angola, Benin, Burundi, CAR, Cote d’Ivoire, DRC, Eritrea, Ethiopia, The Gambia, the Great Lakes Initiative on AIDS (GLIA), Lesotho, Liberia, Madagascar, Mauritius, Niger, Rwanda, Swaziland, Tanzania, Togo, Uganda, Zambia, Zanzibar Asia: Afghanistan, Bhutan, Sri Lanka, Myanmar, Nepal, Mongolia, Caribbean: Antigua, Barbados, Dominica, Grenada, Guyana, Jamaica, St Kitts and Nevis Europe: Albania, Kosovo, Latvia, Moldova Latin America: Chile, Costa Rica, Dominican Republic, El Salvador, Ecuador, Guatemala, Honduras, Panama, Peru, Uruguay MENA: Lebanon, Morocco, Somalia, South Sudan NGOs: Council of Anglican Provinces of Africa, Swaziland Consortium of AIDS NGOs, Mongolia AIDS Foundation (linking partner of the International AIDS Alliance) 8