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Creating a National AIDS Strategy With Impact

By Chris Collins

January 2009

The campaign to create a National AIDS Strategy (NAS) for the United States has been a remarkable success so far. In the last year and a half, the concept has won support from hundreds of organizations and over a thousand individuals. They all endorsed a Call To Action demanding a more coordinated, accountable, and results-oriented response to AIDS in our country. On World AIDS Day, the President-Elect recommitted to developing and beginning to implement a Strategy consistent with these core principles within his first year in office.

The NAS has become the centerpiece of a growing effort to bring attention to the AIDS epidemic at home; but what the Strategy actually accomplishes depends on what comes next from the new Administration and, even more, from us -- the communities most directly affected by HIV/AIDS. We've been down this road before, creating well-intentioned plans full of good ideas that do little more than gather dust. If this NAS is going to have real impact, it will have to be different from the planning efforts of the past.

How?

First, this Strategy needs to focus the federal government and all of us squarely on the bottom line -- improving outcomes in such areas as reducing HIV incidence, increasing access to care and treatment, and reducing racial disparities. Everyone engaged in the response to AIDS is already working for better outcomes, but in many ways the systems we've established don't do enough to measure results effectively, encourage us to assess what is working, or ask how to have broader impact. Even if an NAS does nothing more than challenge us to continually examine our programming and policy in terms of how it will lead to better outcomes then it will have done something good.

For example, on the issue of treatment access, an NAS would likely promote increased resources for programs like ADAP, but it would also drive us to better understand the bigger issue -- why 50% of people living with HIV/AIDS aren't in care. Using that knowledge, an NAS would then lay out steps to deliver a coordinated set of interventions, including ADAP, to increase the percentage of people with access to care. On prevention, an NAS would not only call for more good behavioral interventions but also for bringing the best interventions to a scale where they can have true population impact on reducing incidence. This would also include looking beyond behavioral interventions to structural and network-level approaches to prevention; for example, by improving housing as one strategy to reduce vulnerability to HIV and other health problems.

Second, an effective NAS has to begin with the acknowledgement that simply doing more of the same will not get us the results we need. The domestic AIDS response has been flat funded, or received decreased funding, for years. Resources need to increase, and evidence-based polices must be implemented. But more money and a few improved policies are insufficient to the challenge. Domestic HIV/AIDS programming is largely uncoordinated, unaccountable and limping along without a comprehensive strategic plan driven by clearly defined goals. It's time to step back, take a systematic look at the federal response, and identify concrete ways to make it more effective.

Third, the NAS should be an operational tool for the federal government rather than merely a list of recommendations. It has to help all those engaged in the effort set priorities and identify opportunities to have maximum impact. A Strategy that devolves into a laundry list of all the things we could do with limitless resources won't accomplish anything. Instead, the NAS should serve as a roadmap for the federal government, working with state and local, private and public organizations, to achieve a more effective effort. The office leading implementation of the NAS should eventually have some level of oversight (and perhaps even budget) authority to successfully promote strategic coordination and use of resources across agencies.

Fourth, the Strategy has to bring far more accountability and transparency to the system. The NAS should set a few ambitious but achievable targets for reducing incidence, increasing access to care, and reducing racial disparities. And it should require an annual report on progress towards these goals. The NAS needs to set timelines and assign responsibility for follow up on all of its major action items. When we fail to meet our targets, we must be ready to ask difficult questions about what can be improved. To make such an accountability system work, we'll need to build better information systems to track incidence and understand barriers to care utilization. We'll need to have readier access to information about how the government spends AIDS funding too. The website for the Global Fund to Fight AIDS, Malaria and TB (www.theglobalfund.org) provides a wealth of data on funding sources, allocations, and governance. Why can't we have the same level of access to information about publicly funded programming in the domestic AIDS response?

Finally, an effective NAS will require decisive Presidential leadership along with buy-in from a range of stakeholders. Only the President can enforce a clear directive that the federal response must be truly coordinated, accountable and results-oriented. Only when advocates are engaged in a credible NAS process will we be able to use it to hold the government accountable.

This means that the people appointed by the President to the NAS Planning Panel will need to include leaders from all government agencies engaged in the response to AIDS along with stakeholders from provider and advocacy groups, academia, and people living with and at risk for HIV/AIDS. President Obama should ask panel members to take their institutional hats off and work collaboratively to construct a better prevention and care effort (this is true for those outside of government, but also for government employees on the panel who should be asked for their "professional judgment" rather than their agency's judgment). If the individuals on the NAS panel only represent the narrow interests of their agencies, it will be the death of an effective Strategy.

NAS panel members will have a challenging job ahead of them. They'll need to diagnose what is not working optimally in the domestic AIDS response and chart a course for improvement. They'll need to be willing to say when an agency's programming needs reorganization, current approaches are outdated or not based in evidence, or contracts and funding streams don't have sufficient evaluation and incentive structures. In other words, the NAS panel will need to be willing to think beyond half measures and quick fixes.

The panel's work might start by identifying the questions that need to be asked. These include:

If we do this right, it's going to be challenging because an effective NAS will require doing business differently. The NAS process should focus all of us on improving outcomes rather than simply expanding programs -- on finding evidence-based solutions rather than arguing about ideology. A successful NAS process will force us to ask tough questions about funding and priorities, it will insist that all responders work collaboratively toward common goals, and it will ensure that we hold ourselves accountable for concrete results. The ultimate goal is not creating an official plan on paper but establishing a sustained process of learning what works, refining efforts, and steadily improving outcomes.

A recent review of US government strategic planning efforts over the last few years concluded that some of these efforts were successful, some less so. The process of developing a strategic plan in some cases appears to have been the most valuable aspect of the effort: "it creates a dialogue among stakeholders around developing a common direction ..." A National AIDS Strategy that engenders such a dialogue, then backs it up with greater transparency and accountability, could represent a major step forward in the domestic response to AIDS. As such, the Strategy is wholly consistent to the new Administration's investment in health reform, and is a critically important opportunity to demonstrate commitment around fresh approaches to management of our public health resources.

Chris Collins is a consultant in health policy and communications. He is the author of Improving Outcomes: Blueprint for a National AIDS Plan for the United States, published by the Open Society Institute in 2007. Chris helps coordinate the work of the Coalition for a National AIDS Strategy.

Reference

  1. Kamensky, JM, Making Big Plans: Bush Expands use of "National Strategies," IBM Center for The Business of Government, www.businessofgovernment.org/about/leadership/102006.asp, accessed December 22, 2008

Get Involved In The NAS Process!

Sign the Call to Action for an NAS and find out more about the effort at www.nationalaidsstrategy.org. Learn about and consider joining one of the NAS Working Groups (Communications, Political, Allied Stakeholders, and Community Mobilization) by clicking "Get Involved" on the website. Write info@nationalaidsstrategy.org to receive regular updates and get information about monthly conference calls.




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