Knowing your HIV/AIDS epidemic and tailoring an effective response: how did India do it?

Tremendous global efforts have been made to collect data on the HIV/AIDS epidemic. Yet, significant challenges remain for generating and analysing evidence to allocate resources efficiently and implement an effective AIDS response. India offers important lessons and a model for intelligent and integrated use of data on HIV/AIDS for an evidence-based response. Over the past 15 years, the number of data sources has expanded and the geographical unit of data generation, analysis and use for planning has shifted from the national to the state, district and now subdistrict level. The authors describe and critically analyse the evolution of data sets in India and how they have been utilised to better understand the epidemic, advance policy, and plan and implement an increasingly effective, well-targeted and decentralised national response to HIV and AIDS. The authors argue that India is an example of how 'know your epidemic, know your response' message can effectively be implemented at scale and presents important lessons to help other countries design their evidence generation systems.

Achieving scale rapidly in public health: Applying business management principles to scale up an HIV prevention program in India.

Numerous public-health interventions have demonstrated effectiveness in pilots or on a small scale, but have proven challenging to scale up for population-level impact. Avahan, the Bill & Melinda Gates Foundation's HIV prevention program in 6 states of India, confronted the challenge of rapidly scaling up services to reach 300,000 people most at risk of HIV. This meant working in diverse and complex environments with marginalized and largely hidden populations. This case report presents a number of business-management principles that the foundation drew upon to successfully scale up this public-health program: 1) strategy development through market segmentation and complexity analysis, 2) a dynamic and evolving strategy, 3) developing an implementation and management structure to match the strategy, 4) standardization with flexibility, 5) generating demand to balance supply, 6) a customer-centric approach, and 7) data-driven management. Lessons learned from this experience include the crucial role of data in guiding decision-making and strategic and programmatic change; the need for a central body to set strategy; a willingness to change course when experience and data demonstrate the need; and the importance of partnering with program beneficiaries at all stages of program design, operation, evaluation and sustainability. We believe these lessons are applicable to other development programs that seek to foster widespread and sustainable program benefits at scale.

How the Avahan HIV prevention program transitioned from the Gates Foundation to the government of India.

Developing countries face diminishing development aid and time-limited donor commitments that challenge the long-term sustainability of donor-funded programs to improve the health of local populations. Increasing country ownership of the programs is one solution. Transitioning managerial and financial responsibility for donor-funded programs to governments and local stakeholders represents a highly advanced form of country ownership, but there are few successful examples among large-scale programs. We present a transition framework and describe how it was used to transfer the Bill & Melinda Gates Foundation's HIV/AIDS prevention program, the Avahan program, to the Government of India. Essential features recommended for the transition of donor-funded programs to governments include early planning with the government, aligning donor program components with government structures and funding models prior to transition, building government capacity through active technical and management support, budgeting for adequate support during and after the transition, and dividing the transition into phases to allow time for adjustments and corrections. The transition of programs to governments is an important sustainability strategy for efforts to scale up HIV prevention programs to reach the populations most at risk.

Learning about scale, measurement and community mobilisation: reflections on the implementation of the Avahan HIV/AIDS initiative in India.

Debates have raged in development for decades about the appropriateness of participatory approaches and the degree to which they can be managed, scaled and measured. The Avahan programme confronted these issues over the last 7 years and concludes that it is advantageous to manage scaled community mobilisation processes so that participation evolves and programming on the ground is shaped by what is learnt through implementation. The donor (Bill & Melinda Gates Foundation) and its partners determined a standard set of programme activities that were implemented programme-wide but evolved with input from communities on the ground. Difficulties faced in monitoring and measurement in Avahan may be characteristic of similar efforts to measure community mobilisation in a scaled programme, and ultimately these challenges informed methods that were useful. The approach the programme undertook for learning and changing, the activities it built into the HIV prevention programme, and its logic model and measurement tools, may be relevant in other public health settings seeking to integrate community mobilisation.