Toward a Multi-sectoral Approach to HIV/AIDS Response in the Caribbean Kevin Fenton, M.D., Ph.D., F.F.P.H. Director National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Centers for Disease Control and Prevention Pan Caribbean Partnership Against HIV and AIDS October 28, 2009

Overview Multi-sectoral collaboration –What do we mean? What are we trying to achieve? –Examples of best and promising practice Strategies for effective multi-sectoral collaboration From theory to action: –Accelerating multi-sectoral collaboration Strengthening multi-sectoral collaborations Summary

Multi-sectoral collaboration What do we mean? What are we trying to achieve?

Collaboration Collaboration is a mutually beneficial and well- defined relationship entered into by two or more programs, organizations or organizational units to achieve common goals The collaborative relationship usually includes a commitment to mutual relationships and goals, a jointly developed structure and shared responsibility, mutual authority and accountability for success, and sharing of resources and rewards

Multi-sectoral Collaboration Multi-sectoral collaboration means involving all sectors of society - government, business, communities and people living with HIV at all levels - regional, national and local, in addressing the causes and impacts of the epidemic and required response.

Commitment at highest levels to multi-sectoral collaboration The Declaration of Commitment by governments at the United Nations General Assembly Special Session on HIV/AIDS in June 2001 commits national leaders: – “…to ensure the development and implementation of multi-sectoral national strategies and financing plans for combating HIV/AIDS.” Following this, Commonwealth Heads of Government made another strong commitment to HIV/AIDS in the Coolum Declaration issued from their 2002 Meeting, stating: –” … We urge both the public and private sector, and international organisations, to join with us in a renewed effort to tackle the challenge HIV/AIDS presents to our countries and their people, and to humanity itself.”

Why is a Multi-sectoral approach needed for our HIV/AIDS response? HIV/AIDS epidemic is cross-sectoral and multi- sectoral in nature No one organization has ability to mount a multifaceted approach No single group has needed financial resources, capacity, reach, expertise, experience, understanding, and credibility to respond to the epidemic

Benefits of multi-sectoral collaborations Broaden the mission of member organizations Help develop more comprehensive strategies Help develop wider public support for issues Minimize duplication and increase efficiency of services Increase participation from, and respond to the needs of, diverse sectors Help exploit new resources in a changing environment Increase program accountability and planning and evaluation capacity

Benefits of multi-sectoral collaborations Multi-sector collaboration is an important means of achieving strategic, cross-sectoral change. However, it also presents significant managerial challenges. Identifies and leverages critical brainpower and resources for response Promotes effective partnerships and coordination Useful for design, resourcing, implementation, monitoring, evaluation and sustainability of national response to HIV/AIDS epidemic

Example of Multi-sectoral Success: Thailand Key to Thailand’s success in reducing new HIV infections from 140,000 a year to 20,000 in a decade has been broad-based multi-sectoral action Objective: –Lower HIV transmission via commercial sex and make condom use socially acceptable Key agencies that collaborated –Thai Ministry of Public Health –Ministry of Interior –Office of the Prime Minister Source: Guidelines for Implementing a Multi-Sectoral Approach to HIV/AIDS in Commonwealth Countries, 2003

Example of Multi-sectoral Success: Jamaica Jamaica Multi-sectoral response includes –Government –Civil society –People living with HIV/AIDs –Vulnerable groups –National HIV/STI Programme –National AIDS Committee –Education, health, and labor sectors –Finance and Planning sector –Ministry of Tourism –Ministry of National Security –Business sector, NGOs, –Faith-based organizations, social agencies, media –Regional and international partners, such as PAHO

Example of Multi-sectoral Success: Trinidad and Tobago Expanding the multisectoral response: –Eight HIV/AIDS Coordinators were recruited in the Ministries of National Security; Education; Sports and Youth Affairs; Community Development, Culture and Gender Affairs; Tourism; Local Government; Health; Labour, Cooperatives and Small and micro-Enterprise Development. NGOs are important partners of the NACC and have facilitated access to most at risk and hard to reach population groups, including CSW,MSM,PLWHA, Orphans and Vulnerable Children

Example of Multi-sectoral Success: The Bahamas Lasting and productive partnerships have been forged between the health system and the business community, Civil Society and Religious Organisations. –The Samaritan Ministries, organised by the Bahamas Catholic Diocese trains volunteers from all faiths, and equips them for outreach services in treatment, care and support. Imperial Life Financial, a leading business organisation is a sponsor of the AIDS Foundation of Bahamas which organises a successful annual fundraiser – The Red Ribbon Ball

Example of Multi-sectoral Success: Haiti Impact of Haiti’s commitment to a sustainable national multisectoral response –Successful in scaling up the number of persons receiving ARV treatment from 2000 patients in 2001 to 25,000 patients in –Strengthened partnership between the private and public sector –Strengthened country coordinating mechanism (CCM) in the implementation of the National Strategic Plan –Resulted in resource mobilization to support the national response –All stakeholders shared common goal Source: Ministry of Health of Haiti/MESI Haiti

Example of Multi-sectoral Success: Haiti Key Actors –Ministries Education Youth and Sport Women Social Affairs Justice and Public Security –Civil Society Participation NGOs Faith-based organization Women’s organizations Religious sector, including Voodoo People Living with HIV/AIDS –with 2 persons at highest level represented on the National CCM Representation by vulnerable groups –Women –Sex Workers –Youth (with representation at the CCM) –Police Force Other key variables –Integration of HIV/AIDS in each health department –Participation of international partners

Barbados Long track-record in working multisectorally to achieve a coordinated partner response. HIV/AIDS elevated to a national priority by the Office of the Prime Minister Key partners in the Barbados HIV/AIDS Response National HIV/AIDS Commission Ministry of Health Ministry of Social Transformation Ministry of Education Barbados Defence Force Other line ministries Civil Society (including NGOs and Faith-based Organizations)

Multi-sectoral collaboration: Emerging lessons and Best Practices

Where are we now? The Caribbean Experience An analysis of the Caribbean NSP’s and UNGASS Reports Best Practices suggests that most national programs have included some version of a multi- sectoral approach to planning and implementing their HIV/AIDS response The national organizations that most often lead these efforts are the MOH or the NAC’s The number and type of different organizations involved also varies widely across the region

Where are we now? The Caribbean Experience Some countries engage only a small number of organizations in a very limited and unclear way while others involve a large multi-sectoral cross section of their country in a very central way and have very clear roles and responsibilities. Most countries engagement with other organizations appears to have begun as a requirement of the donor award process so only a few countries have articulated a compelling rational for this approach.

Where are we now? The Caribbean Experience These relationships all seem to be held together by a shared vision or goal and a commitment that each party contributes a unique and indispensible resource to achieving the goal. This contribution is not always financial. The most successful multi-sectoral relationships seem to thrive on shared credit for the accomplishment and energy is spent assuring that all parties visibly benefit in some way.

Best practices for effective multi- sectoral collaboration Be dynamic, flexible, strategic and coordinated Take account of the size of the problem, identifying the vulnerable, high-risk groups; Provide effective leadership which is critical for policy development; strategic planning; Involve national leaders, all government ministries and departments, with each taking responsibility for pre-determined aspects of the overall response Include sectors outside government - business, civil society organisations, communities, PLWHAs and others affected by the epidemic

Best practices for effective multi- sectoral collaboration Define roles and responsibilities, based on the comparative advantage of each player/stakeholder. –It is not always necessary or appropriate for every sector to be involved in every area of activity Should occur at all levels in the country and be linked to action at the international level. Ensure good communication and clear accountability among all partners Each sector should develop sectoral plans of action that accord with national strategic plans.

From theory to action: Accelerating multi-sectoral collaboration

Initiating a Multi-sectoral Approach 1.Preparation –Identify the gaps in your HIV response and search for organizations that might have similar goals 2.Negotiation –Meet with the leadership of these organizations and make balanced plan 3.Action –Follow plan, monitor progress and solve problems.

Potential Partners Public sector –Ministries of Health, Planning, Finance, Labor, Women’s Affairs, Education, Agriculture, Your, Uniformed Services, Housing, Justice and Human Rights, Community Development, Social Services Private sector –Organized private sector coalitions for HIV/AIDS –Workplace HIV/AIDS programs –Business clubs and organizations NGO/Civil Society Sector –People living with HIV/AIDS –Political, religious and traditional leaders, Unions –Professional associations –NGOs and networking associations, Faith-based organizations Bilateral and Multi-lateral Organizations/ Partners

1. Create a more solid foundation for multi-sectoral collaboration Multisectoral responses in place but quality and implementation vary. Variable success across sectors in mainstreaming HIV/AIDS response –Health ministries most active with their constituencies –Other ministries may have policies but no action plans –UNAIDS survey in 63 countries found only 13% had made progress in implementing sectoral plans

2. Motivate genuine private sector involvement Involvement by the businesses community in many countries appears to be fairly modest Involvement relatively low given the concern about HIV impacts expressed by business managers. Reasons vary: –Few incentives; Funding often goes to govts. and NGOs –Not all companies have the skills to do their own programs –High transaction costs with dealing with governments or NACs Success will require radical thinking on how to improve incentives for partnership

3. Strengthen governance for multi- sectoral collaboration The Three Ones calls for one national AIDS coordinating authority with a broad multisectoral mandate The World Bank (2001) recommends that NACs stick to facilitation rather than control, and avoid competing with or duplicating the key role of the health sector in responding to the epidemic Over time, there must be a commitment to evaluate and learn from the successes of multisectoral NACS

Summary A multi-sectoral approach involves all sectors of society—governments, business, communities, people living with HIV and others in addressing the causes and impact of the HIV epidemic and response An analysis of the Caribbean’s national strategic plans and the UNGASS reports best practices suggests that most national programs have included some version of a multi-sectoral approach to planning and implementing their HIV response

Summary Most national programs have included some version of a multi-sectoral approach to planning and implementing their HIV/AIDS response Leadership and engagement at the highest level (MoH or NAC) is key Multi-sectoral approaches that work best and lasted longest have been very strategic and have had a history of top level leadership support and personal commitment

Toward a Multi-sectoral Approach to HIV/AIDS Response in the Caribbean Kevin Fenton, M.D., Ph.D., F.F.P.H. Director National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Centers for Disease Control and Prevention Pan Caribbean Partnership Against HIV and AIDS October 28, 2009