DISCUSSION WITH A. DIALLO, SCMS/JSI:

1) Roll-out of pilot programmes:

There is vertical roll-out and horizontal roll-out of (pilot) programmes. The vertical roll-out is in terms of increasing the number of staff, and the horizontal roll-out is in terms of increasing the number of functions that a particular site has. All sites have to have vertical roll-outs, no matter if your focus is increasing the number of staff or the number of functions, as this naturally leads to a need for more staff to run the additional activities. However, a lot has been written  about this.

In terms of either kind of roll-outs, there is a need of a readiness assessment (RA) to assess the would-be responsible party’s ability and capacity to expand, and a solid and functional plan needs to be worked out as to who’s going to support what in which way. It is very important who’s responsible for the RA, as an erratic RA might lead to approval of a roll-out that the would-be responsible party doesn’t have the capacity to run, and in this case the roll-out sites are bound to fail or at least function at a suboptimal level of effectiveness.

What is of more contemporary interest is what is called MORTGAGE: This means the moral, ethical, financial obligation or indebtedness that a donor will be left (or the need to place it in somebody else’s care) with when ending a programme, no matter whether it is because of a wish to phase out or because the patients in question cease to be part of the target group (e.g. patients in paediatric programmes that are defined to address children of 13 y.o.a. and below. What does the organisation responsible for the programme do when the patients turn 14?).

The donor has to answer questions such as:

-What happens with patients when they cease to be part of the target group?

- How will the money and possibly the technical knowledge to sustain or maintain the programme be found (exit strategies)?

- What happens if the organisation phases out? Is there an exit strategy, is there a local organisation capable to continuing the running of the programme? Can enough locals be trained to fill these positions in the proposed time span before exit?

2) How to combine scientifically derived evidence with local wisdom and locally defined common sense is really social science…

7) Stages/ages of an epidemic is a subject that a lot has been written about. There are still pockets of questions to be researched, but it’s an old subject.

9) Adherence Science: Directly Observed Treatment (DOT) is not a new subject.

14) Women’s Empowerment. One could try to find out which outcomes have been achieved by microfinance programmes. But give it an innovative approach, such as looking at what it has meant in terms of assertiveness, knowledge of HIV/AIDS, growing self esteem, gender relations and such for a group of women who were completely without any means or powers before the microfinance programme. I think this has been done in SA? Check articles. Maybe one could return and see what it means so and so many years later?

SUGGESTION: Is it possible to come up with more appropriate or accurate frameworks or methods or models of dealing with problems? That is:

The CLASSICAL PROBLEM SOLVING PARADIGM is as follows:

  1. Problem Statement   
  2. Magnitude of Problem
  3. Identification of Stakeholders
  4. Identification of Key Factors
  5. Identification of Interventions
  6. List of Priorities
  7. Implementation of Solution
  8. Monitoring and Evaluation
  9. Communication of findings

 Is it possible to develop a problem solving paradigm or evaluation-as-we-go paradigm more suited to the volatile nature of HIV epidemics?

SUGGESTION: Is it possible to come up with more accurate models or assessment tools to better understand and evaluate the effectiveness of a specific HIV/AIDS effort? Better indicators, better evaluation methods, more precise conclusions.

6) Condom use at population level: This is an area that we really have too little knowledge of. There are the classical indicators such as evidence, proportion, percentage, but also considerations as to how to assess the correctness of a general population’s condom use, as in what happens in terms of protection if you start the intercourse unprotected and then put on the condom later, but before the man ejaculates? How long can you wait and still have a significant protection? What happens if the condom breaks and is replaced? How does the population use the condoms when they use them? Which beliefs and understandings does the population have of what correct use of condoms entail?

20) Applicability of Business Sector (BS) or Private Sector (PS) methods both in terms of applying Operations Research methods or methods from Complexity Theory, but also in terms of the management or structural level is definitely very interesting and very needed. However, it is very possible that I would need methods from Business Theory (Business Schools) that are not at my disposal, or that I would have to involve somebody else. It is not impossible though to contact CBS and ask if there’s anybody around interested in that kind of research.

21) Decentralisation of hospital services means a decentralisation at management level too, and of responsibility and therefore of expertise. Initially, the centralised health departments were responsible for the centralised hospitals and for the RA’s when new sites were to be established, but with the decentralisation to district level, the responsibility for performing the RA’s is now at district level, too. It is not known which capacity to perform RA’s is available at district level. It would be very good to know what this means for the quality of the RA and in consequence for the delivery of health services.

22) Returning to Mortgages: We are in a confusing situation with a multitude of donors of a multitude of programmes. Somebody has to pay for the continuation of these programmes, and many developing countries rely extensively or completely on foreign aid for this. What happens when they decide to phase out or cut down on their financial support? “What happens” is meant both in terms of sustainability, ownership, handing over the programmes, phasing out over a period of time, exit strategies.

-Which measures has been put in place in which countries?

-Which (if any) national governments have the capacity to take over?

- Do national governments have funds to keep running projects?

-  Which (if any) national governments have HIV/AIDS line items in their budgets?

- Which policies (if any) do national governments have in terms of sustaining programmes?

- How do national governments prioritise which programmes to continue with their limited funds?

- Is it possible to predict anything about what all this is going to mean for the delivery security of health services?

JSI’s Model for Commodity Security:

What long term plans does the incoming responsible party have in terms of implementation of:

  1. Forecast of demand of commodities
  2. Finance to pay for commodities needed
  3. Procurement of commodities
  4. Distribution of commodities

This model is used as part of their RA’s.

Additional questions could be: How effective is the running of other programmes by the new responsible party? After taking over one would need to ask about the effectiveness of their running of the programme. Are there any (new) results? Do they need to hire more expatriates to comply with the demand for skilled labour?

23) The question of ethics or a standard for ethics compliance in the conduction of studies. How do we ensure that it is ethically right to do what we do? (Ethics monitoring board).