Prioritizing the HIV response: a multi-criteria decision analysis

Results of the research in this dissertation provide the first indication that
evidence use in HIV planning and policymaking has been increasing over the
years. However, stagnation and decline in donor funding for monitoring and
evaluation systems, along with integration of the HIV response into the health
sector, jeopardize the gains made in generation and use of evidence for
planning. This dissertation makes a policy recommendation for incentives to
sustain the use of evidence in HIV planning and policymaking. At the global
level, these incentives could be created by including measures of evidencebased
planning in international benchmarks of governance (Chapter 3). The
instrument introduced in this dissertation to measure evidence quality and use
in planning could provide an input to grant allocation decisions by donors and
development banks, as an indicator of effective decision-making and strength of monitoring and evaluation performance. Application of the instrument before
and after evidence generating activities could help identify barriers and
enablers to evidence use at the national level.
The criteria emerging from the systematic review of literature in Chapter 2
illustrate the success of the HIV response in framing the public health and
emergency response approach to the epidemic, within the context of social
justice and development. As integration of the HIV response with the health
sector is pursued, the policies and practices of integration must remain
accountable to the key criteria of the HIV response. Integration of HIV into the
health sector also implies some elements of the HIV monitoring system may
become weaker in the process, while the overall sustainability of the HIV and
health response gains strength from integration. Policymakers should consider
this trade-off between effectiveness and sustainability in integration of the HIV
response into the preventive health sector.
While greater involvement of the community of people living with or at risk of
HIV in planning is recommended (Chapter 4 and 5), this dissertation recognizes
that the problems and solutions of public health must be jointly owned by the
government and the stakeholders. Findings of this dissertation demonstrate
that the degree of agreement between civil society and government in
prioritized criteria around HIV program choices creates an opportunity for
policy advocacy for greater involvement of civil society in decision-making
(Chapter 5). The dichotomy of views of stakeholders on criteria for
prioritization in scientific and technical decisions, underlines the importance of
investments in technical literacy of community based organizations to
strengthen their role in decision-making or grass-roots movements for
community driven policies in research, science and technology (Chapter 4).
Discrete choice experiments with program decisions in Chapter 5 demonstrate
that theoretical models, and not empirical evidence, drive HIV program
managers’ priorities. These findings imply that policies should be put in place
to ensure accountability for programs that are based on the models.