Rather than a small set of monofocal outcome measures, scaled programmes require nuanced evaluations that approximate programmatic scale by collecting data with different levels of geographical scope, synthesize multiple data and methods to arrive at a composite picture, and can cope with continuous environmental and programme evolution.
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.
BACKGROUND
Abstract. More than 30 years after HIV was first identified as a disease, with disastrous consequences for many subpopulations in most countries and for entire populations in some African countries, it continues to occupy centre stage among the world's many global health challenges. Prevention still remains the primary long-term focus. New biomedical tools such as pre-exposure propyhlaxis (PrEP) and treatment hold great promise for select groups such as key populations (KPs) who are critical to transmission dynamics, and serodiscordant couples. Programs delivering these new tools will need to layer them over existing services, with potential modifications for increased and sustained engagement between health services and beneficiaries owing to the nature of the interventions. Avahan, an HIV prevention intervention for KPs in six states in India, achieved population-level impact with conventional prevention programming, which, however, required high program-beneficiary engagement. Avahan's implementation strategy included articulating clear service definitions and denominator-based targets; establishing routine data systems with regular, multilevel supervision that allowed for cross-learning across the program; and developing a cadre of frontline workers through KP peer outreach workers who addressed structural issues and provided viable and sustainable mechanisms for sustained interaction between health services and KPs. This basic prevention implementation infrastructure was used to expand clinical services over time. Many of the lessons from programs such as Avahan can be applied to KP programs that are expanding service scope, including PrEP and treatment.
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