Assessment Of The Consultations - Part II

Renewing Canada's Strategy : Introduction : Part 1 : Part 2

The consultation process had a clear objective: to shift the emphasis away from developing . Phase III. of a federally controlled strategy and toward a strategy that is owned by all governments and stakeholders and that encourages the involvement of a broad spectrum of players across the country. All of the consultation streams discussed earlier in this report fed into the development of the goals, priorities and budget allocations for the new strategy. Epidemiological trends and current scientific evidence, from the final evaluation of Phase II of the National AIDS Strategy, were also taken into account.

On December 1, 1997, World AIDS Day, the Minister announced the Canadian Strategy on HIV/AIDS, with funding of $42.2 million annually. The new pan-Canadian approach is designed to address the expanding face of HIV/AIDS epidemics, based on the results of the extensive consultation process. It includes more emphasis on programs for at-risk populations such as Aboriginal peoples, women, injection drug users and marginalized youth, including young men who have sex with men. Other features include open and public accountability as well as the establishment of mechanisms to enhance relationships with all new and existing partners in the fight against this disease.

Strategic elements identified during the consultation process and reflected in the strategy are the need to:

• provide education and prevention;
• support community action;
• ensure the availability of care, treatment and support;
• support HIV/AIDS research;
• build and enhance HIV/AIDS surveillance;
• provide an enhanced focus on Aboriginal communities; and
• address the legal, ethical and human rights issues related to HIV/AIDS.

To ensure an ongoing relationship with stakeholders, the Minister of Health also agreed to appoint a Ministerial Council on HIV/AIDS. The Council members are a representative group which includes scientists, health care workers, people infected and affected by HIV/AIDS, and major stakeholders. The provincial Co-Chair of the Federal/Provincial/Territorial Advisory Committee, who holds an ex-officio position on the Ministerial Council, provides a strong linkage to provincial and territorial HIV/AIDS work. The Council will advise the Minister in a number of crucial areas, including:

• keepng the Canadian Strategy on HIV/AIDS flexible and responsive to the changing nature of the epidemic;
• promoting alliances and joint efforts;
• reaching and responding to the needs of groups at risk; and
• assisting in the development of long-term plans for future action on HIV/AIDS.

The Minister will meet with the Council at least once a year to review its recommendations, and will report annually on the progress of the Canadian Strategy on HIV/AIDS.

Opinions On Successes, Barriers And Lessons Learned

The remainder of this report attempts to synthesize the viewpoints expressed during interviews with nine individuals who were either directly involved in creating, managing and delivering the consultation process or were persons living with HIV/AIDS (participants) of the consultations. All respondents were asked the same basic questions, which focused around the following themes.

I think it was a qualified success. It was certainly the best we could do in the circumstances, and it was an improvement on previous processes. On the positive side, the collaboration was very successful. I felt our positions were respected, our advice was sought and acted on.
Russell Armstrong, Executive Director, Canadian AIDS Society and Co-Chair of the National HIV/AIDS
Stakeholder Group

Was the renewal process a success?
To varying degrees and with some qualifications, all respondents agreed that the national consultations were a success. Although some respondents were enthusiastic in their statements of endorsement (notably those who reflected a government viewpoint), others acknowledged success more grudgingly. Success was measured primarily in the fact that stakeholders were involved in the policy development process in a meaningful and unprecedented way.

One of the things that I thought was a success was that people who needed to be involved felt they were . both internally and externally. Groups outside government made it clear that they had to be involved; they were instrumental in making it happen. Government at the highest levels listened.
Elaine Scott,Special Advisor on the renewal of the Canadian Strategy on HIV/AIDS

What were some of the key positive outcomes?
The consultation process resulted in the following key positive outcomes:

• The announcement of a new pan-Canadian HIV/AIDS strategy. The new strategy will be based on the strategic elements identified by stakeholders and others.
• A new level of mutual respect and understanding among stakeholder groups and between these groups and Health Canada. The intense, collaborative process resulted in organizations that had previously been at loggerheads gaining a new awareness and appreciation of each others. viewpoints, how they work, and the different pressures and demands placed on community and government workers. This new level of respect and understanding bodes well for the future work of the pan-Canadian approach to HIV/AIDS programming.
• The realization that . the scene has changed. for HIV/AIDS programming and organizations over the past five years. Given the ever-changing nature of the epidemics, established HIV/AIDS groups will be required to . share their power. with new organizations that may have a strategic role to play in reaching at-risk population groups.
• A recognition of the need to more directly involve mainstream health and social service organizations in the Canadian response to HIV/AIDS.

Given the way the process unfolded and everyone worked together, it might create a better climate for implementation of the new strategy.
Darryl Sturtevant, Manager of the research component of the consultation process.

What factors influenced success? Most respondents said the success of the consultation process was a direct result of:

• advocacy on the part of the HIV/AIDS community. Many respondents cited the community groups. belief in their right to be involved in designing the strategy as well as the capacity of key organizations to continue to advocate as members of the National HIV/AIDS Stakeholder Group.

Without the (political) commitment at a higher level, we would not have had this success.
Russell Armstrong,
Executive Director, Canadian AIDS Society, and CO-Chair of the National HIV/AIDS Stakeholder Group

• political commitment at the highest levels of government. The personal commitment of the Minister of Health and his political staff, strengthened by stakeholder advocacy, ensured that the consultation process was broad, inclusive and stakeholder- driven. This commitment filtered down through Health Canada and was sup- ported, in both words and action, by the department. s senior management team.

Our ability to compromise contributed to the success. We knew we had to make compromises . and we made them.
Russell Armstrong, Executive Director, Canadian AIDS Society , and CO-Chair of the National HIV/AIDS Stakeholder Group

• a shift in thinking and approach within the Health Canada bureaucracy. Most stake-holders acknowledged a . real effort. within government to work cooperatively, listen to others and make changes where necessary. Those within government also noted that . the system allowed us to do what we needed to do.. With the support of senior management, bureaucratic barriers were removed. Emerging issues were addressed quickly and effectively with the aid of a direct line of communication established between the Minister. s Office and the Special Advisor

There was cultural change within Health Canada. There were people who could influence the process internally who understood the issues and the problems.. Greg Robinson, CO-Chair, AIDS ACTION NOW!

• the ability of stakeholders to put aside their differences and work toward a common goal. Although the 11 member organizations of the National HIV/AIDS Stakeholder Group all work in the HIV/AIDS area, they do not necessarily share similar viewpoints or agendas. The organizations. ability to avoid dissension, while managing to forcefully represent the interests of their constituents, was crucial in keeping the process focused and on-time.

• the openness and transparency of the process. Open lines of communication between the Stakeholders Group, the Special Advisor, the Consultation Secretariat and the Centre for Health Promotion promoted a sense of inclusiveness. Hiring a respected, broadly skilled person from the HIV/AIDS community to work within the Consultation Secretariat was also applauded as a demonstration of an open process and as a way to build bridges between Health Canada and the community.

None of the stakeholders and no one from government or the consultants tried to take control of the process. Everyone understood their role and worked together.. Kevin Barlow, National Coordinator, Canadian Aboriginal AIDS Network

• strong, cooperative and shared leadership. Respondents praised the cooperative relationship among the leaders, particularly between the Special Advisor and the community leaders from the Stakeholders Group. Both community leaders and government employees put the national interests of the process ahead of their respective organizational/ departmental interests, demonstrating objective leadership and diplomacy skills.
• flexibility on the part of all players. The clear framework of roles and responsibilities was able to evolve as the process unfolded. When confusion arose, the different players consulted each other to determine who could best fulfill the role in question and get the job done quickly and effectively. As well, the process was sufficiently flexible to allow Health Canada and the Centre for Health Promotion to shift resources in response to new (and often unforeseen) requests and directions from the Stakeholder Group. The negotiation of a separate Aboriginal process was an example of this flexibility.
• the limited timeframe allowed for the consultations. Despite considerable criticism of the limited timeframe (see next section), some respondents saw it as a factor contributing to success. The firm deadline established by the Minister required participants to focus their energy on getting the job done. Several respondents believed that an extended process might have lost direction and intensity.

Were there any barriers to success? Respondents said that the success of the consultation process was marked by a number of barriers:

the severe time constraints. Many argued that a two-month window of opportunity to organize and conduct consultations, analyze data and develop meaningful recommendations was unrealistic, jeopardized the quality and integrity of the process, and placed undue stress on the individuals involved. Some stakeholders stated forcefully that the time constraints were an impediment to widespread and meaningful participation by community-level organizations and by at-risk and hard-to-reach population groups. However, the general consensus was that the best work possible had been done within the allotted time.

Elements of the process should be retained. But there were far too many constraints.
Russell Armstrong, Executive Director, Canadian AIDS Society , and CO-Chair of the National HIV/AIDS Stakeholder Group .

• a perceived lack of inclusiveness. Some community organizations in provinces or regions that did not host one of the city-based meetings felt disconnected from the process. There was also some concern that, in an effort to be all-encompassing, the consultations lost sight of the fact that gay men continue to be the primary group affected by HIV/AIDS. Respondents identified homophobia as an ongoing contributing factor to the exclusion of gay men in addressing HIV/AIDS issues. They also expressed concern that HIV/AIDS issues in rural and remote areas were not given sufficient consideration.
• gaps in the flow of information. Some groups at the regional level expressed frustration at not receiving sufficient and timely information on the consultations. Representatives from the Stakeholder Group remarked that they were often unaware of what was happening in the parallel consultation processes, or how these processes would contribute to the development of the strategy. Many participants, including individuals within the HIV/AIDS Consultation Secretariat, were not aware that Health Canada had made a strategic decision to not encumber the External Stakeholder Process with issues related to parallel processes.
• the lack of preliminary planning. In the words of one individual, . The piece that was missing was an overall strategy for conducting the consultations..

Individual respondents noted other barriers:

• the assumption that participants in the consultations would have knowledge of the work completed under Phase I and Phase II;
• the assumption that the communities consulted would have knowledge about the complex issues being addressed in the Consultation Workbook;
• the lack of planning and marketing to address a distressing level of apathy in the HIV/AIDS community, attributed in part to the effectiveness of new treatment therapies;
• problems in producing and distributing French-language materials in a timely fashion;
• the failure of certain Aboriginal groups to participate in the Aboriginal consultation process, which may have reflected discomfort in dealing with HIV/AIDS issues; and
• the inability of Health Canada to overcome internal . turfism. and research politics to achieve an integrated, coordinated research component for the new strategy. What were the key decision-making points? Respondents identified the following as the consultation. s key decision-making points that made the consultation process a success: holding a national, stakeholder-driven consultation process, within an extremely tight timeframe, that had sufficient funding and other resources; involving the National HIV/AIDS Stakeholder Group in leading the External Stakeholder Consultation, which resulted in a more comprehensive and authentic process;

I think we did a damned good job as Health Canada employees to get the job done in the time frame. We went out to stakeholders and asked them how they wanted to see the next phase. This was more comprehensive than in the past.
Robert Shearer, Acting Director, HIV/AIDS Division, Health Canada and CO-Chair of the National HIV/AIDS Stakeholder Group

• appointing a co-chair from the Stakeholder Group, which empowered one individual to negotiate and act as a facilitator on the Group. s behalf;
• establishing a Steering Committee of the National HIV/AIDS Stakeholder Group, thereby ensuring that administrative and process decisions could be made quickly by a representative group of stakeholders who had the support of their colleagues from the wider community;
• consulting the provinces and territories (which was not done during development of Phases I and II of the National AIDS Strategy);
• appointing a Special Advisor who came from outside the HIV/AIDS field and didn't have a vested interest in the outcome, and giving her carte blanche to manage all the processes;

Hearing from the grassroots level has told us we need to listen to other voices and opinions. Not that much good has come from the AIDS epidemic, but it has taught us the values of other ways of doing business.. Dr. Bryce Larke, CO-Chair of the Federal/ Provincial/Territorial Advisory Committee on HIV/AIDS

• establishing the HIV/AIDS Consultation Secretariat as a group within Health Canada dedicated to making the consultations a success;
• contracting with the Centre for Health Promotion . a third party organization with the required expertise and knowledge . to manage the External Stakeholder Consultation;
• having a separate consultation process for Aboriginal peoples, which enabled Aboriginal peoples to have a strong influence on the final recommendations to the Minister;
• holding meetings in large cities as a means of encouraging a multisectoral dialogue while also seeking the involvement of hard-to-reach and often unheard population groups;

I believe that allowing access for Aboriginal people to provide input to this process was a key success. Definitely the receptivity of the bureaucracy and the government to make this not just a massive paper exercise was important.. Kevin Barlow, National Coordinator, Canadian Aboriginal AIDS Network

• conducting an assertive outreach program to reach unheard voices; and
• remaining firm on the deadline for an announcement on December 1, 1997, which kept the process on track and required organizations to put aside their individual agendas in the interests of a broad national strategy.

In addition to the above points, respondents frequently referred to the personal decisions made by those involved in managing the process, as well as those being consulted, to remain involved in the face of extraordinary work demands and pressures. This was true for both government and non-government participants. The consultation process was tremendously stressful, and often strained long-standing working relationships within organizations and between organizations. Virtually all participants made personal and professional sacrifices to ensure the success of the overall process. Many organizations were forced to set aside their own agendas and priorities for the sake of collaboration with the wider stakeholder community. Participants made difficult compromises to maintain an environment of collaboration and progress toward a common goal.

Was the management process inclusive and effective? The management process and framework for the consultations generally received high marks from all respondents, who:

• said the breakdown of roles and responsibilities was balanced and effective;
• endorsed the range of stakeholder representation on the National HIV/ AIDS Stakeholder Group; and
• believed that everyone involved in the management process had a valid role.

Respondents viewed the involvement of the Centre for Health Promotion . an objective third party which managed the consultations . as a unique and effective approach. However, they stressed that finding consultants with the right mix of knowledge, experience and expertise as facilitators was critical to the success of this approach.

Were the consultations themselves inclusive?

Most respondents believed that the consultations were as inclusive as possible within the limited consultation period. At the same time, several respondents stressed that a lengthier consultation would have resulted in even broader participation, particularly from community groups and hard-to-reach populations.

The process was comprehensive and inclusive . The stakeholders owned the process. The provinces and territories defined how they wanted to be consulted, and we did what they asked.
Isabel Romero, Coordinator, HIV/AIDS Consultation Secretariat

The respondents identified a number of critical population groups that may not have been adequately heard during the consultations, including:

• inmates in a correctional environment (federal and provincial/territorial institutions);
• injection drug users;

The main success in my mind was that the process actually reflected public participation in policy development.
Darryl Sturtevant, Manager of the research component of the consultation process

• young gay men;
• HIV-positive individuals and families; and
• HIV/AIDS researchers.

Inclusiveness was one of the compromises. We did well within the time frame and funding constraints, but I don. t think we achieved what we wanted to.
Russell Armstrong, Executive Director, Canadian AIDS Society , and CO-Chair of the National HIV/AIDS Stakeholder Group

At the same time, it was recognized that the large-city meetings and smaller focus groups allowed the participation of populations that had not previously been considered part of the HIV/AIDS community, such as housing groups, minority women. s groups, and prisoners. In this sense, the consultation process reached beyond the traditional boundaries of the HIV/AIDS world.

Is this consultation process transferable? All respondents agreed that the consultation process used to support renewal of a national AIDS strategy could be transferred to other health issues and other areas of public policy development. However, several respondents qualified their comments by stipulating that improvements and modifications would have to be made to the process, primarily to address the need for more preliminary planning and more time for the consultations themselves. Other specific transferable aspects of the process included:

• the concept of a stakeholder group and steering committee to lead external consultations;
• the appointment of a special advisor and establishment of a secretariat whose collective role is . to make things happen;.
• a consultation workbook (though in a shorter and simplified form);
• the multisectoral city meetings and focus group sessions; and
• the hiring of experienced and knowledgeable consultants to manage the external process.

Some respondents noted that this model is transferable if the systems and infrastructure are there in the form of a broad and diverse range of national stakeholder groups, a committed unit within government, informed provincial/territorial players, and effective leaders. Perhaps most importantly, support must exist for the process at the highest political levels, as well as among senior department managers.

Lessons Learned

When asked about lessons learned through the consultation process, the most common response from both government and non-government participants alike was that they had:

• experienced positive growth in their personal knowledge and awareness of HIV/AIDS issues even though most had been involved in the field for many years;
• increased their respect and appreciation for other individuals working in the field;
• improved their understanding of the viewpoints and agendas of other organizations.

As for the process itself, the following were identified as lessons learned:

• Stakeholders need to be consistent and persistent in their advocacy roles.
• Stakeholders must be made partners with government in a fundamental way to ensure the success of such a national consultation process.
• Preliminary planning is needed to develop the process, define roles and responsibilities, and establish an initial level of trust and partnership.

I think it was a success just having the consultation. The fact that we could bring people together to discuss issues that were important to us in the AIDS community was very empowering for the community and very beneficial to the government.
Wilson Hodder, Chair of The AIDS Coalition of Nova Scotia

• If parallel consultation processes are to take place exclusive of each other, management decisions must be made . and communicated to all participants . at the outset on the parameters for the different processes, the relationship between processes, and how the processes will come together at the end of the consultation period.
• Significant effort is often required to convince people of the importance and benefits of participating in the process.
• Public servants involved in the process need the confidence of senior management in order to make decisions on the run. This requires a release from bureaucratic attachments.
• Central agencies (e.g., Treasury Board) need to be kept informed of what is happening (and why) to facilitate both governmental and financial approvals.
• A dedicated group within the department is needed to coordinate the internal input and feed information to the branches. This is key to limiting interbranch issues that can cause problems.
• To minimize barriers to success (such as time constraints, lack of inclusiveness, and gaps in the flow of information), all of the organizations involved need to have the capacity (systems and readiness) to participate in such a consultation process.
• To ensure that time and energy are not taken up with frequent negotiations on the capacity of the consultation process, all organizations and players need to have reached prior agreement on budgetary allocations and limits.

We made decisions on what was practical based on our understanding of what needed to be done. We were very pragmatic as to what could be done in the time frame.
Robert Shearer, Acting Director, HIV/AIDS Division, Health Canada and CO-Chair of the National HIV/AIDS Stakeholder Group

Recommendations For Future Processes

With regard to changes and/or additions to the process, respondents made the following recommendations:

• More preliminary planning is needed. Stakeholder input should be sought from the outset . even before the consultations are announced . to ensure that the recipients of the consultations can better influence how the process takes place.
• Planning must begin earlier in the cycle. The final year of a multi-year strategy should be a time of assessment and planning for the future.
• Senior management must support the process from the outset. Problems internal to the department (e.g., interbranch issues) must be addressed at the highest possible level.
• Depending on the issue, non-mainstream organizations need to be involved in the consultations to garner their support in addressing the issue, to educate them, and to get their views.
• While a firm and realistic deadline must be established, national consultations of this nature require more time than was allotted. Proper consultations, and the development of reasoned and responsible input, is time-consuming but worth the effort.
• All participants should be kept informed of what is happening in parallel processes (if applicable). Streams of consultation should not be isolated from each other.
• An overall strategy is needed to explain how the various processes will come together at the end of the consultation to inform ministerial decision-making.
• A clearer understanding of how data will be analyzed, as well as sufficient time for the data analysis process, is essential.
• Plans should be made for an ongoing, interactive dialogue in the post-consultation period.

There was a lot of coalition building and enthusiasm around issues. There was some really hard work on a strategy everyone could live with and that would take us forward.
Darryl Sturtevant, Manager of the research component of the consultation processes.

Conclusion

Ultimately, the success of the Canadian Strategy on HIV/AIDS renewal process . a major breakthrough in public policy development . will be measured in the progress made over the next five years in: preventing the spread of HIV; finding and providing effective vaccines, drugs and therapies; finding a cure; ensuring treatment, care and support for persons living with HIV/AIDS, their caregivers, families and friends; minimizing the adverse impact of HIV/AIDS on individuals and communities; and minimizing the social and economic factors that increase individual and collective risk for HIV.

Being part of the process has empowered us.
Wilson Hodder, Chair of The AIDS Coalition of Nova Scotia

APPENDIX

The Stakeholder Group comprised the following organizations:

• Canadian Aboriginal AIDS Network
• Canadian AIDS Society
• Canadian Association for HIV Research
• Canadian Foundation for AIDS Research
• Canadian Hemophilia Society
• Canadian HIV Trials Network
• Canadian Public Health Association
• Canadian Treatment Advocates Council
• Community AIDS Treatment Information Exchange
• Federal/Provincial/Territorial Advisory Committee on AIDS
• Interagency Coalition on AIDS and Development

Renewing Canada's Strategy : Introduction : Part 1 : Part 2