Identify a public health service, either from the literature or from personal professional experience,

where there is an opportunity for service improvement through change. Carefully evaluate this

opportunity and provide a critical analysis of how the change 3 process might be initiated and

managed through to a successful conclusion, with reference to Kotter’s 8-Step Change Model

(Kotter, 2012). IMPORTANT – Kotter's 8-Step Change Model (i.e., the eight-stage change process)

(Kotter, 2012) is covered in the Week 3 Topic Overview of this module and can also be accessed in

detail through accessing the following ebook/online book via the ‘University of Suffolk Library page’:

Kotter, J. P. (2012) Leading Change. Boston, Massachusetts: Harvard Business Review Press.

EVALUATION OF THE CHANGE PROCESS

WHICH RESULTED FROM A PARTNERSHIP

BETWEEN A PUBLIC HEALTH DIVISION AND

AN INTERNATIONAL BODY TO EXTEND HIV

CARE CONTINUUM SERVICES TO THE KEY

POPULATION IN A REGION

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INTRODUCTION

The public health division of a region’s health service has identified that its inability to reach

the key population with Human Immunodeficiency Virus (HIV) care continuum is their

major setback to achieving the 90-90-90 target. The 90-90-90 target was set in 2014 by the

United Nations Program on HIV/AIDS (UNAIDS)/ World Health Organization (WHO). The

goal is that “90% of all people living with HIV should know their status, 90% of those

diagnosed should receive Antiretroviral Therapy (ART), and 90% of those should have

durable viral suppression” (Gisslén et al., 2017). 

To resolve this challenge, the public health division has partnered with an international body

which is experienced in the successful implementation of the HIV care continuum. The HIV

care continuum comprises steps that an HIV-infected person must go through to acquire and

maintain viral suppression. The steps are diagnosis, linking diagnosed persons to care,

administration of ART and other medical care, and viral suppression (Gisslén et al., 2017). 

The HIV care continuum in itself is not a new model for the division. The approach is already

being applied to the general population of the region. What is new will be the strategy to

extend the service to the key population. The public health division has been more passive

than active in delivering HIV care services. This means that they often rely on the natural

evolution of the population to opt for testing. 

Mass screening and offering testing at health facilities has been the norm of this public health

division about reaching the population with comprehensive HIV prevention and care. This

approach has not been effective at reaching the key population. The key population comprises

female sex workers, men who have sex with men, and transgender persons. Socio-cultural

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barriers, stigmatization and fear are some major reasons why the key population do not

usually engage in mass screenings or opt-out testing offered at health facilities.

This partnership between the public health division and the international body is an

opportunity for the division to change how it provides comprehensive HIV care to the key

population. The strategy for achieving the overall vision will involve actively identifying the

key population in the region, offering them comprehensive HIV care, and adopting contact

tracing and index testing to reach more at-risk persons. The partnership will focus on

enhancing leadership skills, strengthening the capacity of local stakeholders, addressing the

job structures, and improving data capturing and utilization. The international body promises

to fund the entire change process.

This intended change will affect the entire division, health care facilities, and other

stakeholders. Leadership will have to take on more roles in coordination, monitoring and

supervision. The human resource unit will have to recruit more staff. The staff would have to

take on new duties, and the financial needs ought to be met by the finance unit, health care

facilities and other stakeholders should be ready to assist with the implementation. 

DISCUSSION

The partnership is an opportunity to improve the HIV services rendered to the key

population. Persons belonging to the key population are highly at risk of HIV infection. The

eventual objective of the change process in the public health division, which is viral

suppression will help reduce HIV transmission. The reduced transmission will help the

country reach low endemicity. The vision of the partnership is to help achieve the 90-90-90

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goal. Achieving this goal will contribute to the global vision of securing viral suppression for

about 73% of people living with HIV (Gisslén et al.,  2017).

The current inability of the public health division to reach the key population with

comprehensive HIV care is health inequity. Eliminating the barriers responsible for health

inequity is the concern of every public health body. Hence, successful implementation of the

intended change through the partnership with the international body will indirectly resolve

the long-standing inequity against the key population.

Public health institutions do not work in isolation. Their work needs constant collaboration

with various stakeholders. Some stakeholders for the public health division include the

regional health service, public and private health care facilities, key population groups, the

media, civil society organizations and the entire population. The intended improvement in the

HIV care continuum allows strengthening collaboration between the division and its

stakeholders. Discussion forums, forming a coalition team, and carrying out outreach

activities together during the change process will promote unity. This sustained solidarity

makes it easy for the division to always get support from stakeholders whenever the need be.

Socio-cultural barriers and stigmatization are the major resistance to this service

improvement through change. This is because, throughout the country where this region is,

cultural values frown on prostitution, homosexuality, and transgender. Unfortunately, these

are the sexual practices of the key population. Thus, unconscious discrimination and

stigmatization of persons who indulge in these sexual practices are almost natural

(Nyblade et al., 2020). Leadership must invest a lot into training staff on how to act

professionally regardless of knowledge of one’s sexual orientation. Failure to train staff in

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this regard could cause the key population to shun the HIV care continuum services being

extended to them.

Managing the change process using Kotter’s 8-step change models (Kotter, 2012)

The leadership of the change need to organize a dialogue meeting for all the stakeholders.

Stakeholders of the public health division comprise the staff of the division, leaders from all

public and private health facilities in the region, the civil society organizations (CSOs), the

health service department of the region, leadership of the key population, the media, and the

general population. At the meeting, both the relevance, threats and urgency of the intended

change should be discussed. The meeting attendees should be made to understand that the

change will make HIV care more accessible to the key population, reduce health inequity,

decrease the rate of transmission resulting from prostitution, homosexuality and the likes,

contribute to low endemicity in the country, and achieve the global 90-90-90 goal. It should

be communicated that the region failed to meet the 2020 deadline for the 90-90-90 goal. Thus

the need to take advantage of the extension to 2030. An honest and convincing interaction

with the stakeholders will win their needed support for the change process.

At the stakeholder's meeting, guiding coalition for the project should be created. The team

should comprise representatives from each stakeholder body and staff from all levels and

units within the public health division. This will make all stakeholders and staff of the

division identify with the objective. They should be tasked with facilitating activities of the

intended change at their facilities, monitoring the overall change process and acting as a

sounding board to any unfruitful deviation. The formed guiding coalition will keep the

change process on track.

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The leadership of the public health division and the partnered international agency should pen

down the vision and strategy for the change. Although the overall vision and strategy for the

change are known, they should be broken down into stepwise goals and tasks. The goals and

tasks should be clear, concise, achievable, measurable and time-bound. By this, the staff of

the division and other stakeholders will know exactly what is expected of them. Leadership

need to discuss the vision, strategy, goals and tasks with the staff of the public health

division. Suggestions from staff should also be welcomed and incorporated accordingly.

Involving the staff in the development of the project’s vision and strategy is a catalyst for

acceptance. 

The leaders of the change process must finalize the vision and strategies and communicate

them back to the division staff and other stakeholders. This should be done unit to unit and

visiting each stakeholder body. Individuals should be allowed to express their opinions and

anxieties about the final vision. This will help leaders to understand the impact of the change

process on each stakeholder. Also, employing the principle of individual consideration and

emotional intelligence to the opinions of stakeholders can help bring out the best performance

from all. Other forms of communication include pasting the vision on various notices and

sending emails to act as reminders.

An empowered board-based action is needed to ensure that all obstacles that could undermine

the success of the change process are eliminated. Creating an environment that welcomes the

opinions of all help eliminate resistance to the change. Both leadership and staff should be

given the appropriate training that will equip them with the needed knowledge and skills for

the tasks ahead. The job structure at the division needs to be redefined and bonuses awarded

for any extra duties that the change demands. Bonuses should also be awarded to managers

whose supervisory roles help a unit achieve set milestones. Organizing periodic conferences
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for all stakeholders is a sure way to maintain the popularity of the change. Ensuring the

confidentiality of the HIV status of the key population and giving incentives to individuals

who agree to be rolled into the HIV care continuum will help minimize resistance from them.

The stepwise goals and objectives set for the project should be categorized into milestones

with timelines. Achievement of each milestone serves as a short-term win for the division.

Whenever a staff or unit completes tasks assigned to them, leadership should reward them.

Rewards could come in the form of bonuses, words of praise, gifts and the likes.

Acknowledging short-term wins motivates change agents to be more committed and creates

the impression that the overall change objective is achievable. Care should be taken so that

short-term wins are not overly celebrated since it can create a false sense that the desired

change has been attained.

Consolidated gains are proof that the change is paying off, they counter resistance and

stimulate more change in the division. To provide supporting evidence to the change process,

proper documentation, data capturing and analysis should accompany the change process.

Documentation should include how many key populations have been reached, how many

have been enrolled on the HIV care continuum, what stages are they on the care continuum,

and so on. A convincing improvement in the change indicators together with short-term wins

should be well communicated. This measure sustains the sense of urgency throughout the

change process.

The change process is not complete until it is anchored into the division’s culture. For this

course, jobs should be restructured to include duties that extend public health activities to key

and deprived populations. At the end of the change process, the guiding coalition should be

tasked to continue encouraging the new practices in the daily duties at the division. The

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coalition team should also deal with any future resistance that may challenge the new

approach. New staff should be endowed with the knowledge and demands of the new

approach during their orientation.

IMPLICATIONS

A strength of the change process for the partnership is that the HIV care continuum which the

division seeks to extend to the key population is not a new phenomenon. It has successfully

been integrated into the general population. Since the activities of the HIV care continuum

are already part of the daily activities at the division as well as among other stakeholders, the

change leaders can focus more on how to reach the key population. Training should be geared

toward identifying the key population groups in the region, educating and convincing them

into the care, retaining them, and adopting index texting to reach their partners.

A weakness of the change process is the guiding coalition and how it was formed. The

guiding coalition had too many members with representatives from all stakeholder facilities

and units at the division. While this will make stakeholders feel belong, it has the potential to

delay decision-making with its long debates. Also, stakeholders handle different aspects of a

comprehensive HIV service to the population making it difficult for one to appreciate the

concerns of another. The regional health service for instance provides funding and procures

resources, health care facilities render the services of the continuum to the population, CSOs

and the public health division organize health promotion activities, the division identifies the

key population, links infected persons to the nearest HIV care continuum, the public health

division monitors and supervises all activities of the various stakeholders. 

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We recommend that a more empowered guiding coalition should be formed for future

projects. It should include members from the division and the topmost leadership of the

project (Kotter, 2007). Through this, the coalition will be more focused on the change

activities. The presence of topmost leadership gives the coalition power to act. Periodic

conferences should be organized for all stakeholders as a measure to win and retain their

commitment to the course.

Relying on funding from the international body could be regarded as both strength and

weakness in the change process. It is a strength because the division has assured funding to

sponsor its change initiative. On the other hand, how much funding is allocated to a change

process is proof of the organization's commitment. Besides, donors often restrict how their

funds should be used (Gisslén et al., 2017). The regional health service department of which

public health is one of its divisions receives fixed annual fund allocation from the central

government. These funds are intended to support known activities initiated by the

government. Therefore, the division’s limited resources cannot support the anchoring of the

new process into the division’s culture when funds from the international body cease. To

have enough funds to support future initiatives, the division should continually solicit and

save funds from cooperative and international bodies.

CONCLUSION

A public health division has decided to change how it reaches key populations with HIV care

continuum services. This change if successful will reduce HIV transmission in the region,

resolve the health inequity to the key population, contribute to achieving low endemicity in

the country as well as the global 90-90-90 goal.

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To carry out this change, the division has partnered with an international body experienced in

reaching key populations with essential services. The international body will also be funding

the change process. Some glaring resistance to the change process is the socio-cultural

barriers and stigmatization of the practices of these key populations. The change agents

should be trained not to use the sexual orientation of these key populations to discriminate

despite the culture of the country.

Kotter’s 8-step change model was used to manage the change process. Since the HIV care

approach is not new to the division, the division can focus on how to win and retain the key

population. Some weaknesses to the change process include sole funding by the international

body and an overpopulated guiding coalition. For improvements in the change process, a

more empowered guiding coalition consisting of topmost change leadership should be

formed. Also, the division could seek sponsorship from cooperative bodies as a means of

securing funds in their coffers. This will make the division self-sufficient in carrying out

future initiatives and anchoring change into its culture.

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REFERENCE

1. Gisslén, M. et al. (2017) ‘Sweden, the first country to achieve the Joint United

Nations Programme on HIV/AIDS (UNAIDS)/World Health Organization (WHO)

90‐90‐90 continuum of HIV care targets’, HIV medicine, 18(4), pp.305-307.

2. Kotter, J. P. (2012) Leading Change. Brighton, MA: Harvard Business Review Press. 

3. Kotter, J.P. (2007) ‘Leading change: Why transformation efforts fail’, Museum

Management and Marketing (pp. 20-29). Routledge.

4. Nyblade, L. et al. (2020) ‘Results from a difference‐in‐differences evaluation of

health facility HIV and key population stigma‐reduction interventions in

Ghana’, Journal of the International AIDS Society, 23(4), p.e25483.

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