The fight against HIV/AIDS must be owned by the host nations. The heart and soul of the President's Emergency Plan for AIDS Relief (PEPFAR/Emergency Plan) is to support national strategies to reach prevention, treatment, and care goals, including building local capacity for sustainable HIV/AIDS programs. Because building capacity goes hand-in-hand with expanding services, the previous sections addressing the Emergency Plan's prevention, treatment, and care activities also summarize efforts to ensure sustainability. This section addresses in more detail specific aspects of capacity building, including crosscutting support to strengthen networks and systems to ensure quality HIV/AIDS services for the future.
Across many of the focus countries, there are common barriers to expanding and sustaining prevention, treatment, and care activities. Among these barriers are a lack of human resources and capacity; limited insitutional capacity; and health care system weaknesses in such areas as health networks, physical infrastructure, and commodity distribution and control.
Building Human Resources and Capacity
Appropriate and adequate human capacity and resources provide the backbone of accessible, high-quality, sustainable care. The paucity of trained health professionals and other human resources in the focus countries to combat HIV/AIDS is a stark indicator of the challenges faced by the Emergency Plan. The Emergency Plan supports national strategies with innovative approaches to training and retention; broadened policies regarding who can administer HIV/AIDS services; and the use of volunteers and twinning relationships to rapidly build the army of local service providers required to combat this disease.
To rapidly expand training activity, in 2004 the Emergency Plan launched a formal program to establish a Twinning Center to support twinning and volunteer activities for implementing the Emergency Plan. The Center will help strengthen human and organizational capacity by using health care volunteers and twinning relationships between similar organizations to facilitate skills transfer and rapidly expand the pool of trained providers, managers, and allied health staff delivering quality HIV/AIDS services. Eligible participants may be public or nonprofit private entities, including schools of medicine, nursing, public health, management, and public administration; health sciences centers; and community- and faith-based organizations.
Policies that mandate that only health professionals can provide health services—when trained community health providers could provide components of care at the home and community level—worsen problems related to the lack of human resources, including people's access to services. Strengthening health provider networks by training individuals to provide services at the hospital, clinic, community, and home levels helps expand the reach of a limited pool of trained professionals such as doctors and nurses. For example, during the reporting period the Emergency Plan supported a program in South Africa to build on existing health care networks to train additional personnel for HIV/AIDS services. The Plan is supporting the development of nine regional training centers for HIV/AIDS prevention, care, and support, which will be paired with tertiary institutions to fast-track necessary training in the regions. In just one site, more than 80 doctors, 65 nurse clinicians, and 25 community health workers had received training as of mid-2004. An important aspect of such networks is to anchor the training in advanced centers to ensure quality. The Emergency Plan is focused on developing tools to assess the quality of the training and, therefore, the quality of the services provided.
In other countries such as Uganda and Haiti, the Emergency Plan is supporting training of home health aides to perform routine follow-up and patient counseling for adherence to drug regimens. In Tanzania, the Emergency Plan supports the training of 470 traditional birth attendants as community health care providers. After training, these aides go into communities to enroll pregnant women in services for prevention of mother-to child HIV transmission (PMTCT), including preventive antiretroviral treatment and ongoing counseling on infant feeding, early detection of complications, and referrals during the postnatal period. Capacity-building programs are increasingly forging relationships with associations and groups of people living with HIV/AIDS and training members to provide patient education, adherence counseling, and conduct patient follow-up. In addition to freeing clinical staff to serve more specialized needs, such strategies for involving people living with HIV/AIDS help combat HIV/AIDS-related stigma.
A special challenge is that while service providers participate in an off-site training program, they are not available to assist patients. The Emergency Plan thus supports programs for on-the-job HIV/AIDS training for health care workers to educate them about HIV/AIDS services without taking them out of care settings.
To reach prevention, treatment, and care goals, and to provide services equitably, networks must reach down to the community level, often in rural areas that are not appealing places to live for many health care professionals. In 2004, the Emergency Plan supported a pilot project in Namibia to provide incentives to physicians and other health professionals to locate to underserved rural areas. As a result of this program, a number of doctors, pharmacists, and nurses moved to these areas and began providing services to thousands of HIV-positive people. In 2005, the Emergency Plan will expand the Namibian program, and other countries, such as Mozambique, will employ similar strategies.
Access to Health Professionals and "Brain Drain"
Ethiopia has one doctor for every 34,000 people in the country and one nurse for every 4,900 people. In Mozambique, 500 physicians serve a country of 18 million people — one doctor for every 38,000 people, or a ratio of 2.6 doctors per 100,000 people. In contrast, the United States has 279 physicians per 100,000 people. "Upstream" causes of limited human capacity include shortfalls in preservice academic training, both in availability of professional education (Botswana, for example, has no medical school) and accessibility of HIV/AIDS curricula within professional schools. The Emergency Plan supports the development and implementation of curricula in preservice settings and preservice training for key health care professionals. HIV infection and stigma also contribute to limiting the number of clinical providers, which is why prevention and leadership to combat stigma remain essential pillars of the response to HIV/AIDS.
Few developing-country economies can support salary structures that encourage retention of medical professionals, particulary in the face of the lucrative salaries offered by wealthy nations. The resulting "brain drain" exacerbates the shortage of health care personnel. Brain drain can also occur within a country — as resources expand, the buying power of certain organizations can deplete human capacity in key institutions such as ministries of health. The Emergency Plan is supporting innovative programs to curtail brain drain. In Guyana, in consultation with the Ministry of Health, five hospitals were selected for upgrading as model PMTCT facilities. Staff at the Guyana HIV/AIDS Reduction and Prevention Project (GHARP), a joint project of the governments of Guyana and the United States, carefully planned the recruitment process for necessary staff. To avoid recruiting health care providers already employed with the Ministry of Health, GHARP staff hit on an innovative solution. Guyana's public service requires mandatory retirement for nurses at age 55. GHARP, in conjunction with the Ministry of Health, brought these highly trained and experienced nurses back to public service. Through advertisements that specifically encouraged retired nurses to apply, GHARP received 495 applications, about half of whom were retired nurses with previous PMTCT training. Some were recent social work graduates, a nontraditional choice for health care outreach but perfect for the counseling positions needed at the hospitals.
Building Institutional Capacity
The President's Emergency Plan has brought unprecedented focus to building the institutional capacity of local organizations — including host governments and community- and faith-based organizations — to plan, implement, and manage HIV/AIDS programs to ensure sustainability. The organizing structure, management, coordination, and leadership provided by capable host governments are essential to an effective, efficient HIV/AIDS response. Local community- and faith-based organizations remain an underutilized resource for expanding the reach of quality services. They are among the first responders to community needs, with a reach that enables them to deliver effective services for hard-to-reach or underserved populations, such as people living with HIV/AIDS and orphans. Community- and faith-based groups, trained in program management and HIV/AIDS best practices, often design the most culturally appropriate and responsive interventions and have the legitimacy and authority to implement successful programs that deal with normally sensitive subjects. The Emergency Plan has provided technical assistance and infusions of key resources to help host governments and local organizations develop and maintain high-quality services, with training in both HIV/AIDS service provision and improving managerial capacity.
The Emergency Plan prioritizes the development of new partnerships with local groups and organizations as a key strategy for increasing access and building sustainability. Review of the U.S. five-year strategy and the annual country operations plan in each country includes an evaluation of efforts to increase the number of indigenous organizations partnering with the Plan. This emphasis has led to impressive results.
Strengthening the institutional capacity of host governments and national systems is a fundamental strategy of the Emergency Plan. Historically, donors have often bypassed these institutions and implemented autonomous management structures, investing directly in sites and providing funding for ongoing expenses. This strategy, however, is inefficient and works only as long as donors are there. Even if financing continues beyond the donor's management engagement, interventions fail because existing health facilities have not acquired management capacity.
The Emergency Plan has sought to avoid this pitfall. As a result, more than 20 percent of Emergency Plan partners in fiscal year 2004 were host government entities, including ministries of health and associated institutions, research organizations, and AIDS coordinating authorities.
The Emergency Plan has supported the development of national policy and training in planning, budgeting, performance improvement, monitoring of activities and finances, and other management skills. In several focus counties, U.S. personnel are located in, or detailed to, ministries of health. Innovative approaches to support human resources in government institutions have been successful. In Namibia, the Emergency Plan supports physicians, nurses, and counselors through contracting agencies.
While working in partnership with governmental authorities, the Emergency Plan is also pursuing innovative approaches to strengthening the capacity of local nongovernmental organizations (NGOs). In Botswana, the United States initiated and supported Tebelopele, the largest provider of voluntary counseling and testing, with 16 freestanding sites and four mobile caravans. In fiscal year 2004, Tebelopele was "spun off" to become an independent NGO, with all staff and assets transferred from the U.S. Mission. A U.S. Government-funded partner is working with Tebelopele to expand management capacity and ensure that it succeeds as a sustainable organization.
Faith-based groups are priority local partners. In many focus countries, more than 80 percent of citizens participate in religious institutions. In certain nations, upwards of 50 percent of health services are provided through faith-based institutions, making them crucial delivery points for HIV/AIDS information and services. In fiscal year 2004, more than 20 percent of all Emergency Plan partners (including both prime and subcontractors) were faith-based. In fiscal year 2005, planned activities indicate that this proportion will rise to nearly a quarter of all partners.
To support expanded faith-based work, South Africa's Emergency Plan program is developing strategic plans with five faith-based communities for training, other capacity development, and service delivery. Tanzania's program is supporting a national needs assessment within the Islamic community to assess current HIV/AIDS work and next steps, with additional plans under way to support voluntary counseling and testing and PMTCT services in 30 dioceses, 13 church denominations, and 20 mosques. The Emergency Plan has launched pilot programs in multiple countries that allow small groups to apply directly to Emergency Plan country teams for rapid approval of small grants in order to get funds quickly to local organizations doing needed work on the ground.
One impediment to working with many local groups is the limited technical expertise in accounting, auditing practices, and other activities required to receive funding directly from the U.S. Government. Under the Emergency Plan, the U.S. Mission in South Africa is using a local "umbrella" contractor to manage these activities for local organizations for a small fee. In fiscal year 2005, several focus countries will pursue the use of local umbrella contractors, including those that serve as local fiduciary agents for the Global Fund to Fight AIDS, Tuberculosis and Malaria. In addition, the Emergency Plan is working to incorporate "graduation" language in contracts and grants with its non-indigenous prime partners. This language provides for the performance of these prime partners to be evaluated, in part, on their success in transferring skills to their indigenous subpartners, who can, in turn, become prime partners of the Emergency Plan.
Strengthening Essential Health Care Systems
Years of development challenges and resource limitations in many of the hard-hit focus countries of the Emergency Plan have resulted in health care systems poorly equipped to respond to the HIV/AIDS crisis. In most of these countries, achieving the Plan's goals and long-term aims in combating HIV requires implementing and strengthening essential systems, including health care networks; enhancement of clinics, laboratories, medical records systems, and other infrastructure components; and commodity procurement, distribution, and management systems. The Emergency Plan is taking these challenges head on, determined to put down the roots that will truly turn the tide against HIV/AIDS.
Health Care Networks
The HIV/AIDS epidemic has placed a huge burden on the health care systems of many high-prevalence countries. In many of the focus countries of the Emergency Plan, AIDS has reached into the farthest corners of the country — where infrastructure and services often cannot reach those in need. Major disparities often exist between urban and rural health services, with a concentration of health professionals and institutions in the major cities. In some countries, as much as 40 percent of the population has no access to formal health care.
Health authorities and service providers in most high-prevalence countries require considerable assistance in order to meet the high demand for prevention, treatment, and care services. The Emergency Plan is meeting the enormous demand for services by rapidly expanding existing indigenous health networks in support of the national HIV/AIDS strategy. This includes supporting the development and improvement of linkages and coordination between central health facilities and outlying health clinics, including those in rural areas, to deliver quality HIV/AIDS services more effectively. The Emergency Plan also helps strengthen linkages and coordination between health and other service delivery institutions and organizations, public and private, that provide necessary prevention, treatment, care, and other support to people infected and affected by HIV/AIDS. The goal is to increase the number of people accessing comprehensive HIV/AIDS services by improving reach and filling gaps in service delivery.
In support of this goal, in fiscal year 2004, a U.S. interagency meeting was held in Uganda, a country with excellent models of networked health care delivery, to examine indigenous HIV/AIDS network models. Opportunities to leverage Emergency Plan resources to strengthen and expand local networks within national plans were explored. These discussions have influenced future operational plans, and the Emergency Plan's efforts to strengthen health care networks will intensify in 2005. Across the focus countries, 500 activities with health network development components — fully a quarter of all Emergency Plan activities — are planned.
Inadequate physical infrastructure is a basic barrier to Emergency Plan implementation. Common obstacles include under-resourced facilities; unreliable electricity and water supplies, especially outside urban areas; outdated or broken equipment; and lack of information and communications technology for basic program planning and monitoring. The HIV/AIDS crisis has exacerbated these conditions, straining limited health resources and facilities. In support of national strategies and Emergency Plan goals, the United States is addressing these barriers by supporting such activities as construction (for example, of additional space at an existing health facility for counseling and testing); renovation; procurement of equipment, supplies, furniture, and vehicles; and financing as needed for expanded HIV/AIDS service delivery under the Emergency Plan.
Improving laboratory infrastructure and capacity has been a specific focus of the Emergency Plan. To meet Emergency Plan goals, an estimated 30 million to 100 million people in focus countries will require HIV testing. Yet in most of these countries, existing laboratories lack equipment and trained staff, as well as established quality control procedures to help ensure the reliability of testing. Emergency Plan staff have worked in all focus countries to help strengthen their capacity to diagnose HIV and related infections. One priority is to support the use of rapid HIV tests. These tests, which require minimal equipment and can be reliably performed by lay counselors, can dramatically expand a country's capacity to perform HIV testing. Emergency Plan staff have worked with laboratory experts in focus countries to evaluate these tests, have trained more than 3,100 people in HIV testing and have helped provide oversight to ensure that the testing was reliable. Thanks to these efforts, nearly 2,200 sites in focus countries used rapid HIV tests and nearly 1.3 million people benefited from HIV testing in fiscal year 2004.
A second laboratory component critical to the success of the Emergency Plan is the monitoring of HIV-related immunosuppression (e.g., CD4 count). This testing is necessary for determining when a person needs to start HIV treatment and to monitor that therapy. Emergency Plan staff have worked with national staff in focus countries to provide advice in the purchase of appropriate equipment, provide training, and strengthen the relevant quality control systems. In fiscal year 2004, 335 addition additional laboratories developed the capacity to conduct the necessary immunological or hematological testing.
In fiscal year 2005, the Emergency Plan will continue its efforts to strengthen laboratory capacity in focus countries. As a result, more people will learn their HIV infection status, and physicians will be able to reliably determine which patients will benefit from HIV treatment and to monitor the success of that therapy.
Quality Assurance, Logistics, and Commodity Procurement
Many focus countries lack adequate systems and resources to operate a safe, secure and reliable supply chain management system (SCMS) for procuring pharmaceutical and other products needed to provide care and treatment of people with HIV/AIDS and related infections. The scale and intent of the Emergency Plan and the national strategies it supports have brought renewed focus to this need. SCMS are necessary to procure, store, distribute, and use high-quality products. These systems include not only the actual purchase of product but also oversight of national drug regulatory bodies and other agencies within host governments to ensure there is appropriate quality assurance. The United States is committed to working collaboratively with host governments to enhance their SCMS activities.
Currently, many focus countries lack adequate national strategies. During the first year of the Emergency Plan, U.S. implementing partners provided technical assistance to host government agencies, helping them with procurement, logistics, and strategies to prevent stock-outs of key commodities. The Emergency Plan has supported multiple in-country assessments of SCMS capacity and needs. Through an interagency process that included in-country consultations, a new SCMS contract is being competed that will provide countries with an enhanced ability to receive key technical assistance on all aspects of the supply chain process. The purpose of the project is to establish and operate a secure, reliable, and sustainable SCMS to procure and deliver pharmaceuticals, including antiretroviral drugs, and other products and services needed to provide lifesaving HIV/AIDS care and treatment in under-resourced settings. Also included will be the design, development, and implementation of improved systems for forecasting, procurement, storage, distribution, and performance monitoring of HIV/AIDS pharmaceuticals and other commodities and supplies. As a necessary tool for ensuring sustainability, the project emphasizes the capacity building of local essential supply chain management personnel to strengthen the quality and expand the reach of effective HIV/AIDS interventions.
The project is initially designed to target activities in the 15 focus countries, but it is also the intent of the United States to help other countries with U.S.-supported HIV/AIDS programs develop appropriate SCMS capabilities to fight the HIV/AIDS epidemic. Requests for the services of this project will be field-driven, in consultation with host governments. Once services are in place and fully functional, the contract may also be tasked with support for HIV/AIDS programs funded by other governments and donor entities, typically on a fully cost-reimbursable basis. Thus programs receiving support from the Global Fund to Fight AIDS, Tuberculosis and Malaria or other entities will also be able to use this mechanism.
Health commodities required for HIV/AIDS prevention, treatment, and care programs will be procured in collaboration with host governments. Categories of commodities will include but are not limited to:
At full scale, it is expected that the contract will cost about $25 million per year and be able to forecast, procure and deliver from $500 million to $800 million in HIV/AIDS drugs and related commodities per year. Proposals were due February 16, 2005, with an expected award in May 2005.