Advancing Resilient Systems for a Sustainable HIV Response

All around the world, health systems are under pressure, and despite the progress made in the global HIV response since 2000, many health systems continue to face challenges on the road to achieving the Sustainable Development Goals (SDGs) and the reality of an AIDS-Free Generation.

On May 17, 2017, the USAID-funded Leadership, Management, and Governance (LMG) Project organized a half-day event, Passport to Leadership: Advancing resilient systems for a sustainable HIV response, to showcase the project’s activities to promote country ownership, build resilience, and advance sustainability.

Resilience and Sustainability

Catharine Taylor, Vice President of the Health Programs Group at Management Sciences for Health (MSH), kicked off the event with an introduction to its theme: resiliency. Resilience is the ability of people, households, communities, countries, and systems to mitigate, adapt to, and recover from shocks and stresses in a manner that reduces chronic vulnerability and facilitates inclusive growth.

Epidemics, political and military turmoil, and global economic changes all have profound impacts on health systems. Through investing in strong governance, leadership, and management, health systems are more resilient and capable of adapting to external changes, as well as to the changing health needs of their populations.To bring the LMG Project’s work to life, Taylor told a story from Uganda, where increased capacity in leadership, management, and governance enabled the government and/or organizations to adapt and function under post-crisis circumstances.

On behalf of USAID’s Office of HIV/AIDS, Acting Branch Chief for Capacity Building and Partnerships Debbie Kaliel opened by connecting the Office’s work on sustainability to leadership, management, and governance. She pointed out that the President’s Emergency Plan for AIDS Relief (PEPFAR) Sustainability Index Development tool has a domain focused squarely on leadership, governance, and accountability. According to Kaliel, of the countries assessed, many scored well – a testament to the investment in leadership, management, and governance – and she noted this continued investment is needed for a sustained response to achieve the 90-90-90 targets.

Megan Kearns shares some of the LMG Project’s achievements with support from the USAID Office of HIV/AIDS. (Photo: MSH)

Building Organizational and Institutional Capacity

The opening panel—moderated by Amy Kay, Senior Health Advisor in the USAID Bureau for the Middle East—discussed how organizational development and institutional capacity can build a foundation for health systems to resist shocks.

When conflict impacts a country, Kay noted that health systems and workers shoulder the burden of maintaining key relationships within and between communities that are essential for conflict resolution, security, and stability. Without these relationships, health services falter. This is why civil society leadership within the health sector is so critical – often civil society organizations are the only remaining health service providers to ensure access.

Middle East and North Africa Region
Manuel Couffignal, Senior Advisor at the International HIV/AIDS Alliance, reiterated the important role of a robust civil society in a challenging political environment. He pointed to the Middle East and North Africa (MENA) region, a somewhat forgotten region in the global HIV response because of its low HIV prevalence, but one where the epidemic is progressing.

In many of these countries, Couffignal said that leadership is insufficient and that HIV is not prioritized in public health because of the populations that it primarily affects. However, focusing on skills building and providing assistance to with civil society were key in responding to the gaps.

He highlighted the work done under the 10-year Responding to Key Populations in the MENA Region Program, supported by USAID through the LMG Project from 2013-2015.  This project  supported civil society partners to increase access to HIV services and information for men who have sex with men and people living with HIV.

In Ukraine, the health system faced a tall order in the form of one of the  highest HIV prevalence rates in Europe and political instability after Russia’s annexation of Crimea in 2014. Stanislav Sereda, a Capacity Development Consultant with the LMG Project, explained how the LMG Project supported the Ukrainian Center for Socially Dangerous Disease Control (UCDC) to strengthen the institution’s capacity to effectively manage grants from the Global Fund to Fight AIDS, Tuberculosis, and Malaria, despite the volatile political environment. Beyond grant management support, the LMG Project and UCDC co-created countless operational strategies, policies, and plans; invested in resource mobilization; and improved communications platforms. Because of UCDC’s strengthened institutional, programmatic, and financial capacity; when the Ministry of Health reorganized its public health institutions, UCDC was selected to be the foundation for a new Ukrainian Public Health Center.

Sarah Konopka – a Principal Technical Advisor in HIV and AIDS for MSH – also pointed out the importance of building resilience given the often shifting global health funding landscape. She highlighted  USAID’s Prevention Organizational Systems AIDS Care and Treatment (Pro-ACT) Project in Nigeria that adopted LMG Project tools and approaches into activities.  In Kwara State, the project mapped  health and non-health stakeholders that influence resource mobilization, conducted organizational and transition readiness capacity assessments to identify relationships and existing structures for influencing policy and political will, engaged political and technical stakeholders to acknowledge and work through the change process, conducted a resource gap analysis to help quantify the direct resources needed to sustain HIV and AIDS services, developed a strategic transition plan, and strengthened governance structures to provide multi-sectoral coordination platforms to improve management efficiency and accountability.

Sarah highlighted that building professional relationships was a critical factor for a successful transition. The project’s success working with technocrats in state agencies and demonstrating how persuasive memos could help advocate for funds showed that a focus on leadership, management, and governance interventions made a difference in PEPFAR’s funding transition. In 2015, Kwara was the first state to allocate and transfer funding for PEPFAR services.

Although we can look back at past challenges, it is impossible to predict the challenges health systems will face in the future; thus, strengthening management systems, establishing governance structures, and understanding relationships within systems are all key steps we need to take towards sustainability and resilience.

Solutions Marketplace: How to Promote and Achieve Resiliency

The LMG Project showcased eight  tools and approaches that strengthen HIV organizations and health systems to promote resilience in the HIV response.

Driving to 2030
Governance Roadmaps Toward Priority Health Targets
Putting Data in the Driver’s Seat
PEPFAR Management Dashboard
Thriving HIV/AIDS Networks
Network Strengthening Program (NSP)
I’m a CCM Member. Now what?
CCM Member Orientation Program
Finding a Path Through Complexity
HIV/AIDS Provincial Planning Simulation (HAPPS) Tool
Children in the Era of Treatment
Improving outcomes for orphans and vulnerable children
Transitioning to HIV Test and Start Guidelines
Transitioning to HIV Test and Start Guidelines in Central America
New Ways of Working
Strengthening the continuum of care in Haiti with a revised Package of Essential Services

Stories of Strengthening Governance

Bob Emrey, Lead Health Systems Specialist in USAID’s Office of Health Systems, introduced the second plenary session which prompted attendees to think holistically about the concepts of governance through TED talk-style storytelling.

Taking Discrimination Head On
Cristina Bisson, Senior Health Systems Strengthening Specialist, RTI
In Ghana, people are blackmailed, harassed, beaten, and robbed, all because of their HIV status. Although policies against discrimination were in place, they were not enforced and no one was being held accountable. Moreover, there was no mechanism for victims to respond or report.

But recently, with support from USAID to strengthen governance, the government of Ghana decided to tackle discrimination head on by creating a formal complaint system for people living with HIV under the broader Commission on Human Rights and Administrative Justice (CHRAJ).

This means that accountability is no longer an ambiguous idea, because there is now a system for complaints to be submitted and tracked. Complaints are now being heard and mediated by the CHRAJ.  Now, people can see that discrimination against people living with HIV is not okay, and they can see the the system has established structures so that people are heard.

Cristina Bisson tells a story of governance strengthening in Ghana. (Photo: MSH)

Why Coffee Breaks Matter
David Jacobstein, Democracy Specialist, USAID
During the mid-1990’s, the US Government made a large investment to build civil society and foster engagement in former Soviet Republics. This often meant that organizations were selected to be trained as regional support centers that could receive and disburse grants, provide training, and coordinate with smaller organizations working at the district level.

When priorities shifted soon after 2000, so too did funding and USAID’s support for some of these programs ended around 2003. In 2012, Jacobstein visited Kyrgyzstan to see what remained from these trainings. During an interview with one of the former participants, he heard an interesting testimony: the most memorable part of the trainings were the coffee breaks.

He continued his visit and continued his interviews with other civil society organizations (CSOs), but that testimony stuck with him. Jacobstein assumed that he would hear criticisms from small organization about the regional support centers or that they never received funding; instead, he heard stories of the support centers helping to connect smaller organizations to national networks or navigate the legal systems.

He learned that a bill had been introduced in parliament to curtail civil society space, but that it was defeated after the regional support centers mobilized district-level organizations to contact local officials and parliamentarians.

During this trip, Jacobstein learned that although it may not have been intentional, the relationships started at trainings 10 years earlier helped lay the foundation of trust and support needed by civil society to organize against that bill. The reason the coffee breaks were memorable: they were the start of these essential relationships.

Rebuilding Trust After Political Controversy
Reena Shukla, Population, Health, and Nutrition Officer, USAID
When Reena Shukla headed to Brazil as a newly minted Foreign Service Officer, she faced the tough task of rebuilding a strained relationship between the US and Brazil.

The government of Brazil prided itself on its effectively governed and inclusive HIV response, but its work with sex workers put the country at odds with US Government policies. Two years of negative press and animosity related to this divide could not be quickly forgotten.  Shukla recognized the existing strong relationship between civil society and the government, and aimed to build upon it. She organized meetings with CSOs and government partners to understand their perspectives, priorities, and the current challenges in the HIV response.

These meetings were a platform to listen to priorities of different key populations, help demonstrate positive intentions, quell negative perceptions, and show USG commitment to addressing challenges. This openness to understanding their differing perspectives helped to build a collaborative relationship and rebuild trust between the Brazilian government and USAID. It took time, but by deliberately building upon existing relationships and allowing CSO partners to take responsibility in coordinating efforts, successful cooperation was possible.

After two years of meaningful dialogue, mutual understanding, and continuous engagement, meetings ended with laughter and progress instead of skepticism and distrust.

Bob Emery gave some concluding remarks which highlighted how the LMG Project applied concepts of systems thinking, saying, “No one part of the health system alone can get over big roadblocks.” He emphasized that leadership, management, and governance play an important role in increasing resilience and responsiveness.

Building Trust and Systems for Resilience

Ken Sklaw – the USAID Office of HIV/AIDS Technical Advisor to the LMG Project – closed the event by sharing a collection of concepts he noted throughout the morning, including: relationships, coordination, policy, accountability, linkages, and trust.

As we stare down the ambitious SDGs, shifting global health funding priorities, and unpredictable shocks, he noted, now is the time to recognize the importance of relationships, trust, and strong systems to deliver a sustainable HIV response.

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