AMERICAN INTERNATIONAL HEALTH ALLIANCE INC

In September 2019, the U.S. Centers for Disease Control and Prevention (CDC) awarded AIHA a five-year grant to implement a wide range of activities to combat the HIV/AIDS pandemic. This multi-year, multi-country project is broad in nature, and provides a vehicle by which AIHA can assist the CDC at the global and country level, in support of the President’s Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria.

The goal of the project – entitled Targeted Programmatic Support Across Countries (CDC1950) – is to provide comprehensive and cost-effective technical support for the acceleration of evidence-based HIV prevention and treatment program implementation, as well as aligned health systems strengthening activities. Among other things, the project aims to increase capacity, particularly of civil society organizations, and to implement direct service delivery (DSD) activities, to address HIV/AIDS across PEPFAR countries globally. This grant builds on AIHA’s successes and collaboration with the CDC, other US government agencies, and other partners over the past 15 years in fighting the HIV epidemic. It also leverages AIHA’s close to 30 years of working to improve capacity among individuals, organizations, governments, and institutions to address various public health issues, particularly among front-line health care workers.

This project has thus far operated in 10 countries: the Philippines, Thailand, Laos in Southeast Asia; Zambia, Tanzania, Nigeria and Kenya in sub-Saharan Africa; and the Dominican Republic, Haiti and Guatemala in Latin America and the Caribbean.

The project has three main components:
• Capacity building: Supporting PEPFAR programs, Ministries of Health (MOHs) and other key stakeholders to implement innovative, effective and comprehensive capacity building strategies for service delivery and human resources for health (HRH) to ensure implementation of HIV programs in line with PEPFAR/UNAIDS and national policies and guidelines;
• Service provision: Supporting PEPFAR programs, MOHs, and other key stakeholders to implement high-quality, high-effectively and evidence-based HIV prevention, care and treatment services for populations at high risk;
• Strategic information: Supporting PEPFAR programs, MOHs, and other key stakeholders to design and implement innovative strategic information approaches to generate data driven evidence to improve HIV policies and programs.

The project has expected short-term, immediate and long-term outcomes. Long-term outcomes are:
• Increased capacity and ownership of country MOH and other key stakeholders to control HIV epidemics in a sustained manner;
• Decreased HIV transmission among high-risk and vulnerable populations;
• Increased viral load suppression for all populations living with HIV on ART.

In the first year of the project, AIHA implemented activities in Thailand and Laos in Southeast Asia; Zambia, Tanzania, Nigeria, and Kenya in sub-Saharan Africa; and Guatemala in Latin America. Activities in Thailand and Laos focused on improving the quality and confidentiality of HIV testing among high-risk and vulnerable populations, tracing their contacts, and linking them to prevention and care services. In sub-Saharan Africa, interventions have been targeted towards improving the capacity of local civil society organizations comprised of and representing vulnerable and marginalized populations to address the pandemic in their communities.

According to the most recent UNAIDS report released on July 6, 2020, a majority (62%) of new adult HIV infections globally in 2019 were among key populations and their sexual partners. These populations—which include sex workers, people who inject drugs, prisoners, transgender people, and gay men and other men who have sex with men—constitute small proportions of the general population, but they are at elevated risk of acquiring HIV infection, in part due to discrimination and social exclusion. The risk of acquiring HIV is:
• 26 times higher among gay men and other men who have sex with men.
• 29 times higher among people who inject drugs.
• 30 times higher for sex workers.
• 13 times higher for transgender people.

In the second year of the project, AIHA is continuing capacity building activities in Zambia, Tanzania, Nigeria, and Kenya in sub-Saharan Africa; and Guatemala in Central America. Project activities have also expanded to Haiti and the Dominican Republic.
AIHA will support KP-led organizations to deliver KPIF services via strengthened organizational capacity and increased resiliency through Social Enterprise.

HIV Key Population Civil Society Organizations (CSO) often have limited sources of financial support, and some depend primarily on one single source for their operations. The sources are mostly large international donors and NGOs. The level of overseas funding for HIV programs has stagnated, and countries that have achieved success in reducing transmission have often experienced fluctuations in donor support. Rapid donor funding transitions and cuts can result in closures and interruptions of essential services, threatening to undo progress towards HIV elimination. Key populations (KP) are especially at-risk because national governments may also be reluctant to adopt mechanisms for funding CSOs that are KP-led or -driven, because they commonly face multiple barriers including discrimination.

CSOs with more diversified streams of funding are better equipped to maintain services when there are fluctuations in funding. Organizations that apply commercially viable strategies to maximize social objectives are often in a better position to withstand these fluctuations, as they are not entirely reliant on the uncertainties of donor funding and fund raising efforts. Organizations that incorporate Social Enterprise activities are more like for-profit businesses that sell products or services to acquire capital. AIHA will focus on strengthening these organizations to incorporate Social Enterprise initiatives to make them more sustainable, and be able to deliver the critical HIV services needed.

AIHA will also start project implementation in the Philippines in 2020. The Philippines has the fastest growing HIV epidemic in the Southeast Asia/Pacific region, with a sevenfold increase in newly diagnosed cases from 2010 to 2018. AIHA’s technical assistance will focus on reviewing current systems with the goal to improve Assisted Partner Services (APS) in at least 2 sites. APS or provider notification for sexual partners of persons diagnosed HIV-positive can increase HIV testing and linkage and is a high yield strategy to identify HIV-positive persons.

AIHA will provide technical assistance on implementation and scaling index partner testing services to stem HIV transmission in the Philippines, including use of social or sexual network interventions. AIHA will also develop training materials and mentorship packages, and work on direct service delivery in District 11 in the Philippines.

According to UNICEF, there were an estimated 13.8 million children and adolescents (0-18 years) worldwide who have lost one or both parents to AIDS as of 2019, 80% of whom live in sub-Saharan Africa. In Nigeria, there are an estimated 2.5 million orphans and vulnerable children due to HIV/AIDS. UNICEF estimates each day 880 children become infected with HIV.

For many years, the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) has focused attention and devoted significant resources to addressing this key population. Currently, there are 22 countries that have PEPFAR supported OVC programs including Nigeria.

In late 2019, the Society for Family Health (SFH), a Nigerian-based NGO, in partnership with American International Health Alliance (AIHA), Save the Children Federation (SCF), and the AIHA established Nigerian organization Twinning for Health Support Initiative (THSI-N) received a five year award from USAID entitled the Integrated Child Health and Social Services Award (ICHSSA 3) Program with the goal to integrate evidence-informed strategies to enhance OVC services, strengthen social services to OVC, and strengthen the OVC systems’ services and support in Kano, Nigeria. Specifically, the objective of the ICHSSA 3 Program is “to ensure that OVC are cared for and protected by their households, communities, local and state government” through civil society and partnerships. Nigeria was selected because there remains a significant risk among adult populations not on HIV/AIDS treatment (40%) and low use of ART among HIV-positive pregnant women (30%) – indicating a significant at-risk population that could benefit from pre-OVC and OVC services as part of HIV prevention and treatment programs. AIHA and our partner organization THSI-N have been working to deliver a full package of technical assistance activities to ensure that local and state governments have sufficient, high performing human resources to protect and care for OVC.

The ICHSSA 3 program is comprehensive, actionable, and integrative, while focusing on reframing ecological levels (system/environment, organizations, community, interpersonal, and individual) of OVC health programming and service delivery in Kano, Nigeria – improving results to households access to OVC services, communities awareness to protect OVC rights, bolster local and state government role in delivering services of OVC, and prioritized subpopulation OVC service utilization.

Recently, the ICHSSA 3 State Team conducted an extensive baseline capacity gap assessment of social workers and community case management in Kano State. The Social Welfare Workforce Mapping and Assessment 2019 Toolkit from Global Social Service Workforce Alliance was adapted to a 3-part ecological questionnaire specific to ICHSSA 3 program goals. The three parts sought information to establish a baseline regarding: (1) social welfare workforce planning, (2) social welfare workforce development and training, and (3) social welfare workforce support. This baseline assessment is guiding the next phase of institutional social welfare workforce curriculum development.

Some additional examples of main ICHSSA 3 program activities and services include:
• Identify government agencies and traditional leaders to champion OVC services
• Kano State Assembly
• Kano State Agency for the Control of HIV/AIDS (KSACA)
• Primary Health Care Development Agency (PHCDA)
• Hospital Management Board
• Ministry of Education
• Strengthen collaboration and partnerships through Kano State Assembly
• Increase verification of households and quality of service delivery from Community Case Management Workers (CCMW)
• Facilitate caregivers’ forums to increase health service capacity, knowledge (nutrition, financial literacy, etc.), and skills
• Implement inclusion activities as part of kids’ and adolescents’ clubs (e.g. 32 activities – story telling, physical and intellectual and emotional wellbeing meetings).
• Support Community Child Protection Committee meetings to plan school enrolment and prevent child abuse

Ethiopia faces a heavy burden of disease, with a growing prevalence of communicable infections. As a result, high morbidity and mortality rates attributed to potentially preventable infectious diseases and nutritional deficiencies are a reality for many Ethiopians. Ethiopia’s Federal Ministry of Health (FMOH) is best positioned to respond to this challenge. It consequently seeks to promote the health and well-being of all citizens by providing and regulating a comprehensive package of high quality promotive, preventive, curative, and rehabilitative health services equitably.

The Health Sector Transformation Plan’s (HSTP) mid-term evaluation results recommended leadership, management, and governance capacity-building efforts to address critical gaps in the health sector, explicitly calling out areas of improvement that include: inadequate capacity to implement a decentralized health system; low utilization of health services; inadequate follow-up on implementation of policies, guidelines, standards and protocols; inadequate coordination of public-private partnerships in health.

To meet the challenge, the FMOH must be able to rely on its greatest asset – its people – to plan, guide, develop, and implement need-driven national health programs and initiatives. Ministry staff must excel not only in public health but also in thinking and acting as true leaders and visionaries for their country’s complex health system. Specifically, selected individuals must be empowered by augmenting their technical expertise with – among other things – critical leadership, communications, and management skills that will help them emerge as leaders of the FMOH’s critical national effort to promote the health and well-being of all Ethiopians.

At the request of the FMOH and the Bill & Melinda Gates Foundation, AIHA developed a concept note for the development and implementation of a Leadership Incubation Program (LIP) for the FMOH, its agencies, and Regional Health Bureau staff that will build the capacity of its staff, thus developing a pool of highly qualified people for future leadership positions.

To meet the leadership challenge in the health sector, the FMOH launched the Ethiopia Leadership Incubation Program (LIP). LIP is an initiative designed to develop a cadre of highly trained public health leaders in Ethiopia to work with advanced public health agendas, improve health outcomes using the newest tools of leadership skills, and improve the performance of these public health leaders at all levels by delivering quality health services in an equitable manner to ultimately improve health outcomes.

To address the mentioned challenges, AIHA received a grant from the Gates Foundation for eighteen months that is being used to develop future leaders and provide an opportunity for them to contribute in the health sector by assuming various leadership positions, so they can chart a course toward a future in which all Ethiopian citizens have access to quality health and allied care services.

This program is being co-managed by the Human Resource Development Directorate of the FMOH, the International Institute for Primary Health Care in Ethiopia (IIfPHC-E) and AIHA Ethiopia. A team of dedicated trainers and coaches from multiple sectors is expected to deepen the knowledge of leadership literature, raise self-awareness, and unlock the leadership potential of the trainees. This is being done through a blended learning approach that combines traditional classroom learning with individual mentoring, coaching, and experiential learning opportunities.

The LIP is a competency-based, six-month training and service program. Upon successful completion of LIP, the Federal Ministry of Health, in collaboration with AIHA and the International Institute for Primary Health Care-Ethiopia (IIfPHC-E), will award a Certificate of Completion. The Program provides the fellows with experience in leadership program planning, implementation, management, and evaluation through specialized hands-on training and mentorship. LIP fellows are being assigned to a field site that provides them opportunities to develop competence as skilled program leaders and to provide service applicable to projects that will improve public health.

In addition to meaningful and challenging on-the-job activities, the LIP provides formal instructor-led didactic training with a focused and short block course of 2 to 3 days maximum. Online leadership courses are also encouraged. Skills are further developed through hands-on developmental activities that enable LIP fellows to learn and practice skills essential to leading and solving public health problems. The curriculum is interdisciplinary and applicable to as many participants as possible. The program includes essential and universal leadership skills such as conflict management, negotiation, financial skills, customer service, time management, as well as strategies to develop interpersonal skills.

Emphasis is also placed on developing competence in program and operations planning, program management and evaluation, communication skills, emotional intelligence, emergency preparedness and response, oral and written communication, team building, negotiation, ethical consideration, and conflict resolution. Graduation from the LIP program signifies that the fellow has gained extensive experience in public health leadership and developed both the management and leadership competencies needed to serve as an effective public health leader in Ethiopia and beyond.

Participants in the training program are health professionals currently working in the health sector or health science education graduate interns who:
• aspire to work in public health leadership, program management or supervisory roles
• are preparing for higher-level leadership roles and are early in their careers

This may include experienced case team leaders or early career supervisory/ management staff with little to no experience in program leadership or management. The LIP provides leadership training and experience so fellows become competent in these areas and more.

Fellows are being recruited and selected through a competitive process from various healthcare institutions- particularly the Federal Ministry of Health (FMOH), Regional Health Bureaus (RHBs) and its agencies from Addis Ababa and the regions. The first cohorts are all from the FMOH who fulfill the criteria.

Responsibilities of the fellows during their training period include designing, developing, implementing, and evaluating programs, supervising staff, establishing and maintaining community partnerships, managing timelines and project work plans, or other public health-related duties as assigned. Individual assignments and opportunities will be made available either at their primary training site or elsewhere to provide for accelerated on-the-job learning.

The impact of the training will be evaluated after six months from graduation, giving the fellows the chance to implement what they have learned.

The goal of this two year award from the Bill and Melinda Gates Foundation is to strengthen the International Institute for Primary Health Care – Ethiopia (IIfPHC-E) to serve as both a national and regional resource for the delivery of quality primary health care service for essential, curative, and preventive services in Ethiopia.

The IIfPHC was established by the Federal Ministry of Health (FMOH) to strengthen Ethiopia's Primary Health Care (PHC) system in the context of achieving Universal Health Coverage (UHC) and meeting the Sustainable Development Goals (SDGs) for health. It does this by serving as a global resource for PHC, building capacity through training and information sharing, carrying out health systems implementation research, and contributing to the global advocacy for UHC through Primary Health Care. It is expected that the Institute will be transformed into a Center of Excellence in PHC Training, Advocacy, and Evidence Generation, and ultimately serve as the first WHO Collaborative Center on the African continent.