Building Capacity and Ensuring Quality: A Rational Approach to Track 1.0 Transition 7 th Annual Track 1.0 ART Program Meeting August 4, 2009

ICAP’s Context for Transition Eight Track 1.0 Country Programs: Cote d’Ivoire, Ethiopia, Kenya, Mozambique, Nigeria, Rwanda, South Africa, Tanzania. Primary focus on supporting Public Sector programs in each country – relatively less NGO, FBO, or private sector support. Support at national, provincial, district and facility levels Key domains of current technical assistance: –Administrative functions –Financial management –Planning activities –Program design and implementation –Intensive mentorship for programmatic excellence –Monitoring and evaluation/quality improvement

ICAP’s Context for Transition (2) More than 200 active subagreements to support service delivery activities by central Ministries, regional / provincial and district Authorities, and individual facilities. More than 400 facilities receiving support Transition to indigenous organizations is a logical extension of ICAP’s ongoing support for health system strengthening and sustainability. We share OGAC’s goals to responsibly transfer Track 1.0 activities, and the associated funding, to indigenous organizations by 2012.

Countries’ Context for Transition Transition to local responsibility cannot be undertaken in the same way, or on the same timeline, in each country: –Other development assistance programs have operated for many years in some countries before substantial assistance from international agencies could be lessened or re-directed. –Some countries have transitioned faster than others because of better economic conditions, political stability, and good governance practice. –Within countries, some regions may take longer to transition because of geographic isolation, greater poverty and/or weak institutional capabilities. HIV/AIDS prevention, care, treatment, and related interventions pose special challenges for transition to local authority and responsibility: –These programs remain relatively new –Rapid expansion of services due to the emergency of the epidemic complicates transition –Clinicians, allied personnel, and program administrators are still in short supply –Facilities remain inadequate –Local institutions managing programs are still developing and building needed capacity in financing, governance and technical expertise –Transition requires substantial health systems strengthening with focus on district health teams, provincial entities and groups in civil society

ICAP’s Program Implementation Approach ICAP has emphasized the importance of capacity-building from the inception of Track 1.0. Strategies include: –Providing support in accord with, and under the guidance of, national programs –Emphasizing support in the public sector –Simultaneous support at national, regional, district and site levels –Emphasizing direct on-site support in management and technical domains –Avoiding development of parallel systems or structures –Implementing programs via local organizations supported by robust technical assistance from ICAP –Involving PLHIV in service components –Delivering technical assistance with the goal of building local capacity in clinical, other technical, management, and financial skills

ICAP’s Approach to Transition 1.Determine which indigenous partner institutions are most appropriate and capable of assuming responsibility for implementing major portions of the Track 1.0 program within a 3-4 year time frame. 2.Determine which functions of HIV prevention, care and treatment and related programs can be transferred to indigenous organizations, the likely time-frame for such transfers, and which type of indigenous organization is most appropriate to house each function. 3.Work with the selected indigenous organizations to provide them with the technical skills and managerial capacities required to implement their functions. 4.Implement transition through additional subcontracting, and/or adjusting the ICAP SOW as local partners receive direct USG awards. 5.Monitor and evaluate the transition process and its impact on the quality of programs and services.

1. Transition to Which Partners? a)Government (Ministry of Health or subordinate institutional units) b)Parastatal organizations (including universities); c)Existing national NGOs d)Existing regional (regions within a country) or community-based NGOs e)New NGOs as they may become established

2. Which Functions to Transition? a)Service Delivery – the collection of tasks required to deliver prevention, care, treatment and associated services to patients and the community b)Financial and Administrative Support - these tasks are closely related to service delivery tasks, but refer specifically to the financing and management of processes related to those services, with particular emphasis on management of USG funds c)Technical Support - tasks requiring specialized skills that may be lacking or under-represented in specific countries.

3-5. How to Operationalize Transition? a)Continue with ongoing capacity building associated with program implementation b)Intensify and formalize this work, with specific objectives, benchmarks and time frames c)Be flexible – adjust plans as necessary d)As local organizations become ready, progressively transfer funding and implementation responsibilities. e)Monitor processes and outcomes during and after transition.

ICAP’s Program Implementation Approach ICAP has emphasized the importance of capacity-building from the inception of Track 1.0. Strategies include: –Providing support in accord with, and under the guidance of, national programs –Emphasizing support in the public sector –Simultaneous support at national, regional, district and site levels –Emphasizing direct on-site support in management and technical domains –Avoiding development of parallel systems or structures –Implementing programs via local organizations supported by robust technical assistance from ICAP –Involving PLHIV in service components –Delivering technical assistance with the goal of building local capacity in clinical, other technical, management, and financial skills

3-5. How to Operationalize Transition? a)Continue with ongoing capacity building associated with program implementation b)Intensify and formalize this work, with specific objectives, benchmarks and time frames c)Be flexible – adjust plans as necessary d)As local organizations become ready, progressively transfer funding and implementation responsibilities. e)Monitor processes and outcomes during and after transition.

Examples of Ongoing Transition Implementation More than 200 subagreements with local partners which support various components of service delivery, and build capacity in program and financial management. Diverse subrecipients: –National entities (TRAC-Plus and NRL in Rwanda, Ministry of Interior in Mozambique) –Regional/Provincial/District entities (DHTs in Tanzania and Kenya, RHBs in Ethiopia) –Non-governmental organizations (Family Guidance Ass’n in Ethiopia, Care for Life in Nigeria) –Private sector organizations (Shebelle in Ethiopia) –Community-based organizations including PLWHA (Mukikute and SHEDPHA in Tanzania) –Health Facilities in all countries ICAP provides mentoring to District Teams in Rwanda and Tanzania, and to Regional Health Bureaus in Ethiopia, to build program management skills. Intensive site support includes clinical and more general mentoring to build clinical skills, supervisory capacity, and program management expertise.

Examples of Ongoing Transition Implementation - 2 Transition Teams have been established in each ICAP Country Office, supported by additional HQ and regional staff resources. ICAP Country Teams include Subagreement Managers and Finance Staff that provide direct financial / administrative TA and capacity building to subrecipients, backed up by HQ staff in similar roles. Subrecipients’ performance is regularly monitored, assessed, and constructive feedback provided through quarterly (minimum requirement) site visits. Improvements in clinical skills and supervisory capacities are regularly monitored both through analysis of site-level data, and ongoing support visits by ICAP technical staff.

Ongoing Monitoring and Evaluation Each Country Transition Plan includes specific steps and benchmarks that will be monitored as transition proceeds. Measures include results of periodic capacity assessments, amount of funding subcontracted, local partners’ burn rates, new functions subcontracted, staff completing USG financial training, etc. Evaluation of transition must include longer- term measurement of any impacts on program performance and quality.

Issues for Discussion and Clarification 1.If a local organization is deemed ready to receive USG funds directly, what contracting mechanisms will be available to assure a smooth transition? 2.Will final “readiness” decisions be made by PEPFAR Country Teams? Will we adopt standardized approaches to making these decisions? 3.At least one country (Ethiopia) has severe restrictions on the percentage of funding that a local NGO can receive from foreign sources. This appears to eliminate local NGOs from the transition discussion, except for very modest activities. 4.How will direct funding (and associated activities) of Ministries of Health be coordinated with new funding mechanisms created by RFAs and RFPs? 5.As transition proceeds, what will be the role of Host Country ministry and diplomatic officials in negotiating the types of work to be contracted to government vs. local NGO vs. international NGO partners?