Program Transition to Locally Controlled Entities August 4, 2009 Track 1.0 Meeting Dar es Salaam

Three Countries – Three Models  Nigeria – Creation of APIN with no Harvard governance representation and independent of Harvard from outset  Tanzania – Creation of MDH with Harvard majority governance, switching to complete local governance after sufficient capacity- building period  Botswana – Creation of BHP, as joint Harvard-MOH initiative, with Harvard majority governance; PEPFAR governed by board committee with local governance majority

Harvard-MDH Transition Plan for Tanzania Dr. Guerino Chalamilla, Deputy Country Director - Tanzania (future CEO of MDH)

Harvard- PEPFAR Program in Tanzania  Track 1 participant funded through HRSA (Tanzania, Nigeria, Botswana)  As of 2004, collaborating institutions included: Muhimbili University College of Health and Allied Sciences (MUHAS) Dar es Salaam City Council Harvard School of Public Health Known as - “MDH”

Cumulative Ever Enrolled Into HIV care 71,925 Active on ARVs 28,843 (65%) Cumulative Ever Initiated on ARVs 44,404 (61.7%) Summary of Patient Enrollment (as of June 2009) Sites  27 Public  14 Private  1 Faith-based

Locations of MDH supported sites in Dar es Salaam

Transitioning  Important for sustainability  Establishment of local ‘Not-for-Profit’ organization – with governance by local/national public health leaders and Harvard faculty and administration  Retain the name ‘MDH’ – Management & Development for Health Ltd  Transition will be gradual and smooth  In transitioning, Harvard to partner (MDH Ltd.) to ensure admin, financial and programmatic infrastructure is strong

Governance Transition  At inception, 7 directors: 4 Harvard-appointed, 3 Tanzanian public health leaders  When MDH has reached capacity for full self- governance, Harvard will relinquish all director positions it holds with non-Tanzanian directors, and those directors will resign  Remaining Tanzanian directors will then appoint all vacant director positions, and local self-governance will be complete  We expect this “switch” to occur roughly at same time that MDH is ready to assume direct funding responsibilities, as prime grantee – likely at outset of Y8

Expectations  For Y6 onward funding will remain the same  Y6-Y9 MDH Ltd will ensure maintenance of current activities and, if possible, add more sites depending on availability of funds  At Y8 Harvard will have transitioned all clinical program activities to MDH Ltd, as well as relinquished role as appointee of directors

Work Plan - Year 6  The formation of MDH, Ltd.  Governance through the establishment of Board of Directors  Develop and establish administrative staff levels, policies and procedures  Prepare for transfer of technical and programmatic units in Year 7  Harvard will continue providing technical and administrative/financial support

Year 7: Administrative Transition  At the onset of Year 7, Harvard will remain as the prime grantee, with three subcontracts in place – MUHAS, Dar City and MDH, Ltd.  The budgets for each subcontract will be revised as functions are re-arranged from one partner (MUHAS or Dar City) to MDH, Ltd.  Programmatic activities will continue

Year 7: Program Activities  Harvard technical assistance will consist of: direct technical assistance mentorship of local MDH, Ltd. staff by Harvard staff for program activities and quality assurance, with support for devising and implementing corrective action plans, as needed  Harvard will review regular performance reports and conduct spot assessments  Harvard will continue providing oversight, provide assistance as areas for improvement are identified and quality assurance of services

Year 8: Program Activities  MDH, Ltd. will have assumed all the tasks of the prime partner and prime grantee  MDH, Ltd. will receive PEPFAR COP funds directly from USG-Tanzania  MDH, Ltd. will subcontract Dar City and MUHAS for execution of various site level patient care activities  If requested, Harvard School of Public Health may choose to be a subcontractor to MDH, Ltd., or may continue to receive some limited funds directly from HRSA and/or CDC to provide technical support and quality assurance functions to MDH Ltd., MUHAS, and Dar City Council

Year 9: Program Activities  Harvard may continue to serve as a source for technical assistance for the PEPFAR program through MDH, Ltd.  Collaboration will continue on the implementation of research, training and education and capacity building activities (for continuous quality improvement and expansion of established programs and services)

Botswana Harvard AIDS Institute/”BHP” Transition Plan Ria Madison, BHP Chief Operating Officer

HSPH and BHP in Botswana  Harvard activities – primarily research projects – far pre-date PEPFAR involvement  Harvard’s continued pre-PEPFAR collaborative effort at Princess Marina Hospital to operate national HIV laboratory  PEPFAR represents only about 20% of HSPH activities in Botswana  BHP chartered in 2007 as new legal entity, in cooperation with MOH  Master MOU between Harvard and Government of Botswana/MOH, grandfathers in BHP

Organizational Structure

Board of Directors  Julio Frenk, Dean of Faculty of Public Health (HSPH)  John Lichten, Senior Advisor to the Provost  Myron Essex, Professor (HSPH)  Richard Marlink, Professor (HSPH)  Modisa Motswaledi, Botswana Ministry of Health  Joe Makhema, BHP Chief Executive Officer  Ria Madison, BHP Chief Operating Officer

BHP Transition Planning Timeline Developed, operational September 1, 2009 Activity Responsible Person(s) Status/Notes Monthly Planned Activity Projected Deadline for Completion

BHP Transition Administration and Finance Governance Personnel Administrative Issues Financial/Budgeting Issues PEPFAR Funding

BHP Transition  Cut-Off periods to Establish Specific Tasks  Review of QuickBooks – BHP & PEPFAR  Review of Lab & General Inventory  Review of VIP Payroll System  Review of Internal Controls

BHP Transition  Review of Workflows & Reporting Structures  LLC Annual Budget  Tax Registration for LLC  Grant Management  Allocation/Apportionment of Expenses to Grants  Timelines for LLC Preparation

Nigeria Transition: AIDS Prevention Initiative Nigeria (APIN Ltd/Gte) Ernest Ekong, M.D., M.P.H., Harvard Country Director for Nigeria, APIN Clinical Director

Introduction  AIDS Prevention Initiative in Nigeria (APIN) was established as a program of HSPH in 2000 with a grant from the Bill & Melinda Gates Foundation  The Harvard PEPFAR(APIN Plus) Program commenced in 2004 building on the gains of the Gate’s funded APIN program  APIN Ltd. was incorporated in October 2007 as a local NGO to gradually take over the functions of HSPH PEPFAR in Nigeria.

Outcomes of APIN Project  Capacity Development Human Infrastructural  Established Collaborations Government local institutions  Evidence in support of interventions  Strong Administrative Presence

Triggers to NGO Formation  Human Resource Management challenges  Need to diversify funding base (sustainability plan)  Visionary leadership by project staff, including PI  Support from the Government of Nigeria  Growing complexity of the program outside of Harvard traditional mandates  Track 1.0 deviation waiver and its requirement for transition to local entities

Organizational Governance MEMBERS Professor Adetukunbo Lucas Professor Ibironke Akinsete Professor Souleymane Mboup Professor Michael Reich Professor Richard Marlink Members (5) Directors (10) Officers (3)

Organizational Governance DIRECTORS Prof. Oladapo Ladipo Prof. John Idoko Prof. Saidi Kapiga Dr. Emmanuel Idigbe Dr. Jean-louis Sankalé Prof. Rob Murphy Prof. Wafaie Fawzie Dr. Wole Odutolu* Mr. Farouk Mohammed Prof. Phyllis Kanki

Systems Development  Strategic Information  Human Resources  Finance and Administration  Pharmacy/Logistics  QI/QA  Procurement  Audits

APIN Ltd and Harvard PEPFAR Sites Nigerian states that currently include sites under APIN Ltd & Harvard PEPFAR 1 1

APIN/Harvard PEPFAR Sites: as of 2007 APIN Program Offices Sites Under Harvard PEPFAR Sites Under APIN Ltd 68 Nigerian Army Reference Hospital Nigerian Institute for Medical Research National Military Hospital, ‘Creek’ Lagos University Teaching Hospital University of Lagos, College of Medicine Mushin General Hospital PHC-Iru Victoria Island Onikan Women’s Hospital 68 Nigerian Army Reference Hospital Nigerian Institute for Medical Research National Military Hospital, ‘Creek’ Lagos University Teaching Hospital University of Lagos, College of Medicine Mushin General Hospital PHC-Iru Victoria Island Onikan Women’s Hospital Sacred Heart Catholic Hospital Lantoro Federal Medical Centre Makurdi Jos University Teaching Hospital Our Lady of Apostles Hospital Jos 8 Satellite Hospitals, 44 PHCs Jos University Teaching Hospital Our Lady of Apostles Hospital Jos 8 Satellite Hospitals, 44 PHCs University of Maiduguri Teaching Hospital State Specialist Hospital Maiduguri Nursing Home Maiduguri University of Maiduguri Teaching Hospital State Specialist Hospital Maiduguri Nursing Home Maiduguri University of Nigeria Teaching Hospital Ahmadu Bello University Teaching Hospital Widowcare Abakiliki Ebonyi Federal Medical Centre Nguru University of Ibadan College of Medicine 3 Satellites under UCH Adeoyo Maternity Hospital University of Ibadan College of Medicine 3 Satellites under UCH Adeoyo Maternity Hospital

Site Allocation: Harvard PEPFARAPIN Ltd  Oyo State 43 Oyo State DOTS Centres  Lagos State PHC Iru Victoria Island  Ogun State Sacred Heart Catholic Hospital  Benue: Federal Medical Centre Makurdi  Borno University of Maiduguri Teaching Hospital  State Specialist Hospital Maiduguri  Nursing Home Maiduguri  Ebonyi: Widowcare Abakiliki  Enugu: University of Nigeria Teaching Hospital Ituku- Ozalla  Kaduna: Ahmadu Bello University Teaching Hospital  Lagos 68 Nigerian Army Reference Hospital Nigerian Institute for Medical Research National Military Hospital, ‘Creek’ Lagos University Teaching Hospital University of Lagos, College of Medicine  Mushin General Hospital  PHC-Iru Victoria Island  Onikan Women’s Hospital  Ogun: Sacred Heart Catholic Hospital Lantoro  Oyo University of Ibadan College of Medicine  3 Satellites under UCH Adeoyo Maternity Hospital  Plateau Jos University Teaching Hospital  8 Satellite Hospitals, 44 PHCs Our Lady of Apostles Hospital Jos  Yobe: Federal Medical Centre Nguru

APIN/PEPFAR Sites: 2008 APIN Program Office Sacred Heart Catholic Hospital Lantoro 68 Nigerian Army Reference Hospital Nigerian Institute for Medical Research National Military Hospital, ‘Creek’ Lagos University Teaching Hospital University of Lagos, College of Medicine Mushin General Hospital Onikan Women’s Hospital 68 Nigerian Army Reference Hospital Nigerian Institute for Medical Research National Military Hospital, ‘Creek’ Lagos University Teaching Hospital University of Lagos, College of Medicine Mushin General Hospital Onikan Women’s Hospital PHC-Iru Victoria Island University of Ibadan College of Medicine 3 Satellites under UCH Adeoyo Maternity Hospital University of Ibadan College of Medicine 3 Satellites under UCH Adeoyo Maternity Hospital Federal Medical Centre Makurdi Jos University Teaching Hospital Our Lady of Apostles Hospital Jos 8 Satellite Hospitals, 44 PHCs Jos University Teaching Hospital Our Lady of Apostles Hospital Jos 8 Satellite Hospitals, 44 PHCs University of Maiduguri Teaching Hospital State Specialist Hospital Maiduguri Nursing Home Maiduguri University of Maiduguri Teaching Hospital State Specialist Hospital Maiduguri Nursing Home Maiduguri University of Nigeria Teaching Hospital Ahmadu Bello University Teaching Hospital Widowcare Abakiliki Ebonyi Federal Medical Centre Nguru 43 Oyo DOTS Centres

Site Transitions: Harvard PEPFARAPIN Ltd  Lagos PHC-Iru Victoria Island  Ogun: Sacred Heart Catholic Hospital Lantoro  Oyo 43 Oyo State DOTS Centres  Benue: Federal Medical Centre Makurdi  Borno University of Maiduguri Teaching Hospital  State Specialist Hospital Maiduguri  Nursing Home Maiduguri  Ebonyi: Widowcare Abakiliki  Enugu: University of Nigeria Teaching Hospital Ituku-Ozalla  Kaduna: Ahmadu Bello University Teaching Hospital  Lagos 68 Nigerian Army Reference Hospital Nigerian Institute for Medical Research National Military Hospital, ‘Creek’ Lagos University Teaching Hospital University of Lagos, College of Medicine  Mushin Gen. Hosp.,Onikan Women’s Hosp.  Oyo University of Ibadan College of Medicine  3 Satellites under UCH Adeoyo Maternity Hospital  Plateau Jos University Teaching Hospital  8 Satellite Hospitals, 44 PHCs Our Lady of Apostles Hospital Jos  Yobe: Federal Medical Centre Nguru

APIN/PEPFAR Sites: 2009 APIN Program Office Sacred Heart Catholic Hospital Lantoro University of Ibadan College of Medicine 3 Satellites under UCH Adeoyo Maternity Hospital University of Ibadan College of Medicine 3 Satellites under UCH Adeoyo Maternity Hospital 43 Oyo DOTS Centres Nigerian Institute for Medical Research Lagos University Teaching Hospital Mushin General Hospital PHC-Iru Victoria Island Onikan Women’s Hospital Nigerian Institute for Medical Research Lagos University Teaching Hospital Mushin General Hospital PHC-Iru Victoria Island Onikan Women’s Hospital 68 Nigerian Army Reference Hospital National Military Hospital, ‘Creek’ University of Lagos Coll. of Medicine 68 Nigerian Army Reference Hospital National Military Hospital, ‘Creek’ University of Lagos Coll. of Medicine Federal Medical Centre Makurdi Jos University Teaching Hospital Our Lady of Apostles Hospital Jos 8 Satellite Hospitals, 44 PHCs Jos University Teaching Hospital Our Lady of Apostles Hospital Jos 8 Satellite Hospitals, 44 PHCs University of Maiduguri Teaching Hospital State Specialist Hospital Maiduguri Nursing Home Maiduguri University of Maiduguri Teaching Hospital State Specialist Hospital Maiduguri Nursing Home Maiduguri University of Nigeria Teaching Hospital Ahmadu Bello University Teaching Hospital Widowcare Abakiliki Ebonyi Federal Medical Centre Nguru

Site Transitions: Harvard PEPFARAPIN Ltd  Lagos Nigerian Institute for Medical Research Lagos University Teaching Hospital Mushin General Hospital Onikan Women’s Hospital PHC-Iru Victoria Island  Ogun: Sacred Heart Catholic Hospital Lantoro  Oyo 43 Oyo State DOTS Centres  Benue: Federal Medical Centre Makurdi  Borno University of Maiduguri Teaching Hospital  State Specialist Hospital Maiduguri  Nursing Home Maiduguri  Ebonyi: Widowcare Abakiliki  Enugu: University of Nigeria Teaching Hospital Ituku-Ozalla  Kaduna: Ahmadu Bello University Teaching Hospital  Lagos 68 Nigerian Army Reference Hospital National Military Hospital, ‘Creek’  Oyo University of Ibadan College of Medicine  3 Satellites under UCH Adeoyo Maternity Hospital  Plateau Jos University Teaching Hospital  8 Satellite Hospitals, 44 PHCs Our Lady of Apostles Hospital Jos  Yobe: Federal Medical Centre Nguru

APIN/PEPFAR Sites: Nigerian Army Reference Hospital Nigerian Institute for Medical Research National Military Hospital, ‘Creek’ Lagos University Teaching Hospital University of Lagos, College of Medicine Mushin General Hospital PHC-Iru Victoria Island Onikan Women’s Hospital 68 Nigerian Army Reference Hospital Nigerian Institute for Medical Research National Military Hospital, ‘Creek’ Lagos University Teaching Hospital University of Lagos, College of Medicine Mushin General Hospital PHC-Iru Victoria Island Onikan Women’s Hospital Sacred Heart Catholic Hospital Lantoro University of Ibadan College of Medicine 3 Satellites under UCH Adeoyo Maternity Hospital 43 Oyo DOTS Centres University of Ibadan College of Medicine 3 Satellites under UCH Adeoyo Maternity Hospital 43 Oyo DOTS Centres APIN Program Office Federal Medical Centre Makurdi Jos University Teaching Hospital Our Lady of Apostles Hospital Jos 8 Satellite Hospitals, 44 PHCs Jos University Teaching Hospital Our Lady of Apostles Hospital Jos 8 Satellite Hospitals, 44 PHCs University of Maiduguri Teaching Hospital State Specialist Hospital Maiduguri Nursing Home Maiduguri University of Maiduguri Teaching Hospital State Specialist Hospital Maiduguri Nursing Home Maiduguri University of Nigeria Teaching Hospital Ahmadu Bello University Teaching Hospital Widowcare Abakiliki Ebonyi Federal Medical Centre Nguru

Site Allocation: 2010 proposed Harvard PEPFARAPIN Ltd  Lagos 68 Nigerian Army Reference Hospital Nigerian Institute for Medical Research National Military Hospital, ‘Creek’ Lagos University Teaching Hospital University of Lagos, College of Medicine  Mushin Gen. Hosp, Onikan Women’s  PHC-Iru Victoria Island  Onikan Women’s Hospital  Ogun: Sacred Heart Catholic Hosp. Lantoro  Oyo University of Ibadan College of Medicine  General Hospital Ijebu-Ode  General Hospital Ogbomosho  St. Mary’s Catholic Hospital Eleta Adeoyo Maternity Hospital 43 Oyo DOTS Centres  Benue: Federal Medical Centre Makurdi  Borno University of Maiduguri Teaching Hospital  State Specialist Hospital Maiduguri  Nursing Home Maiduguri  Ebonyi: Widowcare Abakiliki  Enugu: University of Nigeria Teaching Hospital Ituku-Ozalla  Kaduna: Ahmadu Bello University Teaching Hospital  Plateau Jos University Teaching Hospital  8 Satellite Hospitals, 44 PHCs Our Lady of Apostles Hospital Jos  Yobe: Federal Medical Centre Nguru

APIN/PEPFAR Sites: 2010 proposed Federal Medical Centre Makurdi Jos University Teaching Hospital Our Lady of Apostles Hospital Jos 8 Satellite Hospitals, 44 PHCs Jos University Teaching Hospital Our Lady of Apostles Hospital Jos 8 Satellite Hospitals, 44 PHCs University of Maiduguri Teaching Hospital State Specialist Hospital Maiduguri Nursing Home Maiduguri University of Maiduguri Teaching Hospital State Specialist Hospital Maiduguri Nursing Home Maiduguri University of Nigeria Teaching Hospital Ahmadu Bello University Teaching Hospital 68 Nigerian Army Reference Hospital Nigerian Institute for Medical Research National Military Hospital, ‘Creek’ Lagos University Teaching Hospital University of Lagos, College of Medicine Mushin General Hospital PHC-Iru Victoria Island Onikan Women’s Hospital 68 Nigerian Army Reference Hospital Nigerian Institute for Medical Research National Military Hospital, ‘Creek’ Lagos University Teaching Hospital University of Lagos, College of Medicine Mushin General Hospital PHC-Iru Victoria Island Onikan Women’s Hospital Sacred Heart Catholic Hospital Lantoro University of Ibadan College of Medicine 3 Satellites under UCH Adeoyo Maternity Hospital 43 Oyo DOTS Centres University of Ibadan College of Medicine 3 Satellites under UCH Adeoyo Maternity Hospital 43 Oyo DOTS Centres Widowcare Abakiliki Ebonyi APIN Program Office Sites Under Harvard PEPFAR Sites Under APIN Ltd Federal Medical Centre Nguru

IndicatorYear 1 – COP08 Year 2 – COP 09 Cumulative On Care Adult150021,350 Pediatric2001,050 Cumulative On ART Adult Pediatrics No of Sites15 Cumulative on PMTCT Women accessing PMTCT5,00014,200 Women receiving Prophylaxis852 No of Sites26 Annual Budget$1.705m$12.325m APIN, Ltd

Challenges  Stakeholders’ skepticism  Overlapping Harvard/APIN responsibilities  Different funding Cycles – anticipated gap for each year of transition  APIN’s lack of working capital  Implementation of transition Timeline

The Future  Continue to maintain and improve management systems  Improving access to services at the lower levels  Diversify funding base as a plan to sustainability  Continue to receive technical assistance from non- local partners  Ensure the highest level of good business practice and high quality care and treatment for our patients

Thank You AIDS Prevention Initiative Nigeria