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Strategies to Build Capacity for Prevention, Treatment, and Care of HIV/AIDS in Africa

Key Findings

  • Given increasing numbers of patients, shortages of trained medical personnel, and financial constraints, there is a need to provide treatment and services for HIV/AIDS more efficiently.

  • Governments and nongovernmental organizations in Africa can build additional capacity for prevention, treatment, and care of HIV/AIDS by making the most of existing capacities. They can accomplish this by employing appropriate staffing models to optimize impact and utilizing the capacity of local institutions.

  • The United States and other donor countries can play a role in building institutional and human resource capacity to prepare for the long-term burden of HIV/AIDS in Africa by supporting partnerships at all levels, as well as other capacity-building programs.

This chapter describes a variety of strategies to build capacity1 for prevention, treatment, and care of HIV/AIDS in Africa. Strategies for African governments and institutions as well as the United States (and other donor nations) are explored. First, however, the chapter provides a context for these strategies by briefly reviewing the present state of human resources for health care in Africa.

1

The term capacity building is used to describe an initiative in which an organization engages in enhancing a partner’s human, scientific, technological, organizational, institutional, and/or resource capabilities (UNCED, 1992).



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5 Strategies to Build Capacity for Prevention, Treatment, and Care of HIV/AIDS in Africa Key Findings • Given increasing numbers of patients, shortages of trained medical personnel, and financial constraints, there is a need to provide treat- ment and services for HIV/AIDS more efficiently. • Governments and nongovernmental organizations in Africa can build additional capacity for prevention, treatment, and care of HIV/AIDS by making the most of existing capacities. They can accomplish this by employing appropriate staffing models to optimize impact and utilizing the capacity of local institutions. • The United States and other donor countries can play a role in building institutional and human resource capacity to prepare for the long-term burden of HIV/AIDS in Africa by supporting partnerships at all levels, as well as other capacity-building programs. This chapter describes a variety of strategies to build capacity1 for preven- tion, treatment, and care of HIV/AIDS in Africa. Strategies for African govern - ments and institutions as well as the United States (and other donor nations) are explored. First, however, the chapter provides a context for these strategies by briefly reviewing the present state of human resources for health care in Africa. 1 The term capacity building is used to describe an initiative in which an organization engages in enhancing a partner’s human, scientific, technological, organizational, institutional, and/or resource capabilities (UNCED, 1992). 106

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STRATEGIES TO BUILD CAPACITY FOR PREVENTION, TREATMENT, AND CARE 107 PRESENT STATE OF HUMAN RESOURCES FOR HEALTH CARE IN AFRICA As discussed in Chapter 1, current resource constraints in donor nations and the growing HIV-related needs and demand for treatment in Africa are at odds. Lacking well-functioning health systems,2 African nations are ill prepared to confront the looming HIV/AIDS burden of 2020 to 2025. Accordingly, the inter- national community must focus on enabling them to muster the necessary internal resources. A major requirement to this end is to strengthen health care systems, in particular by building institutional and human resource capacity. The Health Workforce Crisis Health workforces play a crucial role in achieving the United Nations’ Mil - lennium Development Goals (MDGs). For example, the supply of health workers impacts the health of women and children. Yet only 5 of 49 low-income countries have the minimum 23 doctors per 10,000 inhabitants, recommended by the World Health Organization (WHO) (WHO, 2010a). Three major forces challenge the health workforce in Africa. First is the devastation of HIV/AIDS, increasing workloads, exposing workers to infection, and trying their morale. Second is accelerating labor migration, causing losses of nurses and doctors from countries that can least afford the “brain drain.” Third is the legacy of chronic underinvest - ment in human resources; frozen recruitment and salaries; and restricted public budgets, depleting work environments of basic supplies, drugs, and facilities (JLI, 2004). Continued underinvestment in the health care workforce is detrimental to staff morale and the ethos of care. In addition to health workers being compensated insufficiently and asked to work under harsh conditions with few supplies and little support, an extreme imbalance exists in the distribution of credentialed health professionals among regions and countries (and by geographic location within the same country). The problem of insufficient human resources for health care is particularly acute in Africa, which bears 25 percent of the world’s burden of disease but is home to only 1.3 percent of the world’s health workforce (Commission for Africa, 2005; High-Level Forum on the Health MDGs, 2004). Currently, an estimated 750,000 health workers serve the 682 million people of sub-Saharan Africa, representing an extremely low health care provider-to-population ratio; by comparison, the ratio is 10 to 15 times higher in Organisation for Economic Co-operation and Development (OECD) countries (see Figure 5-1) (High-Level Forum on the Health MDGs, 2004). 2 As defined by WHO, a functioning health system should include access to adequate financing; essential medical products, vaccines, and technologies; a well-performing health workforce; reliable and timely health information; and strategic policy frameworks to provide effective analysis, over- sight, and governance (WHO, 2007a).

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108 PREPARING FOR THE FUTURE OF HIV/AIDS IN AFRICA FIGURE 5-1 Health worker density by region. SOURCE: JLI, 2004, compiled from WHO, 2004. fig 5-1.eps bitmap Any efforts to stabilize and improve health in the region must address this shortage of human resources for health care. Health care services cannot be delivered in the absence of a viable workforce. Any sustainable solution to Africa’s health problems will require a stable cadre of medical officers, nurses, clinical officers,3 dentists, and allied health workers—not only as clinicians, but also as teachers, managers, and leaders. A 2005 analysis of the human resource requirements of the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) found that providing even 90 minutes of physician time per year to each of the 2 million patients on antiretroviral therapy (ART) would require about 20 percent or more of the existing physician workforce in 5 of the 14 PEPFAR countries (Ethiopia, Mozambique, Rwanda, Tanzania, and Zambia). The severity of the 3 In Africa, medical officers are the equivalent of a physician and have graduated from medical school. Clinical officers have 3-4 years of post−high school education and are able to perform their duties with a fair amount of independence.

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STRATEGIES TO BUILD CAPACITY FOR PREVENTION, TREATMENT, AND CARE 109 human resource shortage was found to vary widely; some countries are much better positioned for a rapid scale-up of services than others (IOM, 2005c). The training of the necessary cadre of health workers, prepared and supported to confront their countries’ health issues, is a key challenge that all African nations must face (SAMSS, 2010). The Lack of Education and Training Educational systems of developing countries are a major impediment to the ongoing production and retention of health workers. Europe produces 173,800 physicians a year and Africa only 5,100 (see Figure 5-2) (Chen et al., 2004; JLI, 2004). One physician is produced for every 5,000 people in Central and Eastern FIGURE 5-2 Regional disparities infnumbers of medical schools and graduates. ig 5-2.eps NOTE: “Region” refers to World Health Organization (WHO) regions. SOURCE: Eckhert, 2002; JLI, 2004.

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110 PREPARING FOR THE FUTURE OF HIV/AIDS IN AFRICA Europe and the Baltic States, compared with one for every 115,000 people in Africa (IOM, 2005a). Similarly, the output of nurses in Africa lags far behind that in economically developed countries of the world. In 2005, for example, Cape Verde had only 100 nursing school graduates and Mozambique just 128, while in 2006, Guinea Bissau had only 62 (WHO, 2010b). The United States has one nurse for every 125 people, while Uganda has one nurse for every 5,000 people. And in all of Rwanda, there are only 11 pharmacists (IOM, 2005a). Universities in low-income countries often face a number of challenges in meeting the need to educate and train the health workforce, including a lack of funds, weak infrastructure, outdated or misaligned training programs, over- crowded classrooms, and overburdened and underpaid staff (Dovlo, 2003; Tettey, 2006). For students in training, the shortage of teachers translates into little men - torship or academic support. Health program graduates are often ill equipped to perform the critical tasks for which they are needed and are unprepared to deal with the challenges of working in underresourced hospitals and clinics (IOM, 2009; Taché et al., 2008; WHO, 2006). The overall lack of opportunity and career advancement results in low morale, providing little incentive to work in academia or the public sector, or even to remain in the country (IOM, 2009). STRATEGIES TO BUILD CAPACITY FOR PREVENTION, TREATMENT, AND CARE OF HIV/AIDS IN AFRICA Governments and nongovernmental organizations in the United States and other donor countries and within Africa can help build capacity for prevention, treatment, and care of HIV/AIDS in Africa. This section details the gaps to be filled by partnering and the structures, systems, and professions necessary to implement partnerships and other capacity-building strategies, and describes promising strategies that can be implemented now by African nations and the United States to prepare for the long-term burden of HIV/AIDS in Africa. Gaps to Be Filled by Partnering Projects made possible through partnerships, including “twinning,”4 can fill a variety of gaps in current HIV/AIDS prevention, treatment, and care programs. With respect to teaching, for example, partnerships increase access to faculty experts currently in short supply in Africa. Partnerships can also: 4 The Interagency Coalition on AIDS and Development defines twinning as a collaboration be - tween two or more organizations that must be formal—including an agreement or contract—and substantive—meaning the interaction spans a period of time beyond a one-time knowledge- or service-seeking interaction (ICAD, 2002; Vian et al., 2007). In the context of this study, twinning is defined as a bilateral, mutually beneficial capacity-building partnership formed to mitigate the effects of HIV/AIDS in Africa.

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STRATEGIES TO BUILD CAPACITY FOR PREVENTION, TREATMENT, AND CARE 111 • acilitate the introduction of new, cutting-edge technologies for labo- f ratories, informatics, logistics, communications, and teaching through training by partners more familiar with these innovations; • rovide a consultation network offering access to high-level technical p consultants for patient care in such areas as clinical care, pathology, radi - ography, and public health; • acilitate access to relatively rare clinical services, such as reference f laboratory support for anatomic or clinical pathology (e.g., pathologic diagnosis of complications of HIV/AIDS); • enable electronic sharing of curricula and library resources; • rovide access to professional development to improve the teaching p ability of faculty; • ssist in developing grant management capacities to enable African insti - a tutions to obtain support for operations research and evaluation; • provide training in operations research; and • rovide resources to strengthen the entire health system, not just clinical p services. Structures, Systems, and Professions Necessary to Implement Partnerships and Other Capacity-Building Strategies The objectives of HIV/AIDS partnerships depend on both the needs and interests of the host country and the resources available to the partner organiza - tions. Careful consideration of the partners’ basic capacity is essential for sustain - able and mutually beneficial partnerships. Each organization involved must have at least the minimum institutional capacity (including staff, capital, infrastructure, and funding) necessary to support the scope of the planned partnership (ICAD, 1999). If staffing is already stretched thin at one or both of the organizations prior to partnering, the endeavor should be reconsidered. Table 5-1 lists the common types of partnerships for capacity building. Additionally, it is crucially important for the partners to engage within not only the cultural and contextual reality but also the governmental and national planning framework of the host country, as well as to coordinate with other orga - nizations on the ground. Successful capacity building supports national health plans and health system development and is fundamentally based in and guided and led by host country partners—particularly since government capacity is itself crucial to the future course of the African HIV/AIDS epidemic. Promising Strategies for Highly Affected Nations in Africa: Making the Most of Existing Capacities Governments and nongovernmental organizations within Africa can build additional capacity for prevention, treatment, and care of HIV/AIDS by making

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112 PREPARING FOR THE FUTURE OF HIV/AIDS IN AFRICA TABLE 5-1 The Partnership Continuum Type of Partnership Description Short-term consultation/technical assistance A partnership involving the transfer of knowledge or skills from an organization in a developed, donor country to individual employees working for a partner organization in a developing country (Jensen et al., 2007). This transfer of knowledge and skills is accomplished through the provision of physical infrastructure (buildings, vehicles, and equipment), formal education and consultation, and training of staff at large (Jones and Blunt, 1999). Individual to individual A partnership involving training, coaching, and mentoring from an experienced individual to a less experienced individual through on-site shadowing, site visits, or telephone/Internet consultation (McCarthy et al., 2006). Institution to institution A long-term collaboration between two • Universities organizations. Institutional partnerships are the • Health care institutions basis for familiar, long-term relationships in • National academies which the partners share values and experiences • Public health institutes (Dada et al., 2009). • Regional/compact bodies • Professional organizations • ivil society and nongovernmental C organizations • Faith-based organizations Government to government A partnering of national governments or subsets and agencies thereof, such as ministries of health, for the purpose of leadership strengthening and information sharing. These partnerships encourage effective “discharge [of the host country’s] responsibilities for stewardship and governance of country-level health systems” (Omaswa and Ivey Boufford, 2010) (Foreword). the most of existing capacities. This section highlights promising strategies that can be used to this end. These strategies fall into two broad categories: employing appropriate staffing models to optimize impact and utilizing the capacity of local institutions.

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STRATEGIES TO BUILD CAPACITY FOR PREVENTION, TREATMENT, AND CARE 113 Appropriate Staffing Models to Optimize Impact In many settings, HIV/AIDS prevention, treatment, and care are provided through complex, overburdened delivery systems that require specialist physi- cians. Yet many in need of these services live in rural settings, far from special - ized care. To illustrate the point, Figure 5-3 shows that 67 percent of the cost of treatment is not for medication, but for the systems used to deliver it to patients and maintain them on it (UNAIDS, 2010a,b). Given increasing numbers of patients, shortages of trained medical personnel, and financial constraints, there is a need to provide services for HIV/AIDS more efficiently (UNAIDS, 2010b). The committee identified a number of strategies that could be implemented to achieve this goal: use of management and support staff, task sharing, harnessing of the informal health sector, use of modern information technology, analytic planning for the health workforce, and investment in women as health workers. Management and support staff The 2008 Kampala Declaration and Agenda for Global Action recommended that “governments, civil society, [the] private sector, and professional organizations [work together] to strengthen leadership and management capacity at all levels” (WHO, 2008a). In addition to health care professionals, scale-up of HIV/AIDS prevention, treatment, and care programs must rely heavily on personnel from outside the clinical health sector who can - - FIGURE 5-3 Breakdown of HIV/AIDS treatment costs in low- and middle-income fig 5-3.eps countries. NOTE: ARV = antiretroviral drug. bitmap SOURCE: UNAIDS, 2010a.

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114 PREPARING FOR THE FUTURE OF HIV/AIDS IN AFRICA TABLE 5-2 Imbalance in Health Worker Ratios Percentage of Total Health Workforce Health Management WHO Region Health Service Provider and Support Ratio Africa 83 17 4.9:1 Eastern Mediterranean 75 25 3.0:1 South East Asia 67 33 2.0:1 Western Pacific 78 23 3.4:1 Europe 69 31 2.7:1 Americas 57 43 1.3:1 The World 67 33 2.0:1 SOURCE: Dare, 2010. Adapted from WHO, 2006. free up time for health care providers to perform clinical work. For example, laboratory technicians can play an essential role in the administration and moni - toring of ART. Other types of personnel with needed competencies include, for example, nutritionists; counselors; behavioral specialists; management personnel; information technologists; procurement and distribution professionals; drug regu- latory professionals; data analysts; and experts in monitoring, evaluation, and operations research. Furthermore, it is important that management and support functions be performed by personnel with expertise in those roles and not by clinical service providers, whose time is much better spent attending to medical matters. Yet as Table 5-2 shows, there is a global imbalance in health worker ratios. In the Americas, the ratio of clinical service providers to management and support staff is almost 1:1; in Africa, that ratio is almost 5:1 (Dare, 2010; WHO, 2006). A considerable increase in clinical care could be delivered without adding more clinicians if the management and support capacity of others in HIV/AIDS preven- tion, treatment, and care were increased. Task sharing Sharing of roles and responsibilities is not a new concept in the provision of health care; realignment of roles and responsibilities has been a long-standing response to changing health care needs, particularly in emergency situations or underserved areas.5 As a result of the HIV/AIDS crisis, the con- cept has reemerged with increased urgency. One term used to describe shared or realigned responsibilities is “task shifting.” WHO defines task shifting as 5 In fact, what is sometimes understood as realignment of roles is actually formal recognition of the contributions of health workers that have previously been “invisible.” For example, midwives were important providers of obstetrical services even before physician involvement in obstetrical care, but may now be seen as having “inherited” this responsibility from physicians as their roles have become more prominent.

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STRATEGIES TO BUILD CAPACITY FOR PREVENTION, TREATMENT, AND CARE 115 the process whereby specific tasks are transferred, when appropriate, to health workers with less training and fewer qualifications (WHO, 2008c). Although this term does not adequately encompass the concepts of realignment and recognition of appropriate responsibility, it does capture a narrower and sometimes temporary arrangement to meet emergency needs. The underlying assumption is that shifting specific tasks enables more efficient use of existing human resources and eases bottlenecks in service delivery. When additional human resources are needed, task shifting may also involve the delegation of some clearly delineated tasks to newly created cadres of health workers who receive specific competency-based training (WHO, 2008c). The delegation of the health care responsibilities of nurses, physicians, clinical officers, dentists, and other health professionals to others, including community health workers, has been effective in addressing the severe human resource shortages in many African countries (Buchan and Poz, 2003; Glenngård and Anell, 2003; Morris et al., 2009). Because these responsibilities require not only skills but also relevant knowledge, this delegation goes beyond the mere performance of specific tasks. The committee has therefore elected to use the term “task sharing” rather than “task shifting” in this report. Task sharing that is needs-based, is not hierarchical or territorial, and allows roles to expand or con - tract according to need is the most appropriate approach to health care delivery in low-resource environments. Health workers who are normally viewed as auxiliary are increasingly becoming the main providers of health services in many countries. In Africa, for example, nurse aids, medical assistants, and clinical officers are performing essential medical tasks, especially in rural areas. A good example is Malawi, where clinical officers are a major resource, performing surgical procedures and administering anesthesia, as well as providing medical care (Hongoro and McPake, 2004). Another example is South Africa, where the unprecedented challenges of people requiring care and treatment for HIV/AIDS are forcing a rethinking and reorganization of health resources and health systems and a reappraisal of the role of nurses in care for complex and chronic illnesses. South Africa’s health system has historically been nurse driven, and nurses outnumber physicians five to one. Yet while the majority of the population receives formal health care from nurses rather than doctors, it is clear that nurses have been insufficiently empowered, resourced, and compensated to carry out their key roles effectively (Dohrn et al., 2009). Developing HIV/AIDS expertise among nurses has become a national priority, as is illustrated in South Africa’s National HIV/AIDS Stra - tegic Plan (South African Department of Health, 2006). Accordingly, the South African Department of Health initiated new certificate courses in prevention of mother-to-child transmission (PMTCT) and ART for nurses in 2002 (Dohrn et al., 2009). The new ‘‘PMTCT nurses’’ and ‘‘ART nurses’’ are the unofficial gatekeepers of HIV/AIDS knowledge and skills at the primary health care level.

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116 PREPARING FOR THE FUTURE OF HIV/AIDS IN AFRICA They direct HIV testing and counseling services, prepare patients for ART initia - tion, diagnose and manage side effects and opportunistic infections, partner with midwives to provide PMTCT services during the perinatal period, and provide early infant diagnostic services. They are trained to refer patients ready for ART initiation and those with advanced illness and complications (Dohrn et al., 2009; Morris et al., 2009). A recent randomized controlled trial in South Africa compared nurse and physician management of HIV-infected patients receiving ART at two South African primary care clinics and found that primary health nurses were noninfe - rior to doctors in monitoring of first-line ART (Sanne et al., 2010). The inclusion of PMTCT and ART initiation programs in health service basic training programs within African institutions of higher education (rather than during in-service training) could alleviate much of the need for posteducation in-service training and prepare graduates who can enter the workforce capable of initiating and managing ART and related complications. The expansion of the numbers and roles of auxiliaries whose qualifications are not internationally recognized appears to be a quiet success story, providing large numbers of health workers who keep the system running in a number of countries (Hongoro and McPake, 2004). These alternatives are worth investi- gating given that there is a long lead time to increase the health care workforce. Depending on the type of degree and the specific country, the amount of training required can vary. For example, in South Africa it takes 4 years to train nursing or midwife students, 2 years to train pupil nurses, and 1 year to train pupil nursing auxiliaries (South African Nursing Council, 2010). By contrast, in Mozambique basic nurses are educated to grade 10 and have an additional 18 months of training; medium nurses are also educated to grade 10, but receive an additional two and a half years of training thereafter; and superior nurses are educated through grade 12 and must graduate from a 4-year university with a baccalaureate degree (August-Brady, 2010). As with nurses, the amount of training required for physicians varies by country. In Mozambique it takes a medical student 7 years to attain a medical degree (Ferrinho et al., 2010). In South Africa, medical school courses last 5 years (University of KwaZulu-Natal, 2010), followed by 2 years of internship and 1 year of community service, for a total requirement of 8 years to become a practicing physician. Task sharing may not be readily accepted by various professions. Physicians and pharmacists have objected to the delegation of their tasks to those whom they perceive as professionals with less specialized training, while nurses have resisted taking on physicians’ roles without commensurate salary increases. Policies to enable task sharing, such as remuneration packages and clear job descriptions and strategic plans delineating professional boundaries and responsibilities, need to be established (Zachariah et al., 2009). The pivotal issue for the sustainability of task sharing will be how governments and international and bilateral organiza - tions help prepare health systems to implement the practice, develop adequate

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STRATEGIES TO BUILD CAPACITY FOR PREVENTION, TREATMENT, AND CARE 137 cost of maintaining such numbers of staff may be prohibitive in some settings. In addition, stagnant funding is increasing the burden on the program to expand services while working with fewer resources (USAID-AMPATH, 2010). More pressing priorities Some organizations involved in twinning or other partnership or training programs may need to devote all of their energies to the survival of their regular programs (ICAD, 1999). This pressure is bilateral; both partners have pressing priorities beyond the twinning project or partnership. In some countries, a program may not be seen as contributing to PEPFAR goals. Those goals call for reaching large numbers of people with services; some 85 percent of U.S. funds going to Africa have been for PEPFAR, so this is a high priority for U.S. missions in the region. Twinning projects are thought to con - tribute relatively little to the achievement of PEPFAR’s goals, and it is not always clear at the outset how such projects may fit into broader country plans. Hence it has sometimes been difficult to obtain buy-in for projects in Africa for which twinning would be appropriate, and some of the earliest twinning projects in the region could not fit readily into the existing programs of U.S. government teams (Conviser, 2009). Time frame of results Relative to one-shot technical assistance programs, twin- ning programs take time to establish because they depend on the development of institutional and interpersonal relationships. Also, twinning programs require about the same amount of administrative oversight from in-country U.S. govern- ment agencies as larger-budget PEPFAR programs and may be slower to produce results. In-country U.S. government teams have often felt it was not worth the effort to fund relatively small projects that require roughly the same amount of attention as far larger PEPFAR initiatives (Conviser, 2009). Lack of appropriate infrastructure Most African organizations lack an estab- lished infrastructure equipped to serve twinning or training projects (ICAD, 1999), and many of those evaluated have noted information technology chal - lenges (Kangas et al., 2010). Several twinning projects (including projects in Botswana, Zambia, and Ethiopia) have reported that technology was a challenge in maintaining the twinning relationship. Fragile e-mail systems made it dif - ficult to exchange information between partners. Limited access to electricity and telephone landlines was also cited as hampering communication between partners (Conviser, 2009). The AMPATH partnership in Kenya reported dif- ficulties in encouraging patients’ continued compliance with ART (with a rate of loss to follow-up of 1.6 percent in the first quarter of 2010) as a result of several constraints, including limited access to program vehicles, a lack of reli - able public transportation for both outreach staff and patients, and inadequacy of the electronic tracking system in locating patients. Some health care facilities

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138 PREPARING FOR THE FUTURE OF HIV/AIDS IN AFRICA lacked supplies needed to provide STI care, such as patient education materials, condoms, and contact slips (I-TECH, 2009d; Weaver et al., 2008). Extra strain on overburdened staff In low-resource countries, the human resource crisis leaves hospital staff members extremely busy, limiting their com - munication with twinning partners between visits. The amount of administrative work required for the relatively small-scale twinning projects does not differ significantly from the amount of work necessary for much larger projects, chal - lenging small and already overburdened staff (Conviser, 2009). AMPATH’s out- reach and follow-up with current patients, for example, were challenged by a shortage of staffing, as reported in the quarterly PEPFAR performance review for January−March 2010 (USAID-AMPATH, 2010). Lack of an in-country coordinator The AIHA HIV/AIDS Twinning Center’s evaluation described one challenge particular to that organization. The absence of U.S. Health Resources and Services Administration (HRSA) representatives from U.S. government teams or an AIHA office in Africa makes it more adminis- tratively complex for other U.S. government agencies to fund twinning projects: U.S. government agencies must designate the funds for HRSA, which passes them on to AIHA, which provides them to the partners. The funding agencies also must do a substantial amount of administrative work on these small-ticket projects, whose impact in meeting PEPFAR goals, as noted above, may be both minor and delayed. There needs to be a single point of contact for both HRSA and the organization serving as its agent in overseeing twinning projects in Africa, with regular scheduled communication between them. This would help promote both advocacy and accountability in twinning projects, although it would come at the cost of increased work for HRSA’s agent(s) in Africa (Conviser, 2009). RECOMMENDATIONS Recommendation 5-1: Analyze and plan for meeting workforce require- ments. African governments and international organizations should assess and plan for meeting national workforce requirements for responding to the long-term burden of HIV/AIDS. • ecommendation 5-1a: Through partnership programs and other R investments, African governments and institutions, along with U.S. private companies, academic institutions, foundations, and civil society organizations, should establish national databases and information sys- tems for health care worker statistics, as well as bolster the analytic capacity of national planners for determining human resource needs. • ecommendation 5-1b: African governments and institutions should R create staffing models to optimize the impact of the health care work -

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STRATEGIES TO BUILD CAPACITY FOR PREVENTION, TREATMENT, AND CARE 139 force. Such models should include developing cadres of managers and support staff outside the clinical health sector, encouraging needs- based training and task sharing within the health sector, focusing on retention through compensation and other incentives, utilizing infor- mation technologies, and harnessing the informal health sector. • ecommendation 5-1c: In Africa, governments and institutions R should work together in planning the African health care workforce based on projected needs derived from national data and analyses of future human resource requirements. Such planning should involve ministries of health, education, finance, public service, and labor. The private sector and the academic and medical communities should also be brought to the table for such national human resource planning exercises. Recommendation 5-2: Utilize existing African capacity. African govern- ments and international donors should recognize, invest in, strengthen, and utilize currently existing capacity within African institutions and networks to provide local solutions for responding to the HIV/AIDS epidemic. This capacity includes South−South and regional partnerships, universities, African science academies, national public health institutes, and other net - works within Africa. Recommendation 5-3: Develop government leadership and management in health. U.S. government agencies and programs, foundations, and academic institutions should invest in the development of African leadership and man - agement in the health sector. • ecommendation 5-3a: U.S. government agencies, such as the Health R Resources and Service Administration (HRSA), the U.S. Agency for International Development (USAID), and the U.S. Centers for Disease Control and Prevention (CDC) and its global counterparts, should be actively engaged in leadership and management development, and the International Association of Public Health Institutes should be tapped as a resource for advancing these efforts. • ecommendation 5-3b: U.S. foundations and academic institutions R should invest in African leadership and management development through programs that educate African scientists and scholars who may then take on leadership positions in their own countries. Recommendation 5-4: Invest in innovative partnerships. Private-sector organizations, professional organizations, faith-based organizations, aca- demic and research institutions, militaries, foundations, and civil society organizations should increase funding for and participation in meaningful,

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140 PREPARING FOR THE FUTURE OF HIV/AIDS IN AFRICA effective, and innovative partnerships designed to build African capacity now to address the full extent of the HIV/AIDS burden over the next 10 years. • ecommendation 5-4a: New U.S.−African partnerships between R local vocational or technical schools that train allied health profes - sionals, laboratory technicians, informatics specialists, and/or health administrators should be explored and encouraged. • ecommendation 5-4b: Innovative North−South and South−South R partnerships that build human resources for health should be devel- oped. In North−South partnerships, African counterparts should take the lead in developing and controlling the partnership agenda. As a final note, the committee emphasizes that a formidable gap exists between innovations in health (including vaccines, drugs, and strategies for care) and their delivery to communities in the developing world (Madon et al., 2007). Many of the recommendations in this chapter imply a need to perform opera- tions research11 (OR) and implementation research12 (IR)—as well as ongoing evaluation—of programs, partnerships, and interventions aimed at combating HIV/AIDS in Africa. Such efforts can identify the optimal and most efficient approaches for carrying out the committee’s recommendations. Because HIV/ AIDS is a mosaic of epidemics in Africa (see Chapter 1), programs and poli - cies will require tailoring to local circumstances. There is a wide range of OR opportunities in capacity building for HIV/AIDS, including identifying the best methods for: • obtaining and delivering commodities in the health system; • making mass treatment more feasible; • managing patients on fewer doses of ART; • reating for a period of time and then stopping treatment, but monitoring t the patient; • reventing infections and changing behavior in a particular context or risk p group; • sing new communication tools and social media to reach those in need u of prevention messages; • scaling up information and communication technology; • employing task/responsibility sharing; • packaging together interventions for HIV/AIDS, TB, and other diseases; 11 Operations research seeks to identify and address barriers related to the performance of specific projects (Madon et al., 2007). 12 Implementation research seeks to create generalizable knowledge that can be applied across set - tings and contexts to answer central questions (such as how multiple interventions can be packaged effectively to capture cost efficiencies and to reduce the splintering of health systems into disease- specific programs) (Madon et al., 2007).

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