AIDSTAR-Two: Building Civil Society and Other Organizational Capacity for Country-Led HIV & AIDS Programs

Ummuro Adano

Donors, national governments, civil society, and international partners are grappling with three realities in the domain of HIV and AIDS today: (1) the need to accelerate country ownership and leadership of HIV and AIDS programming; (2) diminishing donor resources; and (3) the need to strengthen local implementing organizations and institutions to sustain the AIDS response in terms of: access to prevention, treatment, care, and support services; addressing stigma, discrimination and human rights abuses that key populations continue to face in many parts of the world; and supporting orphans and vulnerable children, their caregivers, and people living with HIV (PLHIV).

Funded by the USAID Global Health Bureau/Office of HIV and AIDS, AIDSTAR-Two is addressing these realities: contributing to stronger and more sustainable, country-led HIV and AIDS programs, organizations and networks by offering systematic organizational capacity building. MSH interviewed AIDSTAR-Two’s Deputy Director and Senior Technical Advisor for Capacity Building Ummuro Adano on the connections between civil society and country-led HIV & AIDS programs in developing countries.

When we talk about “country ownership” in relation to the AIDS response, most people think about the government’s response or government programs. But the AIDSTAR-Two project has worked extensively with civil society in the AIDS response. Can you talk about the relationship between civil society, country ownership, and the fight against HIV and AIDS?

The interest in country ownership is related to many factors, including a growing realization that the effectiveness of external development assistance—including the HIV and AIDS response—will be enhanced when local people and their own organizations and institutions set priorities, genuinely own and control development initiatives, learn from experience, and strengthen institutions and practices needed to sustain progress.

Two other factors are: (1) the demand for accountability and results, and (2) the need to help countries help themselves and ultimately move beyond aid. Most agree that this requires, at a minimum, a commitment to respond to locally-driven needs as well as solutions and strategies co-created or designed by the countries themselves.

Additionally, in the context of country ownership, there is an implicit assumption that “ownership” requires “owners.” Such owners, however, cannot be confined to the top leadership of central government, as ownership also requires action and support from leaders at the regional, district, community level, as well as across all sectors, including civil society and the private sector.

How is civil society helping advance the national response? Can you give some examples of countries where CSOs are succeeding, or struggling, to affect change?

Civil society organizations (CSOs) have, since the start of the epidemic, been advocating for access to quality services; advocating for human rights and an end to stigma and discrimination; and providing prevention, care, support and treatment services to millions of people.

In Malawi, CSOs provide nearly 45 percent of health services in the country. In fact, that is a common trend in many developing countries – putting civil society players at the forefront of the AIDS response, especially for key populations. The Government of Malawi has a long standing Memorandum of Understanding with faith based organizations, through the Christian Health Association of Malawi (CHAM), to cooperate and extend health services to rural populations. Through this partnership, the Government pays salaries and benefits for health workers deployed in CHAM health facilities. I think this is a laudable example of collaborative leadership and partnership at country level that will help countries to translate country ownership principles into actionable practices. But it’s worth pointing out that strong leadership within organizations and institutions and a high degree of collaboration among leaders of these sectors will be required for such partnerships to be sustained.

AIDSTAR-Two has also strengthened the organizational, networking, communications, advocacy, and HIV service delivery capacity of multiple civil society organizations in the Middle East and North Africa (MENA) region, where people living with HIV (PLHIV) and key populations face such heavy stigma and discrimination, and even deadly attacks in some cases. These populations remain isolated from society and government authorities often treat them as criminals, posing one of the most crucial challenges in the AIDS response in the region. Such a pervasively hostile environment has  forced the concentrated epidemic underground, while allowing HIV  to spread into the general population. But a coalition of courageous and committed NGOs are working hard to break the silence around an ignored issue, raise awareness around the rights of these affected populations, and also provide them with much needed services.  

Sustainability is a big issue for civil society organizations and nongovernmental organizations, and this is particularly true in a changing development landscape, where PEPFAR funding isn’t expected to continue after this round (PEPFAR 2), and there’s a rising focus on other disease areas such as non-communicable diseases. Are there things we can do to enhance the sustainability of CSOs and NGOs?

MSH defines sustainability in a systemic way, focusing not only on financial sustainability, but also on the institutional and programmatic sustainability of an organization. In terms of institutional sustainability, our definition states that a well-managed organization is able to consistently adapt its governance practices, structure and systems to remain mission-driven and market- adjusted, allowing the organization to respond to the shifting priorities of its supporters and to new responsibilities towards its clients, while creating a positive work climate for its staff. And by financial sustainability we mean that a well-managed organization is able to consistently secure, manage, and report on the use of revenue from various sources (e.g., user fees, grants, and contracts) to support its ongoing programs and undertake new initiatives. In the case of programmatic sustainability, we are looking at a well-managed organization that is able to deliver quality products and services that respond to its clients' needs and to anticipate new areas of need and is supported by a strong knowledge management system. 

Over the years, MSH has supported many CSOs across the globe to strengthen all these dimensions of sustainability. We have assisted these organizations to develop strategic plans, business plans and resource mobilization plans. We have taught them how to manage grants, write winning proposals, and strengthen their internal HR, financial, administrative and M&E systems. We have worked with them to strengthen leadership and governance. We have worked with them on communications, advocacy, building partnerships and reporting results. But when it comes to financial sustainability, a major gap for most CSOs, there is no right answer. At the end of the day, it is up to the leaders and board of each organization to consider all the funding options available and to choose the most appropriate mix, just as they must determine which core activities and implementation strategies are most appropriate to their mission and goals.

On the other hand, civil society organizations cannot forever rely on donor funding for their existence. As such, some of the things that we can do to enhance the sustainability of CSOs include providing them with targeted technical support and innovations to consider diversification, including fee for service, grants, public/private partnerships, social impact bonds, and microenterprise.

But in certain cases, some of these organizations may consider changing mission or even closing if the organizational relevance no longer exists.

Last summer, I was doing some work in Uganda and met with Professor Elly Katabira, a leading AIDS researcher in Africa and one of the founders of The AIDS Support Organization (TASO), the largest and one of the most successful AIDS NGOs in East Africa. Professor Katabira said:

Our vision says: A world without AIDS. It is very simple and we truly believe in it. And if AIDS disappeared today, we will close TASO the following day. Our task would have been accomplished. We will not hang around and try to reinvent ourselves. We are not that kind of NGO.

The AIDSTAR-Two project is now in its fifth and final year. Has organizational capacity development contributed to strengthening the AIDS response? If so, how?

We need to be clear about one fact: the AIDS response, at any level, requires strong and capable organizations.  There is no other way to deliver services efficiently and effectively and sustain these services over time except through strong organizations and organized communities. Indeed, human development itself cannot succeed without viable organizations.

Under AIDSTAR-Two, we have designed most of our capacity building interventions based on our Capacity Building Framework, which defines capacity building as an on-going evidence-driven process to improve the ability of an individual, team, organization, network, sector or community to create measurable and sustainable public health results. Our technical approach is informed by the following principles that underpin the way the project conceptualizes, designs, implements, monitors and evaluates organizational capacity strengthening and sustainability interventions: (1) ownership and leadership; (2) demand-driven technical support; (3) participation; (4) context-specific; (5) evidence-based capacity building practices; (6) results-oriented capacity building; and (7) learning and knowledge exchange.

As a result of investments in organizational capacity, we have seen the number of people accessing service grow, and the number of key populations in target communities reached with services and interventions also increase. For example, through AIDSTAR-Two’s work with CSOs in Honduras, in 2012, the CSOs achieved 100% of their targets for different PEPFAR indicators in their performance monitoring plans. In addition, their financial and technical monthly monitoring and reporting capacity and overall contract compliance was very strong. The Honduras project was later able to successfully transition its contracting mechanisms with the CSOs to the Honduran Health Ministry in an effort to support the scale up and sustainability of promotional and preventative HIV services to key populations. This was a major step forward toward achieving country ownership.

Learn more about AIDSTAR-Two