When Dr. Charles Holmes left the office of the U.S. Global AIDS Coordinator to come to Zambia at the end of 2012, he had a plan that was both modest and ambitious. He was going to use what he had learned as Chief Medical Officer for the world’s largest program dedicated to a single disease, and build the impact of a local program in a resource-challenged country addressing a spectrum of health issues.
Even before his work for the President’s Emergency Plan for AIDS Relief (PEPFAR), he had been a believer in the combined power of medicine and management. Having witnessed the devastation of Malawi’s AIDS epidemic at a time when treatment was saving lives in the U.S., but not in Africa, he had studied, and helped prove the value of cost-effectiveness analysis both in building health responses, and in building support for them. At PEPFAR, his responsibilities had included not only ARV treatment and PMTCT programs, but programs providing care and support for patients before treatment, and TB programs. He had helped introduce implementation science – the science of analyzing goals, costs, and outcomes – to maximize the reach and effectiveness of PEPFAR programs. He also had headed the program’s first Scientific Advisory Board which provided input on evidence supporting the value of PEPFAR investments.
Now, he wanted to see the principles that had brought life-saving medicine to people around the world at work on the ground every day, and make the difference a lasting one. He wanted – he told the CIDRZ staff when he arrived – “to write the next great chapter in the response to HIV and broader health issues.”
He took the role of Chief Executive Officer of CIDRZ at a turning point. Three years earlier, international organisations providing services through their own programs with PEPFAR support had been given a deadline to turn those programs over to local control, with local boards and management teams that are at least 75 percent local. That deadline had passed when Holmes landed in Lusaka, where CIDRZ is based. CIDRZ had been started a decade earlier by researchers from the University of Alabama. Recently, its in-country leadership had returned to the U.S., to another university. Holmes found a nascent organisation, independent since 2011, and struggling to gain the confidence of donors.
“The first order of business was to build a foundation of stability,” Holmes said recently. With the animation some people show when they talk about art, literature, or popular culture Holmes lights up when he talks about establishing order. CIDRZ went through a series of audits, and with the help of funders, it underwent a governance review to find out what needed to be done. It upgraded its management technology. It recruited board members with proven records, drawing “on the strongest business and medical leadership in the country.” That meant getting referrals, checking references, looking at the performance of organisations for which prospective members had previously served on the boards.
The board now has six local board members, including a leader of the Zambian national pension authority leading the Investment Committee, and three international members, including Dr Eric Goosby, former U.S. Global AIDS Coordinator, and now United Nations Special Envoy on Tuberculosis. Dr Izukanji Sikazwe, a Zambian physician who earned her medical degree in Zambia before going on for internal medicine and infectious diseases training in the U.S. is CIDRZ’s deputy chief executive officer.
“This is what a local organisation looks like,” Holmes said.
Building relationships with the government, to ensure its continued commitment and ongoing investment was critical, Holmes said, but so was clarifying, and diversifying its relationship with external partners, to ensure its autonomy and control over work agreements. “The payoff,” he said, “we have gained the confidence of donors.” CIDRZ has been granted an Equivalency Determination that allows donors to treat it as a U.S. nonprofit, above the level of reporting required of overseas organisations.
In the last year the past and the present came together, with a grant from the Bill and Melinda Gates Foundation to launch the “BetterInfo” study. The study will trace ARV treatment patients, learn their outcomes, and the factors surrounding those outcomes, with a goal of helping programs and facilities understand reasons patients are lost to follow up care, and meet their needs. The idea for the study had its genesis in a PEPFAR Scientific Advisory Board presentation by physician researcher Elvin Geng, who has focused in recent years on finding local reasons for care outcomes.
Word on another grant is pending. In time, Holmes pictures CIDRZ continuing to advance, and eventually without him. “It takes time and energy, but what a great development spillover if you can take the time to do that right,” he said. “If donors and others take the time to appreciate the local environment, you can elevate an organisation.”
Author: Antigone Barton, Center for Global Health Policy