HFG Burundi Final Country Report
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The document summarizes USAID's efforts over 3 years to strengthen the organizational capacity of Burundi's National HIV/AIDS Program (PNLS). Through training, workshops, and technical assistance, PNLS improved in key areas like strategic planning, project management, coordination, and monitoring. This enabled PNLS to take on greater leadership of Burundi's HIV response, including becoming the principal recipient of Global Fund grants. The transformation of PNLS from a weak to effective organization illustrates the importance of building both technical and foundational management capacities.
HFG Burundi Final Country Report
- 1. USAID’s Health Finance and Governance (HFG) project helps to improve health in developing countries by expanding people’s access to health care. Led by Abt Associates, the project team works with partner countries to increase their domestic resources for health, manage those precious resources more effectively, and make wise purchasing decisions. HFG BURUNDI FINAL REPORT ©2014JHSPH,CourtesyofPhotoshare
- 2. Strengthening National Leadership of Burundi’s HIV and AIDS Response BURUNDI Introduction This brief describes the process of strengthening the organizational capacity of the Ministry of Health’s HIV/AIDS program (PNLS) in Burundi from 2013 to 2016. The story of this activity is a remarkable one. In the course of the three years, PNLS went from an ineffective and weak organization to being selected as the Global Fund Public Sector Principal Recipient. This document tells the story of this transformation. PNLS Organizational Capacity Building Background Burundi’s HIV prevalence rate in 2015 is estimated at 1.4% (1.0% among men and 1.7% among women of ages 15-49 years)i. The 2012-16 National Strategic Pl an for the Fight Against AIDS outlines strategies towards “Zero new HIV infections, zero discrimination and zero AIDS-related deaths”ii. Burundi’s National HIV/AIDS Program (PNLS) was created in 2011 and was tasked with leading the long-term implementation of the Ministry of Health’s HIV/AIDS programs. However, it clearly lacked strong management and organizational capacity, resulting in weaker HIV and AIDS program outcomes.
- 3. BURUNDI Strengthening National Leadership of Burundi’s HIV and AIDS Response2 PNLS’s lack of such capacity resulted in strategies that were not operationalized, programs and plans that were not well implemented, stakeholders that were not well coordinated, provinces that were not able to plan and manage their activities, and inadequate mobilization of resources, all of which contributed to weaker HIV/AIDS outcomes. Numerous U.S. Agency for International Development (USAID) and Government of Burundi documents have cited the importance of developing national-level government capacity. The National Health Development Plan 2011-2015 pointed out the importance of strengthening the management and coordination of the national HIV and AIDS response. The 2012 PEPFARiii Country Operational Plan prioritized support by providing technical assistance at the central level for institutional capacity building of the Ministry of Health's HIV/AIDS Program to improve its ability to provide supervision, quality assurance, monitoring and evaluation, and training at the provincial level. These and other documents clearly highlighted the recognition by both the Burundian government and USAID/PEPFAR of the importance of strengthening national-level capacity to carry out core functions in order to achieve better HIV and AIDS results. To address PNLS’s lack of organizational capacity, USAID/Burundi requested assistance from the Health Finance and Governance (HFG) project. Over a three-year period beginning in 2013, HFG worked closely with PNLS staff to develop their organizational capacity. PNLS is comprised of 38 staff assigned to five divisions – Preventing Mother-to- Child Transmission (PMTCT), Care and Treatment, Monitoring and Evaluation, Community Mobilization, and Management. The program is led by a Director and his Deputy Director. Capacity-Building Approach The overarching goal was to strengthen PNLS to be able to fulfill its core functions of planning, implementing, and monitoring HIV and AIDS activities in Burundi, leading to greater access to services and improved health outcomes. HFG took a comprehensive approach to organizational capacity building based on the premise that organizations must have organizational and management capacity as well as technical capacity to be effective. A comprehensive approach is aimed at strengthening foundational management capacity, such as the capacity to develop strategies and plans, clarify its role and functions, implement its activities, mobilize the resources for basic operating costs, and exercise effective internal leadership and management. These basic management capacities would enable PNLS to carry out its core functions that include: Strategic and operational planning and budgeting; Program implementation; Monitoring and evaluation of program implementation; Supervision of provincial offices to support decentralization and improve implementation at the subnational level; and Coordination of internal ministry of health offices and external stakeholders to ensure alignment with national policies and plans. The Burundian Minister of Health, Dr. Sabine Ntakarutimana, hands over IT equipment donated by the US Ambassador to Burundi, Dawn Liberia, on behalf of USAID, to the Director of the National HIV/AIDS Program, Dr. Hilaire Ninteretse.
- 4. 3BURUNDI Strengthening National Leadership of Burundi’s HIV and AIDS Response The first step was to conduct an organizational assessment that also served as a baseline against which to measure progress. The assessment was based on a tool developed by HFG specifically for government offices within ministries of health. The tool is constructed around seven dimensions of organizational performances. 1. Role and functions: clearly defined organizational mandate and functions; 2. Strategy and planning: capacity to develop long term strategies and short and medium term operational plans to implement the strategy 3. Project and program management: capacity to plan, monitor and manage the activities of the organization 4. Coordination and communication: Ability to assess interests and fully engage with and coordinate the activities of stakeholders 5. Organizational structure: Adequacy of the organizational structure and staffing to carry out core functions including clarity of individual roles and responsibilities 6. Leadership and management: Effectiveness of leaders and managers to set direction and plan and implement strategies 7. Resources: Adequacy and efficient use of resources for basic functioning and capacity to advocate and mobilize own resources The assessment consisted of a web-based survey; individual interviews with the director, deputy director, and the five division chiefs; focus groups for each division; and interviews with six technical and financial partners that regularly interact with PNLS. Based on the findings from the assessment, HFG developed a framework for three years and a work plan that was updated each year. The assessment also served to provide a baseline against which progress was measured after 18 months and at the end of 3 years. The PNLS staff present their operational plan to stakeholders—the first operational plan since PNLS was established in 2011, intended to guide their activities and collaboration with implementing partners.
- 5. BURUNDI Strengthening National Leadership of Burundi’s HIV and AIDS Response4 1. Strengthening basic management practices - Developed an organizational vision - Leadership and management training - Built effective work teams, - Created a senior management team - Facilitation and presentation skills training - Management coaching - Updated job descriptions - Provided IT equipment 2. Strengthening core functions - Stakeholder engagement skills training - Built project management skills - Operational planning and monitoring and evaluation training - Developed a national supervision strategy - Training of trainers - Developed plan for external communication 3. Application of skills in carrying out core functions - Developed PNLS operational plan - Validated operational plan and supervision strategy with external stakeholders - Established coordination mechanism for other MOH offices and partners - Prepared PNLS for their role as Global Fund Principal Recipient Figure 1 shows how HFG assistance unfolded in three mostly sequential phases. Phase 1 focused on strengthening basic internal management, Phase 2 on strengthening core functions, and Phase 3 on application of newly acquired capacities and consolidating the gains. Figure 1. Three Phases of Organizational Capacity Building Table 1 summarizes PNLS capacity before and after HFG’s capacity building assistance. Table 1. PNLS in 2013—Before and After Technical Assistance Before HFG’s Technical Assistance Outcomes After HFG’s Technical Assistance PNLS had no vision, strategy or operational plan. Staff roles and responsibilities were not defined. Internal management was very centralized with little delegation to the divisions. PNLS was dependent on outside funding for nearly all activities. There was no system for project management. Teamwork within PNLS was almost non-existent. Basic operating resources were lacking. PNLS was not coordinating activities of its implementing partners. PNLS Organizational vision developed 2015-16 Operational plan developed Coordination mechanism for partners established Supervision strategy developed and implemented Core group of 10 trainers created Established senior management team consisting of director, deputy director, and five division chiefs Strengthened division teams Clarification of individual roles and responsibilities Improved working conditions, e.g. IT equipment, renovation of meeting room, provision of office furniture Culture of participatory management established
- 6. BURUNDI Strengthening National Leadership of Burundi’s HIV and AIDS Response 5 To achieve these outcomes, HFG used a range of organizational capacity building techniques including training, participatory workshops, organizational retreats, individual coaching, task forces, and regular follow-up. The newly strengthened PNLS was able to pass stringent Global Fund criteria around financial management, governance/ project management, monitoring and evaluation and procurement and supply management to become the Principal Recipient in 2016 for Global Fund’s new Funding Model for HIV/AIDS. HFG’s activities concluded with preparing PNLS for its role as the Global Fund Principal Recipient. HFG assisted PNLS in organizing a workshop for 25 PNLS staff to share the Global Fund Concept Note, define the role of PNLS as the Principal Recipient, and become familiar with key background documents. This workshop was a key step in helping PNLS gear up to meet its responsibilities as the public sector Principal Recipient. HFG also prepared and implemented a close-out workshop for PNLS and its partners. The public event, held on March 29, 2016, presented the results and provided an opportunity for remarks by the MOH and PNLS's partners. Organizational Capacity Evaluation Results HFG conducted an end line evaluation of the capacity- building work, using the same methodology and data collection instruments used at the beginning of HFG’s activity in Burundi in 2013. A web-based survey was completed by 34 PNLS staff, in addition to interviews and focus groups with PNLS staff and external stakeholders to measure the progress in PNLS's organizational capacity over the life of the activity. Table 2 shows the results of the web-based survey of PNLS staff at baseline and end line. Table 2: Results of Web-based Survey at Baseline and End Line Dimension Baseline score (2013) End line score (2016) 1. Organizational mandate 3.24 4.05 2. Strategy and planning 3.42 4.08 3. Project management 3.07 3.94 4. Coordination and communication 2.96 3.95 5. Organizational structure 3.38 4.02 6. Leadership and management 2.58 3.8 7. Resources 2.39 2.82 The PNLS staff do a “gallery walk” – or a review of the working group discussions – during a staff retreat.
- 7. BURUNDI Strengthening National Leadership of Burundi’s HIV and AIDS Response 6 Below are some illustrative quotes that summarize the changes in PNLS since 2013 from the perspective of external stakeholders. The evaluation data from PNLS and its partners indicate the strong progress that PNLS has made in assuming its leadership role in the HIV and AIDS sector. The results are especially noticeable in the areas of operational planning, supervision, coordination, and training, all of which are core functions that PNLS is responsible for. A clear theme of the evaluation is, however, that the work of strengthening the organizational capacity of PNLS is not finished, especially in light of its new responsibilities as Global Fund Principal Recipient. Summary of changes from 2013 based on interviews with stakeholders “The program has a vision and understands its role in the response to HIV.” “In terms of commitment and leadership, the PNLS Director believes in his institution and fulfills his mandate. He remains attentive to the partners and he has the willingness to work as does his deputy. The division of labor is well understood between the two.” “Now with the HFG project and new leadership, the staff is motivated. They act like leaders.” “Supervision: there is more attention in the preparation stage. PNLS staff enrich the objectives, they are more active, write better reports and do so on time.” “They organize the district management teams better and the supervision missions are more and more productive.” “There is an improvement in the management of workshops, better planning, and commitment to activities.” “They require their partners to present their plans to organize their contributions.” “There is a better understanding of the importance of planning and a concern for the lack of reliable data.” “Training: PNLS no longer sends anyone without considering expertise; its representatives are more involved in preparation and at all stages.” “PNLS is now among the best organized programs in the ministry of health with leadership and staff motivated to address the challenges and which collaborates effectively with its partners.” Members of PNLS discuss the priorities to be included in their first operational plan.
- 8. BURUNDI Strengthening National Leadership of Burundi’s HIV and AIDS Response 7 Factors for Strengthening Capacity Many factors were identified by the partners interviewed, some being internal to the PNLS structure and others exogenous, to successful capacity building. They included the following: "The HFG project made it possible for PNLS to work differently." "The HFG project came to meet people's expectations: The project was a trigger; a very decisive factor. " "The leadership of PNLS; the director is a good organizer and a good coach." "Youth and the dynamism of managers who lent themselves easily to change." "HFG support in training, supervision, and organizational capacity and motivation as a result of this support." "Support from several PEPFAR partners: URC, HFG, WHO, UNAIDS and others." "The change of staff especially the committed leadership ." "Motivation of being the Principal Recipient for the Global Fund. " All the partners interviewed acknowledged that PNLS is now better positioned as a leader in the fight against HIV / AIDS, although everyone added that the program still needed additional strengthening and support to succeed in its mission. Lessons Learned Time factor: There are no quick fixes when you start with a weak organization. It takes at least two to three years of focused effort. Role of leadership: The importance of effective leadership cannot be overstated. PNLS leadership proved to be an engaged and strong partner, especially the dynamic director appointed in the last year, Dr Alphonse Nkunzimana. Role of organizational development: The organizational development approach recognized that building capacity is more than strengthening systems and procedures and training in their use, but is at its core a people process. Dr. Hilaire Ninteretse addresses participants at the national level supervision-strengthening workshop.
- 9. 8 March 2017 BURUNDI Strengthening National Leadership of Burundi’s HIV and AIDS Response Mix of individual skill building and organizationally focused interventions: The mix of individual skill building (e.g. leadership and management skills, presentation skills, facilitation skills, training) and organizationally focused interventions (team-building, vision and values) is essential to success. Foundational organizational competencies and functions: Focusing on both foundational organizational competencies and functions pays dividends. The foundational competencies such as management and clear roles and responsibilities are needed to carry out core functions such as supervision, coordination, and planning. The impact of HFG’s capacity building activities with the PNLS was even clearer with the selection of PNLS as the public sector Principal Recipient for the time, PNLS will receive direct funding from the new Global Fund grant for HIV/AIDS. For the first Global Fund to support its leadership and management of the national HIV and AIDS response. i UNAIDS and CNLS. 2015. 2015 Country Progress Report; Burundi. Available at: http://www.unaids.org/sites/default/files/country/documents/ BDI_narrative_report_2015.pdf ii Ministry of Health and the Fights against AIDS and CNLS. 2012. 2012-16 National Strategic Plan for the Fight Against AIDS. Bujumbura, Burundi. iii The United States President’s Emergency Plan for AIDS Relief Recommended Citation: Health Finance and Governance project. February 2017. Strengthening National Leadership of Burundi’s HIV and AIDS Response. Bethesda, MD: Health Finance and Governance project, Abt Associates Inc.