GLOBAL PROGRAM Strengthening Health Systems Collaborative Partnerships with Health Ministries
WHO WE ARE WHAT WE DO The National Alliance of State and Territorial AIDS Directors (NASTAD) represents U.S. state health directors with programmatic responsibility for HIV/AIDS, viral hepatitis, and associated public health programs and works to strengthen the role and promote the success of state and territorial public health programs. NASTAD is guided in its work by the World Health Organization s Six Pillars of Health Systems Strengthening: Leadership and Governance; Service Delivery; Strategic Information; Human Resources; Sustainable Financing; and Medicine and Technology. Accordingly, NASTAD s Global Program works to strengthen the health systems of its public sector and ministry of health counterparts across the world. OUR APPROACH Calling upon its members in a peer-to-peer capacity building approach, NASTAD works to: 1. Strengthen the capacity of public sector and ministry of health staff to plan, manage and evaluate public health prevention, care and treatment programs at national and local levels. 2. Build organizational capacity of public sector and ministry of health offices to support the delivery of national and local public health programs. 3. Create sustainability in national and local public health programs. To strengthen public health systems and structures with partner countries, NASTAD does not invent new programs or parallel systems. NASTAD responds to identified health systems strengthening needs of ministries of health and their affiliates and builds the capacity of national and local public health agencies to manage and implement jurisdictional public health programs. NASTAD does this by sharing best practices in organizational management and technical content, and by providing training, mentorship, and support for improvement of existing programs. For NASTAD, success is achieved when government partners take a lead role in design, implementation and long-term management of needs-based public health programs. WHO: The power of existing interventions is not matched by the power of a health system to deliver them to those in greatest need, in a comprehensive way, and on an adequate scale. http://www.who.int/healthsystems/strategy/en/index.html
PILLAR I Public Health Service Delivery Public Health Service Delivery Good public health services are those which deliver effective, safe, quality health interventions to those who need them, when and where needed, with minimum waste of resources. Capacity building in this area relates to public health treatment, prevention, and care. NASTAD Global Strengthens Public Health Service Delivery Via: NEEDS ASSESSMENT We support ministry of health-led design and implementation of program and staff-related needs assessments. NASTAD models data driven planning in all endeavors. PROGRAM DESIGN and IMPLEMENTATION We provide guidance on public health program design, infrastructure and logistics processes, as well as direction for effective program leadership and management. Needs Assessment In Ethiopia NASTAD conducted surveys to identify factors related to ART adherence in rural communities, which has informed the design of the government s and local implementing partners community-level interventions. In a rural Ethiopian setting in which rapid scale-up of HIV treatment occurred, many respondents still characterized HIV as associated with shame or blame, or indicated people living with HIV (PLWH) would be isolated or discriminated against. HIV stigma can hamper both prevention and treatment programs. We identified multiple issues which, if addressed, can help promote a more positive cycle in which PLWH are appreciated as members of one s own community Stigma reduction programs should address knowledge gaps such as fears of casual contact contagion, and lack of awareness of medical interventions to help prevent HIV disease, as well as building upon community-based attitudes of the importance of supporting and showing compassion for PLWH. http://www.biomedcentral.com/1472-698x/12/6 SUSTAINABLE PROGRAM TRANSITION We support the implementation of pilot public health programs, and guided growth and program expansion. NASTAD mentors ministries of health to support effective and sustainable transition. This work is being done in: Haiti Caribbean Ethiopia South Africa Botswana Please visit www.nastad.org for more information.
PILLAR I Building Partnerships In response to assessed need in South Africa, NASTAD supported two provincial departments of health to adopt and implement the national pre-antiretroviral treatment (ART) program, I ACT. The goal of I ACT is to promote retention to HIV care through early recruitment of newly diagnosed people with HIV into community based care and support programs. I ACT strives to reduce the high rate of loss to follow-up from the time of HIV diagnosis to successful commencement of anti-retroviral therapy. Public Health Service Delivery Sustainable Program Transition Medi cal Prod Working closely with the Ministry of Local Government (MLG) in Botswana, NASTAD developed standardized guidelines and processes for development of annual district HIV plans which have been fully integrated into MLG policies and practices. To support this coordinated and evidence-based planning process, NASTAD/Botswana supported the revision of national terms of reference for District Multi-Sectoral AIDS Committees, developed standard guidance for Evidence Based Planning, and provided ongoing on-site technical assistance and training to all districts. More than 1,300 MLG staff and volunteers have been trained and mentored, and the initiative is now fully managed by the MLG. Through focused mentorship, coaching and regular review meetings at district, provincial and national levels, NASTAD/South Africa supports strong and coordinated involvement of provincial and district departments of health, regional training centers and district health facilities to build sustainable I ACT referral networks and linkages. To support continuous quality improvement, NASTAD has also supported the development and roll-out of a provincial and national M&E process of the program.
PILLAR II Health Workforce Development A well-performing health workforce is one that works in ways that are responsive, fair and efficient to achieve the best health outcomes possible, given available resources and circumstances. Capacity building in this area relates to planning and supporting a sustainable and effective workforce. Health Workforce Development NASTAD Strengthens the Public Health Workforce via HEALTH STAFFING MODELS We provide data-driven consultation in the development of ministry of health staffing models. Based on assessed needs, observations, and international best practice, NASTAD helps partner governments to leverage, adapt, or expand upon current staffing models. ON-SITE SUPPORTIVE SUPERVISION We provide training, technical assistance, and supportive supervision to government health workforce staff. NASTAD works with the local government to design sustainable models, and to mentor government staff to take on these leadership roles themselves. PUBLIC HEALTH PROGRAM MANAGEMENT TRAINING We support the development of leadership and management infrastructure within the public health sector to help ensure high impact and best use of staffing resources. NASTAD helps to design and implement training-of-trainers, and supports longerterm mentorship to ensure the application of learning. Available Curriculum Packages Applied Public Health Program Management Cooperative Agreement Management Program Monitoring and Evaluation Surveillance and Epidemiology Data Utilization for Program Planning Evidence-Based Planning CONTENT SPECIFIC TRAINING We conduct content-specific applied staff trainings and mentored capacity building activities. NASTAD favors sustainable training models, supporting legacy curriculum and government-led course offerings. This work is being done in most regions of the world, including flagship programs in: Haiti Caribbean Ethiopia South Africa Botswana Zambia Please visit www.nastad.org for more information.
PILLAR II In Botswana, NASTAD partnered with the Ministry of Local Government (MLG) and CDC s Sustainable Management Development Program to design and roll-out an applied public health leadership program for public health leaders. The Applied Public Health Program Management Training (APHPMT) framework provides a standardized process for assessing program manager roles and responsibilities, and then tailoring a hands-on public health management training and mentoring process to address the identified gaps in the cohort s public health management competencies. In Botswana, District AIDS Coordinators are critical to the management and coordination of the district-level response to HIV and was selected by government as the Public Health Management Training target cohort. In order to effectively train the group, NASTAD/Botswana implemented a skill and competency gap analysis, worked with the MLG and their representatives to design two weeks of applied curriculum and field work, and planned for implementation. Ten Master Trainers from Botswana were recruited and instructed on facilitation of and mentoring for the APHPMT, after which they were supported to roll out the training to the target cohort. To fully actualize the applied elements of the APHPMT, job aids and field assignments were disseminated, and the cohort will be mentored and provided with refresher trainings over a one-year period. Health Workforce Development Health Staffing Models In Ethiopia, NASTAD supports growth and maturation in the national HIV-related staffing model. This support has helped to build strong government staff at the regional and subregional levels who lead targeted and needs-based HIV programs, and has permitted effective community-based task shifting for high-impact interventions. NASTAD/Ethiopia has staff located in Addis Ababa and throughout the country. The majority of NASTAD/Ethiopia staff are public health experts co-located at regional health bureaus, woreda health offices, universities, and health facilities to provide direct support to the regional health bureaus. Support offered includes technical assistance, training, mentoring, and supportive supervision to facilitate planning, implementation and evaluation. Examples of highimpact jointly-supported programs include: - Modification and adaptation of three U.S. evidence based HIV prevention interventions to the Ethiopia culture and context for successful and sustainable implementation by local government. - Organization of regional and zonal level health and HIV review meetings where achievements are compared to plans, and challenges, lessons learned, and the way forward are discussed. - A national task-shifting initiative that used inservice training and mentoring supported health extension workers to become empowered in HIV/AIDS support, especially related to communitybased adherence.
PILLAR III Health Information Systems Health Information Systems A well-functioning health information system is one that ensures the production, analysis, dissemination and use of reliable and timely information on health determinants, health systems performance and health status. Capacity building in this area relates to the support for production, analysis, dissemination and use of reliable and timely public health information at different levels. NASTAD Strengthens Health Information Systems via development of: NATIONAL SURVEILLANCE SYSTEMS We have helped to develop and improve national surveillance systems, ensuring the availability and use of key public health information to guide health programs. NASTAD leverages international best practice with local needs and resources to design sustainable systems. We develop simple data management methods that are in line with local skill and available technology to ensure long-term use, ownership and sustainability. National Surveillance Systems In the Caribbean, NASTAD works with governments to support HIV surveillance and use of the generated data for program planning, monitoring, and evaluation. Leveraging the United States experience implementing the National HIV Behavioral Survey, NASTAD supports the design and implementation of national biological and behavioral surveillance methods for populations at greatest risk for HIV, including processes for adoption of the method for sustainable and routine implementation. Complementing a case-based surveillance system, behavioral surveillance allows for a greater understanding of the local epidemic, and for specific targeting of programs and resources. NASTAD's approach in the Caribbean is to partner with local ministry of health staff to define their surveillance needs, help them plan for and implement appropriate surveillance methods, and support the use of data for evidence based programs and planning. NASTAD's peer-based approach supports the goal of local ownership and implementation for long-term sustainability. NATIONAL MONITORING AND EVALUATION SYSTEMS We have helped to develop and improve national program Monitoring and Evaluation systems, ensuring the availability and use of key public health information to guide health programs. NASTAD leverages international best practice with local needs and resources to design sustainable systems. DATA REPORTING SYSTEMS We support the strategic use of generated public health data to guide and inform public health programs. NASTAD works with local partners to design templates and processes to help create a legacy system. This work is being done in: Haiti Caribbean Ethiopia Zambia Guyana Please visit www.nastad.org for more information.
PILLAR III Health Information Systems In Haiti, NASTAD has partnered with the Ministry of Health to support the development of the national case-based HIV/AIDS surveillance system. Support has included the design and development of the case reporting process, data collection tools, data management practices, and surveillance process and data monitoring and evaluation systems. To ensure effective use of these processes and to ensure sustainability in the national systems, NASTAD/Haiti has designed and delivered targeted curricula throughout the country, and continues to provide supportive supervision and mentoring to Ministry of Health and implementing partner staff. With the HIV/AIDS case surveillance system institutionalized and generating data on a weekly basis, NASTAD also assists the Ministry of Health in routine data cleaning, analysis and utilization. Up-to-date surveillance data are made available on a monthly basis, and national and regional Ministry of Health staff are well trained and mentored in analysis and use of the data. The data are also being leveraged and triangulated with other data sources to allow for a more complete understanding of public health and HIV needs in Haiti. At this time, the HIV/AIDS case surveillance system is being leveraged to support the elimination of mother-tochild transmission, and expanded to also support case-based TB and STD surveillance. National Surveillance Systems National Monitoring and Evaluation Systems In Zambia, NASTAD helped to design, implement and improve the national HIV/AIDS program monitoring and evaluation (M&E) process. Specifically, with the National AIDS Council (NAC), NASTAD supported the joint development of data collection tools and processes, staffing and data management practices, standardizing the national M&E processes, and training and engaging national staff for effective data utilization. In addition to staffing and supervisory support to the NAC as they implement their national M&E process, NASTAD/Zambia has supported the development and institutionalization of two training programs that support the national vision and expectation for program M&E. M&E Short Course: The University of Zambia (UNZA) offers a three-week short course in Program M&E twice per year. NASTAD worked with UNZA to assess the course content and impact, and based on findings, worked with the faculty to expand and reinforce the curriculum into a standard teaching package which may now be expanded to other target cohorts. Epidemiology for Data Users: With much public health data available in Zambia it was noted that decentralized staff could more effectively use the data to plan for targeted, needs-based programs. NASTAD worked with local partners and funders to design and implement an applied public health data utilization course that is now being offered by local trainers throughout the country.
PILLAR IV Leadership and Governance Leadership and governance involves ensuring that strategic policy frameworks exist and are combined with effective oversight, coalition building, the provision of appropriate regulations and incentives, attention to system-design, and accountability. Capacity building in this area supports government to take an active leadership role in guiding integrated national efforts. NASTAD Strengthens Public Health Leadership and Governance via: LEADERSHIP MENTORSHIP We support capacity building of ministry of health staff in public health program management and leadership. NASTAD implements this formally, as standalone curriculum, or integrated into other capacity building activities. BUILDING PARTNERSHIPS We provide leadership and mentorship for steering committee development and use and coalition building among stakeholders and local implementers. NASTAD draws on international best practice models of leveraging consensus and coalitions to drive sustainable public health decision making and implementation. NATIONAL POLICIES and PROCEDURES We support the development and implementation of national or regional policies and procedures that support public health practice. NASTAD assesses local need and leverages international best practice to define direction. Public Health Leadership and Governance context; and assessment and improvement of nutrition services for people with HIV. These partnerships have also helped improve prevention, outreach, adherence and stigma issues with the Ethiopian diaspora in the U.S. This work is being done in: Building Partnerships NASTAD has supported five twinning partnerships between U.S. state health departments and Regional HIV/AIDS Prevention and Control Offices in Ethiopia to facilitate peerto-peer bi-directional exchanges of information, training, and technical assistance. These twining partnerships between Minnesota, Michigan, Maryland, San Diego County, and DC in the U.S. and Oromia, Amhara, SNNPR, Dire Dawa, and Addis Ababa in Ethiopia supported capacity building of the Ethiopian government to plan for and implement needs-based programs such as: Community Conversations that empower communities to respond to HIV-related needs; peer-based support groups that improve treatment adherence; adaptation of proven evidence-based HIV prevention interventions to the Ethiopian Haiti Caribbean Ethiopia South Africa Botswana Zambia Guyana Angola Please visit www.nastad.org for more information.
PILLAR IV Building Partnerships Public Health Leadership and Governance Building Partnerships In Ethiopia, NASTAD supports the government to host biannual Harmonization Meetings with national and regional government branches to help identify and ensure a coordinated response to public health gaps. This opportunity to have key public health leaders around a table and to come to consensus enables government and implementing partners to work in alignment for effective service provision. For NASTAD/Ethiopia, the Harmonization Meetings have proven to be especially effective as NASTAD continues to support, develop, and transition Woreda-Based Health Sector Planning. NASTAD/Ethiopia is the prime partner supporting the Ministry of Health to ensure that all Woreda (counties) have the ability and commitment to use local evidence to plan for coordinated HIV interventions. In response to regional requests, NASTAD/Ethiopia supports the Model Woreda Package to demonstrate and mentor optimal functioning of Woreda health offices in fully implementing existing government strategies and guidelines on HIV mainstreaming, service coordination, and multi-sectoral approach to social mobilization for HIV services. This work is guided directly by the findings of the bi-annual Harmonization Meetings, ensuring that all support and interventions are well aligned with the government s vision. In the Caribbean Region NASTAD has provided leadership on coalition building among stakeholders who are well informed of the needs of high-risk populations. Despite the estimated high HIV prevalence among men who have sex with men (MSM) and sex workers in the Caribbean, few data are available to guide prevention activities or treatment and care programs to reach those in need. Although ministries of health in the region have identified surveillance among higher risk groups as a priority, limited knowledge of the populations have impeded successful surveillance efforts to date. In partner countries, NASTAD has supported the ministries of heath to engage MSM and sex workers, as well as service organizations and community members that serve them in conversation and collaborative planning for surveillance activities and the resulting data dissemination. To support active engagement, NASTAD helped to form representative steering committees, and has provided skills building and planning workshops to ensure a common understanding of mission, approach and commitment. Helping the ministries of health to engage with these public health leaders has allowed for ready adoption and implementation of new and effective surveillance initiatives, and a commitment to use the generated data to better serve populations with the greatest needs. Available Policy Support Surveillance and Disease Reporting Patient Privacy Data Security and Confidentiality Data Sharing and Utilization Sensitization and Accessibility for High-Risk Populations Social Mobilization
PILLAR V Medical Products, Vaccines and Technologies A well-functioning health system ensures equitable access to essential medical products, vaccines and technologies of assured quality, safety, efficacy and cost-effectiveness, and their scientifically sound and cost-effective use. Medical Products, Vaccines & Technologies Generating Demand Capacity building in this area supports the safe and effective availability and use of products and technology. NASTAD Strengthens Access to Medical Products, Vaccines and Technologies via: GENERATING DEMAND We provide support for public health outreach campaigns for the generation of demand for program access. NASTAD draws on international models of community engagement, leveraged with local scenarios, to support effective processes. ASSESS NEED AND BUILD MANAGEMENT CAPACITY We provide assistance in identifying necessary laboratory resources. This work is being done in: Haiti Caribbean Ethiopia Zambia Botswana Please visit www.nastad.org for more information. In response to assessed need in Ethiopia, NASTAD, in collaboration with the Dire Dawa Regional Health Bureau and other partners, developed a program using Traditional Birth Attendants (TBAs) as volunteers to assist health centers to reach pregnant mothers to prevent mother-to-child transmission of HIV. The objective of the program was to promote anti-natal care (ANC) and clinic-based delivery to reduce perinatal HIV transmission. To launch this initiative, a meeting was organized for the TBAs in the presence of religious and community leaders, who were recognized as being referral agents. The TBAs were introduced to clinical staff and health extension workers to strengthen collaboration and coordination. Regular supportive supervision and review meetings were conducted to monitor the program progress. In the pilot period, TBAs visited more than 3,500 households and referred about 500 pregnant mothers to the nearest health facility for services; ANC clinics saw a significant increase in access to services as a result. The Ministry of Health identified this as a best practice model and has scaled it up in five regions as a government program.
PILLAR VI Sustainable Financing and Social Protection A good health financing system raises adequate funds for health, in ways that ensure people can use needed services, and are protected from financial catastrophe or impoverishment associated with having to pay for them. Capacity building in this area relates to promoting transparency and accountability. NASTAD Strengthens Sustainable Financing for and Social Protection within the Public Health Domain via: COOPERATIVE AGREEMENT MANAGEMENT We provide support to ministries of health on grant and cooperative agreement management. NASTAD Global implements this formally as standalone curriculum or integrated into other capacity building activities. Our trainings provide district health managers and government staff with the tools needed to better comply with international grantors expectations, and to better monitor and administer national grants. Sustainable Financing and Social Protection Leadership Mentorship In Angola, NASTAD hosted a five day training for a cadre of government staff in grant/cooperative agreement and fiscal management. The curriculum covered the entire lifecycle, from application to closeout, focusing on financial and programmatic reporting requirements and funds management. The curriculum was delivered using a participatory approach which included several group exercises, as well as, hands-on practice to promote independent problem solving. Participants were also provided with checklists, guidelines, templates and other materials to facilitate success in grants/ cooperative agreement management. Participant feedback from the training showed that knowledge acquired will allow for stronger compliance with international grantors expectations, and better administration of local sub-grants. FINANCIAL MANAGEMENT We support the capacity building of government and implementing partners in responsible financial management, including budget preparation, financial statements and reports. NASTAD supports and mentors grantees in comprehensive reporting that is in compliance with national government and international grantee expectations. This work is being done in: Haiti Caribbean Ethiopia Angola Please visit www.nastad.org for more information.
NASTAD The National Alliance of State and Territorial AIDS Directors (NASTAD) is a U.S. based public health organization that represents state health directors with programmatic responsibility for HIV/AIDS, viral hepatitis, and associated public health programs. NASTAD works to strengthen the role and promote the success of state and territorial public health programs in the U.S. and internationally. NASTAD s Global Program works to build the organizational, programmatic and human resource capacity of its regional/state public sector AIDS program counterparts across the world through strong partnerships, training, technical assistance and supportive supervision. NASTAD works in all regions of the world, and has flagship programs in Botswana, the Caribbean, Ethiopia, Guyana, Haiti, South Africa and Zambia. National Alliance of State and Territorial AIDS Directors (NASTAD) 444 North Capitol Street NW # 339 Washington, DC 20001 (USA) PHONE 1 202 434 8090 FAX 1 202 434 8092 Global.Program@NASTAD.org www.nastad.org