In August 2000, five clinician scientists (including us, the authors of this report) who were experts on infectious diseases and had research experience in Africa, were approached by Pfizer, Inc., for advice regarding the creation of a corporate program designed to provide free fluconazole, an antifungal agent, to African patients. These North American scientists responded that inadequate health care infrastructure and a lack of trained professionals to deliver care were significant barriers to delivering these lifesaving drugs, and they encouraged Pfizer to act to fill that deficit. Specifically, the group proposed that Pfizer invest in an existing academic health center in Africa, enhancing its functions of training, research, and developing models for clinical care.
Establishing the Academic Alliance
Location and goals
The North American physicians met in 2001 with nine colleagues who were professors of medicine, public health, and pediatrics at Makerere University’s Faculty of Medicine in Kampala, Uganda, and established the Academic Alliance for AIDS Care and Prevention in Africa (AA). All agreed that a more collaborative, African-based, and African-led approach to building health care infrastructure and capacity was essential to produce sustainable results. The paramount need was to strengthen and upgrade academic medical centers in sub-Saharan Africa, so they could educate and prepare a new generation of health care professionals, skilled in the best practices to lead a resurgent effort against infectious disease. Such centers would pioneer new and improved therapies and prevention strategies applicable both to rural and urban settings.
The medical school at Makerere University offered an ideal location. The development was enthusiastically supported by the vice chancellor of Makerere University, the Ugandan Ministry of Health, and the Ugandan government, and was spearheaded by Nelson Sewankambo, dean of the faculty of medicine. Recognizing its role in promoting global health and investing in improved health care systems around the world, Pfizer provided initial funding through the Pangaea Global AIDS Foundation and eventually pledged more than $50 million for the establishment and ongoing support of the proposed research, training, and clinical care programs at Makerere under the aegis of the AA, and for the construction of facilities appropriate for such an ambitious venture.
Together, the African and North American physicians involved in establishing the AA’s programs determined that training would be the programs’ primary focus but that research and models of care within the context of inordinate unmet needs would also be important priorities. When this initiative began, HIV care was not available in Uganda or in most of Africa, except to wealthy individuals who could afford to pay for antiretrovirals. In addition, few health providers had training or experience in the use of antiretroviral agents.
In 2001, the 14 founding members of the AA expanded the HIV/AIDS clinic at Mulago Hospital from a weekly to a daily clinic, provided oversight to trainees, ensured that laboratory and pharmaceutical supplies were available, and initiated teaching conferences. The clinic also became the center for a new research program, initially funded through a grant from the Bill and Melinda Gates Foundation, to develop clinical protocols for HIV/AIDS patients in resource-limited areas and to test less expensive laboratory tests for HIV-infected patients.
The founding AA members developed a one-month training course in advanced AIDS care and prevention for physicians throughout Africa, with an emphasis on training trainers who would go on to educate others. The curriculum was designed in partnership with volunteers from the Infectious Diseases Society of America (IDSA), who spent one to three months on-site mentoring the 25 trainees in each class. The course consisted of approximately 50% didactic and 50% hands-on clinical activity in the IDI clinic and other venues around Kampala. To complement the training program, the AA members established the AIDS Treatment Information Center (ATIC), a phone- and Internet-based network for dissemination of HIV/AIDS clinical and drug information to trainees and other clinicians in sub-Saharan Africa. During these early years, Pfizer complemented its financial contribution to the AA with technical assistance to the project through a U.S.-based organization, Pangaea, whose staff managed the building and program development alongside African colleagues.
In 2004, the new 25,000-square-foot Infectious Diseases Institute (IDI) opened to house the flagship programs of the AA, accommodating both training and care programs. The IDI was sited next to Mulago Hospital and the Makerere University Faculty of Medicine. Later that year, the IDI laboratory, one of only three research facilities in Africa accredited by the College of American Pathologists, was established in partnership with Johns Hopkins University.
Remarkably, the vision forged by the founding members of the AA only three years earlier was a reality. To underscore the importance of collaboration and to promote African leadership, the management of IDI was transferred from Pangaea to the Makerere University Faculty of Medicine in 2005. The transfer marked the beginning of a bold new model for governance and transparency for an independent Ugandan nongovernmental organization (NGO) housed within an academic medical institution. This model, discussed in more detail later, has proven to be a driving force for innovation within Makerere University as it establishes and improves other university programs.
The Pfizer CEO and other senior executives assumed leadership roles on the board. Pfizer’s Global Health Fellows spent time in Uganda building local staff capacity in a variety of disciplines ranging from laboratory management skills to budget and strategic plan support. Most important, a jointly developed and transparent schedule of Pfizer’s ramped-down financial contributions for subsequent years continues to provide IDI with both the stability and incentive that its leaders need to build IDI’s internal capacity and develop important partnerships with other sources of support, thus ensuring the long-term viability of the enterprise.
The Academic Alliance Foundation
The Academic Alliance Foundation (AAF) was established in September 2003 as the institutional home for the AA. Its mission is “to overcome the burden of infectious diseases by building health care capacity and strengthening academic medical institutions in Africa.” With offices in Washington, DC, the AAF has assembled a distinguished board of directors and staff, who inform AAF program strategy and design, lead advocacy and development efforts, and fundraise. Communication and coordination vehicles include a weekly conference call between the international AA members, senior IDI management, and AAF staff that keep AA members engaged and involved with day-to-day activities at IDI and that ensure that IDI senior management are informed about opportunities and efforts of the AAF.
The Infectious Diseases Institute
Building health care capacity
Training health care workers.
The IDI Training Program has trained more than 1,500 African health care professionals from 26 African countries (see Table 1). The program began in 2002, focusing on medical graduates, and it was restricted to training regarding HIV/AIDS. It has evolved to encompass training for a broad range of infectious diseases, and recent innovations in management have enabled it to be a multidisciplinary approach to team-based training. The improved effectiveness of this new approach to addressing human resource needs, or capacity building, is already apparent in results from the Joint Uganda Malaria Training Program, in which doctors, nurses, laboratory technicians, and records keepers are all provided specialized malaria training in a team setting.
A recent training needs assessment study conducted by the IDI identified training gaps. This has had a major impact on the evolution of the training portfolio and on future planning. The IDI training portfolio now includes several courses designed to meet the heterogeneous needs identified through that effort. The program still offers an intensive HIV/AIDS course for medical graduates throughout Africa, which consists of lectures, bedside and clinical teaching, clinical case discussions, journal clubs, and group project work. One- and two-week multidisciplinary courses target nurses, midwives, clinical officers, counselors, and laboratory technicians. Additionally, modular courses on more specific topics offer health care workers from different backgrounds and workplaces the opportunity to develop skills according to the needs of their institutions.
In 2006, the IDI training program expanded to include a malaria training program and a laboratory program. The Joint Uganda Malaria Training Program, funded by Exxon Mobil and executed in partnership with experts from University of California–San Francisco School of Medicine and other institutes, offers a one-week course. The laboratory training program has been funded by Becton Dickenson and will provide leadership and management training to laboratory directors and advanced training for laboratory technicians, particularly in clinical microbiology.
HIV/AIDS training programs at IDI are closely coordinated with the on-site location of the IDI adult clinic. Trainees spend approximately 50% of their time learning from patients in the IDI clinic under the supervision of IDI clinical leadership.
Ongoing support services for health care professionals.
The IDI ensures that the enhanced skills achieved during its training courses are maintained and nurtured after the trainee has graduated. The malaria program includes a mobile support and ongoing education team to provide assistance to course graduates after they return to their community facilities, and to help the graduate conduct less formal secondary training programs for peers and colleagues.
Continuing medical education (CME) activities are also offered. Two-day courses were initiated in 2006 in partnership with Makerere University Faculty of Medicine. These CME activities afford health care professionals with unique networking and learning opportunities. These include journal club discussions, highly active antiretroviral therapy (HAART) failure/switch meetings, and case conferences. (failure/switch refers to the failure of the antiretroviral therapy and the need to consider an alternate—a major issue, because there is currently only one alternate regimen.)
The IDI ensures the maintenance of enhanced skills achieved during its training courses through the ATIC. As stated earlier, the ATIC is a telemedicine referral network; it is housed at the IDI and provides health professionals with access to the latest medical information and advice to assist them with patient management. The ATIC meets the need for rapid, accurate responses to a wide variety of questions about HIV/AIDS and other infectious diseases care and management, and it provides a continuous source of well-researched and succinct information free of charge to health care providers. In the first two years of operation, the ATIC has provided specific patient-care information in response to queries from 13 countries via a toll-free phone service, contact visits, and the Internet.
Strengthening health care systems.
The IDI has special expertise in the management of complicated HIV/AIDS cases. It seeks to play a distinctive role within a referral system for Uganda and the region, with associated information systems that focus both on individuals and service providers. The IDI has recently trained caregivers at city clinics throughout Kampala and improved the effectiveness of the overall urban health care system.
The research program
Research at the IDI is conducted by teams of outstanding investigators from around the world and bolstered by state-of-the-art data-management capabilities and an accredited laboratory. One major goal of the IDI research program is to generate information that will help improve the quality of health care services for people with HIV/AIDS and other infectious diseases in sub-Saharan Africa. Research findings can immediately affect the quality of care in IDI’s clinics and elsewhere as those findings are disseminated through workshops, conferences, publications, and other scientific platforms.
The AAF and the IDI have made a major investment in the research infrastructure by developing a state-of-the-art clinical research facility at the IDI for conducting clinical trials, a modern information technology system that has allowed for management of a large cohort of HIV-infected adults and adolescents, and a transparent and reliable grants and contracts organization for securing and managing large research grants. In addition, through its network of trainees at widely disseminated sites throughout Uganda and other African nations, the potential for conducting surveillance of emerging infectious diseases, introducing rapid diagnostic tests, monitoring and evaluating quality of care in HIV/AIDS, and conducting clinical trials is being realized.
There are now 28 externally funded clinical studies underway or completed at IDI, including treatment of Kaposi sarcoma (in partnership with the University of California–San Francisco School of Medicine and the University of Washington School of Medicine); prevention of HIV transmission by suppression of genital herpes (University of Washington School of Medicine); pharmacokinetic studies of drug–food interactions with antiretrovirals (Trinity College, Dublin); impact of HAART on AIDS-associated dementia (Johns Hopkins University School of Medicine); immune reconstitution inflammatory syndrome in cryptococcal meningitis (University of Minnesota Medical School and University of Colorado School of Medicine); development of protocols for management of headache, visual loss, and hepatic abnormalities; and, finally, a large effort to define the impact of HIV infection and subsequent ART on growth and development in adolescents (University of Utah School of Medicine). The IDI has been granted Qualified Reserve status in the recent National Institutes of Allergy and Infectious Disease’s International Clinical Trials Unit competition.
Research scholarship programs
AAF-supported programs at IDI also focus on the critical longer-term goal of building improved research capacity for academic medical institutions. The mentoring and fellowship programs are designed to strengthen the faculty and facilities for training and research at Makerere University Faculty of Medicine as a model for other African institutions of higher education. The Sewankambo Clinical Scholars Program links each of five clinicians with at least one internationally recognized investigator who commits to providing five years of substantive ongoing mentoring. These scholars are provided a salary, pilot research funds, and a yearly international travel allowance by Gilead Sciences, California, a pharmaceutical company. At least 70% of their total efforts are to be devoted to research. The goal of this program is to give the trainees protected time to develop academic skills and make them competitive for international grants. Within five years, young investigators are expected to have peer-reviewed papers and become principal investigators on an internationally recognized grant. The clinical scholars fellowship program is a model for other African institutions to expand the level of “in-country” clinical and applied research.
The Academic Alliance Infectious Disease Fellowship is another initiative to support African institutions. It is also supported by Gilead Sciences and allows African physicians to work, train, and conduct research in the IDI for three years with ongoing mentorship.
The IDI training and clinical research programs have been enhanced by interaction with more than 100 fellows, students, and faculty from North America and Europe who have rotated through the IDI, sharing projects, patients, and ideas. It is as a magnet for young, enthusiastic students from more developed countries who are interested in learning about HIV/AIDS and experiencing medicine in a resource-limited society. Funding for fellows who wish an extended experience at the IDI is available from the IDSA.
The AAF has also been committed to enhancing the scientific and clinical environment of the medical center by embracing the medical students and residents of Makerere University (MMeds). Most medical students rotate through the IDI clinic, and more than 30 MMeds have been mentored by AA members. Currently, the international AA members and other invited clinician scientists engage in a professor-in-residence program. Each AA member spends two- to three-week blocks several times each year in a teaching/mentoring role conducting rounds in the clinic and on the wards of Mulago Hospital, giving one-on-one mentoring to the trainees and participating in research and clinical conferences while ensuring that the quality of the AA’s programs at the IDI are maintained.
The integration of clinical services, training, and research is still unusual in African health institutions. IDI’s clinical services were principally designed as a critical support function to ensure the quality of its training and research programs, but the clinic has become a valuable program in itself. It is exceptionally busy, providing high-quality HIV/AIDS services to approximately 400 adult patients each day. Of the more than 11,000 patients registered for care at the IDI each year, over half are receiving antiretroviral therapy through the Global Fund for AIDS, Tuberculosis and Malaria; the U.S. President’s Emergency Plan for AIDS Relief; and private donations.
The IDI clinic has launched a novel program, called The Creative Initiative, that encourages HIV-infected patients—now referred to as our friends, or, in Luganda, mykwano gyaffe—to explore artistic outlets through song and dance, drawing, and painting. They learn entrepreneurial and life skills, share testimonies, and provide spiritual and social support to one another. Early analysis suggests that the initiative is facilitating a dramatic change in clients’ abilities to care for themselves and to encourage others receiving services at IDI.
The IDI’s independent status within an academic institution is an example of a distinctive and progressive model of governance: it is a registered NGO, but it is also owned by Makerere University. As a semiautonomous entity, and an example of public–private partnership, it is seen as a governance model for potential replication within Makerere University and more widely. Its independent board of directors is a governing board with international representation from the public and private sectors.
Under the direction of its first executive director, the IDI also serves as an exemplar of good governance and institutional strengthening in terms of its financial systems transparency and absorption capacity. The IDI seeks to adhere to stringent international standards. Maintaining high-quality management practices and systems is a prime concern at the IDI. Those systems enable the IDI to reassure funding agencies that any funds granted to the IDI will be used efficiently and effectively for the purposes intended, with prompt and professional reporting.
Although the longer-term results of this innovative experiment are not yet known, the evolution of the AAF and the IDI—the two bodies that are the creation of the AA—presents a pioneering example of how public–private partnerships in global health care may be structured to best guarantee long-term stability and local effectiveness. Jump-started by generous financial support from Pfizer, Inc., the enterprise created by the AA has, in a remarkably short period of time, made impressive strides on the path toward independence and a diversified funding base. By coupling a substantial initial investment with a thoughtful, transparent, five-year plan for diminished funding, Pfizer simultaneously provided the AAF the resources and imperative to develop lasting partnerships with other global organizations. Pfizer continues to provide guidance and technical assistance, along with its diminished but ongoing financial support, to ensure that the AAF maintains its trajectory toward true financial independence.
The critical challenge facing the AAF and the IDI today is to diversify the funding base, to sustain current program levels for the future. As a result, several issues must be addressed to ensure long-term organizational strength and stability. These issues are similar to those faced by a U.S. academic medical center and include:
* Sustaining free clinical care requires that patient care be limited to those that have funding through the third-party payers or are participants in fully funded clinical trials.
* The training program must generate revenue equal to expenses through tuition reimbursement and scholarships from sponsoring agencies.
* Research projects must be fully funded, including associated overhead costs.
* Internationally competitive academic leaders must be secured, and this requires external funding. The AAF has established the Leadership Trust, one of the first of its kind to support an African academic medical institution. The AAF has received its first endowment pledges of $2 million for the director position at the IDI.
Measuring the Success of the Academic Alliance
Measuring the degree to which the AA has been successful in building lasting capacity in Uganda and the region is difficult, because this experiment is still under way. Future historians will critique the global response to the HIV epidemic and other infectious diseases plaguing Africa and identify the seminal events that began to turn the tide. The AAF model attempts to bring together the medical school, public health institutes, the ministry of health, and the private and donor sectors to address human resource issues and solve complex clinical and operational problems that will enable healthy populations. The full impact of this model will continue to be measured into the next decade.
In the meantime, the individual programs of the AAF and its implementing partners must continue to adapt to their changing environments. The Uganda training needs assessment mentioned above, and the way its results have shaped the IDI training program, constitute an example of how the academic process continually measures the impact of interventions in the real world and readjusts accordingly. Similarly, research conducted at the IDI and Makerere University Faculty of Medicine should reveal increasingly effective strategies and technologies for prevention, treatment, and care of infectious disease, in response to environmental changes and available therapies.
The lack of trained health care providers is a crisis. An adequate infrastructure to enable care to be efficient and effective is also lacking. New and emerging infectious diseases appear and reappear on the African continent, and resulting infections account for the vast majority of early deaths. Through continuous innovation, evaluation, and refinement of research and training programs, academic medical centers can be uniquely positioned to respond to these challenges in the future.
The authors acknowledge all who have contributed to enable the IDI and the AAF to be institutional successes and to serve the people of Africa, especially those in Uganda. A particular thanks to Ms. Kelly Willis, whose editorial eye helped improve the writing of this manuscript.