Globally, development assistance for health (DAH) has increased 2-fold in the last decade, to a total of nearly $26 billion in 2010.1 Government and multilateral aid comprises the bulk of such funding, but private foundations have grown in importance and now contribute increasing support to DAH.2 Although direct funding to government represents a proportion of this aid, substantial resources are channeled through international and local nongovernmental organizations to complement the work of governments.3
The multiplicity, unpredictability, and often inflexible nature of DAH funding have spurred many nongovernmental organizations to seek a broader base of funding and pursue relationships with diverse partners to achieve their mission and objectives.4 Working with multiple funders allows organizations to leverage single funder interests to achieve more comprehensive programs and encourages nimble and responsive decision making.5 However, it also introduces challenges such as disparate expectations around program priorities, in addition to practical complexities, including unaligned grant cycles, variable timing of funding disbursements, unaligned reporting requirements, and unsynchronized regular and ad hoc financial and program audits.6
The Centre for Infectious Diseases Research in Zambia (CIDRZ) is an example of an organization that relies almost exclusively on external grant support from public and private funding sources to support its mission of improving access to quality health care in Zambia. Since its founding in 2001 by local and international leaders, CIDRZ has served as a partner to the Government of the Republic of Zambia in the expansion of critical HIV and broader health programs, training, and research to improve programmatic implementation and effectiveness. With funding from the President's Emergency Plan for AIDS Relief (PEPFAR), National Institutes of Health (NIH) and other donors, CIDRZ has supported the delivery of HIV care and treatment services to over 250,000 individuals, and enrolled more than 15,000 participants in studies, including intensive phase 1 pharmacologic studies, individual and cluster randomized clinical and community trials, and large multicountry program evaluations.
After 10 years as an affiliate of the University of Alabama at Birmingham, CIDRZ became an independent Zambian nongovernmental organization in 2011. The organization, with more than 600 employees, now has a majority Zambian Board of Directors and its leadership team is greater than 75% Zambian. The transition from being an internationally facilitated organization to a fully Zambian nongovernmental organization allows for greater local ownership, more flexibility in applying for funding targeted for local partners and the opportunity to build strong partnerships with multiple university partners. Along with this transition, a majority of grant and donor funding is now provided directly to CIDRZ instead of through subcontracts through an umbrella entity. This evolution to fully independent status has presented a series of challenges and opportunities for CIDRZ management as it strengthens its platform for research, program implementation, and training. This article details the strategies used by CIDRZ and other organizations to successfully manage complex funding streams through building strong governance, operational management, and monitoring and evaluation capacity, as well as maximizing synergies between its programmatic and research activities.
MANAGING COMPLEX AGENDAS THROUGH STRATEGIC PLANNING AND STRONG GOVERNANCE
Given the fluid nature of donor funding, organizations are often tempted to apply for any and all funding opportunities that are identified. However, this haphazard and opportunistic approach may ultimately derail higher organizational strategic priorities. To avoid this, organizations managing multiple funding streams and agendas must continually evaluate their projects and opportunities, not only for performance but also for fit into the broader goals and objectives of the organization.7 In most cases, regular strategic planning is essential to organizational development, maintaining clarity of mission, prioritization of new and existing funding streams and directions, and setting and measuring performance goals. However, the potential to engage in an overly reductionist process may ultimately inhibit entrepreneurship, or the ability to evolve quickly, so caution is required to strike the right balance.8
CIDRZ undertook a strategic planning process in early 2013. The process included internal staff and external stakeholders, as well as donors and governmental representatives. CIDRZ was able to identify its strengths, weaknesses, opportunities, and threats; and clarify and update its mission and vision, and prioritize its principal strategic objectives for the 2013 to 2015 period.9 Adapting an approach designed by Harvard Business School faculty, key performance indicators were established for each objective and cascaded into group and individual work plans.10 This intentional approach, conducted for the first time within CIDRZ, has helped ensure clarity of purpose across the organization and has enhanced accountability. However, this 3-month process required a substantial commitment of staff time.
CIDRZ management holds ultimate responsibility for the day-to-day implementation of the strategic plan and monitoring performance on a quarterly and annual basis. This is overseen by the CIDRZ executive committee that reports progress on strategic plan objectives to the CIDRZ board of directors. The governance board comprises individuals with an array of skill and experience and includes persons with expertise in finance, public health, medicine, law, research, and government.
Managing portfolios of program implementation, research, and training funding streams requires the ability to track budgets, expenditures, outputs, procurement processes, and human resources. With a slowing in the growth of available funding, bilateral, multilateral, and private funders are all requesting more detailed information to minimize inefficiencies through increased programmatic accountability.11 For instance, the PEPFAR program requires partners to provide detailed information on categorized expenditures such as transport and human resources, and to link these expenditures to particular program outputs (eg, number of HIV-infected women receiving PMTCT or number of individuals provided HIV testing and counseling) for a fiscal year, by geographical region.12,13 In the context of funding constraints and increased management demands, nascent local organizations such as CIDRZ have particularly acute needs to develop organizational capacity and do not receive the relatively high level of facility and administrative costs that US-based institutions do. These special needs of local independent organizations are being recognized, and funders are increasingly willing to invest in institutions through funded activities or indirect funding within program grants.
Electronic systems can yield substantial efficiencies but require upfront and ongoing investments for training and sophisticated support functions. With the support of PEPFAR and the Centers for Disease Control and Prevention (CDC), CIDRZ has launched an Enterprise Resource Planning system intended to track and monitor individual project funding, and provide greater transparency of financial flows and accountability of departments and individuals. A myriad of unaligned external audits currently sap precious staff time, and it is hoped that the Enterprise Resource Planning system will help to lessen this burden. To augment existing accountability systems, CIDRZ is building a strong internal audit function for risk profiling of projects, identification of correctable problems, proactive risk management, and ad hoc investigations.
Driven by regulatory requirements, research operations require a unique focus and attention to accountability. CIDRZ has completed 76 research projects to date, and the current research portfolio includes 18 individual-site and 14 multicenter studies funded through the NIH, the CDC, the Doris Duke Charitable Foundation, and others. A dedicated research operations department has been convened to review all new grant applications to ensure operational feasibility, to find commonalities with other projects and minimize overlap between recruitment populations, and ensure financial and human resource needs are properly embedded. The department also oversees the development of standardized operating procedures and templates, as well as study tools that ensure careful source documentation, and prepares ethical and institutional review submissions locally and internationally. This group provides research sponsors assurance that quality data are collected and that regulatory requirements for human subjects protection are met.
MONITORING AND EVALUATION
Health program implementation and human subjects research require close monitoring and careful evaluation to protect participants and better interpret outcomes. The Paris Declaration of 2005 committed Ministers of Health and leaders of aid agencies to increasing aid effectiveness, including greater harmonization of methods of measuring progress and increased national ownership.14 To date, however, there has been limited success, and many gaps remain. Many governments and organizations continue to receive multiple funding streams and develop vertical or parallel systems to satisfy heterogeneous donor requirements.15 Recent study suggests that greater service delivery integration may also offer opportunities to achieve broader health benefits, as well as leverage strong vertical systems for monitoring and evaluation.16,17
Several large donors, including PEPFAR, are beginning to focus more on outcome indicators, as opposed to output indicators. These indicators, such as the number of individuals starting ART who remain alive and on ART at 1 year, should allow for better measurement of program effectiveness and impact. However, outcome indicators are more challenging to report and require solid data systems and the capacity to perform cohort analyses.18
Increased demand for high-quality data requires that organizations invest in strong data collection and management systems to meet disparate reporting cycles, variable indicator definitions, and other demands. Data management specialists, data analysts, and monitoring and evaluation staff are the backbone of successful reporting. At CIDRZ, the staff work closely with clinic staff and regional government staff to ensure proper reporting to the national program, and with US government staff to ensure that PEPFAR-specific reporting is accurate and timely. This challenging process requires high-level analytic capacity, flexibility, and the ability to interpret complex data. Quarterly stakeholder meetings supported by CDC have created opportunities for discussions around indicator performance and harmonization and allowed for identification of areas in need of improvement. Data security, including patient privacy rights, is required locally and by affiliated universities and allows the use of deidentified data to enhance clinical implementation and evaluation efforts, and recruitment feasibility queries for particular studies.
CIDRZ has also sought to develop capacity across the continuum of research and supported training in project management, study regulatory affairs, data management, and biostatistics. This institutional support of the research infrastructure is critical for maintaining a robust research portfolio, supports key local institutions and enables further opportunities for talented local investigators to stay and contribute in their home country.
SYNERGIES WITHIN THE COMBINED MISSION OF SERVICE IMPLEMENTATION, RESEARCH, AND TRAINING
PEPFAR has helped to drive increased interest, and funding for, implementation science over the past several years.19 The objective of implementation science is to fill the gap between what is known empirically and what it takes to implement effective interventions for greatest impact at scale. The HIV response has created tremendous opportunities for knowledge generated during implementation to inform research questions and for the results of research studies to directly inform programmatic implementation.
Organizations such as CIDRZ that implement programs on a large scale, and also have access to substantial local and international academic faculty and resources, have been able to contribute to this cross-fertilization. In addition to its work specifically targeting HIV, CIDRZ applies this model to related areas, including cervical cancer scale-up, tuberculosis in prisons, childhood diarrheal disease, and numerous other areas (Table 1). CIDRZ has not only performed numerous influential studies, its relationship and engagement with government policymakers has resulted in direct impact on policy development at the national and global level20; successfully bridging the implementation gap between research and policy, a linkage that is typically under-resourced to the detriment of health programs.
- Research organizations require multiple funding sources to achieve their mission
- Working with multiple funders is complex; because of differing requirements for documentation, parallel systems may be required
- Local ownership and governance allow access to a broader range of funds
- Strategic planning, as well as management and governance structures are critical elements of a successful organization
- Research operations are best centralized with specific standardized study tools and procedures
- Service delivery integration and implementation science may offer opportunities for important programmatic improvements
- In country training programs develop local expertise and are important in succession planning
The development of in-country programmatic and research expertise in young investigators is critical to sustain national research capacity and further supports organizational research and programmatic aims. CIDRZ has developed a portfolio of research training opportunities for local and international investigators to address critical areas of need. These programs include externally supported programs from the NIH, the Doris Duke Charitable Foundation, the Global Health Corps and collaborations with the University of Zambia School of Medicine, as well as the internally developed and administered HIVCorps Public Health Fellowship.21 To date, CIDRZ has trained over 200 Zambian and expatriate investigators. A combination of field attachments, exchange programs abroad, and Masters and PhD degree sponsorship addresses a critical need for education and mentorship within the medical community in Africa.
With the rapid increases in global health funding, opportunities to improve health outcomes through implementation and research have expanded. With this growth has come greater complexity and fragmentation of donor funding models, approaches and reporting requirements. Although donors work toward greater harmonization and country ownership, there is a critical need for strong organizations in the global South that are able to harness disparate funding streams, and manage organizational, operational, and reporting challenges, for the purposes of advancing national health agendas. Local organizations in particular require dedicated support for institutional capacity building to achieve the most efficient and sustainable public health impacts.
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