When Dr. Charles Holmes left the office of the U.S. Global AIDS Coordinator for 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, 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 antiretroviral treatment and prevention of mother-to-child transmission 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 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 Centre for Infectious Disease Research in Zambia at a turning point. Three years earlier, international organizations 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, the capital city where CIDRZ is based. Some international organizations had walked away from programs. Others had made the transition in name only.
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 organization, 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.
The organization 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. The organization recruited board members with proven records, drawing, Holmes said, “on the strongest business and medical leadership in the country.” That meant getting referrals, checking references, looking at the performance of organizations for which prospective members had previously served on the boards.
“An exciting process,” Holmes added. The board now has six local board members, including a leader of the Zambian national pension authority leading the investment committee, and three international, including 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 her country before going on for internal medicine and infectious diseases training in the U.S., is the organization’s deputy chief executive officer.
“This is what a local organization 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, control over work agreements, and “getting a fair shake.”
“The payoff,” he said, “we have gained the confidence of donors.”
The organization 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 organizations.
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 antiretroviral 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 organization.”