Programme Area 4: Programme Management and Institutional Performance

Programme Area 4: Programme Management and Institutional Performance

Over the period of the NSP, several mechanisms were utilised to foster collaboration and capacity building in the private sector, civil society and partner Ministries with the view to delivering effective programming, strengthening management and sustaining the multi-sectoral response. However, several key mechanisms have recently been or are soon to be discontinued, which could weaken the NHACs ability to efficiently and effectively coordinate the national response and the ability of partners to deliver effective and sustainable programming. In moving forward, the NHAC will need to ‘do more with less’. It will need to foster fewer but more strategic placed alliances and coordinate more focused high impact programming to achieve sustainable outcomes.

1. 
   What mechanisms are in place to facilitate collaboration among the private sector, civil society and Government?
   

The AIDS Foundation of Barbados Inc. was established at the initiative of an individual from the private sector in August 2002 with the view to providing better information to employers and their employees with better information on HIV and AIDS. According to the Foundations (still functional) Facebook page, the mission of the Foundation was to ‘…reduce the spread and impact of HIV/AIDS through facilitating and implementation of workplace policies and programmes that focus on behaviour change, reducing stigma and discrimination, and creating supportive environments for persons living with HIV/AIDS’.

The Foundation’s four-person staff largely focused on working with existing Health and Wellness Focal Points and Committees in private organisations to include HIV/AIDS information in the organisations Workplace Wellness Programmes and Policies. This approach was a strategic choice for the Foundation. The Foundation sought to avoid the stigma of HIV and AIDS by incorporating it into more holistic packages for wellness among employees. This appears to have also meant that the Foundation did not seek to link employees with specific HIV-related services (with the exception of HIV testing in some instances). Instead, the Foundation focused on sensitizing employers and employees with messaging on prevention, treatment and care, and, stigma and discrimination. The Foundation was also active in undertaking evaluations of the response to their work and in undertaking research among the private sector. However, much of this work appears to have been lost. Approximately 22 businesses were said to be engaged by the Foundation.

The Foundation’s programmes and organisation were sustained through contributions made by member companies. Companies were categorized in different ‘tiers’ based on the value of their contributions and received different levels of assistance from the Foundation accordingly. When this funding source began to wane due to lack of interest, the Foundation became unsustainable.

At the time of the closure, the Vice President Mr. Steve Soute was quoted in a regional newspaper as saying:

‘The foundation relied primarily on private sector grants, membership fees and governmental as well as international agent subsidies [but] the majority of our funding came from the private sector…Obviously, many of them do not think [AIDS awareness] is a priority; they think they have it covered. It is the prevailing culture within corporate Barbados and maybe the country as a whole which could be to blame [but] the closure of the foundation would work to the detriment of the country.’ (‘Barbados AIDS Foundation closes’, Sarbroeker News, September 2, 2012)

In some instances, the Foundation worked with HIV/AIDS Coordinators and Focal Points from Government Ministries to target the private sector. Some HIV/AIDS Coordinators have continued to engage with the private sector since the Foundations closure, including the Ministry of Tourism Coordinator who continues to target hotels and their staff. However, such work appears to be infrequent, small in scale and not linked to a more comprehensive strategy.

There is space for some Ministries to more effectively engage with the private sector, especially where there are existing relationships and natural allies. The Ministry of Labour, in particular, is well positioned to play a more active role in engagement with the private sector. The Ministry of Labour’s ‘Code of Practice on HIV/AIDS and Other Life Threatening Illness for the Public Sector’ could be reviewed and adapted to be more relevant for the private sector organisations as a starting point for this expanded engagement.

During the period under review, the NHAC engaged civil society partners through monthly Coordination Meetings, a Civil Society Grants System, capacity building efforts and M&E reporting mechanisms. At the conclusion of the NSP period, civil society also had a representative on the NHAC Board.

The NHAC has been active in trying to engage and develop the capacity of civil society groups, but their work has been hampered by several factors including the transient and personality-based nature of the civil society organisations in Barbados. During the NSP period, CHAA played a critical role in both engaging vulnerable populations and developing the capacity of other civil society organisations working with vulnerable populations. Their recent closure, due to cuts in PEPFAR restructuring, is a loss for the national response as it moves into the next NSP cycle. The end of the World Bank Project may also create difficulties for the national response, especially if it results in the scaling back or termination of the Civil Society Grants System.

The monthly Coordination Meetings hosted by the NHAC are viewed positively by CSO and Government counterparts alike. The focus of these meetings is on reviewing planned activities, coordinating activities, sharing information and problem-solving. They provide an effective forum for networking and coordinating with HIV/AIDS Focal Points, HIV/AIDS Coordinators, and CSO representatives. The success of these meetings is reflected by the fact that a number of joint activities appear to have resulted from this forum. There appears to be some concern, however, regarding attendance at these meetings by partners, especially for HIV/AIDS Focal Points whose roles are voluntary.

The Civil Society Grants System and capacity building work by the NHAC has also facilitated the development of closer collaboration with civil society and is also viewed favourably by most CSO partners. Initiated in 2011, the Civil Society Grants System was administered by the NHAC and was designed to fund local civil society organisations undertaking work with vulnerable groups in keeping with the NSP. Grants of between Barbados $10,000 and $20,000 were available to CSOs on an annual basis subject to the submission of a competent proposal.

The Grants System has enabled the NHAC to guide the work of CSOs towards key populations and provide capacity building in the form of training sessions and coaching. However, some concerns were expressed regarding the amount of resources required to maintain the Civil Society Grants System and the capacity of the NHAC to maintain management of the System. Further to this, to date, the Grants System has been supported by a loan from the World Bank, which is scheduled to end without the possibility of renewal at the conclusion of 2014. While the end of the loan does not necessarily mean the end of the funding for HIV and AIDS or the Grants System, given the current economic difficulties facing the Government of Barbados, there are some concerns that programmes such as these may be cut. This would be a great loss for the national HIV response.

2. 
   Were the mechanisms for coordination and management of the NSP effective and sustainable?
   

Given the expected decrease in funding the NHAC will need to rationalise how and who it works with across all sectors. One method of achieving this would be to invest in fewer more strategically placed partners. CSO partners who are engaged should be selected based on their potential for sustainability as well as their positioning with key populations (as identified by existing data) in the new NSP. The NHAC could then provide tailored technical assistance to these CSOs to ensure their sustainability; assisting them in developing a Charter, a Strategic Plan, creating a board, establish financial controls and accounting processes, and in grant writing. It is likely that the NHAC would need assistance to do this as many of these activities appear to be beyond the existing capacity and mandate. The NHAC may look to the Barbados Association for NGOs as a key partner in providing this type of assistance, as well as other international NGO partners, such as Population Services International or the Caribbean Vulnerable Communities Coalition and some partner Ministries, such as the MOH.

Another method employed by the NHAC to strengthen coordination with CSOs and other partners has been through the establishment of an M&E system. Under the Civil Society Grants System, CSOs are required to submit quarterly reports to the NHAC outlining information on the progress of activities and spending. Other partners, including Government Ministries and CSOs, who are not recipients of funds under the Grants System submit reports on a voluntary basis. These reports provide an update on partners work during the quarter, challenges and spending (in the case of CSOs under the Grant System). While a large number of partners submit reports on a regular basis, there remains a gap in the information reaching the NHAC and the NHAC is unable to keep up to date with the activities being implemented by the various partners. While the establishment of the M&E system is commendable, the content and use of the information reported could be leveraged to be more strategic and aligned to feed directly into the National M&E System.

Lastly, the NHAC has also been active in recruiting a CSO representative to the Board in the form of former CHAA Peer Animator and Founder of the CSO CEED. While the evaluation team believed that this was a positive step forward, there are still opportunities to include civil society in a more meaningful manner in decision making processes and, thus, to more strongly embrace the Greater Involvement of People Living with HIV/AIDS (GIPA) principle. The National Composite Policy Index for 2013 reports that a number of CSOs feel left out of key decision-making process. However, to guarantee meaningful contributions it appears that capacity building (as mentioned above) may first be required to ensure that the CSOs are both sustainable and capable of participating. It would also be helpful to establish a baseline for measuring GIPA and related efforts. This may be possible using the Stigma and Discrimination Survey, which was in train at the time of the evaluation.

In addition to the Monthly Coordination Meetings and the submission of M&E Reports the NHAC implemented Monthly Strategic Meetings with HIV Coordinators and undertook reviews of partner Ministry annual work plans to ensure collaboration with partner Ministries during the NSP period. However, the broad focus of the NSP including the broad definition of vulnerable groups and the structure adopted for furthering the multi-sectoral response in Barbados led to a situation whereby activities implemented by partner Ministries were not aligned to the needs of key populations and would not have an impact on the epidemic. Further to this, communication between the NHAC and Ministry of Health is in need of clarification and strengthening.

The Evaluation Team shares the opinion of the Authors of ‘Mid-Term Review of the Second GOB/IBRD HIV/AIDS Prevention and Control Project’ completed in November 2011 which found that:

‘Overall, organizational structures, coordination and communication structures established by the Government of Barbados are a significant accomplishment and contribute materially to institutionalizing and sustaining a truly multi-sectoral HIV response. More specifically, the Board and Secretariat of the NHAC with its multi-sectoral mandate, the establishment of dedicated posts within the civil service for HIV Coordinators in key Ministries (Ministries of Education and Human Resource Development, Labour and Social Security, Tourism, Housing and Lands, Tourism and Social Care, Constituency Empowerment and Community Development) and the designation of HIV Focal points in other Ministries are particularly noteworthy. Ministries and/or Departments in which Core HIV Work Groups are established and functional (Ministry of Labour, the Ministry of Social Care and the Royal Barbados Police Force) facilitate the development conduct of HIV activities.’ (p.25)

The Mid-Term Review went on to note some structural issues that undermine the NHAC from fully realising its role as a multi-sectoral coordinator:

‘The challenge for the NHAC's Board and Secretariat is related to being assigned responsibility for management and oversight of a performance-based loan without the accompanying requisite lines of authority.’ (p.26)

This remains the case at the time of this evaluation. Under the current arrangements, each Ministry is responsible for planning, budgeting and implementing HIV Prevention and HIV/AIDS Care and Support Programming through the Annual Government Budget Estimates process. Through this process, each Ministry is required to allocate monies to HIV/AIDS activities under Programme Line 365 and submit this to the Ministry of Finance for approval. While the NHAC does provide input on partner Ministry work plans were asked, they lack any authority to ensure that these activities are in keeping with the NSP or country priorities. Consequently, many Ministries chose to spend their funding on activities that are easy and non-offensive such as Health Fairs and the distribution of HIV branded materials (t-shirts, pens, cups, etc.) that have little strategic value or potential to curb the epidemic.

While it is commendable that many partner Ministries have an HIV/AIDS Focal Point and, in the case of Key Ministries (including the Ministry of Education and Human Resource Development, Ministry of Youth, Family and Sports, Ministry of Health, Ministry of Housing and Lands, Ministry of International Business and International Transport, Ministry of Transport and Works, Ministry of Social Care, Constituency Empowerment, Urban and Rural Development and Ministry of Tourism) full time and paid HIV/AIDS Coordinators¹¹ the capacity and qualifications of these Focal Points and Coordinators appears to vary greatly. The work of the Focal Points is particularly challenging as their role is largely voluntary and added on to their regular (non-HIV/AIDS related) duties.

As the NSP Mid-Term Review neatly sums up:

‘The NHAC's challenges in working with the Coordinators include:

• 
  Variability in performance levels of the Coordinators;
  
• 
  Variability in HIV qualifications and capacity of Coordinators;
  
• 
  Selection process is outside the NHAC's control;
  
• 
  Selection criteria are internal to individual Ministries;
  
• 
  Coordinators do not all report directly to the Permanent Secretaries as planned;
  
• 
  Coordinator performance review systems do not include ratings or input from the NHAC and implementing partners with whom Coordinators do most of their work.’ (pp.29-30)
  

Communication and collaboration between the NHAC and its primary Ministry partner, the MOH, require strengthening. Issues including personality conflicts, a lack of clear boundaries in terms of roles and responsibilities (as well as differing beliefs about what those roles and responsibilities should be), inadequate formal communication mechanisms and varying capacities have undermined this relationship during the NSP period. However, perhaps most importantly, the development and implementation of the NSP failed to capture key recommendations from the MOH, pertaining to MOH’s area of focus (testing, care, and treatment). As a result, the MOH felt the need to develop their plans to ensure that their work remained focused and reportable and implemented this plan in parallel to the NSP. It is notable, that despite this there was consistent and productive collaboration between the staff of the MOH, CSOs and partner Ministries to implement activities.

While the MOH representatives participated in NHAC monthly Coordination and Strategic Meetings during the NSP, these were not sufficient to ensure the level of cooperation and management needed. The presence of a lower-level MOH representative on the NHAC Board and the non-representation of the MOH on the NHACs Research Sub-Committee were also noted as problematic by the evaluation team. Both the NHAC and the MOH need to invest greater effort in implementing mechanisms to ensure greater collaboration and communication between the two agencies, especially at the highest levels (NHAC Director and Chief Medical Officer). This collaboration and coordination will be increasingly important given the closure of the World Bank Project, the closure of CHAA and the current financial issues facing the country. The recent collaboration in the development of the new NSP and the recognition by both institutions of the need for improvement holds promise for strengthening collaboration and coordination between the two agencies and was seen by the evaluation team as a step in the right direction.

There also exists an opportunity for the NHAC to strengthen its relationship with the Ministry of Finance to resolve the issue of control over HIV/AIDS spending by partner Ministries. Options for how this could occur will be explored in the recommendations section.

The multi-sectoral approach to coordination and management of the national response adopted by Barbados - developed prior to the NSP period, but maintained during it - whereby Ministries are required to plan and implement HIV/AIDS activities is unique in the Caribbean and has the potential to ensure the sustainability of the response and to deliver effective programming. However, more work is required to ensure that the coordination and management of the response is unified, targeted and strategic and that the gains made by the national response are sustainable and continue to have an impact on the epidemic. While a number of the strategies to address coordination and collaboration have been discussed above, there are several other issues affecting the coordination and management of the national response that also need to be dealt with, including the positioning of the NHAC, clarity over the role and function of the NHAC (including its governance structures), leadership and capacity.

An ever-present issue expressed by key informants throughout the evaluation was the ‘lack of power’ of the NHAC to ensure compliance with the NSP. While the evaluation team was sympathetic to this, especially in terms of how the NHAC interacts with other Ministries, it believes that focusing on this issue has stifled creative problem solving in dealing with existing political and structural realities. The notion that the NHAC ‘lacks power’ originates from the fact that when the NHAC was initiated in 2001, it was under the auspices of the Office of the Prime Minister where it wielded greater influence and respect. Since then the NHAC was shifted to the Ministry of Family (Care), Culture, Sports and Youth¹² and then to its current location at the Ministry of Social Care, Constituency Empowerment, and Community Development¹³. Effectively the NHAC is a Government Department and functions as such, despite having the purview of having to coordinate the multi-sectoral response.

There has been much debate around the positioning of the NHAC to optimise its effectiveness. Some believe it was necessary for the NHAC to remain in a Ministry but separate from the MOH to ensure that the national response remains a multi-sectoral ‘development’ issue rather than simply a ‘health’ issue. For many of the NHAC staff, the Commission would be best positioned if put back into the Office of the Prime Minister where it could exert greater influence. Others consider the MOH the natural home for the NHAC. Advocates for this shift, suggest that this would improve the efficiency of the HIV/AIDS response as authority would rest with one Permanent Secretary and the Chief Medical Officer rather than two Permanent Secretaries as it currently does, and that this would improve not only communication and collaboration, but also financial management and the use of data. The merits of some of these different approaches are explored in the PAHO Evaluation of the Health System’s Response to HIV/STIs Report (page 33, 2011). However, it is the view this evaluation team that moving the NHAC from Ministry to Ministry has disrupted the work of the NHAC and contributed to confusion over its role. At this juncture, the evaluation team believes that NHAC needs to refocus on the HIV epidemic and its core functions to ensure that they are effective, and the national response continues to deliver results for the people of Barbados.

Another issue that has hampered the management of the national HIV response has been the confusion over the role and function of the NHAC. The original mandate for the NHAC is enshrined in a Cabinet Decision of 2001 in which the responsibilities of the NHAC were nominated as:

• 
  Advising the government on HIV/AIDS/STDs policy;
  
• 
  Advocating the effective involvement of all sectors and organisations in implementing programmes and strategies;
  
• 
  Monitoring the implementation of the Strategic Plan in all sectors of society;
  
• 
  Creating and strengthen partnerships for an expanded response to all sectors;
  
• 
  Mobilizing resources (internationally and locally) for the implementation of the National HIV/AIDS programme; and
  
• 
  Recommending appropriate research.
  

It is noteworthy, that these responsibilities have not been updated since 2001 when the NHAC was positioned in the Office of the Prime Minister, nor does it appear that any subsequent documents have been produced regarding the role and function of the NHAC and its processes. Consequently, the evaluation team believes that it is important to the stakeholders of the national response to review the internal structure of the NHAC Secretariat as well as the institutional arrangements of the NHAC. This may be achieved through the development of a Terms of Reference (TOR) clearly articulating the structure, role and responsibilities of the Permanent Secretary, Board, Committees¹⁴ and the Secretariat. In this document, the key positions for the Board, Committees, and the Secretariat could be clearly identified and linked to the overall mission and direction of the NHAC (and aligned to the NSP). In this regard, the evaluation team is in concurrence with a finding from the Mid-Term Review:

‘The NHAC, MOH, and partners, should prepare a Governance Structure document that further specifies and clarifies organizational roles, relationships, responsibilities, positions, lines of authority, performance expectations and collaborations.’ (p.27)

Once the TOR is completed, it will need to be clearly communicated to all stakeholders and implemented.

3. 
   Were capacity building efforts effective in strengthening management?
   

1. 
   Develop a TOR for the NHAC (including governance arrangements) considering different models by which the work of the NHAC can be sustained and aligned to the priorities of the NSP.
   
2. 
   Undertake a capacity assessment of the staff of the NHAC as it pertains to the TOR and a capacity building plan for addressing priority areas.
   
3. 
   Focus on fewer but more strategically place partners to implement high impact programming for vulnerable groups as identified by the existing data.
   
4. 
   Engage strategic partners (Ministries, CSOs, and Private sector) for tailored capacity building to reach key populations and develop the capacity and sustainability of CSOs.
   
5. 
   Explore options to maintain the Civil Society Grant System, should the closure of the World Bank Project affect this System.
   
6. 
   Strengthen the participation of civil society in decision-making through the greater embrace of GIPA, developing capacity where necessary and using the Stigma and Discrimination Study if possible as a baseline for assessing the effectiveness of these efforts.
   
7. 
   Identify the structural barriers that can be addressed to reduce vulnerability of other priority populations.
   
8. 
   Partner with the Ministry of Labour to strategize on re-engaging the private sector (through the Business Council, adaption of the ‘Code of Practice on HIV/AIDS and Other Life Threatening Illness for the Public Sector’ for the private sector, etc).
   
9. 
   Engage with the Ministries of Finance and Health to develop a formal mechanism for approving HIV projects by either:
   

1. 
   The implementation of a technical review panel (see Global Fund Model)
   
2. 
   Assigning responsibility for approval and oversight of activities under Line 365 to the NHAC
   

10. 
    Strengthen communication and collaboration with the MOH.