How can an organization work with institutions and communities to ensure the future of its pilot projects and increase the impact of its activities? Our organization, Solthis, was created in 2003, twenty years after the leading French health NGOs, with the initial mission of facilitating access to HIV treatment for patients in Africa. We drew on our own experience and that of the more established sister organizations, while taking advantage of changes in the aid landscape in order to offer a more modern approach.
From pilot project to large-scale project, the delicate art of transition
Solthis uses various means of action: capacity building, partnerships, research and advocacy. Simply put, our model involves analyzing pilot health projects to demonstrate their effectiveness and enable them to be taken over as long-term national programs, based on the concepts of “transition” and “scaling up”.
Transition involves handing projects over to national stakeholders in a way that enables the intervention model to be incorporated into the national strategy and funding. Scale-up refers to the expansion of interventions in terms of time (sustainability) and geographical area in order to reach more people and amplify the impact.
However, because transition is not a science, these simple definitions hide complex realities. Transition is more like a complex art form–without any magic formula. Its outcome is determined by a certain number of driving factors or obstacles. It is dependent on ongoing interactions with civil society (such as user associations), healthcare professionals, health authorities and bodies, research institutions, NGOs, technical partners, such as WHO, and donors.
Early involvement of national stakeholders is vital
Solthis has analyzed several pilot health projects in Africa to identify conditions for success.
The first two conditions were that the intervention model must be integrated into national programs and the healthcare system as a whole. To succeed in this area, the project must meet a need that is identified as a priority issue. This was witnessed in Niger, where Solthis led a pilot operational research project on midwives providing HIV treatment to pregnant women in the context of mother-to-child transmission prevention efforts. The project resulted in a decree authorizing midwives to prescribe triple combination therapy, which changed the management of care for pregnant women throughout the country. This change was possible due to the involvement of national stakeholders right from the design phase. This cooperation helped to identify this goal, as well as the need for midwife training and the collection of data during the pilot phase in order to demonstrate its effectiveness.
Another pilot project led by Solthis was aimed at measuring HIV viral load among patients. The test required certain products, which revealed the importance of working on continuity of supply in order to ensure a successful handover to the government department. In Cameroon and Guinea, the authorities’ handling of the project enabled the Global Fund to take over funding, but it was not so easy in other countries in Africa where projects were not sufficiently integrated into the national procurement systems.
Capacity building among local stakeholders
The third condition for success is ensuring the operational and technical skills of those leading the transition. In this viral load project, one crucial step was to define a capacity building plan to prepare laboratory staff, healthcare professionals, organizations, and the personnel of the institutions concerned (especially the Department of Health), which was officially established in a transition plan.
The fourth condition is to secure funding, either in the State budget or from health donors in fragile economies. In Mali, Solthis supported the decentralization of HIV care services through a coaching project, which eventually led to the integration of this strategy into national policy. This initiative helped maintain funding for the training of coaches in the regions (a total of nearly 300 people). The project will continue after 2021 thanks to the commitments from donors. There are also plans to expand the project to include other diseases (such as tuberculosis).
The fifth condition is the need to provide sound evidence about the intervention, its positive impact, and cost-effectiveness. This aspect is what helps win the support of the authorities in charge of requests for funding, who will be taking over the project, sometimes with technical assistance.
Community support, an essential prerequisite
The Solthis experience has also demonstrated the vital need for genuine demand from the community. This is especially true for health projects related to HIV and sexual and reproductive health, which require advocacy efforts among user organizations, communities and local organizations, who can add the knowledge derived from their practical experience to the evidence for the project, and bring their influence to bear.
Finally, international conditions also exist: the existence of sound evidence can help establish the initial project, and influence international and regional recommendations (WHO), and potentially the use of certified products at affordable prices. The ATLAS project, for example, is being carried out in partnership with the WHO in order to produce a national self-testing strategy in Senegal. Its involvement in the international technical group makes it easier to earn support for future health projects from international donors.
Obstacles and limitations to this approach
There is no such thing as an ideal world, and the art of transition faces multiple obstacles. The main one is the time needed to carry out these transitions and discussions with the various stakeholders, in a context of pilot projects with short-term funding that require quick results. Yet this time is necessary to ensure true ownership of the approach and prevent the perception that the project is being imposed from the outside. The identification of the key players is also essential. High turnover could affect a project’s sustainability if the individuals trained are not well-suited for the job or decide to resign.
Furthermore, demonstrating the project’s impact requires more robust monitoring and assessment methods and approaches, as well as complicated and expensive cost-effectiveness studies, and national health information systems are not always reliable. This is why, from the outset of the ATLAS project, specific HIV self-testing indicators were integrated into the health information systems and supply systems for national pharmacies.
This virtuous approach, based on the expertise of organizations, helps to empower national stakeholders in a context focused on identifying and prioritizing the individuals concerned. However, this model must be improved by comparing the viewpoints of all the stakeholders involved, including NGOs, donors, and researchers. This will pave the way for modern international solidarity based on sustainable and contextualized practices.
The opinions expressed on this website are those of the authors and do not necessarily reflect the official position of their institutions or of AFD.