Feature October-November 2003
Secure the Future -- Building Capacity from the Ground Up in Africa

As pressure mounts around the globe to address the pandemic of AIDS, the business community has begun to step forward to accelerate its response. In recent months, the headlines have been full of news on the latest developments: the Bill & Melinda Gates Foundation doubling funds to fight AIDS in India, deep discounts from the manufacturers of AIDS drugs, and new concessions from the generic drug makers.

Yet the account of one leading company's pioneering efforts -- not just to fight AIDS, but to give communities in the developing world the tools to create and manage their own solutions -- remains largely untold. One of the best-kept secrets in corporate philanthropy, the tale is even more remarkable because it was front-page news when it was launched on the scene in 1999.

The story begins in 1998, when UN Secretary-General Kofi Annan approached Charles Heimbold, then Chairman and CEO of Bristol-Myers Squibb, and asked him to take a leadership role on behalf of industry in finding a solution to the problem of HIV/AIDS.

By that time, the death toll from the AIDS crisis in sub-Saharan Africa was nearly 15 million people -- the equivalent of the combined populations of New York City and Los Angeles. More than 20 percent of these deaths were among children. Even though southern Africa had only one-tenth of the world's population, it bore the brunt of almost 80 percent of deaths worldwide, and 70 percent of people living with HIV/AIDS were located there.

The evolution of Secure the Future

As one of the leading manufacturers of antiretroviral AIDS drugs, Bristol-Myers Squibb had the interest and the resources to join the battle. Given the magnitude of the crisis, company officials wanted to make a commitment commensurate with the need. But the climate at the time for philanthropic action by multinationals in general and pharmaceutical firms in particular was charged with suspicion and hostility on the part of the developing world, where concerns about affordability and access to AIDS drug were paramount.

It was into this turbulent environment that Bristol-Myers Squibb, through its corporate foundation, launched its $100 million, five-year Secure the Future program (www.securethefuture.com) in May, 1999 and pledged what was then the largest corporate commitment ever to fight AIDS in the developing world.

Secure the Future was unprecedented, not only in the amount of funding, but in its dual emphasis on medical treatment and research -- particularly on the subtype of HIV that is endemic in southern Africa -- complemented by community-based prevention and care. The program was focused on five countries: Botswana, Lesotho, Namibia, South Africa and Swaziland, and aimed at women and children, since at least half of all infected adults in the region are women ages 15-49, and in some countries more than 25 percent of pregnant women are infected. Over 90 percent of children orphaned by AIDS live in Africa.

"The way it was designed was incredibly forward thinking," said Mark Kline, MD, director of the Baylor International Pediatric AIDS Initiative (BIPAI) and chief of retrovirology at Texas Children's Hospital. Support from Secure the Future helped BIPAI establish the first pediatric AIDS center in Africa. "It blazed a path in that Bristol-Myers Squibb was fostering a view that HIV/AIDS was much more than a medical problem."

Nevertheless, Secure the Future was not immediately or universally embraced. The high-visibility media coverage that followed the announcement -- which seemed to some more like the launch of a major new drug than a social contract -- only seemed to fan the flames of resentment among some potential beneficiaries. Calls were even issued for the company to simply donate their much-needed antiretroviral (ARV) drugs, but in the absence of an infrastructure to effectively deliver those drugs, this was not an option from the company's point of view.

"In the beginning, there was suspicion and a lack of trust. We didn't want to do it without the support of the national health ministries, or most of our programs just wouldn't be sustainable," said John L. Damonti, President of the Bristol-Myers Squibb Foundation.

Determined to forge ahead, the architects of Secure the Future redoubled their efforts to reach out to essential partners on the ground in southern Africa, listened and learned from the early feedback-and moved quietly forward.

"We agreed to keep our heads down, do what we said we were going to do, and eventually, people would understand that we were sincere about it." Damonti said. The resulting behind-the-scenes dialogues succeeded in cementing critical relationships with health ministries in the five countries and created strong allies among institutions in the region.

Raising the bar for corporate action on HIV/AIDS

What emerged was a greatly strengthened program that has permanently changed the dynamics of the fight against AIDS in fundamental ways, according to Secure the Future's partners. The groundbreaking efforts of Secure the Future have succeeded in bringing other major funders to the table-government and private-raised the bar for corporate involvement in the field of HIV/AIDS, and shored up the capacity of each and every grantee funded by the program.

"You have to think back five years ago to what the situation was like in Africa regarding AIDS and corporate giving in Africa," says Kline. At the time, it was a really extraordinary thing. Others had not made this commitment. It was a watershed event in changing the way that pharmaceutical companies view their responsibilities to HIV-infected people. It set an example for others to follow."

"They were the first and their level of commitment was the greatest," says Dr. Richard Marlink of the Harvard AIDS Institute, who believes that Secure the Future's $100 million pledge was influential in the Clinton Administration's announcement, two months later, of its own $100 million proposal to help Africa stop the spread of the disease. That plan, too, included a substantial focus on home- and community-based care.

"Secure the Future actually focused help in Africa in terms of care and prevention programs, and made other companies realize that getting involved was the way to go," said Marlink, who has worked on AIDS research in Africa since 1985. Marlink believes that it also laid the groundwork for the subsequent $100 million African Comprehensive HIV/AIDS Partnership that the Gates Foundation and the Merck Company Foundation formed with the Government of Botswana.

African solutions for African problems

Guiding Principles: Secure the Future

All programs and activities of Secure the Future must be: Public/private partnerships as embodied in government policies on HIV/AIDS Compatible with national health care priorities of participating countries Governed cooperatively by NGOs, academic institutions, people living with AIDS and ministries of health to promote "African solutions for African problems" Sensitive to local context Ethically unassailable complete transparency in clinical trials; no use of experimental drugs Catalyst for expanded participation Innovative, sustainable and replicable. Finally, they must promote equity

The crafting of such a groundbreaking approach wasn't easy. As the first and biggest commitment of its kind, there were no blueprints to follow. "We learned as we went along, and we had good advisors who understood the context in which we were working," said Damonti.

Months before launching Secure the Future, the Bristol-Myers Squibb Foundation sought input from a range of stakeholders in southern Africa, including medical institutions, major clinicians, people living with AIDS, experts in non-profit management, and representatives of the Ministries of Health of each of the five participating countries. Many of these -- including Kline and Marlink -- became members of the technical advisory committee that consulted on the original operating plan for Secure the Future and reviewed all grant proposals.

What emerged from this series of consultations was a set of guidelines that were put in place with the five Ministries of Health and have informed Secure the Future's work from the beginning (see box above).

The overarching theme of these principles was that the work undertaken with the support of Secure the Future must lead to "African solutions for African problems." And the Bristol-Myers Squibb Foundation insisted that all grants had to be innovative, sustainable and replicable, because "obviously $100 million on this issue is not very much money," in the face of the staggering demand for treatment and care of AIDS, Damonti said.

The fruits of collaboration

Now four years into a five-year program, the Bristol-Myers Squibb Foundation has proven to its African partners that it is here to stay. Secure the Future has a substantial record of accomplishments and a desire to communicate the lessons learned along the way to a wider audience. As of this writing, 130 grants have been made, more than $60 million committed, and more than 40 community-based organization and NGOs have been funded and strengthened in the process. An additional $15 million was pledged in 2001 to expand the program to four countries in West Africa -- Burkina Faso, Côte d'Ivoire, Mali and Senegal.

Broadly, the grants fall into focus areas that include research and development, prevention, care and support, and mitigation. Many involve multiple-partner collaborations, and all but six of the 130 grants have gone to Africa-based partners. Just to indicate their range, these grants have underwritten programs that offer economic opportunities and training for the grandmothers who have now become the caregivers for the millions of AIDS orphans in the region; led to the discovery of new lower-cost tests to monitor HIV blood levels; train lay health workers; develop new approaches to prevent mother-to-child HIV transmission and foster home-based care solutions.

At the community level, Secure the Future is helping grantees harness local knowledge to craft local solutions. For example, Reetsanang Assocation of Community Drama, an umbrella organization for some 78 drama groups in Botswana, uses theater as a powerful tool for community education to destigmatize HIV/AIDS and prevent mother-to-child transmission. Reetsanang's actors visits villages throughout Botswana, tailoring individual performances to the special circumstances of each location and delivering effective AIDS prevention messages in the process.

With so many struck down in the prime of life by AIDS, grandmothers have become the primary caregivers for the children and grandchildren of communities affected by the disease. In hard-pressed Khayelitsha Township in Cape Town, South Africa, a partnership funded by Secure the Future is empowering grandmothers with business skills and counselling about HIV/AIDS. The result is Grandmothers Against Poverty and AIDS, an organization that is mobilizing older women in the community to speak out about HIV/AIDS without fear.

A variety of Secure the Future's grants make possible the badly needed infrastructure to support cutting-edge research, provide treatment, and for the first time, establish outpatient care for individuals with AIDS. Among these is a grant to Baylor College of Medicine to help fund the construction and continuing operation of the largest pediatric HIV/AIDS center in the world, the Children's Centre for Excellence at the government's Princess Marina Hospital in Gabarone, Botswana. The center, which opened on June 20, already has 1,000 children under care. Baylor's Mark Kline wants to replicate the $2.1 million facility in 10-12 other epicenters of HIV/AIDS, and believes such a plan could easily be funded by sponsored research.

Funding from Secure the Future for the Harvard AIDS Institute supported the establishment of the largest HIV-specific research and reference laboratory in Africa, and also helped kick off the first antiretroviral clinic in southern Africa, the Infectious Disease Care Clinic, co-located with the reference laboratory in Gabarone. Critical new research initiatives at this complex center on the subtype of the HIV virus found in Africa. A major study supported by Secure the Future will enroll 650 HIV-infected individuals on an outpatient basis to study resistance patterns to various combinations of ARVs.

A fellowship program sought by the School of Public Health of the Medical University of South Africa was supported by Secure the Future to build capacity in the public health systems of southern Africa. The program is expected to graduate up to 250 new public health specialists; among the newly minted MPHs is P.K. Dlamini, the former Minister of Health of Swaziland.

With Baylor College of Medicine, Secure the Future has developed a nursing curriculum that has become the first definitive curriculum for individuals in the health field working with HIV/AIDS. Developed with the nursing associations of all five countries, the guide has been requested by 48 countries and implemented in 20.

Capacity building from the ground up

As Secure the Future looks to lessons learned from its four years on the ground in Africa, one of the most important discoveries has been the steepness of the learning curve that had to take place among the many small community-based organizations and NGOs that the program wanted to bring to the table.

"We said that we were going to make sure that anyone who had a good idea could compete," said Damonti. To do this, many small organizations had to be brought along from the ground up with training in grantwriting, financial accountability, evaluation and communication strategies.

In each of the five countries, Secure the Future found more mature mentor organizations such as BONASA (Botswana National AIDS Service Organization) and SIMPA (Swaziland Institute of Management and Public Administration) to offer countrywide workshops to teach the fundamentals of grantwriting. To build financial capacity, BMSF contracted with the South African office of its US accounting firm, PricewaterhouseCoopers, to do pre-award surveys for every potential grantee that needed coaching in basic financial management.

In site visits to the prospective grantees, the accounting team would conduct a top-to- bottom audit, teaching the entire organization the essentials of good financial controls. An outgrowth of this effort was the production of an NGO Financial Management Pocket Guide distributed widely at a capacity building conference organized by Secure the Future.

In the critical area of evaluation, the Foundation contracted with Yale's Center for Interdisciplinary Research on AIDS to establish an independent evaluation unit under the supervision of Dean Michael H. Merson of the Yale School of Public Health.

Grantees participated in five-day training workshops, then were assigned an independent evaluator to track the performance of the grant. Further, a public relations firm, Simeka TWS Communications, was hired to work with grantees on the skills needed to successfully share the results of their work, such as getting published in scholarly journals, honing speaking skills, and poster presentations.

For some, the experience and capacity gained through the application process has been arguably as valuable as the grant itself. A prime example is the Botswana Christian AIDS Intervention Programme (BOCAIP), a network of grassroots community AIDS initiatives and church organizations.

One of Secure the Future's first grant recipients, BOCAIP was a small NGO when it came in with a proposal to provide AIDS counseling through the church network. Robert Mbugua, a former partner of PricewaterhouseCoopers who headed the audit team, notes that BOCAIP used the skills gained during its financial review to build the organization and has attracted more than $5 million from other funding sources -- including the Gates Foundation-for its community efforts to fight AIDS. Communications training has enabled grantees such as BOCAIP and others to share their work at forums such as the Barcelona International AIDS conference and at other major gatherings on HIV/AIDS.

Translating lessons into action

The next phase of Secure the Future will take the lessons learned from both the medical research and the community grants and test them in the most seriously challenged environments in southern Africa. Governments have indicated that if it can be can demonstrated that ARVs can be delivered successfully in these resource-limited communities, the programs will be adopted as treatment models for their respective countries. Sites selected to participate in Secure the Future's $30 million Community Based Treatment Support program include Caprivi, Namibia; Bobonong, Botswana; Mbabane, Swaziland; Maseru, Lesotho; and two sites in South Africa, Ladysmith and Rustenburg.

The program will require the mobilization of all sectors of the chosen communities, to provide a comprehensive range of services-from treatment and lab services to nutrition, counseling, project management and home-based care. "The only way to be effective on ARV treatment is if there's complete collaboration between the communities and the treatment," says Damonti. "We have to mobilize the communities to do it themselves." He expects that Secure the Future will remain involved for up to 2-1/2 years, at which time the governments will step in to sustain the program. As with all other drug trials, the Bristol-Myers Squibb Foundation has committed to funding the provision of ARV therapy as long as the patient is responding to treatment.

Beyond AIDS: the value of capacity building

The hallmarks of Secure the Future in Africa have been the same principles that drive the business side of Bristol-Myers Squibb: developing trust among partners, building in accountability, and establishing credibility.

From the start, Secure the Future understood that real capacity building would require more than money alone -- so it built skills transfer and sustainability into every aspect of the program. "The message from the corner office was, 'We're going to fund in Africa, which is the right thing to do. But make sure that that money is spent effectively, '" says Damonti.

In the area of skills transfer, the business sector has much to offer the developing world, and Secure the Future offers a model. "People in corporate America understand distribution, they understand management and they understand infrastructure, and I don't think that's really been harnessed yet," Damonti observes.

Ultimately, the legacy of Secure the Future will be the empowerment of the people and institutions of southern Africa. Damonti notes that he is already starting to see the results, from the grandmothers who have learned to speak truth to power and seek change from their government, to the organizations that are flexing their newly honed muscles.

"One of the things that happens, at least here in the US, is that you always hear about the devastation of AIDS in Africa and you don't really hear the success stories of those NGOs who can do so much with so little and do it so effectively. That story is not told, and there are so many of those organizations out there," Damonti says.

 
© 2003 The Synergos Institute