Lessons Learned: Creating a State-of-the-Art HIV/AIDS Clinic and Training Center in Uganda

The Pangaea Global AIDS Foundation is playing a key role in the construction and development of the new Infectious Diseases Institute (“IDI”) at Makerere University in Kampala, Uganda. This facility, which is scheduled to be fully operational in October of 2004, will serve as both an HIV/AIDS clinic serving thousands of patients every month and a regional HIV clinical training center for physicians and nurses. Its founders, the physicians of the Academic Alliance for AIDS Care and Prevention in Africa (“Academic Alliance”), believe that the IDI will serve as a model for the treatment and prevention of AIDS in a resource-limited environment. How the Ugandan vision for IDI is being transformed into a reality holds lessons for those who are helping to build medical infrastructure in the developing world to support the fight against HIV/AIDS.

Barbara Lawson and Chuck Wilson at the IDI construction site in Kampala, Uganda

The Infectious Diseases Institute is a product of a partnership between Pangaea, the Academic Alliance, and Pfizer Inc, which provided an initial $11 million construction and program grant for the project. Pfizer has a long-term commitment to the project and will be providing over $24 million in funding between 2001 and 2009.

In addition to providing oversight of the construction itself, Pangaea staff members have been working to build necessary financial, legal, administrative, and managerial structures to support the development and successful rollout of the IDI ’s training and treatment programs. Once the facility is complete and and the ongoing IDI governance, management, and administrative systems are in place, the facility and operations will be turned over to the College of Health Sciences at Makerere University.

Many logistical hurdles had to be overcome to complete the project on time and on budget. With stakeholders on three continents and multiple time zones, just getting people together for meetings was a challenge. Building the facility to world-class standards, while working in a resources-limited setting, required careful planning and consideration of different frames of reference.

Julia Martin, Pangaea’s Manager of Programs and Personnel (IDI)

Chuck Wilson and Julia Martin head up the Pangaea team on the ground in Uganda. Julia, as manager for programs and personnel, coordinates the clinical, prevention, and training programs of IDI. Chuck is IDI’s fiscal and administrative manager and has led the on-site construction project team. Chuck and Julia, who are married, live with their two-year-old daughter Ellen in Kampala. Project Director Barbara Lawson, who is based at Pangaea headquarters in San Francisco, recently completed a six-week visit to the project site. As the construction of IDI nears completion, the three project leaders are now working to make sure that the Makerere University/IDI team is in place and has everything necessary to manage the facility and run the clinical treatment and care and training programs that will be present at IDI.

Success Factors

In a conversation in March of 2004, Chuck, Julia, and Barbara identified a number of key factors that have contributed to the success of the IDI project and could have application to other efforts to build health infrastructure capacity in the developing world.

Implement the vision of the end users. Chuck emphasizes that the Ugandan doctors, led by Dr. Nelson Sewankambo, Dean of the School of Medicine at Makerere University, have taken the lead on implementing the IDI project from the very beginning. (See "Dr. Nelson Sewankambo - At the Forefront of the Fight Against HIV/AIDS in Africa".) “Our role has been to help realize their vision of a state of the art HIV clinic and training center. The idea is that the IDI will be a hub for the region, offering an integrated approach to care and treatment. Pfizer provided the funding and Pangaea and its partners supplied the technical support to construct the facility and help build the clinical and training programs, but the vision and drive towards implementation have been contributed by the Ugandan project members with North Americans playing a support and facilitation role. We’re proud to be supporting the Academic Alliance and Makerere University in this extraordinary effort.”

Inside the IDI

Access to key decision makers. Key leaders and decision-makers like Dr. Sewankambo have played an important day-to-day role in moving the project along and supporting the work of the project team. For example, Dr. Sewankambo helped provide access for project staff working with Makerere University’s central administration. According to Barbara: “With so many stakeholders, it’s sometimes difficult to know when a decision is final –the close working relationship between the Academic Alliance and IDI staff in Kampala has definitely made it easier to stick to the plan and move the project forward.”

Flexible funding. The flexibility inherent in the private funding provided by Pfizer has been a major asset to the project. Julia notes that “The Pfizer grant allows for adaptation to changing circumstances. For example, when it became clear that it was necessary to ramp up the clinic and training programs in advance of the completion of the building, the project plan and budget were revised to meet this need. Public funding does not typically have this kind of flexibility.”

The laboratories at the IDI

Dedicate time and resources to communication. Julia emphasizes how important it is to have a communication plan and be willing to spend the time necessary to implement it when those involved come from different countries, cultures and professional backgrounds: “It’s hard to understand going into a project like this how different the stakeholders are. You might have people who come at the same problem from completely different points of view and yet there will be common ground if you take the time to find it. ‘One size fits all’ just doesn’t work in this kind of setting. You have to commit up front to dedicating a lot of time and attention to communication and just talking through all the issues with everyone involved. You take shortcuts at your peril. If you don’t spend the time you need on communication, you are going to end up with people who become estranged from the process and oppose decisions made.”

Create and follow a detailed business plan. Barbara points out how important it was that a meticulously documented business and operating plan, including a detailed budget, was developed and agreed to by all the stakeholders. According to Chuck, “This plan was the reference point for all decisions over the course of the project. The plan was intended to execute the vision of the stakeholders – following the plan closely, with a reasonable degree of flexibility to meet changing circumstances, has been key.”

Build transparent financial management systems. Chuck notes that: “All project audits have come up clean – It’s really been an excellent financial management process led by Barbara and her finance team. This accountability has given the project credibility on a local scale and a degree of attractiveness to new funders that can’t be overstated.”

Infections Diseases Institute Clinical and Training Programs

The development of IDI’s clinical and training capacity has kept pace with the construction of the actual facility itself. Although pediatric and adult HIV/AIDS clinics were functioning before the project got underway, they were limited by insufficient funding and medical personnel, as well as by the absence of adequate space. Julia notes that “At the inception of the project, we took the opportunity to start from the beginning – we examined every phase of activity from how we get the patient in the door to how we treat them to how we evaluate the success of treatment. We worked to develop protocols relating to standards of care, laboratory testing, and provision of drugs, along with administrative areas like medical records and clinic policies and procedures. We’re still working on training – giving personnel the opportunity to become a part of an effective service delivery team in different ways than they’ve experienced before. The doctor training program has been going on for almost three years and has provided training in the treatment of AIDS, including the provision of ARVs, to over 160 doctors from 12 countries. We have a well-developed curriculum that continues to evolve.”

The clinic itself has been growing exponentially in advance of the completion of the actual IDI building. Prior to March 2002, the clinic saw approximately 240 patients a month, with 20% of those being new patients. By December 2003, 3,800 patients had been registered with the adult clinic, with an average of 1,7000 patients seen per month. New patients total approximately 300 per month. Chuck notes this tremendous achievement, but thinks that when the move to the facility actually happens, “The capacity building and skills training of the staff will go up to the next level. The sheer volume of patients that can be seen and staff that can be trained is going to go up very substantially.”

Employ rigorous project management techniques. Barbara notes that some things about project planning are the same regardless of the setting: “There are no shortcuts when it comes to building a facility of this quality. How the construction process was conducted made all the difference. Key factors included the clarification of roles and expectations and the close monitoring of deliverables, costs, and time schedules.”

Adjust timeframes and expectations to fit a resource limited environment. Chuck points out that good project management in the context of a major project in the developing world means that you take the limitations into account: “We knew intellectually but not experientially that you are dealing with limited resources and that timeframes and expectations may have to be adjusted accordingly. The reality of having to contend with so many resource constraints takes some getting used to. You have to be flexible and know that you’re going to be doing a certain amount of learning on the fly.”

Spend time on training. Julia notes that the investment that has been made in local staff is as vital to the IDI’s success as the investment in the building and program design. “We’ve devoted a great deal of time to capacity building – recruiting the best people and then spending the time necessary to support them in their roles.”

Commitment to building local capacity for project sustainability. The IDI is first and foremost a Ugandan entity, and fiscal and administrative support and program implementation has been geared to building sustainable local capacity. Chuck notes: “The building was designed by a local architect who took into account local conditions and materials. Local Ugandan staff have been recruited and trained to fill IDI’s medical and administrative positions.” Julia points out that the clinical and training program models have been designed for achieving high standards of care, rather than simply superimposing Western models. She says that “Part of the vision that’s driving this project is that the IDI will help raise the bar in terms of standards of care for HIV/AIDS patients in Uganda. Dr. Sewankambo and his colleagues are taking the lead in showing their team what it is that they have to strive for, even though limited resources in terms of testing, drugs, and staffing must be taken into account. Ultimately, it’s the faculty and clinical staff at Makerere who will be operating the IDI and so they are the ones who are setting the standards, overseeing the training of physicians, nurses and staff, and ensuring that the highest possible standard of care is followed.”

Chuck and Julia have been in Uganda long enough to see the human toll taken by HIV/AIDS. Looking back, Chuck reflects: “There have been a number of points along the way where the huge global specter of AIDS has become very personal. We’ll get a phone call from a friend saying ‘so and so’ is positive can they come to the clinic. Or you see a patient at the clinic that is so desperately sick that their family has abandoned them. It really drives home that it’s about individual lives and personalities — we’ve had the privilege of touching some of those lives.” Julia concludes: “We have people coming up to thank those involved with the clinics now because the clinics offers hope to the people in this community who are dealing with AIDS. It’s tangible – they know they or their loved ones will receive treatment if they need it.”