Lessons Learned: Finding Common Ground

The AIDS Care Teams operated in different regions of the world, dealt with different political contexts, and functioned with different combinations of challenges and resources. Despite all these differences, several common lessons emerged. Over the five years of the ECI experience, representatives from each of the AIDS Care Teams have had the opportunity to come together at conferences and events to share best practices, discuss concerns, and determine next steps. In the beginning, the Teams were surprised to learn that they shared many of the same insights into the steps necessary for team building and enhancing care. Over time, however, the Teams have come to recognize each other as partners in a common mission with shared experiences despite distance and difference. As a result, we believe the following lessons are relevant not only to the ECI AIDS Care Teams, but to multisectoral efforts to enhance AIDS care in resource-constrained settings.

1. Build Flexible Teams
Coalition building and partnership development are foundational aspects of the Enhancing Care Initiative. In all five ECI countries, health care institutions, PLWHA, universities, NGOs, and government officials began to work together to design and implement HIV/AIDS care intervention research and programs within a continuum of care. Although the process of building this kind of joint effort has not been easy, the partnerships created through ECI are enabling unique approaches to impact AIDS care.

Working together to forge a common agenda often led to reevaluation of priorities, and required that inter-disciplinary conflicts and inherent institutional competition be overcome in the interest of attaining a larger goal. The Teams found that a willingness to reevaluate roles and responsibilities over time was critical to this process, as different individuals or groups were most appropriate to lead during different stages of project development. Shifts in leadership also helped to sustain the long-term engagement of partner institutions. Team composition also shifted over time, as new priorities required the involvement of new participants. In Brazil, for example, Team composition changed when the care of adolescents with HIV and AIDS emerged as a priority, necessitating the greater involvement of specialists in adolescent care. Similarly, the Senegalese Team is currently recruiting additional economists to better support the upcoming analysis of the costs and cost-effectiveness of HIV/AIDS treatment.

2. Focus Locally, Impact Nationally, Think Globally
Recruiting and sustaining the engagement of local experts familiar with the different aspects of HIV/AIDS is essential to ECI. The full involvement of diverse local capabilities and resources has lead to new and unexpected programs and problem-solving techniques. For example, the Thai AIDS Care Team uncovered the importance of strong personal commitment from community members and leaders, and developed its unique People, Research, and Development approach to AIDS care. In rural Chiang Mai province, as in KwaZulu-Natal, communities have mobilized with little outside assistance to create volunteer hospice care, food, and childcare. Traditional healers and religious leaders are working side by side with teachers and nurses to care for themselves and their communities as part of these initiatives.

In the diverse settings of ECI, the term ‘local’ is defined according to country realities, and may refer to certain cities, a region, or a whole country. For example, in a large country such as Brazil, the AIDS Care Team is made up of experts based in, and initially prepared to focus their efforts on, São Paulo and Santos. The Brazilian Team’s research and recommendations, however, are being translated into policy recommendations that are relevant to HIV/AIDS care needs in the rest of the country. In the same way, universal precautions and best practices developed by the Thai Team for health care providers in Chiang Mai province are beginning to be adopted nationwide. The Puerto Rico and South Africa teams are located in areas where HIV prevalence rates are much higher than rates in other regions within the country. These teams have worked with organized advocates to ensure that their traditionally underserved regions are included in national HIV/AIDS policy, as well as in programs designed to better utilize scarce resources in highly affected localities.

Just as ECI lessons learned at the local level have impacted policies at the national level, these lessons are also crossing national borders to enhance care around the globe. In addition to partnering with other countries to develop programs as in the case of Thailand and China, the ECI Teams have published numerous abstracts and academic papers. Representatives from the teams also present regularly at major international conferences including the International Conference on Health Resource Allocation for HIV/AIDS and Other Life-Threatening Illnesses, annual Harvard International AIDS Conferences, the International Conference on AIDS and STDs in Africa, the International Conference on Home and Community Care for Persons Living with HIV/AIDS and the XIII, XIV and upcoming XV International AIDS conferences.

3. Foster Knowledge and Team Communication
Diversity of membership within each of the Teams has been one of ECI’s greatest resources. This diversity, however, has also made communication within the Teams challenging. Language barriers, even across sectors, disparities in education levels and cultural differences have all created obstacles to working together effectively. Simple approaches like regular meetings and internal evaluations have been the most effective in improving group dynamics. In some cases, an "executive committee" was formed from among the Team’s members to facilitate decision-making, conflict resolution, and project administration. By actively fostering internal communications, the teams have been better able to collaborate with external partners, including other AIDS Care Teams.

Communication between the five AIDS Care Teams has brought ECI’s local perspective to a global audience. Since the beginning of the ECI, Team leaders and members have gathered together at in conjunction with international HIV/AIDS conferences once every 6 to 9 months. These meetings created a forum to share approaches, results, and concerns. Throughout the course of ECI, important changes to the AIDS Care Framework, methods of evaluation, and plans for the future of the initiative have been developed through these joint team discussions. In this way, the meetings not only improved the structure of ECI, they also exposed the teams to a global support system. Relationships with experts from around the world added value to local efforts, and provided a means for the Teams to share best practices with other AIDS care practitioners.

4. Research and Implement According to Needs
Through ECI, researchers, policy makers, and practitioners from different fields meet at a common table. The process of partnering to complete and implement the situation analysis mobilizes the range of partners represented to directly impact programs and policy. In this way, research leads to action. The need for improvements to care was so urgent in some areas, however, that interventions were initiated before the formal process of results dissemination was complete. As a result, some Team programs were well established before publication of research results.

Although this flexibility in the order of the Four Phases of ECI was not anticipated at the outset, the change was in accordance with the overall ECI belief in locally-motivated action. Contrary to initial concerns, implementation did not take the place of research, and in some cases actually made the teams more prolific. By allowing research agendas to be shaped by needs, Team findings were enriched.

5. Indicators of Success Take Time
Quantifiable results such as established programs or published papers are the result of hard work by individuals and Teams. Strong personal commitment, compromise, and collaboration are all required in order to establish and maintain the symbiotic working relationship necessary for an effective ECI AIDS Care Team. In each Team, it took time for individual members to feel comfortable enough to put aside their priorities or institutional agendas in the interests of identifying and achieving group monitoring and evaluation frameworks. Partnerships within and between teams were strengthened by individual dedication to making the ECI a success.

In the same way, Teams developed and agreed upon short and long term indicators through a long process of research, discussion, compromise, and innovation. Program evaluation thus required as much effort to set up as program development and implementation. Efforts were structured to ensure that indicators were both locally appropriate and globally relevant. The careful, and sometimes lengthy, work to define these measures as well as to measure success should not be underestimated.