From HIV to Ebola to Zika, the effectiveness of public health responses has never been more critical, and organizations conducting this work are under increasing scrutiny. In Zambia, the Centre for Infectious Disease Research in Zambia or CIDRZ addressed an issue shared by many developing-world health institutions: serious gaps in its organizational capacity to fulfill its mission.
I spoke with CIDRZ Director and CEO, Dr. Charles Holmes, about the changes that he and his team have undertaken over the last four years. They have refocused the CIDRZ mission and vision, re-examined its partnerships, and built systems to become a leading scientific and research institute, patient services organization, and local talent capacity-builder.
CIDRZ today, he explained, is an organization of over 1,000 people with a $35 million annual budget. It performs a wide range of programs and research on HIV and TB drugs and vaccines and service delivery, women’s health, neonatal, and the strengthening of local health systems. Recently, for example, it introduced a nationwide solar-powered cold chain to allow distribution of lifesaving vaccines to prevent death from childhood diarrhea. It also trains the next generation of local scientific researchers in the lab, in clinical trials, in data analysis, and social/behavioral programs.
However, when Holmes took over the organization in late 2012, it was reeling from a range of systemic issues that threatened its existence. Donor confidence, the lifeblood of public health organizations, was undermined, and it became clear that he faced an uphill battle to turnaround the ailing organization.
CIDRZ outlined its reform agenda with a 2013-2015 strategic plan developed with the Government of Zambia, funders such as the Zambia office of U.S. Centers for Disease Control and Prevention (CDC), and community beneficiaries. Holmes recruited a new management team, including leading Zambian physician Dr. Izukanji Sikazwe, who joined as his Deputy. Together they rallied shaken staff and stakeholders toward ambitious goals, including the development of new management systems, transparency and accountability. It sought to build human capacity “through a learning-oriented work environment,” institutional sustainability, and flexibility through diversified funding streams.
The plan also articulated goals of evaluating and improving health outcomes; focusing research on the most relevant and critical clinical, program, and policy questions, and using that research in its local practices; and building local scientific and public health expertise–all with the aim of becoming a model partner to the Government of the Republic of Zambia. CIDRZ leadership was trained in Balanced Scorecard approaches and the strategic plan was cascaded through the organization. Progress was documented in quarterly tracking of performance metrics.
As Holmes told stakeholders at the U.S. National Institutes of Health (NIH) last month, CIDRZ got help in a number of ways. One of the biggest challenges, he explained, was to find donors who understood that local organizations often need more than just program and research funding in order to meet the challenges they face. With support from donors Comic Relief and Ark, CIDRZ engaged audit firm Ernst & Young to assess governance and internal processes, operational policies, and financial systems and controls. Improving these systems enabled the recruitment of a new 10-member Board of Directors. The new board included a cross-section of leading Zambian professionals with background in corporate, government and medical leadership.
It also attracted global health leaders like Kevin Marsh, Oxford University malariologist and long-term leader of a large Welcomme Trust-funded research institute in Kenya. With support from the Bill and Melinda Gates Foundation, CIDRZ’s reforms earned it an “Equivalency Determination” in 2015–meeting strict specifications that its operations and finances were as good as a U.S. 501(c)(3) public charity.
CIDRZ negotiated new Memorandums of Understanding with Zambian government agencies, and instituted regular, data-to policy meetings to improve the relevance and alignment of their work with the priorities of the government. University partnerships were also re-examined, and CIDRZ intentionally moved to work more closely and effectively with universities more aligned with its mission.
The turnaround was as rapid as it was dramatic. Locally, it worked with the University of Zambia and multiple branches of the Zambian government. Internationally, it built new partnerships with leading U.S. research universities such as Johns Hopkins (where Holmes is on the medical faculty), the University of Alabama–Birmingham, and the University of California–San Francisco, and funders such as the CDC, Elma Foundation, the Bill and Melinda Gates Foundation, and the MAC AIDS Fund. Together, these put CIDRZ on solid ground and well-positioned to move forward. CIDRZ so improved program performance through new approaches to implementation and data use that it was informed by a major funder that they considered CIDRZ to have been their highest performing partner in 2015.
Perhaps most importantly, CIDRZ has established training programs that provide the infrastructure and practices necessary to develop long-term local strength. CIDRZ HealthCorps is a new training program for junior researchers and program implementers interested in studying a wide range of local health issues. Junior investigators are given some of the responsibilities of research managers and coordinators on grants, preparing them for future funding.
Holmes is particularly impressed with how young Zambian and expatriate fellows learn from each other. He and his new Chief Scientific Officer, Dr. Roma Chilengi, structured the program such that half of the positions would go to local trainees and the other half from abroad. Collaborations and friendships strengthen the networks of the fellows and their capacity for future research. Word is getting around: CIDRZ had a record of over 300 applicants from around the world for eight positions last year.
Some examples illustrate the local capacity-building underway that CIDRZ is facilitating with a broad array of partners. With help from professors in Switzerland and the United States, and funding from the UK and the Bill and Melinda Gates Foundation, Kalo Musukuma is studying HIV-Hepatitis B co-infection at the University of Zambia. After support in London, Michelo Simuyandi is a CIDRZ Fellow and PhD student at the London School for Hygiene and Tropical Medicine, researching drinking water treatment technologies in Lusaka.
With support from Vanderbilt University, Katayi Kazimbaya is investigating post-vaccination rotavirus in infants. Jenala Chipungu is a Master in Public Health student at the University of Liverpool and a CIDRZ Research Trainee, applying qualitative methods to a range of children’s health issues. After studies in Germany, Njinga Kankinza is a behavioral scientist and lecturer focusing on the development of sustainable health systems structures.
These CIDRZ fellows and others are not only contributing to important science and programs. With mentorship and program twinning/partnerships, they are being taught the skills necessary to compete for large research grants from NIH and elsewhere. They have access to CIDRZ’s solid research platform that is unusually well-equipped to handle regulatory, grants management, and human resource issues.
They are also developing important professional relationships with leading researchers in Zambia, Europe, and the United States. With these tools, they are addressing the pervasive problem among developing-world health institutions: the capacity to fulfill its mission with local talent.
Asked whether he is confident that when he ultimately transitions back to the U.S., the organization will not fall back into mismanagement, Holmes replied that he has “great faith” in the strong governance provided by a diverse and committed board of directors, coupled with the leadership and strong sense of local ownership by the talented management team now in place. “The organization is now much bigger than any one person’s ambitions,” Holmes said, “and is deeply supported by an enormous network of supporters in Zambia and around the world.”
This thinking seems validated by a statement by the Zambian Permanent Secretary for Health in CIDRZ’s latest annual report: “CIDRZ is a data-driven organisation that provides tremendous support for the ongoing capacity development of our staff and systems, and contributes their public health and research expertise to tackling the most pressing health issues of our time. I fully expect that the next great innovations and research discoveries in health services delivery, clinical trials of new vaccines and drugs and new diagnostics will emerge from our close ongoing collaboration. We are proud as Zambians to call such a fine organisation our own.”
After its remarkable turnaround, CIDRZ is doing impressive, important work, and should serve as a model for a wide range of health and development organizations.
More at the CIDRZ web site, http://www.cidrz.org