National AIDS Control Organisation's human resource capacity building initiatives for better response to HIV/AIDS in India

Abstract

Human resource capacity building is a key strategy in the design, delivery, sustainability and scale up HIV treatment and prevention programmes. The review aims to present human resource capacity building initiatives undertaken by the National AIDS Control Organisation (NACO) and to discuss the available opportunities in India.

There was minimal emphasis on human resource capacity building in National AIDS control programme (NACP)-I. The focus of capacity building in NACP-II was on strengthening the capacity of partners implementing various HIV/AIDS interventions. NACP-III (2007–2012) focussed on capacity building as a priority agenda. Other than short-term training programmes, NACP-III is strengthening the capacity of partners through the State Training and Resource Centre, Technical Support Unit, District AIDS Prevention Control Unit, Fellowship Programme and Network of Indian Institutions for HIV/AIDS Research.

Various opportunities to enhance and consolidate capacity building responses in HIV/AIDS in India may include mainstreaming of capacity building, appropriate management of knowledge and resources, effective delivery of training, measuring and documenting impact,accreditation of programmes and institutes,use of information technology, identifying and implementing innovations and working for sustainability.

Growing demand for capacity-building in HIV/AIDS needs substantial efforts to ensure that these are implemented effectively and efficiently. NACO had made significant strides in these regards, but at the same time there are arduous challenges like measuring impact, quality, documentation, operational research, and sustainability. NACO is formulating Phase-IV of NACP. This review will provide feedback to the NACO for strengthening its strategic document for human resource capacity building.

Introduction

Human resource capacity building is a process of improving the knowledge and skills of individuals. Capacity building is a key strategy in the design, delivery, sustainability and scaling up HIV treatment and prevention programmes.¹ Fundamental tenets of capacity building can be categorised as competence-based, peer- connected, contextual, need-based, customised, assessment-based, comprehensive, timely, scalable and sustainable.^2,3

Human resource capacity building programmes are critical for sustainable response to the HIV/AIDS epidemic in India. The need for capacity-building in HIV/AIDS is evident as the responses to HIV/AIDS now includes longterm care for those infected and affected along with prevention and treatment.⁴ India's National AIDS Control Organisation (NACO) has identified capacity building as a specific objective in the National AIDS Control Programme (NACP)-III rather than just a strategy or process.

Considering the importance of human resource capacity development in the HIV/AIDS programme, this manuscript reviewed such initiatives undertaken by NACO and also discusses opportunities to further strengthen human resource capacity building initiatives for HIV/AIDS in India.

Human resource capacity development initiatives undertaken by NACO

After detection of the first case of HIV infection in 1986 in Chennai, India; the Indian government set up an AIDS Task Force under the Indian Council of Medical Research and established a National AIDS Committee Chaired by the Secretary, Department of Health and Family Welfare, Government of India. In 1987, the National AIDS Control Programme (NACP) was launched with a focus on screening of high risk population and blood donors and carrying out educational programmes for creating awareness. ^5,6

In 1989, the Medium Term Plan for AIDS Control was formulated, which focused only on states at high risk of HIV epidemic (Maharashtra, Tamil Nadu, West Bengal, Manipur and Delhi). The State AIDS Cell was established in these states and awareness activities and some early targeted interventions was field tested.^5,7 NACP-I (1992–1997; extended until 1999) focused on reducing HIV transmission, decreasing and minimising the socio-economic impact of HIV infection. Activities such as mass awareness campaigns, blood safety, condom promotion, surveillance, diagnosis and treatment of sexually transmitted infections were undertaken in NACP-I. However, emphasis on human resource capacity building in NACP-I was minimal.⁵

In November 1999, NACP-II was launched with a significant focus on targeted intervention. A standardised approach was used for training in NACP-II. In order to make training programmes more systematic and effective, separate training modules were developed for different levels and different categories of health functionaries. NACO provided training of trainers, training guidelines, training modules, expenditure guidelines and curriculum to be followed while State AIDS Control Societies (SACS) were expected to implement the capacity building programmes. The entire focus of capacity building in NACP-II was on strengthening the capacity of partners implementing various HIV/AIDS interventions.

However it was not until NACP-III (2007–2012) that capacity building became a priority agenda for NACO. NACP-III recognised that availability of a critical mass of well-trained human resource is the backbone for enhanced response to the HIV/AIDS programme in India.^1,5 One of the objectives of NACP-III was to build the capacity of programme managers at national, state and district levels in leadership and strategic management. NACP-III proposed – to enhance the capacity of health professionals and healthcare providers at all levels in technical and communication skills; to build capacity of health care organisations, Community Based Organisations (CBOs) and Non Governmental Organisations (NGOs); and to strengthen technical, communication and counselling skills of grass-roots level workers and functionaries of various government departments. NACP-III also contemplated to identify HIV/AIDS training priorities and needs in areas like technical, managerial, communication, advocacy, and counselling. As per NACO, an estimated 380000 people were to be trained, sensitised and oriented over a five- year period (NACP III – 2006 until 2011) in accordance with their need for knowledge and skills. An estimated Rs. 2200 million was allocated for these activities. ^6,7

NACP-III also emphasised strengthening the system and infrastructure for training. It proposed a decentralised approach for planning, monitoring, evaluation of training and decision making. Training was categorised as component specific and general training. Component specific training programmes were linked to the implementation of the HIV/AIDS programme. General sensitisation training programmes were focused to create awareness about HIV/AIDS as well as services and facilities available for HIV/AIDS. Two broad areas; managerial and technical; were identified for programme- specific capacity building. Programme officers in NACO, SACS, District AIDS Prevention Control Units (DAPCUs) and Technical Support Units (TSUs) were amongst the recipients of managerial capacity building activities, whereas technical capacity building was a key area for service providers. NACO's initiatives also proposed capacity building of public/private agencies, NGOs, CBOs and People Living with HIV/AIDS.⁷

Training was administered as induction, in-service and refresher sessions. Induction training was to orient staff towards goals and objectives, project concepts and strategy, implementation plans, monitoring, quality assurance and participation of key stake holders. Inservice training sessions mostly address prophylaxis, treatment for sexually transmitted infections, antiretroviral therapy, infection control, blood safety, counselling, targeted interventions, surveillance, monitoring, programme management, behavioural change communication, advocacy etc.Reorientation/refresher training programmes were for those who had received training earlier but needed further orientation and experiential training.

Other capacity building initiatives undertaken by NACO under NACP-III

State Training and Resource Centre (STRC):

NACP-III had planned for integrating various training activities and training institutions, strengthening management of training and training resources, setting up a system for quality assurance and monitoring/evaluation of training programmes at state level. To meet this, NACO institutionalised training and capacity building process by creating STRC in each state or group of states. This was to ensure standardised curriculum and quality training to different categories of staff working with NGOs/CBOs on targeted interventions (TIs). ^5,7

Technical Support Units (TSU):

TSUs were created at state level to enhance the quality of interventions and build capacity of partners to implement it. TSUs assist SACS in capacity building, supportive supervision, monitoring and evaluation and other related aspects. ⁷

District AIDS Prevention and Control Units (DAPCU):

These units operate within District Health Society and share administrative and financial structures of National Rural Health Mission. DAPCUs are responsible for capacity building activities such as adolescent education programmes, supportive supervision of TIs in addition to monitoring, evaluation and mainstreaming. Adolescent training/life skill education programmes are component-specific programmes, in which teachers and peer educators are trained.⁷

Fellowship Program:

NACOs Research Fellowship Programme guidelines were released in 2008. The purpose was to facilitate capacity building of young researchers in the country for undertaking HIV research including basics, interdisciplinary, intervention and operational research and communicating research findings for impacting policy and programme. A fellowship programme was proposed to serve interested researchers an incentive to take up quality and need-based research in HIV/AIDS. ⁸

Network of Indian Institutions for HIV/AIDS Research (NIIHAR):

Considering varying demographic and social context and varying capacity building needs for HIV/AIDS across country, there was a need for the identification of relevant research priorities and conducting multi-centre studies to generate evidence that can be used in programmes. To address this issue, NACO proposed a consortium of institutions/organisations with a capacity to undertake research in the health sector, specifically in the field of HIV/AIDS. Guidelines of NIIHAR were released by NACO in September 2008. ⁹

Opportunities to enhance capacity building response to HIV/AIDS in India:

Overall NACOs response to HIV/AIDS capacity building needs in India is immense. Rapid scaling up of training programmes and the number of people trained during NACP-III was extraordinary. However, there remain certain opportunities to strengthen these initiatives, consolidate the gains and maximise the impact.

Mainstreaming capacity building initiatives:

Due to the impact of the HIV epidemic, India is experiencing constraints in existing human and material resources. In addition to this, the purpose of such resources is changing, often in response to a broader and more urgent range of needs for HIV/AIDS response in India.⁵ Therefore, the rapid scaling-up of HIV/AIDS services needs to be integrated with the general public health system so that they are easily accessible to those who need them. ^10,11 This calls for aligning HIV/AIDS capacity building initiatives of NACO with national and regional strategic plans to bring success in HIV prevention interventions. HIV training programmes may be integrated into pre- and inservice training of all categories of healthcare professionals, however there needs to be a regulatory system to ensure that training quality and standards are maintained.

Problems with centrally coordinated capacity building programs:

There are some inherent challenges for centrally co-ordinated training programmes guided by national strategic plans. Stakeholders, capacity building needs and skills vary greatly across states and regions. Therefore, consensus building at national level would be challenging to address the varying capacity building needs and interest of stakeholders. Time, structural barriers, cultural factors, state policies and rules, individual impediments and technical issues further hamper efforts to implement successful capacity building programmes that are centrally co-ordinated. NACO's current decentralised approach and institutionalisation of training for targeted intervention programmes seems to be notable, but its impact has to be evaluated and if successful, such an approach can be replicated for capacity building of care and support programmes.¹²

Management of HIV/AIDS capacity building knowledge and resources:

Developing a managed and co-ordinated system for knowledge management on HIV/AIDS is a huge challenge. The epidemic constantly demands updated knowledge and skills for an effective response to HIV/AIDS. Therefore, an ongoing monitoring system must be in place to identify knowledge gaps or training needs, identifying priority areas for research to generate new knowledge, capturing current knowledge, codifying storage and knowledge retrieval when needed.

Few issues in developing capacity building resources are worth mentioning. Firstly, NACO has a well thought of standardised curriculum and modules to ensure the uniform quality of capacity building programme s. However, while developing these resources, it would be a challenge for NACO to recognise and incorporate effects of regional, social, cultural and religious influences on HIV/AIDS. Secondly, for an effective response to HIV/AIDS programmes, the health workforce needs to achieve progressive skill building and behaviour in completing a task and to develop a positive attitude and feelings.^13,14 Most of the training often aims at developing progressive learning, thinking and enhancing skills in performing tasks. An effort for developing positive attitudes and feelings among participants undergoing training is important and needs to be addressed appropriately. NACO needs to develop resources that support developing positive attitudes and feelings among healthcare workers. Finally, most of the available resources are in English. Recent process evaluations of some training for TI programmes recognise that efforts are being taken to translate training resources in local languages, especially for field level staff like peers, outreach workers and counsellors.¹⁵ It is important for capacity building/training planners to consider these issues in the planning stage itself.

A trained and effectual pool of resource persons is a must to deliver these programmes effectively. NACO and SACS face constraints in identifying and developing a suitable resource pool. It was also noted that if an opportunity is available, resource persons engage in other programmes because incentives in HIV/AIDS programmes is less compared to most other programmes in India.^16,17 NACO needs to plan for competitive incentives for resource persons to retain them in HIV capacity building programmes. Involving community members in training programmes can have an added advantage, as they can understand local context and community problems better. NACO has taken initiatives in this regard for peer training, but training institutes must ensure that community members are properly trained in the delivery of training content.

Co-ordinated efforts and co-operation by institutions that offer capacity building programmes can be strengthened by setting up a knowledge exchange network. Identification, setting up and networking of training institutions and master trainers is essential for sharing best practices and learning from experiences. A harmonised process of establishing a database of all resources, trainers, trainees and follow-up of training as well as establishing a functional coaching and mentoring system is essential for maximising the impact of capacity building initiatives. It is also important to foster co-ordination among all partners to ensure that there is sharing of training plans, objectives, reports and success stories. ^4,10Currently such information is not readily available.

Delivering a capacity building programme:

It is important to trust the competence of community and systems so that the capacity building programmes evolve with minimal interference. An important issue in training delivery is to match programme contents with the capacity building needs of the participants. NACO has clearly identified focused training areas for a particular category of staff; but capacity building needs of participants may be varied, depending upon their experience, education, or any previous training.⁷ These specific needs of participants must be considered in defining content and curriculum of training programmes. Often core contents in different training programme overlap, this duplication may be avoided in content and curriculum planning.

NACO and SACS prepare training schedules well in advance, but they need to be matched with a timeline of implementing organizations or else it becomes very difficult to implement.^11,15,16 Moreover, NACO may specify the number of training days per month or annually for various levels of staff, so that routine work of implementers will suffer the least. Furthermore, ongoing or refresher training may be conducted periodically to provide an opportunity to identify new areas of capacity building to be addressed in future programmes. Identifying mentors who support programme implementers can be a useful strategy for maintaining the continuation of the capacity building process.

Documentation:

Documentation and dissemination of best practices in HIV programmes is essential for influencing policy and practice as well as for replicating innovative approaches. Different framework-tools and models may be used to capture data for analysis, documentation and dissemination for tracking quality, relevance and applicability of capacity building programmes. Sharing of such tools and methods with partner institutions are important for standardisation and reporting. Currently, there is a practice of routine monthly reporting with output indicators and quantitative information, whereas process documentation is infrequently done.^15-19 Comprehensive documentation of the programme would be useful in the evaluation of programmes, particularly their long-term impact.

The delivery of any training programme brings together different stakeholders with differing views. This remains a big challenge especially when their needs cannot be met effectively. Therefore it is necessary for NACO, SACS and training institutions to engage with leadership at all levels: local leaders, traditional leaders and community leaders in delivering a capacity building programme.

Measuring impact of capacity building programmes:

Measuring the impact of training is a key to effective programming. Operational research and follow-up initiatives are relevant approaches to track outcomes and emerging trends in capacity building programmes. ²⁰

Multiple approaches may be used for the evaluation of training programmes such as pre- and post-tests, session evaluations, self-assessment, case-studies, outcome/impact evaluation, cost effectiveness analysis etc. Furthermore, to rigorously monitor and evaluate capacity building programmes, there is a need for common standardised indicators and systems. Using assorted methods, but standardised indicators for evaluation of capacity building programmes will allow for a more insightful and comprehensive assessment of capacity building initiatives.^4,13,14

Currently, assessment of training in India is restricted to measuring immediate change in knowledge, skills or attitudes of participants who attended training. Some training institutions/organisations do undertake process evaluation.^12,16 However, to assess the impact of a programme certain questions need to be answered such as: How did the training affect practice? Did transfer of learning occur? Did participants demonstrate what they have learnt in training in a real-life context? To study the long-term impact one must study if the capacity building programme or training impacts the organisations' performance. ^13,14

Operational research:

Operational research informs evidence- based strategies and approaches for programmes and policies.⁴ NACO made an effort in this regard by launching fellowship and consortium of institutions in September 2008 for undertaking research. ^8,9Few academic programmes on HIV/AIDS are also offered by some institutions/organisations in India. However many such programmes fail to address national HIV/AIDS control priority and as a result they are not sustained. India needs programmes to enhance human resources to generate evidence that can further enhance India's response to HIV/AIDS.

Innovations in capacity building methods and programme delivery:

Institutions involved in capacity building must develop and test innovative models to quickly respond to capacity building needs of the personnel working with HIV/AIDS programmes. However, prior to dissemination and replication of these models, capacity building division of NACO may evaluate innovative models for their effectiveness of design, implementation, utilisation, cost, and outcomes. Innovative culture bound methods (storytelling, drama, singing, testimonies, poetry etc), work-based learning approach, strengthening systems, peer approach for youth, follow-up supportive supervision by mentors and use of culturally appropriate content have already been tried by some training institutions. However there is insufficient documentation of the impact of such methods on the delivery of training and transfer of learning. ^4,20,21

Accreditation:

HIV/AIDS capacity building/training courses and institutions running these programmes must ensure the quality of content and effective delivery of the training. The accreditation process will ensure not only the quality of training offered but will also ensure the level of competence and professionalism for those who acquire them.^4,21 Currently, India has no system for accreditation for either academic or in-service training related to HIV/AIDS.

Use of technology:

There has been a rapid growth in technology recently in India. This can be viewed as a potential opportunity for capacity building programmes to reach as many stakeholders in a short time. NACO and SACS may develop interactive websites (web-based learning or e-learning) exclusively for capacity building initiatives and also offer some online courses through the e-learning site. Currently published (electronic or print) capacity building resources are not readily and widely available to many users. Even if they are available, they are not comprehensive, but tend to focus on the work of a single project, organisation, or donor. There is a scope for developing virtual or physical libraries and databases that can be readily accessed.

Sustainability of capacity building initiatives:

The inability of current HIV/AIDS capacity building programmes to demonstrate linkages and contribution to co-ordinated national or regional health strategies and policy is a significant obstacle in the long-term sustainability of capacity building programmes. Another approach to ensure the sustainability and long lasting impact of capacity development programmes is to maintain and update desired changes in skills, behaviours and attitudes. This can be ensured by developing capacity of implementers and communities to identify their own way to upgrade their knowledge, their ability to use skills and measure their own performance.⁴

Organisational and programmatic capacity building and other initiatives:

In this article we have elaborated on human resource capacity building for HIV/AIDS. Human resource capacity building is just one aspect, and for a better response this needs to be complemented by organisational/institutional and programmatic capacity building initiatives. In addition to initiatives undertaken by NACO, many organisations are directly or indirectly involved in capacity building for HIV/AIDS in India. Many of them are providing short-term programmes or academic programmes. Discussions on these issues were beyond the scope of this article, but their contribution in capacity building initiatives for a better response to HIV/AIDS in India cannot be undermined.

Conclusion

NACO recognised capacity building as one of the objectives of NACP-III. A growing demand and need for capacity building in HIV/AIDS needs substantial efforts to ensure that these are implemented effectively and efficiently. Significant strides have been made by NACO and SACS, but at the same time there are arduous challenges like measuring impact, ensuring quality, documentation, operational research, and sustainability. NACO is in the process of formulating Phase-IV of NACP. This review would be useful to NACO for strengthening its strategic document on capacity building for an effective and sustained response to HIV/AIDS in India.