Lawyer, Health Policy Planner, committed gender advocate, Ms. Juliette Bynoe-Sutherland, a national of Barbados assumed the position of Director, Pan Caribbean Partnership against HIV&AIDS (PANCAP) in July 2011.  In addition to her passion and an inordinate capacity for work, Ms. Bynoe-Sutherland brings to this role a twenty-year career in various areas of the health sector and in academia, in the Region and beyond. She has been professionally involved with the PANCAP partnership since its flagship initiative, the SIRHASC project, which was implemented during the period 2001-2006.
    Ms. Bynoe-Sutherland hopes to influence a greater appreciation of HIV as a development issue and plans to shift the organisation into being a more country-focused, target driven entity that is able to respond flexibly to emerging needs. She also gave her views on a number of issues pertinent to the Partnership and to global health in general.

On her perception of the Partnership’s journey to date and its future direction

I see PANCAP as a model. Over these past 10 years, the fruits of its labour are evident in the solidarity that exists among its many and disparate members at the state and non-state levels. The creative mobilization of its energies to confront this epidemic cannot be denied. The Partnership has drawn significant attention to the crisis. Just by being, it has initiated and continues a dialogue with a variety of groups which, no doubt, has been instrumental in stimulating action and thereby mitigating the impact of HIV&AIDS in the Caribbean. And so for me, PANCAP stands as a model for others to follow and is indeed worthy of commendation. I wish to use this opportunity to once again salute the pioneers, the development partners, the region’s political directorate, the staff of the CARICOM Secretariat and the PANCAP Coordinating Unit for their leadership and dedication. I also congratulate all others who have also contributed to its blossoming into a viable response to HIV&AIDS and to its sustainability.

    I feel however, that this milestone of a decade is just the beginning of the journey. The second decade brings with it even greater “challenges” as we seek to consolidate our gains in an environment of scarce resources at the national, regional and international levels. I am confident that our successes and challenges have taught us lessons that adequately prepared us for the new landscape. This landscape includes a flattening and reduction of resources from external funders such as the Global Fund, based on the persisting global economic crisis. Many of our country members, though classified as middle income states on the basis of GDP, are highly indebted with levels of poverty and inequality and economies deeply impacted by exogenous shocks.  We have nonetheless entered an arena where our HIV programmes will have to be sustained by national efforts. Public/private/non-governmental organizations (NGOs) and countries will have to devise appropriate fiscal responses to meet the cost of prevention, treatment, care and support initiatives.

On the issue of her immediate focus?

I have a strong foundation to build on and a committed team. My immediate focus will be to shift the organisation into being a more country-focused, target driven entity that is able to respond flexibly to emerging needs.  I see this as critical to achieving our goals and objectives, particularly those spelt out by the Caribbean Regional Strategic Framework (CRSF 2008-2012) and those that we reaffirmed at the Tenth Annual General Meeting of the Partnership.

    The “new” operating landscape demands this. I am, indeed all of us are, cognizant that we are now working in a resource constrained environment and must pay greater attention to getting value for money. This demands increased strategic planning and adaptability, without compromising the goals and objectives that we have set in our response to this epidemic.  And so one of my immediate steps will be to actively re-engage our partners, particularly at the country level. Our engagement has to be at the strategic level and to draw to the attention of regional leaders, the paradigm shift in health resourcing.
    We must also work with the partners who have remained committed to the region to show value for money and to improve implementation capacity. Improvements in partners’ coordination and harmonisation are key if we are to ensure that countries have appropriate levels of support to meet their targets.  The sharing of strategic information and utilizing robust channels of communication will be among the changes that should become apparent in 2012.

In the context of being more target-oriented, setting both ambitious and realistic goals, working assiduously to achieve them and evaluating their impact are critical. The Tenth AGM targets signalled an important landmark in refocusing the Partnership’s efforts over the longer term. These are aligned to those of the millennium development goals (MDGs) and so our Member States should be familiar with them. As Director, promoting the need to work with countries to meet their targets is primary.  I have constantly reminded my team that HIV does not operate in a place called the “region”. HIV is at country level and defies geopolitical constructs such as CARICOM, UNISUR etc. So regionalism is not an end onto itself and must be turned on its head, so that regional efforts are in service of country outcomes. That is the essence of the CRSF.
    I hope to bring a greater appreciation of HIV as a development issue. We mouth the words, but do we really understand what this translates into in terms of national programming? In essence, HIV is sexually transmitted and sexual practices are driven by desire along with power relationships, socio-cultural patterns, financial needs, risk environment, social acceptance etc. Unless there is an understanding of the underlying causes of how that sexual encounter is shaped, our efforts will be stymied. Social protection cannot fall off of the radar. The really “vulnerable populations” are those sub-populations where poverty, social inequality, gender-based violence, fear, exclusion and lack of social acceptance and other factors, influence/limit choice, voice and life opportunities or aspirations.  I would like to see more interest in funding at the national level, legal literacy initiatives which improve access to justice, micro-financing schemes and safe houses for women and girls, among other initiatives. If we look at our history of emancipation, labour movements, independence and nationalism, pressure from below has historically been a driver of change and we must equip the voiceless to make changes in their personal and social contexts.      

    I must emphasise the vital role that the PANCAP Coordinating Unit (PCU) must play. I see the PCU as the “engine” of the Partnership, helping to foster a learning organization. The success of the Partnership also demands this.  As a learning organization we must be committed to continuously facilitate the learning of ourselves and our members to transform to meet changing environments. I hope to lead an entity where we can engage in “systems” thinking, challenge inbuilt assumptions and rigidities and thereby better accumulate individual learning into team learning. 

On the question of PANCAP’s prospects for the future

    In February 2011, the Partnership celebrated 10 years of the signing of the PANCAP Commitment.  You would agree that 10 years represent a major milestone in any journey, and given the propensities of partnerships to dissolution, ten years reflect stability and portend the potential for sustainability. The prospects for PANCAP are very good. But, on reflection, is that bad or good? One could suggest that we should be aiming for no PANCAP – that is, work ourselves out of a job. When this occurs it would suggest that the Caribbean has “beaten” the epidemic - sustainable systems for prevention, treatment and support are well integrated into the overall health, social and physical infrastructure; and no threat exists. This would be a good thing, actually an excellent place to be!  Until we reach this place, however, we must press on. This environment of uncertainty and transition, and our mutual vision of a future where HIV is eliminated, dictate a necessary role for PANCAP. I want to assure that this role would embrace even more forcibly, a philosophy of greater efficiency evidenced by, among other things, less duplication in efforts, more targeted evidenced-based programmes, and greater collaboration and cohesion in the Partnership”. I dream of PANCAP which is seen as integral to success at country level; where. PLH and vulnerable communities truly feel our presence. I constantly remind my team, in an effort to motivate, that if we cannot make our presence felt effectively, PANCAP will be relegated to irrelevance. So there is no room for complacency at the PCU and in the agencies that support work at country level.

On the issue of the priorities for the global health agenda and her views on the future directions for PANCAP

The priorities for the 2011 UNHLM essentially centred around five themes: shared responsibility; prevention; innovation and new technologies; women, girls and HIV; and integrating the HIV&AIDS response with broader health and development agendas. The meeting, as you know, was called to undertake a comprehensive review of the progress achieved in realizing the 2001 Declaration of Commitment on HIV&AIDS and the 2006 Political Declaration on HIV&AIDS.

Earlier I alluded to the targets set at the Tenth AGM. These are of particular relevance to the objectives of the High-Level Meeting. The Declaration resulting from this meeting in October /November 2010, in St. Maarten, resolved to place universal access to prevention, care and treatment at the centre of its programme. Specifically, it committed to, by 2015:

  •  eliminate  mother-to-child transmission (MTCT);
  •  increase by 80%, access to care and treatment;
  •  reduce new infections by 50%;
  • accelerate the agenda to achieve human rights for PLHIV including the elimination of travel restrictions.

    The Declaration supports our efforts to be more country-focused and target-driven. So in the context of shared responsibility - a concept which our Partnership demonstrates - our future focus would be to:

     accelerate our work with countries to make HIV programmes more cost- effective, efficient and sustainable;
    commit to the harmonisation of programmes and resource mobilisation and allocation;
    measure  the effectiveness of financial contributions and aid; and
    define roles and responsibilities that are commensurate with the comparative advantage and demonstrated capacity of the partner.

    Shared responsibility is also critical to the financial sustainability of the Partnership. At a time when the gap between investment needs and available resources continues to expand, revisiting traditional organisational and programme forms is necessary. High-cost programmes and  leaner organisational programme formulations are areas that, in collaboration with our partners, will be put on the discussion table for action. The whole notion of shared responsibility demands the exercise of greater leadership by countries in the governance of the AIDS response at all levels, and we must help to facilitate this.

    Of particular mention is our prevention effort in which explicit emphasis will be placed on protecting and promoting human rights as a proven effective means to advance public health. The evidence is clear. Modes of transmission data reveal that some of these populations, particularly men who have sex with men (MSM) and sex workers/clients are significant parts of the epidemic in many countries in the region.  From a public health perspective therefore, these populations need special attention and access to the necessary services. I have begun to actively promote adopting a sexual and reproductive health (SRH) approach to prevention, because efforts need to be grounded in proven methodologies.  SRH compiles both public health and rights-based approaches across an individual’s life cycle. It allows for integration of HIV into health systems and responds well to concentrated or generalized epidemics.
    Care, treatment and support must continue to be kept in focus. HIV and its treatment has shifted the disease into being characterised as a chronic non-communicable disease, with more and more PLH being impacted by co-morbidities, associated with aging and lifestyle such as diabetes and heart disease. As we integrate HIV into the health system, the necessary linkages to chronic non-communicable diseases will become more apparent and move HIV out of isolation. PANCAP has spearheaded guidelines for medical practitioners and psycho-social providers to promote standards of care. Investments in laboratories and improved regional laboratory coordination along with our regional pharmaceutical policy are platforms that can be built on to ensure that treatment is integral to prevention approaches.

In the context of innovation and new technologies, we note that integrating information programmes and systems, and linking institutions of higher learning in the Region, are mechanisms for maximising the use of resources. These could provide useful models to be applied at country level. With this in mind, we at the PCU are currently in the process of developing an electronic repository that would be the Caribbean’s reservoir of HIV&AIDS information. Our emphasis must be placed on devising effective methods and strategies to share good and promising practices and country innovations, thus minimising the duplication of efforts.  We also believe that social media can be stimulated to good effect to engage otherwise unreachable targets.

In integrating the HIV&AIDS response with the broader health and development agendas, it is important to point out that countries cannot afford to sustain vertical programming for HIV. The strategic shift and reorientation of regional governments and the international community towards CNCD as the region’s leading causes of morbidity and mortality, needs to be acknowledged in HIV programming.  There is, therefore, need to explore the extent to which resources already targeted at HIV&AIDS can be strategically shared to build sustainability when resources shift. Laboratory facilities and capacity building initiatives provide two examples.

    In the context of women and girls and HIV, the region’s epidemic is increasingly being feminised.  Sexual violence against girls and women is an accepted cause and consequence of HIV and is known to be associated with sexual and reproductive ill-health. As a gender advocate for the Caribbean Coalition on
Women and Girls/UN Women, I wish to state that singling out women and girls for special focus allows for increased strategic emphasis and resource mobilization for HIV and gender-based programming at country level. There is no need to be apologetic about this. The reality is,  gender-based programming is weak and treating it as “cross cutting” has caused women’s issues to be left behind or in some instances to fall off the radar. There are some countries where the epidemic has been feminized and we must take care that our emphasis on MSM and sex workers are proportionate to each context. We need to better integrate our women’s organisations into national efforts. How well the efforts of our women’s organisations, gender bureaux, Ministries of Health and National AIDS Programmes are integrated will also be key to the success of our prevention efforts.

On the issue of her experience during the first few months of her tenure

For me the high points have been our achievements as a team and the work we have done through our Partners. Our first major initiative under my stewardship was to seek to improve coordination, harmonisation and accountability among the Regional Support Agencies (RSAs) responsible for achieving the strategic objectives of the CRSF at country level. Within days of assuming office representatives of  our RSAs, and  some of our financial partners, sat around the table with the Chair of our PACC, Prof. Figueroa and Dr. Brian Amour of Trinidad and Tobago, Ministry of Health, to set the tone for the remainder of the year. Partners were very receptive to critical introspection.

    We then sought to step up our engagement with the private sector. I was pleased to be part of the Jamaica Business Coalition launch of its private sector foundation in July and I hope to see models throughout the region. In partnership with the Insurance Association of the Caribbean (IAC) and the Pan Caribbean Business Coalition (PCBC), and with support from the United States Government (CDC and USAID), a forum was convened with the objective of building public-private partnerships across the Pan Caribbean Region. We believe that achieving life and health insurance coverage for persons newly diagnosed with HIV will make significant inroads in reducing the stigma associated with HIV, as it will be treated like any other illness from an insurance perspective”. At this forum we made progress on the life insurance end, but must move steadily on the issue of private and/or public health insurance. The portability of regional health insurance which would allow PLHIV to move seamlessly between territories and to have access to treatment in territories beyond their own is also critical.

Of course it would be remiss of me not to mention the A1 rating achieved from the Global Fund in September, which demonstrated the maturing of the regional project implementation capacity. All credit must go to Ms. Jacqueline Joseph, Mr.Leo Casimir and the executive management team of the Office of the Principal Recipient. The dedicated teams of Sub recipients: The Caribbean Health Research Council (CHRC), Centre of Orientacion and Integrated Investigacion (COIN), Organisation of Eastern Caribbean States (OECS), University of the West Indies (UWI), Caribbean Medical Laboratory Foundation (CMLF), PANCAP Coordinating Unit and the Education Development Council (EDC) and the sub-sub recipients: International Labour Organisation (ILO),Caribbean Broadcast Media Partnership on HIV&AIDS (CBMP), Caribbean Network of People Living with HIV (CRN+), and the Caribbean Vulnerable Coalition (CVC).

    Not so much a low point as a challenge to be overcome is the recent development at the Global Fund. This challenge came from an external source largely beyond our control. Regional governments, albeit the world, had looked to the Global Fund for AIDS TB and Malaria (GFATM) to be the doyen of pooled multilateral funding. Unfortunately, the global economic crisis and issues in management of the Fund have resulted in a reduction of resources available for allocation. In its prioritisation efforts, most of the Caribbean and Latin America have been virtually graduated from funding by the GFATM, with priority being given to poorer regions of the world. We are currently grappling with the implication for the renewal of existing grants and for programmes that were targeting Round 11 resources in the OECS and for our Elimination Initiative. We are aware that cuts are necessary as we move into Phase 2 of the Round 9 Grant. We are hopeful, however, that given its stated commitment to incentivising good performance, the Fund will consider our strong track record of implementation.

    This challenge has signaled the complete paradigm shift away from grant funding for middle income states, except to the extent of bilateral diplomatic engagements. The future is now for the Caribbean to demonstrate that unity and resilience we are historically known for. We must mobilize within national resources (public/private/NGO) and as blocs such as CARICOM and the OECS. In looking externally, we must deepen our South-South Partnerships with Brazil and states within Latin America and with countries and organizations committed to HIV and health programming such as the World Bank, the United States, Germany and others. Our existing and new regional institutions, such as UWI and CARPHA, respectively must be retasked and retooled for a revitalized indigenous response. Our partners in regional civil society, donor groups, financing intermediaries and UN agencies must be made to feel integral to planning, evaluation and re-directional efforts at national and regional levels.

    PANCAP must also be prepared to forge new relationships with emerging economies and with non-traditional donors and private foundations. We are able and must demonstrate that the Caribbean offers value for investment in terms of outcomes. Our development outcomes which demonstrate that development assistance can be effective are a source of pride. We must engage externally while recognizing that we must do more to rationalise and set priorities in our national fiscal spaces and to see external assistance as a supplement, rather than a sustainable source of funding.
    I remain confident that we can learn and build on our joint experiences and capabilities as a Partnership.

Volderine Hackett