CHAZ leaders credit their success to "faith in God and in themselves"
In Zambia, one of the countries hardest hit by HIV/AIDS and where the disease is still the leading cause of death, the Churches' Health Association of Zambia (CHAZ) has been an implementer of Global Fund grants, without interruption, since their inception in 2003. The performance of CHAZ's grants is mostly better than that of the other Principal Recipient (PR), the Ministry of Health. The longevity and the 'A2'-rated performance of this indigenous faith-based organization's grants are remarkable in the context of Global Fund grant implementation, which is dominated in Africa by State PRs, United Nations agencies, and International Non-Governmental Organizations (INGOs).
This article analyses CHAZ's path to success; information comes from publicly available documents and a joint interview with Karen Sichinga, CHAZ's Executive Director, and Michael Kachumbi, CHAZ's Head of Programs.
AIDS, TB and malaria in Zambia
Zambia is a landlocked country with a population of 17.1 million in Southern Africa, which is the world's HIV epicenter. The country has one of the world's highest burdens of HIV/AIDS, which is the leading cause of death. According to UNAIDS, HIV is a generalized epidemic in Zambia with a prevalence of 11.3% among adults (age 15-49) in 2018, and an estimated 1.2 million people living with HIV.
The country is moving towards better HIV epidemic control, though. In the 1990s, Zambia had one of the highest rates of HIV prevalence among women attending antenatal clinics, at 19.8%. (Prevalence among pregnant women in antenatal clinics used to be the basis of population prevalence estimates. Currently, estimates rely on surveys of the population at reproductive age, 15-49 years). New infection rates fell by 13% between 2010 and 2018; more than 95% of children born to HIV-positive mothers are free of HIV.
In Zambia, 35,000 people were treated for TB in 2018. Although TB incidence has fallen by 40% between 2003 and 2016, an estimated 40% of TB cases go undiagnosed, according to Zambia's request to the Global Fund for TB/HIV funding.
Zambia targets malaria elimination by 2021 which is ambitious considering the current epidemiology; the World Health Organization estimated that Zambia will eliminate malaria by 2030. Nevertheless, the country has successfully reduced its malaria-related deaths by 70%, from 51.2 per 100,000 in 2010 to 15.5 per 100,000 in 2015, according to its funding request.
CHAZ was fighting HIV in Zambia before Global Fund support
CHAZ was created in 1970 as an umbrella organization for Catholic and Protestant Mission Hospitals. Currently, CHAZ members comprise 157 church health institutions. Among them are 36 hospitals, and 89 rural health centres. CHAZ members account for 40% of the total number of people under national health care and more than 50% of those using rural health-care services. CHAZ covers all of Zambia's ten provinces.
In the early 2000s, when antiretroviral therapy (ART) for HIV was not widely available and HIV prevalence was higher, FBOs were at the forefront of the fight against HIV/AIDS, according to CHAZ's leadership, offering home-based care. This home-based care package consisted mainly of home visits to raise awareness about HIV/AIDS, offer some medications such as pain killers or treatment for opportunistic infections, offer transport to health facilities for people living with HIV, and help orphans and vulnerable children (OVC). CHAZ had about 900 people on home-based care before the advent of the Global Fund (2003) and PEPFAR (2004), both of which made ART more widely available in Zambia.
Since 2003, CHAZ has managed 12 global Fund grants worth slightly more $365 million. Currently, CHAZ has two active grants, both rated A2.
Table 1: Grants managed by Churches Health Association of Zambia (CHAZ) since 2003
Grant Number Grant start (S) end (E ) dates Disease Signed Amount ($) Disbursed Amount ($) Absorption
ZMB-C-CHAZ S: 01-01-2018
E: 31-12-2020 TB/HIV 117,454,641 98,675,700 84%
ZMB-M-CHAZ S: 01-01-2018
E: 31-12-2020 Malaria 28,148,586 22,378,618 80%
ZMB-H-CHAZ S: 01-07-2012
E: 31-12-2014 HIV 85,715,880 85,715,880 100%
ZMB-011-G30-H S: 01-01-2012
E: 30-06-2012 HIV 8,130,270 8,130,270 100%
ZMB-708-G19-M S: 01-10-2010
E: 31-12-2014 Malaria 9,580,635 9,580,635 100%
ZMB-809-G21-H S: 01-01-2010
E: 30-12-2013 HIV 25,378,617 25,378,617 100%
ZMB-708-G18-T S: 01-07-2008
E: 30-06-2013 Tuberculosis 2,810,467 2,810,467 100%
ZMB-405-G10-H S: 01-07-2005
E: 31-12-2010 HIV 64,684,995 64,684,995 100%
ZMB-405-G14-M S: 01-07-2005
E: 31-12-2010 Malaria 11,687,212 11,687,212 100%
ZMB-102-G05-M-00 S: 01-08-2003
E: 31-08-2008 Malaria 3,350,649 3,350,649 100%
ZMB-102-G04-H-00 S: 25-07-2003
E: 24-07-2008 HIV 22,762,451 22,762,451 100%
ZMB-102-G06-T-00 S: 25-07-2003
E: 25-07-2008 Tuberculosis 10,279,103 10,279,103 100%
Source: Global Fund's Data Explorer
Note: The active grants, shown at the top of this list, are both rated A2
Supported by Global Fund grants CHAZ is in charge of treatment and care for PLHIV in 84 facilities: 79 faith-based ART treatment facilities and five private hospitals..
First OIG report in Zambia found all PRs except CHAZ guilty of financial wrongdoing
During its first decade, the Global Fund used a rounds-based system to fund countries. CHAZ has been a Principal Recipient since Round 1. Four Principal Recipients implemented the Global Fund's first few grants in Zambia: two State implementers--the Ministry of Health and the Ministry of Finance--as well as two non-State implementers--the Zambia National AIDS Network (ZNAN) for community-based organizations and CHAZ for Faith-Based Organizations (FBOs).
In 2009, the OIG conducted an audit of the Global Fund grants in Zambia based on Rounds 1, 4, and 7. The OIG found that all the PRs, including CHAZ, had instances of financial misappropriation, fraud or ineligible expenditures. Fortunately for CHAZ, the organization had started three years earlier (from 2006) to restructure itself--creating the departments of Grants, Internal Audit and Human Resources, and improving its processes to accommodate its growing needs. Its staff increased from 23 to 82 between 2003 and 2008, and funds under management increased by 800% in the first two years after CHAZ became a Global Fund PR.
CHAZ thus escaped the axe that fell following the OIG audit: the United Nations Development Program (UNDP) replaced both State PRs, and CHAZ took over Zambia National AIDS Network and part of the Ministry of Finance's activities. (Later, the Ministry of Health became PR again while ZNAN did not.)
Currently, CHAZ has six departments, including that of Health Programs which manages the activities related to the fight against HIV, TB and malaria. CHAZ also has a department of grant compliance that is in charge of procurement. CHAZ procures rapid diagnostic tests (RDTs) for HIV, and artemisinin-based combination therapy (ACT) for malaria to more than 700 facilities in three (out of the ten) provinces in Zambia, with Global Fund grants.
Key success factors
Good collaboration with Government
In Zambia, since the early days of independence, the State has engaged with churches to improve the health and education of its citizens. Generally, for church-sponsored facilities, the State pays for some personnel, running costs and essential medications.
According to the CHAZ director, CHAZ gets along well with the State PR, the Ministry of Health. As Ms. Sichinga puts it, "the MoH is government, we give them the respect; we do not antagonize them." Ms. Sichinga went on to explain that when CHAZ disagrees with the MoH, she requests a discussion with the Permanent Secretary of the Ministry to "air our views." Other issues that cannot be solved at the level of the permanent secretary, such as increasing domestic financing for health, are taken up to the President of Zambia by the advisory committee to the Board of the CHAZ.
A sign of the good relationship between CHAZ and the State is that some government entities are sub-recipients (SRs) of CHAZ. In the Global Fund grant implementation context, this is unusual; government entities tend to be sub-recipients of the State PR. CHAZ government SRs include the Zambia National Medical Stores, which receives CHAZ support for the last-mile delivery of health commodities and logistics management, and the Ministry of Education for HIV prevention among adolescent girls and young women, in school settings.
Robust and fast procurement system
CHAZ has a robust system of procurement which is faster than that of the government. According to its Executive Director, CHAZ sets the procurement guidelines and policies. This procurement process is facilitated by the UNAIDS regional offices for Eastern and Southern Africa, which increases CHAZ's credibility vis-à-vis the Fund, the Zambian government and the potential suppliers.
Staff and leadership
CHAZ prides itself on selecting its staff well and retaining them. According to the organization's leadership, CHAZ's high staff retention rate promotes continuity and the building of institutional memory, which in turn contribute to its successful functioning. CHAZ invests in in-house capacity building for its staff, because "we believe in ourselves as Zambians," the Executive Director said. "We believe we can do it. We need some facilitation, be it in terms of transport or money, but we have the capacity to learn." When asked if a low turnover does not stifle innovation, the ED said it did not. She stated that CHAZ hires new employees who may bring new ideas and innovation, but rarely at senior management level, given CHAZ's emphasis on internal promotion.
The ED explained that management meetings are day-long affairs where all senior management team members update the others about developments in their departments, answer questions, respond to criticisms and note suggestions. Ms. Sichinga said that as an ED, she believes she is easily replaceable by a member of the senior management and for her, this is a sign of good leadership. The Executive Director told GFO that a belief system is at the core of CHAZ's success: faith in God and in themselves.
OIG Audit: Country Audit of Global Fund Grants to Zambia (GF-OIG-09-15), 5 October 2010 Geneva, Switzerland
OIG Audit: Audit of Global Fund Grants to the Republic of Zambia (GF-OIG-17) 22 December 2017 Geneva, Switzerland
Investigation Report: Investigation of Global Fund Grants to the Republic of Zambia Theft of Health Products from Medical Stores Limited (GF-OIG-18-007) 26 April 2018 Geneva, Switzerland.