The purpose of this announcement is to solicit applications for the Twinning Program Cooperative Agreement.  The overall goal of the Twinning Program (TP) is to provide facilitation, management and technical support for the formation of HIV-AIDS-related, voluntary, peer-to-peer institutional partnerships

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for capacity building in collaboration with U. S. government (USG) field offices to support the President’s Emergency Plan for AIDS Relief (PEPFAR) and its strategic vision and plan as stated in the PEPFAR Blueprint for Creating an AIDS-free Generation.

In supporting the TP model, PEPFAR recognizes the need for diverse evidence-based cost-efficient approaches for systems and capacity building.  Activities supported by the TP will need to follow PEPFAR Blueprint principles of:
Making strategic and scientifically sound investments to maximize impact and efficiencies, Working with partner countries, civil society, Faith Based Organizations  (FBOs), and the private sector, Supporting activities that minimize stigma and discrimination with attention to gender equality, Proactively monitoring and improving outcomes and efficiencies.

First started in 2004, the TP will continue to support partnerships between U.S.-based organizations and host-country organizations (north-south partnerships) and between in-country and regional organizations (south-south partnerships and south-south-north partnerships) to strengthen human and organizational capacity.  To date, major objectives of the TP’s partnerships have been to strengthen health systems in various PEPFAR countries/regions by:
Expanding the pool of trained providers, managers, and allied health staff delivering quality HIV/AIDS services, Strengthening organization structures and systems, Supporting limited infrastructure enhancements, Facilitating private sector engagement through volunteerism, and Working in support of in-country Government strategic plans and OGAC-supported PEPFAR team priorities.

Going forward, the TP will sharpen its scope of work to directly support Country Ownership of national HIV responses.  Examples of types of future partnerships that empower local partners to own and manage HIV-related activities include, but are not limited to, those that:
Strengthen organizational, management, and advocacy capacities of professional associations; Facilitate integration of community-based health worker cadres into national structures and systems; Support institutionalization of cadres from other sectors (e.g., social workers) into the national HIV response; Building capacity of sub-national governmental and non-governmental organizations to improved local-level HIV planning and management.

The TP should broker, facilitate, and provide management support and technical assistance for the establishment, maintenance, and graduation of twinning partnerships in support of PEPFAR goals.  Partner organizations may include, among others, governmental and non-governmental organizations (NGOs), schools and academic health-science centers, professional organizations, and civil society including community-based organizations (CBOs) and FBOs.

All TP-related human resources for health (HRH) activities should be complementary to and/or supportive of ongoing HRH initiatives currently supported by PEPFAR, including:
the Medical and Nursing Partnership Initiatives, the Global Health Services Program, the Field Epidemiology (and Laboratory) Training Program, and the Public Health Education Partnership Initiative.

In addition, in support of local ownership, the awardee will need to identify and build the capacity of one or more local organizations so that before the end of this cooperative agreement this/these organization(s) will have the necessary foundations, systems, and expertise to:
Apply for USG or other funding, Broker, facilitate, and provide management support and technical assistance for the establishment, maintenance, and graduation of twinning partnerships.  2.   Background This program is authorized under the Public Health Service Act, Sections 2692 and 307 (42 U.S.C.

300ff-111 and 242l), and under the Tom Lantos and Henry J.

Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008 (Public Law 110-293).

Established in 2003, the President’s Emergency Plan for AIDS Relief (PEPFAR-I) called for immediate, comprehensive and evidence-based action to turn the tide of the global HIV/AIDS Pandemic.

 Following reauthorization in 2008 for Federal fiscal years 2009-2013, the targets for PEPFAR-II were to treat at least four million HIV infected people with effective combination anti-retroviral therapy (ART); care for twelve million HIV infected and affected persons, including five million orphans and vulnerable children; and prevent twelve million infections worldwide.

 During the second phase of PEPFAR, the emphasis has been on strengthening the health systems and training 140,000 new health care workers.

In the forward-looking (November 2012) PEPFAR Blueprint Creating an AIDS-Free Generation, a complementary goal  is to “…work with partner countries, donor nations, civil society, people living with HIV, faith-based organizations, the private sector, foundations and multilateral institutions to effectively mobilize, coordinate and efficiently utilize resources to expand high-impact strategies, saving more lives sooner.”   Institutional partnership (i.e.

twinning) has been a key strategy that was outlined at the very start of PEPFAR for human and institutional capacity building.

 Since 2004, the Health Resources and Services Administration (HRSA) has funded the TP to provide technical assistance to partnering organizations (north-south, south-south, and south-south-north) in implementing specific PEPFAR-related programs.  The TP was last awarded a five-year cooperative agreement in March 2009 to continue partnerships and related activities.  Currently, the TP supports PEPFAR through partnerships, initiatives, limited infrastructure enhancements, and volunteer placements that assist in building critical institutional and human resource capacity to combat HIV/AIDS.

TP has made significant contributions to sustainable development of institutional, organizational, and human resource capacity, supporting national strategies for addressing HIV/AIDS and PEPFAR objectives for strengthening health systems, health workforce, and country ownership.

The twinning model is particularly well-suited to programs that build sustainable human resource capacity because of strong institutional linkages between partner organizations that are dedicated to similar missions.

Working closely with Ministries of Health, USG in-country teams and other key stakeholders, most TP-supported partnerships strengthen pre- and in-service training programs at existing institutions to address healthcare workforce development goals.

Partnerships that are successfully in place and are endorsed by country teams should be sustained and supported.

The TP currently manages over 40 active partnerships in 9 African countries (Botswana, Ethiopia, Kenya, Mozambique, Namibia, Nigeria, South Africa, Tanzania, and Zambia) as well as the Caribbean Region, building capacity across HIV/AIDS technical areas using evidence-based approaches, including training in a broad range of healthcare disciplines such as:
Clinical Pharmacy Social Work and Para-Social Work Nursing Adult and Pediatric Emergency Medicine  Laboratory Biomedical Engineering Mass Media HIV Prevention Mid-level medical providers (“Clinical Associates”) Case Management Palliative Care It is expected that an applicant should be able to demonstrate the capacity to manage all partnerships presently involved in this project.

Twinning Model and Methodology For the purposes of this Notice, “Twinning” is defined as formal, substantive collaboration between two (or more) similar organizations; “formal” means there is a written agreement executed and signed by authorized representatives of the partnering organizations; and “substantive” means the interaction between the twinning partners is significant and lasts for a minimum period of time that is stated in the agreement (usually two-to-three years).

 The TP will be funded through PEPFAR’s Country Operational Plan (COP) /Regional Operational Plan (ROP) process.

Specific activities that the TP will support or lead in collaboration with in-country/regional PEPFAR teams include:
Support of existing twinning partnerships and other Health Systems Strengthening ( HSS) activities such as the set-up of skill labs and e-learning centers; Development of new twinning partnership and other HS activities with increased focus on “south to south” partnership and on Country Ownership; Support the life cycle of these twinning partnerships and other HSS activities including their graduations with a focus on sustainability; Dissemination of lessons-learned; Facilitating the spread of successful innovations; and Proactively measuring the quality, cost/efficiency, outcomes, and impacts of the various twinning partnerships and other HSS activities.

Building the capacity of one or more local organizations so that before the end of this cooperative agreement this/these organization(s) will have the necessary foundations, systems, and expertize to:
Apply for USG or other funding, Broker, facilitate, and provide management support and technical assistance for the establishment, maintenance, and graduation of twinning partnerships.  The TP model is designed to promote local institutional capacity, develop human resources for health, and build sustainable, country/regionally-owned professional relationships through faculty and curriculum development,   pre-service and in-service training, and the development of professional licensure.

One of the greatest strengths of the Twinning model is its emphasis on the careful selection of institutional partners.

Each partner must exhibit a high level of dedication and commitment to the collaborative, proactive, and voluntary process that is the hallmark of TP programs.

Particularly in the case of U. S. resource partners, this includes a commitment to contribute significant in-kind resources, thereby reinforcing the volunteer nature and cost-efficiency of the Twinning model.

Overall, TP facilitates the optimal matching of U.S.-based and/or indigenous resource partner institutions based upon the specific needs of each in-country/region partner.

The peer-to-peer nature of twinning partnerships typically leads to relationships that are sustained well beyond the initial funding period.

 To directly address the issue of sustainability and country/regional ownership, the TP model requires that partners address and continuously review the issue of sustainability in their partnership work plans.  The Twinning model also encourages partners to leverage and contribute resources within their communities and work closely with countries to ensure proper management of these resources Twinning is unique among other forms of global HIV-related technical assistance in both the scope and level of interaction among partners and other stakeholders at all institutional levels.

Particular features of the Twinning model include:
Collaboration between “south to south” partners (i.e.

by supporting and organizing information-sharing exchanges between similar types of partnerships) Building local capacity of health workforce and responding to healthcare shortages through the pre-service training of diverse and innovative cadres of health care and other HIV service workers Advocacy for and support of professional associations, working with local governments to promote health care worker retention and sustain institutional change Support of local organizational development, including business management skills Strengthening in-country/regional health systems by empowering financial, human resource-related, and administrative structures of local institutions including professional associations and those advocating on behalf of persons living with HIV/AIDS (PLWHA) and key populations at higher risk of HIV infection Developing and enhancing mechanisms for improved delivery of HIV health services The TP methodology is flexible and non-prescriptive.

Participating partner institutions can include universities, hospitals, professional associations, community- and faith-based organizations (FBOs) and ministries of health.

Because partnerships are institution-based, they bring the collective knowledge, expertise, and commitment of their constituent members.

At the same time, individuals play a key role by forging collaborative, peer-to-peer relationships in which partners work together as equals.

Together, they find mutually beneficial solutions and participate in a two-way transfer of knowledge that enhances human and organizational capacities on both sides.

Typically, training is accomplished via peer-to-peer mentoring through exchanges and on-site monitoring.

In instances of “north-south” partnerships, a U.S.-based institution with a significant amount of experience in a particular focus area is partnered with an African or Caribbean institution to build capacity.

Increasingly, regionally-oriented “south-south” partnerships are becoming more common, whereby African institutions work together as partners.

In either case, the TP’s partnership methodology empowers host communities by giving them ownership of the programs they create jointly with their partners, thereby encouraging sustainable capacity development on individual, institutional, systemic, and policy levels.

The program further promotes sustainability by strengthening institutional capacity in operational functionsincluding financial management, human resources, communications, and MandE.

The Twinning program will continue to rely on the active investment from overseas partners, host governments, and a wide range of local stakeholders in order to ensure that the unique needs of each institution and the communities it serves are met.  The TP goal of country/regional ownership ensures that program activities are based on national priorities.  Examples of ongoing Twinning partnership activities include:
U.S.-African partnerships focusing on curriculum development and competency-based training in HIV-related nursing, social work, pharmacy and laboratory science U.S.-African partnerships to strengthen the capacity of three African schools of social work for the training of  para-professional social workers to provide case management services to HIV orphans in Tanzania, Ethiopia and Nigeria Three U.S.-South African “Clinical Associate” partnerships for the training and licensure of physician assistants to work in rural areas of South Africa where there are shortages of health professionals Professional association-building and advocacy in nursing and social work in Tanzania A “south-south” partnership, involving a South African–based palliative care association that provides assistance to a Botswana-based organization that is also involved in the provision of palliative care An OPTIONAL activity is an adjunct volunteer program which provides meaningful short-term in-country/region placements for highly qualified professionals, that has included physicians, nurses, pharmacists, lab technicians, social workers, health educators, as well as monitoring and evaluation (MandE) specialists.

These volunteers provide critically-needed clinical, educational, and capacity-building technical assistance and support to host organizations.

Evaluation Activities:
Because Twinning involves multiple partnerships that address critical HIV-related HSS needs that are aimed at resulting in sustainable, country/region-owned solutions, the ongoing evaluation to assess of the effectiveness and impact of TP programs is essential.  Routinely-conducted monitoring and evaluation (MandE) processes need to be part of each country/regional work plan, addressing operational questions related to program implementation within existing and developing health systems infrastructures.  The awardee will be expected to report on PEPFAR-wide indicators.

In addition to process indicators (e.g., numbers of persons trained during a particular period), MandE activities must focus on outcome indicators that demonstrate impact as well as on cost effectiveness measures.  Working closely with USG country/regional teams as well as the host government(s), TP  will ensure that evaluation activities are carried out via appropriate protocols and that they reflect the priorities of both PEPFAR and those of host country governments.  Ultimately, the information and experience gathered as a result of these evaluation activities will be used to improve future program implementation and, ultimately, transition of TP programs to country/regional ownership.

Transition to Local Organization(s) This cooperative agreement will also support PEPFAR vision of country-ownership.

A major role of the awardee will be to identify one or more local organizations that have the potentials to take over all the awardee functions by the end of the cooperative agreement.

The awardee will assess that/these local organization(s) capacities and, as needed, strengthen their foundation, systems, and expertize to:
Apply for USG or other funding, Broker, facilitate, and provide management support and technical assistance for the establishment, maintenance, and graduation of twinning partnerships