One of the few things that all members of Dade County's contention-ridden AIDS community can agree on is that the AIDS-related service bureaucracy has run amok, propagating organizations, acronyms, and red tape at a rate that rivals the virus's own spread while impoverished AIDS sufferers spend their days shuttling from agency to agency, packing files of receipts that document the most intimate details of their lives, and waiting for hours in service providers' anterooms -- often to obtain nothing more than a $25 grocery voucher or a bus pass.
The system is inefficient, excruciating, and seemingly unfixable, despite the county's multimillion-dollar attempts to streamline access to information and assistance. The most recent such endeavor, a monolithic entity called the HIV/AIDS Program Management Organization (HAPMO), floundered this month when its executive director announced his resignation not long after he received a stinging letter from a county official who criticized HAPMO's performance.
Juan Kouri says his decision to leave had nothing to do with criticism of HAPMO. "I think I have a bright future ahead of me and I want to pursue that," says the 32-year-old Kouri, explaining that he has accepted a long-coveted position in the private sector in which he will develop health-care alternatives in Latin America. "This is a time which I think is a crossroads in my personal life and in HAPMO's life, and I made a decision that I am one hundred percent confident will prove mutually beneficial."
Kouri admits, though, that his two and a half years at HAPMO's helm were rocky from the outset. Dealing with turf-conscious bureaucrats, overwrought activists, and skeptical providers has taken an emotional toll on him. "I do feel a sense of burnout, certainly," he says. "Any human would."
Conceived as the berorganization for AIDS in Dade County, HAPMO was created in the fall of 1993 by the Metro-Dade HIV Health Services Planning Council, which advises Metro commissioners about how to spend federal AIDS money. (The council recommends the disbursement of Ryan White Title I funds, by far the largest single grant, worth approximately $19 million last year. A second organization, the South Florida AIDS Consortium, oversees another funding source: Ryan White Title II funds. A third group, the advisory board of Housing Opportunities for People with AIDS, guides the spending of federal money earmarked for AIDS-related housing initiatives.) Kouri, who had been coordinator of the AIDS task force for the San Juan, Puerto Rico health department and project administrator for federal Title I AIDS funds in San Juan, was selected to lead the new organization.
HAPMO's basic duties seemed straightforward: to provide staff support to the planning council and other funding advisory groups, to write grants, evaluate local AIDS programs, assist in long-range planning, and develop a centralized computer system and a comprehensive database of all AIDS patients and the services they are receiving in Dade.
The idea was to form a bureaucracy to end all bureaucracies A in the positive sense. "They wanted to take advantage of economies and efficiencies of scale," explains Bob Ladner, president of Behavioral Science Research, a Coral Gables-based firm that conducted an evaluation of HAPMO for the county last year. That unambiguous concept quickly dissolved into a garbled mush of bureaucratese, prompting Ladner to blast the planning council in his 1995 report for giving HAPMO "unparalleled latitude in building an organization and [approving] a set of grossly under-specified workplan goals and budgets."
To judge from a recent mission statement, HAPMO's purpose is nearly indecipherable: "To assure coordination, integration and reporting of HIV/AIDS services across funding, political and organizational boundaries."
Ladner says Kouri's job description was equally vague. His $72,000 salary was linked to duties of ambiguous scope, such as establishing and maintaining an operational infrastructure, recommending policies regarding external operations, and promoting positive working relationships between HAPMO and other agencies.
The results were predictable: HAPMO's amorphous nature combined with the free-spending tendencies of the guardians of local AIDS money to create a snowballing demand for funds. During Kouri's tenure, his annual budget tripled -- from $550,000 his first year to $1.7 million for fiscal year 1995-1996 A for a grand total of $3.5 million in federal, state, and local funds. HAPMO's staff ballooned to seventeen employees, including five staff members with the rank of director or its equivalent, each of whom earned about $40,000 annually, and an associate director with a salary of $70,000.
Kouri defends the expenditures. The work of HAPMO, he maintains, has led to more efficient use of AIDS money in Dade, saving millions of dollars. "And of course, you have to spend money to save money," he observes.
But aside from citing the standardization of rates paid to service providers, Kouri is hard-pressed to identify HAPMO's specific money-saving achievements. The computer system, which would prevent double-billing, is still not fully on-line. Other examples he mentions -- the development of a "comprehensive needs assessment report," a series of community studies about the kinds of services desired by HIV-infected Dade Countians, and a "case manager training curriculum," which provides standardized training to social workers who deal with AIDS patients -- are impossible to quantify, though their value is widely praised by professionals who work in the field.
In his March 19 letter of resignation, Kouri attempted to summarize HAPMO's gains during his tenure. "One of the primary goals of the first two years was to establish a sound, efficient and effective operational structure to serve as the foundation for the organization," he wrote. "That has been done.
"The arduous process of establishing and maintaining HAPMO's fiscal and operational viability and the circumstance in which they occurred has always been taken for granted," he went on to complain. "In the extremely complex, often contradictory, bureaucratic and convoluted world of federal and local government contract and regulations, HAPMO was able to achieve a superb rate of growth through diversification, while establishing an uniform, information-based approach to decision making."
Kouri's parting attempt to outline his organization's accomplishments came in the wake of a painstakingly detailed and critical five-page letter addressed to him from Beverly Mirman, then-director of the management services division of Metro's Audit and Management Services Department. (Mirman now works for another county agency.)
In that February 6 missive, Mirman lambasted HAPMO for its shoddily written Title I grant application. Calling it "the single most important document that impacts Dade County's funding levels for HIV/AIDS services in our community," Mirman cited HAPMO's "failure to use proper grammar and punctuation in the text," and noted that tables were incomplete and that letters of support were missing. This was the second year in a row that HAPMO had turned in an incoherent grant proposal, Mirman emphasized.
Mirman also listed numerous instances in which county policy had been violated and Florida's Sunshine Law had been disregarded, including HAPMO's failure to provide proper public notice of planning-council meetings, the abrupt termination of the audio recording of one meeting, and the refusal to provide council members with the original copy of a document that had been rewritten by HAPMO staff members without permission of the author (a subcontractor whose arrangement with HAPMO was itself a violation of HAPMO's contract with the county).
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Kouri says the letter puts an unfair slant on HAPMO's activities. A month before it was written, he notes, HAPMO received a positive evaluation from the county. Moreover, Kouri says, he has since had a lengthy powwow with Dan Wall, the project director for Ryan White Title I programs for the Audit and Management Services Department, in which he assured Wall that the county's concerns would be adequately addressed. Kouri followed up that meeting with a February 29 letter to Wall responding to Mirman's criticisms. "HAPMO is undergoing a process of internal self-evaluation with the Board of Directors to assess our organizational structure in light of this and other concerns," he wrote.
Still, Kouri downplays Mirman's letter. "In the context of everything HAPMO does, the letter is minuscule," he contends.
Jeffrey Morris, who is acting as HAPMO's interim CEO while the board searches for a new executive director, is even more blunt. "I just took it that Beverly was having a bad day," Morris says. "If you look at the substance of what her concerns were, you're talking typos, you're talking writing style. There's nothing of substance there." Morris staunchly defends Kouri's leadership and HAPMO's accomplishments. "There are areas in which we could do better, but on the whole I think we have done an incredible job."
Wall, meanwhile, says that despite his conversation with Kouri, the county continues to have serious problems with HAPMO's performance and may seek to replace it with another organization next year.