Two leading AIDS researchers and activists – Chris Beyrer and Chris Collins sound a loud warning in the Lancet Global Health about the risks of a “too rapid” toward increased country ownership of the response to HIV and AIDS. While they underline that country ownership is “fundamental to long-term progress in global health”, they argue that many countries are not ready. Theirs is quite a different take from the one I put forward on this blog last week, and I feel they have fallen into the simplistic trap of seeing country ownership as being about governments.
Much of their concern centres around the funding gap – and they are right to say that many countries are many years away from being able to finance their own AIDS responses (the same point could be made about health or welfare programmes in general). But country ownership is not just about where the money comes from – indeed the fact that country ownership is a core principle of aid effectiveness suggests that it has very little to do with the withdrawal of aid financing. This is not to say that the source of funding does not have an impact on ownership. As I argued in my post, even if a country “can’t support its health care needs right now, what it can do is start to claim a bigger stake in the funding and governance of its health”. Country level campaigns for increased government, private sector, and community spending on health are about countries claiming a bigger stake in their HIV programmes, and building the social contract at a national level.
Beyrer and Collins rightly point to the fact that in many countries, health systems still have limited capacity to implement and monitor programmes. But ten years into the scale up of one of the largest global health ventures – the response to HIV and AIDS – surely this should be the signal for more effort in promoting country ownership in implementation. Promoting country ownership in the context of aid funding means doing much better in terms of building those local systems, and enabling the development of policies at country level. It means working with those who already own their national responses: governments, ministries of health, and NGOs. And it means using operating procedures that are suited to national systems. Another emerging challenge to country ownership is the consequence of donors’ increased focus on results and accountability. The focus itself is entirely appropriate. However, the processes that are being put in place to enable this focus are often premised on an international system of monitoring and auditing. Country ownership means that these functions too should reside at national level.
In many countries there remain considerable barriers to certain types of programming – for instance with key populations. But while Beyrer and Collins are right to point out that most of the programming with these groups is externally funding, these programmes remain underfunded in most countries. The reason that less controversial programmes – such as for antiretroviral treatment and prevention of mother to child transmission – have scaled up so successfully is precisely because governments, ministries of health and NGOs at country level have readily embraced them. We will not see a satisfactory scale up of key population programming simply by mandating from global level that it must happen, or by approaching the issue primarily from the perspective of a humanitarian response. Decision makers, service providers, activists on the ground have to back it. Country ownership doesn’t mean abandoning people in need, it means recognising and working with these processes so that these needs can be met in a more meaningful, sustainable way.