More on country ownership

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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.

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Country ownership? Revisited.

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Mount Cameroon, with Douala port in the foreground. Because I’m sure you don’t need to see another picture of flipcharts or of people talking.

I’m fortunate to have spent the past week working with a group of five health NGOs from West and Central Africa: CéRADIS from Benin, RAME from Burkina Faso, Positive Generation from Cameroon, and Femmes Plus and AMO from the Democratic Republic of Congo.  They asked me to help them think through and plan their advocacy work, and I’ll be following up with some coaching to help them develop funding proposals.

These groups are all involved in working with communities on health issues.  With the global aid environment in full flux it’s been interesting to learn about the priorities as they see them. Here are a few highlights.

Take the debate on health financing.  In global circles we hear a lot about aid dependency, and about the need for countries to increase their own spending – largely in anticipation of a decreasing aid pot.  Positive Generation in Cameroon also wants its government to spend more, but is under no illusions that even a massive increase – say to a 15% government budget spend, as per the Abuja declaration commitment – will be enough.  But, they argue, even if Cameroon 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.  And this is precisely why, when Positive Generation campaigns for an increase in government spending, they aren’t just lobbying the president.  They’re making sure that parliamentary as well as municipal electoral candidates are asked about their position on health funding. And they are so successful at doing this that many candidates are asking them to help them draft a position.  They want to make sure that having a position on health funding becomes standard for anyone running for office.  The same logic explains why these organisations are asking local businesses to invest and have a stake in improving health in their localities.

It doesn’t stop there. Some of these NGOs are also working on the same theme at community level, talking with community members – users of health care – about whether local communal budgets should also set targets for how much they are spending on health.  Communities are demanding not just better health services but are politicising the funding of health.  Municipal budgets in these countries are small, and therefore so are the amounts this process will raise for the local health budget. But it is about the principle. It is about creating a norm or a standard, and showing to decision makers what matters to them; it’s about people having a stake in their health care.

What about aid funded programmes? These organisations are fully engaged in aid programmes, both as implementers, and as watchdogs.  But they are developing their own processes for monitoring what is going on.  While there is a very practical reason for this – they want feedback to help improve services at local level, and they want data to identify systemic problems at national level – there is, again, a political dimension.  In their view, while it is natural for international donors and researchers to care about their investments and closely monitor how they are being used, the communities at the receiving end should care even more.  It is not that they disagree with the need for funds to be used wisely, or efficiently. Quite the contrary: but they feel that national civil society organisations, and communities, should be the ones making sure this is happening.  Positive Generation leader Fogué Foguito put it this way: “I don’t need to wait for the Inspector General of hospitals to come round to point out that toilets in the health centre are filthy”.

There is also a sense that while guidelines and conditions for aid developed at international level can help establish some useful principles for those working at country level, they can also act as a barrier to country level efforts to take the initiative on health.  Take the Country Coordinating Mechanism (CCM), which the Global Fund to fight AIDS, Tuberculosis and Malaria requires all applicants to establish.  Because CCMs are supposed to include civil society and community representation, they have opened the door to a more participatory, transparent approach to funding. However, by all accounts in most countries CCMs are not as inclusive as they should be, nor as effective at monitoring Global Fund programmes as they should be.

The NGOs I have been working with are well aware of this, and yet they are sceptical of suggestions that the Global Fund should audit CCMs and introduce further measures to monitor CCM performance and train or redesign CCMs:  “That’s just not where the priority lies!  If we’re going to monitor something, why can’t we have support to monitor how programmes are getting delivered on the ground? We’re going to end up checking if people are going to meetings in the capital and if the minutes were circulated on time, and meanwhile the implementing organisations are off doing what they want with no-one paying any attention!”.  This may seem counterintuitive since one of the main points of CCMs is to give a voice to actors outside of the government.  But the conclusion from the NGOs I’ve been working with seems to be this: CCMs have been receiving training, funding, and “technical support” for over a decade.  None of these institutions are perfect, and we don’t expect they ever will be.  Imperfect as they are, we’ll keep on using the opportunities that they afford us (for instance, access to discussions that we wouldn’t otherwise be party to), but let’s not get sidetracked with more inputs: what we care about most of all is communities.

Regular changes in international guidance and policy are also disruptive.  Every time something new comes up – three ones, know your epidemic, strategic investment, new funding model* – there’s a new set of consultations and meetings and trainings. People are running around trying to figure out what global health is doing next rather than spending their time looking at what is happening in services on the ground.

And what about “vertical” programming?  For the most part these organisations started out working on AIDS.  But when it comes to advocacy, the perspectives of these organisations are broad.  When advocating for domestic financing, they are advocating for health financing.  When advocating for rights, they are advocating the right to health.  This is not because they consider AIDS to be over – far from it.  AIDS remains very much at the heart of their aims, because despite improvements over recent years there remains much to do to get people on to treatment, protect peoples’ rights, and reach marginalised groups.  But in their desire to base their advocacy on a strong community movement, rather than on abstract principles, they are driven by the fact that people facing health crises don’t necessarily distinguish between one illness and another, or one type of service and another.  Just as people by and large don’t particularly care whether the health care they get was paid for by the government, by a local business, or by an international donor.  What they care about is whether it is good, and whether it is accessible.

The word that perhaps best sums up this approach is “sovereignty”.  It may be an archaic word but it is probably time we found an alternative to “country ownership”, which sounds right but which mostly leads to a polarised, caricatured debate between “government decides” and “donor decides”.  Sovereignty is not about rejecting aid, or evidence, or good practices, or international solidarity and nor is it about saying governments are paramount. It is about shifting the locus of debate and ownership to individuals, organisations, and officials in countries.

It is about getting people, and providers, and businesses, and administrators, and politicians, to have a bigger stake in health, in their countries – which is, after all, where politics and power are.

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*I can’t resist a digression. These “new” initiatives – that appear every couple of years in the AIDS sector – are rarely, if ever, particularly new. They are new labels for incremental developments in the field.  Incremental developments are a good thing.  But they would be far more helpful if they weren’t promoted, campaign-style, as the latest magic bullet for a world without AIDS, accompanied by the requirement that countries start planning all over again.

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Finally, a quick practical note. The meeting was designed and planned by the NGOs listed above, and was funded by GIZ’s Backup Initiative following their request to GIZ for support. Backup is a good source of support for civil society organisations working on monitoring and strengthening Global Fund programmes in their countries.

Value for money conundrum

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Aid donors are increasingly paying attention to value for money in their programmes.  While donors have always wanted the biggest “bang for their buck”, in recent years there has been a step change in the approaches and tools for calculating value for money and in the expectations placed on funding candidates (whether they are governments or NGOs) in terms of demonstrating their value for money (VFM).

Good.  But there’s quite a big catch which, as far as I am aware, is not being addressed.  Donors are applying VFM analysis to their own investments but they aren’t always applying it to the “entire” investment being made in a country.

Take the global response to AIDS, for instance.  As of 2011, for the first time in history, less than half of all money spent on HIV and AIDS in low and middle income countries came from international donors – 51% came from national sources.  But the extent to which the 49% can be spent on programmes that are “VFM certified” largely depends on what the 51% is being spent on.

First example.  In one country, most of the international aid money for AIDS comes from the Global Fund to fight AIDS, Tuberculosis and Malaria.  A good chunk of that money is spent on antiretroviral drugs.  But not any old ARVs: just the most expensive ones. The country produces all of its first-line ARVs – the ones that are the cheapest to manufacture, and that bring economies of scale because they are the ones that are needed at the greatest volume.  What the country  needs assistance for is the second and third line drugs – the ones that have to be imported, and that have to be purchased in much smaller quantities.  For the same budget, the Global Fund could, theoretically, be paying for far more treatments, but it isn’t.  But the imported drugs are no less essential – once someone fails on first line treatment, it is essential to move them on to the next regimen.

Second example.  It is well known that the highest VFM proposition for spending on HIV prevention is to invest in comprehensive programmes with highly affected populations like men who have sex with men, sex workers, and people who inject drugs (“key populations”).  Despite some improvements in recent years, programmes with these populations continue to be chronically underfunded.  Even more significantly, over 90% of money for these programmes comes from international aid sources.  National governments don’t like spending money on this area of programming at all.  In this case, international donors are getting the best VFM (providing the programmes are being implemented properly).  In the longer term though, if the trend toward higher shares of domestic funding continues (and there is no reason to suppose it won’t), these programmes look to be at very high risk of losing support.

A straight contest between the first country and one of the countries where donors pay for all of the key populations work would suggest that the latter is a far more suitable investment.  But it is not that simple. In both cases donors are filling a shortfall in a national response – albeit for different reasons.  It may be that when looked at as a whole, the first country’s response is more economically efficient, even if the aid investment doesn’t make it seem so.  Moreover because things like effective HIV prevention and treatment are made up of many interconnected and complementary interventions, and indeed because prevention and treatment are themselves interconnected and complementary, the cost effectiveness of each intervention often depends on other interventions being implemented.

When looking at value for money, major international donors should think of funding as being “fungible” and should be looking much more at the whole national context and environment for a given programme rather than precisely what they are spending money on.  And if they are funding things that simply can’t or won’t be procured by domestic funds, they need to be thinking about what happens if and when they pull their own funding out.

On running and racing

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Brighton Half Marathon 2013 finishers. How many of them were racing to win?

Jon Pike has a nice article on the Guardian’s running blog about running and winning – take a look.  He points out that unlike other sports, most people who run in events don’t ever expect to win.  To this he says: “I’ve not really worried about this too much. Winning is never part of the game for me: it’s all about pushing myself, setting a time, having a good race, maybe thinking about the odd interclub rivalry – but not winning (and so not losing, either). And for years, I’ve thought that this is what running is about.”

But then he goes on to describe a recent relay race where this all changed – in part because his team had a very good chance of winning.  He really raced, and found it a completely different experience.  He concludes that most runners “…lose out on key parts of the experience and meaning of sport because we are never even close to winning.”

It got me thinking about my own attitude to races.  In the big mass-participation events like marathons and half marathons, where thousands are running, it has never occurred to me to actively try to overtake anyone or to be bothered when people pass me.  A few dozen places out of 8000 is not important – in those events people you are overtaking and being overtaken all the time.  Even our local Parkrun, where 300 or 400 people run a timed 5k every week, is for me more of a race against my watch than against anyone else – there are just too many people to worry about position.

But earlier this year I did a couple of 10k races where there were about 30-50 runners and it was a very different experience.  I was still nowhere near the top places, and I knew they were out of my reach, but something about the small field made it seem more like a race.  In the first race I ran a very steady pace, and as a result I passed quite a few people in the second half who had set off too quickly.  I was still racing my watch but I noticed that everyone who I passed really tried to keep up with me – they weren’t happy about being dropped.  And about 50 yards before the end I heard pounding, sprinting footsteps behind me – they belonged to the person I’d passed a minute or so earlier.  I thought to myself – well, if he wants to beat me so badly, maybe I should let him have it.  But if he wants to race, he wouldn’t want me to give up, surely? So I sped up too, and just managed to cross the line 6 inches ahead of him.

In the second race a runner was 50-100 yards ahead of me for the whole time.  In the last kilometre I was sure I would pass him.  He sped up: and I sped up.  I came close but faltered, and he finished well ahead of me.  But I noticed the change: these were races against others, and beating or losing to others was starting to make a difference – even if it was not so much about winning the whole race, it was about winning the race with the runners I was most evenly matched with.

I also realised something else that I can’t get my head round: just as I was trying to chase that one position in the second race, I also felt quite awkward and self-conscious about the idea of overtaking him… embarrassed about the swagger of taking it on.  So much so that I think it put me off really going for it.  Could I have caught him? I have no idea but I think I’ve now got an inkling of why “hunger” is so important to success.

Global Fund and how to invest in impact

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Some time after Aidspan first raised its concerns about the different ways the Global Fund treats national and international grant implementers, the Secretariat of the Global Fund has replied.  I don’t want to go into too much detail, so to cut a long story short the issue was that while the Global Fund allows international NGOs and agencies to report some of their overheads as “indirect costs”, national ones are expected to provide detailed reports and receipts on every single expenditure, whether it is related to programmes, procurement or management.  

The Secretariat’s response suggests there won’t be much change to this policy. This is disappointing, but not just because it seems unfair that the smaller, lower capacity organisations should have a more complicated reporting burden.  To me it is disappointing because it suggests that the Global Fund’s attitude to risk and to performance based funding has not changed a great deal.  Risk remains, essentially, the risk that money went astray or was not all spent in the way that was planned.  Having hovered around some of the discussions about the development of the Global Fund’s new model in the past year I had a small amount of hope that there would be a new approach to risk.  One that considers the risk of people not getting treatment, or of people being mistreated by programmes,

I understand why the Global Fund remains jittery about financial management.  But it really is too bad that the focus is still all about monitoring inputs.  If the Fund was truly supportive of performance based funding it would worry less about how money is spent and what it is spent on, and spend more time monitoring the impact of its investments.

The secretariat’s response also suggests to me that there will be no move toward allowing small grass roots sub-grantees to report primarily on their results either.  The risk, which I discussed in this post some time ago, is that community groups will continue to be expected to spend a lot of their time and good will bean-counting and less of it doing the work their communities need them to do. 

The US Supreme court and PEPFAR’s “pledge”

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The Supreme Court of the US is currently deliberating the constitutionality of the so-called “anti-prostitution pledge”, a requirement introduced by the US administration in 2003, according to which organisations involved in programmes to fight AIDS had to adopt a policy explicitly opposing prostitution as a condition of receiving funding from the US government’s PEPFAR programme.  The case against the pledge is that it hampers effective HIV programmes and that it constitutes a violation of first amendment free speech rights (the latter, only in relation to US-based organisations).

For more background, I can recommend the primers and analysis by Serra Sippel, Melissa Gira, Melissa Ditmore and Dan Allman, and Chi Mgbako.  The New York Times also published an editorial calling for the Supreme Court to rule that the Pledge is unconstitutional.

While I also hope that the Pledge is lifted, I think it is also important to recognise that, as important as the influence of US funding is to the global response to HIV and AIDS, the Pledge is neither the only nor the main reason that HIV programmes have failed and are continuing to fail sex workers.  Governments across the world have failed to adopt policies and implement HIV programmes with sex workers that are evidence based and respectful of human rights, irrespective of whether they are using their money, the US government’s money, or money from another source.

Nor is the Pledge the main cause of abuses of the rights of sex workers.  In the majority of countries sex workers remain criminalised or quasi-criminalised, and they face a constant threat of violence and abuse from law enforcement officials and medical authorities (one example here).  Removal of the PEPFAR pledge will, no doubt, enable programmes to work more closely with and support grassroots sex worker groups who want to challenge this situation, but they will still be largely constrained in what they can do by the national and legal context.  If governments want to arbitrarily arrest sex workers, or stop sex workers organising and claiming their rights, they will do so.

We know that it is not beyond the UN system and donor governments to be scandalised by human rights abuses – take, for instance, the justified international reaction to instances of homophobic abuse.  That the mistreatment of sex workers by governments and their agents is not a scandal is a sign of how much further there is to go.  We need more than just the removal of the PEPFAR Pledge: we need a commitment to supporting the rights of the most vulnerable, whoever they are.  At the same time we need much more humility about the impact that decisions taken in western capitals have on human rights on the ground, and much more solidarity and support for grassroots organisations.

Carrying 20 kilos of bananas for 15 miles

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Some people say there are 4 Ps of marketing, some say there are 5, and others still say there are 7 or even 8.  But as far as I know Packaging isn’t on any of the lists.  However, just recently the Design Museum announced that its 2013 award for Best Product was going to Kit Yamoyo, an anti-diarrhoea kit containing essential medicines and products that could play an important role in tackling the second biggest cause of death of children in low-income countries every year.

Why a design award? What first inspired the development of the kit was the insight that companies like Coca Cola manage to get their product to the most remote locations.  And so the kit was designed by the organisation colalife to fit neatly into the crates that are used to transport Coke bottles.  The programme is currently being piloted in Zambia.

And yes, the design looks neat, and innovative (that holy grail of development initiatives) and as a result gets noticed.  But the design, and the tie-in with Coke crates, is largely irrelevant to whether this product will end up saving lives or not.

Someone must want to buy these bananas.

Someone must want to buy these bananas.

Kit Yamoyo has recently been covered by Wired, and although the headline, “Clever Packaging: Essential Medicine Rides Coke’s Distribution Into Remote Villages”, also emphasises the coolness of the packaging and the transportation, read through to the end and you’ll see that, as it turns out, the real insight in this story is not about packaging or even delivery of products.

Don’t take away the impression that over 2 million infants and children are dying of diarrheal disease every year because until now the medicines to treat them have come in the wrong shaped boxes.  Coke itself is not the easiest thing to transport in large volumes. It is heavy, it is bulky, and it is somewhat fragile.  The fact that you can find Coke nearly anywhere has little to do with the design of the crates it comes in.  In the same way, there’s a reason the chap in the picture is carrying 20 kilos of bananas on his back for 15 miles.  He’s not doing it because it is convenient (there are no EU directives on straight bananas in rural Madagascar!), he is doing it because someone wants to buy his bananas.  Similarly, if you’ve ever noticed sellers hanging outside nightclubs with cigarettes, chewing-gum and condoms on their trays, it is because people going into and coming out of nightclubs want cigarettes, chewing-gum and condoms.  If they didn’t, there would be something else on the trays.

The real insight here is to do with how Coke, and any other manufactured product, go about producing something that will find its way onto shop shelves and into people’s daily lives.  It doesn’t matter how nice the distribution system is: if people don’t want to buy the product, shopkeepers aren’t going to buy it in from wholesalers to suck up capital and gather dust on their shelves.  And sure enough, the head of colalife, Simon Berry, tells Wired that little if any use has been made by retailers of the design award-winning compatibility of Kit Yamoyo and Coke crates.  But regardless of this he is confident that they have created a product that people want, that they can afford, and that generates profit for retailers and wholesalers.  In very poor regions affordability may continue to be a problem and in those cases programmes need to find a way of keeping in place the financial incentives that get the product to where it needs to be while making sure that those who need it can get hold of it.  This includes being able to afford it.  Many programmes are experimenting with ways of getting vouchers to those who need them, so that they can get health products for free or at a subsidised price while maintaining the profit margin that retailers need to stock the product.

The result of colalife’s pilot will hopefully tell us more about how well the product has sold, who has used it, and whether some components of the kit are more useful than others.  If the product catches on and people in areas affected by diarrheal disease are willing and able to buy it, then it is good news, whatever the shape of the packaging.  More important still will be improvements in access to clean water and sanitation that will reduce the prevalence of disease in the first place.

Another discussion on sales of health products also caught my eye this week: this World Bank blog post about the evidence on different types of incentives used to encourage hair stylists to sell female condoms, coincidentally also in Zambia.  I agree with the broad conclusions of the author: that we haven’t got a whole lot of evidence about incentives, and that findings of a study on incentives for one intervention should not be uncritically assumed to be valid for other interventions.  But I am even less impressed than he is by the study he is describing. Not the quality of the study but the fact that even the best performing stylists, those who had non-cash rewards, only managed to sell an average 15 packets of female condoms in a whole year – compared to 7 packets a year for those receiving cash rewards.  Either way, that’s a pretty low number of female condoms sold – and the study probably tells us more about peoples’ interest in the product than about incentives.  Just like Kit Yamoyo: if people don’t want the product, and retailers don’t have a good reason to stock it, it’s probably worth having a re-think.