Best Practice Principles for Global Health Partnership Activities at Country Level

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Best Practice Principles for Global Health
Partnership Activities at Country Level

• Karen Caines
• Michael Conway

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HLF GHP action points Abuja, December 2004

• To review cross-cutting issues and identify
  opportunities for synergies and harmonization
  between different initiatives and partnerships.
• To support further analytic work that will
  provide greater clarity about guiding principles
  and actual practices, draw out lessons about best
  practice, and support the development of common
  principles of engagement and systems for
  monitoring their application.

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HLF Working Group on GHPs

• Met twice in April and September 2005
• Reviewed available evidence on GHPs role,
  impact, operation and aid effectiveness,
  including findings from a new McKinsey study
• Developed an HLF discussion paper, including a
  set of draft best practice principles for GHP
  activities at country level, drawing on a
  health-specific translation of the Paris
  Declaration on Aid Effectiveness

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Overall GHPs have contributed many benefits . . .

• raised profile of target diseases
• advocated/provided large-scale new funding
• introduced new ways of working
• greater civil society and private sector
  participation
• built consensus and coordination around key
  technical and operational strategies
• accelerated progress
• supported global public goods
• secured economies of scale
• led innovation

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. . . but studies concerns about

• poor coordination and duplication
• high transaction costs
• variable country ownership
• lack of alignment with country processes
• health system capacity/human resources problems
  limiting GHP potential
• sustainability

Note Diversity in nature, scope, scale,
operation of GHPs
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Marked acceleration in action to address some
key problems

• For example
• Follow-up to 2005 report of UNAIDS Global Task
  Team on Improving AIDS coordination, eg
  GFATM/World Bank joint action and UN
  system/Global Fund problem-solving team
• GAVI in its second phase to base support on
  country multi-year plans. Long-term (5-10 year)
  predictable funding a legal requirement of the
  IFFim.
• Health Metrics Network initiating work with major
  GHPs about proposed principle of relying on
  partner countries results-oriented reporting and
  monitoring frameworks
• WHO-led collaboration on GHP support for health
  systems strengthening

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Benefits from GHP interactions select examples

• DRC There are more funds for the DRC now due
  to GHPs. There is a very different spirit now
  vs. 3 years ago. GFATM is to be commended for
  providing money despite DRCs crisis status.

Increased funding
Smarter policy

• Cambodia GFATM money is helping people think
  long term and big picture . . . it has allowed
  the country to test innovative practices to
  address the three diseases, e.g., use of
  long-lasting insecticide-treated nets for malaria

• Burkina Faso Work done to prepare GAVIs
  financial sustainability plan was leveraged and
  expanded to more easily create its medium term
  expenditure framework

Stronger planning capacity
Improved transparency

• Angola TB ME has improved in quality and
  consistency because continued GDF drug supplies
  are contingent on reporting
• Bangladesh Partners consortium in SWAp is
  planning to replicate GFATM performance-based
  funding for 25 of SWAp money

Catalyzed technical assistance

• Zambia RBM partnership helped galvanize
  in-country partners to design five-pronged
  malaria strategy and accelerated progress in
  developing this strategy

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Study findings major negative consequences of
GHP interactions with countries
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Countries struggle to absorb GHP resources
because GHPs do not provide adequate technical
and other support to implement programs
Countries are burdened with parallel and
duplicative processes and systems from multiple
GHPs, since GHPs often bypass and undermine those
that countries already have in place
Consequences of GHP interactions

• Shifts in policy and technology not well
  supported
• Relevant assistance for implementation not
  forthcoming
• Country coordination forums proliferating and not
  set up to be effective

• One size fits all processes do not recognize
  country diversity
• GHP-led efforts on cross-cutting system-level
  issues cause duplication

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Complication GHPs have not communicated
effectively with countries and partners
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Malaria/act technology transition need for
improved communication and support
Angola

• High CQ resistance (40),
• NMCP wanted to switch to ACTs
• WHO and in-country partners dis-couraged switch
  to ACTs

• Applied in Rd 3 Global Fund for Amodiaquine, with
  intention to switch to ACTs in 2007

• WHO policy change post Lancet
• Angola requests to reprogram grant
• Switch allowed after 6 months of negotiation, but
  size of grant unchanged

• Rd 5 application was submitted to meet the
  funding gap for ACTs

Burkina Faso

• Research showed CQ remains gt90 effective in
  Burkina, resulting in national health policy to
  use CQ for malaria treatment

• Global Fund Rd 2 malaria grant approved for use
  of CQ, AQ and sulphadoxine-pyrimethamine

• WHO and Fund policy changes, in addition to gt15
  resistance reported in several districts
• Country pushed to national policy of ACT treatment

• Rd 5 application for full transition to ACTs,
  no other financial assessment or planning done
• Current concerns about lack of sustainability

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Implementation assistance unmet needs in
specific areas of technical assistance
gt 50
Of countries identify need
It would be helpful to receive assistance on how
to link planning with disease prevalence.
MoH, Ghana
Technical assistance in training is our biggest
need. We lack training in management, planning,
and other areas. MoH, Ethiopia
gt 50
Talent and human resources
gt 50
gt 50
gt 50
Our monitoring systems are very weak, we need
help and resources in this area. MoH, Guinea
When evaluating potential shifts to new
technologies/drugs, cost-benefit analyses are
needed. Multilateral, Tanzania
The country is strong in most areas but lacks
information on how others implement programs.
Multilateral, China
Source Country interviews team analysis
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Hosting missions and report writing are major
burdens at the district level
TANZANIA DISTRICT EXAMPLES
Missions can consume 10-20 of a DMOs
time Number of one-day missions to Temeke during
last 6 months
Report writing can consume even more time Number
of full days per quarter spent on writing reports
(Morogoro)
PEPFAR
4
JICA
Harmonizing report writing can help reduce the
burden
GFATM
2
Finnish
NTLP
2
Axios
Gates Foundation
1
UNICEF
Norwegian TB
1
World Vision
EPI
1
MoH TB
UNICEF
1
MoH Malaria
WHO
1
MoH AIDS
NACP
1
MoH EPI
NMCP
1
MoH Maternal Health
Weekly notifiable disease reports
London School
1
Total
Total
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Assumes around 50 working days per quarter and
100 per half year although reported to work in
excess of that Source In-country interviews
DMO visitor log team analysis
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GHP communication is weak on multiple levels,
especially with countries
Communication channels
Weaknesses

• Variation in quality/quantity of communication
  with GHP
• Communication channels inadequate
• Unclear feedback
• Perceived lack of secretariats country knowledge

It is almost impossible to get responses by
e-mail or phone from our GHP contact . .
.. . . . even if were to reach him, we dont
feel like we could push back.
Country
GHP Secretariat
GHP flexibility not clear to country (do not
feel empowered to ask)
We dont have formal agreements with
partners. Field offices receive no guidance on
how they should cooperate with or support GHP
programs.
Lack of clarity on roles/responsibilities to
support GHP activities
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Innovative practices by countries and GHPs to
reduce transaction costs
Complementing existing country processes/systems
Providing resources commensurate with challenge
of absorbing aid
Improving communication

• Experimenting with other models even with
  potential risk of losing GHP financing and
  resources (e.g., Mozambique and Uganda
  discussing pooled health baskets funding
  mechanisms with Global Fund)
• Pushing back against vertical GHP funds for
  health system strengthening until in-country
  mechanisms for funding such cross-cutting issues
  can be developed (e.g., Zambia did not apply for
  health system strengthening money in Round 5
  Global Fund application because the funds would
  not be channeled through health baskets)

• Clarifying roles and responsibilities through
  official MoUs between GHPs and partners (e.g.,
  the Global Fund and Stop TB Partnership
  established an MOU to leverage technical
  expertise of Stop TB Partnership with resource
  mobilization of the Global Fund)
• Investing in understanding the local context
  (e.g., the FPM for Mozambique makes in country
  visits on a regular basis and has 1-2 day
  turnaround on emails from CCM)

• Providing resources beyond commodities of
  funds/drugs (e.g., Gates/PATH MACEPA supporting
  full scale-up of Zambian malaria program, in part
  by co-locating MACEPA staff in National Malaria
  Control Center to transfer skills/build capacity)
• Developing coordinating mechanisms suited to
  local context but which still meet global needs
  (e.g., Krygyz Republic proposing to merge Global
  Funds CCM with Multisectoral Committee on
  HIV/AIDS)

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Opportunities for GHPs to address these
consequences
EXAMPLES
ALTERNATE TO CHART 7
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Relevance of Paris Declaration on Aid
Effectiveness, 2005

• The Paris Declaration on Aid Effectiveness is
  generally relevant to the health sector
• Application of its commitments should improve the
  effectiveness of health development assistance
• In several areas, studies show a gap between the
  principles and GHP practice but no insuperable
  barriers
• The Paris Declaration offers an appropriate
  framework for the consideration of best practice
  principles for Global Health Partnerships

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Proposals for best practice principles in HLF
paper

• HLF paper suggests up to 21 draft principles
• based on GHP-specific adaptation of Paris
  Declaration under its 5 key areas ownership,
  alignment, harmonisation, managing for results,
  mutual accountability
• plus a few GHP governance principles not covered
  by Paris Declaration
• to be tailored to individual country and GHP

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Examples of proposed best practice principles
for GHPs

• Alignment
• To use country systems to the maximum extent
  possible. Where use of country systems is not
  feasible, to establish safeguards and measures in
  ways that strengthen rather than undermine
  country systems and procedures
• Harmonization
• To implement, where feasible, simplified and
  common arrangements at country level for
  planning, funding, disbursement, monitoring,
  evaluating and reporting to government on GHP
  activities and resource flows
• Accountability
• To ensure timely, clear and comprehensive
  information on GHP assistance, processes, and
  decisions (especially decisions on unsuccessful
  applications) to partner countries requiring GHP
  support

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Recommendations to individual GHPs

• Endorse and enact best practice principles,
  primarily relating to alignment and harmonization
• Undertake a self-assessment of practice in
  relation to those principles, and develop
  proposals for action
• Develop country-specific agreements on rules of
  engagement
• Work with countries, and with other agencies and
  GHPs, rapidly to get in place solutions to
  simpler problems, while developing approaches to
  more challenging problems

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Complementary commitments for partner countries

• For example
• develop clear national health sector strategies,
  with MTEF and health sector plan within national
  development strategy (e.g. PRS)
• exercise leadership in coordinating partner
  activities
• ensure good procurement/financial management
  systems (or reform programmes to achieve them)
• develop and periodically review country-specific
  agreement(s) on rules of engagement with GHP(s)

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Complementary commitments for bilateral/multilater
al partners

• For example
• support countries to ensure health is
  appropriately reflected in PRSs, health sector
  plans, MTEFs, and budgets
• provide clear guidance to field staff on their
  role in GHPs at country level
• increase support for technical assistance for
  implementation
• urgently develop guidance on health systems to
  inform GHP approaches to health system
  strengthening

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Going forward a spectrum of possible actions
Annual discussion forum on GHPs More analysis of
GHP impact
other options?
Putting the proposed principles into practice
through joint action in selected countries with
plenty of room for learning and adaptation
other options?
OECD-like mechanism that sets targets and
indicators, produces annual status reports and
provides the basis for enforcement
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Issues for discussion - does the HLF agree that

• the study findings reflect the key issues about
  GHP activities at country level, especially those
  requiring action?
• GHPs should adopt best practice principles? And
  if so, that the Paris Declaration commitments
  should provide the main basis for GHP principles?
• the principles should be operationalised at
  country level, and that GHPs should move rapidly
  to get in place solutions to simpler problems,
  while developing approaches to more challenging
  problems?
• complementary commitments are required from
  countries, and bilateral/ multilateral agencies?
• there is need for follow-up? If so, what should
  be the mechanism?