Country Ownership and Rethinking Global Health Partnerships: From Dependence to Symbiosis

This is a joint post with Christina Droggitis.I recently had the opportunity to sit in on a meeting between donor and high-level Ministry of Health representatives in an African country. In a white-washed public health center with high ceiling fans whirring the tension-filled air, I witnessed a scenario that sadly demonstrated that country ownership and the process of re-thinking global health partnerships is perhaps a long way off. The donors were irate that some money they had given to a common fund had been misappropriated, and they wanted to pull all of their money out. The ministry officials who had survived the scandal were frustrated. In their view, they had done well to identify and fire the accused--they felt that the ministry should get credit that their system works to catch corrupt officials. Not a new story, but one that got me thinking about how findings from the HIV/AIDS Monitor’s research in Mozambique, Uganda and Zambia could shed some light on the issue of country ownership in the context of new U.S. global health priorities.So, when we decided to host our three country partners in Washington, D.C. as the country-level work of the 3+ years HIV/AIDS Monitor program comes to a close, it seemed like the perfect opportunity to hold an event on country ownership at the Center. Several U.S. government representatives joined our research partners for a panel discussion, and we had the incredible honor of hosting Minister Tedros (Minister of Health, Ethiopia) who delivered opening remarks on the topic.Key take-away messages from the event: 1) Country ownership is not a new topic, but it is ascending the U.S. government’s global health and development agenda as donors and countries struggle to find ways to make globally funded health programs more sustainable.2) The U.S. government lacks a clear definition of country ownership or clear guidelines for how it will be applied or achieved in U.S. global health programs. In fact, when the audience was asked to grade the U.S. government on its effort to communicate its definition and approach to country ownership (see below for details), the grade was not surprisingly a C-.3) Maintaining success over the long term (beyond what the U.S. government has committed to until 2014) is becoming a major challenge for U.S. foreign assistance programs—such as PEPFAR. In response, the U.S. government believes it needs to transition to a “sustainable response”—a situation where countries contribute a greater share of financing and take over implementation, supported with technical assistance as needed. One unforgettable remark from panelist Freddie Ssengooba from Uganda: “Ownership comes [up] when success is hard to sustain!”4) Countries need to be active partners. For this to happen, three key issues must be addressed:a. Control over financial resources: Several speakers raised this point throughout the discussion:

I. Minister Tedros and Caesar Cheelo both hinted at the need for greater country-level control over resource management and allocation.II. Don Shriber, CDC said there was a need for collective negotiation about financing.III. Buck Buckingham, OGAC said the question of financial control is “on the table” for partnership framework implementation plans, which are currently being written between the U.S. mission and national governments in several countries.

b. Information: Increased sharing and greater transparency of financial and programmatic information could foster mutual accountability and learning.

I. Complete and comprehensive knowledge-sharing between donors and governments would allow for better planning, implementation and monitoring and evaluation of programs.II. Greater transparency of information would allow citizens to hold their governments and civil society accountable for the funding they receive to implement programs.

c. Capacity: Where and how should countries expand their abilities?

I. Minister Tedros made a strong point that country capacity should be strengthened and not replaced by technical assistance, and that countries should be able to choose technical assistance where they identify the gaps.II. Dirce Costa reminded the audience that building civil society capacity in addition to government capacity is critical.

5) Tradeoffs: Recognizing the tradeoff between the speed and efficiency of an intervention on the one hand and sustainability on the other is critical.

1. A move to country ownership is a move toward sustainability, but donors and countries must be realistic about short-term vs. longer-term successes, and address these tradeoffs from the outset.
2. It is important for donors and countries to understand what country ownership is when trying to achieve; Is it rapid results and scale-up of programs to improve lives now? Or are we also trying to build country capacity—financial, human and infrastructure—to maintain and improve programs?

6) Responsibility and Trust: These are key ingredients for country ownership to work.

1. For donors and countries to trust each other, both sides must fulfill their commitments. While donors should be more forthcoming about information and allow countries greater control of resources, countries also need to demonstrate responsible (read: minimize corruption) and effective use of these resources (read: results).

So, where does this leave us? It is clear to me that country ownership is about shifting the balance from dependence to symbiosis between donors and partner countries. We have a long way to go but the U.S. government and its partner countries have the opportunity through the Global Health Initiative (GHI) to build this type of relationship (of trust and mutual accountability) with real action on information sharing, control of financial resources, and capacity building. The first step is to be clear about that whether country ownership is a means to an end OR an end in and of itself.

Event highlights

For those who have more time and interest in hearing directly from the different panelists, a full video of the event is available online. We have embedded highlights below.To kick off the event, moderator Lawrence MacDonald, CGD vice president for communications and outreach, engaged the audience with four questions about country ownership: How important is it? How do you define it? How do you observe it? How well is the Obama administration communicating their definition of it?Minister Tedros’ candid and thoughtful comments held the attention of the audience for 15-20 minutes.He acknowledged the wide and varied perspectives on country ownership—many people simply define it as “putting countries in the driver’s seat.” Yet, he stressed throughout his remarks that it’s one thing to be behind the wheel, and another to actually map your direction. How much control do you have, the Minister questioned, if you’re driving based on someone else’s route? Minister Tedros addressed the four main steps he views as necessary to promote country ownership, in other words, allowing countries to do the driving AND map the route. Stressing the continued need for country government and donor collaboration, Tedros noted that countries should 1) know what they want and lead with a vision to plan and design the direction of the response; 2) manage the resources and control financing decisions; 3) implement the programs, choosing and assigning technical assistance as needed, “so that local capacity should be strengthened, not replaced;” and 4) design a results framework that drives the monitoring and evaluation of programs, and that can hold all stakeholders accountable. Going forward, the Minister encouraged the discussion to be honest and candid. See in particular his comments about funding modalities and how countries can work with the most ideal (in his view) form—budget support—to vertical funds to make them work for country priorities. I laid out three big questions to guide the panel discussion:1) Why it important to discuss country ownership now?2) What are the objectives of country ownership? For donors? For countries?3) What are the tradeoffs for donors and countries in moving toward a more country-owned perspective?Country ownership has been identified as a guiding principle in PEPFAR’s Five Year Strategy and the Global Health Initiative to move toward a more long-term, sustainable approach to development assistance. Lawrence went straight to it and asked the U.S. government officials why we should care about country ownership.Janis Timberlake of USAID stated that in order to reach critical goals in health and beyond, the U.S. government needs to implement forward-looking policies in ways that will create sustainable systems. Don Shriber of CDC echoed these thoughts and added that with this renewed focus on health outcomes and sustainability, the U.S. government needs to move closer to true collaboration with country governments. In a more direct statement about the need for a transition to a country-owned response, Freddie Ssengooba of Uganda stated that “ownership comes when success is hard to sustain!”While the concept of country ownership is not new, concrete ideas on how to operationalize it are still developing. I posed a question in my opening remarks: Is country ownership a means to an end OR an end in and of itself? I suggested that, in an effort to make development aid more effective, country ownership is about a shared set of objectives between donors and country governments. In this segment both Don Shriber, CDC and Buck Buckingham of OGAC acknowledged that donors AND country governments need to change, with Buck specifically citing the need to become more tolerant of taking risks and less tolerant of inefficiencies.Weighing in on the discussion from a country perspective, Dirce Costa of Mozambique recognized the need to change at a country level. Often times, people associate country ownership with “government ownership.” However, greater attention needs to be paid to the role of civil society in the countries response and how they can be more included in the design, delivery and management the aid they receive. If country ownership is really about a shared set of objectives between donors and country governments, then information sharing and transparency, as Caesar Cheelo of Zambia stated, is vital. Without information sharing across parties—both financial and programmatic—it makes it nearly impossible for country governments to plan.Remember the questions Lawrence asked at the beginning of the event? Our super-duper team at CGD rapidly analyzed the responses and Lawrence shared the results: Not surprising, there was a strong consensus that country ownership was extremely important.Even less surprising, there was no clear definition of “country ownership” or how to measure it. And perhaps least surprising but most importantly, the audience gave the Obama administration a C- on how well they have communicated their definition of country ownership for global health foreign assistance. I think we were being tough on the U.S. government, but in a constructive way and I pointed this out as an opportunity for the administration to improve its grade moving forward: by clarifying its objectives of country ownership and what it will do differently from PEPFAR 1 to meet these objectives, as well as document the process and outcomes. The possibility of producing some real results for country ownership is high given the recently announced GHI+ country learning labs, of which incidentally, Ethiopia is a selected country.We had enough time for four questions from the audience.All good ones, but the one question that stuck with me was from Ed Scott, chair of CGD’s Board, who reminded us that nobody had mentioned the 500 pound gorilla in the room—CORRUPTION. He pointed to the recent example of the Global Fund and Zambia to make his point that donors aren’t going to provide unrestricted support to countries if they aren’t able to demonstrate responsible control and use of these resources.