Monday, November 7, 2011

Health Systems Strengthening and the Role of NGOs

During the week of November 7-11, 2011, I participated on an expert panel of Global Health Delivery Online. GHD Online is an online platform where health care professionals can come together in online communities to pose questions, debate, and learn from each others' experiences in health care delivery in different parts of the world. (It is free and open to anyone who creates a user account). This expert panel was entitled “Strengthening Health Systems: The Role of NGOs.” The growth in international non-governmental organizations (NGOs) working in health care around the globe raises questions regarding how they can best support in-country governments to strengthen local health systems, and the experts on the panel as well as participants like yourselves will work to unpack some of these complex issues.  The panelists included:
  • Dr. Agnes Binagwaho, Minister of Health, Rwanda
  • Ted Constan, Chief Operating Office, Partners in Health
  • Dr. Felix Kayigamba, Access Project Country Director
  • Christina Bethke, Program Coordinator, Tiyatien Health
  • James Pfieffer, Medical Anthropologist, “NGO Code of Conduct” Author, and Director of Mozambique Operations, Health Alliance International
These expert panelists were asked to share their thoughts on the role of NGOs in strengthening health systems and address the following questions:
  1. Please describe some of the aspects you consider crucial to NGOs and Ministries of Health working in partnership to strengthen local health care delivery.
  2. What are some of the main challenges of administering joint programs?
  3. How can NGOs best support building local human resource capacity?
  4. How should partnerships between NGOs and the public sector deal with infrastructure needs?
  5. Are there examples of current partnerships you think have been particularly successful at strengthening health systems?
Below I have copied the responses I sent out through the GHD Online Expert Panel Discussion. 


1) What are the most crucial aspects that make for successful partnerships between NGOs and Ministries of Health?

First and foremost, the country in question needs a vision and a national plan. In Rwanda, it was essential that this plan was part of the national development framework. Further, within that national plan, the health sector must have its own strategic plan. This allows for NGOs to work within the framework of a sector-wide approach like we have in Rwanda (we call it the SWAp, as it is focused on capacity transfer as well as harmonization of NGO and governmental activities). This means that all NGOs working in a country must be committed to the national vision and that the Ministry of Health does not allow NGO partners to diverge from its plan. This structure facilitates coordination within the health sector. However, in order to make this work for in the long run, the national strategic plan must be accompanied by plans for both implementation and monitoring and evaluation.

It is crucial that NGOs do not simply come to Rwanda to implement interventions that have proven effective in Geneva or New York or Washington. Instead, NGOs should implement what has been proven effective (or to work with us to determine what will be even more effective) in Rwanda and respond to the actual need of Rwandans. For this to work across the entire health sector, Rwanda ensures that all planning takes place in a decentralized and participatory process, involving stakeholders at all levels – from the community, all constituencies of civil society, and the local and central government. When the planning is complete, all actors must stick to the result.

Another key aspect for successful partnerships with NGOs is the equitable distribution of activities across the country in order to ensure that the entire population benefits from their presence. The Ministry of Health must ensure that NGOs do not concentrate themselves exclusively in only a few parts of the country. Ministries should make NGOs work together and capitalize on synergies between their areas of work. If they are involved in medical procurement, they should coordinate their activities together to take advantage of economies of scale. Such actions help to avoid duplication of efforts, and they maximize benefits for the population.

For NGOs, it is very important to support the government’s leadership of the national plan, but also to contribute to its design. If there is no comprehensive national plan yet, NGOs should be ready to assist with the planning and implementation of a national strategy that they can be a part of. Such a strategy is not simply a plan for the central government, but the expression of a vision of the entire nation. Collaboration is key – everybody must be brought on board for the inclusive and community-driven planning process in order than it can respond to community needs. Again, however, the government itself must lead, because it is the central agent of planning and implementation efforts. The NGOs and public implementing agencies should be there to buttress and assist in realizing the vision of the government.

As a brief illustration, let us examine the situation in Haiti right now. First and foremost, what should be done is to convince all NGOs operating in the country for the long-term reconstruction efforts to come together and resolve to assist the government in a comprehensive national development plan for the country’s future. A national consultation should be undertaken that identifies the various constituencies and lists all stakeholders in Haiti. The population should be asked directly what their vision for Haiti looks like. All should participate, but the lead voices in orienting the vision should be those of the Haitian population. Together, the government, the population, and Haiti’s many NGO partners could move forward with strategies and planning activities to pursue that common vision for the country. This may seem like a tiring process but it is the only way to assure a comprehensive, participatory plan that takes into account the needs of all.

Fighting corruption is also critical to making the maximum use of the money available. So it remains crucial for NGOs to be honest and transparent about their overhead costs, and for all actors to be accountable be in a framework of zero-tolerance for corruption. In the case of Haiti, the government and the NGOs together need to maintain the primary goal of rebuilding Haiti for all Haitians – never to use the suffering of the population to take advantage of them or gain financially.

In 2005, UNAIDS developed the “3 ONEs” concept for the fight against AIDS: One national authority (the government), one national plan, and one monitoring and evaluation plan. In Rwanda, we have applied the depth and breadth of our participatory approach to planning, implementation and tracking in order to leave no Rwandan outside of the benefits of our progress. And to that end, we always focus first on the most vulnerable to ensure that our entire population enjoys the advancements of our nation’s development."


2) What are some of the main challenges of administering joint programs (i.e. numerous implementing organizations with multiple agendas competing for funding and space)?

First and foremost in the health sector is the process of developing a national vision, one that all policies of the Ministry and its NGO partners follow from. It is important for the Ministry of Health to have zero tolerance for any plan other than the national strategic plan for the country. To my fellow public sector officials, you had better demonstrate that you can say no to some partners, because the time that you spend working towards their goals set up in a city very far from your city that are certainly not aligned with your country’s needs is time that you cannot get back. In Rwanda, we are always ready to kindly accompany NGOs to the airport when they are not willing to work with us towards our vision and our plan.

A second and significant challenge is convincing these various organizations that the program to implement is your program – the Ministry of Health’s program, the national program of the health sector. If the program of the Ministry is well done, meaning in a participatory manner involving all constituencies concerned and responding to the needs of the communities, people should understand that we should not compete over labels or ownership over success, because success is shared. This involves convincing everybody that it is a win-win situation for them to join in the Ministry’s program and work to implement it, as they have worked with their national counterparts to design it.

A third major challenge comes from the multiple planning processes we must undertake simultaneously to meet the requirements of our different donor partners. This makes us lose time, does not serve to increase the quality of our services, and decreases the amount of time that all actors dedicate to service delivery. These duplications result from having to report to donors according to different timeframes and different indicators, despite the fact that we have our own indicators that are adjusted to our own context. If all of our partners used one set of indicators, reporting and harmonization would be much easier, but it is very difficult to push others to use your own indicators.

What we have done in Rwanda is to prioritize our indicators and ask our partners to conform to them. This has not worked for all partners, and it is a continuous fight over definitions even with the best partners such as The Global Fund to Fight AIDS, Tuberculosis, and Malaria. For example, we wasted months two years ago in a struggle with TGFATM over the definition of good diagnosis and treatment for sexually transmitted infections; our national protocol wanted to follow the World Health Organization guidelines of using a syndromic approach. The Global Fund insisted on laboratory confirmation. So, they told us that we were using a bad practice, and were about to cut grant money for these activities, and we had to struggle for weeks to impose our national protocol.

A fourth challenge is to make evidence-based decisions and to convince partners to join in the implementation. This means that we need to promote operational research and to obtain the capacity to do fair and true assessment, analysis, and monitoring and evaluation. This requires the creation of a culture of discipline and entrepreneurship throughout the Ministry of Health and the entire health sector; once this culture is created, NGOs themselves need to be part of and strengthen it. The challenge here is also that partners do not have the same needs in the realm of research that we have; we simply want research that shows us where we stand and where we want to go – research that we have ownership over. Partners, however, often have their own research priorities that are generalizable and based in many countries so that they can compare their own work over time. If you are not careful, you can find your health sector spending time on research that does not benefit your programs or your population. Setting up your own national research agenda is important.

To return to the example of Haiti, we need NGOs and their leaders to have the moral and ethical foundation to commit to helping the government construct an inclusive national plan that respects national ownership. It is the duty of the government to articulate a vision using a participatory process with the population first of all, to design a national strategic plan, to coordinate its implementation – meaning the activities of all sectors: public, private, community, national, and international.

The final challenge has largely been untouched by many in global health – ministries of health and NGOs alike. We can have the vision, the strategic plan, a good M&E system, but we need to use rational ways of implementing our policies to make the money work. An area that very few people are focusing on but one that makes all the difference is in the details of how you implement – how you actually deliver the services most equitably and most effectively.

We need better NGOs, and we need the government to understand that it is its duty to design a strategic plan and to regulate the activities of their NGO partners so that they truly meet the needs of the population and implement in the best of our collective capacity."


3) How can NGOs best support building local human resource capacity?

From the perspective of the government, there are several critical concepts to understand, develop according to context, implement and maintain on all levels with respect to supporting human resource capacity. Underlying these four steps is ensuring that the definition of the word “support” in a given country is understood in the same way by the government and the non-governmental entities. In Rwanda, to support does not mean to dictate or to take the lead and control a given initiative or partnership. Support is technical assistance with long-term capacity transfer components to ensure sustainability. Governments cannot complain about their development partners if they don’t take the lead to assure a shared understanding of the word support.

Before inviting technical assistance, a country should always have a human resource capacity vision that is articulated in a national human resources strategic plan and an annual implementation plan. If you do not know where you want to go – how many cardiologists and pediatricians you want – how can you know what assistance to invite to your country? And how many you have to train to replace these foreigners over time? It is impossible. When a country has a national human resources strategic plan, we should not allow NGOs to do something outside of that plan. Instead NGOs should strengthen the plan. Moreover, governments must maintain and stand by their definition of support and their vision for human resources. If there is any flexibility in the aforementioned, you risk allowing development partners to run your health sector strategy on human resources forever, as you will not have built the capacity to replace them over time.

The first mechanism to put in place after defining the word support and articulating a national vision is to ensure that incentives are in place to keep human resources in-country and in the public sector. It is essential to have similar salaries in the public sector and in the NGOs. In Rwanda, there are specific guidelines for all people employed by NGOs doing care delivery. For those with very specific specializations, these salaries need not match public sector salaries. However, Rwanda still enforces the rule that the NGO-employed specialized care provider transfers capacity to health professionals working in the public sector. This mitigates national brain drain from public service to NGOs.

This brings me to the second mechanism. All development partner-employed care providers are to be paired with national professionals in order to enhance the capacity of our public health system and to uphold Rwanda’s valuation of equity. In fact, in Rwanda, to be a technical assistant you must prove to the Ministry of Immigration and Emigration that you are paired with a Rwandan national to transfer capacity.

The bottom line is to ensure that financial incentives are in place to keep your “brains” in the public sector, and ensure that the assistance you are receiving is sustainable and aligned with your country’s vision.

As all medical training is done with public money out of multilateral and national support (including taxes), we ensure that the training that our physicians receive is paid back to the population over time. Even within the public sector, all Rwandan-trained physicians must sign a contract on completion of their MDs that they have to work for 2 years at the district level. For Rwandan-trained physicians who wish to specialize, each person must sign a contract that they will work for 4-5 years in the Rwandan public sector according to the specialization they receive. During these timeframes where physicians work in the public sector, they are fully paid. This assures an equitable distribution of expertise, and assures that after 2-5 years we can replace them with a newly trained physician if they wish to leave the public sector or leave Rwanda.

But, I must tell you that so far nobody leaves Rwanda, people are even coming back from their training in other places. In place of brain drain, we have a brain faucet. And I am one example of that! What I can achieve here is far more than I could have achieved in the West or North if I count my work in lives saved and improved. And all of my colleagues here have the same feeling because of the environment we are working in in Rwanda.

To make NGOs work, you need a national human resources strategic plan. To avoid brain drain, you need to harmonize salaries between those who provide services that are paid by the public sector and those who are providing services that are paid by NGOs. To avoid international brain drain, you must create an enabling environment for your health care practitioners, including those with specializations."


4) How should partnerships between NGOs and the public sector deal with infrastructure needs?

This is the weakest part of our partnerships so far. This doesn’t concern only buildings but also equipment and material, in addition to the national capacity to build infrastructure, and to choose and use and maintain equipment. So often in many countries, partners find it very easy to buy the pills to put in the mouths of the patient, but not to train practitioners to do it, not to buy equipment that can accurately measure effect of drug, and not to pay for infrastructure required for service delivery. Then, when support is finished, partners leave nothing behind. And there is no sustainability.

To overcome these challenges, we have set human resources development as our priority through our human resources for health strategic plan. We have included in this plan not only physicians and nurses, but also engineers because this technical expertise is a requisite for sustainability in service delivery. In Rwanda, we have set a policy on equipment and maintenance allowing and ensuring that the Ministry verifies all equipment, assures it can be maintained by our people and so on. But this was not the case before, which is why we receive a dialysis machine from an donor organization in a Western country. On it was written “NOT FOR HUMAN USE”. We don’t know what it was supposed to be used for, but it cost us a lot of money to destroy that. This is how the developing world sometimes turns into the filthiest garbage dump full of refuse from the Western world.

We also try to coordinate all the materials we purchase in order to assure that maintenance capacity exists either in Rwanda or in a neighboring country. If this is not in place, we can remain idle for months with a fantastic piece of equipment that is not working for us because we do not have the support to repair or maintain it.

For infrastructure and building, we have sought very special partnerships with those who can support valuable construction. We especially seek partnerships with those NGOs that are using national materials, ensuring infection control, and are also teaching our students of architecture and engineering how to construct valuable buildings. But I can count those partners on my left hand, unfortunately. We have very few, but we hope that there will be more because this is true sustainability and true development."


5) Are there examples of current partnerships you think have been particularly successful at strengthening health systems? Conversely, can you provide examples of 'partnerships' that aren’t working and explain why not?

For the most helpful illustrations of such polar opposites, I find it best to think in general terms. Below I have outlined the characteristics of strong partnerships between governments and NGOs, and weak or harmful partnerships between governments and NGOs. While this outline is not exhaustive, it includes some of the key aspects of each pole that are of most concern in Rwanda.

An NGO seeking to work as a strong and useful partner to the Ministry of Health:
  • Joins the country in designing a national plan for economic and social development
  • Helps the health sector to develop a strategic plan as an integral piece of the overall national development plan, and help all subsectors (NGOs, disease-specific divisions of the Ministry, procurement agencies, etc.) to develop their own plans in a way that is well-aligned with the national health sector plan
  • Goes where the biggest needs are (not the prettiest beaches!), and partners with the public sector to prioritize the most vulnerable first and foremost… when we focus on the most vulnerable, we bring everyone up
  • Undertakes their work with the aim of “working themselves out of a job” – not staying forever with the intention of creating job opportunities for their own grandchildren at the same NGO
A self-serving NGO that can undermine the goals of the Ministry of Health:
  • Moves about the country with an arrogance that says, “we love your people more than you… we know your needs better than you do… and we know how to implement programs better than you.” 
  • Undertakes activities with the primary aim of looking good in the eyes of others in the international community, prioritizing the image they see of themselves in the mirror instead of truly investing in national development
  • Confuses the notion of working as partners for development with lounging at Club Med, simply researching good beaches and pay grades, not actual means of addressing the suffering they exploit from a distance
  • Swallows more than 15% of the money they receive to work in your country for overhead… To put it simply, we are merely the pretext for the staff of such NGOs to have a good life
  • Makes humanitarian work a systematic business for themselves, with outcomes measured in money for themselves – not health and wealth for our population
  • Leaves the country in a worse state than before they arrived, because they didn’t work to create sustainable health systems but rather dependency… When such NGOs depart, the people don’t even know how to do what they knew before"