Partnerships of all shapes and varieties permeate the public health landscape. While the benefits for these collaborations are seemingly indisputable, their challenges are rarely studied in any systematic way. And when they are, the findings usually fit the reality of the implementors (or at least my experiences) - donors demand much but usually neglect the fundamentals or pass the administrative and other burdens off as unfunded costs of doing business with them. And then there's the finding that highly linked and centralized coalitions may be more resistant to adopting innovations than more informal ones.
To add to this wake-up call that coalitions are not intrinsically good, and that donors need to do more that mandate their existence as a precondition for funding projects, Building better partnerships for global health by Michael Conway, Srishti Gupta, and Srividya Prakash in The McKinsey Quarterly (free registration required to read the entire article) examined the activities of five leading international partnerships (The Global Fund, Stop TB, Roll Back Malaria, GAVI and GAIN) and their interactions with 20 national governments. Their findings, while not surprising to people on the ground, need to become more internalized at the other end of the tether.
The authors note key benefits of these global partnerships for local governments including the money and attention they bring to specific health issues and the encouragement and support they provide countries to develop more effective policies to address them…Furthermore, global health partnerships raise the profiles of NGOs and help them scale up their efforts. This can mean the difference between life and death in countries such as Bangladesh and Zambia, where most health care isn’t delivered in public institutions.
On the downside these partnerships, by design, focus on specific diseases whereas the country's health system must serve a much wider range of needs among its population. The infusion of large sums of money to support these partnership activities can also overwhelm government systems and institutions, straining them far beyond their capacities to absorb the money or deliver the intended programs.
However, they found that the relationships between the international partnerships and local governments posed even larger problems.
We identified two significant negative consequences that countries face in their interactions with health partnerships: inadequate support for implementation and the duplication of effort. A lack of effective communication on the part of health partnerships in their dealings with partners and recipient countries intensifies each of these consequences...[emphasis added]
Countries invest heavily in applications for funding (efforts supported by health partnerships and their affiliates) but often can’t execute plans once the grant writers leave for the airport and the check arrives. Health ministers in several countries cited a broad lack of adequate support from partnerships as a significant problem. In Laos, we heard that health partnerships “tend to send people in for intense bursts of activity and leave reports with a lot of 'shoulds’ but not a lot of 'hows.’…Without such hands-on support, we found, countries make unrealistic assumptions and generate overly ambitious targets or, worse, targets that are too modest.
The authors also found numerous and poorly structured country level coordination forums that were mandated by these partnerships and were, for the most part, ineffective. Among the consequences of these multiple forums are duplication of financial, procurement and monitoring and evaluation systems.
Both problems—the inability of health partnerships to provide adequate support for the implementation of programs and the tendency to duplicate efforts—are amplified by poor communication. The resulting confusion and suspicion often lead to wasted time and lessen the effectiveness of all parties involved [emphasis added].
Communication among health partnerships, their partners, and the countries they help is deficient in two ways. First, we found that countries lack channels for delivering feedback to partnerships. Worse, many countries feel powerless even to try. One of the most common misunderstandings is the idea that countries can’t broach the subject of how partnerships might tailor their approaches to meet a country’s needs…A second deficiency is that in-country development partners don’t feel sure of their roles and responsibilities in relation to the work of the health partnerships…As a partner in Vietnam noted, “We are simply unpaid workers of [partnerships] like the Global Fund and GAVI. While there is more and more work, our staffing capacity has not been increased at all.” [They cite one district medical officer in Tanzania who reported spending over 25 days each quarter preparing reports]
Conway et al make the following suggestions that you should feel free to pass along to your funding partners.
Partnerships must begin to let countries lead discussions on the timing, pace, and scale of a technology’s adoption
Partnerships must tailor their approaches, requirements, and processes so that they can better serve the needs of individual health systems. To avoid duplicating efforts—and thereby overburdening countries—global health partnerships should look to one another for support. With better collaboration, partnerships could work with countries to strengthen the unified multiyear health plans that many of them are striving to create, instead of the disease-specific plans seen today.
[To enhance the quality of their communication partnerships donors should] ...increase the size and quality of their administrative staffs to ensure that countries get prompt and appropriate attention. Second, they should designate lead partners within countries (for instance, an NGO or a multilateral agency, such as the WHO) and develop country-specific agreements with the lead partners so that responsibilities are clear. Countries could then look to these local experts, not faraway administrators, for information and hands-on support.