The global health community is tasked with delivering fast and effective development assistance to resource-poor countries, while also working to build the capacity within those countries to sustain improvements in health, education, human rights and other development indicators. For years, international nongovernmental organizations (INGOs) have wrestled with finding the right balance between more direct implementation of program activities and longer-term goals of building local capacity to take on greater program responsibility.
Recently, the question of how to encourage long-term sustainability of development programs has come back to the foreground of the development agenda, partly because donors are emphasizing it, and partly because INGOs have their own experiences to share, test and validate. There is no disagreement on why; it’s where, how and when that pose the most difficult questions.
“Too often, our industry is full of incentives designed to prolong our efforts rather than reduce them or enable transitions,” U.S. Agency for International Development (USAID) Administrator Dr. Rajiv Shah told an audience in January. “As a result, handoffs rarely happen.” As part of a suite of USAID reform efforts introduced last year, the agency is placing a renewed focus on local capacity building. This includes accelerating funding to local NGOs and local entrepreneurs.
“We must seek to do our work in a way that allows us to be replaced over time by efficient local governments, by thriving civil societies and by a vibrant private sector," said Dr. Shah.
The U.K.’s Department for International Development, now known as UKaid, will expand partnership agreements with civil society organizations in developing countries, a vision laid out in a 2009 “White Paper.” Perhaps the single most important driver of increased local ownership of health programs is the Global Fund to Fight AIDS, Tuberculosis and Malaria. The specific programs to which $21.5 billion have been distributed since 2002 are developed by the recipient countries themselves – often through a collaboration between national governments and civil society groups. Principals of sustainability and local ownership are built into every grant that the Global Fund approves.
Various INGOs with an on-the-ground presence in the developing world have been working on these issues long before donors began to insist on them. What follows is a brief survey of how four INGOs approach the question of local ownership and capacity building.
The Christian humanitarian organization World Vision applies a uniform paradigm across its programs to promote capacity building. World Vision calls this approach “transformational development.”
“We want to, from the beginning, think about our transitioning out of communities,” says Linda Hiebert, vice president for Program Effectiveness and Integration. “In order to do that we need to establish local partners and build their capacity to be able to sustain the programming.”
The primary platform through which World Vision seeks to implement this model is called the Area Development Program (ADP). This term refers to both the geographical location of World Vision’s work within a country and also to the way in which programs are implemented in partner communities. An ADP typically covers a well-defined geographical area of between 50,000 and 150,000 people. The specific health and education programs for these communities are developed in a collaborative process that includes local and national stakeholders. The ADPs are always locally managed, but overseen by World Vision national offices. An ADP typically receives an up-front commitment of 15 to 20 years, and built into each ADP is the goal of self-sufficiency and self-reliance.
Over the past several years, World Vision has undergone a review of its ADPs to identify some best practices. This process has led to the creation of World Vision’s Integrated Programming Model, which provides both standards for operating and a recommended road map for working with communities. World Vision calls this “the critical path.”
One important element of World Vision’s approach to questions of sustainability is its advocacy work. This happens at the international, national and even very local level. In Bolivia, for example, World Vision is training activists to petition local governments and municipalities for greater health and social welfare resources for their communities. “Local organizations are now both agents of change as well as agents of control,” says Hiebert. “Communities are beginning to do their own negotiations with the local health systems.”
Over the past 40 years, FHI has evolved from a university-based research center examining contraceptive technologies to a global organization providing technical assistance and capacity building to the health and development sector in the developing world.
FHI’s approach to capacity building includes matching its scientific and management expertise to the local needs of the communities in which they work. “FHI has developed a systematic and comprehensive approach to capacity building that contributes to lasting improvements in the health and well-being of the world’s most vulnerable people,” says Al Siemens, CEO of FHI. “Our customized approach is informed by our deep understanding of local context and by the evidence defining best practices.”
FHI works with partners including ministries of health, research institutions, private sector and civil society to improve managerial and administrative systems. Through workshops, exchange visits and mentoring, FHI builds its partners’ skills in areas such as financial management, reporting, grant writing and resource mobilization. They also train local trainers who, in turn, continue to improve knowledge and skills long after FHI experts depart. Through meaningful collaboration, FHI and its partners consistently achieve high quality delivery of services and research.
FHI’s approach is grounded in the provision of technical assistance, which includes a wide variety of programs like clinical research, strengthening laboratory standards, and building health management and information systems.
FHI developed the Technical and Organizational Capacity Assessment Tool (TOCAT) to support its capacity building efforts. The TOCAT is used to guide FHI’s partners through each step as they use the tool to assess their financial, administrative, and technical needs and develop plans that increase their capacity to manage programs and deliver quality services over the long term. FHI provides customized assistance as partners develop and implement their action plans, improve services and use of resources, and produce lasting results. This approach has led to a number of successes.
Through FHI’s capacity building efforts, it has helped more than 1,000 clinical research sites in 95 countries to improve the way they conduct investigations and report results. In a regional program covering 18 countries in West and Central Africa, FHI supported four institutions to become centers of excellence that provide cost-effective south-to-south technical assistance. Through partnership with FHI, institutions in Cameroon, Burkino Faso, Senegal and Ghana have become the region’s technical leaders in HIV counseling and testing, HIV care and treatment, and services to prevent mother-to-child transmission of HIV. FHI also works closely with ministries of health to bring national programs to international standards. FHI assisted the Government of Tanzania to develop standards and guidelines on HIV/AIDS care and treatment that are now being used across the country. In Zambia, FHI is collaborating with the Ministry of Health to improve the quality of lab services, HIV testing and treatment, and home-based care. These efforts are reaching over 200 health facilities and their surrounding communities.
Looking to the future, FHI and other organizations in the INGO community understand that local capacity building and the successful transition to local ownership of health and development programs will be key. This is a delicate and complex process requiring partnerships and collaboration at all levels. With over 1,400 implementing partners worldwide, FHI is committed to putting the long-term interests of the communities it serves above all else.
Advocacy plays an important role in the work of the International Planned Parenthood Federation. But, as its name suggests, IPPF is not a centralized organization. Rather, it is a collection of member organizations, each of which began as a fully independent organization working in sexual and reproductive health in one of 170 countries reached by IPPF.
“The big advantage of the federation model is that we are responding to local conditions in specific countries,” says IPPF President Dr. Jacqueline Sharpe. “The people working in Iran, Iraq or Afghanistan – those are Iraqis and Iranians and Afghans. They have a vested interest and they understand the culture absolutely and completely.”
Local organizations that seek to join the Federation must undergo a rigorous evaluation process. They must demonstrate that their mission and values align with those of IPPF and they must adopt a constitution that subscribes to IPPF’s code of good governance.
“Membership comes with responsibilities and benefits,” says Dr. Sharpe. Members are expected to work within IPPFs strategic framework, which includes program areas IPPF calls “The Five A’s:” Adolescents and young people; AIDS and HIV; Abortion; Access and Advocacy. Members are then eligible for some financial and technical assistance. The precise level of this assistance is determined by the context in which the member operates. IPPF’s Mexican affiliate MexFam, for example, is skilled at raising independent funds and receives only a relatively modest portion of its funding from IPPF. Other member organizations, like the Family Planning Association of Burkina Faso must rely more heavily on financial support from the Federation.
Advocacy is also at the heart of IPPF’s work. At the Federation level, it lobbies donor governments and international forums like the United Nations and G20 for increased funding and donor attention to sexual and reproductive health. At the national level, Planned Parenthood associations will press governments to integrate sexual and reproductive health in national budgets. The Planned Parenthood Association of Ghana, for example, successfully lobbied the Ghanaian government to include reproductive health commodities in its 2010 budget and to integrate sexual health into its national health system.
These advocacy efforts, says Dr. Sharpe, are evidence of the effectiveness of IPPF’s diffuse federal model. “You could not want a better advocate for anything than the people who are doing the work themselves.”
In the 67 countries where PSI operates, there is no single template for how to strike the balance between the drive for measurable results and the need for greater local ownership. “It should be an evidenced-based decision, and we shouldn’t be ideological about it,” says PSI CEO Karl Hofmann. “But our premise is that deeper local roots are going to lead to a more sustained health impact.” In over half of PSI’s country platforms, operations are carried out through a locally incorporated NGO affiliate, each of which benefits from a robust relationship with a wider, global support network: technical expertise, bridge financing, fundraising, research and metrics methodology, financial management and more.
The timing and pace of the move towards greater local governance of PSI’s programs is determined by the local context, with wide consultations between governments, partner NGOs and other local stakeholders. In Nigeria, Uganda and Namibia, PSI programs have evolved to full independence. For example, in 2009, PSI/Uganda supported a transition to a locally governed, locally managed program called the Program for Accessible Health Communication and Education in Uganda (PACE). The newly independent organization works in family planning, HIV, malaria, and other maternal and child health activities, and receives funding from several different donors. PSI serves in a minority capacity on PACE’s governing board and PSI’s global network provides technical assistance, donor relations, foundation funding and logistical support.
In some contexts, however, health outcomes cannot be maximized through the full transfer to local partners. PSI’s program in Southern Sudan, for example, is managed and supported by PSI global staff. In Cambodia, the program is somewhere in between – not yet fully independent but increasingly reliant on strong internal skills and capacity. The Cambodia program is representative of the majority of PSI programs, which fall in the middle of the spectrum and feature some level of PSI control, a steadily decreasing reliance on expatriate staff and an increasing involvement of local board members.
No matter where they fall on the continuum of local governance, PSI affiliates and partners value staying linked to the network, where they can access resources not available to them locally. “We at PACE stand on our own two feet these days, but we still feel like part of the PSI family,” says Dr. Susan Mukasa, director of PACE. “Whenever we need help in improving our health marketing campaigns, for example, we tap into the wealth of technical experience that PSI has to offer – from headquarters, regional offices or other country programs.”
In January, PSI brought together the presidents of the boards of directors of its francophone African programs for a summit in Benin. “Our idea was to show that they are connected to a larger network of PSI partners and that they have things to share with each other and we have things to learn from them,” says Hofmann.
- Mark Goldberg is a freelance writer based in Washington, D.C.