In this interview, we discuss whether impact drives the formation of new partnerships, why the aid harmonisation agenda has not lived up to expectations, and why partnerships rarely close down fully.
Could you tell us about your background, and what your focus is at CGD?
I started at the Center for Global Development, a DC and London-based non-profit think tank, as Director for Global Health Policy ten years ago. Three years ago, I moved into management, and am now Executive Vice President and CEO of CGD Europe. I still spend around a third of my time working on global health, focusing especially on financing and economics, also with a civil society dimension. I previously worked at the Inter-American Development Bank, Brookings, and started my career at USAID.
CGD has two roles. The first is to propose solutions to big problems, many of which have been picked up in policymaking. Examples of this are our work on advanced market commitments (AMC), priority setting, drug resistance, and impact evaluation (3ie). Our second role is to focus is on analytics and accountability, for example looking at impact claims that are not evidence-based. We always use an evidence and results lens. We see ourselves working between academia and policy.
International development and global health have probably changed quite a lot since you started in this sector. How does the current architecture reflect these changes?
It has changed a lot. When I started at USAID in the Office of Population after graduating in 1992, USAID was a big player. Since then, organisations supported by USAID grew enormously with the start of the Bill & Melinda Gates Foundation, for example PATH.
This shift has also happened with official donors but with an important caveat. Aid agency spending on global health has grown, but at the same time, their own staffing has been limited or even reduced. Donors such as DFID or SIDA used to lead the global health discourse and new initiatives, but we see them now as followers – for example, despite the UK spending about 35 percent of its aid on global health, in a recent speech around the new FCDO, Boris Johnson did not even mention global health beyond a reference to Covid-19.
In global health, we have two visions that do not overlap, at least not yet. One argues that universal health coverage (UHC) is the answer to everything, including preparedness and specific disease goals. On the other hand, we have single purpose funds, such as PEFPAR, Gavi, and the Global Fund. If you look at the IMF policy tracker and its response to Covid-19, there are few significant fiscal investments into health systems, the focus is small-scale and looks to be focused on buying products such as personal protective equipment (PPE), ventilators and tests.
The role of the World Bank is also interesting. Given the Covid-19 crisis, the Bank looks set to be the largest source of external financing, which minimises the role of others, where millions cannot compete with billions. This may change the power structure further.
I am worried about the future of bilateral aid. With Trump, aid increases are unlikely. Imagine Biden wins. His agenda is to regain international standing at WHO and work on global health security, but there are few signs yet of an aim to scale up global health aid even though needs are increasing exponentially alongside Covid-19.
Are development organizations in your view working differently together, and with other stakeholders, if we compare the situation to 10 or 20 years ago?
If we think back to the Paris Declaration, issues such as fragmentation, lack of focus, and transaction costs were big on the agenda. However, most funds didn’t change much. They still stove-piped money and ran things separately. Calling out this behaviour in reports has not helped much.
This may actually not be as big of a problem in all areas. I don’t see a problem if the WHO HIV person speaks to Zambia HIV person only. But we need to make sure health system strengthening financing is aligned. There are health system windows in many funds that coexist alongside more integral approaches (e.g. the GFF) – all these need to work together in order to be more coherent.
Fuller harmonisation would mean budget support to countries. The Global Fund actually does a form of budget support, with few conditions on the use of its funds as long as the aim is to reduce HIV, TB and malaria. In Rwanda, for example, early Global Fund grants helped pay salaries of local health teams that attended HIV/TB and malaria patients as well as attending to other health needs. That’s great as it sounds efficient. But was the HIV program actually working?
We have cautionary tales of budget support and SWAPs too, and donors have become shy despite evidence that budget support works well in many cases. In the Tanzania basket fund supported by the World Bank and the GFF from 2016, the Global Fund, Gavi, PMI, and PEPFAR were nowhere to be found. One group aligning other partners doesn’t seem to work. There are some exceptions; in our previous reports, we point to Burkina Faso for example, where Global Fund, Gavi and others pooled with the World Bank’s Health Results Innovations Trust Fund (HRITF) to fund services and verify performance. We need more like this.
Most organizations engage in multiple partnerships. Is this a positive development? If yes, why?
I came from the Inter-American Development Bank, with a strong country focus. Projects from the partnerships were just not a big deal and were not even mentioned when we were negotiating loans. But since then players such as the Global Fund are not marginal players anymore.
One question is: Are single issue funds effective for outcomes at the big level? Probably, but it’s hard to see what the counterfactual would be.
One problem is that donors don’t have the capacity to participate in the governance of so many different global health initiatives and partnerships, and to achieve policy coherence across their global health investments. Maybe different staffing would make this work, but current staffing is not up to it. In the US, for example, USAID leads on Gavi, the State Department on Global Fund, and the Department of Health on WHO. They apparently talk to each other, but in practice this way of operating doesn’t always cumulate to greater effectiveness and coherence.
“One problem is that donors don’t have the capacity to participate in the governance of so many different global health initiatives and partnerships, and to achieve policy coherence … current staffing is not up to it.”Amanda Glassman, CGD
We could also look at the World Bank Trust Funds with ad hoc governance mechanisms, or the GFF governance that sits alongside the governance of the Bank with all the same donors in each spot. Instead of new trust funds, could the Gates Foundation participate in IDA governance? The Foundation contributes more funds than many country governments, wouldn’t we just be acknowledging reality? Of course, I know this creates a whole new set of issues, but at least it would place this major funder within the regular governance arrangements thereby avoiding ad hoc approaches.
So, I’m divided. In ideal world we would expand bilateral agency staffing to enable adequate oversight and coherence. We do all have boards, and they play an important function to ensure that we are managing things right, getting stuff done, and following laws. We are all large enough enterprises to warrant this oversight.
Over the past years, there has been a lot of focus on partnerships at the country level. Has this changed how organizations partner, and whom they partner with?
Moving everything to country level is part of but not the entirety of the solution. For example, IDA or SWAPs work if the country is behind it, and there is representation of external partners and joint programming. But if PEPFAR, Gavi and Global Fund don’t participate in the SWAP or basket fund – that’s 60 percent of funds missing and becomes less meaningful.
Partnerships at country level without money, and without tools to coral everyone on board, don’t work. Everyone just does their own thing. They have their own interests, they ultimately have to respond to constituents at home, even if they join partnerships or meetings. In reality this just results in lots of papers on the web, and little action.
“Partnerships at country level without money, and without tools to coral everyone on board, don’t work. Everyone just does their own thing.”Amanda Glassman, CGD
I hope to see new instruments that have enough money and also people, coordination requires constant follow-up. We therefore need different staffing and different incentives. Right now, it’s better to have a government-owned partnership.
Could you provide examples of what you consider successful partnerships in international development, and why these are successful in your view?
The GFF conceptually looked good. It was claimed to be the path to sustainability, had the right players, incentives, and enough muscle bringing together grants with loans. What’s happening now is that donors still don’t fully understand how the World Bank works with its clients. And the Bank side could also be clearer in the design of its programs and on communicating the purpose/role of a trust fund vis a vis its other instruments – what can be delivered, and what can’t be delivered. But it still has potential.
Gavi also works great, and everyone loves Gavi. The criticism is not as much in how it operates as a partnership, but its focus on the problem and the results it achieves. The real problem is not only procurement of vaccines; it’s mainly delivery, and the costs and incentives of delivery. The upstream focus on reducing the costs of new vaccines has been met, but the downstream part to actually deliver vaccines still struggles. Gavi is quite unique, though, in that donors and stakeholders agree where it should go. With Global Fund this is less the case, although it’s a huge hit in terms of raising money and has a good brand.
Do you think the value add of partnerships can be measured? How?
We all know from aid literature that aid money can be used well or poorly, but at the margin what should count is: Are you making a difference? The top success would in my view be: What happens with the result for which the partnerships were created, and what was their own role in achieving this result? And can this be shown? But this is not what happens in practice.
“What should count is: Are you making a difference? … But this is not what happens in practice.”Amanda Glassman, CGD
Other criteria include whether transaction costs are being reduced. This needs to be defined ex ante. Whose costs? Ideally countries, as they bear most of the brunt of fragmentation. Or donors? We also need to move away from micro-management and receipt administration. Every organisation providing services and products experiences this, we do too. We also know longer term commitments add more value. Ideally, we’d have commitments over 10 years, at least 3-5 years.
Also important are the addition of knowledge and learning, and their dissemination. HRITF had a huge learning agenda, its data sets were published, and it was evidence based. What’s still not clear is whether these really fed into policy. Global Fund, for example, has no clear knowledge and learning work to date. What works, for example, in its investments made into training, is never captured. This should be an integral part of the transparency agenda.
Creating visibility is also important. Partnerships bring together all the big players, and they see what good their spending achieves, and this creates a constituency for the overall cause. This is at least good for the aid enterprise; some may also trickle down to the country level. What’s questionable is why we have replenishments if, for example with the Global Fund it’s the same 14 donors that cover 98 percent of the funding requirement each time. But maybe that’s the only way to raise the money.
To what extent do you think impact determines which partnerships are formed between international development organizations, and with other stakeholders? What other factors drive the formation of partnerships?
I have to hope that they are driven together by the desire for impact. But it depends on who you ask. For example, US policymakers fund PEPFAR because they want to be ones to end AIDS. It’s tough to sell something like “resilient health systems”, there’s no tangible objective, no clear lives saved, etc. At other times partnerships are formed because something was left out, for example reproductive, maternal and child health with the GFF.
However, I do not feel that organisations are run with impact in mind. Perhaps that’s why there’s a perception that existing ones do not work as we wish, and maybe we could do it better.
There’s also the view that this is how we get stuff done in global health. Take the example of Gavi and the Global Polio Eradication Initiative (GPEI). Why is GPEI different from Gavi? Because it includes middle income countries in its focus, and includes Rotary? Could it easily be part of Gavi? Of course, it could. There are lots of legacy initiatives, defining what the problem is, and what the strategy should be. And sometimes they kind of merge, like the global drug facility for TB, which the Global Fund uses as a procurement mechanism to buy TB drugs. It has in some way eaten the thing that came before. What’s clear is that our current system is inefficient.
Not all partnerships live up to their ambitions. What do you think should happen when partnerships struggle to provide value add, or lead to more impact?
Partnerships don’t die. The Health Metrics Network is the only example I can think of, although that’s one I wish wouldn’t have died. River blindness and schistosomiasis control should probably be listed as successes, they mostly solved the problem – they initially expanded to deal with the problem and – as the problem was solved – these partnerships contracted.
You could argue that some of the UN agencies represent early partnerships. And some have nearly been closed. UNESCO, for example, lost confidence, donors and partners just left. But they seem to be making a comeback, the organization didn’t die. An interesting case is also the birth and death of multi-donor Trust Funds at the World Bank. The Partnerships for Maternal, Newborn and Child Health (PMNCH) and Family Planning 2020 also make interesting cases.
Other partnerships struggle. Many people are advocating for more focus on non-communicable diseases (NCDs), but there’s no real appetite. But if I said childhood cancer, I might get a partnership. The specificity is in our sector linked to the ability to fundraise, and hopefully have some impact.
The main question should be: did we solve the problem? But like any organisation, you have to engage your funders and board – and show all the time that it’s working. Those who fail at this will fail as partnerships. I can’t think of any partnership that succeeds on the impact side but fails on this, and still thrives. Donors can also drive a lot of incoherence, especially through small, fragmented grants.
One idea could be to introduce something like the UK multilateral aid review but focus on partnerships. How aligned is a partnership with our own goals? How good is the partnership at achieving goals? How does the partnership rate on impact, knowledge, transparency, and reducing transaction costs? The US Administration and Congress would definitely have interest in this.
“One idea could be to introduce something like the UK multilateral aid review, but focus on partnerships.”Amanda Glassman, CGD
If you look forward 5 to 10 years, would you hope that organizations work differently together? If yes, how?
Covid-19 may lead to fiscal contractions, and this could result in infighting and make country work and coordination a living hell. I think it would be a good idea if e.g. the Global Fund would also do procurement in middle-income countries, and that we do not create a million different procurement facilities, e.g. for PPE, diagnostics, etc. But this is unlikely.
Ideally, I really would like them to say something about what the partnerships are actually achieving. I was once told that this is not possible with local ownership, that this would be antithetical to a results-focus. That can’t be: results must surely be part of the local ownership and health systems agenda. Otherwise what’s the point? We need less blah-blah rhetoric, and more action. How many H4, H8 and SWAPs can the system and the people involved take?
At minimum we need to have more learning, and document this in the public domain. This does not mean just publishing a grant documentation, and what was bought, but what’s actually being achieved.
Find out more about CGD’s work here.
Key points summarized:
- The power structure in international development and global health partnerships has shifted greatly over the past twenty years.
- The Paris Declaration for more aid harmonisation has not ended stove-piping of funds and running programs separately.
- Limited donor staffing and capacity has resulted in lack of meaningful oversight in partnership governance bodies and continued lack of policy coherence.
- Meaningful partnerships at country level require money and capacity to coral everyone to participate.
- Many organisations are not run with impact in mind, which may explain why new organisations and partnerships are continuously established. There are also many legacy initiatives.
- Partnerships rarely die or are closed, some may temporarily or permanently contract or merge.
- Glassman, Amanda and Morris, Scott “The US and China Have Very Different Takes on IDA and the Global Fund: Why that Matters for the Future of Multilateral Aid”
- Morris, Scott “Mapping multilateral concessional financing landscape”
- Barder, Owen; Ritchie, Euan; Rogerson, Andrew “Should multilaterals be contractors or collectives”