Part four of the 8-part series In the Driver’s Seat: A Series on Country Ownership of Health Programs. Rosann Wisman is the director of Ministerial Leadership Initiative for Global Health (MLI), which works in five countries to help support leaders in Health Ministries. MLI is a program of Aspen Global Health and Development.
Q: Why are so many people talking about country ownership now?
A: I think it’s because there’s an effort to examine what has been effective and what hasn’t in development during the last 20 years or more. The countries where there has been the most progress in health reform are places with major political and government leadership in the process. That’s not to say the NGOs haven’t played a major part, but without the government leadership, the political leadership, there aren’t too many examples of large-scale success. It’s become more and more apparent in some countries where you have governments serving the donors rather than actually getting the work done. That led to some of the issues around the Paris Declaration and the IHP process. Development partners are saying, "Wait a minute, we don’t want to be the focus of the work, we want to help make sure the work gets done."
Q: Can you give a couple of examples where countries are taking more ownership recently?
A: Two come to mind. One is in Sierra Leone, and the recent effort led by President (Ernest Bai) Koroma to launch free health care for pregnant women, lactating mothers, and children under five. It was a bold move. It was certainly controversial – there were and still are development partners who said it wasn’t time and the country wasn’t ready for it. Yet the president pressed on and it was an example of how his leadership galvanized the development partners to work together, and focused the government to make improvements on health delivery systems.
In Mali, there’s another example of the government taking the leadership of launching universal health programs through their expansion of mutuelles, or community-based insurance plans. Government partners had supported this, but it took the leadership within the Ministry of Health and the Ministry of Social Development, Solidarity, and the Elderly, to really get the momentum behind this. It wouldn’t have happened without government ownership.
An example where country ownership is really lacking is Haiti. It is a country where proportionally there’s been a tremendous amount of development support over the past many years, and had a huge number of NGOs flourishing, and yet when the earthquake hit, it wasn’t the NGOs taken to task. It was the government taken to task. What happened there was almost a parallel structure that evolved with the NGOs providing services and the government services not getting the support that they needed.
Q: What’s the level of frustration in countries that are getting more ownership for their programs?
A: Even spending a few days in some of these Health Ministries, I find it disheartening. You look at these leaders trying to get work done, and practically all they can do is go from donor to donor, meeting to meeting, replying to requests from donors. In some of our MLI countries, they have a hard time keeping a handle on what outside development partners are trying to do in their country. They are trying to just keep track of it, let alone trying to influence it. Poor countries are in a bind. They don’t want to say no to any donors. I’ve had ministry leaders say to me, "We say yes to everything, hoping some of the offers come through." But when it comes to their priorities, they are not being listened to.
In Nepal, we’re starting to see some exciting progress, trying for instance to give them support in how they negotiate with the donors. Now some very innovative new partnerships between the Ministry and partners are developing.
Q: What’s your advice to donors?
A: Donors have to listen to the country leaders at the Ministry of Health, at the Ministry of Finance, and the head of state. Too often, development partners come in with a plan and they know exactly how they want to spend this money and governments can take it or leave it.
Q: But what about corruption?
A: Everyone is worried about it. But if we look at the last 20 years of aid through donor-driven efforts, a lot of people would say we’ve also lost money with that approach. One of the things that Ethiopia’s Health Minister Tedros (Adhanom Ghebreyesus) says is while some donors are so worried about corruption they have also wasted money, and now they should take a little bit of risk in allowing the government to take leadership.
In the Driver’s Seat: A Series on Country Ownership of Health Programs
MLI works with ministries of health to advance country ownership and leadership. This blog covers issues affecting the ministries and the people they serve.