Also In This Issue

Climate Change: Skeptics Step Aside

Connecting the Dots

Will Bugs Creep North as Climate Heats?

People on the Move as the World Warms

From the Front Lines of the Global AIDS Fight

A Photographer’s Encounter in Kroo Bay

Probing Health Ministries

John Donnelly

 

FREETOWN, Sierra Leone – Inside the fifth-floor conference room at the Ministry of Health and Sanitation, Minister Sheiku T. Koroma faced a team of visiting financial auditors, and laid open his troubles.

"We have a budget of nearly $11 million, and here we are in the seventh, eighth month of the year, and we've spent just $3 million," he told them. "Something is wrong. There is money. But how do we spend it? We don't know. The system is broken and we want you to help us.''

If the auditors were startled, they didn’t show it. They simply nodded and scribbled notes. They were at the meeting as part of a project by the Ministerial Leadership Initiative for Global Health (MLI), a four-year initiative funded by the Bill & Melinda Gates Foundation and the David and Lucile Packard Foundation to help strengthen the capacities of five health ministries in the developing world.

The auditors’ very presence was noteworthy. While some people in global health speak of neglected tropical diseases, a recent Rockefeller Foundation report found that health ministries themselves have been long neglected, calling them one of the most forgotten parts of government in poor countries. The report detailed a history of how donors place heavy demands and expectations on the people who run their country’s health system, but rarely help them succeed in meeting those tasks.

But signs of change are beginning to emerge – inspired from a gradual understanding that the crush of new global health initiatives will not work to potential unless health officials strengthen their systems, allowing them to absorb new funding and new programs.
 
Now, a few relatively small pioneering efforts have begun to start supporting leaders in the ministries. They include MLI’s $11.2 million initiative in five countries and Synergos Institute’s Gates-funded work in Namibia, along with new funding made available for health system strengthening by the World Bank, the Global Fund to Fight AIDS, Tuberculosis and Malaria, and the GAVI Alliance; that system-strengthening money could potentially be put toward bolstering the capacity inside ministries. The dollars overall are not huge yet, but no longer are almost all the funds going toward programs, drug purchases, or vaccine campaigns or research.

"One reason for the low funding has been that the big international donors and most countries see the health ministry as part of a consuming sector as opposed to a growth sector that could contribute to economic development," said Jo Ivey Boufford, president of the New York Academy of Medicine who helped lead the Rockefeller study. "Another reason is that the structural adjustment patterns in the 1980s and 1990s focused on shrinking the public budget. The first thing that governments did was cut administrative expenses, and ministries of health absorbed many cuts in staff. The ministries have not been a strong political force in these countries."

Boufford and Dr. Francis Omaswa, who also helped direct the Rockefeller report, both said that ministries deserved much more direct assistance, ranging from helping them sort out their financial systems to day-to-day peer management training to building a work plan on reproductive health issues.

"They all know what their problems are," Boufford said of the leaders in health ministries. "But they generally do not have many people who can do needs assessments and policy analysis. In many of the poor countries, supporting institutions such as universities and think-tanks ought to be available to the ministries, but they, too, lack capacity to help."

Omaswa, who was director general of Uganda’s Ministry of Health from 1999 to 2005, said that international donors could help the long-range performance of their programs if they helped build a better-functioning ministry. Instead, he said, most donors focused on the short-term results from their own programs. He cited one prominent example – the U.S. global AIDS program known as PEPFAR.

"PEPFAR helped save many, many lives," he said. "It also put U.S. ambassadors in charge of the program in their country. Now the U.S. government is saying the countries have to take it over, even though PEPFAR hasn’t allowed the countries to have ownership of the programs until now. In an environment like this, which has undermined the ministries in the past, outsiders should think about ways of supporting the countries and each of its institutions – ministries, think-tanks, universities – so that they will be able to use aid as well as possible."

MLI, a program of Realizing Rights that is housed in the Aspen Institute, is working with ministries in Sierra Leone, Senegal, Mali, Ethiopia and Nepal. Each of the five countries has helped design the type of assistance it most desperately needs. MLI hasn’t focused solely on ministers – three of the five countries had a turnover in the position in 2009 – but rather has sought to help the entire senior leadership in the ministries.

MLI’s assistance has been in three policy areas: equitable health financing and resource allocation formulas to make sure money was going to reach the poorest; coordination of donor activities and projects; and working on reproduction health policy toward improving access to quality services, especially for the most vulnerable.

Rosann Wisman, MLI director, said the feedback has been positive so far. "Health systems are important to strengthen, but you’ve got to have leaders to make the systems work," she said. "The approach that is emerging for us is placing more importance on collaborative learning, peer learning, and developing trusted relationships with a range of partners, including donors, NGOs, and people inside other ministries."

In Nepal, Dr. Baburam Marasini, chief of the Health Sector Reform Unit at the Ministry of Health and Population, said MLI helped the ministry start to build a better relationship with donors. He said one of the most difficult issues for the ministry is not knowing exactly what the various non-governmental organizations are working on. He estimated that 25 percent of the money spent on health programs in Nepal – more than $50 million – came from NGO-funded programs.

"So much of what is happening in Nepal's health sector is done by donors but not coordinated by us,'' Marasini said. "Our government has to build up their capacity so that we can understand and track these programs much better.''

John Heller, senior director of Partnerships at Synergos, said that his team’s approach in Namibia has been to listen to people in the ministry tell Synergos what they need – and then to act on it.

"One of the underlying lessons for us is there’s leadership and capacity within the system, but that it is latent and hasn’t been pulled out yet," he said. "We help bring people together in the right kind of way to help unblock things. We assume they know what they are doing. But we also know they need coaching, guiding, helping and supporting ways to help remove the blockages."

Despite these new initiatives, Boufford remains concerned that donors and governments will not continue to support the ministries of health.

"The management capacities of these groups have not been valued," she said. "There has been so much more priority put on drugs, vaccines, and now workforce. But the systems and infrastructure has to be managed properly."

In Sierra Leone, Minister Koroma is grateful for the help – as are people in charge of his numerous departments, from environmental health to reproductive health.

"We need to bring many things under control – financially and with our programs," Minister Koroma said in an interview after the auditors left to begin their investigation. "We have the people in the ministry who can make things work. We need outside help to guide us, to help us do our jobs better. We have a big problem in Sierra Leone – rebuilding a health system from 11 years of civil war. But we can do it."

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John Donnelly is a freelance writer based in Washington, D.C. Part of his reporting for this story was done on a trip to Senegal and Sierra Leone supported by the Ministerial Leadership Initiative for Global Health. He can be reached at (JavaScript must be enabled to view this email address).