Partnerships for health development
There is a tension between the often short-term goals of donors, who require quick and measurable results on their investments, and the longer-term needs of the health system. That tension has only heightened in recent years, where the surge in international aid for particular diseases has come with ambitious coverage targets and intense scale-up efforts oriented much more to short-term than long-term goals. Though additional funding is particularly welcome in low-income contexts, it can often greatly reduce the negotiating power of national health system leaders in modifying proposed interventions or requesting simultaneous independent evaluations of these interventions as they roll out.
Harmonizing the policies, priorities and perspectives of donors with those of national policy-makers is an immediate and pressing concern – though with apparent solutions. In addition, the selective nature of these funding mechanisms (e.g. targeting only specific diseases and subsequent support strategies) may undermine progress towards the long-term goals of effective, high-quality and inclusive health systems.
Even where this funding has strengthened components of the health system specifically linked to service delivery in disease prevention and control – such as specific on-the-job staff training – the selective nature of these health systems strengthening strategies has sometimes been unsustainable, interruptive and duplicative. This puts great strain on the already limited and overstretched health workforce. In addition, focusing on "rapid-impact" treatment interventions for specific diseases and ignoring investments in prevention may also send sharply negative effects across the system’s building blocks, including, paradoxically, deteriorating outcome on the targeted diseases themselves.
Many of these issues have been recognized internationally, and a number of donors have agreed to better harmonize their efforts and align with country-led priorities – as outlined in the 2005 Paris Declaration on Aid Effectiveness (see figure). However, although some progress has been made in applying the Paris Declaration principles, it has been slow and uneven. Change in the process and the nature of the relationship between donors and countries requires time, focused attention at all levels, and a determined political will.
This section of the Partnerships for health development profile is structured as follows:
The Liberian health system has developed a foundation of public–private partnerships over the past two decades. Charities, faith-based organizations, nongovernmental organizations and private providers have been major contributors to the health delivery system. For example, the creation of the Christian Health Association of Liberia in 1975 recognized the key role that the faith-based community played at that time in the provision of health services, at the clinic, health centre and hospital levels.
Similarly, a number of private-for-profit clinics and hospitals, for example Firestone Rubber Company, not only operated health facilities for their employees but also provided services to the surrounding community. At that time it was estimated that approximately 25% of Liberia’s health facilities were owned and operated by private-sector partners with funding assistance from external sources (missions), company income, user fees, and/or Ministry of Health and Social Welfare funding.
The Ministry of Health and Social Welfare and its partners have allocated resources and expertise to improve coordination at all levels of the health system. Historically, donors have been coordinated according to health facility or activity (e.g. immunization, malaria or nutrition). During the war years, donor coordination was driven by proposals developed by nongovernmental organizations seeking humanitarian funding for health facilities that they had selected to assist. This coordination by health facility successfully avoided duplication of assistance to the same health facility.
However, it did create a situation where three, four or five nongovernmental organizations were working in the same county. Having multiple health nongovernmental organizations working in the same county typically results in duplication of management functions, fragmentation, reduced economies of scale and competition for human resources, and it requires increased effort to coordinate by the County Health and Social Welfare Team.
Since 2006, the Ministry of Health and Social Welfare has sought strong, structured partnerships around shared objectives and approaches, within and outside the health sector, required to improve the health and social welfare status of the Liberian people. The Ministry is effectively managing the diverse set of health sector partners who are motivated by a range of different mandates, interests, resources and ways of working.
Liberia needs effective partnerships that are characterized by:
- continuous and frank consultations
- information sharing
- clear rules of engagement and conflict resolution
- transparent transactions
- explicit incentives.
Partnerships are guided by the Ministry of Health and Social Welfare to ensure actions are coherent with the principles of the National Health and Social Welfare Policy. The involvement of potential partners in policy formulation and planning during the early stages is the first step towards strengthened collaboration. Presently, there are few leadership and management structures within the health sector that are geared towards strengthening coordination and partnership.
The Health Sector Coordination Committee, Pool Fund Steering Committee, the Immunization Coordination Committee and the Global Fund Coordinating Committee (Liberia Coordination Mechanism), bring together a wide range of stakeholders to improve health service delivery. In addition to donors’ willingness to consolidate their programming, the establishment of the Pool Fund has helped to build countrywide support from only one partner in most counties. This has reduced fragmentation, increased overall efficiency and provided for one principal partner to work with the County Health and Social Welfare Team.
An objective of the current National Health Plan is to improve donor coordination and thus nongovernmental organization activities across the 15 counties. Under the National Health Plan, the responsibility for coordination of partners and stakeholders will be decentralized. The public health sector continues to work in close partnership with all stakeholders in health, including private medical practitioners and complementary health care providers.
The Ministry of Health and Social Welfare will seek the opinion of health service users in planning, implementing and evaluating of all health programmes, projects and activities at both the national and peripheral levels. It is noteworthy that donor coordination also exists by programme (e.g. HIV/AIDS, malaria and the Expanded Programme on Immunization). The Ministry recognizes the need for specialized national programmes of this nature and the reality that donor funding by programme will continue into the future. At the same time, the Ministry recognizes the need for programme integration at the local level to make a more efficient use of resources.