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Country Ownership, But of What? The Case for Efficiency and Effectiveness

May 5, 2011

Country Ownership, But of What? The Case for Efficiency and Effectiveness

Arin Dutta PhD and Farley Cleghorn MD, MPH

Futures Group

The global public health community has been actively engaged in debating and strategizing the concept of country ownership; it is finally the moment for putting words into action. There are several frameworks and initiatives ongoing in this context, from the Paris Declaration to the Three Ones and we will pick one to make our point.

A McKinsey initiative on country ownership, funded separately by the US government and the Gates Foundation, is to begin in South Africa and Botswana by engaging government, international technical agencies and implementing partners. This initiative aims to produce a working understanding of how to implement and measure country ownership. We discuss this initiative and use it as a case for including efficiency and effectiveness—doing more with less—as an objective in implementing country ownership, and as an indicator of the success of country ownership for HIV/AIDS programs.

The McKinsey initiative has identified four draft country ownership criteria to further the common understanding of all partners. Later we will also use these as a framework for discussing efficiency and effectiveness. The criteria are rendered with country and donor perspectives:

(1) Political ownership/stewardship: from a country perspective, this codifies and makes visible the government's role as architect and overseer of the overall process with input from other sectors. From a donor perspective, country ownership is held as a core principle by all agencies and takes priority in aid relations.

(2) Institutional ownership in a country perspective requires local entities (government, NGOs, civil society, private sector) to make decisions, bear responsibility, and manage funds. From a donor perspective, participation is necessary to help shape the process and to help ensure that civil society is supported as a partner.

(3) Capabilities reside in local institutions, as above, who implement, perform or outsource activities. They also refine and modify programs based on evidence at each stage. Donors would in turn align their organization, vision, plan, activities, allocations, and evaluations to the national strategy as well as the idea of country ownership.

(4) Accountability of the local institutions for services and results to citizens as well as donors through performance-linked, transparent mechanisms with measurable outcomes. Civil society would contribute feedback into the mechanism. Between the donor and the country, mutual accountability would obtain, with checks and balances, clear communication of incentives/penalties, responsibilities, and ways to agree and measure outcomes.

The current resource crisis in HIV/AIDS programming is a function of declining or plateauing financing and increasing demands of scale and complexity. Additionally, the focus on disseminating treatment gains has not been matched by prevention success and hence long run costs based on present conditions are not sustainable even in middle income countries. It is the primary motivator for seeking more effective interventions that generate more output for current level of resources and efficiency gains that produce the current level of output for fewer resources. We argue below that efficiency and effectiveness initiatives clearly reflect the attitudes exemplified by the four criteria above, and hence should be one of the primary objectives of country ownership. Indeed, efficiency and effectiveness is the answer to the question: "what should be owned (by countries)"?

First, putting in place efficient and effective HIV/AIDS program management strategies is now a political imperative for national stakeholders. The international financing situation has reached a point of inflexibility where a plateau in PEPFAR-2 contributions has been manifest over the last few years. Recently the Global Fund received firm pledges in its recent replenishment of only 70% of an amount it thinks will finance future activities at "significantly lower levels". Even so, leaders of HIV/AIDS programs have made commitments to PLHIV in their countries to scale-up services of all kinds and to improve quality of care. This contradiction cannot be resolved without a commitment to sustainability that invokes efficiency and effectiveness. And the situation where local stakeholders do not architect and oversee such a process is not tenable. Country government leaders must be visibly willing to own a process which is known to be sustainable or leads to sustainability, and this must be understood and supported by donor partners.

Second, responsibilities for efficiency and effectiveness are rooted in institutional roles. There is no one institution which can deliver on the entire panoply of initiatives that are needed to achieve significant and lasting gains. For example, greater effectiveness in service delivery for HIV treatment will require more effort in learning, improving, and evaluating by government, NGO or for-profit implementers, health workers, etc. Similarly, efficiency gains can be made by better procurement practices or process improvement, both stemming from partnerships that challenge established public-private linkages. Responsibility for sustaining the gains must fall on civil society and donor partners. All of the institutions can own components of the efficiency and effectiveness process. This can be described as meaningful multi-sectoralism.

Third, ownership of the efficiency and effectiveness process is deeply woven with an understanding of capabilities. Technical knowledge to find and enact the necessary change resides in key implementers and technical agencies. The ability to oversee, evaluate, and finance the changes resides with government and donors. Understanding such capability also clarifies roles. Country ownership defined without reference to capacities will very likely not be implemented. An efficiency and effectiveness focus here clarifies capacity to the extent that country ownership begins to move forward and can take on bigger and brighter overtones.

Fourth, the process of achieving efficiency and effectiveness gains can be a marker of accountability for the local stakeholders across the process, and an indicator of their desire to create positive change. Sustainability is the best proof of the government's desire to become a steward of the destiny of the HIV/AIDS sector, and a demonstration of its commitment to the citizens as well as the international partners. Relatedly, supporting this change is the best way such partners can show that they too are willing to be held accountable to the demands of the current resource-constrained era.

Country ownership and the continuous improvement process that is hinted at by efficiency and effectiveness in HIV/AIDS programming are intertwined in our understanding. Not just because sustainability is in such crisis in the sector, but because success in this field will ensure that country ownership becomes an actual, living principle rather than an abstract concept.

Arin Dutta and Farley Cleghorn, Futures Group

IAEN Partners