Sustainability is an overarching goal of most global health and development projects. It’s also one of the hardest to achieve.
How do we ensure that effective health programs can be maintained after international donors and partners leave? One of the most popular answers is “country ownership”—the idea that countries, governments as well as civil society, should lead efforts that impact their communities. Country ownership means that local stakeholders feel ownership and advocate for the program, and the government recognizes a responsibility to support it through supportive policies and resources.
Low and middle-income countries receive 30 percent of their health budgets from foreign assistance. Etienne Krug, MD, MPH, Director of the Department for Social Determinants of Health at the World Health Organization, explained at an event this week that international foundations and other donors still play a critical role in filling public health gaps in low- and middle-income countries.
He spoke alongside other experts at during this year’s 75th U.N. General Assembly, where representatives from philanthropy, government, civil society and multilateral institutions discussed how local advocacy can contribute to health program sustainability. (You can watch the event here.)
- The big takeaway? Plan for sustainability from the beginning.
Other speakers included Bloomberg Philanthropies’ Dr. Kelly Henning and Kelly Larson, Vietnam Labor and Social Affairs Vice Minister Nguyen Thi Ha, Tanzanian maternal health NGO Thamini Uhai’s Executive Director Dr. Nguke Mwakatundu and Global Heath Advocacy Incubator (GHAI) Regional Director Anuradha Khanal. Drawing on their vast collective experience, they shared practical wisdom for building sustainability into the DNA of health programming. All are uniquely positioned to talk about this topic — because all have focused on it from their own vantage points.
The journey to health program sustainability is multi-pronged and context-specific, but it relies on some universal, broad principles, according to experts. Key elements include involving local leadership in program concept and design; planning for the long term from the beginning; identifying and filling any gaps in skills or expertise; building public buy in and finally: advocacy, advocacy, advocacy.
Through our sustainability programs, GHAI bridges the gap between donors the local partners. We help local experts strengthen their own capacity to drive public health advocacy efforts, while also working with funders to bring together global best practices in harmony with local need, context, culture and capacities.
One example comes from Tanzania, a country that took over a maternal and reproductive health program when donor funding ended. The program was effective and innovative, so the funders’ decision to exit was met with resistance. The program had been running for a decade, but did not have an economic model in place to ensure continuity — and to explain to the government what it would need to keep it going.
- Lessons learned: When funds are finite, as they often are, best to figure out who will pay for it when you no longer can. In general, it’s harder to sell a program to new funders after it’s already been up and running.
The program had another challenge as well: While the health outcomes were exemplary, it hadn’t done a good job of selling itself. When it was time to end funding, there was little understanding among policymakers and the public about what it would mean to lose services, and what needed to be done to keep them.
- Lesson learned: Positioning the program through communications, media and advocacy efforts is critical to generate buy-in to continue the program after funding ends.
At GHAI, we worked with local experts to prioritize program elements that needed to stay. Together, we mapped out the entire budgeting process and the political actors who would make the decisions (this took several iterations, because what is written on paper is often not how things work in practice). We also worked with community health workers, doctors, nurses and journalists to shape a narrative around, and bring visibility to, the implications of ending the lifesaving program — and why others should care. We helped build a coalition outside of the government, which included a diverse set of stakeholders such as program beneficiaries, elected representatives, media and civil society.
These efforts provided policymakers with the public demand and support to approve increased human resources — 365 new health workers — and approve budget requests from Kigoma. Because all of the work was led by local partners, all of the public health advocacy capabilities stayed in Kigoma even after the program closed. They can be applied to other health issues prioritized by the community.
The transition unfolded over three years. As we were finalizing an event commemorating the handover, Tanzania’s Regional Medical Officer looked at the agenda and said, “Let’s remove this part where donors thank the government. Why don’t we thank the donors for their excellent work in implementing our national priorities?”
If global consensus is the first step in advancing country ownership, then collective intention to build sustainability and local ownership into the earliest phases of program planning is next. It’s up to all of us — donors, governments, civil society — to advocate for this vision.