An appealing title and a high level list of participants made me believe I was heading to some important break through meeting. In fact, I just attended an impassioned afternoon where an NGO, has been presenting how good they have been performing at strengthening health systems through a malaria control programme. Coming out of the afternoon, I was a bit disappointed. Of course they achieved good things. They probably achieved results. Partners that they invited to testimony where very satisfied of their work but what else do you expect from a 4.5 million Pounds project. But take this list of good marks one by one.
They achieved good things. This NGO has been working in four countries over the last five years: Zambia, Uganda, Mozambique and Ethiopia. When the project started seven years ago, their original objective was to strengthen malaria programmes but doing so in an integrated and contextualized manner. We have to laude them for this approach at times of vertical programming. The way they approach the project is very much beneficiaries driven: Identify needs of the system and adapt their project to the needs identified. i.e. Work on HMIS in Uganda, emphasize quality supervision in Zambia or working hand in hand with government civil servants at all levels. All this and more is exactly what I expect from a sound NGO driven project that aims at strengthening public health systems.
They achieved results. Unfortunately they did not come up with any evidence of their impact, not even on inputs, outputs or costs engaged. We merely had an apercu of processes they followed to strengthen health systems and supposedly improve malaria outcomes. In the discussion arose the interesting issue of the institutional arrangements of such a project and how it could fit in health systems. We can postulate that a well funded, carefully designed and well staffed project had some impacts on outcomes but as Bryce et al. (2010) have argued it is difficult to point the specific added value of this particular project compared to a concurrent project run by a concurrent implementer in a neighbouring district. However it would have been interesting at least to document the institutional arrangements. It is an interesting model that an African staffed, Northern funded NGO stands by the government hands on to support health systems at district level.
Representative from the MoH of Uganda underlined the benefits of the project for the HMIS in the particular districts they worked. They even brought interesting policy changes to the country if you believe the NGO’s executive director but scaling up this ditrict level project is the issue all projects struggle with. In Uganda they have been working in 11 of the 110 districts. The representative from Zambia who had been invited to speak about partnership while underlining the partnership between the NGO and other organisations such as PEPFAR and the President’s Malaria Imitative suggested this money would have been better used if pooled into the sector budget support. As a participant rightly stated what we need are arrangements where results from such local grassroots levels projects with no global impact, can merge with global initiatives that have the means to have impact but lack something to achieve effective universal coverage.
Personally, I was mainly frustrated because this project is far from innovative. What they have been implementing is what has been tried out since 1978. They just had some means to do it and they have applied it to the 21st century’s technology for example of Rapid diagnostic tests for Malaria and ACTs. But they did not apply it to the 21st century health system where countries struggle with health workforce availability and motivation, where a large majority of people seek first care from informal and private health providers, where public health services aren’t cheap nor serving the poorest.
In short they have adapted the primary health care model to include modern malaria control strategies and supported public health services to implement it. Although we feel there could have been major lessons learned in these fields, we have had no view on cost effectiveness, equity, institutional arrangements and scalability of the project. The project despite its claims did not bring breaking through innovative strategies to integrate disease control and health systems. It further overlooked the funding issue of going to scale and the silent majority of the health system providers who are informal and nearer to people demand. Doing more of the same will not be enough.