By Pierre Barker, MD.
There is much to celebrate on improved health outcomes since 1990. While none of the Millennium Development Goals were met across all countries, there was remarkable progress in many countries. Maternal and child mortality and HIV treatment are standouts, but even there a yawning gap exists between rates of treatment and mortality in high- and low-income countries.
The global health community has mobilized around the new Sustainable Development Goals, but is it really acceptable to wait another 20 years to halve today’s mortality rates in low- and middle-income countries? A different pace of improvement requires a different relationship between governments, funders, researchers, and technical supporters.
Nongovernmental organizations (NGOs), funders, and UN-affiliated organizations have played an increasingly prominent role in providing technical assistance to governments trying to achieve the MDGs and now the Sustainable Development Goals. But what has been the return – measured in quality, coverage, and sustainability – of the billions of dollars of investment over the past 25 years?
The landscape is littered with successful but wasteful pilots that have no hope of being scaled up or sustainably incorporated in the health systems of low- and middle-income countries. In some cases, pilots are undertaken by NGOs who are more intent on showing the effectiveness of their interventions than in scaling them up or ensuring that they are sustainably woven into government programming. In other cases, pilots were not designed in collaboration with governments and so have to be expensively reverse-engineered into existing programs to be scalable and sustainable. NGOs have a major opportunity to contribute to innovation and to demonstrate effectiveness, but if their efforts are not coordinated with governments from the outset, the innovations may be unusable.
Beyond the ubiquitous focus on effectiveness we need to design pilots with other attributes in mind from the outset if we want them to be scalable or sustainable. For example, while it is reasonable to ensure optimal resources (knowledge, training, personnel) for a proof-of-concept study, the design of any implementation study destined for scale up should account for the resources and technical capabilities that will be available when scale-up occurs. This lens will determine the availability of personnel, data systems, training, management, supply chains, patient engagement, and improvement capability of that system.
At the Institute for Healthcare Improvement, we have supported the effective implementation and national scale-up of complex interventions, but we have learned that the sustainability of those interventions is secure only if the implementation strategy is deeply integrated into and nourished by the existing health system. We advocate for NGOs, funders, and UN agencies to collaborate more closely with governments to ensure that technical support for implementation is directed to efforts that show effectiveness, scale-up, and sustainability of country priority programs.
A starting point for better collaboration and coordination of technical support is for countries to develop national quality policies and strategies that provide leadership and common implementation approaches for NGOs and funders. Only then will country health programs be truly country-led and the possibility for better return on global aid be realized.
Pierre Barker is senior vice president of the Institute for Healthcare Improvement. He presented a webinar on the issue of scale-up for quality, coverage, and scalability on May 11,2016.
Download the presentation:
You can find the recording of the presentation here.