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The Chicken or the Egg? A Partnership Reflection

By - Sep 10 2015

which-came-first-teh-chic-006What came first, the chicken or the egg? The financial vehicle and partnership governance, or the issue advocacy and initial financial commitment to trigger it all? This is a question we asked and answered through the Neglected Tropical Disease (NTD) Initiative in Latin America and the Caribbean (LAC). The product of a collaboration between us here at the Inter-American Development Bank (IDB), the Bill & Melinda Gates Foundation, the Global Network for Neglected Tropical Diseases of the Sabin Vaccine Institute and the Pan American Health Organization (PAHO), this partnership set out to explore the feasibility of integrated approaches to NTDs and to develop a regional trust fund to scale-up efforts to control and eliminate them. In the end, however, it accomplished much, much more.

And here is where we ran into chicken and egg question: do you first develop the financial vehicle and partnership governance? Or begin by advocating and create the needed structure and financial vehicle once you have the first financial commitment? Here is our reflection:

Building on these recommendations, the LAC NTD Initiative proposed a regional fund to channel financing from public and private sector partners to support the collaborative implementation of proven, cost-effective interventions. Crucially, it planned to integrate NTD control initiatives with programs from other sectors in order to leverage those efforts and contribute to a sustainable reduction of the NTD burden.

To support mutually reinforcing activities, the Initiative proposed the creation of a Multi-donor Trust Fund to pool partner resources from into one account to finance integrated activities. The IDB would provide partners with technical and fiduciary oversight of projects in addition to monitoring, supervision, execution, and evaluation services, and also offered a platform for transparent and competitive procurement and strict social and environmental compliance standards. PAHO would assist countries with technical advice in preparing their national NTD plans.  The Global Network/ Sabin, in turn, would lead advocacy and resource mobilization efforts.  As part of the preparatory activities for establishing such a mechanism, the partners formed a working group to create common monitoring and evaluation guidelines as a critical input for achieving shared measurement. We were set! However, we encountered several challenges to setting up the trust fund, including:

  • Varied perceptions as to what is regarded as a priority NTD. The list of priority NTDs varies by stakeholder, region and country. For example, the World Health Organization’s NTD list includes 17 diseases, while PAHO names 12, and the United States Agency for International Development identifies five.  Also, since regional NTD advocacy must compete with many other clearly defined and universally recognized global health priorities, the lack of agreement on what qualifies as an NTD complicates advocacy efforts.  Furthermore, LAC’s geographical and socio-economic diversity means that the NTD burden varies radically both between and within countries.  This made it challenging to advocate for a pooled funding mechanism because regional efforts to raise awareness for NTDs are often detached from local realities.
  • NTDs affect primarily isolated and poor communities. While NTDs can be addressed in multiple ways and have important health and educational consequences, their prominence among isolated and poor communities makes it more difficult to engage non-traditional partners, especially corporate partners based in the region’s main capitals. Additionally, the suffering caused by NTDs is often less evident than that from other competing and more visible issues.
  • The LAC region is low on the priority of global health efforts. Globally, NTD treatment programs rely heavily on funding from two bilateral donors—the United States and the United Kingdom—neither of which have prioritized LAC for NTD health assistance. This is mainly due to the fact that many of the endemic countries in the LAC region are thought to have the ability to fund their own NTD programs. Yet, more than 70 percent of the global NTD burden exists in middle-income countries, such as Brazil and Mexico.
  • Potential partners are interested in specific locations and diseases. Foundations, high net-worth individuals, bilateral donors, and private sector companies often have country-specific and disease-specific priorities. In many cases, they will support only those programs that are targeted toward specific diseases in certain countries or regions within countries. They may have interest in working with a pre-identified implementer. Thus partner interests, rather than actual need, can drive global health programming.
  • Potential private funders prefer not to work with governments as implementing partners. It is easier to engage non-traditional funding partners when governments are not implementing the activities, as governments are often less malleable than NGOs and other organizations when it comes to partner priorities and needs. Yet in reality, projects are more likely to be sustainable, and there are more opportunities for capacity building, when local or national governments serve as implementing partners. Public-private partnerships are key for societal impact.

So what did we do? To demonstrate the benefit of implementing integrated NTD programs, we decided to recruit partners to support key projects in the region.  The Sabin Vaccine Institute and the Global Network, through a foundation grant, provided $2.5 million for the initial projects in Mexico and Brazil, and the initiative later mobilized an additional $8.8 million in grants from other sources, including financing from the Mesoamerica Health Initiative 2015 for deworming activities and private sector partners such as PepsiCo Foundation, FEMSA Foundation, Fundación Cinepolis, and the University of Notre Dame, to name a few. Furthermore, the Initiative leveraged IDB loans in health and water and sanitation worth $407 million, most of which financed water and sanitation infrastructure. Additionally, the initiative organized three workshops in 2013, commissioned two studies on costing estimates published monitoring and evaluation guidelines, and published a number of other short articles on the web.

Faced with the fact that the main bilateral funders, were not prioritizing the LAC region, the initiative sought out a variety of alternative sources of funding for its demonstration projects, pursuing partnerships with local, state, and national governments, NGOs, private foundations and corporations, universities, bilateral donors, and multilateral organizations. Middle-income countries with high NTD burdens are the largest potential sources of new NTD program financing, followed by bilateral donors and which can occasionally be completed by private sector or other partners. Table 4 below summarizes the multitude of partners that contributed to four of the initiative’s demonstration projects.

Table 1111

By offering initial seed funding for demonstration projects, the LAC NTD Initiative succeeded in convincing local governments in Brazil and Mexico to make significant investments in NTD control and elimination programs. The initiative was also able to secure contributions from private corporations and foundations such as PepsiCo Foundation, Fundación FEMSA, and Fundación Cinepolis to support individual projects. Adding NTD components to projects from other sectors also proved to be highly successful from a corporate engagement point of view. The initiative secured funding for deworming campaigns in Haiti and Guyana by attaching health components to existing water and sanitation loans.  By refocusing its efforts on financing demonstration projects, the LAC NTD Initiative was effectively able to illustrate the advantages and drawbacks of integrated NTD programs and produce a number of important lessons that will improve the implementation of such programs in the LAC region.

Was the partnership successful? Yes! Did we demonstrate that an integrated approach is possible? Yes!

What did I learn? That unless the region has been prioritized in global commitments, and an anchor donor has been identified setting up a regional fund may not be the most appropriate vehicle. Partnerships should focus on the end goal, and then figure out through what financial or non-financial mechanism to ensure the goal is met.

Are we done? No way! We currently started a Chagas project in the southern cone, with the Government of Japan (Japan Special Fund, JICA, and the Embassy of Japan in Argentina), Fundacion Mundo Sano, PepsiCo, Fundacion Newlands, and the Health Ministries of Argentina, Bolivia and Paraguay. Want to know more? Check it out here!

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