Importance of Natural Resources

Scaling Health Solutions Through Government Partnerships | SkollWF 2019


– I’m James Nardella, I’m a principal here at the Skoll Foundation. I’m excited to welcome
you to this session, Scaling Health Solutions
Through Government Partnerships. I see a lot of people here in the room, who are working in global health so thank you for being here. This session will explore
two cases where government and global health NGOs
are working together, to realize their aspirations
of universal health care. Our speakers will share their lessons from their active collaborations and I just invite you as
speakers to be very frank, so that we can learn more. With that, I wanna introduce
Erin Worsham who’s a friend and also the Executive
Director of the K Center at Duke University. Thank you James. Good afternoon everyone. Thank you so much for
joining us this afternoon for this exciting session. As James mentioned my
name is Erin Worsham, I’m the Executive Director
of Case at Duke University and I am thrilled to be here today and be part of this conversation. Not only do we have some amazing panelists that you’re going to here
from in a few minutes but we also have the unique opportunity to dive into and discuss
two critical topics for social change. The first is around
universal health access. So now in 2019, at least half of the world’s population does not have access to a
central health services. I’m gonna let that sink in for a second, 50% of the world’s population
does not have access to a central health services. And the problem is even more
acute in Sub Saharan Africa where are panelists are
all diligently working. In Sub Saharan Africa, the
average life expectancy is 50 to 70 years. Under five mortality rates
range from five to 20% and I can give you a laundry
list of other statistics but I hope what that helps
you ask yourselves is why? Why in 2019 are we still
struggling with this? What is it that’s stopping us from allowing all citizens,
regardless of location and regardless of income levels to have access to the basic
human rights of health care? So I’m excited to learn
more from our panelists about achieving universal
health care access. And the second topic that I am excited that we have the chance
to dive into today is, is this topic of government partnerships. So in many impact eco-systems
and certainly in health, government is an essential
player in any solution. But what we know about government and social enterprise partnerships is that they on the one hand
can be incredibly powerful and on the other hand are incredibly challenging to get right. So let me take a pause
and ask the audience, for those of you who have
worked in partnership with government and social enterprises or have seen those partnerships happen, I just wanna have some call outs, what are some adjectives that pop to mind when I said that word, those words of social enterprise
government partnerships. – [Man] Frustration. – It was like chorus of
frustration from the corner. – Glue.
– Glue I love that. What was that. – Human rights.
– Human rights. – Slow.
– Slow. – Rock and roll.
– Rock and roll. This is one of my favorites
from a previous conversation. – Empowering.
– Empowering, great. – Scale.
– Scale, fantastic. – Fundamental.
– Fundamental, and this is perfect I couldn’t
have scripted this better. To say that if you think
about those adjectives, there’s a lot of really
powerful ones, positive ones and there’s a lot of ones
that point to the challenge of getting these partnerships right. And so I and my team at Case, feel so strongly about the potential of social enterprise
government partnerships and about the challenges
of getting them right that we actually wrote
a report on the topic. In front of all of you if
you’re here in the room, you should have a hand
out with the framework from this paper which is part
of the Scaling Pathway series. If you’re watching us online, you can go to scalingpathways.com and download the full report there. But what we were able to do is interview a variety of leading social
enterprises around the world and get their lessons
learned about how to make government partnerships work. Everything from the very
first step of figuring out your goals for government partnership, as a social enterprise you’re
hoping that the government out sources to you, let’s
you implement and control. Are you hoping that the government adopts that you’re handing off to them and they’re taking the
reigns and making it happen? Or perhaps you’re thinking
at a systems level and working with
government to change policy and really change the underlying systems of the issue that you’re facing. With those goals come
different strategies. So the report talks about tactics for getting your organization ready for partnering with governments as well as techniques of
how to actually execute and implement those. So I hope that is a helpful resource for all of you in the room
that are trying to learn more about effective government
social enterprise partnerships but more importantly we’re here today because you can hear about it live, you can hear about it
from our esteemed panelist in the room. So just quickly in terms
of flow for this session, we’re gonna start with what
we call paired interviews to give us a chance to
dive just a little bit into some incredible government and social enterprise partnerships. So we’ll start off with a partnership between Partners In Health
and the Kingdom of Lesotho. We’ll then have a
conversation with the partners from Last Mile Health and
the government of Liberia and then I’m gonna bring all
the panelists back up to stage together so we can have
a discussion with you and have the chance to
have your questions asked and answered and hear
you’re perspectives as well. So we’ve got a lot to cover, does that sound good to everybody? You excited? Good energy in the room. Okay, I know it’s after
lunch, always the worst time but we’re still early in the week so hopefully we’ve got
some good energy still. So with that why don’t I
welcome our first pairing to the front to join me. I’m going to ask Abera
Leta, the Executive Director of Partners In Health, Lesotho. As well as Thabelo Ramatlapeng, the Director of Primary Health Care, the Ministry of Health
in the Kingdom of Lesotho to join me and while they’re
settling in what I’d like to do is just give you a little
taste, a little overview of the partnership that they
are embarking on together so that we all have a shared understanding of what their partnership is before they dive a little bit deeper into it. So the government of Lesotho first invited Partners In Health into
the country in 2006 as a response to the HIV epidemic, where nearly one in
four citizens of Lesotho are HIV positive. Partners In Health worked
on HIV in seven clinics in some of the most isolated areas, proving that they could help manage and improve HIV treatment. From there they went on to work on other health issues
beyond HIV, tuberculosis and many others. And then with a foundation
of working together and achieving great things in partnership, Partners In Health and
the government of Lesotho, in 2014 began to work on the National Health Care reform effort to drive towards universal coverage of health care in the country. Through that partnership they’re building primary health care platforms, ensuring supplies are available, training and recruiting over
4000 village health workers and to date have reached
approximately 40% of the population with ongoing work to continue
to scale that nationally. So amazing things already
then have been achieved and more incredible work to come. We are so thrilled thrilled
have you both here with us today so thank you for joining. – Thank you.
– thank you. – to I’d love to start
with you if would mind. Tell me a little bit more and
help the audience understand the context of this work. What are some of the
main challenges facing delivering health care in Lesotho. – Well, Lesotho is a
very mountainous country and one of the challenges is
access to health facilities. People at any time in
the mountainous regions have to walk one way
direction for five hours to access health care services. Because of the HIV and AIDS epidemic there’s been a hiGh turn over and a difficulty to retain
trained health professionals in this mountain health services. And so, the communities
have lost confidence in the health care provided. As a result there is
high under-utilization of existing facilities. So much so that we have one
of the highest mortalities of maternal mortalities in the region, around 1,155 per 100,000 deaths. We have one of the highest
prevalence of HIV and AIDS ranked second in the world
and highest prevalence of TB. So the government has
been looking at solutions as to what can happen, what can retain the
health care professionals in this facilities? How can we ensure that
communities utilize facilities? One of the solutions was engaging with village health workers and making sure that village
health workers facilitate follow up of patients, they
facilitate identification of at risk people at community level and refer them to health care facilities. One of the issues was
actually the actual allocation of resources to primary
health care is very minimal. Why? When there’s so much getting
into the health sector. Government allocates about
11% of his GDP to health care. We have a lot of partners in the country helping us with addressing
the HIV/AIDS scare. So why are we having all these problems? Is because this resources that are there, some of them are directed
to vertical programs and they are not addressing
the weak health system, government resources
also are not necessarily trickling down to the communities. They are more focusing
on tertiary health care. So the result is a very weak system for really identification of these people who need services, you cannot
get them if you do not have a robust health system
that can pick them up. And therefore, there
will be high mortality and there will be loss of confidence in the facilities that are provided. These are the challenges that we face. – That’s such a helpful summary, to think about the
challenges being faced there of not only the typography and the access through the mountainous regions these challenging health indicators but seeing as there are, as you said, resources that are available but not being put towards
the system strengthening that is so important. And so to see that in the midst of such a challenging context, the progress that is being
made by the government and also in partnership
with social enterprises like the Partners In Health is incredible. So Abera, let me turn to you. Why don’t you tell us a little bit more about the goals that Partners
In Health in Lesotho had when engaging with the government and how have those evolved over time. – Thank you very much. Yeah, our goal is actually to
provide preferential option in health care for the poor and we always do that in
collaboration with the government by accompanying the government
at different levels. – Can I just ask, can everybody in the back
hear our speakers okay? Good. – Okay. So when we landed in Lesotho
by the government invitation in 2016, we were invited
to support the government– – Six.
– In 2006 sorry, to respond to the HIV epidemic crisis and hard to reach area of the country in the mountainous clinics but once we landed there, when we trying to support the AIDS patient at that moment, it was very difficult to
provide needed service to their AIDS patients because
the system was not in place. The supply issue, the
human resource issue, the laboratory issue. There was no system in place at all. So we ended up just to build the system that comprehensive primary health care where we can engage the community through the village’s worker build the capacity of the
health facility to provide comprehensive quality
primary health care service to all the need of the people,
where it is maternal child, the diabetes, hypertension, TB, HIV and we have to also build the capacity of the, we have to increase the number
of the staff, train them, equip the facility, to a good mentorship and in that harder to reach
area where the government used it to do a monthly outreach using Lesotho flying doctors, now just we made the service
available seven days a week, 24 hours a day and at the end of 2013, when the Prime Minister of the country visited one of those sites, he found that, all indicators are amazing, the countrymen’s population
were getting a good coverage facility based delivery is almost 100%, no home deliveries and mortality, maternal
mortality at facility and unit and mortality was almost zero and this was a time that the
government of Lesotho asked PIH to support scaling up the approach. The comprehensive primary
health care approach that really worked at harder to reach area at mountain clinic, while the low land health
facilities and urban and the pre-urban health facilities still are not meeting the targets that they are supposed to meet. That is just, that evolved to
accompanying the government in terms of building the system in four of the 10 district
in the country where about 42% of the population are living. So in this area also just we are help with the government to
implement the same approach. Building the capacity
of the health facility. Making sure that all health
facilities are providing the package of service
needed for the community. Building the community
health village program, that is strong that can help
to accompany the patient and also adhere the patient on treatment and ensure the supplies are in place and also build the capacity of
the district management team for health so that they can
have a capacity to supervise and mentor the health facility and also manage their
finance and logistic. So when we look into the progress actually we have observed
huge change in terms of moving, decentralizing
services, for example, only 2% of the health care
facilities were providing delivery services when we start. Now almost 98% of the health centers are providing facility based deliveries and that increase actually
the number of women who are delivering at
an institution by 30% over the period of month, four years. This is one example. So when we see over,
to summarize evolution just we are implemented, show evidence that strong primary health
care can help to reach to poor people and then
we support the government to actually scale up at large by adopting the approach and even at the moment there are also the change, in policy at national level
which has been drafted to scale up the approach
across the country and that is on the table
for the end of the month. – That’s fantastic, thank you for walking us
through that evolution. Two comments on that, one I love hearing the statistics
about the positive change in maternal mortality rates going from 2% to 98% of institutions being able to have deliveries at them as somebody who’s eight months pregnant those are music to me
ears to think about people being able to have access
to those facilities. And I said to everyone earlier that, if this baby decides to come earlier I feel like I’m in good hands with all of the community health and medical professionals here. But other reflection is
just on that evolution of social enterprises role. We often see that in
government partnerships, social enterprises can play
a really important role of what we call de-risking
from the government partner. So Partners In Health coming
in and having the opportunity to do a proof of concept to prove that you could begin to
this systems strengthening In some of the most isolated areas and then based on that
success and that evidence then continuing to work
with the government to scale that throughout the country and accompany to the government
along in that journey. So I think that’s a really important note in that evolution of
beginning with this idea of the social enterprise
and helping de-risk, helping prove that something works and then continuing to partner, to scale to national levels to think
about policy change et cetera. Thabelo let me come back to you. I wanna get behind the curtain, I wanna peek behind the
curtain of what it’s like to really work in these
partnerships together. So I’m gonna ask for as
honest and tactical an answer as you can give me. What has been one of
the biggest challenges that you and the government have faced as you’ve been partnering
with social enterprises and how have you over come it? So biggest challenge and
how you’ve overcome it. – Well, the biggest challenge is that the social enterprises come, they have their mission, they come with their mission and they have a target to achieve that may
not necessarily be aligned to what the government has as its targets. In this situation we have
managed to address this problem by engaging with Partners In Health. And one of the things that they did when they did an assessment and determined the disease burden in our communities and together we came up with the targets to say this is what we need to do together to make sure we that access
the communities in this areas that we have assigned
to Partners In Health. They are assigned four districts and the health centers
where, 68 health centers and in all in all we have a
population of two billion, they were serving a target of
about 42% of our population. So it was a significant population that would fall within in their cashment and wanted to make sure that
whatever they are doing, we are working together. So that actually has helped. We needed to align these facilities to the local government structures because at this time the
government had decentralized we had a decentralization policy. Why align it? Because we wanted the local leaders to facilitate
the uptake of services. Like I said, people have lost confidence and we need to have people
with influence to make sure that the facilities
that have been upgraded, oh, by the way, we had
upgrading of facilities which was funded under the MCA,
Millennial Challenge Account and which we’re not being
utilized adequately. So the facilities were there but nobody was using
them, so we need the local leaders to make sure that
these facilities are utilized. We worked together with Partners In Health to look at the policies that
are for training and selecting village health workers. We are now going to be
giving village health workers more responsibility and
they needed to be confident and be looked upon with
respect in their villages. So we looked at this model
with Partners In Health and we said, this is a good model, let’s strengthen it, let’s
develop materials together, like Abera has said, we even went as far as
developing policies, to make sure that we succeed. So at the moment we are working
together in implementing these policies that we
have developed together. We have taken onboard other partners, like the World bank which is
taking up the performance-based financing with the health
workers who are working above what we feel is their responsibility. We have riders for health who are also helping
with the linkage between health centers and the communities in terms of spacement and transportation. So, what we are doing
with Partners In Health, personally I feel if it is rolled over to this other partners and we’re working on
the same scheme together we can actually overcome
most of our problems. – Love the positive outlook and all of the partnerships
that you’re undergoing. And where you started
saying one of the challenges is social enterprises coming in with their own mission
and their own targets and I think that great advice
for the social enterprises in the room and also for the funders. That are often our funders
are the ones driving us as social impact organizations
to have those missions and targets and so can all
the partners in the ecosystem make sure we’re approaching government partnerships correctly. Abera let me ask you the same question but from your perspective what has been the biggest
challenge that you’ve had working with governments and how have you and Partners
In Health overcome it? – Yeah I think when we do
this especially when we work on reforming the system and
improving the system to ensure universal coverage through building the decentralized and
strong primary health care there are a lot of challenges actually. One of the big challenges the change in leadership
at the government level. That by itse;f is a big challenge because during the last four years, there was a change in government there was a change in senior leadership, like a minister, Pri-nce Pas-gre-tor he’s our deputy minister so we worked with about four
ministers during this four years. So that by itself is a challenge because whenever someone come in they come with their own kind
of promise, political promise and they also with their
own vision to provide care in the service to the citizen. So for us, we have to just
prove that this approach comprehensive integrated
primary health care is the best strategy to ensure
universal health coverage in the country. So that can take sometimes so
that whenever someone come in we have to just take a brief
pause under them, on vault, and what actually makes us
strong is the confidence that we have in our approach, the design that has been proven, that
has been locally generated, that really worked in harder
to reach area of Lesotho. So that is one biggest
challenge that we had. There are also other challenge
that Thabelo has mentioned like huge funding coming
for a single disease bu itself is a challenge
when you just want to do the comprehensive and the
integrated primary health care to build a system because
donors or implementers who came with vertical hedge fund can also somehow attract the attention
of the health care provider to focus on one single disease then forget the other. So for us we need to make sure
that they are not focusing on a single. So that by itself is also
another challenge that we faced. – So let me ask one final
question for either one of you about funding, and so of course
putting myself in the seat of the audience in the room I might be reflecting, this
sounds like amazing partnership you’re doing great work, how are you paying for it? Where are the funds coming from? Tell us a little bit more about that. – Well, government is actually investing a lot of money. It is substantially
supporting the initiative. We are now paying the incentives
for village health workers and it’s not just in the pilot districts, it’s country wide. Every village health worker
is getting something like 400 loti per month. This actually for government
is a huge investment. Government is paying for the training of village health workers. When Abera said now, we agreed together that
there are some activities that were being paid for
by Partners In Health that give is now ready to absorb which is village health workers. So everything that deals
with village health workers we are now funding. We are also involving the
communities themselves. Communities have issues like transport, which they can actually assist with from the communities we are
identifying the business people who can actually support transportation , specially of emergencies. Government also is supporting
the referral system from the village to the health center or from the health center to the hospital. So all this actually is being funded. – That’s incredible to see
the resource commitment that the government is making especially around things like paying community health workers which we know is such an important part of making sure that is effective now NWHO guidelines et cetera. So really important aspect of the work. Abera is there anything
that you would add to that? – Yeah actually I would
like to thank the government for just taking over some of the cost. It was also challenging at the beginning as I mentioned when we start we just design the payment, this is the government
control, this is the PIH role but because of the change in
leadership it was challenging at the beginning so PIH
has to use the funding that we were supported
from the Skoll Foundation and then really take the
responsibility to initiate the reform for example, the greeting about 4000 villages, worker training them and paying them for two years. Are absorbed the payment
of those villages worker and also mentorship, supervision building the capacity
of the health workers and also helping just the district leaders to retain them because some of them we brought them back from South Africa to lead the district. And so some of the incentive top up that is based also on their performance and also capacity building, not only clinical skill
building for the care providers but also on the government
and the leadership for the district management team as well has been paid by PIH and also just these things
are starting delivery service or expanding that service
from 2% to 98% of itself needs a lot of things because some of them are located where there is no power supply, where there is no transportation and it is risky even
for the health workers to take initiative and then do
delivery service in that area because they cannot do anything
if someone is complicated so for that also just we designed the innovative
referral mechanism where they can use the
local cars, just transfer and we pay for that. And also where they don’t
have the power supply to sterilize equipment is to
reutilize them for delivery just we provide disposable delivery pack which is innovative approach
so they can use those equipment safely and then also for the
mothers who should travel maybe three, four hours to reach the health
facility just we established the mother waiting where
they can stay for a week or two weeks prior to
expected delivery date and then provide food and cook as well. So those, initially in the
sum of them now just absorbed by the government but
still the need is huge, the gap is really huge because
the utilization is increasing and actually the supply is also just needed more supplies needed. – So it’s interesting
think about a partnership and the evolution of that
partnership from a funding aspect as well of Partners In
Health really investing that partnership and then
over time evolving that and turning parts of that over
to the government as well. So I’m sure there’s lot of
questions that everybody has for this dynamic duo that we have here. So jot them done but what
I wanna do is if I can ask you both to return to your seats and we’re gonna bring up the next pairing before we have everybody with us on stage. so I’ll ask Alice For-wuia, the Director of the Community
Health Services Division and the ministry of health,
the government of Liberia to join me as well as Alicia McCormick who is the Chief operating
Officer for Last Mile. Another partnership here
in Liberia this time. Again, let me give a little bit of context and overview of the
partnership before we dive in. So, in Liberia for those
of you that don’t know civil war ravished the country for about, civil wars over the
course of about 15 years and by the end there was very low health sector capacity there. One of the stats that I’ve heard is that at that time there
were I think 51 doctors in the country serving
over four million people. So if you think about the
lack of health sector capacity there at that time. So in 2007 Last Mile Health was asked by the government of Liberia to come into the country
started by embedding staff with the ministry of health and beginning a proof of
concept in one county to prove, again, a proof of concept, around community health assistant or community health worker model. and from this proof of concept, again, we see this evolution of health really seeing a
partnership that could evolve hand-in-hand together and so now they are working
together to integrate this community health assistant model into the national public health system. Last Mile Health continues
to directly implement programs in three of the
15 counties of Liberia and then also works to
train county governments, to train other NGOs, to
help spread the model to the rest of the country. And is also working on policy and working on policy
implementation with the government. So a very similar kind of
evolution that we’ve seen. Alisford, I wanna start with you. Thank you for joining us, first of all. Tell us a little bit
more about the challenges of delivering health care in Liberia. And in particular I would love
to hear your personal story of what ignited your passion
of this work and brought you to be the director of community
health services there. – Thank you very much. So Liberia, Africa, is that small country right? But it has very difficult terrains, very hard to reach communities,
very rural communities, and providing quality
services in those communities poses lot of challenges. The traditional method of
providing quality services to allow the community to come to you at the health faculties. And so that in itself, in my mind is not a very nice thing for the community members
because some of them have to work like four, five hours, eight hours away. So they just won’t come. I had a specific story and I mean, couple of
them that are real relief and it really touched
me, it really brought possibility to be able
to make some changes with the little I have. At the time I was serving
a the HIV TV focal person for one of the sub
eastern country refugee. My responsibility was to
provide HIV and TB services to those who were positive and make follow ups. I had this one specific case, a mother, she was pregnant at
the time just like you. So unfortunately she was positive for HIV but at the same time coinfected with TB. She lived in the community,
in the district called Tiempo, in one of the community called Kra-quee. that is about eight hours walk away from the nearest health facility where we had a momma care. But because of my passion of
following up on my patient I try my best to always meet her. Unfortunately she got in
her nine month safely, she got into labor, community health worker to identify those things just internally and make time, the referral. However, the community tried to refer her but working eight hours with
a pregnant women on a hammock you have two men in front, two men behind, and the pregnant women is
laying there in the hammock, it’s terrible, it’s very terrible. – I wish that on none of you. Please don’t carry me in a hammock anyway. – After several hours of work, I mean, unfortunately,
by the time they got to, so the ORC send a message to me that, hey, this is the situation
your patient have died. It really broke my heart. It broke my heart to see that people who needs this services make effort to get it but because of lot of challenges they aren’t able to get it. So at that point I was just a supervisor. A couple of months later
I had the opportunity to be promoted as the director for the county community health program. So I used that position to change things in the county. Reestablish all of the
community health structures, ensure that we have community volunteers at the time we used to call them GCHV, general community health volunteers in all of those communities. It was difficult because
there were diverse views on the issue. By the end of the day the community saw that it was necessary for them to have those, for us to carry services to them. So that story, other story really had a very strong lesson on me. Make me to have this true
passion for community health. – It’s such a powerful
example, for all of us as we think about scaling
to universal health coverage or we talk often at this conference and in this field about systems change and the level of impact
that we want to have but to remember it’s also
about the individuals. And for you to have that powerful story that’s really driving
and motivating your work is a sad story to have to bear but also one that I think is driving you to do incredible things. So thank you for sharing that. – Sure. – Alicia, let me turn over to you. This is sort of a tactical
question for you actually. One of the things that
we often hear is that part of the challenge of working with, between social enterprises and government is there is just a lot of systems that need to be put in place in order to manage and
implement that partnership. So tell me a little bit more about how Last Mile Health has
thought about, in Liberia, creating systems or executing systems that will help make the
partnership effective. Any advice you wanna share? – Yeah absolutely, thanks Erin. It’s great to be here with you all and particularly terrific to sort of stand on the shoulders of giants
like Partners In Health. I think the systems is a really good one and it’s quite astute and
I think my initial reaction is that the first thing you need to do is not to build parallel systems. So frequently when we
actually enter into this work and we talk as social enterprises about working with government, we talk about our model, our methodology and sort of treat it as if it’s a baton that’s eventually going to
be passed from to Alisford and then he’s just gonna
happily take and run with it. And that’s actually not a
particularly respectful way to engage in a partnership, right? So I think as you said in
your opening remarks Aaron, we in the work that we’ve
done at Last Mile Health has very much been one
of approaching this work with an attitude of
listening and learning. I think from our get go, we really looked to the
ministry of health to say, what are your ambitions? We know that it’s
important in this country of over four million people that you have 1.2 million who are living outside the reach of health care and what are the types of
questions you’re looking to answer to be able to better serve them and the types of questions
that they were asking were not necessarily related
to evaluation of evidence or randomized control trials it was actually around
implementation and cost effectiveness how do you do this thing
and how do you pay for it? So I think that in terms of
the work that we’ve done, a lot of it has very much been in partnership with
colleagues like Alisford and others at the regional and then at the central
ministry of health in terms of how we actually actively acquire lessons to inform the way that policy
reform and systems design can be undertaken and then
also in terms of making sure that there’s a level
of proximity in the way in which we work. I think we, went though difficult times in Liberia, certainly
through the Ebola epidemic, even prior of sort of some
of the mode day crises in health care and the
notion that we were able to be a steady, relevant, reliable partner to the ministry as
something I think we felt was our last commitment and hopefully is something
that than has also permitted us to also have honest
conversations with one another when there are moments when tension arises or there are areas of
very vital importance to our ministry partners
that actually might fall a little bit outside
oof our mission purview and how do you actually
have that discussion around the things that we are
actually able to flex and we lean into and we’re able to work on with our colleagues and how are there moments where
perhaps there are endeavors that we are not as a social
enterprise well-equipped or capable of leaning into
and how do we then help support the ministry to
identify others or to re-orient the way in which they are looking to strengthen the health system. – Do you ever feel like there’s examples, where you’ve gone too far on that line one way or the other that
you’re willing to share of? – That’s a good question. Do you have any specific
things that pop to mind for you also? – What I think about government and working with other
organization partnership especially will ask my health and the other folks in Liberia. I think we’ve been able
to start a very strong worker relationship,
partnership and coordination such that we speak very friendly on each. For me I don’t sugar coat issues. – [Erin] Alicia’s shaking her head. – Yeah, I’ll tell you how it is not with the intention to
make you feel otherwise but with the intention that the both of us will identify the actual
problem and solve it, alright? And so with this kind of relationship I think we have been
able to achieve a lot. There are a lot of case that we can mention. So I think that we have a very wonderful partnership going on. Last Mile Health have
been on of those strong partnership that we really enjoy but I’m not letting my guard down, I’m still nearby. – Noted that’s on record. – Yeah, exactly. – And I love that point
about really being frank and not holding back and how that’s such a critical
part of any partnership is that you’re making sure
you’re on the same page and revisiting that and
being honest with each other. Alicia, reflect on that for me though because I think from the
social enterprise side that can be hard. There are many NGOs,
many social enterprises that Alisford and the team could be selecting to work with. So how do you think about, from Last Mile Health’s
perspective also being frank, and honest and open has
that been a challenge and any sort of advice
to share on that front? – Yeah, thank you. I think that sort of a few
pieces maybe that I would pull on in your question is kind of the
notion that within this work and I think there are many
other exceptional implementers in this room that we’ve been
fortunate to partner with. The way in which we’ve
undertaken the work that we do as a social enterprise is very
much around the orientation of how do we scale impact
and not just an organization. And by virtue of that
approach that actually means that we are working in collaboration with an enormous amount of frequency in which it’s not a zero sum game. There are assets or
attributes that I think other organizations bring to the table. I think Liberia is an exceptional example in the national community
health assistant program is one that the ministry lead, Last Mile Health was able to support and sort of serve as a
secretariat in sort of assembling a constellation of actors to orient around a particular policy to achieve universal health coverage in remote rural areas
for 1.2 million people with a standardized set of measures in which there was going
to be implementation in which the work in these
areas was going to be evaluated. And I think in doing so one of
the things that we work to do is to actually put the ministry in the drivers seat so they could actually hold implementers accountable. And that is not necessarily
always incentivized for in this space, right? So to actually hand and give
Alisford and his colleagues at the ministry, a tool through which could actually as you rightly referenced we’re working to support policy, we’re working to support
technical assistance, we’re also undertaking
areas of implementation with the notion that that’s
then helping to inform the effectiveness and
demonstrate how powerful this particular program could be but we’ve also established
tools through which Alisford and his colleagues can evaluate our implementation effectiveness and accordingly
hold us accountable. So I think that when
there is an orientation around sort of a shared vision
of what we’re aiming to do and where we’re driving towards together and then various different
tools that can actually be used both qualitatively and quantitatively to assess the way in which a
partnership is actually going and how it’s actually
improving health outcomes and health system makes for a very good foundation in terms of being able to speak
very specifically to areas where there might be issues or bottle necks that need to be called out and then there needs to be
adaptation through which– – So it’s not necessarily
personal feedback it’s based on data and what
you’re seeing actually happen in the field which actually
makes it easier I think to have those sort of
blunt, frank conversations. Did you have a couple of
examples of some of the metrics that you all track as you’re thinking about the implementation? – Yeah absolutely, do
you wanna speak to that? You would have taken notes on it. – Yeah.
– Okay. – Currently in Liberia the program is structured such that we have a standardized package, right? Working with last Mile
Heath and other partners where we have structured a
well standardized package that you as a partner you don’t just come in Liberia and say you wanna do community health and design your own structure,
it’s not gonna work. Yeah it’s just not gonna work, even if you, it’s difficult
to just by pass this system because the system is
structured such that even down to the community level whenever you just go
to the community level the community member is gonna
ask you whether you have reached up there. So it’s difficult so we have that strong leadership in place. Besides that, the program have generated a lot of good results over the years. Of the 1.5 million population
that the program is serving we are reaching like over
700,000 on a monthly basis. 700,000 plus on a monthly
basis with quality services. Over the years we have seen facility based delivery have
gone up from as low as 56% to up to 96%. We have seen community based
delivery have dropped down from around, we were
experiencing like 2,000 plus on an annual basis, it have reduced to as low as 700 to 500 last they’re counting. So, this is a very powerful
collaboration that we have and to see that it’s
having that strong impact on the overall health care
delivery system of the country I think it speaks volume to anyone that would want to
partner with the country with government of Liberia. So we think, when we do this kind of partnership you may have a brilliant idea,
you may have the connections, you may have the ability
to source funding, I may not have those, right,
but I know my priorities. So you come with your good ideas and I give you my priorities, we integrate the two and we achieve a lot. – I love it, yes. That’s fantastic, well, why don’t I ask Abera and
Thabelo to join us at the front, we’ll pull some chairs
over, thank you Emmanuel, so that we are all up here together. We’ll squeeze in a little bit. Let me ask one final question of our government representatives and then I’m opening up to you. So that’s your final warning. I’m gonna ask one more question. I’ve got tons more questions I could ask but I hope that you do as well. So for Alisford and Thabelo, what is the one piece of advice that you would give to
social enterprises or NGOs that are seeking to
partner with government? So what do you want, we have many social enterprises
that are represented here at the forum. What should they know or what
should they do differently to more effectively partner with you? – So I would say government will always exist, whether we like it or not, – That is a true statement. – It is the responsibility
of every government to provide services to its people. Not withstanding, unfortunately
we are not that strong like Lesotho, but we have an agenda. Coordination and collaboration
is very key to us. The government of Liberia
with its pro quo agenda is such that if you look
at the entire agenda it is there to take services
to the very rural communities and our community health
program fits just right into the agenda. So we want that strong collaborations, we want that strong partnership between us and our partners that we’re working so
that at the end of the day it’s a win win situation, it is not just us. – So it’s back to that true nature of collaborative partnerships.
– Exactly. – Aligning vision, aligning
priorities et cetera. So at that clearly is a common theeme that we’ve heard throughout
this conversation. Making sure you’re not
bringing your own mission and targets in but aligning in that way. Thabelo is there anything that you’d add? – Over and above that I think that the social enterprises have to know the situation in countries they have to appreciate there
are many sensitive things that are there within our structures, that they need to accept
that this is the norm in this situation and I’m going to work within this framework and together we should look at that and together agree on how to go forward. They should not come with
predetermined programs and directions which are inflexible, they should be flexible
enough to accommodate small nuances that happen
within in a country. – Excellent, excellent advice. So let me turn it over to the audience. There are mics going around. As a reminder we are
recording so please wait for the microphone before
you ask your question. Looks like we have one of there. Emmanuel right there. – Hello so my question
is about community health and looking at the current climate of universal health coverage, the standard declaration
that was geared towards primary health care and
universal health coverage as well as that’s also
geared towards addressing the STDs especially ACG3 focused on infectious
diseases but also focused on noncommunicable diseases
and the partnerships, so my question is in terms
of community health care I’m aware that in the wake of countries it’s a really huge issue to
identify non-communicable diseases and treat them adequately. So what strategies are
you putting in place to ensure universal health
converge of non-communicable diseases for adults and children? My second question is on
multilateral and bilateral funding what are your experience
between as government agencies between multilateral
and bilateral funding for these projects and what
do you think is the best way forward to make sure that
whatever sources of money that come in are geared
towards the same initiatives. – Thank you so two questions. I’ll open it up to the panel
you can take either one. – First of all thank you
so much for your question. Well let me disabuse
your mind with the notion that it’s not possible
for community members to identify disease cases. That’s a myth, let me
be very frank with you. There is a female in her community that knows the tradition, that knows how to go
about getting things done. You are from the big city and you came to that community between you and that community dweller, who do you think has the best
knowledge of that community? It’s obvious. So let us remove from that idea that community health members
may not be able to identify and I’ll tell you, with
us in Liberia and our work with the partners, our
community health workers are not just providing curative services, they are also doing active
surveillance alright? They may not know the
terminology that we may use as health care providers, professional health care providers but they know in their local language they can be able to identify it. So it’s just a matter of
bringing them up to speed of that you think there is, because they will be able
to identify it for you. With that in mind what we need to do is to
work very closely with them, train them, bringing them up to speed with what we have learned so that they can have
that active surveillance in their community and it’s
working very well in Liberia. The community health workers
are actively involved into surveillance, identifying
community triggers on a daily basis. A few days ago someone asking me, we have heard that there are
new cases of Ebola in Liberia. and I said, mm-hmm, I don’t think so. There might be some suspected cases because the community health
care system are identifying suspected Ebola cases and other cases in their own local term
having them trained, alright? And they are reporting it timely. So as we train these ones, they can serve in those
capacity that we ourselves may not necessarily have
to be there every day. Does that make sense to you? – Speaks to the power of the quality and the rigor of the
training that you are doing in partnership with Last Mile
Health and other partners. – Also to add on to that, I think in Lesotho we have trained a new type of village health worker who because of the high
unemployment among youth people, we have completed Cambridge CUSC, certificate. Most of them are not employed. We have trained these people as community health workers now so they are trainable. They can actually do
anything you train them to do in noncommunicable diseases. So this people quite recently they have gone out to conduct
research at a district level. Village health workers
determining their coverage enriching every child with immunization and we
have a made a big deal of this study because
it was initiated by them because they were seeing that they cannot, there are some pockets
within their districts that are not reachable. So all I’m saying is the
village health worker of today is a trainable person who
can deal with any problem. – It’s a powerful force the
village health worker of today. Any reflections on the second question around the multilateral
or bi lateral funding? Alicia do you have on? – Sure I guess many,
really quickly to clarify, your question was around
alignment of multilateral, bilateral funding towards NCDs or towards broader priorities? I’m sure I can speak to
that a bit and then others should of course add in. I think one of the experiences that we’ve quite humbly had in Liberia is the recognition that you
actually need to have something that is a general standard
or program or policy to which you can then steer
multilaterals or bilaterals and that absence of that a fragmented system is
just inherently generated because everyone’s kind
of doing their own thing. I think the thing that we’ve
seen and have been able to help support the ministry to really translate private philanthropic capital
to grow what was at one point roughly $3 million of
community health investment into over $52 million of
community health investment has been around having
something that is a uniform standard that has
implementation characteristics and guidelines attached to it and then also a strong evaluation
and measurement framework layered on though which you
can then work with groups like the World Bank and Global Fund and USA ID who have been
instrumental partners within the Liberian
context around investment in the community health assistant program to have them sort of
match their investments recognizing that they might be coming with their own constraints
towards that program. I hope that’s helpful. – Yeah that’s fantastic. Abera other thoughts? – Yeah I think for the
first one just about the NCD and the universal health coverage I think just from us from
the experience we have to achieve the universal health coverage or to implement a standard
declaration whatsoever, we need to have a strong platform, that is the main thing we need to have. Just the funding comes
through most bilaterals, some multilaterals, there
are some still focusing on achieving a universal health
coverage for certain diseases. Like it can be HIV, it
can be maybe one disease and when we do the baseline
assessment about NCDs like if we take hypertension in
harder to reach rural area in Lesotho, 30% of the
population have hypertension but when they come to the facility, if the facility doesn’t do
the blood pressure measurement when they complain about the headache and then somebody give them paracetamol, that is not the kind of health
care service we want to have. We want to have a comprehensive integrated primary health
care which can address both communicable and
noncommunicable diseases. And when it comes to also
the community health workers, yes they can do. Because most of the
noncommunicable diseases like hypertension, diabetes, they are a life long
disease that needs care. So these community health care workers they can help us in preventing
the noncommunicable disease by improving the life style
through the health promotion the disease prevention, not only for noncommunicable but also for not only for communicable
but also for noncommunicable as well as also to retain those patient with none
communicable disease in the care for it. So I think they are very, very critical but the point is now just
we really need to channel our funding toward building
that strong primary health care which can ensure universal
access to the need of the people whether it is communicable
or noncommunicable. – Great add on, thank you Abera. Let me see if there’s a question
on this side of the room. Yeah Oliver who ever you wanna
give the mic to, you pick. – Thank you, my name is Inthabile
Lapoto, I’m from Lesotho, so I’m happy to be with Dr. Am-ata Fr-ing and that from public health. I really don’t have a question other than to really be a firsthand proof of how partnership really help achieve the goals of the government. I’m working for Touching Tiny Lives, it’s an organization
in Mo-hoto and Mo-hoto is not one of the pilot projects where PIH has been helping the government, but because our goal is also working with the
government to reduce mortality rate our organization is focused on addressing malnutrition issues for
children under five. So the partnership we have
had for the past 15 years with the government through maternal health department has allowed us to contribute towards
significant reduction of mortality rate. And I’m really saying this
because also in Mo-hoto, there is PIH clinic way
out of the main town and it’s because of that
partnership that the PIH staff clinic in the rural, they know when they need
an emergency support that really goes to changing
the life of a child under five. They know we are the only
organization in Mo-hoto that will help respond to those. So I’m really just saying
that the proof that working together between the
government and grassroots organization on even
international organization it’s providing that holistic approach and I’m really a proof
of evidence of how best village health workers
can support the work we do because they live in the community and thanks to technology
now, they can send you an SMS and say hey, a mother has just
passed away in this village and we don’t know how to feed this baby and we need support and
all we have to do is drive. Whether it’s five hours drive
in the bad roads or whatever but they know that that
child will survive. So I’m happy that the
partnership has worked for us as a small grassroots organization. – Thank you for that testimonial and for the incredible
that you’re doing as well. Is there another last
question in the room? What about up at the top, Lesley. – Thank you. My name is Lesley Flynn and
I’m with Partners In Health. But I don’t get to ask
these questions very often so I’m gonna take the chance to do it. I wondered if our government colleagues could talk a little bit about what they do when they get conflicting instructions, whether it be from donors or
from partner social enterprises how they work to solve for that given their desire to continue to partner and work with outside organizations. – Great question. – Difficult question. – Do you have thoughts Thabelo
that you’d like to share? – No it is a difficult question. There is a forum for partner coordination in Lesotho where all partners meet regularly to share their experiences and discuss issues that
they feel are not as, they’re not going the way they should and usually we have WHO
which usually comes in because WHO is the technical
arm, is our technical arm in health which would
actually take a situation which is causing conflict. Discuss it, ask for a
wider stakeholder forum to look into this issue. We had recently a situation
where we had rubella, a vaccine administered and as a result, not as a result but unfortunately there were children who became sick. One or two died and because of media and many other channels
where people get information they look at rubella as being a vaccine that would actually
contribute to child mortality. This caused a lot of conflict
even among donors and partners and we needed to sit down, really discuss how we
want to resolve this issue and I must say WHO played
a very significant role in getting technical expertise. We did that, we had to go
into that expenses, government to pay for, called TA,
to come into the country and conduct an assessment independently and that information actually
contributed to demystifying a lot of issues that were
tied around MR vaccines and provided us with an
opportunity and a platform to discuss with
parliamentarians, with chiefs, with everybody who had influence about MR and right now as we are talking we are seeing an increase in the uptake of the measles rubella vaccine. – That’s great. I feel like we could continue
this conversation for hours there’s so much more to dive into but unfortunately we are out of time. So I hope that all of
you are walking away with not only tactics but also inspiration from the incredible panelists
that we’ve had today and als some resources with
the Scaling Pathways work that I mentioned at the beginning. So my final request of you are to fill out your little note cards in front of you with a review of this session. Hopefully only high marks allowed but also to join me in
thanking this incredible panel.


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