How to face donors with a health plan

Many of our problems are to do with the donors, says past Mozambique Minister of Health, so we'll do things differently

>RHN: Francisco Songane, you've been said many times how important it is for countries to have control of their whole health programme, although they're overwhelmed by initiatives which come from agencies outside. Tell us a bit more about that. Why is that important? What was your experience?

FS: If you really want to address the issues affecting people, you have to listen to the people who are leading them, the people who are responsible for the organisations in that country, and the people who are in government.

We have to make sure that when we are approaching those countries, that we respect what is in place. If something is wrong, we have to sit at the same table, together with the government and the other partners.

If you take the case of Africa, most of the countries are no longer planning alone, with the government sitting in a cabinet and making their plans.

What happens is that each different sector sits with their partners, the donors, and the implementers, the agencies like NGOs, and they discuss what the plan should be. So that process of participation, with the different players inputting into the plan, is taking place.

If something is wrong, then what we have to do is to insert ourselves into that process and sit there and be part of the process of consultation, and say that, we don't agree with this part of the plan, because of one, two, three, and we propose to amend it as A, as B, or C.

This is the right way to go, so at the end we'll come to a conclusion and we'll have a paper, we'll have their counter-plan and also our joint plan. And when I say ‘our’ plan, I mean the government together with the different partners sitting around the table. That is the notion.

So it's not a plan drawn by the government and the cabinet and imposed on the partners, but a process, which respects the leadership of the country in setting the direction of that plan.

>RHN: Are you talking specifically about the Prime Minister of Norway's proposal for a Global Business Plan [see previous article], or just a general principle?

FS: Just a principle. We need to look into the international health architecture. How is the international health architecture doing? How are we behaving?

We need a process of change of [international] behaviour and accountability, because many of the problems in countries are a result of the different approaches the donors are taking when they provide money to a country.

They can say, ‘I can give you US$50 million for two years for a particular programme, but I want you to do this and this’. And this is what we have to do.

>RHN: But that's a very striking statement. You're saying many of the problems in the developing countries in health are to do with donor actions? That's a bit extreme, surely?

FS: Many, many problems that are happening, are happening around international aid. How we use international aid in the countries has to do with the approaches the donors themselves are taking.

There are problems within the countries, in terms of management, the way they are planning, and so on. But we should not forget, if you take the case of Global Fund for HIV/AIDS, Tuberculosis and Malaria, or the PEPFAR, the US Presidential Emergency Fund for AIDS Relief, they're typical examples of programmes with a considerable amount of money, but they are vertical programmes with many conditions and very top-down. If you don't follow those conditions, you lose the money.

>RHN: And you need to report differently for each programme?

FS: Exactly. And that's what causes the problem. So if a country really needs the money, they take this money and they have to go down the direction set by the donors. This causes distortions on the ground, and you get the consequences.

>RHN: It's commonly said that among the major problems with health systems in developing countries are management problems and lack of management expertise. Are you saying that donor programmes can make management difficult?

FS: They don't even address that. You have to understand that they even don't want to address it; they don't want to hear ‘health systems’ in their vocabulary.

But the health system is core. If we don't address the health system, we cannot talk about sustainability. What the Prime Minister of Norway is proposing is to go to this core issue, and raise the additional money that is needed.

We need to change our behaviour in terms of health architecture. We have to see how to combine the different monies coming from different sources and address the activities they support, but at the same time, develop the health system. If we want health improvements to be sustainable, we just have to make sure that that the system to carry on providing health in the long term, is there in place.

Norway now has partnerships with India, with Pakistan, and they're developing now a process with Tanzania, and probably with Nigeria very soon, but those are bilateral approaches between Norway and those countries.

But at the same time, Norway is addressing the issue globally by driving the process of the development of the Global Business Plan and MDG 4 and 5 [and later 6]. They are doing two things at the same time.

>RHN: Will this provide a model for development in health?

FS: At the Partnership for Maternal, Newborn and Child Health we are involved in the development of the Global Business Plan. But we are not calling for a plan specific for MDG 4 and 5 alone. MDGs 4 and 5 will be icons, which will be used to drive the whole process of the improvement of the health sector in a country.

But in fact, if you look at the reality in most of the 75 poorest countries, the high burden countries, more than 60% of the activities at the primary care level are for maternal and childcare. If you address those issues, you are addressing the health system.

>RHN: Could you tell us your experience with PEPFAR? I understand that when you were Minister of Health for Mozambique you nearly refused to take their money?

FS: That's our experience. Mozambique is one of the beneficiaries of PEPFAR. So we were approached by the managers of PEPFAR to start the process of reaching an agreement, a programme, to benefit from the money.

And then the conditions were set out, that this is the money solely to use for antiretrovirals (ARVs), this is the money to use only for the distribution of ARVs and nothing else.

And then we presented the situation in our country. We showed that we had a health plan, with a specific segment of the plan for HIV, which had been discussed together with other partners, and agreed what should be done. All we lacked was the funding.

So, if we get this funding, we said, we can address this plan. But if you say we can’t address these activities or those, because this is what I want, that is not serving the interests of Mozambique, it's causing a distortion, it's taking us backwards instead of moving forwards.

>RHN: It's also arrogant.

FS: It is. Well, when you go that far, you're right, it's arrogant. And then we had a series of discussions and finally they were refusing. They said that these are the conditions and that’s that. And we were saying that, well, if these are the conditions, probably Mozambique will say it's better we find other solutions, rather than going down that route.

But what happened then was that we came to Washington twice to discuss the situation with the Ambassador Randall Tobias, who was running the programme. And we told the Ambassador: “Probably you are not getting the right information. Please, we invite you to come to Mozambique and see what's happening, so you can understand the stage we are at.”

Ambassador Tobias agreed to come to Mozambique. He visited for three days. At the end of the visit, before he left for the airport to come back home, he said, ‘I agree. We're going to follow your programme. The only difference is that our money's not going to come out of the common basket, because we're barred by Congress. But you are not going to get a separate programme for HIV in Mozambique’.

So he went to see the US President. He told the President what he’d decided. Because when he came, he met the people, he saw what we're doing, and he understood the context. He said, I agree.

That was a major achievement, but it took months to come to that stage. And we were consistent; we were repeating the same things, that this is what we want.

And I should appreciate the role of the partners, the other partners who were working with us in the preparation of the plan. They were behind our position, they were supportive. They said that this is our plan. It's not just the minister of health's plan, it's our plan too. The ministry, together with us as partners, this is what we want.

>RHN: This was really a whole sea change in the nature of aid.

FS: Exactly, and it was dramatic. It was an extremely important development. We did the same with the Global Fund for HIV/AIDS, Tuberculosis and Malaria. They were saying we want a local agent to allocate the money. And we said, no, we have got a mechanism here. Please use this mechanism. And then the partners, who were working together with us in the preparation of those plans, who were working together in a manner of consultation, supported us.

>RHN: What this shows other countries is what can be achieved, if you have the quality of minister, if you have the quality of staff, and the determination.

FS: And if you have the instruments, the plan which has gone through a process of proper consultation, a plan which has really been bought into by the others.

>RHN: But there are countries where things are not well managed and are not likely to be well managed. We've heard stories of misappropriation of funds in Uganda just recently, for example. It happens in many countries. Only some countries are ready to do the kind of thing that you're asking to be done.

FS: There are problems in some countries, definitely. There are problems in this country [RealHealthNews was speaking to Mr Songane in the US]. There are problems in the largest funding institution, the World Bank. You have to tackle the problems when they arise.

But we cannot use an example of a situation of misuse of money in one country to say we put a blanket over all the countries in Africa, all the countries in Asia. We cannot say they are all corrupt, we cannot trust them, so we do things on our way. That's wrong. We are not fixing the problem. If we identify the problem, let us fix the problem and move forward.

We have to sit at the table with the government and other partners and discuss issues. We can discuss and put our arguments on the table and say, we suggest that given the current situation with what the country's facing, let us use the money this way. So we address the problems together.

>RHN: Is your Partnership for Maternal, Newborn and Child Health going to be negotiating with countries, to develop these kinds of plans?

FS: Exactly. We will be working with them together with the partners. The principle of the Partnership is that we are focusing on countries.

Number one, we are country led. And number two, we are not going there to establish vertical approaches, to establish parallel systems. We have to leave what is there. If something's wrong, let us establish a process of changing it, and putting things on the right track. But we will not come in with a vertical approach.

>RHN: I understand. But you're also going with a certain vision of what works and what doesn’t.

FS: Absolutely, absolutely. But the approach I have to take if I go to a place, is to hear their story. Then, I sit down together with the other partners, and I say, let’s look at the picture in this country. These are their problems. They are here and they are there. Why are the people dying or getting consequences of illness? And what are the consequences of how we tackle this at present? So we propose that we need this and this. So, we say, compare what you'll be spending in buying this machine or that, versus what do you need to address our findings, and let’s decide where you will get your best use of money.

>RHN: If I could put it this way, it's a more respectful approach?

FS: Exactly. It's both respectful - and informative. You have to understand that when we talk to the minister, probably that minister has never been briefed about the real situation in his or her country, and the way he or she should use whatever they have got in hand to change the situation. So we must be respectful and be informative.

Most importantly, it's informative. Because if we inform people about what's going on in the country, what's the picture, what do you need to tackle, people are empowered with information, and say ‘now I understand the situation better. Let us use the money that way. I think that should be the approach’.

>RHN: I understand. But you're for sustainability, I’m sure – and ministers change. As of course you know, you were a minister, you're no longer a minister.

FS: Yes.

>RHN: So you need to work also with the ministry of health and perhaps with the ministry of finance, too? With the officials?

FS: Absolutely. That's a very good point you are raising. Consistency in policy setting is important. To be sure that when the minister changes, the policy doesn't change, if it is the right one. And we have examples where success was built because of that.

Take the case of Malaysia, Sri Lanka, Thailand, Kerala State in India, Mexico, which was a subject of analysis and publication in TheLancet last year. They had long-term consistency in terms of policy. Even now, I'm informed that with the change of government in Mexico, with the new minister of health, the same [good] health policies in Mexico are continuing. This is extremely important.

So it is important to take the experience from these countries, analyse them in a scientific way, for the scientific community, and then to find ways of messaging these in a simple manner for the different ministers and heads of state, so that they don't rush and change things when they are right.

Because in those countries, they took some 20-30 years to change their situation, but they were consistent and they changed. It's a very important point you are raising. You're absolutely right. There is the ministry, is the whole system which have to be very involved, and the key people in the ministry.

>RHN: So what we will really see is that a few countries will begin to lead the way?

FS: Exactly. And then, if this process of the development of the Global Business Plan takes the right course, with this change of the international architecture, the way we approach international aid, that Partnership for Maternal, Newborn and Child Health will complement this change very well.

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