Country ownership and capacity building: the next buzzwords in health systems strengthening or a truly new approach to development?

There is a general consensus in the literature that capacity building is a difficult concept to define [3‐5]. Some explanations for this difficulty include the expansiveness of the term, its increasing popularity since the 1990s, and the inconsistency with which it has been applied [3, 6, 7]. These factors work in concert to hinder analytical understanding of the concept’s meaning. It is, however, possible to identify commonalities and differences among the various capacity building definitions in circulation.

Capacity building is a common concept across health and business sectors and is often described as either a process or an action aimed at the development of one or more organizational components [4, 8‐11]. It is also defined as a means to improving an organization’s ability to meet its stated goals [8, 12], achieve its mission or enhance its efficiency or effectiveness [10, 13‐15]. Other commonalities among capacity building definitions include that these efforts are generally linked in some way to improved performance of an organization and related to the core tasks and functions of an organization [8, 16, 17].

Despite the commonalities in definitions, capacity building is generally described more precisely within the business and management literature than in the health literature. Examples include terms such as organizational innovation, organizational development, absorptive capacity; strategic management and strategic transformation are described as approaches to building organizational competitiveness, effectiveness, growth, sustainability and responsiveness [18‐21]. The differences in terminology may be reflective of differences in the organizational objectives in each sector [22]. In for-profit business, organizational expansion and increased profit margins are often the desired outcomes of capacity building efforts [23]. In the non-profit/non-governmental organization sector, organizations achieve success by fulfilling their missions often through service provision; capacity building in this context is directed toward enhancing programming and service delivery [24].

In order to establish a working definition of capacity building, it is necessary to examine and incorporate additional concepts. Capacity building is essentially an internal process that can be enhanced or accelerated by outside groups [16, 25]. In resource-poor settings, there may be limited organizational energy (time, skills, expertise, funds, facilities and equipment) to direct toward activities such as strategic planning and needs assessments, which should ideally precede capacity building activities [22]. Collaborations between donor/partner organizations can maximize the effectiveness of capacity building ventures by focusing on key activities [26]. Unfortunately, capacity building efforts driven by outside organizations or funders are often ineffective in cultivating a sense of ownership within the partner organization [27].

All organizations must already have some level of capacity as a pre-condition to effectively build more capacity [28]. Organizational readiness for capacity building is comprised of qualities such as the organization’s willingness to question itself, its understanding of its own mission and goals, and the level of commitment from key organizational stakeholders to participate in capacity building efforts [7]. The development of new organizational capacities is often reflected by an organization’s openness to change and the ability to adapt to shifts in its environment. Successful change efforts are largely predicated on the willingness of the organization’s leadership to support and facilitate that process [7, 23, 29, 30]. At the same time, individuals are the building blocks of organizational capacity and the willingness of individuals and groups within the organization to change their behaviors can significantly affect the success of a capacity building intervention [29, 31, 32].

If capacity building is to become a process that is not externally driven, but is locally owned, it is important to reflect on some of the lessons learned over the last three decades. Firstly, technical assistance on the part of donor organizations is must be carefully tailored, given the wide variety of needs and resources present among partner organizations [33]. Secondly, it should not be assumed that past successful capacity building initiatives could be replicated exactly under different conditions. Thirdly, capacity building should be a participatory process, both as a collaborative venture between the partner and donor organization and also in terms of engaging staff and stakeholders at all levels of the partner organization [27, 34]. Fourthly, it is necessary to identify relevant indicators to monitor and evaluate the success of a given capacity building effort. Fifthly, capacity building is a continuous process wherein the organizations involved set and monitor time-limited goals but are constantly and actively aspiring to improved levels of functioning [12, 31, 35]. Finally, capacity building should stress building an organization’s ability to adapt and respond in changing environments [4].

Country ownership is an approach to development assistance that strives to empower partner countries to take, "effective leadership over their development policies, and strategies and co‒ordinate development actions" [36]. The Paris Declaration for Aid Effectiveness of 2005 and the Accra Agenda for Action of 2008 detail the principles of country ownership, which involve the partner country defining its own development priorities and designing and leading programs that promote these priorities. The country ownership paradigm represents a departure from past international development approaches, which were largely externally driven. The capacity building theory and tools prior to the advent of country-ownership were generally targeted for use by external organizations. Country-owned efforts involve building-up in-country technical knowledge and promoting organizational sustainability to minimize partner countries’ reliance on expensive, external expertise that is necessarily time-limited [36].

Country-ownership recognizes the need for endogenous drivers toward development in partner countries [37]. It is rooted in ideological values, including self-determination, and advanced by evidence-based analysis of effective approaches [37]. Country-ownership requires partner countries to accept full responsibility for success of the development activities. The assumption states that a partner country will be more likely to allot the necessary resources to ensure the full implementation of a program if it is accountable for its outcomes [38]. Critics of the concept cite theoretical difficulties in achieving country-ownership given the heterogeneity of interests among key stakeholders in the partner country, and challenges to designing a representative consultative process in planning and implementing programs [39].

The focus of country-owned capacity building should be to give organizations skills necessary to respond to challenges, solve problems and build capacity independently in the future. The Global Fund experience in building country-ownership aims to encourage partner country organizations to generate technically sound proposals for funding that are reflective of country needs, and to ensure that nongovernmental organizations play an instrumental role in designing, implementing and overseeing programs [40]. Successful country-owned capacity building projects echo the importance of inclusiveness in the planning process and excellent working relationships between partner/donor organizations that produce true partnerships [41, 42]. Donor organizations require expertise in building governance, management systems and organizational development in order to effectively build capacity in collaboration with partner organizations [22, 43].

Having now explored the terms “capacity-building” and “country-ownership” in closer detail, it is possible to offer a working definition that combines the two concepts. This definition aims to clarify the interaction between the terms and to account for specific considerations that must be addressed by organizations engaging in country-owned capacity building efforts. Capacity building in the context of country ownership is therefore, “a continuous and participatory process undertaken independently or in collaboration with external partners to empower the organization to systematically identify and respond to its institutional needs and the needs of the population it serves in order to better meet its stated mission and goals, solve problems, implement change and increase efficiency”.

A theoretical framework is a tool that can help to operationalize country-owned capacity building by providing a structured way in which to carry out the processes described in the definition above. There are many examples of capacity building frameworks, both in the peer reviewed and gray literature [22, 44‐47]. These frameworks share a number of commonalities, including the identification of organizational “core competencies” that each require a certain level of capacity in order for an organization to be effective.

Organizational effectiveness is contingent upon the interplay of these core competencies, examples of which include governance, financial management, leadership, technical capacities, human resources and systems and infrastructure. Core competencies are also called ‘domains’ or ‘elements’ of organizational efficiency, and can be described by a variety of individual terms (i.e. ‘aspirations’ versus ‘mission and goals’). Each core competency houses a number of smaller capacities, sub-domains, or “target areas of intervention”, that are implicit within the larger competency (i.e. financial management includes budget preparation, internal auditing, etc.). The relative importance of each core competency remains unclear, as does their respective temporal ordering, which precludes agreement among practitioners about which capacity building framework is superior [47].

Frameworks also highlight the steps in completing capacity building projects. Often, these steps include an initial assessment phase wherein the organization identifies areas of needed development [22, 44, 46, 48, 49]. A period of planning and implementing capacity building initiatives generally follows the assessment stage and monitoring and evaluating the initiative is often the final stage. These stages are broad and general and can be deconstructed further into to their component parts in order to allow for greater understanding. Table 1 provides a description of the steps in a capacity building framework for county-owned projects.

In the text that follows, partner refers to the local organization (government, non governmental organization, faith based organization, civil society organization, private company, etc), while donor refers to any groups that provide funding to the partner organizations.

The need to conduct organizational assessment prior to engaging in capacity building projects presupposes that any initiative to improve organizational functioning or performance should be in response to an identified organizational need or deficiency [34]. Organizational assessment is the process by which organizations obtain systematic information about their performance and the factors that affect it in order to diagnose competency areas and areas in need of investment [50]. Organizational assessments should be carried out under the partner organization’s leadership in the country-ownership context, to ensure that these organizations can effectively self-assess in the future without the support of external partners.

Organizational assessments can be facilitated by using tools. These tools vary in terms of their focus and approach; some tools assess the organization as a whole while others assess effectiveness one specific area (i.e. governance). Assessments use heterogeneous language to identify and describe the organizational core competencies that are evaluated, similar to the capacity building frameworks previously discussed. Assessments diagnose organizational weaknesses by probing into the organization’s current functioning or performance level and offering indicators that reflect the characteristics of an organization operating efficiently to serve as a comparison.

There are collections of tools available via internet databases, many of which are free for use by the public. There is little information available concerning the validity, quality or effectiveness of each tool, though some tools (like the McKinsey Capacity Assessment Grid) are often cited in the literature and have gained credibility. Existing tools only enable subjective assessments of organizational capacity, which makes objective measurement of capacity which has been built, impossible. Donor and partner organizations should collaboratively identify tools that address areas of relevance to the partner organization and work to ensure the partner organization becomes well versed in conducting organizational assessments.

The goal of the assessment phase is to identify areas of organizational strength and weakness. Once weaknesses have been identified, it is necessary to define the impact that these weaknesses have on organizational performance. Partner organizations should lead the processes of both prioritizing the order in which the identified weaknesses will be addressed and then deconstructing the highest priority weakness into small, manageable ‘challenges’. Capacity building efforts should be designed to address one specific challenge at a time.

The assessment phase allows organizations to identify a specific challenge(s) on which to focus their capacity building efforts. The challenge will correspond to a target area of intervention, one of the many component parts of the larger core organizational competencies.

Once identified, the organization must design indicators that will demonstrate the effectiveness of the capacity building intervention to stakeholders (boards of directors, funders, beneficiaries etc.). Indicators can vary by type, including process, output, outcome and impact indicators [51]. Indicators provide clear metrics by which the capacity building project can be monitored and evaluated throughout its life. Outcomes are often difficult to link to efforts in practice, as there is rarely a financial bottom line to appraise [22]. Logic models are a commonly used method to identify and define indicators for capacity building. Indicators should be reflective of the specific findings gleaned from the organizational assessment phase.

A capacity building approach is the general strategy by which an organization is able to address organizational challenges [52]. In the country ownership context, approaches refer to the methods used by the donor/partner organizations collaboratively to help partner organizations better achieve their mission and goals and solve problems that may arise in the future. Capacity building approaches are often boiled down to training and technical assistance provided by the donor organizations; however, there are a myriad of different forms that these approaches can assume. These include professional training, peer assessments, process consulting, performance contracting, executive coaching, mentorship, international organizational collaboration, and a variety of partnership types.

Each approach can be operationalized by means of a variety of tools and activities. For example, a partner/donor organization may decide to address an organizational need for enhanced capacity in governance, which was identified through a process of organizational assessment. Within the arena of governance, this organization might have identified the need to increase and diversify board membership as the challenge to be addressed. Specific indicators would then be defined in order to track the capacity building effort’s progress in addressing that challenge (i.e. the number of different community sectors represented by board members). It is then necessary to identify the desired approach to addressing the challenge of building governance capacity. The chosen approach, (technical assistance around board development for example), is operationalized through use of a specific set of activities and tasks such monthly consultations between the donor and partner organizations regarding sound board member recruitment and retention methods. This tool can be further divided into its component parts, or activities, which could include the preparation of specific questions to pose at the monthly consultation meetings and so on. The application of the defined tools and activities represent the implementation phase of a capacity building project [52, 53].

Evaluation in capacity building projects is necessary to increase the accountability of both donor and partner organizations, to allow donor organizations that sponsor capacity building initiatives to engage in more evidence-based grant making, and to compare the effectiveness of different capacity building approaches [22]. Capacity building in the context of country ownership has undergone little formal evaluation and there are numerous explanations for this dearth of evidence. No standardized approaches to monitoring and evaluating capacity building measures are currently defined due to the range of activities and circumstances that comprise capacity building interventions [31]. Monitoring and evaluation is distinct from the initial assessment phase in that it aims to measure change over time whereas the initial assessment is diagnostic and identifies organizational gaps [53]. Difficulties inherent to defining ‘capacity’ and measuring an organization’s progress toward it are major challenges to evaluating effectiveness, particularly when evaluating ‘soft’ capacities, like leadership development or employee motivation, that are challenging to quantify [54‐56].

Capacity building projects are often facilitated through grant funding, part of which may or may not be allocated for evaluation purposes by the funder organization [57]. In the absence of designated resources, effective evaluation efforts may be difficult to conduct. Partner and donor organizations may also have disparate understandings of the capacity building initiative’s actual goals and, by extension, how they should be evaluated. The existing evidence base of capacity building evaluations generally describes either success in individual case studies or among small samples of organizations, which hampers the generalizability of their findings [32].

Partner and donor organizations should be prepared to test new strategies and approaches to monitor and evaluate capacity building initiatives [53]. Currently utilized methods range from the traditional donor-driven approaches to the participatory and ultimately self-directed activities of partner organizations; it is the participatory approach that should be embraced in country-owned capacity building [55]. Evaluation activities can serve two integrated purposes; assessing the effectiveness/impact of a specific capacity building intervention and building the partner organization’s capacity to conduct evaluations independently [32]. Because capacity is a multi-faceted construct, it is necessary to remember that any one indicator tells only part of a complex story. To ensure ownership, attempts to capture changes in capacity over time should be pursued through the use of indicators that are defined by the partner organization and relevant to locally determined concepts of change [31].

Once the organizational challenge has been addressed and evaluated, the organization will have evolved in some manner. Addressing the original identified challenge will ideally result in increased organizational capacity and efficiency; however, capacity building should be continuous process. Improved capacity in one area may expose other areas of organizational weakness that also require intervention, or the other pre-existing weaknesses may still be present. The ‘new’ organization must be re-assessed and another cycle of capacity building activities should commence in order to address the next high-priority organizational challenge identified.

The above process of partnership between donor organization and local partner should ultimately lead to local organizations capable of conducting the cycle of capacity building activities internally without external guidance or leadership, as described in Figure 1.

Effective organizational capacity building will contribute to an organization’s sustainability and, in the context of country ownership, enhancing the sustainability of the partner organization and the health outcomes it aims to produce is often a top priority [34]. Capacity is an organization’s ability to perform its defined functions, set and implement developmental objectives, and adapt and respond to changing environments effectively, efficiently and on a sustainable basis [4, 16]. Capacity building activities should be designed to endow partner organizations with the skills and abilities to sustain current built capacity, to grow the skills necessary within the organization to continue to build its own capacity, as well as to respond to and proactively create changes in its environment into the future, absent of donor organization and country support [36, 55].

Agreement on the importance of building capacity in a sustainable way is necessary from the outset of the partnership between donor and partner organizations [36]. Leadership within the partner organization will ultimately be responsible for directing and stewarding future capacity building efforts; however, buy-in from all levels of the organization and other relevant stakeholders and the identification of internal and external champions of the capacity building process will help ensure its future sustainability [5, 23, 34]. To ensure that donor organizations impart all relevant expertise, opportunities for technical support and training should be demand-driven and informed by the partner organization’s knowledge and understanding of local context and organizational needs [34]. It should not be assumed that best practices that are effective within the donor organization’s own country or experience will translate seamlessly into the partner organization’s context [21, 36].

Training-of-trainer approaches and coaching techniques (that can augment traditional supervision or mentoring relationships by drawing upon the unique knowledge and experiences of both the coach and coached), could also be employed to build in-house expertise among the partner organization’s leadership in any necessary skill set. For example, training several partner organization staff members to train others in skills relating to board development or to pursuing new and strengthening existing partnerships with other organizations will ensure that this technical expertise remains within the organization regardless of staff turnover. Certain competencies, including those concerning organizational finances and strategic management, that contribute directly to an organization’s future sustainability can be prioritized for training and technical support [21]. Donor organizations can assist partner organizations in creating sustainability plans that can quantify the partner organization’s capacity building goals prospectively and provide a framework for measurement and evaluation in achieving those goals, increasing the likelihood of successful and long-lasting organizational change [30].