Background
Partnerships for health
True partnership is difficult
“As long as we agree, you say that the money belongs to both of us. But the moment we disagree, you say that the money belongs to you” ( [27], p.1).
Research on partnership processes: a public health priority
Mechanisms for accountability in partnerships
The case
Partner roles and resource contribution | Ministry of health MH | Development partner 1 CDC | Development partner 2 ACHAP | PEPFAR | Bill and Melinda gates foundation |
---|---|---|---|---|---|
Financial contribution/In country donor | ✓ | ✓ | ✓ | ||
Development Partner (in the country) | ✓ | ✓ | |||
Coordinator and owner of program | ✓ | ||||
International donor | ✓ | ✓ | |||
Provides scientific expertise and skills | ✓ | ||||
Provides training of staff on surgery | ✓ | ✓ | ✓ | ||
Provides training of staff on demand creation | ✓ | ✓ | |||
Provider of implementation staff for surgery | ✓ | ✓ | ✓ | ||
Provider of general medical equipment | ✓ | ||||
Provides MC surgery kits | ✓ | ||||
Marketing and advertisement of MOVE (large scale) | ✓ | ||||
Provider of staff for mobilisation (Demand Creation) | ✓ | ✓ | |||
Provider of infrastructure nationally | ✓ |
Conceptual framework
The Bergen Model of Collaborative Functioning (BMCF)
The Bergen model of collaborative functioning: Fig. 1 should fit here
Methods
Research sites
Participants and recruitment
Data collection
Data analysis
Results
Basic themes | Organising themes | Global themes |
---|---|---|
1. Botswana government HIV National Strategic Framework (NSF) lead by NACA 2. All ministries, development partners CBOs, NGOs and private sector are part of the NSF 3. MH, DP1,DP2 are three main partners in the SMC program 4. DHMT works at district level 5. All partners involved throughout the planning process since 2007 6. All partners target HIV negative men aged 15–49 years to circumcise through SMC 7. All partners aim to have circumcised 80 % of HIV negative men by year 2016 | Clear Partner Mission | Input |
8. Botswana government integrated circumcision within health services nationwide since 2007 9. DPs introduced MOVE project in 2011 to help government push set target in selected areas | Approaches to the mission | |
10. DP1 viewed as a major financial contributor: more monetary funds; sub-constructs companies; built 2 permanent clinics; provides surgery kit; provides mobile clinics and transport 11. DP1 contributes funds and funds medical personnel and transport 12. MH contributes funds; provides health structures nationally; provides medical equipment and transport | Financial Resource Contribution | |
13. DPs deployed medical staff to Government health centers to do SMC 14. DPs deployed staff moved to form dedicated MOVE teams 15. DP1 brings in special scientific expertise 16. MH’s avails its medical staff nationally to participate in SMC | Partner Resource Contribution | |
17. MH as owner, coordinator, chair, provider of space and financing 18. DP1 as technical advisor, expert, advertising, mobilisation, provider of clinics structures and main donor 19. DP2 as donor, implementer and community mobiliser | Clear Partner Roles | Throughput |
20. Partners developed short term and long term communication strategies; training manuals and reporting system together | Communication | |
21. Development partners use different reporting systems than MH’s 22. Development partners do not report to MH systematically 23. Reporting between partners was not transparent 24. Development partners reported directly to their international donors 25. The Government reported all donor funds usage to OECD 26. Way of accountability give blurry structure | ||
Financial resources
27. More finances spent but less numbers of circumcised men causes conflict 28. MH’s financial contribution queried to be not transparent 29. Ownership seems linked to finance contribution 30. MH’s ownership of the program is questioned 31. MH sees structures as big contribution | Input Interaction | |
In-kind resources
32. Donors keep sending more equipment for circumcision 33. Lots of equipment is wasted 34. There is inconsistency on balance sheet for number of circumcision instruments, wasted and remaining 35. MH is blamed for not taking care of such equipment | ||
Partner resources
36. MH viewed as a weak coordinator at times 37. MH ownership is queried 38. Government health centers is blamed to be participating little in circumcision 39. MH feels MOVE strategy naturally creates dependency on government health staff 40. Districts prioritised attending to ill patients than circumcision 41. DHMTs blamed for not prioritising SMC 42. Health centers viewed SMC as the DPs’ program | ||
43. Partners consulted with the national traditional leadership at planning stage 44. MH is seen as a leader and owner 45. There is not enough support from the highest national leadership to influence men for circumcision 46. MH’s placements of coordination leadership is queried 47. DHMTs are said to not take leadership role accordingly | Leadership | |
48. DPs blame MH for setting the target high 49. DPs blame MH for not putting enough effort and resources to push the set target 50. MH is frustrated about the mathematical model used by WHO to set country target 49. Unattainable target is seen as the highest risk in program implementation 51. MH and DPs express frustration that the 80 % target is not attained regardless of their massive efforts 51. DPs report pressure from donors on reconciling dollar to numbers | Mission threatened | Feedback mission |
52. DPs indicate that the donors will cut down on the funds 53. International donors reduce funding support to Botswana | ||
54. DP2 pulls away its employed doctors gradually from 2013 and leaves a gap in implementation 55. DP1 pulls away its financial and technical assistance abruptly in 2014 and leaves a gap in implementation | Antagony | Output |
Input
The partners’ mission
We, the DPs are always in the country. We are here to help with all HIV/AIDS intervention strategies. (Lead officer 5 in Gaborone, during the second round interview).
So we have at best 40 % of the 100 thousand target that is to be covered. At best 40 % of the target is our aim as DP1.
We aim for 25 % of the target…
Approaches to the mission
Government’s long term plan is to integrate SMC into the normal health system. We worked on this with our partners from the beginning.
We expect clinics to circumcise one client per day or 5 clients per kilometre through our integration strategy.
…..but then this idea of the MOVE project came in in 2011….It was introduced by PEPFAR through DP1. Through move MC is marketed and advertised to get many numbers of men to circumcise at the same time.
The Government is not enough alone. We are weak alone…you see? We welcome the development partners to fill in the gaps…, you see… With targets set, Government needs assistance…. We appreciate the MOVE project because there is a lot of good in it; to help us reach the numbers.
Government emphasises equity. We need to strive for equity, not just a few districts for the MOVE project but all districts. Circumcision, circumcision, circumcision is our breath.
Resources
Because of challenges of resources we thought the idea of combining resources with DPs was a good one.
Financial resources
Many people turn up for circumcision when the MOVE teams from the DP1 contractors come. They come with lots of resources you see…last time they were here they brought vehicles which were used to fetch people from settlements around to come here in the hospital for circumcision. They also have lots of staff. We don’t, we are overwhelmed with many other duties. Not just circumcision.
Partner resources (skills)
So what we bring to the table as DP1 is a level of scientific knowledge that many organisations don’t have….Prepex study… but we also bring in experience from other countries on how partnerships work and how coordination can occur and how systems can be built…monitoring and implementing change…that kind of a thing.
When we started the integration program, the DPs deployed their staff (seconded doctors and nurses) to government health centers to work with our nurses and doctors in circumcision.
When they promised dedicated MOVE teams and we know that in Botswana we have skeletal staff…..just the few of us, why would we refuse?
When the MOVE idea came in it overpowered the original one. In MOVE, DPs brought in demand creation strategies like adverts on TV and radio, public campaigns, mobile clinics for circumcision and staff to do the job.. So we cover many people at a time. Integration is a long term program and is not as fast as MOVE.
We serve as catalysts to government..basically making it do things faster because we are always focusing on cost effectiveness. We have brought in 30 medical doctors to help move target.
We provided 30 doctors to train other staff and to do surgery in dedicated clinics.
Throughput
Clear partner roles (roles/structure)
Communication
Year 2007–2008 was a planning period. As the other presenter stated all operational documents were developed then. We formulated these together….The integration of SMC in all health centres started in 2009.
We, MH, started the SMC project as “parental states” 1 but with the partners participating. We started with trainings, formulation of strategies and so on. Development Partners have always taken part in SMC from the beginning with government leading.
Remember we got guidance from the House of Chiefs on what circumcision is called in Setswana [Botswana national language]. We tried to engage those who could help in proper language.
So you see…, when we were developing the curriculum that time we were getting a lot of input from the clinicians as to how we can improve it.
We need to fast track the issue of the different training manuals so that we have a document that is standardized. The manuals between MH and DPs have differences here and there…. we need something standardised.
Input interaction
Partner resources (staff)
Our districts had a challenge to take circumcision in at a massive scale. So it was good for us that the DPs seconded their staff to the health centers.
Forming dedicated teams was the best arrangement for the MOVE project so that we can focus and push target.
You know the MOVE team sometimes needs vehicles for mobilisation of other activities. But we cannot always provide them with vehicles. Most of the time our transport is committed to other health duties, transporting sick patients…and then we are seen as not supportive of SMC.
SMC is not a priority within Government clinics. When there is a diarrhoea outbreak or a bleeding patient or something, that is what is given attention. SMC clients are made to wait or return.
If you go to the district these days the districts are not seeing SMC as anything.
You see, it is not that we are not taking SMC serious. This is a prevention program. But sick patients are a priority to us. Also, we are understaffed in clinics and so we have to prioritise…but we try.
There is evidence that when DHMT coordination is leading and participating, things move, but when it is not there, little moves. We need a way to make DHMT own the program.
This is not the first time I hear of this suggestion. You wouldn’t be happy if I do that to your office.
About Peace-Corp I do not know what they are doing. I really don’t know if they can make any impact when Batswana youth are failing.
Financial and technical resources
The Government is supposed to govern..,. You see now we say DP1 brings so much money to the program, DP2 has so much money… The Government keeps quite, that’s why we are asking can the Government tell us what its budget is… This is one question I have never gotten an answer for.
So, in terms of funding circumcision, the Government of Botswana has money. The Government creates its funding pot from all over, I cannot exhaust the list. For example 19 million pula is projected to come from (an international organisation mentioned).
How does Government make its plan then? Is it donors first, then Government.
You are supporting me. Don’t ask me what I have, bring what you have….The Government provides all clinic structures, we provide staff, and we provide equipment.
I do not think the main issue should be resources only as you see it. You know even during large MOVE campaigns here in Francistown [second largest city] where we have all resources in place men come to listen in quite large numbers we still have a few turning up to circumcise.
…78 000 kits were bought and given out; 33 000 kits were used therefore 45 000 remain. But only 25 000 were accounted for… This means 20 000 kits are missing or wasted. Hundreds of kits are sent to districts yet only a few SMCs are done in a month. We overestimated numbers.
This exact issue is the same thing we are going to be nailed about as we account to the ambassador and to Washington DC.
Blurred roles and structure
When the high office in MH reports to OECD he reports all funding as the Botswana basket. He cannot tell them that most of the donor funds are spent on overheads, paying contracted companies and administration, not on the client, even though this may be true. He has to speak like a parent, in a way that would bring more support in the future.
It is not easy to ask “how much are you paying your Coordinator?” It is an internal thing. That is how it is and that is the life we have to live…We have to account and have to ensure that we are not blamed.
Leadership
..with a new program you will always experience a challenge in the first 2 years of implementation.
All health programs start as vertical programs and have challenges, but the aim is to see to it that these programs are integrated within the existing system.
But in my opinion have you ever seen the high leadership of this country coming out and saying “citizens of Botswana lets circumcise.”
Do not mention higher leadership when talking about this program.
The committee we met at parliament said “Our hands are full, consult with the community. Whatever the chiefs say is what the communities do…”
We also talked to the House of Chiefs and they complained that they are not being involved in the program. They said they needed adequate information to articulate issues that are to be addressed.
Feedback on the mission
Officer 1: There was pressure of 100 000 not being negotiable or debatable… If these directives are not realistic they have to correct themselves on the way. You cannot achieve by just demanding the plan.
Officer 1: …there is an option that we could increase the number of years but maintain the target but this will affect impact. Although the targets are not negotiable, they cannot be reached…. It’s a risk.
Officer 3: It’s even worse that we did not even achieve 50 %… The DP1 target was 30 000 but we met only 9 000.
My comrades at MH… we are all really doing the best we possibly can but we are being pressurized from above by our superiors.
….In the integrated sites where there are no development partners, the performance is down.
The mission threatened
You can’t wean a baby overnight. You can’t do it just like that. It should be a process.
We are not weaning the baby; we are not weaning Government now. So do not worry.
We certainly know one of our competitive advantages is money, and that’s great but you can throw money out to a problem and it does not solve a problem, which we are learning and that is why we are opting to stop if we are not successful.
The mission unaccomplished - Partners compelled to pull out (Year 2014)
Yeah I mean we are required to account for every dollar used. They would calculate a certain number of circumcisions to dollars….so the development partners have to account for this….. We reached only about 39 % of the set target in 2012……. It is not their choice to be pulling out. They have pressure from the donors… the donor pulled away… They feel their funds are not used efficiently.
Since DP1 pulled out men are coming to the facilities for circumcision but there is not enough staff there to circumcise them. So we are back to square one. We are experiencing the very slow numbers we were experiencing when we started… Government Development partners pulled out from dedicated clinics. Now it is expensive for Government.
The mission revisited -MH revisits the SMC strategy
We are now back to the basics to tell the truth. We have lost the support of partners as a country. But we are not going to sit back and say VMMC is not possible in Botswana. We are not giving up…We are thinking of addressing these basic issues. Like this year we really want each district to ensure that we are involving the local authorities…
We really missed it. We missed the behavioural issues… and the cultural issues. We should be one in this issue with the tribal leaders such that when I leave here and go to Ramotswa, the chief should not see me as Ministry of Health, but as one with his community, to help the community…..they should be saying we are in this together…
We need some kind of synergy between what the SMC does and the traditional practices out there.
..when you talk about demand creation, we have learnt lessons from MOVE. We now know that we cannot use young people to talk to older men. It doesn’t work.
Output
Additive results
Synergy
Year | Numbers reached |
---|---|
2007–2009 | planning period |
2009 | 5424 with integration only |
2010 | 5773 with integration only |
2011 | 14,661 with integration and MOVE |
2012 | 38,005 with integration and MOVE |
2013 | 46,793 with integration and MOVE |
2014 | 30,033 with integration and MOVE |