While we often think of the importance of doctors, nurses, community health workers and even politicians as being the key to strong health systems, it is just as critical to have lawyers, accountants, and governance experts who understand the technical aspects of ensuring that doctors and nurses have what they need to be successful by managing resources responsibly.
The U.S. Global Health Initiative is a government-wide effort, seeking to save lives and improve health outcomes through strategic integration and supporting countries’ own efforts. Its goals – dramatic reductions in maternal and child mortality, are ambitious but achievable. Its overall success — and a brighter future for children, families, communities and countries, — will depend on improvements in everyday issues like buying and tracking expenditures.
So for the GHI’s goals, having a diverse team assess the ability of our partners to manage and deliver health interventions is key to reforming the way we do business in development.
I just returned from two weeks in Nepal where I joined such a team, comprised of USAID colleagues from Washington, India, Bangladesh and Nepal. Our goal was to look at how the Agency can work with more and varied partners to empower the Nepali people to care for themselves. We were looking specifically at how USAID can invest in the government, through existing public financing mechanisms. This includes broadening the civil society partner base, and strengthening private sector capacity. This strategy is part of a larger effort at USAID, known as USAID Forward.
One of the most interesting experiences during the trip was sitting in a small District Public Health Office. Having visited municipal level health offices all over the world, my initial impression was very positive. The facility was in great shape: our meeting room had electricity, decent furniture, a landline telephone, and fax machine. The health superintendent had a strong commanded of his health office. Although I had a hard time following all of the discussion with the strong accents of the local staff, and my own lack of financial acumen, after the first half of our meeting it seemed as though there was a solid, basic system of accounting in place, and appropriate management and oversight controls. Our Team Leader, the Chief Financial Officer for USAID, even seemed impressed.
That all changed when, asking for some clarification, someone asked to see the actual books and records that tracked the system we were discussing. An assistant confidently went to get the ledger and showed us the entries that reflected those transactions. The series of careful inputs and outputs reflected effective record keeping. The staff knew were the books were, they were filled out, and it matched what they had just explained to us.
However, for our CFO, the reaction was entirely different. He nearly fainted when shown the manual ledger that looked like the books he used 30 years ago. For a split second, I saw the whole exercise being for naught – how could we even consider putting money directly into a system, which, at the district and local level, was managed in paper books and pencils? The exciting part was that over the next few hours, after further visits to district municipalities there was a clear recognition that, despite the weaknesses of a cash only system, we would be able to move forward. Although it will require finding a safe harbor, investing in building the capacity of our partners, and of USAID Staff, there is an opportunity for USAID, both in Nepal and the many of the other countries where we work, to work directly with national and local government partners.
In Nepal, and in many other places, USAID’s global health team is already leading the way. For example, last summer USAID Nepal joined other Development Partners in a Joint Financing Agreement (JFA), which sounds fancy but is really just a simplified management system to track money and resources from other countries to Nepal. While the tracking system is still rigorous and strong, the whole process is easier because all donors agree to the same approach. This means that instead of having to create different reports for different donors, the health ministry can use one report for all donors. It also requires the government of Nepal to take a leadership role in the implementation of the National Health Sector Plan.
Ultimately, governments have to decide upon their countries’ health needs and strategies. They are responsible for making and sustaining progress, and they must be accountable to those served by their health systems. It is our hope that using approaches like JFA will increase the collective impact of our work by furthering government ownership and leadership in the health sector. The goal of course, is to improve access to health services for women and children, and health outcomes for all.