tentative thoughts on ownership: work-in-progress

i am road-testing a few ideas from the conclusion of my thesis, in which i try to bring out two themes recurring throughout the analyses on adoption and implementation of the phase I pilot of the amfm in ghana, between 2010 and 2012. these themes are ownership and risk-taking. i have already written a bit about risk-taking here. below, i share some of my tentative ideas and questions on ownership (slightly edited from the thesis itself, including removing some citations of interviewees for now).

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delighted for comments.

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one undercurrent running throughout this thesis is the idea of ownership of: the definition of the problem and solution at hand, the process of adopting the amfm, and of the program itself and its implementation.

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in chapter 4, i introduced stakeholder ideas of paths not taken, including how the program might have “develop[ed], not negate[d], local production capacity,” including through support to local manufacturers to upgrade to meet WHO prequalification and through work to bring local government and industry (rather than global industry) into closer partnership. both those ultimately receptive and resistant to the amfm acknowledged that all national stakeholders “would have preferred to have had quality, local drugs.” the very strength of the amfm design — high-level negotiations and subsidization — precluded local, structural changes.

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in chapter 5, i highlighted that several key stakeholders refused to take — that is, to own — a stand on whether ghana should apply to the phase 1 pilot. moreover, the key, institutional decision-makers in the country coordinating mechanism for the global fund (ccm) vacillated on whether or not to send the application while a variety of circumstantial stakeholders felt they had stake in the decision and worked to influence the process. in chapter 6, i analyze how global ideas and actors played a role in ghana’s adoption of phase 1. in chapter 7, i describe the way the amfm coordination committee (amfm-cc) was set up which, in composition and process, differs from the ccm.

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these points on alternatives not considered, on vacillation, on avoidance, and on outright resistance relate to conceptions of country ownership of development initiatives, as in the paris declaration. the absence of a national politics and aligned problem stream, in particular, neatly dovetails with the ideas of david booth that clarify what should be meant by country ownership (booth 2012). he proposes that it means an end to conditionality to “buy reform” and an end to channeling aid funding through “projects” as a way of by-passing country decision-making bodies, processes, and institutions (booth 2010)

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the ccm represents an interesting example with which to examine country ownership. their explicit raison d’ětre is to foster ownership and they do indeed bring together representatives of government bureaucracy, business, and civil society, “representing the views and interests of grant recipient countries.” yet this structure allowed for vacillation within and strong views without. we must consider this and also juxtapose the make-up of the ccm versus the amfm-cc in terms of the stakeholders represented, the capacity and legitimacy to make relevant decisions, and a sense of ownership about the work ahead. having done this, it seems that, at a minimum, we must question whether the ccm composition when adopting phase 1 allowed for sufficient ownership. given the effort of ccm members to yield decision-making power to the minister of health, it seems that ccm members did not think so.

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however, it is not fair to critique apparent limited ownership without raising three additional questions:

  • would ghana have tried out the amfm if political or bureaucratic actors had to take initial responsibility for the design?
  • did limited national ownership of the design and adoption decision allow national stakeholders to better, “energ[etically]” implement the initiative, maximizing credit-seeking after minimizing risk for blame during adoption (while recognizing that policy entrepreneurs and others still felt this risk keenly)?
  • how should we interpret ghana’s decision to continue with the global fund’s private sector co-payment mechanism?

these questions offer avenues for further analysis of the role of donors, the state, and the public.

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indeed, ownership is not only an issue for capital-based elites; Fox (2015) recently highlighted that “the current aid architecture deprives both african governments and african publics of agency.” in chapter 7, I introduce views of the citizens and businesspeople at the street-level of implementation. about 20%, during in-depth interviews, spontaneously said they wanted to see the amfm continued — a view that seems to have had no way of entering any debates about the future of the amfm and is absent from the academic literature on this initiative.

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though the minority, some respondents specifically voiced that they should have learned about the amfm through a government agency or professional association. two specifically raised their position as stakeholders. one, who heard from her supplier, said “i think it wasn’t fair because as major stakeholders, we should have been briefed before.” another, who heard first from the media, said “i felt this was wrong since we are a major stakeholder. we should have met as partners.” these concerns relate to relations between ghana and the global fund as well as between accra-based elites and tamale-based retailers.

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the events of both adoption and implementation of the AMFm suggest that ownership is important (in no way a novel claim). note, though, that there may be certain amounts of freedom to innovate accorded by being just an implementer, rather than having clear ownership of a new idea, decision-making power over adopting and implementing that idea, and, accordingly, more risk if the idea does not pan out.

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also, if we accept that ownership is indeed important, which seems a plausible lesson to draw from this thesis, we also learn that simply giving decision-making power to some national stakeholders is insufficient. the right national stakeholders and their existing decision-making structures need to be in play. we may glean something about relevant national stakeholders in this case through the composition of the amfm-cc and the committee characteristics raised as important (transparency, collaboration). but, given the views of some street-level implementers, ownership may require further consideration.

Thinking About Stakeholder Risk and Accountability in Pilot Experiments

This post is also cross-posted here in slightly modified form.

Since I keep circling around issues related to my dissertation in this blog, I decided it was time to start writing about some of that work. As anyone who has stood or sat near to me for more than 5 minutes over the past 4.25 years will know, in my thesis I examine the political-economy of adopting and implementing a large global health program (the affordable medicines facility – malaria or “AMFm”). This program was designed at the global level (meaning largely in D.C. and Geneva with tweaking workshops in assorted African capitals). Global actors invited select Sub-Saharan African countries to apply to pilot the AMFm for two years before any decision was made to continue, modify, scale-up, or terminate. It should also be noted from the outset that it was not fully clear what role the evidence would play in the board’s decision and how the evidence would be interpreted. As I highlight below, this lack of clarity helped to foster feelings of risk as well as a resistance among some of the national-level stakeholders about participating in the pilot. . . as  . .

To push the semantics a bit, several critics have (e.g.) noted that scale and scope and requisite new systems and relationships involved in the AMFm disqualify it from being considered a ‘pilot,’ though i use that term for continuity with most other AMFm-related writing. . .

In my research, my focus is on the national and sub-national processes of deciding to participate in the initial pilot (‘phase I’) stage, focusing specifically on Ghana. Besides the project scale and resources mobilized, one thing that stood out about this project is that there was a reasonable amount of resistance to piloting this program among stakeholders in several of the invited countries. I have been very fortunate that my wonderful committee and outside supporters like Owen Barder have continued to push me over the years (and years) to try to explain this resistance to an ostensibly ‘good’ program. Moreover, I have been lucky and grateful that a set of key informants in Ghana that have been willing to converse openly with me over several years as I have tried to untangle the reasons behind the support and resistance and to try to get the story ‘right’. . .

The set-up of the global health pilot experiment, from the global perspective, the set-up was a paragon of planning for evidence-informed decision-making: pilot first, develop benchmarks for success and commission an independent evaluation (a well-monitored before and after comparison) — and make decisions later. . .

In my work, through a grounded qualitative analysis, I distil the variety of reasons for supporting and resisting Ghana’s participation in the AMFm pilot to three main types: those related to direct policy goals (in this case, increasing access to malaria medication and lowering malaria mortality), indirect policy goals (indirect insofar as they are not the explicit goals of the policy in question, such as employment and economic growth), and finally those related to risk and reputation (individual, organizational, and national). I take the latter as my main focus for the rest of this post. . . . .

A key question on which I have been pushed is the extent to which resistance to participation (which meant resisting an unprecedented volume of highly subsidized, high-quality anti-malarial treatments entering both the public and the private sector) emerges from the idea of the AMFm versus the idea of piloting the AMFm with uncertain follow-up plans. . ..

Some issues, such as threats to both direct and indirect policy goals often related to the AMFm mechanism itself, including the focus on malaria prevention rather than treatment as well as broader goals related to national pride and the support of local businesses. The idea of the AMFm itself, as well as it a harbinger of approaches (such as market-based approaches) to global health, provoked both support and resistance. . . .

But some sources of resistance stemmed more directly from the piloting process itself. By evidence-informed design, the global fund gave “no assurance to continue [AMFm] in the long-term,” so that the evaluation of the pilot would shape their decision. This presented limited risks to them. At the national level, this uncertainty proved troubling, as many local stakeholders felt it posed national, organizational, and personal risks for policy goals and reputations. Words like ‘vilification‘ and ‘chastisement‘ and ‘bitter‘ came up during key informant interviews. in a point of opposing objectives (if not a full catch-22, a phrase stricken from my thesis), some stakeholders may have supported the pilot if they knew the program would not be terminated (even if modified), whereas global actors wanted the pilot to see if the evidence suggested the program should (not) be terminated. Pilot-specific concerns related to uncertainties around the sunk investments of time in setting up the needed systems and relationships, which have an uncertain life expectancy. also, for a stakeholder trying to decide whether to support or resist a pilot, it doesn’t help when the reputation and other pay-offs from supporting are uncertain and may only materialize should the pilot prove successful and be carried to the next stage. . . .

A final but absolutely key set of concerns for anyone considering working with policy champions is what, precisely, the decision to continue would hinge upon. Would failure to meet benchmarks be taken as a failure of the mechanism and concept? A failure of national implementation capacity and managerial efforts in Ghana (in the face of a key donor)? A failure of individual efforts and initiatives in Ghana? .

Without clarity on these questions about how accountability and blame would be distributed, national stakeholders were understandably nervous and sometimes resistant (passively of actively) to Ghana’s applying to be a phase I pilot country. To paraphrase one key informant’s articulation of a common view, phase I of the AMFm should have been an experiment on how to continue, not whether to continue, the initiative. . . .

How does this fit in with our ideas of ideal evidence-informed decision-making about programs and policies? The experience recorded here raises some important questions when we talk about wanting policy champions and wanting to generate rigorous evidence about those policies. Assuming that the policies and programs under study adhere to one of the definitions of equipoise, the results from a rigorous evaluation could go either way.

What risks does the local champion(s) of a policy face in visibly supporting a policy?

Is clear accountability established for evaluation outcomes?

Are there built-in buffers for the personal and political reputation of champions and supporters in the evaluation design?

The more we talk about early stakeholder buy-in to evaluation and the desire for research uptake on the basis of evaluation results, the more we need to think about the political economy of pilots and those those stepping up to support policies and the (impact) evaluation of them. Do they exist in a learning environment where glitches and null results are considered part of the process? Can evaluations help to elucidate design and implementation failures in a way that has clear lines of accountability among the ‘ideas’ people, the champions, the managers, and the implementer’s? These questions need to be taken seriously if we expect government officials to engage in pilot research to help decide the best way to move a program or policy forward (including not moving it forward at all).

dear sir – response to AMFm article in the economist

on 24 novemberthis article was published in the economist on AMFm and the Global Fund. below is the response i would have liked to have published because a few things in the article were maddening. particularly frustrating are those celebrating the end of AMFm as though ending a subsidy on ACTs in the private sector are the same thing as removing ACTs from the private sector. it’s not. so far as i know, we have not yet heard whether pharmaceutical companies intend to keep their ACT prices low, in order to tap into the non-premium market uncovered in AMFm. in any case, malaria programs moving forward need to address the reality of treatment-seeking behavior and expectations for fever in the wake of AMFm. 

‘Sir – At least two things on the horizon for malaria treatment – for both the Global Fund and the larger global health community – are not cloudy in the dust of the Affordable Medicines Facility–malaria (AMFm). Yet these points remain under-discussed.

First, the end of the AMFm subsidy for malaria treatment does not eliminate the obligation to scale-up malaria and broader fever diagnosis in both the private and public sectors. The globally recommended treatment for malaria – ACTs – are legally available over-the-counter in three of the seven countries that piloted AMFm. This includes Nigeria, which accounts for one-quarter of global malaria deaths. It also includes Ghana and Uganda.

Even where citizens cannot legally access ACTs over-the-counter, they can often obtain these treatments as easily as if the laws supported such access. Unless the global discussion shifts to changing and enforcing national drug regulations – which it has not – we need to continue talking about scaling-up diagnosis at the gamut of fever-treatment points. This remains the case with or without a subsidy.

Second, it is a false dichotomy that aid money be directed to either a drug subsidy or a community health worker (CHW) effort. Instead, we need to discuss how to apply lessons from successful CHW programs to the variety of workers on the front-lines of treating fevers. Again, those in both the private and public sectors who are, in reality, treating fevers. Researchers working with community health workers suggest that, where in place, CHWs can appropriately distinguish and treat fevers, as well as encourage their charges to complete treatment. However, the CHW model has not proved viable in each context it has been tried. As such, not every malaria-burdened country has trained, scaled-up, and maintained CHWs, despite attempts since the late 1970s. We need to discuss the current realities of safely treating fevers in countries shouldering malaria burdens in order to develop both short- and long-term plans.

if it doesn’t kill them, it makes them stronger (III) / why would you do things that way? (II)

well, this is bad and annoying.

bad: malaria resistance to ACTs is being increasingly reported in Thailand.

annoying: the article’s narrator & interviewee go on to say that immediate steps need to be taken.

then, instead of listing some possible steps, they highlight that maybe a malaria vaccine is on the horizon.

1. what should we do now? use rapid-diagnostic testing? encourage proper use (dose-completion) of ACTs? encourage prevention with bednets?

2. what do we think is that actual probability of having a viable malaria vaccine in three years? if so, how likely is its protective immunity likely to last for an inoculated person?

3. why are we so, so, so jazzed about a malaria vaccine when malaria elimination & eradication in the past has been very much about environmental management? is sanitation not sexy enough? do we not think that governments in malarious countries can and should be providing drainage, sewage, and other services that reduce malaria breeding habitats?

from The Making of a Tropical Disease (Packard)

In the end, the book males a simple point. Malaria policy needs to be informed by history. The history of malaria tells us that malaria cannot be understood or eliminated independently of changes in the societal forces that drive it. This is not to argue that past and current malaria control efforts have had no effect on reducing the burden of malaria. Nor do I believe that malaria cannot be controlled before social and economic impediments to health are completely removed. Rather I argue that the array of biological weapons mobilized in the war against malaria needs to be joined with efforts to understand and improve the social and economic conditions that drive the epidemiology of the disease (xviii).

from The Fever (Shah)

The uncomfortable truth is that ending malaria over the long-term will require difficult social and economic adjustments in African communities, just as it has elsewhere. Infrastructure will have to improve. Settlement patterns and housing styles will have to change. Education and healthcare systems will have to be built. Antimalaria activists know this. But it is not possible for them alone to transform Africa’s economies and cultures. The best they can do is offer partial, short-term solutions. That is, in the meantime, they can blanket the continent with treated nets and better drugs… After all, the perfect need not be the enemy of the good. The question is how the short-term solutions impact the long-term ones. Usually, something good today doesn’t reduce the probability of something better tomorrow. But in malaria, it can (237).

The conflict over short-term solutions and long-term sustainability has yet to be adequately resolved. The US antimalarial program, government malariologist Thomas Ritchie says, ‘is pouring obscene amounts of money’ into quick fixes against African malaria, but is spending little on supporting local antimalaria leadership or building antimalarial infrastructure. Plenty of African clinicians, scientists, and community leaders are dedicated to taming malaria, Ritchie says, but when the world’s richest country decides to help, ‘they give these people nothing, not a cent!’ (238).

The conflict plays out in heated debates at international malaria meetings. At one, an official from the Nigerian MoH became engrossed in a long argument with a representative from Sanofi-Aventis, which was at the time the sole purveyor of WHO-recommended ACT drugs. Finally she turned to me. ‘Write it in your paper,’ she commanded. ‘We need to build African capacity to make treated nets and ACTs. That is the only way we can solve malaria. They don’t want to do technology transfer,’ she said, motioning to the drug company rep. ‘They just want us to buy, buy, buy’ (238).

Although it publicly recognizes the need to build infrastructure in endemic countries, RBM has also stated that tackling the disease cannot be the responsibility of local governments. ‘If malaria control is left to governments to plan and execute,’ RBM wrote, ‘malaria will not be controlled.’ This is, of course, exactly backward. It is the only way malaria will be controlled. Malaria-endemic societies have proven this over and over again, from when the Italians distributed quinine to their populace – and built the schools and clinics and roads they needed in order to do it – to when Malawi banned the sale of chloroquine and rid the country of chloroquine-resistant parasites… ‘You can do a lot of good with bed nets, with spraying,’ says malariologist Tom McCutchan, ‘but in the end, you have got to give power to the people who are at risk’ (239).