Whose National Strategy?
Cindy CarlsonArticle Type:
Article Number: 2
Donors encourage country ownership but what does this mean in practice?
In the first of two articles looking at the much-vaunted principles of country ownership, we focus on national strategic disease plans or NSPs. These were originally developed in response to the need for a national-level plan for how a country would address its disease responses over a finite time period. This enabled investment to be based on a longer term strategy for tackling the disease. But the playing field has changed since that first Ugandan HIV NSP; and national processes appear to be increasingly globally driven. Looking at countries scrambling to get their NSPs ready to accompany their Global Fund Grant Cycle 7 funding requests, we ask whether countries would still go through this process were it not for donor pressure – and exactly how representative are NSPs of a country’s realistic and achievable ambitions?
National HIV/AIDS strategic plans (HIV/AIDS NSPs) are key documents for signposting what a country needs to do to ensure the combined efforts of society are working towards ending AIDS as a public health threat. They are assumed to be developed and owned by a range of country stakeholders who have responsibility for leading, managing and implementing the country’s AIDS response. I’m increasingly wondering whether this assumption holds true and the implications this has for effective implementation and meeting NSP targets.
Where did national HIV strategies first come from?
I’ve developed, evaluated, prepared guidelines for and assessed the quality of national health and national HIV/AIDS guiding documents and programs for almost thirty years. During this period I’ve observed and worked within several policy shifts around what is expected from national HIV/AIDS strategic plans in particular, almost all of which are globally driven. This is ironic as the first national AIDS strategies developed in low income countries came out of primarily national processes, with Uganda pioneering the first national AIDS control programme and national AIDS plan in the mid-1980s in Africa, with help from the World Health Organization (WHO).
Within fifteen years, as the AIDS pandemic continued to expand, international funders encouraged more countries to follow the Ugandan model, culminating in the global push for the ‘Three-Ones’ (one agreed national HIV/AIDS action framework, one national AIDS coordinating authority and one country level M&E system) by UNAIDS in the early to mid-2000s (UNAIDS itself only being launched in 1996). In the intervening years guidance for developing HIV/AIDS NSPs has multiplied, with UNAIDS and different UN and funding agencies listing what they think should be included in HIV/AIDS NSPs (and other technical sector HIV sub-strategies, e.g. health, education, social welfare, etc.).
The Global Fund and national disease strategies
In 2008 the Global Fund to Fight AIDS, TB and Malaria (Global Fund) initiated a pilot ‘National Strategy Applications’ (NSA) process, whereby new funding requests would be based on national HIV/AIDS, TB or malaria strategies, in an effort to make the funding application process more streamlined and lighter. A ‘first wave’ was rolled out to three countries who were guided by the Global Fund and supported by a number of national and international consultants. At the same time the Global Fund engaged with the International Health Partnership plus (IHP+) initiative, hosted by WHO, to develop a strategy assessment framework that had generic enough features that it could cover whole health sector strategies, and related sub-sector strategies, like HIV (and TB and malaria). The incentive for joining forces with the IHP+ was to have an agreed, internationally endorsed assessment tool that could determine the robustness of NSPs, which, if applied to any of the three disease NSPs would provide assurance that grant applications would be founded on strong NSPs. The outcome of what became a multi-donor, multi-UN organisation effort was the Joint Assessment of National Strategies (JANS) tool and related processes.
On the basis of lessons learned from the first wave the Global Fund Board approved the funding for the Second Wave of NSAs, which comprised ten countries in 2011. During this second wave multi-sector assessment teams visited all ten countries and held meetings as well as ran workshops to undertake an in-depth assessment of the relevant disease strategy, using the JANS Tool. The teams prepared reports raising any ‘critical issues’ with the national strategies they’d assessed, which were broadly welcomed by country stakeholders. Using the JANS tool, while providing a comprehensive assessment framework and process, was also expensive, both in time and funding. Furthermore, although the countries included in the NSA second wave process had volunteered themselves knowing that their strategies would undergo this intensive assessment, it was at times a very top down process. Unfortunately, after all this effort, the second wave pilot NSAs fell victim to the Global Fund Round 11 financing crisis, and ended up not being used.
NSPs under Global Cycle 7 (GC7)
More recently the Global Fund has resurrected the NSA idea and now requests certain countries to submit their funding requests using a ‘Tailored for National Strategic Plan Funding Request’ approach. Like NSAs this channel was set up to reduce the funding application burden on countries, as, in theory, they would only need to refer to specific parts of their NSPs when filling the funding request template, rather than preparing a heavier set of documents. The experience of the current (2023) round of Tailored NSP funding requests suggests some countries have been able to take advantage of the flexibility that the channel affords, although most do not.
Who really decides the priorities?
The principles behind asking countries to prepare ‘robust’ national strategies and then use these as the basis of their funding requests to a multiple set of funders, including their own governments, are appealing. The assumptions are that national strategies reflect the national priority needs and actions for addressing these needs. But I have an increasing unease about prioritization processes, the influence on HIV/AIDS NSP periodicity and who ultimately ‘owns’ national HIV/AIDS strategies.
Prioritization remains one of the holy grails of NSP and resource mobilisation. It is something much sought after and considered desirable by many, but truly effective evidence-based prioritization is rarely seen. Prioritization is meant to be done on the basis of strong epidemiological and program response evidence of what is happening with the AIDS epidemic in any particular country. Using this evidence countries can then focus their attention and resources on where they are most needed to bring down the number of new cases of HIV and number of deaths due to HIV. There has been much research undertaken and guidance provided on what the key areas of action need to be to address particularly underperforming areas of a country’s HIV response. There are global targets that countries are asked to contribute to, none more so than by the Global Fund. None of this is a bad idea in principle, and can help to counteract national reluctance to address particularly sensitive areas of the HIV response, often to do with the negative socio/cultural views of those who are more likely to be most affected by HIV. Yet too often it is because of these negative views that even when programs for these key groups are written into NSPs and grant proposals, little action occurs in those countries. Essentially lip-service is paid to what should be priority areas of intervention because political-social-economic-cultural constraints are too strong. Putting objectives and activities into an NSP because you are told to do so makes a mockery of NSPs being country-owned and driven plans.
Shouldn’t NSPs align with a country’s planning cycle rather than that of donors?
Furthermore, we are seeing that countries are also developing HIV/AIDS NSPs to fit with the Global Fund funding cycle, in part because of the requirement for NSPs to ‘overlap’ with the grant duration. Over the past two Global Fund grant cycles the group I work with has seen the extraordinary disruption that the onset of a new cycle creates. A number of countries will undertake a full consultation process for reviewing and revising a current NSP, or developing a new NSP document and then move on to organizing (or simultaneously conducting) multiple consultations for developing a new funding request. The more country stakeholders are called on to contribute to these consultations, the less time they have for implementation. In addition, whereas NSPs are mean to be ‘foundational’ to Global Fund funding requests, many are completed after the funding request is submitted, and occasionally worse, country stakeholders suggest they’ll finalise their NSP on the basis of their funding request. Further, the Global Fund three-year grant cycle rarely, if ever, corresponds with the country’s own national planning cycles, which are often five years or more.
So what is to be done?
Of course nations are not monolithic entities – they are highly pluralistic, made up of many different interest groups, so planning processes do need to be inclusive. Good NSP processes try to represent the different needs of those groups most involved in implementing and being impacted by the national and local plans. Excellent NSPs differentiate between the importance of these needs and interests in terms of ending AIDS as a public health threat in their countries and are driven by leadership that prioritizes these needs and interests, and gathers the combined resources of the country and external partners for operationalizing their plans.
Perhaps large external partners should NOT insist that NSPs be the basis of their grant proposals. This could enable country stakeholders to drive their own processes and align HIV/AIDS plans more directly with their own planning and budgeting cycles, rather than to those of major donors. NSPs might then be genuinely owned by government and community leaders, who have laid out what they see as needed, made commitments to their populations that they will get this done and can determine where they will get the funding from to deliver.
External funders could still ask countries to provide the most recent HIV/AIDS plan as background documentation, and still insist on funding applications that also respond to the funder’s own requirements, including ensuring funding is requested for areas that aren’t covered in national plans where needed and relevant. Unchaining disease or other sector plans from donor requirements might better enable greater country ownership, reduce the planning redundancies we’re currently experiencing and free up time for what is really essential: delivering quality HIV/AIDS programs and services to those who need them.
*Cindy Carlson is Senior Principal Consultant, Health Systems Strengthening, Oxford Policy Management, and former Chair of the Global Fund’s Technical Evaluation Reference Group