Essential reading for those who work in global health, this practical handbook focuses on what might be the most important lesson of the last fifty years: that collaboration is the best way to make health resources count for disadvantaged people around the world. Designed as a learning resource to catalyze fresh thinking, Real Collaboration draws from case studies of teams struggling to combat smallpox, river blindness, polio, and other health threats. In honest appraisals, participants share their missteps as well as their successes. Based on these stories, as well as on analyses of many other enterprises, this accessible, engaging book distills the critical factors that can increase the likelihood of success for those who are launching or managing a new partnership.• Features a solutions-oriented approach• Covers leadership skills, management approaches and lessons from experienced project teams• Information is clearly presented in graphics, sidebars, checklists, and other useful features• Supplementary teaching aids including a DVD and additional online resources
About the Author
Mark L. Rosenberg is President and CEO of The Task Force for Global Health. Elisabeth S. Hayes is Associate Director of the Center for Global Health Collaboration at The Task Force for Global Health. Margaret H. McIntyre is President of MHM Associates. Nancy Neillis a writer and consultant who has worked with global health teams for more than a decade.
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What It Takes for Global Health to Succeed
By Mark L. Rosenberg, Elisabeth S. Hayes, Margaret H. McIntyre, Nancy Neill
UNIVERSITY OF CALIFORNIA PRESSCopyright © 2010 The Regents of the University of California
All rights reserved.
Why Collaboration Matters and Why It Happens Too Rarely
In the mid-1980s several organizations involved in global health wrestled with how to get a stalled immunization effort back on track. They formed the Task Force for Child Survival, a partnership that quickly reinvigorated the effort and allowed the organizations to reach the goal. The partnership had another impact: it provided a stunning example of what partnerships could achieve through real collaboration. Briefly, this is how the story of the Task Force unfolded.
In 1974 member states of the World Health Organization (WHO) had passed a resolution to bring vaccines to children across the globe. At the Alma Ata Conference in 1978 they had set a concrete goal of immunizing 80 percent of the world's children against common childhood diseases by 1990. But by 1984, after climbing from 5 percent to 20 percent, immunization coverage had leveled off.
To break the impasse, these organizations decided to form a task force composed of senior leaders from WHO, the United Nations Development Program (UNDP), the World Bank, UNICEF, and the Rockefeller Foundation. They formed a secretariat, the Task Force for Child Survival, and charged it with helping the partnership rejuvenate immunization efforts and overcome the competitive and divisive forces that had slowed down the previous effort. The Task Force did more than coordinate efforts of the respective organizations. The individuals in the partnership were able to look beyond the separate interests of their own organizations and problem-solve together. they became a team. Under their guidance the task Force secretariat created a unified plan of action, addressed political roadblocks to pave the way for in-country efforts, solved technical problems as they arose, and kept the commitment and momentum alive.
By 1990 this partnership had raised immunization rates from 20 percent to 80 percent. James Grant, director of UNICEF at the time, called the initiative the "largest peacetime mobilization in the history of the earth."
This collaboration would become a touchstone in global health.
Because of efforts like this, the closing decade of the twentieth century saw a rapid rise in partnerships responding to emerging health threats. From 1995 to 2000, for example, key partnerships (including "alliances" and "coalitions") emerged in the following five disease and threat areas:
Onchocerciasis (1995). The African Program for Onchocerciasis Control (APOC) launched an effort to help local communities in nineteen African countries organize and manage treatment for river blindness with the drug Mectizan. APOC was formed by the World Bank, WHO, UNDP, the Food and Agriculture Organization of the United Nations (FAO), the governments of nineteen developing countries and twenty-seven donor countries, twenty nongovernmental organizations (NGOs), and the global pharmaceutical Merck.
HIV/AIDS (1996). Seven UN agencies established the joint United Nations program called UNAIDS.
Tuberculosis (1998). Attendees at the World Conference on Lung Health launched the STOP-TB initiative.
Malaria (1998). WHO, UNICEF, UNDP, the World Bank, and other partners founded the Roll Back Malaria Partnership (RBM), with the goal of cutting the incidence of malaria in half by 2010.
Vaccine preventable diseases (1999). A combination of governments, foundations, development agencies, and NGOs formed the Global Alliance for Vaccines and Immunization (GAVI).
Partnerships had become the preferred approach to global health.
As the coordination costs of global partnerships became clearer, however, participants and donors had second thoughts. Participants themselves became more conscious of the huge time requirement for traveling to global meetings and the slow pace of building trust across organizations, time zones, and cultures. Donors began looking at the return they were getting on their investment of time, effort, and money, to see if partnerships really paid off.
KEY DONOR REPORTS: DO PARTNERSHIPS PAY OFF?
The attempt to measure impact was complicated. While businesses typically measure cost-effectiveness, public health had traditionally measured input or output—the level of demand for services or the number of people treated, for example. Russell Linden, a writer and lecturer on management, recalls: "When I directed a nonprofit organization that served handicapped people and their families back in the 1970s, I simply had to show an increasing demand for my nonprofit's programs in order to justify a budget increase from its funding agencies."
By the 1990s, however, that approach to measurement was no longer considered satisfactory, and funders began to look for better ways to measure results (reduction in the number of people affected by a disease, for instance) and, ultimately, cost-effectiveness. Measuring such impacts was challenging, since global health projects typically lacked the accountability, tracking systems, and financial controls common in business. Nevertheless, two donors analyzed the results of projects they had funded, and produced reports: The Bill & Melinda Gates Foundation (the Gates Foundation) and the British government's Department for International Development (DFID).
The Gates report, developed by a team from the management consulting firm McKinsey & Company and released in April 2002, recognized the dominant role partnerships had come to play in global health: "Simply put, there are few global public health challenges where any single player has the funding, research, and delivery capabilities required to solve the problem on a worldwide scale.... As one measure of their importance, alliances represent nearly 80 percent of the value of global health investments made by the Bill & Melinda Gates Foundation." The McKinsey team found that "more than 80 percent of public health alliances appear to be working." By "working," they meant the alliance had accelerated, improved, or reduced the cost of an initiative, compared with what agencies could have done on their own. But using a higher standard for realizing their potential, the Gates report concluded that those alliances had not performed as well: "For example, some alliances spend the first six to eighteen months doing little more than developing operating plans rather than attacking the disease burden. And other alliances, even after being launched, are hamstrung by limited resources or difficulties in arriving at decisions among the various partner organizations." Partnerships, in other words, were worthwhile, but many were underperforming.
DFID reached a similar conclusion in its report, released in 2004. It looked at the global health partnerships (GHPs) it had been involved in and concluded that "individual GHPs are seen overall as having a positive impact in terms both of achieving their own objectives and of being welcomed by countries studied.... The general theme of findings from most evaluations is one of GHP success, but with clear scope for yet further achievement if challenges are resolved." The return-on-investment answer was a qualified yes. Even in the polite language of the reports, it was clear many of these partnerships fell far short of their potential. An improvement opportunity undoubtedly existed.
LINK BETWEEN SUCCESS AND CLOSE COLLABORATION
How could partnerships perform better? As these reports were being released, we had already begun to explore the issue of how to improve, collaboration in global health. To begin with, we found that no definition of collaboration was widely accepted. Global health leaders (from all sectors) use the word "collaboration" broadly. As Linden points out, "To some, it suggests polite cooperation. To others, it includes everything from shared data to joint operations." We realized that collaborative partnerships existed along a spectrum, from having a common purpose but operating independently (perhaps with one organization coordinating activities) to aligning efforts and acting cooperatively to actually forming an integrated team, where members work together toward a single shared goal. The words "coordination," "cooperation," and "close collaboration" are sometimes used to make distinctions along that spectrum and suggest a useful framework.
Using this spectrum (Figure 1.1 and Table 1.1), we looked for examples of each type of collaboration in global health, and we began to understand some distinctions. The left side—coordinating in some way but continuing to operate independently—seems to be the most feasible way to respond to such large disasters as the tsunami that struck Indonesia in 2004 and Hurricane Katrina, which ravaged the Gulf Coast of the United States in 2005. For the tsunami UN officials played a major role in coordinating efforts. These efforts were run in parallel, without much sharing of information about survivors' needs and capabilities. A report from the Federation of the Red Cross and Red Crescent Societies indicates that fewer than a quarter of the two hundred agencies present in Aceh a month after the tsunami had provided UN coordinators with activity reports. While more extensive sharing of information would undoubtedly have been helpful, organizations will always be driven to saves lives first in times of disaster.
The middle of the spectrum—acting cooperatively—allows a more coordinated and targeted response. Clinton Foundation efforts to support developing nations are a good example. After conducting focus groups in Africa to determine the key development issue, the foundation heard a clear answer: AIDS! With treatment then averaging US$320 per case each year, the cost of drugs was a major problem, and analysis showed that unpredictable demand kept prices high. The foundation pooled demand from twelve countries, ensuring predictability of demand so that drug companies could manage production and lower costs. Interestingly, no drugs were ordered through the foundation: orders and shipments went directly between countries and drug companies. The Clinton Foundation simply helped these countries cooperate to effectively share information as a way to lower costs.
The right side of the spectrum—forming an integrated team—is appropriate, we realized, in highly challenging, long-term projects like the childhood immunization project of the 1980s. Because the Task Force for Child Survival became an integrated team, they were able to debate challenges and come up with practical solutions. This close form of collaboration, referred to in the title of this book as "real collaboration," is not and should not be the norm for global health partnerships, because it requires the greatest resources. It is also, however, absolutely necessary to accomplish certain goals and is the most powerful form of collaboration.
Rob Lehman, who heads the Fetzer Institute, describes the nature of close collaboration. "Collaboration, on the surface, is about bringing together resources, both financial and intellectual, to work toward a common purpose. But true collaboration has an 'inside,' a deeper more radical meaning." He continues: "The inner life of collaboration is about states of mind and spirit that are open—open to self-examination, open to growth, open to trust, and open to mutual action.... The practices of true collaboration are those practices of awareness, listening, and speaking that bring us into openness and receptivity." After interviewing dozens of global health leaders throughout the course of our research, we are convinced this willingness of partners to set aside business-as-usual and consider new possibilities together is what sets apart the most successful collaborations.
As with the Task Force for Child Survival, close collaboration has to take place between the individuals in the partnership, not between the organizations they represent. Open, productive debates and problem solving can only occur among a core team of individuals who bring the passion, willingness to understand other points of view, creativity, and sheer force of will to make the effort work. In Figure 1.2 these individuals are indicated inside the center circle. This realization helped us define what our book would not be about (Table 1.2). After considering the spectrum of collaboration, we realized we had found an area of focus for our research: partnerships pursuing a single, shared goal performed better when they became an integrated team—the end of the spectrum called "close collaboration." That was where we wanted to concentrate our research efforts.
RESEARCH ON CLOSE COLLABORATION
Unfortunately, that kind of collaboration does not happen often. Leaders in the field of global health often talk about "collaboration" as if it were an ordinary and expected quality of partnerships. And it is, if you consider the spectrum of definitions. However, our experiences at the Task Force for Global Health (the Task Force) have taught us that, despite excellent role models and our predisposition to work collaboratively, our own teams and our colleagues' teams often lack the insights and skills to achieve real collaboration. At the Task Force, for example, we had ample opportunity to work collaboratively. Tackling global issues like tuberculosis, river blindness, and the rising toll of road-traffic injuries in developing countries meant we had the chance to work with partners across the world, including governments, UN agencies, and NGOs. But these partnerships often failed to deliver the full impact we had anticipated. Why was that? And what could we do about it?
In 2004, with grants from the Gates Foundation, the Rockefeller Foundation, and the Centers for Disease Control, we launched a research effort to explore the question, How can global health leaders achieve close collaboration and have a bigger impact? When our planning was complete, we had decided to conduct more than a hundred interviews, hold dozens of face-to-face meetings with thought leaders in the fields of collaboration and global health, form an advisory group to provide early guidance, and convene a symposium to communicate and explore our emerging conclusions. We would look for specific examples of partnerships that either achieved close collaboration or learned valuable lessons through their successes and failures. And we would consider each partnership in the broad context of other efforts to address the disease/threat, outlining the history of those efforts.
The most important part of our research turned out to be the interviews. People from global health, organizational development, education, business, and government were candid and engaging, working with us to make sense of the contradictions and challenges inherent in every global health project. They also told us the stories that anchored our research in the realities of day-to-day work in a partnership.
Based on their input, we came up with a list of partnerships that demonstrated the elements needed for close collaboration (Table 1.3). Bill Foege, former director of the CDC and a leader in numerous global health partnerships, provided a great deal of guidance in making these selections, encouraging us to include such partnerships as the bottom three in the table, which are focused on political outcomes and are inherently more difficult to measure. We did not select the partnerships based on their success or because they represented the full range of global health issues. Rather, we chose them because they were rich in lessons to apply to other partnerships and because the partners were willing to look back on their efforts to reflect on their strengths and weaknesses. We have supplemented this list with lessons from efforts to address other diseases, such as HIV/AIDS, malaria, and guinea worm.
These were not broad efforts to attack a disease/threat, and they were not permanent organizations. They were temporary partnerships of people whose primary identifications were with their own organizations. While each of these partnerships had their imperfections, the stories are about real collaboration—those rare times when people from different organizations come together with passion and purpose and accomplish dramatically more than any agency or person could do alone. After almost two years of research, we convened an advisory group in November 2005 to help us calibrate what we had learned. With their input over the next year we refined the framework for organizing the lessons learned and began drafting this book.
Excerpted from Real Collaboration by Mark L. Rosenberg, Elisabeth S. Hayes, Margaret H. McIntyre, Nancy Neill. Copyright © 2010 The Regents of the University of California. Excerpted by permission of UNIVERSITY OF CALIFORNIA PRESS.
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Table of Contents
Foreword Daniel M. Fox Carmen Hooker Odom Samuel L. Milbank ix
Preface William H. Foege xi
1 Introduction: Why Collaboration Matters and Why it Happens Too Rarely 1
Part 1 Challenges Affecting Collaboration
2 The Diverse Landscape of Global Health 17
3 Nature of the Disease / Threat 31
4 Cultural and Social Challenges 52
Part 2 Insights from Past Partnerships
5 Lessons along the Partnership Pathway 69
6 The First Mile 85
7 The Journey: Discipline and Flexibility in Management 108
8 The Journey: Complementary Leadership Roles 127
9 The Last Mile 143
10 Ways for Donors to Encourage Collaboration 157
11 Conclusion: The Purpose of Real Collaboration 176
Toolkits The First Mile 179
The Journey: Management 197
The Journey: Leadership 211
The Last Mile 222
The Donor 133
Appendix 1 Coalitions and Collaboration in Global Health: A Dialogue Hosted by the Task Force for Global Health (formerly the Task Force for Child Survival and Development) 243
Appendix 2 Coalitions and Collaboration in Global Health: A Symposium for Global Health Leaders 145
Works Cited 249
What People are Saying About This
"This book should be required reading for anyone considering setting out on the path of a global health initiative."Jama