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Know-how

  • Empowering the little guys through the Trade Advocacy Fund

    by User Not Found | Dec 18, 2015
    After Afghanistan received approval to join the WTO in December 2015, our Sarah Trewhitt wrote on the Guardian Global Development Professionals' Network about the fund that has helped it to get there.


    Eleven years after Afghanistan first submitted its application to join the World Trade Organisation, it officially acceded to the global trade group this week, at its 10th Ministerial Conference, being held in Nairobi.

    It’s taken a lot of work to get to this point – lots of small, painstaking steps to help Afghanistan steadily gain the strength and capacity to become the ninth Least Developed Country to join the WTO since 1995. It’s exactly the kind of work that DFID established the Trade Advocacy Fund (TAF) to support. Since 2011, the fund, which is jointly managed by Crown Agents and Saana Consulting, has disbursed grants to countries and regional trade groups or for projects with global relevance, all with the common purpose of ensuring international trade agreements better reflect the interests of the poorest countries.

    In the example of Afghanistan, you can see TAF’s impact front and centre. The Trade Negotiations Training and Capacity Support to Afghanistan project was one of the 58 grants that have been disbursed by TAF, helping to fund vital support to the Government of Afghanistan to aid it through the WTO accession process. This grant’s work began in September 2014, supporting Afghanistan’s Ministry of Commerce and Industry to effectively negotiate new trade and transit agreements that will expand trade and support an enabling environment for private sector-led growth and development. The grant funded training for the Ministry’s staff on areas including the economics and law of international trade, the use of trade data, key international trade agreements and the preparation and delivery of trade negotiations. Furthermore the grant provided advisory services to the Afghan government in the lead up to this week’s historic MC10 conference. 

    With sustainability the operative work in virtually all development work these days, the grant also funded international experts to work with Ministry staff to set out a Trade Negotiation Management Strategy, meaning that the impact of the grant will endure long after the money has been spent. Documenting the work that is being done by TAF is a vital part of the mission: if it isn’t documented, what hope is there of it making real cultural changes – of it becoming embedded in the fabric of the relevant country or region’s own trade habits? Since its launch, TAF has produced 174 analytical papers that have allowed for important research to be carried out in to issues of trade development that will help LDCs to better advocate their positions in bilateral, regional and global trade negotiations. 

    The impact of TAF on Afghanistan is clear and quantifiable, but much of its impact is seen in the leg work being done around the world to steadily bolster countries’ capacities for international trade negotiations. TAF-funded work has helped 701 beneficiaries around the world – a number, along with the number of analytical papers produced, that far exceeds the targets that were set for the fund. The effects of this work have been felt at the very highest levels of international trade negotiations:

    • TAF has been supporting the African, Caribbean and Pacific (ACP) Group in WTO negotiations since 2013 through provision of on-demand technical assistance, advice and coaching to ACP trade delegates in Geneva. This has enabled the ACP Group to become a key player in WTO negotiations, including in the run-up to the 9th WTO Ministerial Conference in Bali 2013 resulting in a new multilateral trade facilitation agreement that reflects developing country needs and interests. 

    • Support from TAF to the Group of Least-Developed Countries (LDCs) in Geneva has enabled the LDC Group to become a proactive negotiating group in the WTO and to table a collective request on trade in services. As a result, 17 WTO countries, including the United States, China, India and Japan, have made binding commitments that give preferential market access to LDC services exports. More countries, including the European Union, are expected to notify their commitments in response to the LDC Group’s collective request. 

    • TAF is supporting the Advisory Centre on WTO Law (ACWL) until June 2016, helping the Geneva-based intergovernmental organisation to act as an “in-house” legal adviser for LDCs on issues such as WTO accessions and dispute settlement.

    • TAF provided technical assistance to the African Union to support negotiations to establish the  Continental Free Trade Area (CFTA) by 2017, which is considered a critical step in fostering African integration and could increase the share of intra-African trade by more than 50% by 2022.

    While the fund closed for grant applications in September 2015, the work under the grants already awarded is set to continue throughout 2016. 

    Membership of the WTO will have clear, tangible and quickly-felt effects on Afghanistan’s economy. It will help to remove its vulnerability to the gouging of customs duties on its exports, allowing it to trade freely without discrimination. Afghan goods and services will be recognised and awarded most favoured nation treatment by the WTO’s 162 member countries. As the changes become embedded in the country’s trading landscape, Afghanistan will be able to attract foreign direct investment in various sectors, increasing job opportunities and reducing trade costs. 

    It’s for advances such as these that TAF was first conceived. As well as Afghanistan, there are now many more other countries and regional trade groups that have greater confidence and capability to take to the world trade stage with stronger stances, louder voices and brighter economic futures. 


    This article first appeared on the Crown Agents partner zone on the Guardian Global Development Professionals Network. 
     
  • Jump-starting a single window with a Trade Information Portal

    by User Not Found | Dec 08, 2015
    Ahead of taking part in a Live Q&A on the Guardian Global Development Professionals Network in April 2015, Crown Agents Single Window expert, Andrea Hampton, looked at why Trade Information Portals (TIPs) are vital steps on the way to opening up a country’s international trade capabilities.


    Put yourself in the shoes of a small business owner or a farmer. You’re doing well for yourself, your crop is good, your domestic trade is strong and you’re well placed to take your business to the international stage – but you have no idea how. What do you know about international trade? Where do you even start to find out about it? When you do find out about it, you find that the procedures are time consuming and complicated and, when factored in to your daily duties of keeping your farm running, just don’t add up to good business. 

    Many governments cottoned on to this a long time ago. They want to help their small traders and producers to grow their business and help them internationally capitalise on their countries’ natural resources and capabilities. Some governments, like that of the Philippines, have built a Single Window (SW) – a centralised portal through which large and small-scale traders are able to easily (and electronically) submit all the information they need the necessary export permits and licences that unlock the door to international business. 

    Before the submission stage, however, they need to get all the information out to the traders – to provide them with the forms, legislation, small print and publications they would then need in order to submit to the Single Window. This way people like our farmer can make informed decisions about their decision to expand their trade internationally. That’s where a Trade Information Portal (TIP) comes in and that’s where governments can kick off their missions to set up their Single Window.

    So what is it? Well, through a TIP, traders have a single authoritative access point to the information they need to comply with all regulatory obligations for all the government agencies involved in international trade, in accordance with the WTO’s Trade Facilitation Agreement (TFA) Article 1 on the publication and availability of information. It helps with cost savings on processes, minimising compliance conflicts and, over time, reduces the overall time and cost of doing business. 

    Building a foundation

    In setting up a trade information portal, many elements need to be raised to a level where they can work equally and effectively with each other and provide leverage for work towards a Single Window. In terms of governance, work towards the TIP can be helped by National Trade Facilitation Committees (NTFC), which provide umbrella structures for the agencies involved in the information portal to come together under. The best NTFC have inputs from both public and private sectors, including groups representing the interests of small business and people like our farmer. At Crown Agents, we’ve set up inter-agency groups like this in the Dominican Republic and Kyrgyz Republic and are encouraging links between TIP/SW work and the NTFC in Bangladesh. 

    Establishing a means of consistent data collection for the portal is also vital: it’s only as good as the data entered into it, so country and agency ownership and motivation is crucial to make sure that the information is relevant and accurate. In our work for the Single Window in the Philippines, we created integrated change management and training plans, which enabled more than 30 government agencies to participate, regardless of their level of automation or technology, and gave them better tools to communicate with trade. The portal also needs to be supported by a strong brand, in order to breed confidence in the subsequent trade development work. Transparency, trust and consistency is what traders want to see and a strong brand that carries through the TIP and Single Window work goes a long way to earn that. 

    Winning support

    A new system for trade requires building an understanding of the opportunities being opened up. Historically, TIPs have often provided information mainly for importers but, as tools of economic growth for developing countries, they need to be just as focused on exporters like our farmer. To achieve this, effective change management, communications and training can’t be underestimated. It’s about changing mindsets – convincing people of the value of such a set-up, be they the people using it or the people running it, and making it accessible. 

    Interfaces need to be customisable and user friendly, tailored to the habits and abilities of local professionals. In Guyana, for example, we set up a Single Window Automated Processing System (SWAP), then developed and implemented an organisational management change plan, prepared operating manuals on the updated processes and designed and delivered training on the new procedures. In doing so we made sure that the Guyanese staff who were responsible for the system had a complete sense of ownership over the system and had no problem taking command of it. 

    Changing convention

    Legislation is key. If a government is unified behind work towards a TIP it signals to business people a commitment to economic growth. Formalising expectations on both sides through Memoranda of Understanding and service-level agreements is common practice, with changes often reaching the very highest levels. These then need to be made public for traders like our farmer to see clearly what they may expect from the regulatory agencies. In the Dominican Republic, we undertook a detailed analysis of the country’s legislative environment and drafted reforms at the highest national levels, gaining a Presidential Decree to support the change. The decree sets an even understanding and a level of standards that ensures that all agencies are working to a common quality and towards common aims. 

    Imagine again that you’re that farmer – but now there’s a TIP in place. Providing you can find access to the internet (and work on mobile technology TIP platforms is moving at a pace with technology itself) the horizon of opportunities now stretches far beyond that which you can see from the borders of your community. A TIP and Single Window provide you with the vehicle by which you can embark on your journey into international markets. 

    About the author

    Andrea Hampton is a senior project manager for Crown Agents, based in Brussels. She specialises in global customs and trade reform project management, with a focus on technology in economic development.
  • Balancing risk, results and grants in fragile contexts

    by User Not Found | Dec 03, 2015
    How do you navigate the risks and unforeseen factors inherent to fragile states to achieve real progress? Crown Agents’ Peter Howes explores.
    Syria Scoping Project
    One of the most pervasive organisational issues development stakeholders face is the question of risk appetite. To what extent do we in the development community take risks in order to try and secure results? This question is particularly pertinent in situations of state fragility.

    Donors accept that they are perhaps overly risk averse. The cross-UK government Building Stability Overseas Strategy accepts that the UK “must also be realistic about the pace of change, providing long term predictable support, taking risks and accepting some failures in order to secure transformational results.” The OECD’s International Network on Conflict and Fragility (INCAF) similarly noted that “achieving long-term transformational results demands appropriate risk taking with political backing and appropriate institutional processes.”  Striking the right balance of risk and potential reward can be challenging, but there are some effective tools that can help with this complex sum.

    Contracting out some programmes and projects to multilaterals, NGOs and the private sector with all the separation of responsibility and liability that that often entails (see: Duty of Care) is only a partial answer. In addition to being willing to accept occasional failure as well as success, there are a number of considerations that donors and implementers need to bear in mind during identification, design and delivery. These are particularly relevant when the programme involves financial transfers in some form, be it in the form of grants to local partners or budget support.

    A fund can be a useful way of ensuring synergy across diverse interventions, that all stakeholders are aware of overarching objectives and have appropriate risk management policies in place. This logic is also applicable for donor portfolios as well as at project and programme levels; the new UK Conflict, Stability and Security Fund and other donor funds such as the Danish Peace and Stabilisation Fund evidence this. 

    The evidence base for the importance of engaging local stakeholders irrespective of the detail of the particular intervention is strong. Grant contracts can be a good means of achieving this; the contextual understanding and community-level reach of local civil society organisations is often unparalleled. When managing grant and fund contracts, we recognise this and compliment the skills of our partners with risk mitigation measures such as a robust monitoring approach, financial management assessments and formal and informal capacity building to offset any identified shortfalls.

    Effective fiduciary risk management is not about saying that a particular idea is not possible, but rather about finding the best way to deliver it with the maximum developmental results within the donor’s risk appetite. We know that working with government systems has its own particular challenges. On our numerous fiduciary risk assessments including in the most fragile of contexts, we always endeavour to not only review a particular modality but also to provide recommendations for how any risks could be minimised through both medium-term mitigations and short-term safeguards.   

    Working alongside political stakeholders is an essential part of any development intervention. This should always be balanced with a reasoned approach to political risk management, which could include stakeholder mapping and an engagement plan. This should inform all aspects of delivery, including grant award decisions.

    Similarly, a crucial part of project design is in-depth contextual analysis, incorporating Do No Harm and conflict sensitivity approaches and ensuring to cascade these principles to subcontractors and grantees. This should very much be seen as an ongoing process, through, for instance, considering adding conflict sensitivity questions to routine programme monitoring. On Crown Agents’ work on the Health Pooled Fund in South Sudan, conflict sensitivity has been at the core of programme delivery.

    When designing and delivering grant programmes in fragile contexts, an adequate and robust monitoring and evaluation framework is essential. Consideration should be given to the right mix of methods and modalities – when should a third party or independent monitor be used? Is a logframe the right approach? Would an iterative approach to M&E be most effective?

    Particularly in the highly changeable environments of fragile and conflict affected states, it should be remembered that Payment by Results is no panacea; numerous factors can preclude achievement of results. 

    Due to the complexity and unpredictability of operations in these regions, donors should consider new approaches and be more willing to use approaches such as a larger number of smaller-scale ‘trial’ grants which can later be scaled up depending on success. This can be a good way of being more innovative and responsive but again require an acceptance of occasional failure and particularly robust, in-depth M&E. 

    Above all, it is essential to recognise that achieving tangible, sustainable developmental progress in fragile and conflict affected environments necessarily requires a degree of calculated risk taking. Many of the most transformative interventions are the most inherently risky.

    About the author:
    Peter Howes is a Consultant and Project Manager in Crown Agents’ Governance and State Building department, where he focuses on project implementation in fragile and conflict-affected states. 
     
  • Development, security and the Congolese National Police Force

    by User Not Found | Sep 11, 2015

     

    Crown Agents consultant, Roxane Burstow, recently wrote for the Guardian Global Development Professionals Network on how police reform in the Democratic Republic of Congo is helping the country's peace and prosperity.

    Security is an essential condition for sustainable development.  A government’s inability to protect its people and control its territory often undermines progress on everything else. The international community has recognized the link between security sector reform and development and the 2015 Sustainable Development Goals (SDGs) acknowledge the role of violence and fragility in cycles of poverty and the interconnected nature of conflict and development. 

    An enhanced security environment lies at the core of a peaceful and prosperous Democratic Republic of Congo (DRC). The government recognised the importance of this in the 2006 Governance Compact, putting security sector reform (SSR) (including disarmament, demobilization, and reintegration (DDR)) at the top of the agenda. The 2007 report of MONUC (Twenty-third report of the Secretary-General on the United Nations Organization Mission in the Democratic Republic of the Congo) concluded that there was a growing need to push for the creation of a national police force that could take policing responsibilities back from the Congolese Armed Forces (FARDC).

    EU-funded program to support the National Police Force  

    Police reform is an important entry point for security sector reform. The police are arguably the most visible and immediately present aspect of the security system, in a unique position to provide the foundations for stability, security and confidence in the state. The reform of the Congolese National Police (PNC) to create a more efficient, accountable and active police force is therefore a critical milestone to DRC’s SSR efforts. The European Union (EU) has been supporting the Government with these efforts, including through a programme (PARP) to reform the National Police of DRC. EUNIDA, a grouping of EU Member State implementing agencies was contracted for Phase II of the PARP programme with Crown Agents as the leading implementer. PARP II, which will run from 2014 - 2016, focuses on four areas, providing comprehensive support and strengthening of all the necessary facets of development within the PNC:  

    • Planning and implementation of the reform
    • Support to the Human Resources Department
    • Support to the Department for Budget, Finance, Management Services and Infrastructure Maintenance
    • Reconstruction and rehabilitation of training facilities.

    Nationwide census of the Police Force

    A key step in the reform process is a nationwide census of PNC staff, estimated to number 110,000. Even though this is considered a high estimate it still falls short of what is needed. With a population of around 70 million, the DRC would need an estimated 150,000 officers to have an adequate ratio with civilians. 

    The census is critical for getting a more accurate picture of the total number of active police and identifying recruitment and training gaps that need to be filled. It will also help reveal possible ghost workers. The results of the census will set the groundwork for salaries to be paid electronically to all registered policemen, limiting opportunities for extortion and leakage. In recognition of the importance of a stronger police, the government recently marginally increased monthly salaries. 

    A census, usually a relatively straightforward exercise to complete, is more challenging for somewhere like DRC. Its ground transport has always been difficult: the terrain and climate present serious barriers to road construction and the distances are enormous. Local travel by air is unreliable and often travel by river is the only way to access remote provinces, though undoubtedly no more secure or rapid than alternative options.  
    PARP II has been helping to roll out the census simultaneously in 11 provinces since April 2015. We recently travelled to one of the census sites in DRC’s largest port town, Matadi, as part of a review of the project’s progress. Though it should have been one of the most accessible sites, a seven-hour car journey on one of the most well maintained roads in the country turned into a fifteen-hour odyssey, giving us a flavour of the logistical difficulties faced by our staff and the police officers involved in completing this exercise. It’s problematic for both the census teams and for the policemen travelling to the census sites. The latter often have to travel on foot, some for up to two weeks to reach the sites. Once there, they are registered into the system and receive electronic ID cards containing information about their rank, location etc. 
     
    The census is an ongoing process given that it has to be repeated every few years to capture new recruits and remove those no longer serving, so it’s vital that the government takes ownership of the exercise and avoids overreliance on the international community. Yet completing the census may well become more challenging with the recent division of the provinces from 11 to 26, effectively more than doubling the required census sites, requiring ever more human and financial resources.

    Improving financial and human resources management 

    Running parallel to the census is training covering different basic aspects of police work, as well as responsibilities related to the budget department to ensure sufficient resources are captured and allocated to the PNC. Progress is ongoing on building a police training academy, ACAPOL, which is being partly funded by the DRC government. 

    While these combined elements form the stepping stones to ensuring that the PNC can act as a demilitarised unified force that is trained and adequately resourced, a lot still needs to be done. There is a need for a long-term approach, recognising that the difficulties faced by similar countries in the security sectors, notably in policing, are not amenable to short-term inventions. They require changes in culture and attitudes as well as institutional and human resource capacity development which take years to achieve. 

    Security sector reform must, therefore, be viewed as a process that requires long-term persistence. This is certainly true in DRC.

     
    This article first appeared on the Crown Agents Partner Zone on the Guardian Global Development Professionals Network

  • Learning lessons: educating Ghana's out-of-school children

    by User Not Found | Jun 26, 2015

    In May 2015 leaders from 160 countries gathered in South Korea for the World Education Forum to develop a framework for action on education that will guide the achievement of the United Nation’s Sustainable Development Goals .

    This is considered the most important meeting on education in a generation and concluded with an important political declaration that puts equity and learning at the heart of an ambitious and aspirational education agenda.

    While school enrolment has improved over the past 15 years, the world has failed to meet the goals of universal primary education, with 58 million children of primary school age still reportedly out of school. Implementation of the Education for All goals and the education-related Millennium Development Goal has failed to prevent the most disadvantaged children being left behind.

    As the international community that gathered in South Korea is drawing on lessons from the past 15 years and preparing for the future of education, we reflect on some of the lessons that Crown Agents has learned by helping the Government of Ghana reaching its most marginalised children.

    School participation in Ghana has increased substantially between 2003 and 2008 but despite these significant gains access to education is still inequitable. Several barriers work in combination to deny children an education – especially those in the most deprived areas of Northern Ghana. The main reason why children are out of school is the high cost of education for families, compounded by the loss of income from a child’s labour. Poverty usually interacts with socio-cultural factors, such as early marriage and child fosterage, along with supply factors such as shortage of schools and other inputs, to increase disadvantage.

    Over the years Ghana has introduced policies that sought to make basic education more accessible and in 2005 introduced Capitation Grants to abolish school fees. Although this scheme led to a surge in enrolment, a significant number of children from disadvantaged backgrounds and those living in rural areas still do not attend school. The question remains whether universal basic education can be achieved by relying exclusively on the expansion of public systems or other resources need to be mobilised.

    The answer is in non-formal education programmes, which can provide ‘second chance’ education for out-of-school children and expand education to areas beyond the reach of the mainstream public school system. One of these non-formal programmes is complementary basic education (CBE), which has been tried successfully in Ghana and other countries. Complementary programmes improve access to basic education in countries with large out-of-school children populations, bridging formal and non-formal education to allow pupils to return to mainstream public school. These are community-led programmes implemented through partnerships between communities, civil society organisations and governments. Local management best serves the needs of the communities and helps to overcome certain limitations of formal education.

    A model of CBE has been implemented in Ghana for 15 years on a limited scale and with Danish financial and technical aid. Evaluations have found it to be effective and efficient in helping to enrol excluded children from underserved communities into public school. Part of what makes this model work is that children learn in the language spoken at home and the curriculum is more limited and focused, delivered through materials that are locally relevant in terms of language and content. In only nine months it covers the language and maths instructional objectives for grades one to three.

    In 2014, CBE was formally written into government policy, to ensure access to basic education for every child in Ghana. CBE classes are organised and managed by NGOs, working with communities and the government. The programme is financially and technically supported by DFID and USAID working through Crown Agents (in partnership with Associates for Change and CFBT to expand enrolment, and prepare the country to take the lead. There are valuable lessons that we have learned in the process:

    Successful complementary models grow from the culture, context and the people they serve in the communities and depend on effective, enduring and innovative partnerships between local civil society organisations, communities, government and other funding agencies. All parties need to come to an understanding about the roles, responsibilities and resources each can provide.

    Quality training and voluntarism are essential for successful expansion. Training helps to transfer expertise and values and to maintain standards, ensuring that these assets are not watered down as the programme expands. It is vital to the success of the complementary programmes since the lessons are taught by local volunteers and not qualified teachers.

    The ethos of supportive supervision and monitoring applies throughout the organisational structure of the programme. At all levels, the emphasis is on frequent field visits, meetings and coaching. The central management unit spends a lot of time tutoring project staff in the field and hearing people on the receiving end of the programme’s support.

    To achieve the goals of social justice in an era where governments can’t spend, it is essential to mobilise resources from the public, private and non-profit sector, developing and regulating local partnerships deeply rooted in the communities they serve.

    Donato Pezzuto is Crown Agents’ Deputy Practice Lead for Governance and State Building and is Project Manager of the Ghana CBE work for Crown Agents.

    This article first appeared on the Crown Agents 'Transforming Institutions' Partner Zone on the Guardian Global Development Professionals Network. 

  • Private sector lessons can improve public health supply chains in Africa

    by User Not Found | Jun 18, 2015

    Crown Agents’ Innocent Dube looks at how private sector lessons can help to build steady and stable medical supply chains in developing countries.

    Nigeria NACA clinicSupply chain transformation is on the tip of the tongues of many people in the development sector, but what does it mean and how can it bring about excellence and performance in the public health sector in developing economies? Transformation projects involve a complete shift in ways of doing business – essentially challenging the status quo and calling for organisations and sectors to think and act differently from the top and all the way down. Transformation therefore is something bigger than business process re-engineering and requires a clear understanding of the nature of a business, its goals and the extent to which these goals are achieved.  Transformation is by no means a quick fix, but typically a long arduous journey where benefits are achieved incrementally along the way. 

    Major public companies such as GSK, Coca Cola, DuPont and Proctor and Gamble have undertaken supply chain transformation projects which have kept them at the top of their chosen markets and enabled growth – in each case benefiting from access to large budgets, exceptional leadership and skills to deliver the required change. But in each case lessons have been learnt that apply across both the private and public sectors.

    Du Pont, on its transformation journey, identified five strategic elements to be targeted for improvement to include (1) customers and markets (2) metrics and measurement capability (3) supply chain and enterprise systems (4) processes and process capability and (5) people development and competency – It is imperative to get these right.  By correctly targeting these 5 elements DuPont increased free cash flow, sold excess capacity together totalling over $3 billion in bottom line benefits. Experience suggests that public health supply chains in developing economies will soon be bombarded with consultancies and donors seeking transformation in the footsteps of the success of the larger corporates. In particular consultants and consulting firms with experience of delivering private sector transformation will be looking to take that experience and apply it in new markets. 

    In sub- Saharan Africa pharmaceutical supply chains that support health services provided by the state are mostly in the hands of government controlled entities mandated to ensure pharmaceutical products are available on the frontline. For decades, these entities have had difficulty delivering efficient supply chains to ensure health for all. These complex supply chains are typically led by staff whose core training and profession is not in the field of supply chain management, and will have had little practical exposure managing and delivering high performing supply chains. Therefore, they lack the core knowledge of fundamental supply chain practices and methods required to deliver lasting change and bring about high performance. These supply chains are typically highly deficient in their development of, or access to, the 5 strategic elements stated above. With limited funds, diverse stakeholder communities, management drawn from outside the supply chain industry, poorly rewarded and motivated staff together with basic processes and systems, it is difficult to deliver an efficient supply chain service. 

    Taking the case of public health supply chain systems in sub-Saharan Africa, we findEfforts intensify to treat children living with HIV that the transformation of these supply chains requires a different mind-set when thinking about how to deliver successful change.  Our experience working in sub-Saharan African countries has shown us that public health supply chains in Africa are not short of complexities; one has to balance government bureaucracy, individual donor interests, infrastructure limitations, vested interest and the influences of the wider political economy to deliver a high performing supply chain.  Budget limitation tends to highly feature as a major constraint not only for transformation projects but also for commodity procurement – to quote a senior Director in Zambia’s Ministry of Health “we have a $100 need yet we only have $1”. Support from donors until recent years has been focused on providing medical commodities to cover the shortfall left by national governments but has fallen short in financial and technical support to formalise and strengthen the national supply chains required to deliver products to the end user. Initiatives to transform supply chains have at best been piecemeal and fragmented and have so far not provided a holistic solution to challenges faced. The support that is provided is seemingly ad hoc and targeted at addressing parts of the supply chain.

    We have come to know and understand that supply chain transformation projects in the public health sector in Africa can be complex ventures that present a critical need to balance and address competing interests from multiple stakeholders. Current evidence suggests that major corporate transformations take 10 years or more before they fully mature with small short term incremental benefits being realised along the transformation journey. Considering the successes and achievements made by major private sector companies transforming supply chains, it seems logical for one to simply take the same solutions and methods which have worked in the private sector and replicate them in public health supply chains in Africa – the assumption being that the transformation surely cannot fail if it is led, designed and implemented by the best in class.

    However, one of major pitfalls faced by successful, highly competent and experienced private sector practitioners when designing and implementing public health supply chain projects in Africa is the failure to discern the dynamics of the sector’s blurred lines of vested interest, genuine lack of knowledge, fragmented initiatives and lack of follow through on critical issues by staff running the business of government. Failure to recognise and reconcile these competing interests can in no uncertain terms lead to failure of a good change initiative no matter how robust the proposed solutions may be. 

    For real change and transformation to take place, there is need to have new experienced people leading from the front implementing new initiatives, but this is not particularly easy to construct in the civil service as most countries guarantee jobs for life with little to no chance of changing staff or creating new positions with the relevant expertise. The support provided by donors is well recognised; however it is time-bound and often aligned to the objectives of their principal governments with funding cycles seldom seeing transformation projects through to the end. The governments receiving aid on the other hand are driven by their own political system and aligned to the policies of the ruling party and politicians of the day.  Political support is more readily given where change is promised within a single political cycle such that it can be used by the incumbent government to support re-election. These cyclical changes and instability often disrupt transformation projects which by their nature are long term ventures requiring unwavering leadership to see them through to the end.

    It is also important to recognise that while private and public sectors seek the common goals of high customer service levels, efficiency and cost reduction the ultimate motivation for delivering supply chain transformation in each sector is quite distinct and driven by divergent objectives; profit for the private enterprise and social outcomes for the public sector.

    It is therefore imperative that agencies entrusted with leading the change and transformation programmes in the public health sector in Africa identify and assimilate the often unrecognised competing forces in order to bring to bear change that contributes to positive health outcomes. There have been calls for greater collaboration between the private and public sector in Africa, these collaborations and solutions need to be applicable and relevant to the specific context and take into account the local political economy and multi-stakeholder interest.  The point to take home is that however difficult successful supply chain transformations are to achieve in the private sector it is much more so in the public sector particularly if you want the change to stick!

    TRANSFORMATION IN ZAMBIA: For a decade (2004 – 2014) Crown Agents Limited worked with Medical Stores Limited, a Zambian state owned pharmaceutical distribution company on its transformation journey.  By engaging a private company through competitive tender to lead the change, the Government of Zambia demonstrated great determination and commitment to turn around the country’s pharmaceutical supply chain by first strengthening its national distributor. The gains made during this journey, steadily built confidence in the organisation and saw multiple distribution channels transition into a single nationally led distribution channel. The Board of Directors of MSL recognised that transformation was something that could not be achieved overnight but needed a long-term window of intervention hence successive governments continued to support the transformation project over the 10 years.

    This article first appeared on the Crown Agents 'Transforming Institutions' Partner Zone on the Guardian Global Development Professionals Network.
  • The processes and priorities of fund and grant programmes

    by User Not Found | Jan 02, 2015

    “Anyone can give away money or spend it: but to do all this to the right person, to the right extent, at the right time, for the right reasons, and in the right way, is no longer something easy that anyone can do.”

    It was 350BC when Aristotle said that, and in the intervening millennia, the effective spending of funds and grant programmes in the developing world has become much more complicated than even he could envisage. Grant programmes aimed at tackling health-related issues have long been a successful way of getting money to the people and projects that need it the most. Fund and grant managers still face inherent tensions, however, between managing risk and improving programme effectiveness, which must be carefully balanced using good judgement and good research.

    Grant programmes take many forms, but differ from other programmes in that they are often demand-led, less prescriptive and more flexible. Recipients can be funded to develop and implement more innovative and fluid projects that can provide tailored solutions to health concerns, be it developing an ambulance network, training eye care specialists or building a support network for people living with HIV/AIDS. Some grant programmes have taken aim at tackling specific diseases or health issues – such as the Global Fund, which focuses on HIV/AIDS, tuberculosis and malaria, or the Scaling Up Nutrition Fund in Zambia – while other funds have sought to raise overall healthcare standards in particular regions or countries, like the currently-underway South Sudan Health Pooled Fund and results-based financing programmes in many countries. Broader-spectrum funds have spread their nets more widely, like the Global Poverty Action Fund, which in aiming to tackle off-track Millennium Development Goals has funded a range of health projects, and some – like the Civil Society Challenge Fund – focus on strengthening advocacy work. 

    A grant manager’s job requires intricate technical knowledge and the ability to balance management of risk with efficiency, while being the servant of multiple masters, including funders and grant recipients. Money must be spent well and transparently, while reaching deserving pockets of society and gaining the greatest impact for the money. So what is it that goes into allocating these life-saving grants among the people who need them most?

    Building structures and measuring success

    A clear, over-arching strategy for a fund means it can outline and account for its ultimate purpose and guide decision-making. An important factor in building a successful grant management programme strategy is developing a strong logical framework, or logframe. This is a tool for planning and managing development initiatives, setting out what the project or programme is trying to achieve and a framework for assessing risk and effective monitoring & evaluation of progress against targets.

    Individual grant recipients must also have their own logframes to outline their stated objectives, how they will be achieved and how they align with the overall purpose of the fund. A grant’s specific logframe needs to set out realistic objectives and targets for the grant in question, which takes into account the fact that targets must be aligned to specific circumstances: even if two grants have the same purpose, the measures of success would vary if one was being delivered in Zambia and the other in Benin.

    In instances where logframes are absent or poorly structured, the overall purpose of a grant programme or fund can become muddied and indistinct, as no one has answered vital questions about objectives, strategies and measuring achievements. The absence of a strong logframe can be most stark in large funds that are not confined to tackling a single area, but rather seek to address a wider mission. As the money is divided and the grants trickle down to a diverse array of projects and purposes, if a fund does not have a clear strategy, it can quickly turn into a quagmire of small pockets of money that are not aligned to a cohesive mission.

    Outreach – engaging with the service providers

    Reaching out to the right recipients and making sure grants are spread evenly, fairly and effectively is a major early challenge for a fund manager. A cohesive fund programme strategy will drive how a fund reaches out to its potential recipients, and the challenges and needs of this outreach varies according to the size and scale of its target recipients. Larger NGOs working in developing countries often have dedicated staff who are already trained and experienced in spotting and capturing funding opportunities. Communications can be much trickier, however, for funds that need to reach out to and engage smaller, more grassroots organisations, where much of the truly penetrative work is carried out.

    Local NGOs often do not know how to play the application process – if they even know it exists at all. Fund managers must therefore work out the most effective means possible to inform and engage their target recipients and raise the impact of their funds’ work. For some this means going out into the field to stage workshops and information-spreading exercises throughout eligible regions and demographics, inviting representatives from potential beneficiary organisations and providing a forum in which they can explain the aims of their fund and answer any questions about it. Tapping local knowledge networks is also vital, as we have found out with the South Sudan Health Pooled Fund, a Crown Agents-managed fund to strengthen healthcare structures in six of South Sudan’s ten states. We have made use of the South Sudan NGO Health Forum – an independent coordinating body of national and international health NGOs working in the country – to spread word about the fund among potential recipients. Outreach programmes such as these are vital to making sure that funds and grant programmes do not suffer from selection bias and become the preserve of organisations that have the resources and experience to seize funding opportunities or that have already benefited from grant funding in the past.

    Assessing capability and capacity

    Smaller organisations may have passion and purpose in abundance but the strict requirements and regulations that accompany international grant money can sometimes outstrip their capabilities. Through capacity assessments, the technical ability, financial management capability and ethics of grant recipients must be thoroughly assessed, to make sure that they meet the relevant eligibility criteria and are able to effectively manage a grant and to identify any risks. 

    While making sure that the money is going to recipients that can spend the money well, grant managers must make sure these processes do not limit the ability of smaller, local organisations to access funds. The biggest risk for a grant fund is failure to achieve its stated objectives, so due diligence processes must be designed so that they do not hinder it from this. This again highlights the balancing of tensions that fund and grant managers must perform, requiring not only technical expertise but strong judgement and a pragmatic approach. Well-structured and implemented due diligence should not be a series of hurdles that must be cleared, but rather a tool to identify gaps and risks, as well as the means to address these through grant implementation.

    If organisations are able to succeed here, then – if funding allows – they can often benefit from a much greater level of assistance from grant programmes. With the validity of their mission ascertained and their strengths and weaknesses identified, grant managers can build their organisational capacity in areas such as financial management, monitoring & evaluation and governance, which can improve grant implementation and help achieve grant programme objectives, as well as having more long-term sustainable benefits for both organisations and beneficiaries.

    The future of healthcare grant funding

    Funds and grant programmes will continue to be vital mechanisms through which philanthropic and donor money is channelled to the world’s developing nations. Experience has shown that they are able to support real changes at the most elemental levels: there is no doubt that funds like the Global Fund and GAVI have helped save lives. The challenges for the future lie in maintaining their efficiency and ensuring funds are able to reach those most in need and can help to create substantive and sustainable changes in health and other sectors. Increasing innovation is likely to drive change in the future – for donors and recipients – but what effect will that have on larger and smaller beneficiaries and the overall demographics of who receives grants? Will the role of advocacy and capacity-building funds grow in order to increase the sustainable impact of donor money? However global priorities shift in the coming years, grants and funds will continue to create structures to improve the quality of people’s lives in the developing world and drive down disease, but the question of how they manage to do so will be an ongoing challenge.

  • How to improve the use of challenge funds for private enterprise

    by User Not Found | Dec 03, 2014

    by Defrim Dedej, Senior Consultant at Crown Agents

    In recent years, a number of donors have increasingly championed the importance of supporting economic growth to help bring about sustained gains in developing countries. Large volumes of public capital from DFID, SIDA and others have been targeted at developing markets and boosting private enterprise. The approaches to facilitating this may vary but one mechanism utilised with enthusiasm, one which is seen to yield real results, is the Challenge Fund (‘CF’).  

    As a grant making mechanism, CFs are used in a variety of contexts and targeted at a specific group of people or issue. Managed carefully, they can achieve not only the desired outcomes but also encourage innovation and foster genuine partnerships among various stakeholders - which can lead to better learning and stronger impact in the future.

    Some of the benefits arising from using a CF mechanism can include:

    • A cost effective and transparent funding mechanism
    • A mechanism that encourages competition through triggering a search for smart and cost-effective solutions
    • The ability to generate and test new business ideas without distorting the local market
    • A mechanism which if managed well can encourage and achieve systemic change which can benefit the poor.

    But no funding mechanism is without risks, and there are none that can’t be improved upon.  From Crown Agents’ wide experience in managing donors’ funds in this way, here are just a couple of ways in which improvements could be made, increasing the likelihood of more efficient use of public capital and enhanced developmental outcomes.

    Better programme design 

    Strengthen the design of CFs to ensure they are based on good research, a strong theory of change and carefully constructed logical framework. Currently, a number of active CFs appear rather unfocused and overly ambitious as well as failing to take particular local conditions into consideration. The potential implication of this is damage or distortion of local economies – which goes against the key “do no harm” principle of grant making. 

    Think about the different components of a CF and how they work as a whole – recognising that there is a series of decisions to be made.  These include the area of focus; the type of grant winner desired and proposals that will lead to grants; and of course the outcomes anticipated. Each decision made impacts upon others and may limit a donor’s choice in other areas or even rule out other choices completely. It’s important to consider how decisions relate to each other; no decision should be taken in isolation since this could lead to a huge waste of money and resources.  

    As part of the CF design process, donors also need to specify the outcomes and impacts they are seeking to achieve and their plans to measure success, or the lack of it. Without doing so and without clear KPIs attached, the end result can take on an Alice in Wonderland uncertainty, which is to nobody’s ultimate benefit. 
    Would you tell me, please, which way I ought to go from here?'` That depends a good deal on where you want to get to,' said the Cat.
    `I don't much care where--' said Alice. `Then it doesn't matter which way you go,' said the Cat,`--so long as I get SOMEWHERE,' Alice added as an explanation. Oh, you're sure to do that,' said the Cat, `if you only walk long enough.‘  

    One approach to focus this is, for example, to concentrate on a specific country and/or particular sector (agriculture, mobile technology, health, education), rather than a multi-country and more widely-focused approach. Such targeting can increase understanding of real dynamics and needs and improve the learning cascade in the chosen sector, opportunities for replication, and end impacts. The resources available to manage the CF can be used more efficiently - which can improve services to the grantees.  For example, the CF Manager can deliver capacity building to grantees through a workshop instead of a one-to-one basis. All grantees will benefit when they speak the same language, and all are operating in the same field and might be facing similar challenges with, for example, the legal system. 

    Undertaking monitoring and evaluation would also be easily facilitated as meaningful standard indicators can be used allowing a donor to report succinctly on the CF’s overall outcomes and impact.

    Balancing risk with returns on successful innovation

    By design, the key purpose of a CF is to encourage innovation which, given the possibility of a lack of best practice on which to base business activity, implies risk. And remember too the high proportion of new business failures for a wide range of reasons even in Western markets.  

    This means a mind-set which acknowledges the risk and a clear acceptance of a CF’s fundamental role in funding experiments and finding new approaches and, at best, creating a breakthrough change by transforming the way that we tackle a particular complex problem.  

    And in turn, this might mean accepting a higher risk of failure – but along with the trade-off of a truly game-changing investment if a venture succeeds. So, the key question when assessing CF proposals aimed at supporting private sector development is less ‘Is this going to work?’ and more about ‘what will the end impact be in terms of poverty reduction and wealth creation?’  And a subsidiary point may be that by funding only those business ventures that are deemed sure bets a donor runs the risk of distorting local markets since they might anyway be more likely to obtain commercial loans.

    So risk and reward trade-offs hold good for CFs – with the key aim of generating larger scale, positive social impact when successful, set against the potential downside of financial loss when innovations fail. Failure in itself is not a bad thing, so long as lessons can be learnt and not repeated.  

    Bearing in mind the above, when creating a private sector-focused CF, donors could take several steps to manage the risk while also seeking strong impact:

    • Collaborate more with private trust/Foundations, whose risk profile may be less constrained by use of private (rather than public) funds. They may be aimed at finding innovative solutions to complex social problems and learning from their experience or 
      • Concentrate the CF objective on supporting the scale up those innovative business venture ideas that have proved successful. 
    • Require the CF Manager to be more proactive at identifying and reaching beyond the “usual suspects“ in order to scout for promising new business ventures whose successful growth will significantly assist the poor. 
    • Use a selection process that views positively engaging unconventional problem solvers and high-risk, high-reward business venture ideas.
    • As well as providing capital, provide targeted technical assistance to the new ventures as they develop. Take a hands-on approach in helping to shape and guide early-stage ideas as they move from concept to implementation – using mentors or others who have good experience of micro business and its growth path.
    • Closely monitor and evaluate all funded business ventures and consider diverting funding from weaker performers to the more promising ideas, allowing enough time for ideas to percolate, iterate, and emerge.

    To conclude, the challenge for donors as far as deploying the mechanism of CF to support PSD is to achieve a realistic and balanced approach. In practical terms, this means improving the CF’s programmatic design and finding innovative means of management and perhaps accepting a higher risk profile. A key point worth remembering is that the biggest risk to any donor is not financial loss but inability to achieve the desired outcome/impact for their funds.

    For more information contact def
  • Back to Basics: Designing an appropriate health financing system

    by User Not Found | Nov 14, 2014
    Zimbabwean health administratorsGovernments are issuing inspiring declarations of intent to provide health coverage for all citizens. Development partners are promising to back their efforts and Universal Health Coverage (UHC) has made it on to the shortlist for adoption as a post-2015 goal[1]. This should be good news for the world’s poor.

    Ultimately UHC is about ensuring that all citizens have access to accessible, affordable, quality health provision, regardless of their wealth, gender or other circumstances. We are, however, a long way from this target. Every day 800 women die during pregnancy or childbirth, while 8,000 new born babies die during their first month of life[2]. Each year 100 million people are pushed into poverty by health costs[3]. Crucially, health inequality remains a life-and-death issue: being born into a poor household in Sub-Saharan Africa typically raises the risk of child mortality by a factor of three[4].

    Finance is at the heart of the problem[5]. Governments too often spend too little of their limited resources on health, and allocate scare resources in an inefficient and inequitable manner. The World Health Organisation recommends that for a developing country to provide a basic package of essential services it must spend at least US$34 per capita, per annum. Yet in 2012, twenty-two countries across Africa spent less than $50 per capita, per annum and eight countries spent less than $25 per capita[6]. The result is limited coverage and poor quality services that people have to pay for when they fall ill. Around two-thirds of health spending takes the form of out-of-pocket payments[7] – and no money means no treatment.

    So, if finance is at the heart of the problem, what can be done? In the first instance, governments can take a critical look at how their health systems are financed to deliver the desired outcomes, and assess options for the future. There are a number of key principles that can be applied in this regard:

    • Understand the inputs, demographic trends, outputs and outcomes of the system that is being addressed;
    • Analyse options from the perspective of three basic principles of public finance: revenue collection, risk pooling, and allocation of revenues across a range of services. Healthcare financing reform implies introducing changes to one or more of these key functions of financing.
    1. Revenue collection is the way health systems raise money from households, businesses and external sources. Revenue for the health sector may include taxes and charges, grants and loans from development partners, private and community insurance payments and out-of-pocket expenditure by health users. Functional health financing systems seek to raise an adequate and sustainable level of revenue in an efficient and equitable manner.
    2. Risk pooling involves combining resources so that the members of the pool (health users) share collective health risks, thereby protecting them from large, unpredictable and catastrophic health expenditures.
    3. Resources need to be allocated to maximise health outcomes and ensure equitable access to good quality health services. Health services may be purchased by a government agency, social and private insurance providers, employers and individuals. An understanding of health financing will necessitate analysis of the different purchasers.
    • Guide financing design decisions by taking into account the following criteria:
    1. Is the mechanism (e.g. government financed, social health insurance, private health insurance and/or community-based health insurance) sustainable and feasible?
    2. Does the mechanism pool risks and ensure financial protection?
    3. Does it lead to greater efficiency in revenue collection and allocation? and
    4. Will its application enhance equity in financing and access to services?
    • Take a medium-to-long-term perspective, and ensure political and institutional factors are at the forefront of any assessment.

    Zimbabwe health thumbApplication of this approach is not new – policymakers within Ministries of Health and central government make macro level financial decisions to steer their health systems to deliver. Yet much of the recent debate is focused on ‘new’ financing models (e.g. results based financing), the degree of risk sharing between public and private and a relentless push for a ‘back to basics’ approach within the public financial management community.

    As a ‘new’ topic, results based financing (RBF) for health refers to any programme that transfers money or goods to either patients when they take health-related actions (such as having their children immunised) or to healthcare providers, when they achieve agreed performance targets (such as immunising a certain percentage of children in a given area). Overall evidence suggests that RBF programmes increase utilisation of services, but results are ambiguous as to how it affects health system measures such as quality, efficiency and outcomes.

    Crown Agents with HERA, is currently responsible for scaling up a RBF model across 42 districts in Zimbabwe, in close partnership with the Ministry of Health. The programme hopes to deliver improved quality, access and utilisation of primary and maternal, newborn and child health services. This will be achieved through the removal of user fees for pregnant and lactating women and children under 5 years, as well as through the incentivisation of specific services by health facilities (and support and supervision by district and provincial health executives). The programme aims to achieve improvements in both quantity and quality, the latter achieved through greater community participation in health service delivery, as well as improved support and supervision. What is already clear is that having good health information systems are key to the success of RBF.

    Governments and development partners understand the importance of supporting UHC – good health improves labour productivity, facilitates learning and contributes to economic growth and poverty reduction – but policymakers need evidence. RBF approaches, if monitored and evaluated, can provide this evidence; but implementing RBF alone may not deliver improvement in all health outputs or outcomes. It would be folly to consider any new innovation as the silver bullet to strengthening health systems. Instead we must continue to be guided by the principles of health financing and then consider innovative approaches. Undoubtedly taking a holistic view – technical, institutional and political - may be more onerous to measure, but without doing so we are less likely to see sustainable, long-term change.


    References

    1. Proposed Target 5a states: “Ensure universal coverage of quality healthcare, including the prevention and treatment of communicable and non-communicable diseases, sexual and reproductive health, family planning, routine immunisation, and mental health, according the highest priority in primary health care”. www.unsdsn.org/resources/goals-and-targets/
    2. http://www.savethechildren.org.uk/sites/default/files/images/State_of_World_Mothers_2013.pdf
    3. http://www.who.int/whr/2010/10_chap01_en.pdf
    4. http://www.odi.org/comment/8458-universal-health-coverage-but-mind-equity-gaps
    5. Financing is a key system building block of any health system alongside: service delivery, health workforce, health information systems, access to essential medicines and leadership/governance. As noted by the WHO (2010) these building blocks are needed for improved health (level and equity), responsiveness, social and financial risk protection and improved efficiency. WHO, 2010: Monitoring the building blocks of Health Systems: A handbook of Indicators and their measurement strategies.
    6. WHO (2012): Health financing data set. http://gamapserver.who.int/gho/interactive_charts/health_financing/atlas.html?indicator=i3
    7. http://data.worldbank.org/indicator/SH.XPD.OOPC.ZS/countries?display=default


    Jo Kemp is Crown Agents' Practice Lead for Governance and State Building. A former ODI fellow and consultant to the World Bank, she has particular interest in the relationship between PFM and service delivery.

  • Corporate social responsibility- going beyond compliance

    by User Not Found | Oct 13, 2014
    According to a report by the UN Department of Economic and Social Affairs, Corporate Social Responsibility (CSR) is the ‘overall contribution of business to sustainable development’. The European Union states that ‘CSR is the concept to explain the way companies integrate environmental and social concerns in their business activities and interaction with shareholders on a voluntary basis’ (Herbert, C. M. & Schantz, C. V. (2007, p. 4).

    What CSR should therefore be is a perfect arrangement of ‘internal business goals with externally set societal goals (those that support sustainable development)’1.

    CSR has become an increasingly important part of business processes. Whether a part of the government agenda or under a ‘business case’, the need for companies to respect and give to the society and environment that they are set up in has become a growing principle.

    A recent UK government response to call for views on corporate responsibilities highlights the evolution of CSR from “…an add-on… to a more integrated and disciplined field…” Albania, amongst other countries in the Balkan region, strongly advocates the integration of economic, environmental and social concerns within its social and business activities. 

    We have worked in Albania since 1997. In 2013 we signed a contract with the government of Albania to support the development of the Albanian Customs Administration and increase the collection of legitimate revenue to support government initiatives. As well as assisting in developing the nation’s Customs Compliance and Enforcement, we aim to enhance the Albanian civil society through a CSR programme that combines a number of elements including education, sports, environment and welfare.

    One strand of our CSR programme is focused towards the support of the Centre for Women and Children (CWC) based in Tirana. The centre provides support to vulnerable women and children with special needs. We aim to enhance the welfare element of a currently less efficient system. CWC is among the few charities that remain fully dependent on charitable donations.

    Albania 2nd CSR eventOur first CSR event, a themed Garden Party was held in July, where representatives of foreign diplomatic missions, the government and the business community attended and were invited to make voluntary contributions. Most recently we hosted a beneficiary paintings auction in the Rogner Hotel in support of the CWC. The funds raised from these events, the costs for which were underwritten by Crown Agents and staff, all go to the running of the centre. Ms. Rajmonda Prifti, Director of the CWC thanked all attendees for their generosity, as well as Crown Agents for the initiative and remarkable support.

    Going beyond compliance, CSR is to some extent the only support charities like CWC receive. Such centres’ existence and sustainability without CSR programmes is questionable, leaving the society’s vulnerable women and children to chance? 


    1UN February 2007 report, Issue 1. CSR and Developing Countries.
  • Efforts intensify to treat children living with HIV

    by User Not Found | Oct 07, 2014
    Efforts intensify to treat children living with HIVThe fight against HIV and AIDS has seen huge progress in recent years, but treatment for children still lags far behind that of adults.  UNAIDS recently reported that 69% of eligible adults are receiving treatment 1, but only 33% of children living with HIV are on treatment. 

    We have made huge strides in reducing the level of transmission from mother to child during pregnancy, at birth and while nursing.  New HIV infections among children have fallen by 58% since 2001 and dropped below 200 000 for the first time in 2013 in the 21 most affected countries in Africa. Countries including Botswana, Namibia and South Africa provide treatment to prevent mother to child transmission to over 90% of pregnant women, but treatment of infected children remain stubbornly hard to achieve similar levels.  Why should this be, surely we have a moral duty to protect new born babies and young children?

    There are multiple reasons why it can be difficult to get and keep children on treatment including difficulty in obtaining the right medicines to treat children.  The market for paediatric antiretroviral drugs (ARVs) is much smaller than that for adults and is very fragmented. Part of this fragmentation is inevitable because obviously a tiny baby will take very different dosage and cannot swallow pills, compared to an 8 year old for example. Innovation in available drugs and changes in WHO’s recommended treatment guidelines 2 3, the most recent of which were issued in July 2013, have added to the number of drugs on the market. 

    To address this challenge a specialist working group of the WHO/UNICEF led inter-agency task team for the prevention and treatment of HIV infection in pregnant women, mothers and children undertook a thorough review of the 61 approved drugs available to create what they call the Optimal Paediatric ARV Formulary. The team, which was co-chaired by Crown Agents’ David Jamieson who is seconded to the Partnership for Supply Chain Management in Washington DC, came up with a list of just 10 formulations to treat the majority of children of all ages and weights according to the current WHO recommendations. In addition to the optimal list of 10, a further 13 were listed by the group for limited use.  This latter list includes some new drugs and some that are rapidly declining in use and others for use where the first-line drugs from the optimal list are failing or the patient reacts badly.

    David reports that: “By focusing treatment on the optimal list we can coordinate purchasing into larger orders that meet manufacturers’ commercially viable manufacturing batches creating a more attractive market that will ensure regular supply and hopefully price reductions.  There are still a number of gaps in the formulary, unlike adults there are very few fixed-dose combinations that would enable children to take a single pill and most of oral solutions for babies taste bad, which makes them hard to administer.  If you’ve tried to give a baby something they don’t like you’ll know the problem.”

    “Getting more children on treatment is one of my great passions in the fight against HIV/AIDS.  I am confident that this list will make a difference, but I’m going to keep working at it with my colleagues until we truly have the optimal list and all of children who need treatment can receive it and live healthy fulfilling lives” said David Jamieson.
    The IATT report containing the lists is available from http://www.emtct-iatt.org/wp-content/uploads/2014/08/IATT-Formulary-webinar.pdf

    Based on starting treatment when the patient’s CD4 count drops below 350
    http://www.who.int/hiv/pub/guidelines/arv2013/en/
    3 http://who.int/hiv/pub/guidelines/arv2013/arvs2013upplement_march2014/en/
  • The significance of community engagement in strengthening health systems

    by User Not Found | Sep 26, 2014

    The significance of community engagement in strengthening health systemsThe worst outbreak of Ebola ever seen is currently occupying headlines across the globe. As of 9 August, 1848 cases and 1013 deaths had been reported by the World Health Organization (WHO)1 with health systems in Guinea, Sierra Leone and Liberia struggling to cope. In an editorial in June, The Lancet noted the key reasons why the new strain of the Zaire Ebola subtype was proving difficult to control: tracing infections across three countries with constant movements of people across porous borders is difficult; the countries already have weak health systems – compounded by the fact that health workers had never before dealt with Ebola; and finally, but perhaps most importantly, a lack of community trust in government has greatly hampered the response effort. The extent of this distrust was evidenced in Sierra Leone’s Kailahun district, where Ebola was initially seen by communities as a government conspiracy to depopulate the area. The stoning of health workers was the result.2 

    Prior to the current outbreak of Ebola, the largest outbreak had been in Uganda in 2000. Francis Omaswa was then Director General of Health Services in Uganda and oversaw the efforts to control that outbreak. Writing in August in the Lancet Global Health Blog, he emphasised the importance of community engagement in tackling the epidemic: ‘The single most important lesson we learned was that building and holding public trust by the government and health personnel is the foundation for all control efforts’.3 Intensive communication with communities, supported by engagement with the media and local leaders working alongside community health workers (village health teams), and the introduction of field technology for quick field diagnosis were seen as key to the response. Mr Omaswa highlighted the importance of strong primary healthcare principles: leadership, good governance, and ‘active participation of the people themselves’. He cautioned that these principles should be institutionalised, because they are needed anyway, and because there will be future Ebola outbreaks. The primary healthcare principles that Omaswa refers to were laid out in the Alma Ata Declaration of 1978, described by WHO as the ‘major milestone of the twentieth century in the field of public health’.4 Article 4 of the Declaration enshrines the importance of community engagement in healthcare: ‘The people have the right and duty to participate individually and collectively in the planning and implementation of their healthcare.’ A systematic review conducted in 2011 noted that ‘community engagement and participation has played a critical role in successful communicable disease control and elimination campaigns in many countries.’5 Examples cited in the review included the elimination of malaria in Taiwan, of schistosomiasis in Guanxi Province in China, of malaria in Aneityum, Vanuatu, and of onchocerciasis in 2002 in 11 West African Countries. 

    Community engagement means different things in different contexts. It covers a range of terms such as ‘community participation’, ‘community involvement’, ‘community empowerment’, ‘community based’.6 Only by adding the question ‘for what?’ to the end of each of these terms do we get closer to understanding what motivations inform a specific intervention and what the term might look like in practice: ‘community participation for what?’ The ‘spectrum of community engagement’ proposed by the International Association for Public Participation provides useful clarification. It consists of five stages along a continuum of increasing community impact: inform, consult, involve, collaborate, empower. At the inform end of the spectrum, information is provided to the public, while at the empower end, final decision-making is taken at the community level. In between, communities might be consulted to obtain feedback, involved in developing options and collaborate in implementing solutions. 

    In the lessons learnt from the management of Ebola in the Uganda case, we can see that elements of the first four stages were seen to be necessary. As we progress from one stage to the next, the distance between the community and the official diminishes. Decisions become less remote and are increasingly within the purview of the community. As the distance reduces, clarity emerges about the necessity of interventions. Misinformation can be better managed. Community concerns can then be more quickly recognised and addressed. To what extent this actually happens and how responsive officials are, is fundamental to creating and sustaining community trust. It is a gradual and ongoing process to enable the success of interventions. If community trust in the system does not already exist to some extent, then interventions flounder, as can be seen in some areas of the current Ebola response. 

    So, how can we foster community engagement in health systems beyond the informing and consulting stages of the engagement spectrum? Healthcare committees are one mechanism for bringing together health workers and community representatives to plan, implement and monitor health services, and activities in many countries in Africa. But if they are to be effective, a number of factors need to be in place. Research conducted by Equinet in several African countries has resulted in a number of recommendations. 

    To increase the effectiveness of healthcare committees, the following are essential: 
    a. Healthcare committees need to be backed up by enabling national public health laws and policies. 
    Without them, the committees may not be recognised by health managers nor able to receive funds.
    b. Such enabling laws and policies should themselves be supported by constitutional rights to health, to healthcare, and to public participation and information. 
    c. Governments should establish by regulation the roles, composition, powers, duties, capacities of and resources for healthcare committees, including to:

    • Facilitate health literacy and public health information;
    • Facilitate community identification of health needs and priorities and bring this evidence to health services;
    • Ensure community voice in health systems, with attention to disadvantaged groups;
    • Prioritise, plan and budget services with health personnel;
    • Engage stakeholders and communities on resourcing and implementing health plans;
    • Monitor health expenditures, services and actions and their impact;
    • Ensure accountability of services to the community;
    • Provide feedback to and review progress with communities;
    • Report and engage on the progress, challenges and needs of community and primary care levels at higher levels.

    d. Healthcare committees should be democratically elected.
    e. Healthcare committees’ capacity to fulfil their roles should be built in an ongoing way, with resources provided within health budgets for both the capacity building and functioning of the committees.
    f. Tools and guidance to enable the monitoring and accountability of the performance and impact of healthcare committees and health services (‘social accountability tools’) should be established.

    At Crown Agents, we have had to work extensively on building community empowerment into the South Sudan Health Pooled Fund, as was stipulated as one of the primary objectives of the whole project. We are fund manager of the three-year, multi-donor programme, which is aimed at delivering and strengthening health services in six out of South Sudan’s ten states. We had learned from previous funding mechanisms that community engagement and participation, when done in an ad hoc fashion, had achieved inconsistent degrees of success, and that interventions and innovations from Non-Governmental Organisations had not been fully documented. As a result, we established a Community Strategy Advisor role, who specifically led work to engage with the community and Ministry of Health perspectives, as well as with crosscutting stakeholders. The Community Strategy Advisor has worked with community-based organisations, community healthcare committees, the fund’s staff, and with individuals told draft, implement and maintain a comprehensive Community Strategic Plan. The plan to support and build the vital links would allow the people of South Sudan to assist with the building of their own healthcare provisions. 

    It is vital not to underestimate the importance of law and policy in helping to create an enabling environment for community engagement and, by extension, the effective delivery of and access to services and therefore, health outcomes. The recent AIDS2014 conference held in July in Melbourne, Australia highlighted the importance of this, particularly in relation to Key Affected Populations – those most vulnerable and likely to be exposed to HIV, including men who have sex with men, people who inject drugs, sex workers and transgender people. Speaking at the conference, 
    Lord Fowler, former UK Health Secretary under Margaret Thatcher noted: ‘Thirty-five million have HIV - half have not been diagnosed. One of the reasons for that is obviously the prejudice and ostracism that comes with either being gay, or having HIV, or being a sex worker. 

    It’s such a hostile environment to come forward. If you’re going to be prosecuted, it’s most unlikely you’d want to come forward to say: ‘please test me I think I may have HIV’.”7

    It is therefore imperative to establish robust political and regulatory environments in which community interventions can flourish, built on foundations of trust, collaboration, and cooperation between the community and health services.

    References

    1. Ebola virus disease update - west Africa.
    2. The Guardian, Fear and ignorance as ebola 'out of control' in parts of west Africa
    3. Regaining trust: an essential prerequisite for controlling the Ebola outbreak
    4. http://www.who.int/social_determinants/tools/multimedia/alma_ata/en/ accessed 11 August 2014.
    5. Atkinson, et al. ‘The architecture and effect of participation: a systematic review of community participation for communicable disease control and elimination. Implications for malaria elimination’.
    6. Sarrami-Foroushani P, et al. ‘Key concepts in consumer and community engagement: a scoping meta-review’. BMC Health Services Research 201, 14:250.
    7. Cooper C. ‘Decriminalise sex work to stop HIV, says former Health 
      Secretary Lord Fowler’, The Independent. http://www.independent.co.uk/life-style/health-and-families/health-news/decriminalise-sex-work-to-stop-hiv-says-former-health-secretary-lord-fowler-9630850.html
  • Providing capacity building interventions in development programmes

    by User Not Found | Jul 25, 2014
    Health Commodities ProjectCapacity building has become a much touted term on health projects, and is often included as a key output in a plethora of programmes. Often, when development professionals discuss the cross sectorial theme of ‘capacity building’, there is a tendency to automatically equate it with ‘training’ – but that is far from the complete view of it. The basic tenets of capacity building are empowerment and change – to embed the concept of national ownership into a project from start to end. It is about building social capital and institutions that will lead to independent entities, and achieving this sustainability after limited-term funding has come to an end requires action from multiple angles and stakeholders. What is key in all sectors, including health, is determining how capacity building can be more holistic – and subsequently more effective – in providing expected services. 

    While capacity building is not purely training related, the training of frontline staff, technicians and managers is absolutely vital to making sure that a health project is maintaining quality and collective understanding. Training can be a method in itself to incentivise the retention of a keen and able staff, especially in a clinical setting. Furthermore, given that programmes struggle to show results in all aspects of capacity building, the number of training sessions provided and number of people successfully trained becomes a measure that can easily be used for donor reporting. This shifts focus away from other essential aspects of capacity building. 

    Medical Stores Limited in ZambiaA comprehensive capacity building package is often perceived as an expensive and time-consuming endeavour that has historically been relegated as an after-thought for development funds. Donor programmes have long had to decide whether to allocate their money for short-term impact or long-term structural and institutional reform – with short-term impact often being the most feasible option, due to the allocated length of programmes and funding. Donors are now keen to do both, however, making capacity building an integral part of development programmes. Resources are now often made available on the condition that they will produce future benefits in addition to immediate ones, allowing donors to successfully navigate through the inherent paradox of capacity building that sees them giving funding in order to be able to stop giving funding. 

    There is scarce information, however, on what strategies have been shown to work in these circumstances in different settings and for different health issues. While quantifiable results and impacts are still relatively hard to come by, there are projects underway around the world that are setting precedents and building the intellectual and strategic substance needed to inform future capacity building initiatives. An example of a project that is bridging long term capacity building needs with short term service to deliver requirements is the multi-donor South Sudan Health Pooled Fund (HPF). 

    The £121 million fund is managed by a consortium that is led by Crown Agents. It is supporting the delivery of essential primary healthcare and referral health services up to county hospital level as well as providing health system strengthening at the national, state, county and community levels for the independent future of those structures. The design and management of the programme has been closely linked with South Sudan’s Ministry of Health (MoH) throughout its development and implementation. This link has ensured that activities are always aligned with government strategy and that the government’s own capacity is being developed to a level where it is able to provide the requisite strategic support to their successors. Work on areas including supply chain, finance service delivery, human resources, Information Technology Services (ITS) and governance has been devised with capacity building as an integral operation. NGOs have been co-located with government bodies, allowing for the sharing of skills and knowledge and the easy coordination of operations. 

    It is imperative that local counterparts are involved from the very outset, when incorporating capacity building into projects. Their capabilities and needs must be taken into account to set a baseline for a programme, developing a relationship between the providers and recipients of the programme. Then there is the question of whose capacity is it that requires building? It is worth acknowledging that those at more central levels of government, or staff with more central roles at hospitals, tend to have more opportunities than those at a more decentralised level, which may need to be a consideration when designing programmes and projects.

    If capacity building is to become an integral part of healthcare development programmes then the donor community needs to work with the recipient countries to develop a strong capacity building component in all projects. There must be an agreed understanding of the scope of the capacity that needs to be built, and a strong emphasis on it during the strategic planning and implementation of developmental projects, accompanied by clear monitoring and evaluation plans with measurable indicators. Capacity building needs to move beyond rhetoric and become quantifiable and specific, making the message loud and clear to the recipients that they will have a supportive environment in which to start building their own futures.
  • The growing role of smartphone technology in the African healthcare

    by User Not Found | Jun 19, 2014
    Nigeria St Mary HospitalIn sub-Saharan Africa, diseases such as HIV/AIDS, malaria and tuberculosis are the focus of high-profile health campaigns with the aim of fighting their spread, but there is one epidemic pervading the region that is being actively encouraged and harnessed to help tackle health problems: the epidemic of mobile technology. The pace at which mobile phones have spread globally is unmatched in the history of technology: between 2000 and 2012, the number of mobile phones in use worldwide grew from fewer than 1 billion to around 6 billion. Mobile penetration in Africa hit 80% in the first quarter of 2013 and is growing at 4.2 percent annually[1], driven by massive reductions in the costs of owning a mobile phone. And this surging uptake of mobile technology has only been so endemic because it has stemmed from organic needs and abilities of the population: mobile technology is not being imposed – it is naturally growing from people’s needs and habits. 

    One of the biggest advantages that this prevalent and keenly-adopted network has given rise to is the bridging of physical distances in regions where infrastructure can be extremely poor. Remote areas now have virtual links to professionals and services that would have previously been unavailable to them or only available following difficult and time-consuming journeys. The potential that this has created for helping to tackle diseases and health problems in sub-Saharan Africa has been quickly seized upon by governments, medical bodies, NGOs and other actors in the health sphere – giving birth to ‘mHealth’. The rush to pilot applications of the consistently advancing mobile technology has, however, created a hindrance to ensuring the mass replication of effective applications that improve healthcare provision and standards in developing countries. 

    The applications of mHealth are already being demonstrated in their abundanceSouth Sudan Health Pool Fund throughout the world but are taking strong hold throughout sub-Saharan Africa. World Bank figures published in 2012 showed that there were 29 countries in the region that had already rolled out mobile health applications, compared to three in Europe and Central Asia. The Freedom HIV/AIDS programme is an example of how mobile games are being used to deliver mass-orientated tele-education. Since 2006, the mobile phone games have been rolled out in Botswana, Kenya, Malawi, Mozambique, Tanzania and Uganda – some 6 million handsets in total – and are helping to educate participants about HIV/AIDS and fight stigma and discrimination surrounding the disease. In Ghana, the Mobile Midwife project is part of an over-arching Mobile Technology for Community Health (MoTeCH) initiative, and aims to improve antenatal and neonatal care among the rural poor. It provides text and voicemail information for women during their pregnancies then provides post-partum information on essential vaccinations and the management of critical childhood diseases while also allowing community health workers to keep electronic records and retrieve patient information using their mobile phones. In the first two years after the programme was launched in 2010, more than 20,000 had enrolled on it[2].

    Kenya’s Changamka Medical Smart Card combines the use of mobile technology in both finance and health to help people save money for medical treatment using transfers through M-Pesa, the mobile-phone based money transfer and microfinancing service. By using their mobile phones, people who have no access to medical plans or insurance cover can save money specifically for primary health care, specified laboratory tests and drugs at pre-contracted prices. The health savings programme has now been extended to cover antenatal, delivery, post natal and outpatient care, via a public private partnership (PPP) programme with a maternal health clinic. By the end of 2013, Changamka had distributed more than 10,000 smart cards specifically targeted at pregnant women[3]. 

    The issue now facing the more than 850 mHealth applications[4] that have been established around the world is making sure that their impact does not go unevaluated. In order for the scale up of applications  and for mHealth to be integrated into future strategic health plans, developers must be able to access evidence-based information on their advantages and disadvantages, as well as their ultimate usefulness. Little research has so far been carried out on them, so there has been sparse strategic feedback on certain factors that are integral to the success of a project: how well can they work around regional language differences and literacy levels? How much are they affected by irregular or basic mobile networks? Are they bound by the timeliness of responses from people and professionals and what can be done to improve that? What roles do financial incentives have in improving their impact? How vulnerable are they to misuse? Effective research and monitoring & evaluation of mHealth technology will allow developers and governments to keep creating meaningful and efficient systems that can keep pace with evolving demands and purposes. Analysis of the impact of technology will allow for the streamlining and simplification of applications, to ensure that they remain appealing and easy to use for healthcare professionals and the wider public.

    It is then a matter of putting this research to use. The greatest financial costs of establishing mHealth structures lie not in their development but in their effective integration with existing health systems and the human and technical infrastructure already in place. Ensuring that there is research, precedent and documented methods in place should provide donors and funding organisations with increased confidence in the potential impact of projects and their value for money. In order for this information to be obtained, however, it must be easier for healthcare professionals and developers to freely exchange information and feedback. The existing forums for such information sharing must be strengthened and easily efficient and make it easier for the user experience to be documented – which can, of course, be carried out on mobile phones. 

    And it is here where governments need to start developing their roles in the advancement of mHealth technology. mHealth, as a commodity, needs national institutions to start establishing strategies and plans so that its development does not start losing control and focus – but at the same time they must not stifle creativity and natural innovation. Governments can play vital coordination roles that can prevent overlap, align developments with longer-term plans and health sector strategies and make sure that mHealth projects are viewed holistically rather than in the segmented and individual formats in which they now largely exist. If there is a move towards a more decentralised model, where the patients demand services, then controls need to be in place to ensure structure and efficiency – which can be cultivated and advanced by governments through technology strategies and technical working groups. Again, however, these governments must navigate a difficult course between capitalising on potential and not dampening natural development. Government buy-ins for new technology have the potential to contribute to a sense of country ownership over mHealth systems and foster greater efforts to encourage their development and the public uptake of them.

    mHealth has already staked out an important position in the future of tackling health problems in sub-Saharan Africa, but the challenge that healthcare managers, providers and beneficiaries now face is solidifying its role and building more solid foundations upon which further applications can be strategically developed. The scaling up of mHealth is crucial if the smaller pockets of success it has created so far are to be translated into wide-spread improvements in health and well-being in the developing world, but its bold potential and solid impacts mean that the future for effective mass healthcare in sub-Saharan Africa is looking increasingly mobile.

    References:

    [1] Maximizing Mobile: Information and Communications for Development; World Bank, 2012
    http://siteresources.worldbank.org/EXTINFORMATIONANDCOMMUNICATIONANDTECHNOLOGIES/Resources/IC4D-2012-Report.pdf

    [2]‘Mobile Mdiwife’ empowers Ghanaian Women
    http://www.impatientoptimists.org/Posts/2013/11/Mobile-Midwife-Empowers-Ghanaian-Women

    [3] http://sites.healthunbound.org/content/changamka-medical-smart-card

    [4]Millennium Development Goal 6: How mHealth is Supporting the Combat of HIV/Aids, Malaria and Other Diseases 
    http://www.gsma.com/mobilefordevelopment/new-infographic-on-mdg-6-how-mhealth-is-supporting-the-combat-of-hivaids-malaria-and-other-diseases
  • Maximising revenues from extractive industries

    by User Not Found | Apr 24, 2014

    The Crown Agents Foundation’s three-day event on extractives industry revenues in Liberia in November 2013 was a lively and productive workshop that drew a broad range of attendees.

    The event, which was held in Monrovia, was themed around maximising revenues from the extractives industry and getting it right from the start. It focused on challenges and issues in Ghana, Liberia and Sierra Leone and welcomed representatives from eight different government agencies from across the three countries.

    Among the 53 attendees were representatives from ten different international organisations, including the World Bank, International Tax Dialogue, AusAid, the UN Development Programme and the German Society for International Cooperation (GIZ). We also welcomed industry delegates from BHP Billiton and Arcelor Mittal, as well as a representative from the Revenue Development Foundation, which has been active in extractives work in both Liberia and Sierra Leone.

    A number of challenges were highlighted, demonstrating the importance of such an event and the sharing of international good practice and regional and local knowledge. The event also generated a number of workable solutions for participants to apply in their respective countries.

    As a result of the Foundation workshop, the Crown Agents tax team has produced this detailed position paper, examining how OECD’s ‘Right from the Start’ initiative can be applied to extractive industries.

  • Improving care for children living with HIV/AIDS

    by User Not Found | Apr 23, 2014

    NACA clinic, NigeriaIt is very well established that the proportion of children living with HIV that are receiving antiretroviral treatment is far below that of adults. David Jamieson, Crown Agents Senior Health Supply Chain Adviser was a contributing author in a recent multi-article supplement in AIDS, the journal of the International AIDS Society addressed this challenge.

    David explains, “The challenge of why more children aren’t on treatment is very complex. This series of articles, prepared by the Child Survival Working Group of the Inter-agency Task Team on Eliminating Mother to Child Transmission, addresses the challenge from a wide range of angles."
    “I used my supply chain experience to contribute on cost containment to achieve best value for money and on the supply chain challenges.”
    David contributed to the articles:

    The full supplement is available free from the AIDS Journal website:http://journals.lww.com/aidsonline/toc/2013/11002#472502066

    David Jamieson is seconded to work with the Partnership for Supply Management in Washington DC working on the Supply Chain Management System contract. The contract—which is funded by the President's Emergency Plan For AIDS Relief (PEPFAR)—supplies HIV/AIDS commodities to PEPFAR-supported programs. Improving treatment coverage for children and combatting mother to child transmission is one of David’s great passions in the fight on against global HIV/AIDS epidemic.

  • Exploring China and Africa's health supply chains

    by User Not Found | Mar 25, 2014
    2013 marked the fiftieth year that China has been sending medical personnel and equipment to operate in Africa. Since its first work on the continent – in Algeria in 1963 – thousands of Chinese health workers have served in 43 countries, contributing expertise and technology to hospitals, malaria centres and other medical establishments. 

    ChinaThe work at August’s Ministerial Forum on China-Africa Health Development in Beijing focused heavily on China’s efforts in tackling the shortages of healthcare workers in Africa. The provision of personnel, however, is not the only area where the world’s second biggest economy is making an important impact in Africa. China’s role in African supply chains is a burgeoning position that will provide mutual opportunities and benefits for both regions. But what exactly are the opportunities – and obstacles – that will stand before China and Africa in the development of their supply chains?

    China is still regarded as the “world’s factory”. Despite the recent rise in manufacturing from sector-specific countries such as India, Bangladesh and Vietnam, the manufacturing might and natural resources in China have contributed to an economic growth forecast of 8% in 2013. With its intellectual capacity strengthening and the scope of its manufacturing increasing, mutual relationships with African governments and trade blocs are being cultivated. The task of establishing these relationships and business networks is not an easy one, however, with both sides having certain reservations about their work with each other. 

    From the African side, there are concerns with the quality of Chinese goods, demonstrated by incidents such as the 2008 tainted baby milk scandal, which claimed the lives of six Chinese infants and affected more than 300,000 children and babies in total. The latent impact of the scandal is that there is a general assumption of poor quality of Chinese products. An antidote to that assumption however, is that Chinese goods for export are often higher quality than those for domestic sale. International buyers of Chinese goods benefit from superior quality to the goods distributed within China but that knowledge is still in the process of penetrating the awareness of African purchasers and must be a focus of long-term work. Corruption issues such as the recent scandal involving some of GlaxoSmithKline’s Chinese executives – in which doctors were allegedly bribed to prescribe the firm’s drugs – have also highlighted image and bureaucratic issues that could hamper the development of professional relationships.

    Fears about dishonesty are mutual, however, as Chinese suppliers often have a perception of corruption and misappropriation of goods within many African countries, causing hesitancy over trade deals. The establishing of trade blocs and regional economic communities is helping to tackle these perceptions: groups such as the Common Market for Eastern and Southern Africa, the Southern African Development Community and the Economic Community of West African States are setting out trade standards and enforcement, but the commitment to them must be sustained and emphatic. 

    So what is next on the path to establishing effective supply chain collaboration between China and Africa? It will be vital to surmount the mutual trust issues between the domains, but key business structures must also be cultivated, such as quality-controlled supplier networks, collective buying deals among African governments and the structured move away from the dominance of donor-driven commodities. 

    DTTUWhile the development of reciprocal trust between the two regions will allow for effective collaboration between China and Africa, they must also work to mitigate risk in their dealings by finding common ground and engaging in information sharing. The trade networks that currently exist are rudimentary and only apply low down on supply chains – from supplier to supplier, with no large-scale network of partners. The elevation and exploration of these networks to the higher levels of governance will generate greater understanding of cultural and legal differences, while lowering risk through the identification of common ground. That China still perceives itself as a developing nation is positively viewed by many Africans: according to World Health Organisation Director-General, Dr Margaret Chan, China and Africa share a “south-to-south model of development cooperation based on mutual interests and respect”, which has already helped China to become a significant force in Africa’s development and has the potential for much more. Improved dialogue between the economies involved will create deeper understanding between them that will benefit all levels of the supply chains, from contract management and sourcing all the way through to last mile delivery.

    There are areas of the Chinese pharmaceutical market that can already be taken as examples of how Asian developers and manufacturers can become important African suppliers. Most of the active pharmaceutical ingredients for the antiretroviral (ARV) drugs being used in the fight against HIV/AIDS in Africa are manufactured in China. The Sino-implant contraceptive device, developed by Shanghai Dahua Pharmaceuticals, has also helped make great strides in contraceptive health in Africa. It has gained support from bodies including USAID and the Gates Foundation for clinical trials, which will strengthen the product’s reputation for quality. 

    In order to perpetuate these advances, Chinese manufacturers must be creative in how they develop appropriate products and more business for the African health markets – particularly in terms of equipment and devices. An ultrasound machine made for a high-income European market, for example, with all the bells and whistles, will not be suitable for the needs and budgets of most African markets. For them, an ultrasound machine built with the same quality but without the costly extras that are the norm in Western Europe, will be far more suitable for their needs. Chinese developers will be able to bring down costs while providing equipment that will be much more appropriate for the developing nation context.

    Looking to the future, the growth prospects for China and for Africa’s leading economic nations are among the strongest in the world. Economic growth forecasts up to 2018 consistently place China within the top three for GDP growth, with Nigeria, Egypt, Libya and Angola all featuring frequently among the top ten countries for GDP growth in the years between now and 2018.  China is currently working to establish seven economic and trade cooperation zones – two each in Zambia and Nigeria, and one each in Mauritius, Egypt and Ethiopia – which will allow it greater access to supply chains across the continent, while allowing African counterparts greater access to Chinese trade portals. 

    The concept of safe spaces is expected to play an increasing role in the enhancing of the Chinese-African health supply chains. It will allow the involved parties to engage in talks and negotiations in a mutually-agreed territory – Hong Kong, for example – where the personnel and infrastructure can help create a forum for better understanding and deal brokering. With initiatives and systems such as this being used, the supply chains between Africa and China will have the opportunity to strengthen and grow, bringing consistent and regimented flows of resources to Africa that can help to improve the healthcare conditions for people all across the continent. 
  • New Office of Togolese Revenue to boost economic recovery

    by User Not Found | Mar 11, 2014
    The Togolese Republic has gone through ups and downs over the last two decades…. In the early 90s the country entered a new political era amid the fall of the iron curtain. But the democratic process in Togo was a hectic one until the death in February 2005 of late President Gnassingbé Eyadéma, one of the longest serving Presidents in Africa. During that time, there was declining international donor support, reduced exports of phosphates, coffee, cocoa, cotton and other natural resources and the stagnation of the tourist industry.

    However, in the last eight years, the country has moved fast towards democracy with the current President Faure Gnassingbé being re-elected in 2010. The successful Parliamentary elections held in Summer 2013 added value to a dynamic reconstruction process which is now bearing fruit.

    Located between Ghana, Burkina Faso and Benin in West Africa, the country has a population of 6.5 million people, but a total GNP of only US$3.6 billion and an average GDP per capita of about US$500.

    Over the past few years, the Government of Togo (GoT) has launched a series of proactive reforms aimed at injecting renewed life into the business climate, promoting Togo as an attractive place to do business, winning back international support, achieving the Millennium Development Goals and, ultimately, improving the quality of life for its people. The country is fairly endowed with natural resources including phosphates, marble, and iron, but its main assets lie in the deep sea port. Nevertheless Togo is witnessing a classic turnaround scenario with huge potential to restore and grow its fortunes.

    Working with the Togo Presidential Investment Advisory Council (TPIAC),the GoT has launched multiple projects covering every area of reform from governance, tourism and health to agriculture, education and infrastructure. In addition, a new Investment Law passed by Parliament in 2012, a Court of Accounts and General Finance Inspectorate is helping to ensure transparency. A three year programme to modernise the state bureaucracy through e-government also began in 2012.

    President Faure Gnassingbé approached Sir Paul Judge, a member of the TPIAC and a former director of Standard Bank of Africa, to prepare a framework, called Project Vision 2030, to develop Togo over the next 20 years. Sir Paul is a key benefactor of the Judge Business School at the University of Cambridge and recruited a team of alumni to research nine key sectors – Crown Agents made recommendations on one of these sectors, business development.

    The President stated “Togo is addressing an image problem inherited from the long years of crisis in this country. Our efforts to rid ourselves of the bad image of the past are yielding results, but we still have a long way to go. We should do more to attract foreign investors, to make them look at Togo with fresh eyes and to understand the extent of the positive changes that have happened in this country in recent years.”

    Sir Paul’s team presented their research on how to attract foreign as well as government investment during a visit to Togo in July 2012 . Recommendations ranged from introducing solar energy kits to replace costly and dangerous kerosene lamps, to boosting investment in the mining, coffee, cocoa and palm industries to attracting resources to improve education and health services. The government is now looking at ways to incorporate the recommendations into policy and to select, for immediate implementation, four or five top priority projects with particular impact on poverty reduction. Targeted sectors recently identified to start with are agriculture and food security, health, and education. In January 2013, Sir Paul’s team was in Togo to formulate specific projects to be implemented under the three sectors.

    “Africa is a rich continent but unfortunately many of its people are poor and this project has the potential to show other African countries how they can successfully develop,” says Sir Paul, adding: “Togo is a fertile country, endowed with resources and there may be even more resources if gas and oil are found off shore. Rule of Law is key, and if Togo can get itself well-organised, it has a very good future. It could become the Jewel of West Africa – a jewel being small but very bright.”

    Integral to Togo’s reform plan is creating an efficient and effective revenue administration to improve the provision of public services and goods, reduce poverty and corruption and promote private sector development. The previous decline in international support has also made it increasingly important for the GoT to leverage more funds through its revenue administration.

    As part of the ongoing reforms, Crown Agents is working as a strategic partner to help the Ministry of Economy and Finance to integrate the operations of the Taxes and Customs Directorates into the Office of Togolese Revenue (OTR) which will be the first semi-autonomous revenue authority in Francophone West Africa. This model has already been successfully adopted by several countries in sub-Saharan Africa. Crown Agents’ previous work in tax and customs administration reforms has resulted in significant increases to revenues in countries such as Angola, Mozambique, Sierra Leone and South Sudan.

    “It is refreshing to be involved with a team that is extremely committed to drive through the many reforms they are implementing” says Michael Canvin, Director Tax at Crown Agents, adding: “The reforms are not easy and require careful planning and management, but it is clear from the engagement of everyone, from President Faure Gnassingbé and Minister Adji Ayassor down, that the Togolese are committed to reform and want the OTR project to be a success”.

    Early signs of progress are emerging in Togo with the economy expanding at a rate of 4.9 per cent over the past year and inflation falling to 2.6 per cent in 2012 from 3.7 per cent in 2011.

    In the past year, the African Development Bank (ADB) has installed a local office in Lomé with the aim of strengthening ties with Togo. Key areas of cooperation include: developing sound pro-growth policies, particularly in infrastructures, good governance, human capital and private sector development.

    According to Finance Minister Adji Ayassor, “It took time to have ADB back in Togo. The fact that the Bank has an office now in Lomé is a clear indication that the country has gained credibility and is on the right track. This will open new avenues for enhanced cooperation with other partners. I am quite confident that the new OTR will take us further in our quest for good governance and sustained economic growth.”

  • How to improve quality of laboratory equipment and diagnostics in Africa

    by User Not Found | Jan 29, 2014
    Crown Agents Technical Manager David Whybrew offers some thoughts on maximising the efficiency and effectiveness of the medical laboratory

    South Sudan health careWell-functioning diagnostic technologies and laboratory services are vital factors for effective disease control. They detect and diagnose disease more rapidly and at an earlier stage; they allow for more targeted and effective treatments options; they enable more efficient monitoring of chronic diseases; and they help to limit healthcare spending. Major scale-up efforts over the past decade to combat the three major diseases in Africa – HIV/AIDS, malaria and tuberculosis (TB) – have helped increase recognition of the importance of effective and affordable diagnostic equipment and services. There is a growing collective acknowledgement that initiatives to improve access to medicines must be supported by effective diagnosis and subsequent monitoring of patients, if treatments are to be successful and infection rates are to be brought down.  

    While treatment of HIV/AIDS, malaria and TB has advanced rapidly in recent years, the advancement of high quality, affordable and appropriate laboratory equipment and diagnostics has been somewhat overlooked leaving it as something of a Cinderella figure in health spheres. Progress in improving access to diagnostics and laboratory equipment has been slow in many African countries: the laboratory networks are weak, staff training is insufficient and infrastructure is often under-developed. Only around 8% of laboratories in sub-Saharan Africa meet international accreditation standards, with most rural laboratories facing poor infrastructure and insufficient staffing and equipment while catering for anywhere from 5,000 to 15,000 people[1]. National governments are keen to build their diagnostic capabilities, but most lack the laboratory networks and national reference laboratories that are critical for the accurate testing and analysis of samples.

    So why is implementing such systems so tricky? When it comes to quality there is noZimbabwe Delivery Team Topping Up (DTTU) set system of agreed international standards that laboratory equipment needs to meet, unlike electrical standards, for example, or the standard formulae that exist for pharmaceuticals. The Maputo Declaration – championed by the World Health Organisation (WHO) in 2008 and agreed on by governments, multilateral agencies, development partners, professional associations and academic institutions – sought to address laboratory challenges that limit the scale-up of services for TB, malaria and HIV diagnosis and care[2]. The declaration demonstrates the stakeholders’ attempts to set standards that will improve the level and consistency of diagnostics equipment across Africa. It aims to move the stakeholders towards agreement on what systems and capacity they need in order to ensure that diagnostic networks can meet countries’ health policy priorities.

    As part of its own steps to help implement the Maputo Declaration, WHO launched a prequalification programme for diagnostics in 2010, known as PQ Dx[3]. Under the programme, WHO maintains prequalification lists of diagnostics products that have been evaluated against certain criteria and state the levels of quality and operation that they have achieved. The lists are laying the foundations for networks of independent knowledge upon which WHO member states, UN agencies, procurement agents and other partners can gauge their selection of test kits and technologies that are suitable for use in resource-limited settings. The PQ Dx has concentrated primarily on diagnostic equipment for HIV/AIDS, malaria and TB control programmes and complements WHO’s existing prequalification structure for medicines and vaccines.

    While the PQ Dx is addressing the front end of the need to raise equipment standards, it can only fulfil a small part of what must be done to improve the overall quality of laboratory equipment and other diagnostic supplies. For any piece of equipment, it is critically important that installation, commissioning and training are included in any contract with the supplier, and that a separate after-sales servicing and maintenance agreement is put in place.  These ‘terotechnology’ requirements need to be built into procurement processes and tender documents and appropriate contracts need to be put in place and effectively managed.  The role of local agents becomes particularly important given this need for “after-sales service” for equipment. In addition, it is important that any equipment is properly registered in country, and where appropriate it is beneficial for equipment, reagents and supplies purchased to be compatible with any existing equipment to encourage the considerable benefits of harmonisation and ensure effective utilisation by staff.  If systems are not in place to ensure that compatible reagents are available or that adequately skilled staff – or relevant skills training – are accessible for future servicing and maintenance, then the long-term value and effectiveness of equipment will be limited.

    Given the complexities in supplying safe, reliable and appropriate laboratory equipment and diagnostics, there must be high-level and efficient coordination between all stakeholders involved in the chain. Each of the stakeholders – including procurers, end users (such as laboratory managers and medical professionals), programme managers (such as health ministries) and funders – has an important role to play in achieving the programme goals and complying with the relevant national health policies. Through its role as procurement agent, Crown Agents has served in a coordination role on a range of successful disease control projects across Africa, providing a crucial link between all the players involved through the challenges and helping to avoid potential pitfalls of the processes, enabling the supply and roll-out of laboratory equipment and diagnostics that help to save lives and improve health efficiently and economically.

    While the gulf between the standards and systems for diagnostic equipment and supplies and those for treatments in Africa has grown in recent years, efforts are increasing to improve laboratory systems and capacity. There are also increased efforts to develop new tools and technologies that bring diagnostic services closer to the point of care. In Malawi, for example, a new machine has been developed by the University of Cambridge that offers viral load testing, CD4 counts and early infant diagnosis for HIV, on-site in the country’s poor, rural communities[4]. This machine could eliminate the need for samples to be sent long distances to testing laboratories – journeys that can take many months and often see samples spoiled or lost during the process. Implementing the groundwork and necessary support structures to raise the standards of laboratories and diagnostics in African countries are long-term tasks – marathons not sprints. The vision is now strong, however, among governments, health agencies, donors and other partners to ensure that diagnosis is brought on par with treatment and cure in the efforts to save lives across the continent.

    Click here to download the article.

    References:

    [1] Reliable diagnostics a huge barrier to improving health across Africa
    http://www.amrefcanada.org/media/rx-africa-prescriptions-for-better-health/reliable-diagnostics-a-huge-barrier-to-improving-health-across-africa/ 

    [2] The Maputo Declaration on Strengthening of Laboratory Systems
    http://www.who.int/diagnostics_laboratory/Maputo-Declaration_2008.pdf

    [3] Optimizing and Streamlining WHO Diagnostics Prequalification
    http://www.who.int/diagnostics_laboratory/131213_streamlining_pqdx_final.pdf

    [4] Samba machine a welcome boost for people living with HIV in rural Malawi
    http://www.theguardian.com/global-development/poverty-matters/2013/dec/30/samba-machine-hiv-malawi-chiradzulu

  • Maximising revenues from west Africa's natural resources

    by User Not Found | Dec 10, 2013
    The lands of West Africa harbour a wealth of natural resources: Ghana alone is estimated to have oil reserves of more than 800 million barrels, with around 110,000 barrels currently being extracted daily. These resources have the potential to make a major dent in the perpetual fight against poverty in the region – providing that the right systems are in place. In order for West Africa to truly benefit from its natural wealth, the 'resource curse' – by which resource-rich nations are often hindered rather than helped by the presence of valuable natural commodities – must be tackled effectively and appropriately from the outset.

    Maximising revenues from west Africa's natural resourcesAt a recent Crown Agents Foundation workshop in Liberia, some of the challenges facing three of the region's most resource-rich countries – Ghana, Liberia and Sierra Leone – were examined in depth. Representatives from government agencies, international organisations and private sector and development companies gathered to explore how to build and implement the fiscal regimes and the state participation that will allow countries to maximise the revenue collected from extractives.

    For the main theme throughout the workshop, Crown Agents looked at the Organisation for Economic Co-operation and Development's (OECD) 'Right from the Start' compliance approach. This approach offers proactive – rather than retrospective – strategies for revenue authorities to save administrative costs and resources, benefits taxpayers through better services, improves the quality and increases overall tax compliance.

    The four pillars of the OECD approach are:

    • Acting in real time and up-front, so that problems are prevented or addressed before they occur.
    • Focusing on end-to-end processes: rather than just looking at the revenue authorities processes try to design processes in line with key stages of a taxpayers business cycle.
    • Making it easy to comply by simplifying processes and procedures and reducing cost of compliance for taxpayers.
    • Actively involving and engaging taxpayers, their representatives and other stakeholders, so as to achieve a better understanding of taxpayers' needs and increase co-operation.

    By establishing the right policies, procedures and structures for extractives from the start, countries are able to make sure that the fiscal regime, administrative capacity, contractual framework and legal requirements are appropriately shaped and developed to ensure maximum revenue from their natural resources. From an administrative perspective, the revenue authorities involved will be able to develop their capacities and abilities to successfully identify and collect the correct revenues owed to them under the relevant laws or contracts. In addition, a more stable fiscal regime and government agencies that are more approachable and understand the commercial requirements of the industry, make the decision to invest by the private sector far easier.

    "Such efforts to get it right from the start are already under way in Ghana, Liberia and Sierra Leone", said Crown Agents consultant, Stephen Macey. "Examples of these developments formed a major focus of the workshop. It was clear, though, that further work and knowledge sharing was needed to ensure revenues were maximised from extractive industries".

    Examples of these efforts included:

    • Implementation of a royalty tax regime in Ghana with state participation to ensure that it is able to levy and collect the correct taxes from its petroleum sector, along with the creation of an oils and petroleum unit within the Ghana revenue authority.
    • The setting up of a natural resources tax unit in February 2013 within the department of revenue, ministry of finance, in Liberia. Work is also progressing on the creation of a revenue authority in Liberia, with the launch scheduled for mid-2014.
    • Formation of the national mineral agency in Sierra Leone to assume responsibility for the implementation of minerals sector policy, legislation and regulations. Through the creation of a new agency, the government is building an organisation that is able to keep the policy implementation separate from the policy making.

    Alongside these presentations, experts from international organisations including the World Bank, International Tax Dialogue (ITD) and the UNDP – as well as Crown Agents – contributed to the discussion. The head of the ITD Secretariat, Alan Carter, said "All of the ITD's component organisations – which include the OECD, the International Monetary Fund, the World Bank and the International Development Bank – are working together to aid the development of revenue structures for the extractives industry."

    He added, "We must ensure that the countries in the West African region and beyond – who are grappling with the difficult and complex problems of managing significant oil discoveries and new major mining projects – get the technical support they need to ensure the substantial potential economic, social and revenue benefits that extractive activities can generate are realised in practice."

    Crown Agents director of tax, Michael Canvin said it was a productive workshop, sparking some lively debate: "We identified many challenges – a key one being the need for greater inter-governmental collaboration and the agreement on roles and responsibilities for those managing extractives for the country. It was clear, though, that by getting it 'right from the start', the development of the region's extractives industry will be able to advance hand-in-hand with the driving down of poverty and raising of living standards, building a brighter future for those with natural resources."

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