What Does America's Government to Government Collaboration for Health Look Like?
Have we seen this somewhere before?
The US government plans for implementing programs funded under the America First Global Health Strategy will come with significant reporting, oversight and management responsibilities on both the United States and the co-signatory countries that bear a passing resemblance to those of the Millennium Challenge Corporation “compacts” originated under George W. Bush’s first term, along with PEPFAR.
The MCC used performance- and milestone-based financing for time bound compacts to incentivize countries to attain pre-specified results; the compacts were were implemented through dedicated, stand-alone government Accountable Entities (MCAs), rather than existing central government grants or treasury offices.1
Based on descriptions of country briefings with senior Department of State officials this week, and my review of the “MoU Implementation Plan Companion Guide,” the America First Global Health Strategy frameworks have some similar approaches.
The MCC comparison has been swirling around AFGHS for a while, and I predict that it will come back in force when the details of the approach are shared more publicly. I’m making it here myself, not because I am convinced it is apt but to put a skeptical voice on record, rants be damned. I fear that the AFGHS-MCC resemblance is dangerous camouflage for a program that cannot possibly accomplish what it claims it has set out to achieve.
Alt text: A really terrible water-wasting AI image that I found on the internet of a wolf wearing brown tortoise shell glasses, a blue shirt with a lace collar and cuffs and a red plaid shirt standing in front of a house with a lot of lights on, and a bike in the bushes. Grandma doesn’t have giant incisors or a fur coat.
As described in the Implementation Plan Framework, the Transition Management Office is a dedicated team focused on helping ensure day-to-day implementation of the MOU, including ensuring a smooth transition to partner government ownership and ensuring outcome and process metrics are achieved.
On calls with US country teams last week, AFGHS architect Brad Smith reportedly emphasized that the TMO should be staffed by a senior official, such as a top lieutenant of the health minister, in addition to the both country government employees, US government employees and, where needed, US contractors listed in the Implementation Plan Template.
He stressed that the TMO structure is more important even than the Joint Health Cooperation Steering Committee, also stipulated in the Implementation Plan Framework, that will guide, oversee and monitor MoU implementation.
He also reportedly said that if countries would like to use pre-existing structures for their steering committee, a leadership role for a United States government in country must be assured.
The TMO will play a central role in setting up and managing the awards or contracts to support agreed-upon activities. That’s where some similarity to the MCC comes in: in-country operations were run by the Millennium Challenge Account, a government-run, operationally autonomous entity. In some instances, the MCA structure was retained even after the compact period, and a contemporaneous write-up of the Honduran compact celebrated, “The result: a new—and wholly Honduran—government unit that, over the last decade or so, has built a reputation for sound program management and a solid track record of efficient implementation.”
More similarities arise in the proposed approach to government-to-goverment, or G2G, awards. The majority of funds will be allocated on a performance or milestone basis, according to a draft of the MoU Implementation Plan Companion tool close or identical to the version recently submitted for approval at the Department of State. The “G2G Scope” tab (3.3 on the Excel spread sheet, reformatted and included at the end of the post), offers this direction: “In general, the U.S. Government will contract using performance-based and milestone-based reimbursements, with cost-based reimbursement only approved in rare circumstances.”2
The MCC also used performance- and milestone-based reimbursements, with assessments showing that the efficacy of the approach in terms of tying outlays to impact depended heavily on whether the co-signatory government had robust systems in place for financial management, procurement and routine monitoring and evaluation. Struggles emerged when the compacts were signed before implementation plans were in place, and when oversight for reimbursement requests was cursory and box-ticking.
After a year—to this very day—of surreal levels of disruption, dissolution, confusion and chaos, it does feel comforting to see an approach taking shape that looks somewhat familiar.
But, as I realized last week, I am no longer capable of, or interested in, being comforted.3
Putting AFGHS is in the lineage of the MCC, or other aid practices, is like saying Operation Absolute Resolve—the US operation to capture Venezuela’s President Maduro—was birthed by Operation Neptune, aka D-Day. Sure, you can make the comparison. But you risk missing some much larger points about the nature of the government taking those actions. Seeing the similarities might feel good; naming the differences can lead to interventions that save lives.
Where the MCAs were government-staffed and -designed, the TMO structure and composition appears to be being imposed by the AFGHS team, down to the stipulation that the senior Ministry of Health official in charge and other government staffers be dedicated at close to full time effort—without additional portfolios.
TMO will oversee the implementation of activities related to HIV/AIDS, maternal child health and pandemic preparedness and response for which there are already pre-existing government units, working groups and organizational structures, risking duplication in the same way that the Steering Committee’s mandate to serve as a coordination platform during outbreak response risks duplicating a country’s sovereign health security systems.
Where the MCC reimbursement milestones were measurable, could be tied back to impact, and were included in Congressional Notifications submitted on a regular basis prior to the disbursement of funds—just like PEPFAR—the process and outcome metrics that are in the Memorandum of Understanding agreements are ill-defined, insufficient, irrelevant and/or difficult to measure, and Congress hasn’t seen them anyway. Where past foreign aid was absolutely tied to US interests and therefore transactional in any number of ways, the AFGHS architects are using foreign aid as a bargaining chip for obtaining market access and mineral rights.
It is thrilling that Congress is seeking to appropriate sizable sums for global health, including the Global Fund, and it is touching to see legislative language that refers to PEPFAR, when the program’s core attributes including interagency collaboration, data-driven decision making driving to measurable impact on the health of most-impacted communities, and earmarks and explicit care for orphans and vulnerable children have been eliminated.
At the same time—money doesn’t translate automatically translate into impact. Not under the MCC, USAID, PEPFAR or PMI. How a program operates matters a great deal, not just how much money it has. The how for AFGHS looks like MCC if you squint, but if we’ve learned anything from the past year, it’s to keep your eyes wide open.
Arguments that US foreign aid has always been transactional or that the US has always set up parallel systems (not sure, really, what else to call the TMO with its embedded US government staff and phalanx of contractors), are only worth as much as the detail that supports them. What were the terms of the transaction? What was the purpose of the parallel system? Without this detail, it’s a dangerous game. What big eyes you have.
There is no large-scale MCC precedent for using performance- and milestone-based reimbursements for US government health programs. In Lesotho, a country that had both MCC health investments and PEPFAR, the MCC compact missed on the clinical outcomes (including percentage of people living with HIV alive a year after diagnosis), and only hit its construction targets for building new clinics.4
A performance- or reimbursement-based approach is particularly high risk in countries with a history of corruption, and requires extensive reporting and due diligence for both US and co-signatory governments. The guidance in the Companion Tool doesn’t make a distinction about country eligibility, though perhaps this nuance will appear later.
And of course, the MCC had measurable, relevant metrics, unlike the AFGHS which adds new, equally useless measures in the Companion Tool, like “the percentage of facilities reporting data on the number of people diagnosed with HIV.” Community-based testing, mobile vans and self-testing have all been slashed or eliminated, meaning that many people at risk of HIV will simply not get tested. Even if 100 percent of facilities report data, this metric doesn’t measure whether the testing services are meeting the goal of finding people who have HIV and are not aware.
Just because you do a lot of something, and, ideally, count it well, it doesn’t mean you’re doing it right—by providing the services to the people who need them, in the way they want them, so that they can flourish or at least get on with their lives. And if you’re not doing it right, then hitting the milestone really shouldn’t matter.
Country stakeholders can affirmatively decide to measure more than what the US asks for, including gathering information to drive data-based decision-making, strengthen health systems, ensure effective disease control, timely disease detection and surveillance, and achieve epidemiological impact across all populations. But they can also decide the low bar is just fine, since it makes reimbursements easier to secure. The MCC tells us that this can happen.5
Congressional and country stakeholder oversight into the G2G awards could make a difference, if these agreements are required to include more detailed, public-health relevant metrics. This oversight would be best provided by a Steering Committee that includes representatives of communities impacted by health inequities including disparities in access to HIV, tuberculosis and malaria, maternal child health and primary health care. The MCC required civil society consultation during compact development. PEPFAR required it throughout. But the AFGHS architects have made it abundantly clear that these communities should not be involved in accountability mechanisms and governance approaches to the programming. What big teeth you have.
The Companion Tool also makes it clear that the US is expecting funds to continue to flow through implementing partners—those “third parties” that are so troublesome to Secretary of State Marco Rubio, other Department of State Officials and the authors of the America First Global Health Strategy. Implementing Mechanisms are in the drop down menu for the “Budget Detail” sheet and have a dedicated, pre-populated summary page.
As I discussed in a recent post, a review of existing mechanisms is the first step proposed for the implementation planning process. In any given country, some of the mechanisms that are still operating will receive additional funding to ensure continuity of services while the details of G2G grants are worked out. Continuity, attention to transition, extension of services through providers who are already on the ground: these are all good things. And they’re there. But so are warning signs, flashing red and bright, that it is not grandma under that hood—and that cozying up to this enterprise could be (as it already has been) deadly.
https://www.gao.gov/products/gao-10-52
https://www.cgdev.org/blog/efficiency-and-effectiveness-legacy-mccs-investment-honduras
A fascinating and bracing post from the Chief Science Officer at the Bureau of Global Health Security and Diplomacy that was titularly directed at me, by name, was illustrated with a painting that I found terrifying to an extent that, frankly, took me by surprise. I am grateful that the image was removed by the author and for the insights, intentional and collateral, I gained in the process.
https://www.mcc.gov/resources/story/section-lso-ccr-health-sector-project/
