Plenary Three: Results-Based Programs and Accountability

Ladies and gentlemen welcome to afternoon program and plenary session three, from the United States Agency for International Development and coordinator of the President’s Malaria Initiative Admiral Tim Ziemer.

Admiral R. Timothy Ziemer: This morning our speakers and panel, and now with the President, we've had many references that intersect with the subject of this panel and its theme, that results-based programs and accountability is a key development principle. It can't be said any better than if you look on the inside of your program and read and be reminded of President Bush’s comment. For decades, the success of development aid was measured only in the resources spent, not results achieved.
We must accept a higher, more difficult, more promising call. I think we just heard that the President has delivered. As we address results and accountability here in the next few minuets, it is my distinct pleasure to introduce our three panelists. They bring a tremendous wealth of experience and have made major contributions to improving the health of the people in their countries by producing results and showing impact. They represent the multinational community, the national community and the NGO community.

His Excellency, the Honorable Dr. Tedros Ghebeysus has served as Minister of Health for the Federal Democratic Republic of Ethiopia since October 2005.  Prior to that, he served as the State Minister of Health in the federal government and other various leadership positions.
Currently, he serves on many boards. I know him best as the Chair of the Rollback Malaria Board. It’s there that I've gotten to know him as a man of principle, a man of action, a man of credibility and a leader that I look up to. Sir, it’s good to have you here.

Dr. Bill Pape is an internationally recognized infectious disease expert. In his native Haiti, he’s credited with developing guidelines for the care of children leading to a 50 percent decrease in national infant mortality. Dr. Pape is recognized for the first comprehensive description of AIDS in the developing world and also for implementing programs for the prevention and control of AIDS and TB in Haiti. His efforts are key in seeing the prevalence of HIV in Haiti decrease by over 50 percent. Dr. Pape is currently serving as the director and founder of GHESKIO in Haiti and is the professor of medicine at Weill Medical College at Cornell University.

Our third panelist, Dr. Uche Amazigo is Director of the World Health Organization Africa Program for River Blindness Control, which is a regional initiative based in Burkina Faso. As a scientist, Dr. Amazigo is managing 108 community-directed treatment projects in 19 African countries, overseeing and promoting health development, poverty alleviation and women empowerment programs in over 70,000 communities. She hails from Nigeria. It’s a distinct pleasure to have you with us, ma’am. Now before we get into our question and answer session, I want to just share a couple of thoughts that might help frame the next session.

First, health as a development issue - improving health of populations by reducing the spread of the impact of disease is a goal that we all share and pursue. We've been hearing about it all morning. There are many direct and indirect benefits of that pursuit. It gives us more productivity and greater economic growth. We all know that healthier populations go to school, go to work, participate in community affairs and live more normal lives. That's pretty general. Let me give you some specifics.

Recently I saw some data coming out of the Anglo Gold Ashanti mines. They work in Ghana.
For a $1.5 million investment, malaria prevalence dropped by 74 percent. They saved $326,000 in one year by not having to buy as many anti-malarial drugs. But here’s the clincher. The last lost man-days for that year dropped from 6,983 to 304. Now if you're in business, it seems that that would be an excellent investment and a good return on your investment. That represents a results-based program. Secondly, results-based programming is central to the (inaudible) of the United States foreign assistance program. President Bush addressed that in his remarks. He’s led the call for international funding and had it linked to specific programs that we, as a global community, can stand behind and hold each other accountable. President Bush has demonstrated that we're not only making promises, but we are delivering. In the three major programs, we are seeing specific significant results. And I’m not going to reiterate what the President just told you about the significant progress being made through PETFAR. Neither am I going to brag about the President’s malaria initiative, the program that I’m privileged to lead, because he just gave you all the statistics.

But let me give you just one little anecdotal story. When I was in Senegal last month I was introduced to a woman who said last year all four of her children were infected by malaria.
This year, after her home was sprayed, none of them have had malaria. That’s a pretty nice story.
More than one billion people worldwide suffer from one or more painful debilitating tropical diseases. In the first year of operation, U.S. Aid’s Neglected Tropical Disease Program delivered more than 36 million treatments, benefiting 16.5 million people. By delivering results, we're not only accountable to the U.S. taxpayer, but more importantly to those we seek to serve. By showing impact and being accountable, we have a higher chance of sustaining our efforts over the long term.

Thirdly, we recognize that we can only achieve our mutual goals through effective partnerships.
It’s at the heart of our strategies. We heard this morning that the most significant partner is the host country itself. And to focus in and work from their national plan as the common denominator is serving us well. The United States works aggressively with the Global Fund, the World Bank, the Bill and Melinda Gates Foundation and many other bilateral and multilateral partners to come together to serve the national plans in these countries. Community and faith-based organizations play a critical role in broad partnership efforts to scale up prevention and treatment at the national, district and community levels where no one else is.

The private and business sectors are key partners that continue to play an increasing role through production of pharmaceuticals and other healthcare products and increasingly as donors as part of their corporate philanthropy. I think though when we talk about partnership, it isn't informing the partnership it’s really doing the partnership. And I think that the other important part and the major challenge is to merge all the funding partners, all the care providers, all the educators and the technicians to deliver on the plan, on the commitments and then hold each other mutually accountable to the plan and meeting the requirements.

And lastly, on the accountability piece, we have the component of transparency. Transparency provides us an opportunity to be accountable. It’s good stewardship to the U.S. taxpayer, it’s a way to show fiscal accountability and program transparency. In PMI all of our plans, all of our partners, all of our funding allocations are on the Web for your scrutiny. Transparency invites scrutiny. It invites frank and constructive dialog, and I think it’s the foundation of our core business model.

So with those general comments, I’d like now to jump right into our panel and ask the first question.

Dr. Tedros, based on your experience as Minister of Health in Ethiopia, do disease-specific programs improve the overall health systems? And if so, how can this be done better?

Dr. Tedros Adhanom Ghebreyesus: Thank you very much, Tim. It’s really a great pleasure to have this opportunity of participating in this panel. As (inaudible) said we are in the same boat and he’s a great leader and we find out this as a team. And I would like also to thank Mark Raymond, my friend, who really made the country ownership principally happen. And today is one of the beneficiaries. We own the program and we're making some progress and I thank you for all his hard work. And I would also like, as what many of us, because before me, including President Selnief said, PFR and PMI are really creating hopes for millions globally. And we should congratulate President George Bush for this wonderful initiative, and representing my country we're very grateful for this generous support.

Then, coming back to the question - by the way (inaudible) was meant as a vertical program and financing HIV-AIDS and PMI financing malaria. Although the funding was raised vertically, in Ethiopia we use it horizontally or you can call it diagonally. And we're using the funding actually to strengthen our system. And also some people believe that, you now, the vertical programs or specific financing could actually affect the overall health system or weaken hence the overall system, that’s not the experience in Ethiopia. And we're actually using the vertically raised funding not only paid for in PMI but even Global Fund and GAVI money to strengthen our health system.

And we even are trying to better prepare our health system to fight for the future. So we can have the two, actually complement with each other - the vertical supporting the general health and the general health also helping the specific program targets succeed. And if I give you some of the examples we have, we're using, for instance the PFR money to strengthen our information system to strengthen our logistic system, to strengthen our human resources and to strengthen the other system issues and even the new design for health insurance is getting support from PFR money and without affecting actually our progress in terms of the specific targets which you're saying accountability for whatever targets we have for HIV.

In Ethiopia, for instance, three years ago we only had 900 people on free treatment, although we had around 8,000 in pain. From that 900 in free treatment, as I speak now we have more than 160,000 on free treatment. And that’s why I said, you know, these programs - PRF, PMI - are creating hopes to millions in Ethiopia. It’s already a huge progress comparing the 900 on free treatment three years ago to 160,000 in just three years. And we're also extensively relying on prevention. And almost each and every village is actually working on prevention because that’s the centerpiece and that’s actually the best medicine. And based on that, our capacity on counseling and testing is increasing. And three years ago we used to test only 500,000 a year, now this year alone we tested 4.5 million in just one year.

And you can see how people are motivated, coming forward for get tested, because there is an incentive of treatment. So what I’m saying is that vertically funded, we can keep the balance and use the funding to strengthen the health system, but in addition to that we can actually better results, encouraging results in the specific program that we have committed to, which is the accountability issue. Thank you.

Admiral R. Timothy Ziemer: Thanks, Dr. Tedros, I have a follow-up but I’m going to include the other panel members here and then I’ll come back to you on that. Dr. Pape, one question for you.

Can you tell us, given the poverty and the instability in Haiti, how an investment in the health system has seen such dramatic results?

Dr. Jean William Pape: Thank you for being here and thank you for the question. Indeed, Haiti has had its share of problem - political, economic and social. In the last 25 years we've had 18 different governments.
On the health sector, we he the highest infant mortality, highest maternal mortality, highest prevalence of TBB in the region, highest prevalence of HIV outside of Africa and on and on and on. We also have many factors that favor the spread of HIV, including the fact that it spread very early in the general population, the fact also that we have a high rate of sexually transmitted infections among sex workers and in the population, a nature type of culture which clearly doesn't help and also very poor infrastructure to the point that we only have one physician per 10,000 inhabitants and 80 percent of maternal deliveries are occurring outside the health system. Now how could this be done?

Very interestingly, many of the main themes of those panels are the core of the success of our program. Country ownership, accountability were essential. Country ownership first, Haiti is the first country that recognized AIDS in the developing world. So we are very concerned by this particular problem. It was our problem from the very beginning and we have to find a solution.
So we could not agree that there was nothing that could be done, as they were telling us early on. So very early on, we accepted that this was our problem, not anyone else. Secondly, the partnership that we've created with (inaudible) was essential. Private/public partnership has been also at the core of our success. Very importantly as well is the fact that we are oriented toward results. We needed to prove that the situation was not desperate. And what's very important is the fact that we are able to show and we have the chance, the opportunity, to have national NIH support for research, to develop very specific research-based interventions.

We also had (inaudible) international support for training, which made it possible to train a large number of individuals so when PETFAR came along, we already had a model of prevention and care that could be scaled up nationwide. So I think that if you put all those ingredients together, I think this has been the basis of these results.

Admiral R. Timothy Ziemer: Thanks. It’s not easy. It takes a lot of work and coordination, and it’s clear that your leadership and your staff has had a significant impact in pooling it together. Dr. Rutay, we've been talking a lot about accountability and transparency. You know, our government puts a lot of emphasis on that.
The size of the program that you have oversight responsibility of, is the emphasis on transparency with so many donors donating through the World Health Organization and perhaps directly to your programs, is the notion of accountability and transparency specific to the U.S. or is it across the board by all donors?

Dr. Uche Amazigo: Thank you very much. I think before I come to your question I would like to make a point. If I had my way, coming to this forum, I would have come here with 500 rural African women for them to tell the story of how America, through the United States Agency for International Development, has thousands, hundreds of thousands of African men and women, and prevented them from going blind. Our story is this, a huge success story. America does not know what you have done, how you have touched the lives of hundreds of people in rural Africa, people who live beyond the end of the route where there are no doctors, no roads, where the hunger is greatest. I wish they were here to tell you their own stories. But on their behalf, I thank the people of America.

The African program, which you're referring to, the African Program for Onchocerciasis control, is a multi-donor regional-based disease control initiative, a partnership between the private sector, the multilateral agency, bilateral donors, governments, beneficiary communities and the private company Merck, which is a U.S.-based company which has donated this job since 1987 for as long as it’s needed free of charge, so it’s timeless. To your question, transparency is important to us. APOC is a model that shows that good governance can be achieved even in partnerships, in public/private partnerships. The transparency and accountability of the program is not limited to the United States Agency for International Development, it is to all donors.  And APOC is supported by 20 donors from the United States to Canada to Great Britain to France, quite a number of them. But our accountability is something that the partnership holds very close because each partner from the communities, the beneficiary communities have their own clearly defined roles and responsibilities.

If I might tell you this, the communities collect the drugs themselves from the nearest health service. They select their own distributors who would distribute the drug. The health system with the funding of the donors and the support of the donors like the USAID train the community methods and distributors who now distribute this drug to their people. And lastly, 54 million people in sub-Saharan Africa in 15 countries were treated by more than 500,000 (inaudible) and distributors who are not paid. So communities share in costs. And the drug, too, that the medicine provides the program through the World Health Organization to these 117,000 communities in sub-Saharan Africa, the drugs are kept by the communities themselves. And up to date, we have no records that those drugs are stolen. Communities are accountable each year to more than 500 million publics of (inaudible) and that is the level of accountability that we see in this program.
I am sure, ladies and gentlemen, distinguished guests, you have been to the World Bank.

And when you step into the World Bank here in Washington you see a blind man being led by the child. Or you go to the Merck, you find the blind man, or the World Health Organization in Geneva. That is a  symbol of our program. That is a symbol of defeating river blindness. We are not yet there but we have done a tremendous job in many countries. And thanks to the communities, the reason for the success is because the communities are fully engaged and they are empowered to take decision and to plan this, manage the distribution. All the health system does is to train them and to bring drug to the nearest collection point. And the donors provide the funding, so it’s a very solid, very unique partnership that many new partnership been modeled after the Onchocerciasis partnership. Thank you.

Admiral R. Timothy Ziemer: Thank you for those comments.

Dr. Tedros and Dr. Pape, I’m going to come to you in just a second, but staying on this theme of transparency but then accountability, with all that you are having to manage in terms of programs and the requirements which are very vast and complex, how do you manage meeting different donor expectations coming in from the bank and the Global Fund, perhaps private foundations and then the U.S. government’s expectations? How do you manage that and is that a distraction for you to have to meet those exceptions and yet at the same time get the work done to serve the people? Dr. Tedros, you first and then Dr. Pape, I’d like to hear your comments on that.

Dr. Tedros Adhanom Ghebreyesus: Yeah, thank you very much.

I think dealing with many development partners, as anyone can imagine, is very, very difficult because each and every partner has its own planning formats, its own, you know, financial transaction regulations and its own reporting mechanism. And to really handle that is really a tough job and we're trying to handle that. But for us, that’s like a firefighting for the moment.
What we're actually trying with our partners for the future is on how we can go for one plan, one visit and one report which can make our life easier, actually. And, as some of you know or many of you know, Ethiopia has signed - the first country actually - to sign the International Health Partnership Compact. And 13 development partners have already signed this compact, and pledging to join the MDG performance fund, a pull system, and we will use one planning system, one visiting and one reporting system at least for these development partners.
But we believe that this kind of partnership is really a process and we cannot really expect all partners to join this system, you know, all of them in one go.

And we would entertain (inaudible) in our project-specific support or program-specific support while building the momentum for this arrangement, which can make life easier and even accountability actually better. Because with the partners that we have signed this compact with, we have agreed on a results framework, selected indicators on immunization contrasted to HIV prevalence, malaria and TBB, and then see how we really progress toward this achieving this and ultimately the MDGs. And this could make our life easier, the harmonization and alignment and then, as some people call it, tough love, so which is really tough.

Admiral R. Timothy Ziemer: Thank you.

It is something that is very attractive, isn't it, to think that we're working towards a point of common standards that we can merge towards one plan. The difficulty will be bringing everybody together to make sure the expectations of the donors and the partners are met along the way.
So we're making progress.

Dr. Pape, would you like to please comment on that?

Dr. Jean William Pape: Well I really co-essentially very much do same findings. Managing complexity is really the name of the game. We see it in research, where we have to report to many different ethical communities. There also we have to report to many agencies. When Ambassador Dybul and the Director of the Global Fund, Dr. Kazatchkine, visited our site, they saw one PETFAR
pharmacy and one Global Fund pharmacy on each floor. And they said, “This is nonsense.”
And we are very happy that they saw that. So I know that at their level they are trying to solve this. But clearly at this point, we have no other issue than reporting to each agency according to their guidelines. It’s clearly taking away time that we could use to do other chores. But eventually I'm certain that we all agree that this has to be changed and it will happen at some point.

Admiral R. Timothy Ziemer: Thank you.

Dr. Uche, this is from the audience.
How do you recommend that we proceed in training, organizing and assisting indigenous and foreign NGOs in Africa that promotes results-based programs and accountability? What can be done to standardize it through training?

Dr. Uche Amazigo: For the local NGOs, for the local- could you repeat that please?

Admiral R. Timothy Ziemer: Yes.

Dr. Uche Amazigo: Could you repeat your question?

Admiral R. Timothy Ziemer: Oh yes. How do you- what would you recommend that we do, as we proceed to provide training, organization and assisting indigenous and foreign NGOs to come along and be more effective partners for what you're doing?

Dr. Uche Amazigo: Thank you very much. I think what we need to do first is to expose the NGOs to the principle of community ownership, partnership with communities and to get them to buy into the importance of ownership, of country ownership, of community ownership of programs. You cannot achieve sustainability of any program that is community-based if the community people are not partners, are not given the authority to decision making. And if we have to bring the local NGOs to be part of this, we have to them help them to understand the importance and to buy into that. Then our train- and once they buy into the idea of a bottom-up approach and help to promote that bottom-top approach and imbibe it, then we can bring them on board. And they will certainly be a very strong partner because we need them. They are very important and most of them are at the community levels, that we need to invest in making sure that they buy to that attitude of community ownership of programs.

Admiral R. Timothy Ziemer: Yeah, excellent.

I've been involved with many different organizations and, again, the goal is not partnership. The goal is standardization with partnership so that we can achieve the common technical delivery.

Dr. Pape, would you care to comment on that? And then one additional comment came in from the audience based on the weather and the storms in Haiti. Has that affected your ability to deliver primary care services on the island?

Dr. Jean William Pape: First of all, some comments on the last question. I agree fully with what was said. In addition, I think site-to-site collaboration is essential. Having young people go and visit and spend time at sites that have been successful in the various aspects that we have indicated such as  accountability, community ownership, is really the best way to promote these kind of ideas and to move things forward. Regarding Haiti, this is correct. This is the first time in 30 years since I've been there that we've had such terrible disasters, four successive hurricanes within a four-week period. The capital is cut to the north and to the south. And as we run 46 institutions nationwide, is was very difficult to reach them by land. So what we had to do is to go by small planes because we have mobile teams that include a physician, nurses, pharmacies, accountant in our mobile team. They had to go onto small planes to make sure that things were going right.

But, except for the Gonaive area where about 200 patients have defaulted on their drugs, more than 18,000 people who are on ERT are still taking their meds.

Admiral R. Timothy Ziemer: Excellent.

Dr. Tedros Adhanom Ghebreyesus: Dr. Tedros, from the audience, we've been delicate about addressing accountability and complying with accountability expectations by your donors. But doesn't that really conflict with country ownership to feel that you're being managed and driven by outside requirements and accountability? Does that conflict with country ownership? You mean accountability by the donors?

Admiral R. Timothy Ziemer: Yes.

Dr. Tedros Adhanom Ghebreyesus: No, it doesn't actually. The accountability of partners is toward a certain goal that we really set. For instance, the MDG could be one, you know, commitment of partners, the government, the development partners and others, to MDGs so are we accountable to those results.

And partners and the government actually committing to these goals or, you know, being accountable to these goals. And in the recent framework, which I said, of the signatory of this, you know, the government and the development partners, we have set targets when to achieve it by 2010, by 2015. And this was, by the way, originally prepared by the government in relation to, you know, the MDG goals. And all development partners said, “Yeah, this is fine and we would like to support you on this.” So it’s country-owned but commitment was then requested from development partners and we both, as partners, have committed to these goals.

By the way, before accountability, the morning session I think is important. I think ownership comes before accountability. If you're not- if you don't own something, you cannot be accountable for. And even before ownership comes commitment. So at the end of the day, it's the commitment, or as some say, the political will, which comes above everything. And if there is that, then there could be that ownership will be easy to ensure ownership and through that, be accountability.

Because it will be easier, actually, with that setting that you can at least track whatever you have set together.

Admiral R. Timothy Ziemer: Let me follow up. As the Minister of Health in Ethiopia and as you're looking at this compact strategy, what would be your appeal or your desire for donor countries, say five or six years out, as your plan matures? What would you- what message would you like to communicate to the donors in order to meet your national objectives?

Dr. Tedros Adhanom Ghebreyesus: Yeah, my appeal would be we're now in the right direction and we're making progress.
We have these encouraging results now. I was trying to tell you what we have achieved on HIV only, but HIV is declining in Ethiopia and malaria, as President Mushava actually indicated, a decline in both mortality and morbidity by 50 percent. We have managed to distribute more than 20 million meds, which is the biggest distribution actually in sub-Saharan Africa. And immunization now is above what is required for herd immunity. We're above 80 percent.

Of course, we want to increase it further. And contrasted to (inaudible) countries it was around 33 percent until recently and now it’s around 51 percent.

And we're making progress. And even the education and other areas, economic growth for instance, more than 10 percent growth, which is the highest the last five years in non-oil producing sub-Saharan Africa. And education crude enrollment is more than 93 percent now.
So these encouraging results, I think have to be sustained in order to have a lasting impact in Ethiopia. And through this pooling system or the International Health Partnership, what we're asking is although it’s a process to really go into one mechanism of managing the whole, you know, system. And that could make life easier for us. Not only that, but we can even achieve better. When we arranged that, we're not only looking for the, you know, efficiency in terms of management, but we expect increased volume of assistance, plus predictability of funding, minimum of three years or up to even ten years. That's what we are asking.

But as I said earlier, this is a process and we wouldn't expect all partners to join. And we would be happy, as soon as they make up their minds, see the benefits, see our capacity and join us and better have, you know, this better system, which can be- which can have a better impact.

Admiral R. Timothy Ziemer: Thank you. Our time is running short and I would like to follow suit on the closing question on the first panel from this morning, starting with you, ma’am and then I’d like to just to work down. Could you perhaps give us your perspective for the advice that you'd like to give the next administration on how best to build and sustain on the current success of the health initiatives that you are managing and then any closing remarks in about a minute and a half?

Dr. Uche Amazigo: Yeah, thank you very much.

Recently, President Bush announced a $350 million initiative to tackle neglected tropical diseases. These are diseases of poverty, these are diseases that will impact on our achieving the millennium development goals. If we do not deal with these diseases, I cannot imagine any country achieving any of the MDGs. So I would humbly request the next president of America to follow on, to sustain this request and increase it and, indeed, ask the other G-8 countries to come on board as Britain has done. And also I would like the next president, if it’s possible, to visit the countries, to touch base with the poor people that you're helping so much. And one visit from a president of America makes a big difference to the developing countries, to the people, to the poor. And I believe that such a visit would be extremely helpful for the world.

Thank you very much.

Admiral R. Timothy Ziemer: Thanks, Dr. Pape?

Dr. Jean William Pape: I’ll go on the same way to indicate that we need to capitalize on the results, that a long-term effort must be sustained. PETFAR we see it in many ways is unprecedented. It’s the first time all U.S. health agencies have worked together. I wish that there was even stronger interaction between NIH, for instance, and CDC and USAID because NIH is providing research-based results and those research now could be fed into services. And finally, the U.S. remain on a bipartisan course on this very important effort.

Admiral R. Timothy Ziemer: Thanks, Dr. Tedros?

Dr. Tedros Adhanom Ghebreyesus: Yeah, thank you. I can see how the next president will be in a very difficult situation, especially with the financial crisis and the bailout which is the 700 billion, it may increase even. So I sympathize with whoever will be the next president because whatever was done by President Bush us really historic proportion, it’s really huge. So the level is really high and I don't know how they can even achieve that rate, alone double it. And that’s why I said I sympathize. So what I hope for is they can- I hope that they can make at least a very, you know, good decision. That's what I- but it will be up to them considering their situation, you know, to make the decision. But I hope it will be the right one.

But above all, I sympathize with whoever is coming because they're under a difficult situation.
But in addition to that, I also hope- I also wish to the people of the United States during these difficult times, you know, to have their strength and unity to overcome it. I think that matters most of any, Americans at the moment the domestic issue. And then if they can balance the international issue, welcome. Otherwise, I wish you all the best.

Admiral R. Timothy Ziemer: To the panel members, I just want to thank you for your time and for representing the multilateral community, the private community and the national governments so well. I know you all are busy.
You have very, very significant programs. We're inspired by your leadership and we look forward to continuing to partner with you.

Thanks so much.

Dr. Uche Amazigo: Thank you very much.