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ORIGINAL ARTICLE
Open Access

Saving Lives Together: A Qualitative Evaluation of the Saving Mothers, Giving Life Public-Private Partnership

Anne Palaia, Lauren Spigel, Marc Cunningham, Ann Yang, Taylor Hooks and Susan Ross on behalf of the Saving Mothers, Giving Life Working Group
Global Health: Science and Practice March 2019, 7(Supplement 1):S123-S138; https://doi.org/10.9745/GHSP-D-18-00264
Anne Palaia
aBureau for Global Health, U.S. Agency for International Development, Washington, DC, USA.
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  • For correspondence: apalaia@usaid.gov
Lauren Spigel
bICF, Fairfax, VA, USA. Now with Ariadne Labs, Boston, MA, USA.
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Marc Cunningham
aBureau for Global Health, U.S. Agency for International Development, Washington, DC, USA.
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Ann Yang
aBureau for Global Health, U.S. Agency for International Development, Washington, DC, USA.
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Taylor Hooks
aBureau for Global Health, U.S. Agency for International Development, Washington, DC, USA.
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Susan Ross
aBureau for Global Health, U.S. Agency for International Development, Washington, DC, USA.
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    FIGURE

    Saving Mothers, Giving Life Partnership Governance Structure

    Abbreviations: ACOG, American College of Obstetrics and Gynecology; EMC, Every Mother Counts, M&E, monitoring and evaluation; USAID, United States Agency for International Development; USG, United States Government.

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    TABLE 1.

    Saving Mothers, Giving Life Partner Roles and Responsibilities, by Geographic Scope

    Geographic Scope
    PartnerGlobalUgandaZambia
    American College of Obstetrics and GynecologyThought leadership on implementation scienceMentorship training of OB/GYN society (USAID)Support national adoption of uterine balloon tamponade (USAID-supported)
    Every Mother Counts
    • Advocacy/media campaigns

    • Co-Chair of Communication Committee

    Fund emergency transportation and referral systems
    Government of NorwayThought leadership on health information systemsFunded Project C.U.R.E. to provide supplies/equipment
    Merck for Mothers
    • Support Phase 1 Secretariat

    • Support website/communication

    Strengthen local private health care providers in Uganda
    • Develop entrepreneurial approaches for maternity waiting homes

    • Support Zambia endline census

    Project C.U.R.E.Co-Chair of New Partnership CommitteeEnsure availability of critical supplies/equipment for services (funded by USAID and Government of Norway)
    USAID (lead USG agency)
    • Lead SMGL for USG

    • Support SMGL Secretariat for Phase 2

    • Co-Chair and fund M&E Working Group

    • Lead MNH technical oversight, support country programs

    USAID Mission support for postpartum family planning, voucher programs, private-sector services, and quality assuranceUSAID Mission support for behavior change efforts, technical training and mentoring, and district coordinators
    State/OGACTechnical guidance and funding to country teams, outside of the Country Operational Plan fundsCDC and USAID Missions provide HIV/AIDS technical oversight and support to country programs
    CDC
    • Lead M&E efforts for the SMGL initiative, including cross-country analysis

    • Co-Chair M&E Working Group (funded by USAID)

    Lead M&E activities for the country including RAMOS, HFAs, POMS, MDSR, and BABIES (funded by OGAC)Lead M&E activities for the country census, HFA, MDSR (funded by OGAC)
    U.S. Department of DefenseN/AN/A
    • Support work with 7 government military health facilities, including upgrading maternity wards and operating rooms

    • Construct 7 maternity waiting homes

    Peace CorpsDevelop training curriculum on MCH for Peace Corps volunteersN/ASupport community health workers located in SMGL districts
    • Abbreviations: BABIES, Birth Weight and Age-at-Death Boxes for Intervention and Evaluation System; CDC, U.S. Centers for Disease Control and Prevention; HFA, health facility assessment; M&E, monitoring and evaluation; MCH, maternal and child health; MDSR, maternal death surveillance and response; MNH, maternal and neonatal health; OB/GYN, obstetrics and gynecology; OGAC, Office of the U.S. Global AIDS Coordinator; POMS, Pregnancy Outcomes Monitoring Survey; RAMOS, Reproductive Age Mortality Study; SMGL, Saving Mothers, Giving Life; USAID, United States Agency for International Development; USG, United States Government.

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    TABLE 2.

    Participant Sampling Groups

    SampledParticipated*Interviewed on the Governance FrameworkInterviewed for Country Ownership
    U.S. government, headquarters151192
    U.S. government, field1411710
    Host government, national5313
    Host government, subnational10909
    Global partner1312113
    Total57462827
    • ↵* Some participants were interviewed both on the Governance Framework and for Country Ownership.

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    TABLE 3.

    Saving Mothers, Giving Life Partnership Strengths and Weaknesses Compared With Overall Partnership Success Factors

    Success FactorsSummary of Partnership Literature2,3,13,14,16,17SMGL Findings
    StrengthsWeaknesses
    Shared vision/operational approachAt the vision level, there are often high levels of agreement, but it is more challenging to align operational approaches and resources.The partners had a shared vision in terms of reducing maternal and newborn deaths.
    Initially, operational approach was not clear, but the partners successfully negotiated a mutually agreed-upon operational approach and budget.
    Country governments had limited input in developing the initial goal, but goal expectations were later modified.
    Partners assumed it was easy to integrate PEPFAR and MCH platforms.
    TrustGaining trust takes time and initially relies on personal connections.
    Staff changes can significantly destabilize a partnership.
    While there were many changes in the partnership, organizations continued their commitment to the partnership, even if at a lower funding level.The rapid startup limited time at the outset to develop trust and define roles and responsibilities.
    Clearly defined roles and responsibilitiesOften, lack of clarity in roles and responsibilities can delay activities, create duplication, waste resources, and lead to miscommunication/mistrust among the partners.As the operational plan was clarified, the roles and responsibilities became clearer.Initially, there was confusion over roles and responsibilities, which was particularly challenging for some of the smaller partners.
    ResourcesThe partnership can mobilize additional resources, but often fails to be suffciently resourced to meet ambitious goals.
    There are high transaction costs.
    Due to inadequate use of country systems and poor harmonization, resources can be duplicated/wasted.
    Pledges are not always been realized.
    The partnership facilitated the use of PEPFAR funds for maternal health activities.
    Presence of a private-sector partner provided more engagement with private service providers.
    Additional partners were leveraged to fill gaps and expand the approach.
    The initiative was not fully funded, partners had to revise their pledges and recommit themselves to the partnership.
    The partnership was limited in its capacity to provide infrastructure support.
    • Abbreviations: MCH, maternal and child health; PEPFAR, U.S. President's Emergency Plan for AIDS Relief.

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    TABLE 4.

    Saving Mothers, Giving Life Governance Strengths and Weaknesses Compared With Established Success Factors

    Success FactorsSummary of Partnership Literature2,3,13,14SMGL Findings
    StrengthsWeaknesses
    Governance structureLow participation from countries and NGOs on governing bodies but boards are becoming more representative.
    Partnerships require dedicated staff to support them.
    The partnership developed a defined governance structure with voting and clearly identified organizational points of contact.
    Composition size was seen as a positive.
    MOHs were not included on the Leadership Council during Phase 1. They were invited to join during Phase 2, but country factors inhibited their participation.
    SecretariatThe Secretariat plays a vital role in the effectiveness of the partnership; the costs of coordination and communication are often not well understood or resourced.The Secretariat provided stability to the partnership and was praised for its leadership.
    Governance process: M&EAgreement on common metrics, data collection approaches, and partner roles are essential.
    It is important to have indicators that reflect the outcomes as well as the partnership processes.
    Rigorous M&E enabled the partnership to demonstrate success and make program adjustments.The Phase 1 evaluation touched on the partnership, but the partnership did not have any metrics that measured the partnership processes.
    Governance process: decision makingDominant decision makers are usually related to the size of funding.Regular (technical, results, and financial) updates were provided via the Operations Committee and Leadership Council.The partnership was largely seen as Washington-driven and USG-funded.
    There were some conflicts of interest and power dynamics between larger and smaller partners.
    • Abbreviations: M&E, monitoring and evaluation; MOH, Ministry of Health; USG, United States Government.

    • View popup
    TABLE 5.

    Saving Mothers, Giving Life Country Ownership and Sustainability Strengths and Weaknesses Compared With Established Success Factors

    Success FactorsSummary of Partnership LiteratureSMGL Findings
    StrengthsWeaknesses
    Country ownership20–24Country ownership of partnership activities can strengthen national health policy processes, raise profile of specific health issues, and establish international norms and standards.
    Partnerships often fail to address broader health systems issues.
    Limited harmonization leads to considerable duplication, emergence of parallel systems, and little alignment between recipient country and partnership priorities.
    Parallel budget systems raise concerns of government ownership and sustainability.
    SMGL activities were built on national policies/road maps and international best practices.
    The partnership reinvigorated commitments to reducing maternal/newborn deaths.
    The partnership focused on enhancing district health systems, both public and private, to achieve results.
    SMGL built health worker and community capacity to increase demand for and provision of quality maternal and newborn health services.
    Rapid startup limited initial government ownership.
    Some misalignment between partners and country priorities existed.
    Sustainability25–29Transition planning is key but not sufficient.
    Ensuring financial sustainability is the most challenging aspect of partnerships; it is important to understand the cost of the entire system to be sustained, rather than just commodities.
    More studies and indicators to monitor successful transitions from donor-funded programs to country, public, civic, and/or private stakeholders are needed.
    SMGL was designed to front-load funding so the MOH and other stakeholders could sustain the efforts.
    Communities and some districts were able to mobilize their own resources.
    The partnership between the MOHs and SMGL leveraged US$100 million from donors to continue key aspects in the short run.
    Partners used its results to advocate with key government stakeholders to sustain SMGL.
    While there was a high level of government ownership for SMGL, this did not result in national-level budget increases.
    • Abbreviations: MOH, Ministry of Health; SMGL, Saving Mothers, Giving Life.

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Global Health: Science and Practice: 7 (Supplement 1)
Global Health: Science and Practice
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Saving Lives Together: A Qualitative Evaluation of the Saving Mothers, Giving Life Public-Private Partnership
Anne Palaia, Lauren Spigel, Marc Cunningham, Ann Yang, Taylor Hooks, Susan Ross
Global Health: Science and Practice Mar 2019, 7 (Supplement 1) S123-S138; DOI: 10.9745/GHSP-D-18-00264

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Saving Lives Together: A Qualitative Evaluation of the Saving Mothers, Giving Life Public-Private Partnership
Anne Palaia, Lauren Spigel, Marc Cunningham, Ann Yang, Taylor Hooks, Susan Ross
Global Health: Science and Practice Mar 2019, 7 (Supplement 1) S123-S138; DOI: 10.9745/GHSP-D-18-00264
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