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

doi:10.9745/GHSP-D-18-00264

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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
Partner	Global	Uganda	Zambia
American College of Obstetrics and Gynecology	Thought leadership on implementation science	Mentorship 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 Norway	Thought leadership on health information systems	Funded 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 Committee	Ensure 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 assurance	USAID Mission support for behavior change efforts, technical training and mentoring, and district coordinators
State/OGAC	Technical guidance and funding to country teams, outside of the Country Operational Plan funds	CDC 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 Defense	N/A	N/A	Support work with 7 government military health facilities, including upgrading maternity wards and operating rooms Construct 7 maternity waiting homes
Peace Corps	Develop training curriculum on MCH for Peace Corps volunteers	N/A	Support 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

	Sampled	Participated^*	Interviewed on the Governance Framework	Interviewed for Country Ownership
U.S. government, headquarters	15	11	9	2
U.S. government, field	14	11	7	10
Host government, national	5	3	1	3
Host government, subnational	10	9	0	9
Global partner	13	12	11	3
Total	57	46	28	27

↵* 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 Factors	Summary of Partnership Literature²^,³^,¹³^,¹⁴^,¹⁶^,¹⁷	SMGL Findings
Success Factors	Summary of Partnership Literature²^,³^,¹³^,¹⁴^,¹⁶^,¹⁷	Strengths	Weaknesses
Shared vision/operational approach	At 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.
Trust	Gaining 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 responsibilities	Often, 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.
Resources	The 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 Factors	Summary of Partnership Literature²^,³^,¹³^,¹⁴	SMGL Findings
Success Factors	Summary of Partnership Literature²^,³^,¹³^,¹⁴	Strengths	Weaknesses
Governance structure	Low 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.
Secretariat	The 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&E	Agreement 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 making	Dominant 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.

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TABLE 5.

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

Success Factors	Summary of Partnership Literature	SMGL Findings
Success Factors	Summary of Partnership Literature	Strengths	Weaknesses
Country ownership²⁰^–²⁴	Country 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^–²⁹	Transition 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.