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

Goal Alignment

Partner goal alignment was strong. Most respondents identified a 50% reduction in the maternal mortality ratio (MMR) as the primary goal of the partnership. While it was frequently perceived as “very ambitious” or “aspirational,” several respondents suggested the ambitious nature of the goal mobilized commitment and resources that supported program success. One respondent from a subnational host government explained:

It was a very ambitious goal that in the first year [we would have a] 50% reduction in MMR. We looked at people [SMGL partners] and said, “Are you going to make this? This goal is very high.” And they said, “It is good to aim high and then see how things work. At least we got to 30%. And then progressively we'll be able to reduce the maternal mortality ratio by more than 30%.”

Respondents further noted that partner alignment on the goal facilitated decision making and coordination. One of the global partners commented:

I know that there's the typical sort of bureaucratic challenges, rivalries, funding challenges—all the things that are always inherent in any kind a project. It just seemed like [the partners] really had the mission first and foremost in mind … I think that's one of things that made SMGL function, was that the partners were sort of aligned on the key topline objective.

Partner Expertise

Respondents from both USG headquarters and field offices indicated that the diversity of technical expertise and funding was a key strength of SMGL, as illustrated by comments from a field office representative:

I think the partnership was aiming to achieve first of all, having a pool of varied resources. So we have a lot more than if we had one or two people involved, both financial as well as the technical support and understanding. And also just bringing the varied experiences from the different partners, I think, from the very beginning.

The respondents also found that the ability of the private sector to finance efforts directly was useful in filling public funding gaps, along with the ability to fund outside the set funding cycles of government and foundations. The presence of private-sector partners encouraged public-sector partners to consider the private sector when working in-country.

Strength of Leadership

Strong USG leadership, particularly from the Secretariat, was highly valued by the respondents. Respondents indicated that the small number of members enabled the Leadership Council to respond quickly to concerns. Partners expressed satisfaction that strong, consistent leadership allowed them to achieve results, such as a uniform maternal and neonatal health reporting system that would support efforts toward mortality reduction in spite of funding gaps and shortfalls. Leadership, in this case, was perceived by many respondents to fill a coordination role rather than a directive role, which supported partnership success. As one global partner explained:

I think that effective leadership made a difference—there was always a sense of team. And that doesn't happen without effort. There was remarkably little ego, which is really hard to do with these separate agencies with their own separate missions coming together for one mission as a team, so a lot of that was just really strong leadership and management, and tone setting, those types of things.

Strength of Monitoring, Evaluation, and Learning

SMGL prioritized MEL from the planning phase. The partners jointly developed a results framework and MEL plan that stipulated core indicators to capture through health facility assessments and baseline and endline program evaluations that were regularly tracked. Partners expressed positive sentiments about the creation and use of robust monitoring and evaluation systems at all levels of the partnership, from the community to global level. For example, a respondent from USG headquarters said:

It's kind of a hallmark of SMGL that we don't just produce fluff, we actually provide health outcome data, which is extremely rare in USAID-led projects. I'm very proud of the M&E [monitoring and evaluation] we have done and our ability to work across agency silos capturing outcomes in a really sterling, top-notch way.

Furthermore, a field representative applauded the SMGL's encouragement of country innovations in MEL:

We decided to use our district health systems strengthening approach but with contiguous districts. … So bottom line to me was there was this allowance to allow systems to innovate within the countries of need, which has even happened in Nigeria.

Of the partners that referenced learning, the majority were from respondents in Uganda, who often referenced learning from Zambia MEL findings and using them to improve health outcomes in their own country.

Country Ownership

Perceived ownership of SMGL was high at the subnational level in both Uganda and Zambia by the end of the program. Partnership approaches that facilitated country ownership included working within and strengthening the existing health system rather than a parallel structure; engagement of government national and district staff during program design; and alignment of SMGL with existing national health road maps. During a funding gap in the partnership, elements continued through a “relentless, gritty continuation of the approach and the outcomes,” as one USG headquarters respondent explained, attributed to district ownership and leadership. A subnational respondent from Uganda described how active involvement of local players helped to instill a sense of ownership in SMGL activities:

Partners have not done activities in the district without consulting the DHO [District Health Office], the Chief Administrative Officer, and with the Chief Administrative Office, the District Executive Committee. And monthly there have been project coordination meetings and that makes us own whatever we do, that we are implementing in these areas.

The level of support at the national MOH level was mixed. While the USG and the MOH in Zambia reported national MOH engagement was high, Zambian District Health Office staff and other donors commented on gaps in Zambian MOH engagement at the national level. In Uganda, respondents indicated that additional human and financial resources at the MOH to support and engage in program management would have enhanced country ownership. Still, as one respondent from Uganda explained, successes at the subnational level helped fuel support at the national level:

The district and local leadership were very excited about it. And then when it started to show pretty incredible successes, the government really got behind it, embraced it and wanted to roll it up and package it as one of their everyday work.

Sustainability

During the proof-of-concept phase, SMGL front-loaded funding to allow the respective MOH officials time to gradually assume increasing management and financial responsibility for the program. Upfront investments included hiring additional staff seconded to the ministry, purchasing vehicles and equipment, and providing construction and renovation of health facilities and limited commodities. The partnership's decision to build this infrastructure for staffing, transportation, and construction within the existing national MOH system provided sustainable assets that the MOH could build upon moving forward.

Other elements aimed at achieving sustainability and scale-up of the program included incorporating SMGL elements into other USG-supported programs; ensuring MOH staff were involved in project roll-out and thus maintained institutional memory to continue incorporating SMGL elements in government-financed programs; and encouraging new donors to support the SMGL model in their programs. A respondent from Uganda indicated:

A lot of infrastructure improvements have been done … and equipment—those can probably stay longer. Maybe, five years or more. A lot of capacity has been built of the health workers and a number of them have been taken on by the districts of the government of Uganda. They have been put on the government payroll, so I believe with that knowledge that has been passed on to them, that is something that can stay on in the long term.

The Swedish International Development Cooperation Agency (SIDA) provided and continues to provide funds in Uganda and Zambia and to the Global Financing Facility, and the Global Fund to Fight AIDS, Tuberculosis and Malaria. The Belgian Technical Cooperation also continues to provide funds for the SMGL model as of 2018. A respondent from USG headquarters explained:

[In Zambia] the scale up had been quite vigorous and had attracted other financial support. I think that the Swedish aid agency directly provided financial support to districts to implement the SMGL model.

Representation in SMGL Governance Structure

Most partners acknowledged that the governance structure made sense on paper (Figure 1), but some felt that the implementation of the committees did not always reflect the diagram, noting underutilization of some partners, unclear roles of specific working groups, or confusion over the value-add of different committees. Some partners mentioned areas of expertise they wished had been represented on the Leadership Council in order to address service delivery gaps on the ground, including midwifery, nursing, water, sanitation, construction, infrastructure, transportation, and supply chain. For example, a Zambian respondent at the subnational level indicated:

They'd say as a district we're having a problem with transportation, but the partner comes with so much resources but cannot meet the one need that will actually impact everything else.

In addition, while partners reported strong district-level engagement in both countries, absence of national MOH representation on the Leadership Council was considered a missed opportunity. A respondent from USG headquarters stated:

They [the MOH] weren't even represented on the Leadership Council in the early days. And I think that was a serious mistake and something that I hope has been corrected and will continue to be corrected. The problem is that you don't have high officials in a host government who are willing to sit through long conference calls or travel to Washington for meetings talking about leadership and governance.

Roles and Responsibilities: Clarity, Resources, and Organizational Structure

Roles and responsibilities varied widely across partners and included areas of communication, data and analytics, advocacy, program implementation, and procurement. Individual partners and working groups within the partnership frequently reported a perceived lack of clarity in roles and responsibilities. A global partner explained:

The partners were kind of cobbled together pretty quickly, it seemed without a lot of thought of what would they do, how would they contribute in distinctive ways. And that's something that took a long time to resolve, and I'm not sure it even really was resolved.

Smaller global partners noted that it was more difficult for them to make a significant contribution given their limited resources and the ambiguity associated with their role. Two such smaller global partners described:

If I did it all over again, I don't know that I would have entered it [the partnership], only because of our [small] size and scope. I mean, just to think back, and it just seems kind of incredulous to think that we could have contributed more than we did.

I always felt almost bad when we would start celebrating the early reductions that we were talking about, and I don't feel like we really played a super meaningful role because it wasn't set such that we could think about “How can [we] help here? What can we do to play a meaningful role in the goals that have been set here?” … You know they're bigger … bigger budgets, bigger organizations. But we were tiny. So we could sort of stand aside saying, “What do you need us to do? Put us in coach.”

In a few cases, mid-program shifting priorities within a partner organization resulted in reduced compatibility between the organization's mission and partnership needs. Other respondents suggested that large-scale partners possessed an inherent rigidity through their own internal governance structures and organizational objectives, which might have limited their role in the partnership.

Bureaucratic Processes

Bureaucratic processes were unique to each partner and sometimes resulted in funding delays, which begot implementation and human resources challenges. Several respondents at the country and global levels noted such challenges:

You can't just hire 'willy-nilly' [haphazardly or spontaneously] just because you have money and you have a program … following these rigid rules of hiring also affected a lot of the timing, in terms of when you can hire. (Zambian partner)

There was a gap of almost 1 year, whereby there was no funding that came into the country. That was again a real challenge and delayed the program for almost a year. (Ugandan subnational partner)

I think in any partnership, a funding cycle has different sorts of decision makers and timelines, and I would not say we were fast. There were several delays in our funding, but it was often [because], you know, we didn't have congressional approval or things like that. So it's hard to control but it's the reality of how funding gets allocated. (Global partner)

Leadership turnover during political transitions impeded strategy and vision alignment across partners. One partner in Zambia, for example, discussed the difficulties of hiring short-term employees to fill human resource gaps due to discordance between local labor laws and unpredictability of USG funding. While many partners acknowledged that bureaucracy is inherent in government partnerships, some suggested that the private sector was not fully leveraged to counterbalance this challenge and that the partnership should have sought funding with more flexibility. One global nonprofit partner explained the type of flexibility it had in contrast with larger organizations:

It's a lot easier for a tiny little startup non-profit to say, “We're deciding where we're going to spend our money based on what we decide we want to do, so yeah, tell us where to put it.” We could do that. I think for these bigger organizations it's just unrealistic to think that they could [do that].

Compressed Timeline

The desire to launch activities quickly and to show significant impacts in a brief period of time seemed to undercut planning and relationship development. Some members found themselves playing “catch-up” after implementation began, finding it necessary to insert themselves into a moving process, rather than taking position in a prearranged operational structure at the outset of program activities. One partner noted the challenge posed by the initial short timeline to gathering sufficient evidence, as countries were not guaranteed additional financial support unless they had achieved significant reductions in MMR during that year. Another partner explained:

I think some of the ground work that would ordinarily happen when trying to put together a partnership of this size, it just didn't because speed seemed really important. There's this real desire to get something off the ground quickly, and so there wasn't the planning and the groundwork that you would usually see with something like this until it was catching up and learning more information, figuring out how to plug in. So it wasn't the ideal dynamic.

Perceptions of Power

Financial capacity affected power dynamics in several ways. In at least one case, a partner on the Leadership Council was financially supported by another council partner. Partners of both public and private sectors observed that those with larger financial contributions had more decision-making power. Since USG invested more money than other organizations, this shifted more power to USG partners. One of these USG global partners explained:

Huge decisions like how many years to keep SMGL going [were] largely driven by funding. … I think the USG held a huge role in decision making because we had the big purse.

Other partners described this imbalance with the terms “big P” and “small p” partners to illustrate the functional differences between certain partners:

[A]nd by big P [Partner] and small p [partner], it had to do with who had the biggest investments and therefore gets the biggest seat at the table. So that was a little bit concerning for us, because those big P partners seemed to have had more of the say in the partnership.

Generally, USG partners felt that the funding level of an organization reflected its level of commitment and hence determined its ownership. Some USG partners even questioned the value of including non-USG partners, arguing that the administrative burden outweighed their added value.