How to make global health partnerships work: Key insights from the field

MAPUTO, Mozambique — Partnership will be the key to UNITAID’s new $50 million, five-year investment in increasing antimalarial treatment for pregnant women in sub-Saharan Africa. The Transforming Intermittent Preventive Treatment for Optimal Pregnancy — or Tiptop — program will introduce community-level distribution of quality-assured sulfadoxine-pyrimethamine (SP) to 400,000 pregnant women and their babies in Mozambique, the Democratic Republic of the Congo, Nigeria, and Madagascar, and inform change in policy recommendations from the World Health Organization. Tiptop is implemented by a partnership between Jhpiego, a nonprofit affiliated with Johns Hopkins University, and the Barcelona Institute for Global Health (ISGlobal). In Mozambique, Devex got the inside track on how this partnership came together — and gathered advice on how to make collaboration work in global health. 1. Create synergies for impact No one organization has all the answers, notes Leslie Mancuso, president and CEO of Jhpiego. Successful partnerships are built on the right mix of organizations with differing, complementary skills. Tiptop is the first partnership between ISGlobal and Jhpiego. Both organizations had previously discussed opportunities for collaboration with the WHO on malaria in pregnancy and coalesced around the call for proposals from UNITAID. “It is not about having one organization undertake all aspects of a project, but about bringing the right experts to the table and ensuring they conduct the activity they are best at,” said Ana Álvarez, program officer for UNITAID’s operations team. Delineating how each partner contributes is important to implementation, but also to secure funding, said Clara Menéndez Santos, lead researcher for Tiptop. “The synergy between Jhpiego and ISGlobal was crucial to show the donor [UNITAID] that we were the right match and that each of us was equally necessary.” In order to ensure the sustainability and transition of the project, UNITAID was looking for a grantee with “very good links with local partners and ministries of health but also at the global level” to major funders and U.N. agencies, said Alexandra Cameron, a technical manager for UNITAID’s strategy team. The partnership’s initial proposal put forward twice as many partners and pilot countries, but “the donor decided to half them for the sake of efficiency,” adds Santos, who is also director of the Maternal, Child, and Reproductive Health Initiative at ISGlobal. A unique aspect of Tiptop is UNITAID’s role as a partner rather than a mere donor. “During the proposal process we really worked hand in hand with the technical and programmatic team at UNITAID,” said Elaine Roman, Tiptop Project Director for Jhpiego. “This is instrumental in setting the stage for success from the beginning.” 2. Beware of role creep Role creep is a common pitfall for partnerships. This is why Lelio Mármora, UNITAID’s executive director, stresses the need to clearly define roles and responsibilities, both in geographic and programmatic terms. “Overlapping triggers competition among partners, and this is the enemy of partnerships,” he told Devex. Establishing clear roles from the outset is all the more crucial given the complexity of global health projects. The Tiptop partnership is built around a prime partner grantee, Jhpiego, which reports biannually to UNITAID and coordinates the implementation, and a sub-grantee, ISGlobal, which leads the research and evaluation components. In turn, Jhpiego and ISGlobal work to support ministries of health and closely collaborate with key enablers in drug supply — Medicines for Malaria Venture (MMV) — and policy — the WHO. MMV, which operates on a separate UNITAID grant, works with manufacturers to ensure the production of quality-assured SP. Jhpiego also liaises with scale-up partners such as PMI, the Global Fund, and national governments. In parallel, ISGlobal has undertaken the process of identifying suitable research partners in pilot countries. 3. Align principles and goals — and put them in writing “Every detail — be it institutional, technical, financial, or scientific — must be put in writing,” said Antoni Plasència Taradach, director general of ISGlobal. “[Reaching] these consensuses may take many months, but without them it is impossible to conduct the project.” Roman recounts how the Tiptop partnership worked from the outset to establish clear and transparent communication. “It reaffirms that we all come from the same place. We all bring different talents, but there is respect across the partnership,” Roman said. The agreement between grantee and donor includes a logframe that clearly establishes goals and indicators to keep track of the progress, says Álvarez from UNITAID. Both parties signed a $50 million budget for five years, but disbursement will be based on the biannual programmatic and financial reports by Jhpiego. Performance-based funding, though, is tricky for innovation-driven initiatives. “As opposed to mechanisms such as the Global Fund, our projects are not linear; they must start by laying the ground, so you may not see results from the very beginning,” said Álvarez. UNITAID takes this into account when designing logframes so as not to unfairly penalize projects. 4. Build trust through a collaborative mindset Successful partnerships strategically nurture trust throughout the project. Mármora says this process includes “not competing [with partners] from a financial perspective, letting everyone show off his work, and doing what you said you would do.” In Tiptop, the prime partner, Jhpiego, plays a central role in building trust. Just four months old, Roman says, the partnership is “at a place now that sometimes takes at least a year to get to” in trust building. She attributes success to working closely in the proposal process, defining principles early on, and welcoming individual achievements as collective successes. Transparency and consistency are also central. Jhpiego has built a project management team that includes the WHO and MMV and holds teleconferences on a monthly basis. In addition, the organization holds regular one-on-one calls with various partners and monthly discussions with UNITAID. At the country level, technical working groups for malaria in pregnancy bring health authorities together with implementing and supporting partners on a quarterly basis. Two years into the project, all actors will meet to decide on the expansion of the pilots. Cameron, from UNITAID, offers two pieces of advice: Make sure your communications are clear so that you are not perceived to be saying different things to different partners, and make sure everyone has all the information and guidance you would offer at any given time. 5. Be ready to adjust course Innovation-driven projects will need to evolve as they go, by sharing results and learning from mistakes, according to Mármora. But adjusting course is a major challenge, like “fixing a plane in the air,” he said. Tiptop uses data to track progress, identify best practices, and build on lessons learned, explains Roman, who is also co-chair of the Roll Back Malaria-Malaria in Pregnancy Working Group. This informs routine discussions between grantee and donor. Projects focused on innovation are “much less linear than a normal delivery project, so you need to correct course much more often,” said Cameron. In response to this, the organization is finalizing a standard operating procedure outlining how changes to the scope and scale of projects have to be implemented, added Álvarez. 6. Hardwire transition into the project design UNITAID’s projects aim to set the stage for deploying innovation at the national, regional, and global levels. “You have to go into these projects believing in scale,” Mancuso said. Preparing for scale means considering a transition or exit strategy before the project begins. UNITAID engages with scale-up partners before getting the board’s endorsement for an initiative. “By being aligned with the priorities of WHO, the Global Fund and PMI — by not choosing strategic areas that are of no relevance to the major donors and to the countries — we are already setting ourselves up for the transition of our eventual projects,” said Cameron. At the proposal stage, candidates must describe their plans for transition, including main scale-up partners such as governments and donors. The Tiptop project has “a whole output stream focused on transition, with indicators and annual targets,” said Álvarez. To ensure the sustainability of Tiptop’s community-based approach, Santos adds, both partners have also engaged civil society and nongovernmental organizations from the beginning. Read more Devex coverage on global health.