NGOs must prove relevance to survive in 'America First' health strategy

Nongovernmental organizations can carve out a space for themselves in the new U.S. bilateral health deals — as long as they prove their relevance to the governments that America is partnering with, and are willing to adapt to the new realities. That’s what health experts said during a Devex Pro Briefing on Tuesday. The U.S. launched its new “America First” global health strategy in September, which prioritizes direct memorandums of understanding with countries and aims to work with the private sector and faith-based organizations. In previous administrations, U.S. global health funds were often funneled through large NGOs — of which the Trump administration isn’t a fan. It repeatedly criticized what it calls the “NGO industrial complex” for having high overhead costs and creating parallel systems — leaving country governments with little say in how health care money was spent. It’s a criticism that has resonated with many but has also left NGOs — both international and local groups that aren’t faith-based — wondering what role they might play in these new bilateral deals. But after the U.S. signs these deals with countries, those partner governments have the discretion to decide who will implement health programs, said Dr. Mark Dybul, former executive director of The Global Fund to Fight AIDS, Tuberculosis and Malaria, during the Pro Briefing. “Organizations will remain relevant to the extent that they shift and understand the countries are in charge, which is what should have happened a long time ago,” he said. In the past, U.S. funding often went to international NGOs and then was subcontracted to local organizations — but management roles weren’t often transitioned to those local organizations. That was an absolutely necessary step that was neglected and is now making this process more complicated, Dybul said. While the bilateral agreements aren’t publicly shared, those that have circulated outline predictable, multiyear commitments, with yearly transition plans of ownership to partner governments. Some countries have begun to build this into their financial forecasts, Dybul said. “This is actually an opportunity to start putting things together and actually delivering on what we've been promising for 25 years and haven’t delivered at all, which is supporting the countries in their sovereignty,” he said. The “America First” global health strategy reflects a high level of risk tolerance in its quick shift to work with countries on assuming ownership of programs — in areas like governments taking over supply chain systems and assuming health care worker salaries, said Dr. Jirair Ratevosian, senior fellow at Duke University Global Health Institute. “This administration deserves a lot of credit for making all of this happen in such a short amount of time,” he said. Ratevosian said that this level of health system strengthening was viewed with a lot of skepticism in many parts of Washington, D.C., not too long ago. “To me, it’s pretty remarkable,” he said. “It’s important to recognize just how fast the center of gravity has moved here.” But taking on that high level of risk also needs to be mitigated — ensuring American taxpayer dollars are protected. NGOs can play a role in helping to manage that risk in the auditing and reporting back, he said. “In my mind … NGOs and implementing partners become more important, not less,” he said. “They will increasingly, I think, be more involved in helping with risk management, by listening closely to governments, working through local institutions and partners to identify what those capacity gaps are, and then being part of the delivery to ensure that no population is left behind.” It will also be a stress test for how integration looks in practice. “Many countries are being asked to absorb these long-term wage bills and operating costs on timelines that may outpace fiscal possibility and even political cycle,” Ratevosian said. Aggrey Aluso, executive director of the Resilience Action Network Africa, noted that NGOs should also play a crucial role in holding governments accountable as these deals are implemented. “The importance of driving accountability on both ends is something that NGOs, on both the American side and the local implementing NGOs, can do,” he said. But he also expressed concerns around ensuring that NGOs are engaged in these new agreements in ways that provide health services to marginalized groups, such as populations that are at high risk of contracting HIV but which may not be targeted by the faith-based sector or governments. The U.S. State Department has been moving around the African continent in recent months, negotiating these deals. Agreements have already been signed in Kenya, Uganda, Rwanda, Liberia, and Lesotho — with dozens more expected to be signed in the coming weeks. Before the agreements go into effect in April, there will be discussions between the U.S. and country governments on turning these high-level agreements into more detailed plans, Dybul said. “Pathogens come from other countries that don’t necessarily sign MOUs with the United States, and that’s why we need the global system. That’s why we need multilateral cooperation.” --— Dr. Jirair Ratevosian, senior fellow, Duke University Global Health Institute Aluso noted that his organization and others have had concerns around how this process has so far been managed — without broad stakeholder engagement and transparency. This is particularly relevant because countries are expected to cofinance these agreements with their own national budgets, and the public should be involved in defining what its priorities are for where money is spent, he said. For example, the U.S. is providing Kenya with $1.6 billion, while the Kenyan government is allocating $850 million. “It’s something that now needs parliamentary oversight,” he said. “It needs public participation, because we have other evolving challenges in the health sector.” Ratevosian said that these bilateral agreements also can’t come at the cost of multilateralism. “Pathogens don’t recognize MOUs. Pathogens come from other countries that don’t necessarily sign MOUs with the United States, and that’s why we need the global system. That’s why we need multilateral cooperation around all of this,” he said.