Q&A: Reimagining technical assistance to progress global health

Reimagining Technical Assistance, a concept developed by JSI with a comprehensive cohort of partners, challenges norms and pushes forward an evolving conversation about localization. For years, it has worked toward putting communities in the driver’s seat to lead their own agendas and coordinate their programs and initiatives. “But it can be an ambiguous and nebulous topic, and even overwhelming — because it is about shifting power and authority,” said Margaret Crotty, CEO at JSI.

As an international NGO with a mission to improve health outcomes for all, JSI has a history of implementing projects and providing technical assistance. JSI had long been working with new, human-centered approaches to technical assistance, Crotty explained, “and in 2018, the Bill & Melinda Gates Foundation urged us to codify our work and articulate practical steps for localization and power shifts.”

Through nine “critical shifts,” the Reimaging Technical Assistance, or RTA, body of work aims to strengthen recipient countries’ capacities and health systems while recognizing local expertise.

“The stewards of programs should be in the countries and communities where the work is being done,” said Crotty. “RTA is really about building sustainability from the beginning so that we prioritize contextual expertise on the ground, establish true buy-in, learn and adapt during the work — and therefore have the biggest impact.”

In a conversation with Devex, Crotty elaborated on issues related to current approaches to technical assistance, and why RTA is so crucial to global health progress.

This conversation has been edited for length and clarity.

What are the main challenges and constraints related to traditional technical assistance approaches within global health?

The assumption has traditionally been that the technical expertise comes from what we’ve called a home office or a headquarters — this has also been incentivized by our funding structures. But what we've learned at JSI is that our most impactful work happens when the project is co-created, implemented, and evaluated with the communities where the work is done.

Ideally, governments and communities who know their contexts best should coordinate the programming and the solutions. Technical assistance cannot be “one-size-fits-all” — we need to better prioritize the expertise that comes from lived experience and integration with the communities. Coming in with a pre-set agenda and inflexible TA will never give you the best data, buy-in, or outcomes. To build sustainability from the beginning, you need expertise from the communities to drive the agenda from design, implementation, adaptive management, and evaluation.

Can you tell us more about the JSI-supported initiative to reimagine approaches to technical assistance?

We’ve been working on this for a long time — it came out of studies about what makes our work successful and impact stronger. In 2018, the Gates Foundation asked us to start codifying the way we were thinking about our technical assistance. We called it “reimagining” because it really represents a mindset shift.

We first collaborated with TA partners — government representatives, local and international NGOs, and funders — in the Democratic Republic of Congo and Nigeria. We led the second phase of co-creation with additional TA partners from 13 countries with active involvement and support from the Gates Foundation, U.S. Agency for International Development, and the World Bank. The result was the codification of nine critical shifts from traditional TA approaches to a vision for the future.

Can you elaborate a bit on the concept of critical shifts?

Imagine a system where communities and governments set their own agendas and coordinate their own programming. Donors and funders would prioritize trust-building with partner governments; leverage in-country capacity; and listen and respond to local needs. The result would be a system that uses local resources and expertise and establishes mutual understanding and accountability across all groups. Local structures and institutions would be stronger in the long term as a result. Imagine a system where we prioritize continuous learning, adaptation and innovation — how much faster could we make progress? The shifts guide us to this vision.

RTA has three categories of critical shifts. The first three ask us to consider who sets priorities, who receives funding, how we foster trust, and how we prioritize buy-in from the beginning of a program. At their heart, they ask us whether our work perpetuates current power structures and mistrust in institutions and individual motivations.

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Critical shifts 4-7 call for improved approaches and practices to support coordinated, long-term, and contextualized programming. They move us away from fragmented and piecemeal efforts with an inflexible approach and rigid compliance. These shifts are about continuous learning, about pivoting if something isn't working. JSI is talking a lot about continuous learning: Are we willing to make mistakes, admit them, and then pivot?

The third set of shifts, 8-9, is about bigger macro issues. They highlight the urgent need to recognize the role of gender equity in health outcomes. We want to make sure that we're not reinforcing gender oppression and other kinds of injustices that have caused health disparities to begin with.

What does RTA aim to achieve in terms of impact, scale, and replicability?

RTA lays the groundwork for locally led solutions. It’s about building on the ways in which we’ve been most effective and articulating road maps for our commitment to localization.

As part of our work, the team has created a self-assessment benchmarking tool that we are using to check ourselves as we design and implement programs. It is a practical, scalable tool.

RTA has been supported by World Bank, USAID, and the Gates Foundation, which funded the work. We offer this body of work with humility — we are on a journey — but also with optimism, because we are on that journey together. This will only achieve scale and replicability if all the partners co-create an ecosystem with a shared language and shared objectives. We hope RTA can be a helpful framework to bring us together.

What makes JSI so well-positioned as an implementer of the initiative?

First, our enormous experience and competence assembling expertise and implementing large-scale projects around the world — flagship USAID and Gates Foundation projects.  We’ve developed insights and perspective about what is effective, and at times, what is not.

We have integrated a human-centered design approach that guides our large and small projects. That was the foundation of the development of these nine critical shifts, and the logic behind convening a donor coalition. We worked with an inter-agency working group including USAID, the Gates Foundation, and World Bank that has signed on to drive forward the critical shifts.

Then, our commitment. We are committed to this work because of the way it started: self-reflection about how we achieve our mission. Our assets are people and knowledge, and we have a responsibility to ensure that we are stewarding our assets responsibly.

Finally, we are at an inflection point ourselves as we consider how to organize ourselves for equity and excellence — a vision for the future.

What call to action on reimagining technical assistance would you like to share?

We hope that the nine critical shifts provide a framework to align global health partners around common goals and approaches, guide mutual accountability among partners, and inform the design of global health strategies. At JSI, we are using RTA tools for self-assessment — and we would love to continue to convene our colleagues to expand on this work, to keep refining it, and to hold ourselves accountable.

We know that these changes require more than technical solutions; they demand fundamental shifts in how we address global public health. To refer to the often-quoted metaphor from Dr. Prabhjot Singh, director of systems design at the Earth Institute, we can’t spend all our resources designing the bridge. We need to think about the needs of the people who are crossing it. The result will be better outcomes for all.

Visit www.JSI.com/rta for more information about reimagining technical assistance.