Q&A: The role of transparency in preventing maternal and child deaths

Alma Golden giving polio drops at a health center in Kilifi County, Kenya. Photo by: USAID

Investments in health, whether made by the private or public sector, must be transparent in order to safeguard health systems, according to Dr. Alma Golden, assistant administrator of the Bureau for Global Health at the United States Agency for International Development.

“All of us are aware of experiences in the past where a lack of transparency created a skepticism about investments in health care,” Golden said, adding that transparency can help hold investors accountable for where and how financial resources are allocated, particularly in the area of reproductive, maternal, newborn, child, and adolescent health, or RMNCAH.

“A culture of accountability benefits policymakers, managers, health workers, and communities,” she said. “Transparency allows them to identify how funds flow, the financing gap, and pinpoint where resources are needed most and for what types of essential health care and lifesaving commodities.”

It also facilitates assessments of the investment risk and enables the entire health system — including private health providers — to respond and adapt appropriately to the continuously changing health needs of populations, particularly for those who are most vulnerable, she added.

Speaking to Devex, Golden discussed how USAID is tracking private sector investments, shared its best practices for doing so, and detailed why transparency in investments is so important in achieving the agency’s goal of preventing maternal and child deaths.

This conversation has been edited for length and clarity.

Of the commitments USAID makes in global health, how much funding is directed toward RMNCAH and how much is invested in the private sector?

Private sector engagement

As defined by the Organisation for Economic Co-operation and Development, this is an activity that aims to engage the private sector for development results, which involve the active participation of the private sector. The definition is deliberately broad in order to capture all modalities for engaging the private sector in development cooperation, from informal collaborations to more formalized partnerships.

To read more about the definition and how Maternity Matters: Funding the Future is exploring the topic, click here.

Through the bipartisan support of Congress and the compassion of the American people, the U.S. government has invested more than $19 billion from 2012 to 2019 to prevent maternal and child deaths. As a result of these investments, USAID has helped 84 million women and children access essential and often lifesaving health care in just 2019 alone.

USAID has been a pioneer in drawing on the power of the private sector and innovation to tackle challenges in RMNCAH. As a founding partner of Saving Lives at Birth, USAID aims to identify and scale some of the groundbreaking approaches to saving the lives of mothers and newborns, particularly focused on hard-to-reach communities in and around the time of birth.

Over eight rounds and from a competitive field of more than 4,000 applicants, SLAB has funded over 100 innovations with the potential to save 150,000 lives or more by 2030. Beyond the original donors, the program and its innovators are estimated to have leveraged $147 million today in support of its overall aim to improve health in low- and middle-income countries. This is truly a testament to the sustainability of these new approaches.

USAID’s first Private-Sector Engagement Policy came out at the end of 2018. What has changed about the way the agency engages with the private sector since then?

The agencywide call to action encourages staff to work hand in hand with the private sector to design and deliver programs across all sectors — development and humanitarian — and to harness our resources to strengthen markets and open opportunities for local as well as U.S. businesses. This intentional shift pursues market-based approaches and investments.

Consequently, USAID is transforming the way we approach planning and programming. Now USAID strategically consults with the private sector from the start. We harmonize goals and objectives to ensure alignment and collaborate to implement with the private sector to achieve a much broader scale, greater sustainability, and ultimately better health outcomes.

In addition, the USAID Bureau for Global Health supports private sector innovation using strategic planning, market shaping, and innovative financing to identify and scale the interventions that have been proven.

An example of innovative financing at work is a co-designed initiative called the Maternal Outcomes Matter — or MOMs — Initiative, a collaboration between the [U.S. International] Development Finance Corp., MSD for Mothers, and Credit Suisse. USAID mobilizes these blended financing solutions by combining debt and grant funding so that we can scale innovations and support market-based approaches to ensure that healthy pregnancies and safe deliveries are available where women are most in need.

The MOMs Initiative makes catalytic investments in promising enterprises that are primed to have an even greater impact on maternal health outcomes because of their successful track record in areas that directly and indirectly contribute to maternal health.

How has USAID’s strategy toward guiding grantees and partners changed since the introduction of the Private-Sector Engagement Policy?

Our PSE Policy has been instrumental in strengthening private sector engagement into how we do all of our work and engage with our partners. A key tenet of the PSE Policy is moving from a donor-led approach to a co-creation approach. Co-creation is not just part of the procurement process; it's a philosophy that’s based on four operational principles.

The first principle is that we want to engage early and often so that the private sector is a regular stakeholder. The second is to incentivize the private sector participation throughout the program cycle. So that would include helping to identify what our goals and objectives are, what's reasonable in that environment, those sorts of things.

The third is to expand USAID and private sector approaches so that we're looking beyond what we traditionally have done. And then fourth, of course, as we can build on what works, let's look at the evidence that both the private sector and USAID bring to the table so that we can really think through what this creation process should look like and what the resulting program should be for.

Our new suite of MOMENTUM [Moving Integrated, Quality Maternal, Newborn, and Child Health and Family Planning and Reproductive Health Services to Scale] awards is a prime example. Here, USAID used an extensive co-creation process to refine the challenges we wanted to solve, and the specific expertise needed in order to improve the landscape of possible partnerships, in turn creating avenues for new and underutilized partners, including the private sector.

We recently awarded MOMENTUM Private Healthcare Delivery with a ceiling of up to $75 million, subject to annual appropriations, to strengthen the capacity of private health providers to deliver comprehensive and quality care for women and children. By expanding local private sector partnerships and promoting a total market approach, health care coverage in high-burden countries can be improved.

With a focus on RMNCAH, what best practices could you share with other funders and the wider community about the need to measure how donors engage with the private sector?

With the introduction of our PSE Policy, USAID made a commitment to be accountable for results, measuring impact, and developing a robust agencywide perceived learning agenda.

Utkrisht Development Impact Bond

USAID partnered with MSD for Mothers and others on the Utkrisht DIB as a results-based financing approach, where payments to implementing partners are tied to achievement of specific health outcomes or outputs. The DIB aims to reduce the number of maternal and newborn deaths in the Indian state of Rajasthan.

In this structure, private capital from UBS Optimus Foundation covers the upfront costs of improving the private clinics while USAID and MSD for Mothers pay back the investment only if the project meets specific targets, particularly the accreditation of the facilities. This allows for a high degree of transparency, as well as a more efficient use of resources, flexibility, and implementation, and shifts risk to the investors.

In the past, private sector metrics have largely focused on tracking the financial resources that the private sector brings, and we didn't really look that closely at the value-add and helping achieve better and more sustainable development or even the humanitarian outcomes. Historically, this focused on dollars leveraged, but that doesn't always equate to greater development impact.

In response, USAID released the Private-Sector Engagement Evidence and Learning Plan in May 2019, and this helped fill a critical knowledge gap to improve the rigor of the PSE research.

The plan outlines three qualitative learning questions on which the agency is currently focused: one, how and to what extent private sector engagement improves the development and humanitarian outcomes; two, what specific factors drive effective engagement with the private sector; thirdly, which private sector engagement relationship qualities influence results so we understand who best to partner.

When we document what works, where, and for whom, we can design stronger, more effective programs and make targeted investments that are responsive to private sector needs. Ultimately, all of these efforts advance our collective vision of a world where all women and children have the same chance of a healthy life, regardless of where they are born.

The Funding the Future series is supported by funding from MSD, through its MSD for Mothers program and is the sole responsibility of the authors. MSD for Mothers is an initiative of Merck & Co., Inc., Kenilworth, NJ, U.S.A.

Join the conversation on funding the future of RMNCAH.

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