IHP+: think creek, think paddle
IHP+ Results – the consortium currently evaluating the International Health Partnership plus related initiatives (IHP+) has just published its 2010 update. We had already been primed that something was amiss in an intriguing commentary in the Lancet – IHP+: little progress in accountability or just little progress? – by the IHP+ Results’ Advisory Board, where we learned that the IHP’s steering committee (the SURG) was stalling publication of the evaluation findings. It was released, finally, at the World Health Assembly, although it has yet to be uploaded to the IHP+ website. So what’s all the fuss about?
Well, it’s not all bad. The update notes that there are more signatories to the IHP+ Global Compact – 46 by the end of 2009 compared to 26 in 2007; SURG has convened a Mutual Accountability Working Group; two seats on the SURG are now allocated to civil society; and there is a Civil Society Health Policy Action Fund to support civil society participation in national policy processes. The update reminds us that a Joint Assessment of National Plans and Strategies (JANS) is currently being piloted as a basis for IHP+ partners to coordinate their funding support, and some IHP+ partners have also signed up to the International Aid Transparency Initiative. Globally, then, there are complementary reforms underway.
At the country level, the update provides numerous examples of positive IHP+ partner activities: the Global Fund and AusAID’s support for national procurement systems; GHWA’s ongoing support for HRH; alignment of Development Partner priorities and national health plans; Development Partners’ “greater awareness of and commitment to being more transparent” about funding. This is all good news, but the reader is left to infer that these actions are evidence of IHP+ progress. More of this later.
So, the findings of the update may not be all bad… but they’re still pretty bad. Reading between the lines, it’s difficult not to draw the conclusion that the IHP+ is going nowhere, fast. By the end of 2009 (i.e. 2 years since the IHP was launched), we read: “It is not yet evident what added value IHP+ Compacts have over existing agreements, such as SWAps, MoUs and Codes of Conduct” – perhaps explaining why only four countries have signed one. There are still no concrete examples (although plenty of promises) of donors providing incentives and empowering staff to work in a coordinated way, a core recommendation of the 1st external evaluation of the IHP+. The update finds minimal reporting by partners of progress on their commitments, leading it to conclude: “most agencies had not yet incorporated the IHP+ expectations into their internal performance targets and measures”. Furthermore, despite some progress in alignment, the update concludes: “most national plans still tend to accommodate competing priorities that reflect the availability of donor funding or preferences”.
The update also raises some important questions about evaluation, specifically a blurring of the boundaries between independent evaluation and advocacy. For sure, this has not been an easy ride for the evaluation consortium, and the fact that it has hit a wall both in terms of its methodology and tools, but also an uncooperative donor community, 18 months into its evaluation does not augur well. But there is a more fundamental problem at the heart of this endeavor. IHP+ Results is wearing two hats: an independent monitor of the IHP+ and an accountability mechanisms. There is a clear conflict of interest here, and IHP+ Results is in danger of becoming a de facto stakeholder in the very partnership it is supposed to be monitoring. The consortium describes it’s hybrid monitoring and accountability role as “paradigm-shifting”, but at what price for the integrity of its final report?
An evaluation is a barometer: it tells us whether the IHP+ is working or not. For it to have any credibility, it must be distant from its subject. The IHP+Results Advisory Group recognises this: “In moving forward it will also be important to guard against any erosion of IHP+ Results’ independence from the Scaling-up Reference Group (SuRG) to which it reports”. But how will this be assured when the IHP+ Mutual Accountability Working Group has been charged – by the SURG – to “improve IHP+Results as an accountability mechanism”? [emphasis added].
Putting aside the schizophrenic personality of IHP+Results, what of the requirement that we infer IHP+ progress from individual stakeholder actions? Attribution is important for this particular partnership, although less helpful when claimed by other global health initiatives (as Oomman et al make clear in their report Are funding decisions based on performance?) More so with the IHP+ than with other partnerships and initiatives, we need to see a clear chain of events that start with the IHP+ and end in accountable behavior change, otherwise we end up with a nebulous description of global events within which IHP+ is just one, indistinguishable, element amongst many. The shift towards innovative financing for health, is a good example of IHP+ catalysing change. The High Level Task Force on Innovative Financing is intimately entwined with IHP+ and it has been instrumental in energising a much broader debate – and praxis – around global health financing. It’s recommendation to establish a joint funding platform has been picked up by GAVI, the Global Fund and the World Bank and they are running with the ball.
At the national level, we learn from the update that GHWA is continuing to support HRH; AusAID is supporting pooled funding; Nepal, Ghana and Malawi are planning to expand access to health service; civil society in some countries has some degree of influence on something. Good, good, good, and good – if vague. But can we really attribute an IHP+-effect to each of these actions? The Mali case study tells us: “National stakeholders consider that the IHP+ has led to more effective government-partner working relationships and has started to reinforce existing processes”. Again, this is vague: national stakeholders? Who, how many?; consider – in what way?; the IHP+ has led to – causally, accidentally, tangentially?; has started – when?; to reinforce – meaning what? And there are many more statements of this kind in the update. The point is that actions that individual donors may well be doing as a matter of course – why wouldn’t GHWA be supporting HRH? – are being associated in some implicit way to the IHP+ process without any obvious justification.
Ultimately, what the IHP+Results 2010 update tells us is that, after almost three years of partnering, there is still no agreed accountability framework; development partners (i.e. DfID and AusAID – Germany, Italy, France, Norway, Sweden, the Netherlands and Portugal are all conspicuous by their absence in the update) have barely begun to put any commitments into practice, and UN agencies’ performance is little better; and, in an ironic twist, the IHP+ steering group SURG (a collection of representatives from the same partners and agencies who are failing to report, so perhaps we shouldn’t be too surprised) is obstructing a process of accountability that should be in everyone’s interests.