Effective Governance
READ THE STORIES: Strengthening Evidence and Governance in Health | Adapting to Emergency Conditions in Ukraine | Building a Blueprint for Inclusive Policy Making in PNG
Strengthening Evidence and Governance in Health
Governments have limited resources for healthcare, and the needs of the people they serve are significant and complex. Allocating health resources equitably and efficiently, establishing national health priorities that take diverse population needs into account, and ensuring those priorities are reflected in plans and budgets are critical to enhance health outcomes across the globe.
Global Evidence to Inform Local Change
The Abt-led USAID Local Health System Sustainability Project (LHSS) collaborates with governments and other stakeholders in low- and middle-income countries to achieve sustainable improvements in affordability, access to, and quality of health care. We also generate knowledge and promising practices on health systems strengthening issues many countries share.
Although health sectors have limited resources, their challenges are not just about resource scarcity. Countries often struggle to establish national health priorities in a way that consistently uses evidence-based, transparent, fair, and inclusive decision-making processes. We recently generated important insights on how to institutionalize such processes for setting national health priorities. Establishing an evidence-based, fair, and accountable approach to priority setting helps ensure that a country's health investments are aligned with national health goals, such as universal health coverage, and that the needs of underserved groups are fully considered.
Health financing and governance go hand-in-hand, as sector resources need to be spent in the best way possible. This requires strong public financial management, among other things. Last year, LHSS advanced global learning on health budget execution by compiling lessons learned from eight countries that have made good progress. Experts met as part of the LHSS-Joint Learning Network for Universal Health Coverage Health Budget Execution Learning Exchange. They reached five key conclusions on how to improve budget execution:
- Health and finance ministries must collaborate for better budget execution
- Government-wide health budget reforms must account for health emergencies, uncertain utilization, and varied financing arrangements
- The Ministry of Health must engage with stakeholders to gain acceptance of health budget reforms
- Reforms require capacity development at all health-system levels
- Governments must commit and invest over the long term to improve budget execution.
Strengthened Governance: Foundational for Resilience
Effective governance is especially important when a country faces an unexpected system shock that disrupts health care services or increases the number of people needing access to health care, or both. Such shocks can include conflict, natural disasters, health emergencies like the COVID-19 pandemic, or economic crises.
Countries in Latin America and the Caribbean have faced such a shock amidst recent widespread migration flows, including the influx of migrants leaving Venezuela due to the country’s economic, political, and social crisis. An estimated 5 million people and counting have left Venezuela since 2015, many of whom transit through or stay in communities in nearby countries like Colombia and Peru. Helping health systems respond to this challenge is part of the LHSS Project’s work in the region.
In Colombia, our work with national and subnational governments has increased access to health care for migrants and host communities and has helped include migrants’ needs in health planning. The LHSS “Comunidades Saludables” (Healthy Communities) activity supports government partners in addressing the needs of migrants and other people who are underserved by the health system, especially in areas with high concentrations of migrants and/or low capacity to respond to their arrival.
With LHSS support, migrants participated in the development of Colombia’s Ten-Year Public Health Plan for the first time. This was significant in ensuring their voices were heard and considered as part of health system planning for 2022–2031. Our support led to the inclusion of migrants in national and regional health priorities.
LHSS also identified key community-based organizations in strategic cities like Cali and worked with them to improve people’s awareness of how to access integrated health care services. Our technical support and grants helped expand the healthcare system’s inclusion of Venezuelan migrants, Colombians who have returned after migrating abroad, and others in host communities. Since 2021, we have helped Colombian health authorities enroll more than 90,000 Venezuelan migrants in Colombia’s national health insurance system.
Peru has also received an overwhelming number of migrants: By the end of 2022, Peru had received approximately 1.4 million Venezuelan migrants, including about 490,000 asylum seekers, the highest number of asylum claims from Venezuelans in any country. More than 320,000 Venezuelans in Peru are expected to need some form of assistance, including health care, and the influx of migrants is expected to continue.
In response, LHSS helped establish a new mechanism to improve access to the data required to prepare and respond to the growing need. The Peruvian Observatory of Migration and Health was launched in 2022, through a grant awarded to the Universidad Peruana Cayetano Heredia. This rich database gives Peru and other countries on the migration path timely data that helps them plan and coordinate efforts to deliver health services to people who need them and strengthen cross-border continuity of care.
Since its launch, over 2,360 people have accessed the observatory data and over 300 people or organizations have received newsletters with migration and health insights. And this has led to action. For example, in May 2023, the Observatory hosted an online forum in partnership with the Chile migration observatory to discuss the migrant crisis at the Peru-Chile border, and called for action.
In other important work, LHSS collaborated with UNAIDS and the ministries of health in Peru, Ecuador, Colombia, and Chile to assess cross-border HIV-related information and develop a road map to facilitate continuity of HIV care for Venezuelan migrants along the migration route. The road map was validated by the HIV program directors of Chile, Ecuador, and Peru, and USAID and UNAIDS representatives.
LEARN MORE: Local Health System Sustainability Project Overview | Institutionalizing Explicit Processes for Setting National Health Priorities: Learning from Country Experience
PROJECT: Local Health System Sustainability Project (LHSS)
CLIENT: U.S. Agency for International Development (USAID)
Adapting to Emergency Conditions in Ukraine
It has long been said that in war, no plan survives the first contact with the enemy. It is also true for plans to improve governance. When war broke out in Ukraine and the environment changed radically, Abt’s Good Governance Fund Technical Assistance Facility Eastern Partnership (GGF TAF EP) project responded to accomplish our mission in a variety of critical areas, including economic recovery, energy policy, and war damage assessment.
It was not the first pivot for GGF in the region. Funded by the Foreign, Commonwealth and Development Office (FCDO), GGF TAF EP was supposed to provide technical assistance and capacity building in four countries: Ukraine, Georgia, Moldova, and Armenia. In 2021, FCDO budget cuts eliminated the work in every country except Ukraine.
Then in 2022, Russia invaded. That posed a major challenge to the program. Our team of a dozen people adapted to address Ukraine’s new needs. In-country clients that the British Embassy Kyiv had identified and Ukrainian ministries set the priorities. It was an achievement to do any work at all in the conflict-affected country, much less complete projects. We were able to do so thanks to our adaptive management approach.
Business Revitalization
The war wreaked unimaginable havoc on Ukraine’s economy. Estimates of documented damage ranged as high as $143.8 billion as of February 2023. Planning for rebuilding was an understandable priority. Abt partnered with the Kyiv School of Economics to promote the growth of the often overlooked Ukrainian small- and medium-enterprise (SME) sector. But many SMEs had fled Ukraine during the war, so the project and Ukraine’s Ministry of Digital Transformation started supporting them in Poland as well.
While the forced migration to Poland may have been heart-breaking, it also opened opportunities for businesses. “The geographical position and common history of Ukraine and Poland create a powerful potential for business development and partnerships,” noted Valeria Ionan, Deputy Minister of Digital Transformation. “We believe that Ukrainian and Polish companies will be able to successfully develop the established partnerships and mutually strengthen each other’s results.”
Among other things, Abt has:
- Supported an analysis of the SME sector and worked on SME support policies, including an SME Support Strategy. Those policies suggested ways to address the institutional problems and practical challenges faced by SMEs led by women and underserved individuals and included gender equality and social inclusion (GESI) indicators in monitoring and evaluation.
- Helped update the outline of the SME Support Strategy to include post-war recovery needs and budget estimates. The strategy focused on the needs of unoccupied regions and underserved individuals such as disabled veterans and female veterans, family members of those Missing in Action, and internally displaced persons.
- Piloted export support initiatives. The project team selected 20 SMEs and promoted their exports by developing an online Ukrainian Exporters Catalogue for each SME with dedicated pages about their business and the goods they produce. GGF TAF EP also supported promotional activities in the Polish market.
Energy Modelling
The war particularly strained Ukraine’s energy sector. Ukraine’s energy infrastructure was significantly damaged by the hundreds of bombs Russia had dropped, and the country’s dependence on Russian energy was exposed when Russia cut supplies. “Once again, women are forced to light potbelly stoves, look for firewood, portable gas burners, and other improvised means to provide warm food, water, and heating to their loved ones,” says Nataliya Boyko, a member of the supervisory board of state-owned Naftogaz, Ukraine’s largest oil and gas company.
Ukraine had launched the development of an Energy Strategy for 2050 (ESU2050) before the war, then had to switch gears to take the conflict into account. With feedback from key Ukrainian stakeholders and international energy organizations, Abt and its delivery partner KPMG Ukraine supported the Ministry of Energy with models, data, capacity development workshops, and energy-relevant updates to the National Recovery Plan. We also helped draft the implementation plan for the ESU2025. The ESU2050 was adopted by the Cabinet of Ministers of Ukraine on 21 April 2023.
We also conducted a pre-feasibility study of the reconstruction of the existing thermal power generation facility, changing the energy source to biofuels. The shift toward decarbonization and climate neutrality will be crucial for attracting future investors to secure the new direction of Ukraine’s energy sector.
War Damage Assessment
Russia created punishing conditions for Ukraine’s civilians. Cities such as Mariinka and Bakhmut in Donetsk region were completely destroyed. It was critical to understand the scale of what Moscow had done and determine the enormity of the rebuilding task and the scope of legal claims for international courts. So Abt and the Kyiv School of Economics developed a methodology for and performed a war damage assessment.
At a national level, the sectors most affected by the war have been housing, infrastructure, and industrial businesses. After a year of war, Russian armed forces had destroyed or damaged more than 150,000 residential buildings valued at $54 billion; $36.2 billion of infrastructure, including more than 25,000 kilometers of roads and 344 bridges; and $8.1 billion of energy infrastructure, including all Ukrainian-controlled thermal power plants, hydroelectric power plants, 13 combined heat and power plants, and 30 oil depots. Russia didn’t spare any sector, though. The Russian military struck businesses, agriculture, education, healthcare, cultural and religious institutions, transportation, and finance.
The scale of the war and the constant destruction as Russia tries to create the maximum humanitarian, energy, and financial crisis has been unlike anything the European continent has seen since World War II. It has required a new approach to planning donor aid projects; the usual risk matrices and long-term indicators have become irrelevant. In response, GGF TAF EP developed seven standardized methodologies to assess damage and losses, in the process taking GESI and environmental considerations into account. The team provided consultation, data collection, and analysis to nine ministries and trained 123 civil servants on the use of the Geo Informational System in assessments.
GGF TAF EP’s work has earned widespread recognition. The team was asked to join the National Council for the Recovery of Ukraine from the Consequences of the War, a consultative and advisory body that reports to the president. Government of Ukraine representatives—the Invest Ukraine Office; Ministry for Communities, Territories, and Infrastructure Development; and Ministry of Justice, among others—used the results of GGF’s war damage assessment. The project team explained the assessment methodology at the request of the World Bank, the International Organization of Supreme Audit Institutions members, and the National Bank of Ukraine.
If the war continues, GGF TAF EP may have to pivot yet again. But for now, Ukraine has the tools to start planning to rebuild the energy sector and other parts of the economy with strategies that just might survive the first contact with peace.
PROJECT: Good Governance Fund Technical Assistance Facility Eastern Partnership (GGF TAF EP)
CLIENT: U.K. Foreign, Commonwealth and Development Office (FCDO)
Building a Blueprint for Inclusive Policy Making in PNG
Government capacity to plan, manage, and deliver quality education is a key building block for sustainable development, especially where there are stark equity gaps. And the most effective way for policymakers to know what to do and how to do it involves working and consulting with the people and organizations most affected. This process helps ensure that solutions are designed with and tailored to the unique needs of communities. This is why the Partnership for Improving Education (PIE) program in Papua New Guinea (PNG) has focused on helping government officers learn about and undertake participatory policy making.
Funded by the Australian government and implemented by Abt, PIE works to improve the delivery of, access to, and quality of education for children in early primary grades. The program supports PNG’s National Department of Education (NDoE) in its efforts to promote equity throughout the education system. We provide training and technical support that helps the NDoE develop and implement a Gender Equity, Disability, and Social Inclusion (GEDSI) in Schools Policy.
We’re not writing policies for our government partners, as many externally-funded programs do. Instead, PIE takes a long-term and participatory approach. We helped the NDoE by developing tools and training so that a network of NDoE GEDSI staff could undertake comprehensive stakeholder consultations. To understand different perspectives, the NDoE staff consulted a wide range of stakeholders, including provincial and district education authorities, school leaders, teachers, parents, and even students.
The consultations sought input not only on the content of the policy, but also on the capabilities and resources required to implement it. Involving school-level stakeholders helped build momentum and instill confidence that the policy would be taken forward in meaningful ways. The NDoE Policy Planning Division was so impressed by the process that it plans to develop a new policy development manual using the GEDSI in Schools Policy process as a blueprint.
PIE’s collaboration with the NDoE has helped strengthen skills and processes that will lay the foundation for more equitable education services.
LEARN MORE: Partnership for Improving Education Program
PROJECT: Partnership for Improving Education (PIE)
CLIENT: Australian Department of Foreign Affairs and Trade (DFAT)
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