the mli model for advancing country ownership - Ministerial ...

THE MLI MODEL FOR ADVANCING
COUNTRY OWNERSHIP
A Legacy Document
The Ministerial Leadership Initiative for Global Health
Aspen Global Health and Development | The Aspen Institute

In the world of global aid and development, country
ownership has become one of the most debated issues.
But what does country ownership mean in practical
terms to donors, development partners, civil society,
and country governments? If the goal is to put each
country into the driver’s seat, how can we get there?
For nearly five years, the Ministerial Leadership Initiative
for Global Health – MLI – has forged new pathways for
advancing this critical development issue, working with
five countries in Africa and Asia. What emerged is a
distinctive MLI Model to advance country ownership.
Dr. Bocar Daff, Director, Reproductive Health Division, Ministry of Health, Public Hygiene and Prevention, Senegal.
The Theory
Behind MLI
MLI’s work is grounded in the theory that health
policy reform and implementation can be brought
to scale more rapidly, resulting in greater numbers
of individuals served and more equitable access
to health care, when ministries of health:
• Identify and act on their government’s priorities;
• Build upon existing political will to advance
those priorities;
• Mobilize national government and donor support
to carry out their work.
Roman Tesfay, Director General, Policy, Planning and Finance, Federal Ministry of Health, Ethiopia.
What is the
MLI Model?
MLI has developed and implemented an approach
that translates the concept of country ownership
into reality. MLI has helped its five partner countries
– Ethiopia, Mali, Nepal, Senegal, and Sierra Leone
– make major strides toward more ownership and
enhanced leadership of their health programs by
providing high-quality support in response to
ministry priorities. While MLI specifically focused
on the areas of health financing for equity, health
systems strengthening, and reproductive health,
the MLI Model can be applied to any area of
development practice.
02

The MLI Model to Advance Country Ownership
DONORS, DEVELOPMENT PARTNERS,
AND COUNTRY COLLABORATION
COUNTRY-LED
PLANNING
DEMAND-DRIVEN
TECHNICAL
ASSISTANCE
SOUTH-SOUTH
EXCHANGE
GOVERNMENT
STEWARDSHIP AND
FISCAL ACCOUNTABILITY
COUNTRY
OWNERSHIP
CIVIL SOCIETY INPUT
BRINGING HEALTH
POLICY TO SCALE
GREATER NUMBERS
SERVED
STRATEGIC
COMMUNICATIONS
MORE EQUITABLE
ACCESS TO HEALTH CARE
The MLI Model:
Working with Governments
1. Country-led planning: Listen to ministry leaders, earn their trust,
and work intimately with them through jointly selected senior advisors
(known in MLI as country leads) to identify their priorities. Learn about
the challenges they face in implementing their strategy, identify
specific objectives that advance country priorities, and move together
with ministry leaders to meet definable goals.
2. Demand-driven technical assistance: Help meet ministry leaders’
requests for technical expertise and fill those needs with the right
person or team for the job – someone whom ministry officials have
helped to select and supervise and can call upon in the future.
3. South-South Exchange: Bring ministry leaders from different
countries together through face-to-face and virtual exchanges so
they can learn from one another, offer peer support, and address
shared challenges. These opportunities foster ongoing relationships
that will benefit future work.
4. Strategic Communications: Help ministry leaders tell their stories
so that people in their communities and in communities around the
world can learn about their work to improve health and save lives.
Additionally, facilitate meetings among ministry leaders and government
and development partner representatives in donor countries to give
regular updates on progress and challenges. This opportunity for
broader exchange promotes ministerial leadership on
a global scale and collective advocacy for country ownership.
The MLI Model is an approach to advance country ownership. In
order for country ownership to be achieved, though, there must be
full engagement of country governments, civil society, donors, and
development partners. MLI demonstrates how development partners
and donors can strengthen country ownership by working with
government bodies, mainly ministries of health. MLI has worked with
country governments that have addressed donors’ concerns about
possible corruption by working to install transparent fiscal systems to
monitor the spending of all funds. Further, MLI has helped ministries
lead effective consultative processes, bringing in the perspectives
of both donors and civil society stakeholders and has shown how
governments and donors can work together to monitor and evaluate
shared goals.
AN ETHIOPIA Story
In Ethiopia, the Federal Ministry
of Health (FMoH) approached
several donors to secure support
for a new strategic planning and
management system called Balanced
Scorecard (BSC), but donors
were not responsive. When the
Minister of Health, Tedros Adhanom
Ghebreyesus, told MLI that BSC was
his priority, MLI listened and was able
to negotiate funding to support the
launch of the work. The BSC tool,
which has been implemented in the
FMoH, one of its national directorates,
and one specialized hospital under
this directorate, allows participants to
understand how their performance
contributes to the achievement of the
strategic objectives of the Ministry;
it helps align the Ministry’s vision with
the work people do on a daily basis.
BSC has been so well received that
the government of Ethiopia now
plans to use this model throughout
the entire government and has
leveraged additional funding from
the Bill & Melinda Gates Foundation
to ensure this is possible.
03

What made the MLI Model successful
and distinctive?
MLI never intended to be a primary implementer;
its goal was always to help ministries of health clarify
their country’s priorities and leverage additional
resources for them to implement and realize their
objectives. By working effectively in partnership with
ministries of health, MLI was a catalyst to advance
a number of health policy and systems reforms
in its five focus countries and framed the country
ownership agenda for strategic global audiences.
Dr. Kisito Daoh, Chief Medical Officer, Ministry of Health and Sanitation, Sierra Leone.
Because MLI was a small program not tied to bilateral
funding, it was able to be nimble and flexible in
adapting to ongoing changes in context and needs.
This focus on country priorities, support for ministry
leadership, and the ability to adapt all contributed
over time to developing a solid foundation of trust
in relationships – something not easy to do in a
context where development remains a business
and trust is a luxury.
Successful when:
MLI focused on meeting country needs and building
long-term sustainability.
MLI focused on building relationships with
ministry leaders.
Ministry leaders committed time and attention to the work.
Ministry leaders and MLI committed resources for
planning, collaboration, implementation, monitoring,
evaluation, and documentation.
Ministry leaders and MLI maintained open and
honest communication.
Ministry leaders and MLI understood the different contexts
in which they were operating (i.e., realities of a country’s
cultural, economic, political and infrastructure context,
and of funding and policy constraints of MLI).
Distinctive because:
MLI placed country priorities first, acknowledging
the value and experience of local leadership, and
recognizing and supporting ministry leaders as
primary actors in development.
MLI developed a solid foundation of trust in
these relationships.
MLI facilitated this work by providing jointly selected
(MLI and the ministry) trusted advisors to work
side-by-side with the ministry.
MLI focused on “learning by doing” and raising the visibility
of the ministry's work.
MLI and ministry leaders expected a high level of
two-way transparency in their partnership.
MLI maintained flexibility to actively learn from and adjust
to political, contextual and funding changes.
04

Women and children wait to be seen at a hospital in Freetown, Sierra Leone on the first day of free health care in April 2010.
A MALI Story
In Mali, an effort to make health
services more accessible to the
informal and agricultural sectors in
the country through a communitybased
health insurance program
had sputtered for nearly two
decades. Only three percent of
the 14.5 million population was
being served. However, during
an intensive period, MLI, in
coordination with other partners,
provided demand-driven technical
assistance to the Ministry of
Health and the Ministry of Social
Development. This included an MLI
sponsored study tour to Rwanda
to learn about its impressive
health insurance scheme, which
proved to be a critical turning
point for Mali’s program, known
as mutuelles de santé. In early
2011 the national strategy for the
expansion of mutuelles, which
includes a government commitment
of 50% co-financing, was officially
adopted. The strategy contains
an explicit focus on prevention
services including reproductive
health and family planning. Now,
the government’s target is to provide
health services through mutuelles
to eight percent of the population
in the three pilot regions by 2015,
extending insurance to 1.2 million
people currently uninsured before
scaling up nationwide.
A SIERRA
LEONE Story
In Sierra Leone, the Ministry of
Health and Sanitation had two
major requests. One was for a
financial audit to account for and
report on all government and donor
health expenditures. This was
completed and paved the way for a
structured process to increase aid
effectiveness with a higher degree
of trust and accountability between
the government and development
partners. The second was to help
Ministry officials, as well as other
senior leaders in the government,
tell the story of the improvements
in the country’s health system,
including the introduction in 2010
of a free health care initiative for
pregnant women, lactating mothers,
and children under five. MLI has
helped government leaders step
onto a world stage to make their
case to donors. With MLI support
and training, Sierra Leone’s leaders
reached multiple outlets around
the world including The New York
Times, BBC, and the Guardian to
tell the story of the dramatic health
progress and continuing challenges
facing Sierra Leone.
A NEPAL Story
In Nepal, the Ministry of Health and
Population asked for assistance to
improve a range of ministry systems
and capacities. First, they wanted to
learn to become better negotiators
with donors and within government.
As a result of intense negotiation
training supported by MLI, Ministry
leaders described better outcomes
in defining their priorities and
negotiating contracts, including one
with a union representing Ministry
workers. Ministry leaders had also
long sought to create an effective
centralized information system
accessible to policy makers, donors
and civil society. Their goal was both
to promote learning and create more
informed dialogue to build national
consensus on health sector policy
options for scaling up services. With
support from MLI and through a
peer exchange opportunity with a
similar project being implemented
in Nigeria, the Ministry was able
to launch its new digital library.
The new system is in place and
includes a catalogue of over 3,000
documents available in both English
and Nepali. It has opened a window
into the policies and programs of the
Ministry for development partners
and civil society. It is now much
easier for health policy information
and relevant research to be shared
throughout the Ministry and among
development partners so that they
can make more informed decisions
and target efforts and resources
toward areas of greatest need.
05

A SeNEgAL Story
After joining Mali on an MLIsponsored
study tour to Rwanda
and being inspired by Rwanda’s
successful performance based
financing (PBF) system, Senegalese
leaders returned to their country
determined to adapt the Rwanda
model to their specific needs. A
technical committee was quickly put
in place at the Ministry of Health,
Public Hygiene and Prevention in
charge of developing the national
PBF strategy and subsequent pilot
program. Impressed by Senegal’s
leadership and determination, donors
quickly mobilized technical assistance
to support the Ministry in this process.
Now, the Ministry is currently piloting
their country-led PBF strategy in
three districts of Senegal and donors
have pledged to finance more than 80
percent of the two-year pilot project
and to put local and international
support at the group’s disposal.
Recognizing that ministry leaders are
an untapped resource to serve as
catalysts and champions to advance
health policy, MLI also worked with
leaders in the Reproductive Health
(RH) Division in the Ministry to create
an “Advocacy Inside Ministries”
model for reproductive health. The
RH Division is now better positioned
to develop and disseminate relevant,
timely, and targeted advocacy
messages and information to
the appropriate audiences and is
emerging as the leader of these
efforts, with partners supporting its
overall agenda. As a result, during
the 2011 International Conference
on Family Planning, President
Wade of Senegal announced that
not only will the RH Division be
elevated to a Directorate within
the Ministry in 2012, but additional
government funding will be
provided for the procurement
of contraceptive commodities.
06
Mariama Sow at the Institute d'Hygiene Social Hospital, Dakar, Senegal.

Dr. Salif Samake, Director, Planning and Statistics Unit, Ministries of Health, Social Development, and Women’s Affairs, Mali.
Looking ahead
Over the last five years, MLI’s partner
countries have emerged stronger in their
determination and more strategic in their
vision for country ownership. Below are three
major recommendations and guidelines
to replicate the MLI Model, drawn from
the Country-Led Development in Health:
Practical Steps Forward Call to Action, which
was produced and officially signed by MLI’s
five partner countries in Geneva in May 2011:
1. Government leaders, including ministers
and their senior teams, must be clear about
their priorities.
- Government leaders need to clarify and articulate
their priorities consistently and cohesively. Donors
and development partners can provide the needed
support to government leaders to help facilitate
that process.
- With a clear plan to move forward, specific capacity
gaps and tailored assistance to advance country
priorities should be identified and updated as
ministry needs evolve.
- Technical support should only be provided if it
helps strengthen the government’s capacity to
lead and improve program performance on its
determined objectives.
2. Development partners must be flexible,
willing to listen and follow the priorities
defined by country leaders, while ensuring
mutual accountability.
- Through demand-driven technical assistance,
senior ministry leaders can build skills to lead more
effectively and become stronger advocates for the
people of their countries.
- Ministries can manage and monitor their technical
support budgets and workplans with guidance
from donors.
- Development partners must support countries as
they work to build their own capacity to develop and
implement effective public policies. Projects may be
smaller initially, but the experience will contribute to
greater country ownership.
- Working together, country leaders and development
partners must confront challenges and make
adjustments in plans as needed.
3. Countries must be given greater opportunities
to learn from each other, developing ongoing
relationships between leaders.
- In leader-to-leader exchanges, opportunities should
be created for country leaders to learn from and
support each other.
- Ministry leaders must be given greater
opportunities to tell the story of their successes
and challenges in improving the health of their
populations to their own communities, as well as
to donors and development partners.
07
A one day old baby girl rests at the Thiadiaye Health Center in Thiadiaye, Senegal.

Dr. Tedros Adhanom Ghebreyesus, Minister, Federal Ministry of Health, Ethiopia, with his team.
“From day one, MLI believed in
country ownership and that
was really one thing I thought
from the very beginning that
showed this is indeed a genuine
partnership. I advocate for
country ownership because
when countries own their own
business, commitment comes
from that, and when there is
commitment, there are results.”
– Ethiopia Health Minister Tedros Adhanom Ghebreyesus
MLI is a program of Aspen Global Health and Development at The Aspen Institute. MLI received generous funding
support from the Bill & Melinda Gates Foundation and the David and Lucile Packard Foundation and worked in
partnership with the Results for Development Institute. For additional information on MLI, please visit
www.ministerial-leadership.org.
All photos by Dominic Chavez. Front cover: Durga Dahal, 22, and her child, one-year-old Samrina, stand outside their home in Tamaghat, Nepal.