17 June 2015

Africa: Gates Foundation Changes Focus to 'Last Mile' of Delivery

Photo: Bill & Melinda Gates Foundation
Nutrition is very different from other health interventions. It's much more multi-sectoral, says Dr. Ayo Ajayi.

AllAfrica's Juanita Williams and Melissa Britz interviewed Dr Ayo Ajayi, the director of the Bill and Melinda Gates Foundation's Africa Team, about the foundation's new approach to working with the continent. Excerpts:

On why the foundation has changed the nature of its engagement with Africa:

The change was needed because the foundation has spent several years mostly on the assumption that if you develop innovations and provide resources, you can actually have an impact. But when the foundation stepped back to look at its impact in the places where it really thought it was most important, it wasn't commensurate with the level of effort that had been put into it. And what was missing was that the foundation had underestimated what was needed to get the innovations and the technologies to where they are most needed, what we call the last mile.

The connection between availability of resources and the availability of technologies, and their actual use to change lives on the ground needed a bridge. And that bridge is what the foundation is seeking to provide by a presence on the continent, particularly close enough to the people who are most involved with making the development efforts really matter - that's the government, civil society and a lot of the partners that we work with. It's just more effective when you're on the ground which is why decided to have a presence in Africa.

On the foundation's priorities in Africa:

The foundation works in more than 45 countries. We prioritise a few of them. We encourage governments and civil society to prioritise areas, because you can't do it otherwise. The foundation prioritized its presence on the continent, so we have three areas where we particularly feel that our assistance can make a big difference. So we have offices in Johannesburg, Addis Ababa, and Abuja.

In addition to those, we also have full-time consultants who work for the foundation in seven other countries: Kenya, Tanzania, Zambia, Senegal, Burkina Faso, Ghana, and more recently, the DRC (Democratic Republic of Congo). These are the geographies where we feel that if we can get our assistance much closer to the ground, we can interact with partners and with governments. When we understand their priorities, we can be much better aligned, and be much more effective in our development assistance to them.

The plan is to be as close as possible so that the strategies used, the advice and resources we give them, can be much more effective. The foundation  as you know is focused on impact and impact measurement. If you can't measure it you probably can't figure out what's happening. So we try to make our impact measurable. We think being closer will make it easier for us to do that.

On the importance of innovation:

I think the foundation, first and foremost, prides innovation as one of its hallmarks. The foundation's initial focus in its earlier years was on upstream development technologies, that will be applicable to health and agriculture, and we're still very focused on that. But it's important to recognise that for those technologies to have an impact on people, you have to bridge the delivery gap.

We previously assumed that that would be taken care of. We're much smarter now at figuring out what partnership arrangements we need to provide effective delivery. We are working with the public sector as well as the private sector. The private sector is also very close to the people who benefit from it. In many cases they complement the work that the government does.

By being close to the ground, we know which partners are effective, what their strengths are, and we're able to have a combination of approaches - both public and private - that effectively provide the impact that we think is needed. This requires dialogue, to make sure that we are aligned, and people understand what the innovations are that can improve the lives of their people. So we provide feedback to our teams based back in Seattle, for much more insightful designs of what will be helpful on the ground.

On the fragility of the health systems in West Africa before the Ebola outbreak:

Those... health systems have been fragile for a long time because they were involved in civil wars and were recovering from them... Sierra Leone hadn't completely rebuilt its health system when the Ebola crisis hit.... Conflict, like Ebola, accelerates or dramatises the weaknesses in your system. Things don't function as they should.

The work of rebuilding those systems is not a single foundation's job. Donors are thinking how they can help, because what affects one country affects everyone else. They are thinking about how they can build a more sustainable health system in these countries, and to get the governments to focus on prioritizing the rebuilding of health systems; in addition to that, [of] the school systems and other civil society institutions that support the health systems, because health systems don't exist in isolation.

The foundation did provide immediate assistance and help with thinking through, with others, what needs to be done on a longer term basis. It's not a matter of if we'll have another Ebola crisis, we know that there will be another crisis, it may not be Ebola, but it will be something else that will dramatise the weaknesses of those health systems. The important thing will be to build those health systems so that when you have shocks, like Ebola, they are detected early, and the procedures are in place to act. The quicker you act, the less damage.

We saw that in the case of Nigeria. They contained it immediately, but that was a very new experience for them. The Nigerian health system is not the strongest on the continent, but it was able to contain it because people came together and put in place procedures that were known. Those things have to happen, but they have to have a much more robust service delivery system in place for emergencies just like that.

On the role of development aid:

I'm happy that the perception of Africa as a continent completely dependent on aid is beginning to erode. People are beginning to see Africans as partners in development. That's not changing fast enough, governments have to be much more fastidious and much more focused on developing their own countries.

Africa has enough resources not to need donor aid. I don't think Africa [would] need aid to the extent that it does right now if it doles out its own domestic resources appropriately... [Inappropriate use of resources] includes various forms of corruption, various forms of neglect, not collecting taxes that need to be paid, or people not paying those taxes. I think we can do better, and I think we can do better if Africans hold their governments accountable more than they currently do. They have to recognize the government's role is not enough. They have to become active participants in this process, become active participants in paying those taxes, and active participants in demanding accountability from their government. If we do those things, in part we will do better.

I don't know if we'll ever be completely devoid of aid, it will probably take quite a while because resources are inequitably distributed. That's just the way it is. Some countries have oil, some don't. Some have diamonds, some don't. I think Africa as a whole can do better. I think domestically, we're trying to get people to realize that; the resources and the aid that comes from donors only helps to catalyse, or to complement, or to magnify the work that they themselves have done, rather than be completely dependent on that.

On the multi-sectoral nature of initiatives aimed at addressing nutrition:

Nutrition is very different from other health interventions. It's much more multi-sectoral. Not only is it critical for the development of the fetus, when the woman is pregnant; it is critical for the development of the brain when the child is born, so it can achieve its full potential.

The issue of nutrition goes beyond just food. It goes to educational status, how to prepare the food itself. This takes it outside of just health, it takes it into agriculture, into social services, into much more than just being able to have just the food itself.

What we are excited about is the beginning of a confluence of a lot of our programs. Our work in health and agriculture increases the productivity of the smallholder farmer, provides them the opportunity to have more income so they can spend it on health, but also on education, [and] most importantly on  nutrition as well. For us this is kind of a robust offering of assistance to countries. We can help you with your agriculture, and your health systems. We are becoming a full service organization, [also] helping you set up your financial services system so that you can include those who previously wouldn't have had access.

We're also helping you get more access to markets, both domestically and internationally. We feel all of these things holistically are interrelated. Because we are a learning organisation, and can make the changes internally, we can provide a lot more relevant and appropriate assistance to the countries where we are. Being closer dramatizes the fact that we are there to help. In 15 years I think the foundation has become quite well known for doing an effective job.

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