Anne Peniston

MLI is conducting interviews with development partners to get their views on country ownership and leadership in MLI countries. The first entry features Anne Peniston, Director of the USAID Office of Health and Family Planning and Global Health Initiative Field Deputy for Nepal. Peniston has worked in U.S. and international public health for more than 30 years as a clinician, researcher and program manager. She has worked with USAID/Nepal since 1997 when she was recruited as a senior technical advisor. 

Do you see greater evidence of country ownership and leadership in Nepal, and if so, in what way?

Given the context of Nepal, from ten years of conflict to a transitional democracy which is still writing its constitution, and with changing leadership in the government, it’s been difficult for the Ministry of Health and Population to be able to take full ownership of development assistance and run with it. But I’ve seen good examples of commitment to good governance in the health sector, even in these unstable times. We have some very hard working and committed public servants at the Ministry of Health and Population at all levels who have embraced the idea of ownership. But I think we have still a way to go before we have what I would say is great evidence of country ownership and leadership.

Is increasing country ownership and leadership a positive development?

Absolutely a positive development, absolutely. No one else can do for the people what the government of Nepal can do, and should do. They are ultimately responsible for the people and for a democratic and prosperous Nepal, and in that equation is the health and well being of the people. They’re not responsible for delivery of all the services, however, that’s where the government must create an environment where the private providers meet the needs of the better-off, freeing public services for the poorest. But they’re certainly responsible for good governance of the health sector. So yes, it’s a very positive movement on the part of the government.

What changes have you seen in the health sector related to increased government leadership?

The government and donors have developed a common health sector plan for five years and a joint financing arrangement (JFA) for on-budget support. USAID had been providing on-budget support through separate agreements, but under the sector plan we have also committed to the JFA as a non-pooling donor. USAID decided to join the JFA because first of all, we want to demonstrate our commitment to increasing aid effectiveness through better alignment and harmonization, and secondly because it can improve transparency on all parties to track development assistance and outcomes through a single reporting process. Most importantly, it puts into practice the basic principles of President Obama’s Global Health Initiative for which Nepal was designated a “Plus” country, putting us on the vanguard of development assistance reform in the United States government. There has been better alignment, increased harmonization and more commitment to a single vision for the health sector. We’re also working on a joint technical assistance arrangement where all the donors and the government will agree to the technical assistance that is needed and what donors will provide.  This is all part of working better under an aligned sector plan and really supporting the government’s leadership in this area.

In terms of health outcomes, there have been health improvements in some sub-sector areas, but those are areas where we’ve been aligned for a while. They are mainly in maternal and child health, and a bit less so in family planning. All the donors that support family planning, maternal, newborn, child health and nutrition work very closely under the government’s leadership in technical working groups. As a result, there’s been an almost 50% drop in under-five mortality since 1996, and significant reductions in maternal mortality.  So yes, we can see some outcomes toward achieving maternal and child health Millennium Development Goals (MDGs). In fact, Nepal received the award for being on-track to achieve MDG 5 at the UN MDG Summit in September 2010. But many challenges remain to achieve the targets -- and even when we do, Nepal still has a ways to go to achieve high standards of health status for its people.

What does health services delivery look like when the country isn’t taking the lead?

When a country is not taking the lead, health service delivery is very fragmented, there are no national standards or protocols to follow, there’s a lot of duplication of effort. The supply chain of medicines, drugs and equipment is inefficient and probably costs way too much when we’re not working together on commodity forecasting of essential drugs and supplies. In Nepal, we’re seeing much, much less fragmentation, duplication and inefficiency than we have in the past.

It’s also very important that we’re working with the government, and that the government is making policy decisions about programs and health interventions based on evidence. When the donors and the government are working together and making decisions based on evidence and not political pressure, we know we can move forward together in a very constructive way.

Is the Ministry of Health and Population relating to donors in a different way?

This is a very interesting development in Nepal. I do see the Government relating to donors in a better way and I think there are a couple of reasons for that. First of all, the donors have a strong, committed donor group we established beginning in 2002, which led to our first formal commitment through a Statement of Intent in 2004 signed by the Government and 12 health sector donors. Later, international signatories of the International Health Partnership (IHP+) developed a Country Compact with the government with input from USAID as a non-signatory. All of us worked closely together to develop two consecutive health sector plans (2004 to 2010 and 2010 to 2015).  Since 2004, we have elected chairs and co-chairs for our donor group with terms of references. We meet almost every week with each other, and we try to meet as often as four times a year more formally with the government. Because of the strong partnership among ourselves, I think it’s made it much easier for the government to deal with us with greater effect and transparency. The formal structure helps the government of Nepal really understand how we work with each other and makes it easier for them to communicate with us.

There has also been consistency at the Health Sector Reform Unit at the Ministry of Health and Population. The focal person has been there for many years and he’s highly respected and he doesn’t change when the Government changes. Having that consistency on that side has been a major bonus. He also serves as the institutional memory and he’s the one who briefs the new ministers as they change, so that has helped a lot.

What has changed since Nepal became an IHP+ country?

It’s hard to say what the IHP+ has done to change Nepal since Nepal has been on a progressive track since 2002, 2004, etc. But I think the IHP+ has encouraged the Government and donor partners to review how we are working together and what we’re already doing, and it also has brought international attention to a successful partnership model. I think it has been helpful to the Ministry of Health and Population to realize that their decisions and their programs and polices matter not just to Nepal but are also potential best practices, bringing global scrutiny to Nepal’s health sector. The progress Nepal has made with the donor group, the sector wide approach and the commitments that have been generated in Nepal have been a factor in naming Nepal a U.S. Global Health Initiative Plus country.

What are the most important things development partners can do to strengthen Ministry of Health and Population ownership and leadership?

We need to be clear in our common goals and consistent in our commitments, and that includes predictable financing. We need to better coordinate our technical assistance for true capacity enhancement, truly helping to enhance capacity in a sustainable way and allowing the Ministry of Health and Population to decide what capacity enhancement they need.

MLI’s capacity enhancement efforts and plans and those of USAID and other donors are very important. We want to be sure we can continue to work together to carry out planned activities because we have worked very hard with the Ministry of Health and Population to identify valid and much-needed capacity enhancement. They need our continued commitment to help them improve the health and well being of all Nepal’s citizens.