Decolonising global health: lessons from Zimbabwe

The process of shifting control of public health programmes from the global north to local organisations needs to be carefully planned and navigated, say researchers involved in the transition of HIV programmes in Zimbabwe. Transition plans should be sensitive to challenges and opportunities linked to the local country context and to historic relationships between local and global organisations. Those involved should assess the local organisations’ capacity for making the transition, provide enough time, and achieve an equitable balance between local organisations and the global partner organisations.

Local ownership of health programmes in low- and middle-income countries gives local stakeholders autonomy over their public health agendas and the freedom to design, oversee, finance, and deliver health care to their own populations. Yet, historically, many programmes have been led by organisations based in the global north. Shifting management to local stakeholders is essential to increasing local autonomy, achieving long-term sustainability, and using resources efficiently. However, achieving this transition is challenging.

A recent article published in PLOS One tracked the process of shifting control of Zimbabwe’s voluntary medical circumcision and HIV care and treatment services, funded by PEPFAR (the US President’s Emergency Plan for AIDS Relief), from a US-based organisation to a newly-formed Zimbabwean organisation. The authors interviewed 16 stakeholders in the US and Zimbabwe involved in this transition.

The interventions were originally managed by a unit of the University of Washington, known as the International Training and Education Center for Health (I-TECH), who partnered with the University of Zimbabwe Clinical Trials Research Centre, which served as the local hub managing the programme’s financing and administration. I-TECH also partnered with local organisations such as the Zimbabwe Partnership to Accelerate AIDS control to implement the services. In 2018, midway through the project, I-TECH’s role changed when PEPFAR committed to shifting funding away from US-based organisations to legally-registered local organisations that acted independently. As a result, local organisations in Zimbabwe that had been managing the voluntary male circumcision programme and the HIV care services merged to establish a new, independent organisation (Zim-TTECH). Zim-TTECH was designed to manage and deliver these two HIV-related public health programmes, free from I-TECH’s management and oversight.

The researchers describe factors that facilitated the transition process, as well as some challenges. They suggest that their findings should inform other groups seeking to make similar transitions from global to local health programme management.

Developing a clear vision. While PEPFAR’s change in policy was crucial, there was a long-standing commitment to local ownership by I-TECH and the Zimbabwean team, as one interviewee described:

“This term local ownership, or who is the principal recipient and who is the driving force of a programme, is an issue. Within I-TECH, transition to local ownership has been a principle … a high-level philosophy. It is something we all think is important and need to aspire to and move towards … We’re not supposed to be keeping ourselves going.”

To achieve local ownership, funds were directly allocated to Zimbabwean organisations rather than through the US-based I-TECH. This minimised I-TECH’s presence in terms of administration, infrastructure, and personnel.

Empowering leadership for change. Roles were divided: I-TECH staff acted as project coordinators and support staff, while Zim-TTECH staff made key decisions and implemented the transition on the ground. This division of roles made the transition more acceptable to local staff members, who appreciated their own empowerment while also recognising I-TECH’s ability to take a broader view. One Zimbabwean participant explained:

“What I liked about it is that they [I-TECH HQ] did not take ownership of it … Unlike if they had owned the process and then throw it back to us, there would have been some resistance ... In terms of policy making, there’s more of a guiding approach to everything which I thought was a very good thing because then we also took ownership of the process.”

Developing plans and strategies for the transition. This planning began with a week-long series of meetings in which the transition team established timelines, key roles and a transition plan, agreed a new organisational relationship between I-TECH and Zim-TTECH, and established ways to transfer important documents to Zim-TTECH.

A supportive local context. Several participants said the Zimbabwean team’s technical expertise and understanding of local political and regulatory environments was critical to the transition’s success. There was a strong sense of trust between I-TECH and Zim-TTECH, built up over seven years of collaboration, while an in-country leader played a key role in negotiating between partners to resolve challenges. These local capacities and strong relationships eased transition processes:

“The good thing is over the years, I-TECH and I-TECH Zimbabwe were growing. We were kind of already setting a transition in motion because we are now recruiting almost parallel systems with what existed in the parent administration organisation … So we were drifting towards our own independence. I think that’s what made it easier to transition, not by design but because of the nature of increasing amount of work and amount of funding.”

Clear communication about the transition’s risks and benefits. Creating clear, open channels of communication between and within I-TECH and Zim-TTECH helped to ease fears, overcome difficulties and meet milestones. While some members of the Zimbabwean team were “excited about the change because it meant more independence and freedom to run the programmes exactly as they felt were necessary”, others“felt the current model was effective, advantageous and had worked well and resulted in programme success.” Some were concerned that the transition would lead to job losses and reduced funding, or felt that the programme’s lack of global oversight would make Zim-TTECH vulnerable to Zimbabwe’s unstable political and economic environment. Some were concerned that international funders’ misconceptions about local organisations that would lead them to deny Zim-TTECH funding. One Zimbabwean participant explained that international funders believed that

“local institutions sometimes fall victim to resources, deficiencies in corporate governance, corruption and even theft … If we are painted with the same brush, people may assume every local institution has no capacity to operate independently.”

Other participants were confident that Zim-TTECH’s capacity was well known and respected. They cited the benefits of making the transition, which ranged from “greater access to local funding opportunities and greater autonomy from the University [of Washington] system” to the greater flexibility that local organisations enjoyed and that allowed them to better respond to local contexts and issues that might emerge.

One participant in a managerial role said:

“That hearts and minds component, and making sure that people are really on board, is the difference between teetering on success and failure.”

Communication with stakeholders. Zim-TTECH leaders actively engaged stakeholders from national health ministries, partners, and donors, assuring them that the transition would serve the interests of people living with HIV and would not affect the programmes’ aims or scope of work:

“For the programme directors out in the field, things haven’t changed that much … The most significant changes were for the central staff to manage the finances, scan for opportunities, and create collaborations to allow discovery of funding opportunities. Stakeholder confidence in the transition came in once this was understood, and with reminders from Zim-TTECH that we were still the same organisation.”

Engaging and mobilising staff. The transition required that Zim-TTECH construct new systems and infrastructure, including for financial management.  However, doing this was made difficult by two local constraints: the lengthy time frame for registering as an independent organisation, and Zimbabwe’s volatile banking system. A key resource for engaging and mobilising staff to tackle these challenges came from I-TECH’s technical expertise, drawing on transition experience in other countries.

Clearly defining short- and long-term success. A key criterion for Zim-TTECH’s success was becoming recognised for its high performance and as, in one Zimbabwean participant’s words, “a self- sustaining organisation that has the capacity to do research.” Another criterion was securing funding as an independent, local organisation. However, these markers of success are not usually included in the monitoring and evaluation of programme transition and many timelines were difficult to meet.

Conclusion

The authors emphasise the importance of carefully navigating the transition from international management of public health programmes to local management. This is an important part of a larger shift to country ownership of public health programmes, including those delivering HIV prevention and care.

The authors identify moves that international donors should make to enable these transitions. Donors should consider whether the complex funding application processes and related requirements that large, US-based organisations are accustomed to completing are accessible, equitable, and do not impose unnecessary barriers to local applicants. Donors should also support local investments in infrastructure to ensure that health programmes are sustainable in the longer term.