Partnership principles in program strategy
Kenya’s National NCD Strategy 2015–2020 [25] underlines a need for cross-sector partnerships, but it does not specify expectations about how partnerships develop their strategies. Although there are no formal policies or laws guiding the design of industry-led NCD programs, informal local norms exist that govern how companies should act if they intend to launch a NCD program (see Table 4 below for a summary). In our interviews, representatives of the national government clearly stated their demands for strong government ownership, including expecting to be consulted on any corporate activities that are linked to the health system. One industry representative recognized this:
“We strongly engaged with the NCD department in the Ministry of Health. Together we came up with a good approach. They were of the mindset of wanting to work with pharma in improving NCD care. Their only request was to not create parallel health systems and align well. If we kept them informed about anything we did, they would be happy to work alongside us.” (Interview #31, industry representative)
As the quote alludes to, technical experts in the public sector explicitly demanded that companies developed programs that aligned with local priorities and systems. Because companies are often relying on the public health infrastructure for the implementation of their programs or need to cooperate with regulatory bodies, the government has leverage opportunities to pressure the companies to meet its expectations.
However, the degree of government representatives’ insistence on its norms can vary on a case-by-case basis. According to other accounts, norms have at times been undermined. A civil society representative, for instance, asserted that high-level political leaders sometimes agree to companies’ preferences before technical experts were consulted.
“Companies will not come and negotiate with the Ministry’s NCD division. They go to a higher office. Then, the project is brought to you as an order from above. So, inasmuch as on the technical level you are able to give these inputs and set conditions for when you are coming to do a NCD project, this is the biggest challenge.” (Interview #29, civil society representative)
Misalignments between corporate and public health interests have produced huge inefficiencies in programming. For example, in one case a company prohibited an NGO from using funds provided to screen for diabetes to also screen for cardiovascular conditions, as the company was only interested in diabetes. However, government and civil society were often hesitant to push companies on adhering to partnership principles, as they fear the loss of corporate support.
“So when they said, ‘no these are our priorities at the moment,’ we had to make a decision and say, ‘Okay, it's better to focus on something than nothing.’ I think we just agreed to give in…It's just that we felt that maybe if we asked for too much they might decide to go elsewhere.” (Interview #44, civil society representative)
For companies that are willing to ensure the alignment of their programs with national priorities, a broad set of national policies and disease-specific strategies exist and are easily accessible. However, on the county level priorities are less clear. While county development plans broadly address the health sector, few counties have laid out specific plans related to NCDs. Moreover, interviewees reported that it is difficult to get access to reliable data on disease prevalence and health systems capacities, making it difficult to understand the needs. Publicly provided data are incomplete in many cases; in other counties, the data simply do not exist:
„The information system is also what we lack…we don't have a sufficient data registry on cancer that's national. So decisions are being made on emotional grounds.” (Interview #21, civil society representative).
Still data availability is gradually improving, but some interviewees expressed concern that growing pressure to protect patient data more strictly might make it more difficult for non-state actors to access data in the future.
Some companies were able to build on ad-hoc support from the government in order to achieve alignment. In selected cases, interviewees reported that the national Ministry of Health assigned technical staff to help develop program strategies, for example by advising on the selection of counties in which to operate:
„We engaged with the Ministry of Health at high level who then cascaded it down and appointed a team to work with us.” (Interview #16, industry representative).
The NCD division of the Ministry of Health has grown substantially; however, it still has limited human and financial resources when compared with other divisions in the Ministry. Thus, it could not assist the growing number of potential industry partners approaching it for support on an ad-hoc basis. In order to deal with limited resources, and to empower local stakeholders, the NCD division works closely with civil society organizations on governance of the sector. To this end, the NCD Strategy of 2015 proposed the creation of an NCD Interagency Coordinating Committee and various technical working groups (TWGs) on specific themes. Government representatives explained that companies are expected to submit their program ideas to the relevant TWG, thereby ensuring alignment and stakeholder involvement at the same time. However, the potential effectiveness of this structure has been undermined by budgetary constraints and frequent leadership changes in the Ministry of Health. While several TWGs have become operational, companies relied on their own networks for stakeholder engagement in previous years.
“We selected the key players that we worked with at the time. Yet I was not sure if we got all the right and necessary stakeholders back then. Since then we did a lot of rejigging.” (Interview #31, industry representative)
The Kenyan government has regularly called on companies to invest more in harmonization among their initiatives—this represents another informal norm. Many interviewees including government representatives complained publicly about inefficiencies that result from companies’ unwillingness to collaborate effectively.
Everyone wants exclusivity, but I say: “The other company came last week and had almost the same program as you. Since you are not competing would you be able to partner so we use the same platform?” (Public statement, government representative [34])
Despite its calls, the government provides only limited support for harmonization. For example, there is no public registry of ongoing programs addressing NCDs. This makes it harder for potential new partners to obtain an overview of which actors are already working, in which counties, and on what issues. Government representatives also mentioned that initiatives are sometimes launched without their knowledge, especially when partners either go to the county level or decide to fund NGO activities directly.
“I think that quite a number fall through the cracks and the Ministry also gets to know about them after private sector players have already engaged with the counties or facilities.” (Interview #24, government representative)
In 2018, the national government and the international NGO PATH undertook a stakeholder mapping exercise that was supposed to be the foundation of a standing oversight platform. Several interviewees noted that this effort missed many initiatives and has not been regularly updated. These gaps are partially remedied by the existence of the Access Observatory, a database of programs financed by the Access Accelerated alliance [35]. However, the information listed in the Observatory is neither detailed enough for harmonization at the county level, nor does it include non-corporate NCD programs. Moreover, several interviewees suggested that the platform is not well-known among Kenyan stakeholders.
The government could improve harmonization by hosting regular joint planning forums with partners working on NCDs. The TWGs of the NCD Interagency Coordinating Committee are already providing such a platform in some disease areas. The Kenyan government has also hosted several broad NCD stakeholder meetings with the support of Access Accelerated; however, according to interviewees the conferences did not incorporate joint planning or coordination exercises and mainly had a representative function.
“Understanding the dynamic and bringing people together, to have a conversation and to agree on the direction and on the implementation model—Access Accelerated currently has not done this very well. Everyone comes to the platform and showcases what they're doing differently and nothing is coordinated to exploit each other’s strengths and competences.” (Interview #1, industry representative)
Beyond government, the Development Partners in Health roundtable, which is managed by several international organizations, meets regularly for the purpose of harmonizing among donors. However, the roundtable has not yet put NCDs on its agenda. Further, it does not recognize corporations as development partners. Thus, companies cannot participate in its meetings.
Table 4
Kenya Results: Program strategy
Partnership principles | Governance elements | Assessment questions | Assessment of the situation in Kenya |
Program strategy | Cross-cutting | Regulation | Do formal policies or legislation exist that regulate program design? | • No formal rules or laws existed at the time of the research. • The health sector partnership framework was under development. |
If not, do clearly stated informal norms exist of what government expects from companies in this regard? | • Government expects to be consulted on programs that interact with the health system. • Government and civil society expect companies to use NCD technical working groups for stakeholder consultation. |
In how far are these rules or norms backed up with sanctions to enforce compliance? | • Only informal sanctions are currently in place to pressure companies into meeting government expectations (e.g. through non-cooperation or withholding licenses). |
Alignment | Direct government support | Does government support program design processes with public resources (staff time, funds etc)? | • MoH assigns technical teams to support program development. • MoH lacks sufficient capacity to do this for all industry-led programs. |
Provision of strategies and policies | Do sector strategies exist for companies to align with? | • A broad set of policies and strategies are in place at national level. • County development plans do not always exist and are often not costed. |
Is this information accessible for companies? | • Existing strategies are publicly accessible. • A complete and easily database is not available. |
Provision of data | Does government provide data (e.g. on NCD prevalence and health system capacities) for needs assessments? | • Publicly available data are not always complete or updated. |
Is this information accessible for companies? | • Health data are only partially accessible, but companies were able to work with KEMRI for better access to data in some cases. |
Harmonization | Mechanisms for information sharing among partners | Does a registry of existing NCD programs exist for better harmonization? | • The government conducted a mapping exercise in 2018 and results are available by request; beyond that, a government registry is not available. • Access Observatory (AO) exists as a privately funded alternative |
Is it complete and updated regularly? | • The 2018 mapping was not comprehensive and remained a one-off project. • AO is also not comprehensive. It is updated annually, but its future depends on AA’s continued funding. |
Can companies access this information? | • The AO is publicly accessible. • The 2018 mapping information was not published, but could be provided on request. |
Does government host an exchange structure for partners to plan jointly? | • There is no regular public structure. There was a private initiative: AA country team hosted two large-scale networking meetings. • The Development Partners in Health Roundtable is the leading coordination platform in the health sector where partners meet on a regular basis. |
Is it open for companies? | • AA/MoH meetings were company-focused. • Existing donors have thus far neglected NCDs and do not accept corporations as development partners. Thus, the Roundtable has yet to invite corporations to its meetings. |
Ownership and stakeholder involvement | Structures for stakeholder engagement | Does the government host stakeholder engagement structures? | • An NCD Interagency Coordinating Committee and different technical working groups (TWGs) on specific NCD themes include various stakeholders. • The TWG structure was only established effectively in 2019. Meetings are still irregular. |
Do companies have access to them? | • Companies can make use of these TWGs to discuss the design of their NCD programs, but are not full members. |
Partnership principles in program implementation
As summarized in Table 5, we found no laws or rules regulate how corporate programs should govern the programs they implement. Interviewees said that the public sector does not strongly promote monitoring and evaluation frameworks, nor does it place a high priority on their development. Thus, there are also no informal norms that could nudge companies towards adherence to the principle of managing by results.
“The government did not give us clear requirements on reporting. There were some local standard things that local partners know and many were already collecting that information.” (Interview #31, industry representative)
Programs that deliver health services, including screening, diagnosing or treating patients, are bound by local regulations to report on basic indicators, such as the number of cases of a specific disease treated, to the general Kenyan health information system. Yet, company representatives explained that the existing public health information system mostly captures output indicators. It is not sufficiently elaborate to inform a unified results framework that could guide outcome-oriented management for more complex NCD programs. To fill this gap, companies can draw on a repository of logic models and indicators offered by the Access Observatory, but some have resorted to independently developing their own results management frameworks.
We identified very few norms, either formal or informal, regarding accountability. Government representatives stated in interviews that they wanted companies to respect their leadership and to inform them about and invite them to any activities related to the public sector, such as capacity development for public sector health workers or the dissemination of health management guidelines.
“We do it in partnership with them. We would be very cross with them when they did the training without our involvement.” (Interview #24, government representative)
Beyond that, however, there seemed to be no expectations regarding reporting modalities, transparency, or involving government and stakeholders in decision-making and oversight bodies. If invited by companies, government representatives agreed to join oversight or advisory bodies of programs with formal governance structures. However, government representatives explained that they do not have the capacity to be closely involved in individually monitoring all industry-led programs.
“In terms of government monitoring, it is not an organized space. But it can only happen if there are functional technical working groups. Now there is the National Cancer Institute, but it is yet to be fully commissioned.” (Interview #21, civil society representative)
Neither national nor county governments offer many supportive structures for companies proactively seeking to ensure accountability. No public reporting platform exists that companies could use to share their results and create transparency. Thus far, companies aiming to be publicly accountable use either the Access Observatory or their own websites for that purpose. However, most of the Kenyan stakeholders interviewed reported that they rarely used these channels to inform themselves about companies’ activities. Accountability could also be supported through regular progress review meetings with local stakeholders. However, these opportunities remain very limited. Some county governments do organize regular stakeholder meetings on health or even specifically on NCDs, during which implementing partners report on their activities and results. However, the frequency and quality of these forums varies widely from county to county.
“In some counties, like in Kericho, the county calls meetings. Probably because of this one guy at a hospital who was really enthusiastic about the program. He made sure we had a quarterly meeting for a World Diabetes Foundation program. Very rigid quarterly meetings. They are important. Some counties do it, others don’t.” (Interview #23, civil society representative)
These meetings are supposed to take place in each county on a regular basis as part of the general health governance system, but county governments generally depend on donor funding to support them. Moreover, the pharmaceutical companies are rarely actively involved, although they may be represented by their implementing partners. In some counties, interviewees were unaware of the corporate involvement in local NCD programs, as they only dealt with implementing partners that did not actively disclose their corporate funding.
“When we started the program, the company was not part of it. All I knew is that of course this NGO has some heavy funding and maybe they were looking for counties where they could work. They never told me where their funding was coming from.” (Interview #40, government representative)
On the national level, NCD-specific learning and exchange forums involving corporations have taken place irregularly. In 2018 and 2019, national forums were hosted by the Ministry of Health in collaboration with the NCD Alliance Kenya, funded by Access Accelerated. Previous meetings also depended on donor funding preventing those meetings to function as an independent and regular accountability structure. With the outbreak of the COVID-19 pandemic, national NCD forums have been interrupted.
Table 5
Kenya Results: Program governance
Partnership principles | Governance elements | Assessment questions | Assessment of the situation in Kenya |
Program governance | Cross-cutting | Regulation | Do formal policies or legislation exist that regulate program governance? | • No rules exist addressing either internal accountability structures for industry-led programs or in how and how often they must report progress to the government. • Only programs that use health service delivery strategies, such as screening, diagnosing or treating patients, are bound by local regulation to report on basic output indicators to the Kenyan health information system. |
If not, do clearly stated informal norms exist of what government expects from companies in this regard? | • Weak norms exist. The public sector does not push strongly for M&E frameworks for programs and puts little priority on their development. • The only clear expectation is respect of government ownership, as shown by informing and inviting government representatives to events that relate to public sector responsibilities. |
In how far are these rules or norms backed up with sanctions to enforce compliance? | • There are informal sanctions in place. |
Managing by results | Results framework | Does the government provide a unified results framework that companies can build on? | • The existing country-wide health information system is not sufficient to guide the design of M&E frameworks. • Access Observatory (AO) has a repository of logic models and indicators for companies as a private alternative. |
Accountability | Reporting structures | Does the government provide a public reporting framework where results can be shared transparently? | • No official platform exists for Kenya. • AO allows companies to transparently report progress of their programs but it is not widely known or used in Kenya. |
Government oversight | Does government join governance structures of corporate programs? | • If invited, government representatives attend progress review meetings or sit on governance boards of programs. • However, government participation may be limited by staff capacities. |
Review meetings | Does government host regular review meetings where companies can report on progress? | • A few platforms exists for stakeholder exchanges. Some county-level governments organize regular stakeholder meetings. • The frequency and quality of county-level meetings vary. • Companies are rarely actively involved in such meetings. More often, companies are represented by their implementing partners. • Nationally, NCD-specific learning and exchange forums have taken place twice, through AA in cooperation with the MoH, but no permanent structure exists. |