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Page 1

Midterm Evaluation

Transforming Health
Systems Initiative

Arnon Mishkin Independent Consultant

Final Report

January 2011

Page 64


Rockefeller Foundation Transforming Health Systems Initiative

While the team is clearly doing good work, there appears to be an opportunity
for the team to improve its overall dynamics. There is less dynamic creative
tension – which typically improves output – than one might anticipate, par-
ticularly given the apparent success of the work to date. In meetings I’ve
attended there is less give-and-take than one would anticipate. There is a
tendency to view document and output requests as “corporate requirements”
rather than development and management tools. Of greatest concern, some
people on the team put a high stock in not confronting differences of opinion,
while others resent decisions made that are not first hashed out in public.

This manifests itself in several suboptimal ways.

• Too much of the overall communication and overall documents needs to
be written by the team leader, who presumably knows slightly less about
each different workstream than the workstream leaders themselves.

• There is less opportunity to improve the communication of the hypotheses
and results of each of the initiatives than one might hope

• Differences of opinion that need to be resolved sometimes do not get dis-
cussed in an appropriate forum

• Leadership decisions get perceived as arbitrary fiats rather than appropri-
ate. [There is no way to know for sure if a given decision is appropriate or
arbitrary if it’s not full vetted in discussion with the group.]

Interviews with team members, outside Rockefeller staff, grantees and
observers, we’ve heard various explanations for the sources of the tension.
Some blame management skills of the participants, other say it is a function
of the difficulty foundation/academics have in working in groups where deci-
sions need to be made as a team rather than individuals getting a particular
budget and then deciding how best to use it in granting, others say it stems
from challenging interpersonal dynamics given the personalities in the group.

Everyone on the team is aware of the challenges and has been receiving
appropriate coaching. We believe it is essential to keep working with the team
to seek to improve the dynamics. In particular, we think the team should

• Continue working with team coaches

• Set itself a challenge to try to work as a group on the revised theory of
change – and to not allow any one individual to take the sole lead in its

• Refocus on the tool of the “Results Based Framework” – and seek to
ensure that it aligns with the actual work of each of the work streams

Page 65


Midterm Evaluation and Recommendations for Course Corrections

D. Analysis of
the portfolio of
activities of the
THS initiative,
aligned against
measures or
interim signs
of impact

In this area, we assessed the portfolio that the THS initiative had pursued, to
align different streams of work – and specific grants – with actual deliverables
or impact. The goal was to understand both patterns of granting – and whether
there were implications to the pattern as well as to identify questions of
“value for money” if any.


• The THS initiative has spent about $46 million grants in pursuit of its
main strategies or workstreams – Research and Agenda Setting, Enhancing
Capacity for Stewardship, Harnessing the Private Sector and Leveraging
interoperable e-health Systems.

• The grants have been in pursuit of three core RF outcomes: Universal
Health Coverage is accepted as a feasible and desirable goal, Capacity for
stewardship is built, and Interoperable e-health systems, Public Private
partnerships & International networks are developed. Roughly $8 million
has been spent in pursuit of the leadership agenda, $22 million in capacity
building and $16 million in building innovation, tools and partnerships.

• Each of the workstreams, with one exception, has achieved a clear set of
interim milestones or indications that it is on track, as described above.

- The one exception is Strengthened Capacity for Stewardship.
RF had to change its strategy early in the project and now the
bulk of the focus on capacity strengthening resides in the country
initiatives. To the extent that the team wants to continue to focus
on Stewardship, they may want to revisit the earlier challenges and
identify how they will now overcome them.

• The different workstreams and subworkstreams are arrayed below against
the outputs and achievements of each.

• Roughly 5% of the projects accounted for 40% of the total money
provided. Many of these very large grants appeared to be “contractor” type
grants where the grantee is in fact managing several sub-grantees. While
there are many good reasons for those kinds of grants, RF may want to
be more explicit about them, particularly so it can better link outputs to
amount invested.

- The team may want to review these grants to ensure that they were
as efficient as possible

Page 127


Midterm Evaluation and Recommendations for Course Corrections

“All for Universal Health Coverage” Laurie Garrett, A Mushtaque R Chowdhury, Ariel Pablos-
Mendez, August 20, 2009 - The Lancet

“Public stewardship of mixed health systems” Gina Lagomarsino, David de Ferranti, Ariel Pablos-
Mendez, Stefan Nachuk, Sania Nishtar, Suwit Wibulpolprasert, The Lancet (doi:10.1016/S0140-
6736(09)61241-1) Volume 374, Issue 9701, Pages 1577 - 1578, 7 November 2009

“Public Stewardship of Private Providers in Mixed Health Systems,” Gina Lagomarsino, Stefan
Nachuk, Sapna Singh Kundra; Synthesis Report from The Rockefeller Foundation-Sponsored
Initiative on the Role of the Private Sector in Health Systems in Developing Countries, Results for
Development, 2009; ISBN 978-0-9788790-9-9

“Innovative Pro-Poor Healthcare Financing and Delivery Models,” Donika Dimovska, Stephanie
Sealy, Sofi Bergkvist, Hanna Pernefeldt; Landscaping from The Rockefeller Foundation-Sponsored
Initiative on the Role of the Private Sector in Health Systems in Developing Countries, Results for
Development, 2009; ISBN 978-0-9788790-8-2

“The global financial downturn—imperatives for the health sector” Sania Nishtar, Ariel Pablos-
Mendez, The Lancet, Volume 373, Issue 9658, Page 124, 10 January 2009 (doi:10.1016/S0140-

“ The U.S. Commitment to Global Health, Recommendations for the New Administration,”
Institute of Medicine of the National Academies, (RF Sponsored)

“Leveraging HIV Scale-Up to Strengthen Health Systems in Africa” Bellagio Conference Report,
September 2008; International Center for AIDS Care and Treatment Programs, Mailman School of
Public Health, Columbia University;

Bulletin of the World Health Organization; Special Theme: public health education, Volume 85,
Number 12, December 2007, 901-980

“Making the eHealth Connection: Global Partnerships, Local Solutions, Pathways and Progress,”
Pamphlet, The Rockefeller Foundation 2008

“The Role of the Private Sector in Health Systems, Challenges and Opportunities,” Pamphlet 2008
The Rockefeller Foundation, Results for Development, iHPP Thailand

“Pocantico II, The Global Challenge of Health Systems,” Conference Report, 2007 The Rockefeller

Intellectual Property Management in Health and Agricultural Innovation, a handbook of best
practices, MIHR

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