To understand and appreciate the impact of the recently ended Health Policy Plus (HP+) project, it helps to go back to a point before it began and to the decisions made then that, three decades later, affected the essential nature of HP+ work.
In the 1980s, the donor world was concerned with population growth and set up programs focused on family planning to curb that growth. A decade later, in the late 1990s and early 2000s, large donors were focusing on a more urgent need—to curb the HIV/AIDS epidemic engulfing the globe. As a result, the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) began in 2003 as the largest health program devoted to a single disease. This was the essence of a “vertical” or “siloed” health intervention, as programs, data, and measures served one purpose—and both HIV and family planning programs fit that description.
The opposite approach was a holistic strategy that some espoused, arguing to address the larger determinants of health: reducing poverty, increasing livelihoods, and directing funding and programs to local areas. This approach could claim it would be more lasting, but the odds were it would take years, decades, to accomplish. Vertical programs, however, were contained, manageable, and their results faster to come and easier to see. Vertical programs could bypass country governments and their often weak health systems and lack of accountability. Vertical served urgency and placed accountability on outside implementers but did nothing for the in-country health system. There was its weakness: it would last only as long as the outside funding and outside implementers were there.
“These were parallel systems of financing and delivering health services, vertical programs, set up in host countries but running on their own,” says Eduardo Gonzalez-Pier, the senior technical director for health financing at Palladium. And after two decades, as HIV became less an epidemic than a chronic disease, the donors did begin to pull away, and countries were unprepared to take over. “One big contribution of HP+ was that the money was going to run out, and someone needed to work to reintegrate these vertical programs,” Gonzalez-Pier says.
As the U.S. Agency for International Development (USAID) thought about the impacts of donor attrition in low-resource countries, it funded several policy programs—two programs from 1995 to 2005 and then the triumvirate Health Policy Initiative (2005–2010), the Health Policy Project (2010–2015), and HP+ (2015–2022). These holistic programs were focused on family planning but also aimed to enact wider health policies and strengthen health systems so country governments could sustain the health gains made to date. And, indeed, this ambitious work was destined to take years, decades, to accomplish.
But the policy approach did accomplish much and laid a foundation for countries to succeed. Countries had left family planning and HIV concerns to donors and focused chiefly on clinical services delivering vaccines, urgent care for mothers and babies, and running hospitals in urban areas. Building up primary healthcare to serve rural areas and to focus on health promotion and prevention of life-threatening issues was not robustly in the mix. As Palladium’s three most recent health policy projects came on the scene, each immediately following its predecessor, things were about to change.
Change Takes Time, and People
“While public health is a complex political space, in many cases people forget that healthy people are the result of many processes, such as job training, employment, prices, food availability, and education, among others,” says Herminia Reyes, program director in Guatemala, where HP+ is called the Health and Education Policy Plus (HEP+) project. “All of this is important and the HEP+ activities allowed us to contribute to improving conditions for access to public health for the most vulnerable populations.”
Reyes notes the policy integration resulting from that mindset: “HEP+ had a positive influence on people, systems, laws, and policies across various sectors, including in areas as broad as banning child marriage, supporting open budgeting in public finances, creating frameworks for the decentralisation of 10 ministries to streamline investment in health, education, nutrition, water, and sanitation at the local level. It improved the civic participation of youth in civil society networks to prevent irregular migration and new models to advocate for policy compliance and budgeting for maternal-child health strategies. It helped develop and implement 76 policies, strategies, and regulations that were taken up by the government.”
Reyes gave an example of one policy that HP+ worked on and can be proud of. “For the first time, 17 years after the approval of the Decentralization Law, the government at the end of 2019 established a general government policy for 2020–2024, to define government’s responsibilities to strengthen decentralisation in order to reduce bureaucracy and corruption.”
As that was a change in Guatemala, Anne Jorgensen, technical director for capacity building at HP+ and Palladium, has seen change in several countries. “I’ve been able to see remarkable changes over time as countries take on more leadership and teach others to do these things. For example, a group we helped to form in Ukraine is now an organisation that we partnered with in a recent funding bid. It’s been a long time since the early 2000s. But we’ve shown that we can help people come together, learn things, and shine.”
Reyes also spoke of the need to foster staff competency. “Public health approaches and public management practices urgently need well-structured continuous training for everyone from senior officials to local staff,” she said. “People are the most satisfying outcome of the project, and HEP+ has created a wide network of people who create and promote change.”
If HP+ used its own experts, the work might take less time but would be less effective, Jorgensen says. “I’m very interested in localisation. The ways we have helped countries identify what they need to further their own goals is something I see more and more. Over the years, HP+ has helped them develop, from our earliest policy work and onward, so that now we’re very into the implementation of policy. Turning policy into action, helping countries be accountable and keep their promises. It’s all coming to fruition.”
Linking Policy to Action
It was a tough ask at first, as countries weren’t necessarily considering years ago that donors would pull away funding, leaving them holding the obligation to deliver health on all fronts. HP+ entered that shifting environment to suggest that countries should consider their policy environment and should then enact good policies to address their own needs. But that is how HP+ begins work in any country.
“What HP+ did was we said, ‘we can help you mobilise resources, advocate for more funding, and integrate your programs.’ We came with solutions,” says Gonzalez-Pier. “And we helped them and tailored the work to the specific countries, depending on what was already in place.”
Trying to fix the fragmentation that resulted from vertical approaches was going to be hard and HP+ understood that. But aside from the challenge, it was an opportunity to work at a broader level of health, outside the confines of a specific disease, says Nicole Judice, technical director for health at HP+ and Palladium. Even as HP+ is trying to mobilise money for family planning, for example, Judice notes that resources for foundational health needs are essential at the same time—funds for infrastructure, training staff, supply chains for medicines, and a myriad of other health needs. “We helped them look at the bigger picture and understand it was possible to do more with what they have,” she says. “It’s a new thing, or it’s greater than it used to be.”
To help countries find more resources, Judice said the HP+ approach was to enlarge the size of the pie. HP+ relied on its in-country national staff to navigate the environment of other sectors, other players—economic growth, trade, education, social services—and to develop relationships there to jointly mobilise funds that could be used to further large goals.
Data is an essential part of taking policy from paper to action. “Under HP+, we elevated financing data,” says Judice. “We did a lot of work in modelling, costing, and some epidemiology data in prior work, but HP+ really doubled down on financing data.” HP+ helped countries generate data and then use it to inform where they would invest, what new programs should begin, how to realign spending. One of the project’s result indicators is to show it helped a country generate finance data.
“Policy to action is how HP+ makes an impact broadly,” says Judice. “We allow USAID to have a more lasting impact on the health sector and to support and empower countries to make sustainable changes for good health delivery. Yes, service delivery projects play a good role but when they end, the pieces they put in place can fall apart. But HP+ work, by its nature, creates a lasting effect on the country.”
That sort of work is not always perfect. Olive Mtema, the former HP+ country director in Malawi, felt that success was mixed. “We learned a lot from the HPP project because, for example, we worked at the national level and it worked, but not well. Policies need to be put into action, so with HP+, we worked in several districts to show them what it means to roll out a policy and the skills it takes—we tried to show them the HOW.” One learning was that policy must be shared and explained, she said. Policies need to be interpreted for different audiences—like religious leaders and youth—so they understand what they should be getting.
Translating policy work into action takes time to achieve and, for the people doing the work, Mtema suggests it requires “integrity, patience, understanding, and knowing the context,” she says. “Malawians who are brought up here and educated here know why people do what they do. We can work together and help achieve the goals. And we did achieve because HP+ was highly respected by the government.”
As Gonzales-Pier says: “Policy is complicated. It’s difficult to communicate to the general population. It’s about better finance, blended finance, better practices, but people are used to boxes of medicines or better pay for doctors. This is more vague,” he says. “The fact that it lasted for so long says a lot about HP+’s success in policy work and its ability to communicate. It says a lot about how it created impact. You work on the ground, you benefit thousands. But policy makes it possible to help millions.”
The hallmark of achievement in policy work is to ask and answer the question: will it work and will it last? “We focus on sustainable results—things that can last when the project is over,” says Jay Gribble, senior technical director for health at HP+ and Palladium. “For example, improvements to health systems, effective policies that lead to improvements, and stronger management structures that include the input of people who are affected.
Under HP+, we worked more at subnational levels, where more decisions are made. What we used to do only at national levels now happened among people and organisations at district and municipality levels. This means we must think creatively, expose the right people to new ideas so the ideas get traction and are sustained.”
As often happens, money is an indicator of success. “HP+ has the largest field support money allocated that we’ve ever had—about 25 percent higher than on any other project,” says Jay Matthias, a director of health for Palladium who managed the financial pipeline for HP+. He says this shows that USAID missions and countries want to work with us to solve their problems based on HP+’s reputation, track record, and leadership. “HP+ had experts from the country and they are the ones that the missions trust. It’s the local teams that drive the project,” Matthias adds.
There is No One Way
“We help countries make the decisions and set the priorities,” says Jorgensen. “We’ve done it for a long time because you can’t do policy without the government. We help them set an agenda but we don’t have a product to sell.”
The HP+ teams in each country are led by local colleagues who come from within those systems and can navigate them in a way outsiders never could. So from the start, if a country agrees to work with HP+, it is a partnership and HP+ is not imposing a point of view but is looking with countries at problems and finding solutions. For Jorgensen, this is the secret sauce. “It’s the light bulbs that go off as we help people understand new ways of working, addressing real challenges, and coming up with questions to get to the other side."
"Whether it’s a small group, one person, or an entire organisation, I love to be in the room where change is happening,” she adds.
Because every country is so different, the challenges, the people, the successes, and the learning are different. HP+, working in policy in Asia, Latin America, eastern Europe, and Africa, had to continue to refine its tools while being open to change for any context, depending on the maturity of the policy environment in each country, the pool of local experts, and the political will that existed. That is the starting point. The desired trajectory is that HP+ helps the country stand up so that HP+ can begin to stand down.
“Where the political will might be weak, we know the partners, they know the waters, they know the system and so there are fewer surprises, even though there can be setbacks,” says Jorgensen. The work of HP+ takes listening deeply in the field, a willingness to learn what you don’t know, a belief that incremental change does happen and that leaders will emerge, and a solid dose of humility. “We don’t always know best. Our partners know more,” Jorgensen adds.
That sentiment aligns with what Gonzalez-Pier says were attributes of the success of HP+ “First was the tailoring of approaches at the local level by our country offices and the USAID mission in that country. Sometimes it was HP+ proposing an idea to the mission to fund this or that and HP+’s global footprint helped us know what was working and what was not working, and we could make it specific for each country. The second was from the USAID side because it also has a big footprint and are in touch with governments and know what other countries are doing. Together our country staff and USAID get the conversation going.”
Forging a Lasting Legacy
“The trust we managed to gain from the partners and USAID are the most important asset of the project,” says Reyes. “These are people who believe in the capabilities of the team.”
“Our work has had lasting impact because we helped governments to put a policy in place and start to implement it,” says Judice. “For example, in Kenya at the start of HP+, we supported government to figure out the cost to implement the “Linda Mama” program to help mothers and newborns. “We figured out the cost to provide all maternity, newborn, and postpartum care for free and how to reimburse providers through insurance. And then we helped government evaluate the program a year later and fix gaps and problems. Many years later, the program is still functioning.”
Judice reports she has seen the change in impact. “I am proud of the level of true country leadership that we shifted to on this project. We always had country directors and teams negotiate the scope of work and write the workplan. It’s sometimes hard and there’s reworking, but I felt a definite shift from seven years ago. I can see a difference in how we look to countries to lead the way.”
Subsequent projects that are now in the works to follow HP+ are in part based on what was learned in HP+. Integration of policy and programs to address many health needs is a theme gaining strength. Integration of multiple sectors to do their parts to foster health is another, as is localising work through community health workers and local civil society.
The work will continue in the policy to action vein, built on the legacy of HP+, says Suneeta Sharma, project director for HP+. “We need to align policies at different levels, not limited to one sector,” she says. “We see how any sector is linked to a policy financing framework. It’s not money for family planning or HIV. You need money for the larger health sector, like primary healthcare. HP+ showed that. It was a major learning that’s going to be very important.”
“In a lot of countries, we’ve helped them build a policy framework over 25 years,” says Judice. “That’s a springboard to improve equity and mobilise resources so there is something to build on. HP+ had a role there.”