A Pivotal Moment: How to Achieve Localization in Global Health
By Janet Fleischman
This is a pivotal moment for the Biden administration and the U.S. Agency for International Development (USAID) as they formulate a new vision for sustainable global health and development. The chief proponent is USAID Administrator Samantha Power, who is championing locally led and inclusive development, known as localization. The aspiration is to make U.S. foreign assistance more accessible, equitable, and responsive by shifting leadership, decision-making, and funding to local actors — government, civil society, and private sector. While previous U.S. administrations promoted country ownership, the current discussion has taken on far greater urgency; it is happening amidst a pandemic and a global reckoning around structural racism and social determinants of health, decolonization of global aid, and the power imbalances inherent in donor-driven development. Despite many challenges ahead, this vision holds the promise of advancing partner countries’ needs and priorities and transforming the global health landscape through a more equitable, collaborative, and sustainable approach.
Through numerous global and bilateral projects, such as the Health Policy Plus Project (HP+), Palladium is a leading USAID partner in global health. As the aid agency moves forward with localization, lessons learned from the HP+ experience in partnering with local actors in 49 countries to design and apply policy, advocacy, financing, and governance solutions to health challenges can help inform the way forward. Accordingly, the six key components outlined below can be a resource for transforming how programming to strengthen the policy environment is designed, delivered, and monitored, thus further catalyzing effective and inclusive localization.
Most discussion around localization in USAID’s global health programs centers on transitioning service delivery and procurement to local partners, which are easier to measure than transitioning support to strengthen the policy environment. This gap in translating localization to the policy arena requires a different kind of engagement with national and subnational governments and local actors — prior to and during implementation –to foster an enabling environment where governments and local actors truly lead, and where civil society is involved in ensuring accountability, identifying needs, and defining priorities. Taken together, these components form the foundation for health policy development, advocacy, decision-making, civil society engagement, and domestic financing. USAID’s success with localization will hinge on how capacities and leadership of initiatives to support policy, advocacy, financing, and governance are strengthened and transitioned to local actors.
Key Components for Catalyzing Localization in the Health Policy, Advocacy, Financing, and Governance Space
- Make Technical Assistance for Capacity Strengthening Responsive and Demand Driven
Making technical assistance responsive to local needs requires a meaningful process of jointly assessing, defining, and co-creating project aims, work plans, leadership, and terms of engagement, and ensuring that local actors occupy leadership roles with significant responsibilities to provide technical assistance. This requires up front, joint planning to determine the roles and responsibilities for each party and to agree on which responsibilities will shift to local actors, and to set actionable benchmarks and accountability for that transition.
2. Strengthen and Diversify the Local Marketplace for Expertise by Supporting Local Professionals and Local Organizations
The goal of strengthening the skills and expertise of local actors is to create a repository of individuals, consultants and organizations with capacity in providing technical assistance to strengthen the health policy and enabling environment as well as in the management of USAID contracts. Support is also important to strengthen local actors’ organizational capacity, financial management, personnel management, and accountability. Such an approach would increase effectiveness and efficiency through faster response times and greater familiarity with local health systems, power dynamics, communities, cultures, and languages.
3. Ensure Equity through Participation and Leadership from Women and Girls, Indigenous Communities, LGBTQI+ people, Youth, and Other Marginalized Groups
Supporting local actors with the tools and capacities for decision making, processes, and implementation requires that representatives from marginalized groups are at the table. This means engaging a wider range of organizations focused on the health and rights of women and girls, LGBTQI+ people, under-represented communities and other marginalized groups, and promoting gender equity and equality. Advancing equity also requires adopting a multisectoral approach to include the range of government ministries that contribute to health outcomes.
4. Improve Use of Data and Measurement to Propel Performance and Equity
Localization requires local actors to develop meaningful measurement metrics and evidence to bring into health decision making and planning, through strengthening their capacity to interpret and use the data to develop concrete recommendations. This also involves identifying data and evidence related to barriers to health access and health care, such as gender inequities and discrimination against marginalized groups.
5. Expand Mobilization of Domestic Resources and Engagement of the Private Sector
Support for local actors helps to secure funding for health from government and the private sector, aimed at pooling risk, diversifying funding, and ensuring financial protection. This involves increasing advocacy by civil society and government for health financing at the district and national levels, as well as for Ministry of Health officials to advocate for resources with the Ministry of Finance, and for mobilizing other domestic resources.
6. Build on Joint Accountability for Inclusive and Sustainable Results
Joint accountability involves citizens and civil society organizations engaging about health priorities and commitments, accountability mechanisms, and how to achieve those commitments. This should include a wide range of local actors and resources, including civil society, government, the private sector, the media, private philanthropy, and domestic sources of funding.
Concerted Action Needed to Advance Localization
Implementation of localization will face many challenges, including the inherent tension between asserting that local actors should drive the agenda and the reality that USAID — and the U.S. Congress — are unlikely to hand all the reins to local actors. Another potential challenge is that localization does not necessarily ensure equity, especially where local biases, norms, and attitudes may conflict with equity and gender transformative approaches. USAID itself can be a barrier to localization, given its onerous compliance and reporting requirements, which make direct funding to local actors complicated and underscoring that USAID’s risk tolerance will have to increase.
Yet this historic moment of global reckoning demands concerted action to revamp the way USAID and its implementing partners operate, geared toward joining with local partners to design, collaborate, and innovate new approaches to drive health improvements. In Administrator Power’s words: “To engage authentically with local partners and to move toward a more locally led development approach is staff, time, and resource intensive — but it is also vital to our long-term success to sustainable development.”
Janet Fleischman is a consultant for HP+.