INTRODUCTION

Why Collaboration Matters and Why It Happens Too Rarely

In the mid-1980s several organizations involved in global health wrestled with how to get a stalled immunization effort back on track. They formed the Task Force for Child Survival, a partnership that quickly reinvigorated the effort and allowed the organizations to reach the goal. The partnership had another impact: it provided a stunning example of what partnerships could achieve through real collaboration. Briefly, this is how the story of the Task Force unfolded.

In 1974 member states of the World Health Organization (WHO) had passed a resolution to bring vaccines to children across the globe. At the Alma Ata Conference in 1978 they had set a concrete goal of immunizing 80 percent of the world's children against common childhood diseases by 1990. But by 1984, after climbing from 5 percent to 20 percent, immunization coverage had leveled off.

To break the impasse, these organizations decided to form a task force composed of senior leaders from WHO, the United Nations Development Program (UNDP), the World Bank, UNICEF, and the Rockefeller Foundation. They formed a secretariat, the Task Force for Child Survival, and charged it with helping the partnership rejuvenate immunization efforts and overcome the competitive and divisive forces that had slowed down the previous effort. The Task Force did more than coordinate efforts of the respective organizations. The individuals in the partnership were able to look beyond the separate interests of their own organizations and problem-solve together. they became a team. Under their guidance the task Force secretariat created a unified plan of action, addressed political roadblocks to pave the way for in-country efforts, solved technical problems as they arose, and kept the commitment and momentum alive.

By 1990 this partnership had raised immunization rates from 20 percent to 80 percent. James Grant, director of UNICEF at the time, called the initiative the "largest peacetime mobilization in the history of the earth."

This collaboration would become a touchstone in global health.

Because of efforts like this, the closing decade of the twentieth century saw a rapid rise in partnerships responding to emerging health threats. From 1995 to 2000, for example, key partnerships (including "alliances" and "coalitions") emerged in the following five disease and threat areas:

• Onchocerciasis (1995). The African Program for Onchocerciasis Control (APOC) launched an effort to help local communities in nineteen African countries organize and manage treatment for river blindness with the drug Mectizan. APOC was formed by the World Bank, WHO, UNDP, the Food and Agriculture Organization of the United Nations (FAO), the governments of nineteen developing countries and twenty-seven donor countries, twenty nongovernmental organizations (NGOs), and the global pharmaceutical Merck.

• HIV/AIDS (1996). Seven UN agencies established the joint United Nations program called UNAIDS.

• Tuberculosis (1998). Attendees at the World Conference on Lung Health launched the STOP-TB initiative.

• Malaria (1998). WHO, UNICEF, UNDP, the World Bank, and other partners founded the Roll Back Malaria Partnership (RBM), with the goal of cutting the incidence of malaria in half by 2010.

• Vaccine preventable diseases (1999). A combination of governments, foundations, development agencies, and NGOs formed the Global Alliance for Vaccines and Immunization (GAVI).

Partnerships had become the preferred approach to global health.

As the coordination costs of global partnerships became clearer, however, participants and donors had second thoughts. Participants themselves became more conscious of the huge time requirement for traveling to global meetings and the slow pace of building trust across organizations, time zones, and cultures. Donors began looking at the return they were getting on their investment of time, effort, and money, to see if partnerships really paid off.

KEY DONOR REPORTS: DO PARTNERSHIPS PAY OFF?

The attempt to measure impact was complicated. While businesses typically measure cost-effectiveness, public health had traditionally measured input or output—the level of demand for services or the number of people treated, for example. Russell Linden, a writer and lecturer on management, recalls: "When I directed a nonprofit organization that served handicapped people and their families back in the 1970s, I simply had to show an increasing demand for my nonprofit's programs in order to justify a budget increase from its funding agencies."

By the 1990s, however, that approach to measurement was no longer considered satisfactory, and funders began to look for better ways to measure results (reduction in the number of people affected by a disease, for instance) and, ultimately, cost-effectiveness. Measuring such impacts was challenging, since global health projects typically lacked the accountability, tracking systems, and financial controls common in business. Nevertheless, two donors analyzed the results of projects they had funded, and produced reports: The Bill & Melinda Gates Foundation (the Gates Foundation) and the British government's Department for International Development (DFID).

The Gates report, developed by a team from the management consulting firm McKinsey & Company and released in April 2002, recognized the dominant role partnerships had come to play in global health: "Simply put, there are few global public health challenges where any single player has the funding, research, and delivery capabilities required to solve the problem on a worldwide scale.... As one measure of their importance, alliances represent nearly 80 percent of the value of global health investments made by the Bill & Melinda Gates Foundation." The McKinsey team found that "more than 80...