A Foundation Set Out to Bolster African Health Systems. What Has it Achieved?
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A hospital room in west africa. RZ2y8sSeP8Xa/shutterstock
Making progress on global health challenges is beyond the limits of any one institution, and even the biggest private funders working in this space—like the Gates Foundation and Wellcome Trust—collaborate with a wide range of stakeholders to move the needle.
The Doris Duke Charitable Foundation has also practiced what it calls “partnership philanthropy” in its African Health Initiative, which has sought to “catalyze significant advances in strengthening health systems” in sub-Saharan Africa.
Now in its second—and “most likely” final—phase, the program has focused on supporting local ownership of solutions and creating shared learning systems. It’s gathered a wealth of data that the foundation hopes can guide decision-making long after grantmaking has ended.
Here’s how it evolved.
DDCF Program Priorities
The Doris Duke Charitable Foundation (DDCF) was established in 1996 with $1.3 billion in proceeds from the estate of tobacco heiress Doris Duke. Its four national grant programs follow the passions she pursued in life: supporting the performing arts, seeking cures through medical research, protecting the environment and promoting child well-being.
It also preserves Duke’s legacy properties and collections, including the Duke Farm in central New Jersey and Shangri La, a Hawaiian estate that’s now a museum showcasing the bulk of her Islamic art collection. The Doris Duke Foundation for Islamic Art conducts a single grantmaking program, Building Bridges, which works to increase understanding between Muslim and non-Muslim communities through arts programming.
The African Health Initiative (AHI)
Two factors contributed to the launch of DDCF’s African Health Initiative in 2007: earlier research in this area and the foundation’s 10th anniversary.
Doris Duke was an early supporter of HIV/AIDS interventions, and the African Health Initiative grew from that work. In 1993, the year she died, Duke contributed $1 million to the Elizabeth Taylor AIDS Foundation, and double that to support AIDS research at Duke, the university endowed by her father, then named for her grandfather.
As a result, the foundation conducted two competitions to improve the care and treatment of AIDS patients, inform policy and scale antiretroviral therapy within the “diverse and often daunting constraints of individual African countries.” In 2006, its Operations Research on AIDS Care and Treatment in Africa (ORACTA) challenge awarded $4 million in funding to 20 teams of scientists and investigators in nine African countries. Ten more teams received a total of $2 million during the second round in 2007.
Around that time, the foundation was celebrating its first decade, and challenged its staff to identify an urgent and compelling need within the mandate of Duke’s will—something that well-timed and well-aimed resources could impact significantly in a finite amount of time. The Medical Research Program team saw an opportunity to address health disparities in Africa more broadly, and DDCF began researching the best approach to the work.
A Structural Approach
Evidence showed that essential medical care was riding on the back of fragile healthcare systems that weren’t talking to each other, and acute worker shortages. The systems themselves were the problem, and DDCF soon realized that any sustainable solution meant partnering with the entire foundational health system.
It was unique in that approach. While the region was attracting numerous other health funders, their work either centered upon single-disease illnesses like AIDS and malaria, or disciplines like child mortality. But epidemics, natural disasters and medical issues affecting the largest cohorts of patients didn’t fall neatly into any one category.
Phases
The foundation rolled out the African Health Initiative in two phases. Phase 1 centered upon proof-of-concept. Phase 2 focused on replicating and scaling partnerships and platforms.
In 2009, the foundation made four grants to five institutions ranging from $8 million to $15 million for five population health implementation and training (PHIT) partnerships. Projects were funded five to seven years out, and located in countries the foundation had worked in during the ORACTA competitions: Ghana, Mozambique, Rwanda, Tanzania and Zambia. Local care providers were trained on implementation research that built integrated, sustainable systems that could respond quickly when new challenges arose.
Drawing on lessons learned from Phase 1, the foundation focused on improving maternal and neonatal health in Ghana, Mozambique and Ethiopia. Lola Adedokun, director of DDCF’s African Health Initiative, says the geographies were chosen because they had the right supports to become embedded. All had “adequate to visionary” local leadership, the attention and commitment of national government leaders, and strong evidence of strengthening impact or systems. They also sparked the interest of other donor partners and had opportunities for catalytic investment.
Embedding Locally
The foundation adopted three components to embed programs locally. The first was supporting local ownership of solutions by involving government at all levels. The second was activating learning systems that allowed local care providers to collaborate, enabling research and problem-solving in real time. And the third was building partnership-based philanthropy, a three-pronged approach that brought together national health ministries, U.S. and African universities, and global funding organizations.
A dozen years after the original five countries received Phase 1 funding, three are considered embedded. Two, Ghana and Mozambique, received Phase 2 funding from DDCF. Ghana received $8 million over five years, and Mozambique received $8.8 million over six years. Rwanda is self-sustaining, and all three geographies found footing with funding partners and government ministries.
DDCF was willing to make hard decisions when programs didn’t take root, and considers flexibility a primary factor in program successes. When partnerships in Tanzania and Zambia failed to draw enough government support or additional funding, the foundation exited. But DDCF began new work in Ethiopia—a $5 million investment over five years to support “thought partnership” between five Ethiopian Universities and the country’s health systems at all levels.
Partnership philanthropy was key to local lift-off. The program in Ethiopia came with built-in partners: the Gates Foundation, and a national government that’s recently adopted a health transformation plan that prioritizes learning and data-driven systems. Ghana developed a “very positive funding partnership” with the Korean aid agency KOICA, as well as local government support. Mozambique and Rwanda attracted significant program funding.
Self-sustaining Programs
Adedokun says DDCF’s work evolved into “supporting the place and the space, the people” who best understand the challenges to their communities, and are critical to sustaining advances.
The partnership the foundation ran between 2009 and 2016 in Ghana is a case in point. It worked to strengthen community-based service delivery systems in three of Ghana’s poorest rural districts, where 60 percent of the population lives. Initially led by DDCF, the Ghana Health Service and Columbia University’s Mailman School of Public Health, leadership has now transferred to government leaders at all levels, putting solutions in the hands of the people, and supporting local community-driven approaches that have reduced child deaths by nearly 45 percent.
