Health care status gaps continue to widen globally across age groups, gender, race and ethnicity.1 In Africa, disparities in health persist in part due to inexistent or weak relevant policies; lack of political will and mechanisms to implement policies; inadequate investment in developing resilient health systems; and populations inadequately equipped to meaningfully interact with health systems.2 The limited number of well-trained and equipped health workforce in Africa could be the most important factor since only four African countries had regional physician, nurse, and midwifery densities greater than the World Health Organization (WHO)-recommended 4.5 per 1000 people in 2018/19.3 Yet, Africa only allocates 5% of its gross domestic product (GDP) to health with a per capita health expenditure of US$ 89 compared to 13% of GDP and a per capita health expenditure of US$ 6078 in developed countries.4 Thus, prevention, diagnosis, effective treatment, and management of diseases is suboptimal, requiring innovative approaches such as partnerships to improve.
Forming both upstream and downstream partnerships, which are collaborative relationships between stakeholders pursuing Sustainable Development Goal (SDG), universal health coverage (UHC), and health security, can effectively advance health and improve health outcomes.5 For example, they can mobilize resources to develop policies and implement initiatives for sustainable health development.5 The United Nations (UN) SDG number 17 on partnerships acknowledges a multi-stakeholder approach in addressing challenges facing humanity.6,7 The multi-stakeholder response to the COVID-19 pandemic emboldened partnerships as effective in sharing knowledge and skills, mobilizing resources, and maximizing global health impact.8 Partnerships also develop leaders and build capacity toward establishing resilient health systems that can sustainably provide essential services even in the midst of crisis.9,10
Meaningful partnerships are based on a common strategic goal, openness, and effective communication, as well as deliberate monitoring and assessment of the partnership.11 Setting a clear basis for a partnership, connecting socially to build trust, openly and regularly communicating, and acknowledging cultural, motivational, and capability differences can enhance partnerships.12 Additionally, a guiding strategy based on any of the available frameworks facilitates the selection of the most suitable partner, agreement on goals, objectives and activities; and management and tracking of partnerships.13
The WHO Regional Office for Africa (WHO AFRO) embedded partnership in the Transformation Agenda (TA). TA is a vision and strategy for change initiated by WHO AFRO’s regional director Dr Matshidiso Moeti in 2015 to expedite the execution of the WHO reform agenda in the African region. It was expected to boost WHO AFRO’s responsiveness and collaborative spirit with member states toward leadership in the development and protection of health. It focused on four areas: pro-results values, smart technical focus, responsive strategic operations, and effective communication and partnerships.14 WHO AFRO focuses on strengthening strategic partnerships to enhance its support to member states with additional financing, outreach, brainpower, agency, and alliances.15 In response to requests by key stakeholders, WHO AFRO deliberately invested in partnership development and communication and tracked their effectiveness and sustainability to enhance internal communication and external communication, and strategic partnerships.
This study assesses the effectiveness and sustainability of partnerships and communication based on WHO AFRO’s experiences during the actualization of the TA to valuably contribute to health sector development.
METHODS
A qualitative study design comprising document analysis, key informant interviews (KIIs), and focus group discussions (FGDs) was conducted for triangulation. The KII guides and FGDs schedules were based on the 360-degree assessment, which is publicly available. Forty-seven participants in the KIIs and FGDs comprised representatives of all offices involved in the implementation of the transformation agenda. The participants were mainly external relationship officers in the following offices: external relations, partnership and governing bodies (EPG) cluster at WHO AFRO (n = 6); emergency preparedness and response (EPR) cluster at WHO AFRO and Dakar hub (n = 2), Universal Health Coverage/Communicable and Non-Communicable Diseases (UCN) cluster at WHO AFRO (n = 2), Universal Health Coverage Life Course (ULC) cluster at WHO AFRO (n = 1); healthier populations (UHP) cluster at WHO AFRO (n =1); Kenya, Nigeria, South Sudan, and Uganda country offices (n = 2 each); and other country offices (n = 1 each) (figure 1).
Data collection
Document analysis
WHO AFRO’s documents on partnership and communication published during the implementation of the TA between 2015 and 2021 were retrieved for analysis. Some documents were provided by WHO AFRO and others were accessed through search engines such as Scopus, Web of science, Google, and Google Scholar. Reports, presentations, strategy papers, conference proceedings, regulations, and guidelines were retrieved for the document analysis.
Key informant interviews
KIIs were conducted among WHO AFRO staff in the regional and country offices familiar with the TA and were key stakeholders in partnerships, external relations, and communication. The KIIs collected data on the background information, objectives, activities, and results of the partnerships and communication focus area of the TA. A semi-structured interview guide was used for the KIIs to ensure only relevant data were collected. The interviews were conducted online through Zoom, Teams, and telephone calls.
Focus group discussion
An FGD was conducted with a group comprising representatives from South Sudan, United Republic of Tanzania, Ghana, and Congo (Brazzaville regional office). Participants of the FGD played various roles in WHO AFRO including external relations, partnership, communication, and donor relations, which are within the partnerships and communications focus area of the TA. An FGD schedule was used to restrict the discussion within the confines of the study’s objectives. The FGD was conducted online through Zoom.
Ethical considerations
Informed consent was sought from each of the participants before data collection. Only general expert input on the participants’ work for the WHO were sought, which is public information that staff members responsibly share. No personal identifiable data or confidential data were collected from the participants; hence the study did not pose any risk to the participants. The privacy of the participants was guaranteed by anonymizing the data as defined in the latest issue of the Declaration of Helsinki.
Data analysis
The relevant information from the document analysis were triangulated with the information from the KIIs and the FGD. The information were manually categorized into three themes: description of the problem or issue that WHO intended to address through communication and partnerships; discussion of the effectiveness and outcomes of the communication and partnership efforts; and sustenance of effective and mutually beneficial partnerships. Thus, deductive thematic analysis was done; it entailed familiarizing with the data, using the three categories as the initial coding structure, manually applying predefined codes to the data, grouping related themes, reviewing the themes, and defining the themes.
RESULTS AND DISCUSSION
Issues targeted by partnerships and communications
Health problems beyond capacity
The TA was conceived to address African challenges in using weak healthcare systems to address overwhelming health problems. WHO AFRO member states struggle with a high burden of infectious diseases,16 multiple emerging diseases, high prevalence of neglected and tropical diseases,17 high mortality rate due to non-communicable diseases, and poor maternal health outcomes.18 Therefore, the TA focused on transforming the health workforce toward increasing the resilience of the healthcare system to adequately meet the needs of WHO AFRO stakeholders despite the intractable health challenges as espoused in the vision “the WHO that staff and stakeholders want”.14
Need for multi-stakeholder engagements
The diverse health problems require multi-stakeholder engagements. WHO AFRO recognizes in the TA that it must work with other stakeholders to effectively address Africa’s health challenges. The realization necessitated the prioritization of partnerships as a focus area in the TA. The twinning of partnerships and communication was strategic because without effective communication, partnerships, just like all the other organizational functions, cannot be optimized.
Headquarter-focused staffing
A mapping exercise conducted in 2018 found that WHO’s external relations (EXR) staff resources were heavily concentrated at the headquarter (HQ). A total of 376 full-time equivalent (FTE) staff members were working on the mapped EXR functions (resource mobilization/communications and advocacy/ partnerships/ governing bodies). Two-thirds of the resources were located in the WHO headquarter, 18% in WHO regional offices, and 16% only in WHO country offices.19 Thus, headquarter-centric staffing may have compromised coordination with local stakeholders and alienated national health priorities in WHO AFRO’s agenda, strategies, and programs.
Inward-focused communication
Before the TA, most of WHO AFRO’s communication was inward-focused. Communication with existing or potential external stakeholders in member- and non-member states was given little attention.20 This constrained the growth of vital relationships that would have contributed the knowledge, finances, and human resources needed to improve health in Africa.
Outcomes of partnerships and communications efforts
Capacity building and decentralization
TA empowered WHO Country Offices to engage with stakeholders and to increase transparency and responsiveness. The External Relations and Partnership Team of the EPG worked to significantly improve the external relations capacity in the WHO AFRO beginning in the 2020-2021 biennium and continuing in the 2022-2023 biennium, which was within the framework of the WHO Global Resource Mobilization Strategy. Effort and resources were employed to enhance the capacity of WHO AFRO country offices with exceptional and competent External Relations and Partnership personnel. For the first time, external relations and partnership focal points were trained and deployed to 39 WHO country offices across the Africa Region in the 2020-2021 biennium.
Bilateral engagements
Secondly, the External Relations and Partnerships enhanced bilateral engagements with key stakeholders including state and non-state actors. The Regional Director and senior WHO AFRO leadership met key stakeholders, and visited many partners across the globe to deepen the cooperation and mutual understanding of goals between them. This was reciprocated as senior officials comprising governments, international NGOs, and donors also visited WHO AFRO in Congo Brazzaville.
WHO AFRO anchored and streamlined its partnership with non-state actors (NSAs) in line with the 2016 World Health Assembly’s Framework of Engagement with NSA (FENSA).21 It equipped its workforce with the skills necessary to promote interactions with NSAs at national and regional levels, particularly through facilitating partnership for increased impact and resource mobilization. Building on its ongoing cooperation, AFRO developed additional resources and tools to support the exchange of best practices at the regional and national levels and expedite the evaluation and approval of proposals for engagement with NSAs.20 Consequently, FENSA approval was expedited from 3 weeks to 24-72 hours, and requests for approval increased by 193% in the TA period. Besides, WHO AFRO raised about US$34 million from 62 NSAs in 2018/2019 and over $57 million from 183 NSA in 2022/2023.20
New partnerships
Strengthening and engaging new partners for health development in Africa was the driving force behind WHO AFRO’s convening of the first ever Africa Health Forum in 2017 in Rwanda themed "Putting People First: The Road to Universal Health Coverage in Africa. Over 800 participants from governments, the private sector, civil society, and young people converged to seek solutions for the region’s ongoing public health problems by among other initiatives partnering to support WHO’s reform program. The forum culminated in the Kigali Call to Action: "Call-to-Action – Putting People First: The Road to Universal Health Coverage in Africa"22. The call came with a promise to assist member states’ renewed commitment to achieve the SDGs and UHC through partnerships with the private sector, WHO, and other UN agencies. It was agreed that the call to action needed to be implemented right away, and WHO AFRO was tasked to devise a plan to operationalize the meeting’s conclusions.23
The 2nd Africa Health Forum that was held in Cape Verde in 2019 followed up with the theme “Achieving universal health coverage and health security in Africa”24. The event brought together leaders, policy-makers, implementers, representatives of governments, donors, United Nation agencies, nongovernmental organizations, the private sector, academia, youth, and media. Discussions were on how to address the persistent health challenges in the African region and promote stronger ownership and governance for health at country level. Participants also explored specific and practical ways for partners to contribute to reforming the work of WHO in the African Region towards achieving the goals of the "Africa Health Transformation Programme 2015-2020".24
Emergency response
The COVID-19 pandemic necessitated WHO to work closely with national and regional partners and member states to enhance contact tracing and surveillance, increase oxygen supplies, and provide medical staff with comprehensive case management training.25 WHO used the International Health Regulations and the Emergency Response Framework to repurpose its Incident Management System for pandemic response preparedness. Thus, countries established emergency operation centers, which included promoting health care services at international borders and increasing national emergency management teams (EMT)’ capacities. These strategic accomplishments, which are the outcome of partnerships between WHO and its member states, are now established fixtures in the African health emergency and preparation landscape, addressing COVID-19 while also preparing countries for other crises.25 In "The Future of WHO COVID-19 Response Operation in Africa in 2022" by WHO AFRO’s Emergency Preparedness and Response Cluster to address the COVID-19 crises from 2022, WHO AFRO committed to diversify collaborations with existing and new partners.26
Infodemic response
WHO AFRO partnered with its member states to produce and disseminate over 200 videos that attracted millions of viewers across its Facebook and X (formerly Twitter) platforms. The videos provided verified and useful information to audiences seeking to improve their health and well being. WHO AFRO also launched the African Infodemic Response Alliance (AIRA), a unique network composed of 14 leading public health agencies and affiliated members from the civil society (fact-checking organizations and academia) and the private sector (Meta) to coordinate and mobilize resources to counter the rampant misinformation and disinformation during the -COVID-19 pandemic.27
WHO AFRO hosts the AIRA secretariat, whose achievements include creation of the Viral Facts Africa (VFA) content hub to disseminate factual and genuine information on COVID-19 and other health topics in multiple languages.28 The VFA communication messages were all based on the results of the social listening analytical reports that AIRA produces on a weekly basis (120 reports published between 2021 and 2023). The partnerships also entailed AIRA conducting training in 44 out of the 47 member states and supporting the integration of infodemic management into the communication strategic plans and coordination mechanisms of 25 member states. Subsequently, AIRA’s scope of work significantly expanded to other health priorities in the Africa region including cholera, Mpox, childhood routine immunization, malaria vaccine, climate change, and health.
Harmonizing health systems’ strengthening
WHO AFRO steered the relaunching of the Harmonization for Health in Africa (HHA) platform,22 which was established in 2006 to support and coordinate development of all facets of health systems strengthening in Africa.29 The HHA partners assist in infrastructure development, ICT, governance and service delivery, medicines and supply chains, human resources for health, infrastructure, and pharmaceuticals. The HHA mechanism conducted a mapping exercise in 39 countries to evaluate the efficiency of partners’ country-level coordination and collaboration as well as identity the obstacles associated with coordination and harmonization. At the 10th anniversary of HHA in 2016, an independent review of the mechanism was conducted to decide on the future of HHA. This led to relaunching of HHA in 2017, resulting in increased cooperation with other UN agencies and bilateral and multilateral partners to hasten the region’s transition to UHC.22
Training and briefing sessions
Knowledge bridging was a key component in establishing and maintaining partnerships. The EPG unit conducted over 60 group training sessions and briefing sessions with partners. These dialogues contributed to increased and strengthened regional and country engagements with partners such as NSA. In addition, they contributed to improved coordination among partners in response to governmental priorities, and the provision of vital and strategic health information to guide interventions at the national and regional levels. Finally, the trainings and briefing sessions contributed to avoidance of redundant roles and efforts, particularly with significant regional partners. They brought partners closer, created trust between them, and helped keep the goal of the partnership in focus.30
Devolved resource mobilization
The WHO AFRO’s resource mobilization strategy and work plans emphasized devolving resource mobilization to the various levels of the organization. Each organizational level was required to maintain existing partnerships and establish new ones through unquestionable credibility and a good reputation.31 Remaining relevant in partnerships by analyzing the needs and interests of each partner was also emphasized in the strategy to tap available resources from state actors and NSA at all levels. Consequently, the mobilized resources increased by 22% from US$ 594 million in 2018-2019 to US$ 730M in 2022-2023.32
Revamped communication
WHO AFRO invested efforts and resources in enhancing external relations, improving communication with all stakeholders, and streamlining processes. It aimed to “communicate effectively both internally among staff members and externally with stakeholders, build lasting relationships, and enhancing transparency and trust”.33 WHO AFRO conducted a communication audit of its internal and external communication, which was the basis of the restructuring of the communications unit with additional staff and development of a regional communication strategy.22
WHO AFRO developed a communication strategy to improve internal and external relations, create visibility for the organization, enhance and broaden engagements with existing and potential stakeholders, and mobilize the much-needed resources for improved health outcomes in Africa. Using different media to engage stakeholders raised the visibility of WHO AFRO and the health issues that needed attention. Communications’ focal persons in country offices were re-trained on the use of the Popullo engagement application, which enhanced engagement with stakeholders.
Streamlining reporting
WHO AFRO focused on streamlining strategic processes in communication and partnerships for the desired impact. It responded to requests from both partners and member states to enhance its internal control and reporting mechanisms and establish a regional structure for programmatic implementation. Besides, it established a report monitoring system through a dynamic and accessible interactive Power BI platform to avoid reporting delays and enhance the quality of reports for accountable and transparent communication with partners. Subsequently, the backlog of reports shrunk from 300 to less than 70.
Sustenance of partnerships
Increase and diversification of funding
Revamping the external relations functions across all levels set the African region on the path to sustainability. It contributed to the growth and diversification of partners and the broadening of funding streams from an expanded pool of philanthropic sources. It also led to an increase in joint UN funding. Overall, the external relations officers facilitated and directly helped to raise $622 million out of the US$1.7 billion raised in the 2020-2021 biennium. The increase and diversification of funding sources is a bedrock for sustainability.
Institutionalization of decentralization
WHO AFRO empowered people at all the levels of the organization in key areas including stakeholder and partnership engagement, communication, and resource mobilization. Capacitating country offices with high-caliber external relations and partnership expertise equipped the offices for sustainable effectiveness. In addition, WHO country offices’ priorities were aligned to national health priorities, which streamlined partnerships with the member states by avoiding conflicts and duplication of activities.34 Furthermore, enhancing the communication and partnerships functions, providing training and resources, and monitoring the initiatives made them effective and efficient in the long run. The leaders’ commitment to transformation activities inspired partners to embrace the country.
Challenges to sustenance of partnerships
Basing partnerships on the traditional actors seemed unsustainable, hence a need to diversify stakeholder engagement efforts to include more non-traditional partners such as philanthropies, private sector entities, and community-based organizations to broaden the reach and impact of initiative was apparent. Geopolitical shifts, technological disruptions, and changes in funding modalities requires continuous training and capacity-building to keep team members updated on the latest trends and best practices in external relations for sustenance of partnerships. Besides, the decreasing opportunities for resource mobilization are increasing competition among partners, which is reducing the sustenance of partnerships.
Limitations
The main limitation of this study is that it only analyzes WHO’s experiences yet partnerships and communication involve multiple diverse stakeholders. Another limitation is that the study was not longitudinal as it did not track the experiences over time, hence the suggestion of causal pathways between the changes in partnerships and communication and improvements in outcomes was cautious.
CONCLUSIONS AND RECOMMENDATIONS
The WHO AFRO TA was a visionary idea whose outcomes are already evident and impact will be felt years to come. Focusing on four areas and objectives and strategizing around them ensured efficient use of energy and resources. This research assessed the effect of the TA on partnerships and communications aspects of WHO AFRO. WHO AFRO invested resources in developing partnerships at all levels. Staffing and revamping the communications units improved WHO AFRO’s relations with existing partners and visibility to potential partners. The monitoring and evaluation component helped track the status of the communication and partnerships strategy. Importantly, the WHO AFRO’s regional director and other senior leaders were actively involved in the implementation of the TA, hence the buy-in among staff members and partners. Consequently, WHO AFRO’s visibility and external relations improved significantly, strengthening existing partnerships and establishing new ones including with non-state actors as evident in enhanced resource mobilization, increased diversity of contributors, and more funding from both legacy and new partners. The diversification of funders and institutionalization of the decentralization of staffing are the hallmarks of sustainable effects of the partnerships and communication interventions in WHO AFRO’s TA.
Continued involvement of WHO AFRO’s leadership in external relations, partnership development, and stakeholder engagement is recommended since WHO engages with leaders and policymakers at the highest levels of governments and corporations. Continued investment and development of communication and partnership functions through allocation of more resources can facilitate better development of the personnel, facilities, and systems for optimal partnerships and communication. The engagements with local communities, associations, and organizations should be strengthened by including their experiences in future assessments to tap into their resources to improve partnerships for better health. Moreover, research, monitoring, evaluation and learning components should be institutionalized in the partnership and communication systems for enhanced tracking of progress and continuous improvement.
Acknowledgments
The authors would like to thank WHO AFRO for making this study possible. The effort by the regional and country teams, specifically the partnerships, communications and external relations units to provide the information analyzed in this study is also acknowledged.
Disclosure
SG and DK are independent consultants for the WHO AFRO Transformation Agenda. The other authors are members of staff of the WHO AFRO.
Funding
This study was funded by the World Health Organization Regional Office for Africa.
Authorship contributions
Conceptualization, P.D., S.G., K.D., A.L., K.N.; data acquisition, P.D., S.G., K.D., A.L., K.N.; data analysis and interpretation, P.D., S.G., K.D., A.L., D.K., K.N.; visualization, D.K.; drafting the manuscript and reviewing it critically, P.D., S.G., K.D., A.L., D.K., K.N. All authors approved the final version of the manuscript to be published.
Disclosure of interest
The authors completed the ICMJE Disclosure of Interest Form and disclose no relevant interests.
Correspondence to:
Sospeter Gatobu
Independent consultant
393 Bamberg Crescent, Waterloo, Ontario, N2T0B5, Canada.
sgatobu@uwaterloo.ca
Dennis Kithinji
Meru University of Science and Technology
313-60600, Maua-Kenya
dennohkithinji@gmail.com