Interview – Agnès Binagwaho and Peter Piot

The intersections and overlaps between the work of foundations, national governments and multilateral agencies are complex and often contentious. But, as Peter Laugharn of the Bernard van Leer Foundation found when he talked to Agnès Binagwaho, head of the Rwandan national AIDS programme, and Peter Piot, Executive Director of UNAIDS, partnerships with foundations are a vital aspect of their work in fighting HIV/AIDS.

Both Binagwaho and Piot stress the importance of foundations aligning their activities with the national efforts, but they also point to other valuable roles that foundations can play. ‘Thought leadership’, doing the ‘forward thinking about the next 10, 20, 25 years’, is one that Piot sets particular store by.

It seems that both the Rwandan government and UNAIDS have had plenty of experience of working with foundations. And Agnès Binagwaho and Peter Piot seem to agree that foundations make valuable partners, both at the national level of the Rwandan government and at the multilateral level of UNAIDS. Central to both Binagwaho and Piot’s assessment of foundation work is the extent to which foundations are able to adapt their programmes to the wider context. If what they do is to be sustainable, foundations have to find appropriate pathways into the larger national effort.

Aligning with the national effort

Binagwaho cannot make this point strongly enough. Foundations ‘are very useful partners when they come to the support of the national response,’ she says. ‘That means they come into the country and align their activities to the national policies and the national efforts. The entry point is the National Aid Policy and the Ministry of Finance. They have to say which action they are going to support, where, how long, etc. If they do so, they are really very helpful.

‘If you want to create something, and you want it to be sustainable, you want it to remain when you’ve left the country, you just have to come and support what exists. If you help communities within the framework set by the Ministry of Health, for example developing local health centres, this is something that will remain for the community. But if you create something outside the national framework, it will collapse when you go.’

However, Piot says, ‘I don’t think it’s the role of foundations to fund the government, that’s not the issue, but I do think it’s important that the work of anybody in any country is part of an overall, comprehensive effort. When you do work alongside national efforts, the work can take more time and effort to set up initially but you will have a better chance of sustainability in the longer term. If foundation work is completely out of step with national policies, the impact will be at best limited.’ He feels that UNAIDS’ less positive contacts with foundations have arisen when this all-important context is ignored.

He cites the example of their work with foundations in Asia and Eastern Europe, where at times ‘the work has actually not been at all conforming with official government policy’. In this case, the results ‘can be totally counter-productive when it comes to the fight against AIDS’.

However, with UNAIDS acting as ‘a go-between between the government and the foundations’, progress has clearly been made. With the help of UNAIDS, governments have agreed to foundation-led projects around harm reduction for injecting drug users, for example, projects that Piot says they would otherwise have been reluctant to support. ‘It was actually thanks to Open Society Institute money that the first demonstration projects could be done. We didn’t have the money but we opened the doors and made sure that there was agreement from the government to do it. So there is room for experimentation and demonstration projects and so on. And that’s the kind of brokering role that we’ve played quite a few times. But the basic principle should be that the foundation contributes overall to the national effort – otherwise I frankly don’t see the point.’

Progress to be made

While the work of the Bernard van Leer Foundation does to an extent intersect with national frameworks, Peter Laugharn feels that there’s progress to be made on both sides of this relationship. ‘I don’t think we have made enough effort to let the national authorities know about what we’re doing,’ he admits, but then again, ‘I’m not sure that the national authorities have made sufficient effort to know what the foundations are doing.’

More generally, he’s ‘not sure that most foundations do align themselves with national efforts sufficiently. They could check in, say, every year or six months, and say, “OK, this is what we’re doing.” I think the general point should be made to foundations that, particularly if they want to have greater leverage than just working in one little project, they need to link themselves in with the national authorities.’

But Binagwaho insists that experiences of working with foundations in Rwanda have been overwhelmingly positive. Partners coming into the country have on the whole been very responsive to the national context, ‘not only in the field of HIV/AIDS but also in other sectors like agriculture’.

This is not to say that the objectives of incoming foundations dovetail completely with those of the national government: ‘When they come, you just put on the table, “Those are our needs in the field of agriculture.” Sometimes it’s a bit frustrating because they say, “Your priority doesn’t interest us. We want to do this.” But you know, you cannot oblige people who are coming on a voluntary basis to do what you want when they want to do something different because it’s their mandate and that’s what they have to report on.’

But as long as foundations work within the national framework and follow the national policies, are transparent about their goals, and ‘we really know why they come’, this slight mismatch between the priorities and objectives of the two sides need not get in the way of good collaborative work.

Money … and more

What emerged from this conversation was a feeling that foundations are uniquely positioned to play a role that is open to neither national governments nor the UN. Money is clearly important. Piot points to the Gates Foundation’s funding of ‘a massive project on truck drivers and sex workers and HIV in India – they’ve invested close to $250 million there. These are the kinds of policies and approaches that we’ve been advocating for at UNAIDS but there was no money for it.’ The same was true of the harm reduction demonstration projects funded by OSI in Eastern Europe, which UNAIDS advocated for but couldn’t afford to fund.

But money is not the only thing foundations have to offer. They also have connections. One example offered by Piot is UNAIDS’ partnership with the Clinton Foundation in their efforts to reduce the price of anti-retroviral drugs. Where UNAIDS were able to successfully negotiate a 90 per cent reduction in the initial price, the Clinton Foundation picked up where UNAIDS left off. ‘We got stuck at 90 per cent, and here Clinton came in and in a very systematic way – and because of who he is and his contacts – he was able to bring it down further, and that we would not have been able to do.’

Binagwaho agrees that her work in Rwanda has also benefited not only from foundation money but also from the greater powers of manoeuvring open to them. ‘What they bring is not just money, it’s connections, expertise, technical capacity. So it’s more than money.’

And this isn’t all. According to Piot, foundations can ‘do far more innovative work, can take risks’, in part because ‘it’s not their job to be there permanently’. In addition, ‘they have their visibility, outreach, influence – and they can bring to the table new approaches and innovation.’

Smaller foundations should not be intimidated by the wealth and influence of the likes of Gates and Clinton – there is a role for them too. As Piot says, ‘Collaboration among foundations is possible, particularly with local institutions. But I think that actually a small foundation can sometimes bring more value for money because it is far more focused.’ In fact, the advantages of foundations identified by Binagwaho – ‘a foundation can be more flexible, more capitalist, more innovative’ – arguably apply more to smaller operations.

Taking a long-term view

While Laugharn agrees with Binagwaho that the sustainability of foundation work is largely dependent on foundations supporting national efforts, he points to the fact that ‘in some countries where BVLF works, we worked with the ministry of education longer than any serving minister – in Jamaica and Kenya it was 25 years or so. I think sometimes the value of the foundation’s potential to work really long term is underestimated by both foundations and national government.’

So it seems that foundations can offer not only flexibility but also a long-term perspective that is often absent from the agendas of bilateral or multilateral cooperation, the timescales of which are all too often dictated by the electoral cycle. Where NGO work is typically ‘action-oriented in today’s problems, a foundation should be able to take a longer perspective’.

Binagwaho agrees: ‘A foundation has its own objectives, and most of them are long term. When somebody creates a foundation, it is not for the short term, it’s for long-term problem-solving. It’s not like an NGO, which is there to respond to a problem immediately.’

Development partner or thought leader?

Piot suggests a distinction ‘between a foundation that is acting as let’s call it a development partner – you see that especially with the very big ones, Gates particularly – and the foundation as innovator, incubator, thought leader. I think where foundations have often been extremely valuable in the past is in thought leadership – around the big new issues (we’ve certainly seen that in the environment in a big way) and around some aspects of development, governance for example.’

And he expresses a hope that this role won’t be confined to the past. ‘I hope foundations will also contribute to what we need in AIDS, and that is forward thinking about the next 10, 20, 25 years.’

When acting as thought leaders, says Piot, ‘I think that being a bit outside the mainstream, outside a too rigid framework, is actually good. We need thinking out of the box, we need innovation and the long-term view, and we in UNAIDS or in government don’t always have the time for that. It’s not our pressing priority.’

In fact the development partner role seems to be a potentially tricky one for foundations. In Piot’s view, ‘engaging in let’s say classic development projects may not be their real strength’. And Laugharn points out the difficulty of exit. ‘There may be quite a dilemma for Gates these days because they’re taking on obligations that they won’t be able to back out of, in terms of providing anti-retrovirals, etc. And in the end they will be less flexible.’

The Joint Learning Initiative

Foundations’ longer view and thought leadership role are well encapsulated in the Joint Learning Initiative on Children and AIDS (JLICA), which involves players like the Rwandan government and UNICEF as well as a number of foundations. Binagwaho explains: ‘The aim of the JLICA is for us to look at the situation of children, and why children are so often left out of programmes in the field of HIV/AIDS. And this is a worldwide problem. It’s not just in poor countries that they are not taking enough account of them.

‘So the JLICA wants really to reflect on why some countries are doing better than others. We want to go and see why what some countries are doing is working and what others are doing isn’t working. To sum up, we want to see what is missing in some countries in terms of taking children into account – at the level of the family, the community, the programmes, national policies. If we find something that’s working, and find out why it’s working and what is making the difference, we will have evidence-based, researched, proved lessons that we can offer to the world.’

In an initiative like the JLICA, Binagwaho points out, ‘it’s sometimes easier to convince foundations to carry out a study than to convince the government or bilaterals to do it. Because this is not the priority for a government, but it can be a priority for a foundation.’

Adapting to each other?

When asked ‘should foundations change the way they work if they want to work better with governments or do the governments need to change?’ Binagwaho responds: ‘It’s a good question. Government has to recognize that they can direct foundations to align with the national policy whatever they want to do. Take, for example, a foundation wanting to promote artists. There are national laws and policies for youth and culture, so you tell them, “OK, this is our rules, what do you want to do that will meet your objectives and ours, according to our policy and our needs?” Do you see? The foundation has to align whatever they want to come to do with our national policies and to support sustainability. This is the core, the key issue of development.’

Yet, as Piot points out, in some ways there is more ‘added value’ to be had from foundation actors outside of this ‘development role’, when they are taking on the kind of ‘thought leadership’ role that has already been mentioned. Many foundations derive from the business world, and people often value them because they come from a business background. ‘We have worked with Google,’ says Piot, ‘and they bring in a totally new dynamic – just as some of the other new IT foundations do, particularly on the west coast of the US – and I think that’s great.’

Importance of an exit strategy

There are of course downsides to the work that these ‘edgier’ foundations do. The fact that they are able to accept a greater level of risk doesn’t necessarily lead to fully developed projects and sustainable results. The danger is that with too much emphasis on ‘innovation’, experiments are never properly assimilated into the mainstream. The results can be pilots that don’t go anywhere.

But this, as Piot says, should not be the case if a foundation has an appropriate exit strategy. ‘One of the weaknesses of many innovative and incubator efforts is the lack of an exit strategy. An exit strategy is as vital for a foundation as the entry strategy and launching of a programme. For example, you can have a beautiful demonstration project, but by the nature of that approach the unit cost of your intervention will be much higher than can be sustained, certainly in the public sector in poor countries. So you need to think how a foundation can withdraw and hand it over. I think an exit strategy is critical for a foundation. Otherwise what’s the difference between them and say the Department for International Development?’

But Piot and Binagwaho both agree with Laugharn when he says, ‘I would be happier with the phrase a leverage strategy than an exit strategy.’ According to Laugharn, ‘Both funders and national governments and foundations are comfortable with the idea of foundations doing something valuable and innovative that is then leveragable by either the national government or a larger funder.’

‘Or,’ as Binagwaho adds, ‘they fund something because they want to find a solution to something. There is a results orientation; they want results and they give a time frame.’

Where next?

What seems clear from this discussion is that while foundation work intersects with that of both national governments and multilateral agencies like UNAIDS, their contributions work on fundamentally different levels.

It’s also clear that there are different types of foundation. As Laugharn poses the question to Binagwaho, ‘Are you looking for foundations that have a problem-solving mentality? If we look at Clinton or Gates, that’s the way they work. But there are other foundations that are supporting the works of the grassroots. What is your idea of what such a foundation should contribute?’

Binagwaho’s answer is that ‘There is not one type of foundation, we need foundations acting in all areas, reflecting, acting, being catalysts, solving problems. But their added value is that they are more flexible. If they align themselves with the national policy, working with communities for sustainability, we cannot dream of more than that.’

For more information
For more about UNAIDS, visit http://www.unaids.org or email executivedirector@unaids.org
For more about the Rwandan government national AIDS programme, contact Agnès Binagwaho at cnls@rwanda1.com
For more about the Joint Learning Initiative on Children and AIDS, see http://www.jlica.org


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