Melding Disparate Cultures and Capacities to Create Global Health Partnerships

As public health problems in the developing world grow more complex and resources to address them remain limited, global health partnerships become increasingly important. No organization working alone could hope to control or make a significant dent in health issues ranging from HIV/AIDS to sleeping sickness. The power of partnerships is in bringing together actors with diverse yet complementary skills and resources around a shared vision that none of the actors could realize by themselves. Although partnerships can bring many benefits, making them work—and optimizing their efficiency and effectiveness—can be a tough challenge.

CHALLENGES AND REWARDS

The CARE–CDC Health Initiative (CCHI) combines the experience of the Cooperative for Assistance and Relief Everywhere (CARE) in working alongside poor communities to help end poverty with the scientific expertise and surveillance capability of the Centers for Disease Control and Prevention (CDC). In partnership, CARE and CDC seek to provide better solutions to problems that pose a threat to both the health and the livelihood security of people in poor communities in developing countries. Making this partnership work has required effort. Through focused, good-faith efforts and the involvement of the CDC Foundation, an independent, nonprofit organization established to promote and facilitate effective partnerships between CDC and others, conflicts and obstacles that initially hampered the CARE–CDC alliance have been resolved. As several articles in this issue of the Journal will attest, the CCHI partnership has strengthened the ability of both organizations to fulfill their missions and has enhanced the effectiveness of services provided at the community level.

WHEN MISSIONS ALIGN

Merging the cultures of a large federal agency and a global nonprofit organization can be challenging, at best. The 2 organizations' missions, while related, are different. CARE's mission is to serve individuals and families in the poorest communities in the world (unpublished minutes of the meeting of the Board of Directors of CARE International, Phnom Penh, November 1999). CARE works alongside these communities to help end poverty. Health is seen as one component among several—including education, clean water and sanitation, agriculture and natural resources—that together contribute to livelihood security. For CARE, a positive health outcome is not an end in itself; rather, it is an important aspect of the improved livelihood security of families and communities. Because CARE operates in some of the poorest, most remote, and most marginalized areas of the world, the communities with which it works frequently suffer from poor health brought on by poverty, malnutrition, lack of access to clean water and sanitation, little or no organized health care, and high prevalence of chronic and infectious diseases.

CDC's mission is “to promote health and quality of life by preventing and controlling disease, injury, and disability.”1 The agency accomplishes its mission through surveillance of populations to detect emerging health problems and identification and control of risk factors through applied research. Its activities, of necessity, require a rigorous, scientific approach and a global view of large populations.

Where the 2 agencies' missions converge—around health problems with potentially large-scale impact in poor communities—is where they have the best opportunity for real partnership. It is here that CARE's and CDC's capabilities are complementary and that the potential for valuable, mutual learning and growth is greatest. CARE's activities are rooted in the needs and aspirations of poor communities and are very practical. CDC follows a rigorous scientific approach with a detached global view. The partnership with CDC allows CARE to tap into valuable technical expertise that can be leveraged to have an immediate and positive impact at the community level. The partnership with CARE enables CDC to work more effectively at the local level, understanding community needs and capacities and learning ways to mobilize communities.

EXPERIENCE GAINED

Both CARE and CDC gained important experience in the process by which they eventually melded their cultures and began to institutionalize their working relationship. This experience could serve as a guide for future partnerships in global health:

Flexible, external funding provides a strong, positive incentive for the systematic design and implementation of a workable alliance. Flexible funding from the Robert Woodruff Foundation, Atlanta, Ga, provided an incentive and means for the 2 organizations to study various approaches to partnering and then test them in various community settings and in a variety of different programs. The Woodruff Foundation's emphasis on the desired outcome—a successful and institutionalized partnership and not specific methods—allowed the flexibility to modify budgets and approaches during the initiative. This flexibility was critical to incorporating new learning and enabling success at the project level.

Solid, visible, and continuous commitment from the top at both participating agencies is vital. In her essay “World Class Leaders: The Power of Partnering,” Rosabeth Moss Kanter states that leaders must “become cosmopolitans who have the vision, skills and resources to form networks that extend beyond their home base and to bring benefits to their own group by partnering with others.”2^(p91) From the beginning, the president of CARE and the director of CDC were each strongly supportive of this project and committed their agencies formally to full participation in the partnership. Without such focused leadership, the project might have failed.

In each organization, the commitment of knowledgeable and experienced staff dedicated to making the partnership work is imperative. Through experience, both agencies learned that effective coordination required in-depth knowledge of each organization's respective capacities and culture. They eventually formed a small but highly functional team of coordinators and project officers who shared parallel functions at CARE and CDC. This was critical to ensuring smooth and effective coordination and communication between CARE's field staff and CDC's scientists. Because productive coordination involved complex interaction at multiple levels within each organization, familiarity with each other's organizational culture and processes was critical.

Mechanisms must be available to pool and then flexibly and quickly assign funds. Woodruff Foundation funding for the project consisted of 2 awards: one to the independent, nonprofit CARE and the other to the independent, nonprofit CDC Foundation. As a government agency, CDC's ability to receive and then flexibly assign funds was limited. But the CDC Foundation, with its congressionally authorized capacities to support staff and activities inside CDC and its agility as a nonprofit organization, provided an ideal mechanism for ensuring that the funding from the Woodruff Foundation could be deployed in an effective and timely manner. Decisions about project expenditures were initially made independently by CARE and CDC. Eventually, the partners decided to treat all grant funds as a virtual pooled budget with resources assigned as needed for each project. Having CDC's funds deposited with the CDC Foundation accorded the flexibility so vital to starting, testing, and then sustaining new joint ventures.

The involvement of in-country personnel is critically important when creating new programming that is appropriate for, and of value to, the participants. In the introduction of his report to the Rockefeller Foundation titled Making Waves: Stories of Participatory Communication for Social Change, Alfonso Gumucio Dagron emphasizes the importance of local involvement and ownership to the success of development projects.3 Over the course of the CCHI, programming evolved from headquartersconceived and -generated ideas offered to countries to country-generated project proposals that competed for funding from the central office. The latter approach led to more relevant, accepted, and successful in-country programming.

A RELATIONSHIP INSTITUTIONALIZED

The original purpose of the Woodruff Foundation grants was to support the institutionalization of a relationship between CARE and CDC. As a result of the grants, staffs of both organizations in Atlanta and in the countries where projects have been implemented have gained appreciation for the respective missions of each organization. Relationships have now been established that proactively take advantage of each agency's strengths to further both organizations' goals. At the onset of the project, one official observed that CARE and CDC staff only occasionally became aware of each other during their work in various countries around the world. Increasing numbers of CARE and CDC staff are now able to approach joint engagements with a unified vision that enables each partner organization to contribute to a cohesive plan. The positive outcomes of the CARE–CDC relationship go beyond the projects administered under the aegis of CCHI: being able to work in concert and draw on each others' strengths enables both CARE and CDC to respond more effectively to health issues in poor communities throughout the world.

CHALLENGES FOR THE FUTURE

Although the impact of partnerships such as CCHI on global health must continue to be monitored, the accounts of CCHI projects in this issue indicate tangible benefits for both CARE and CDC. Both organizations will continue to deploy staff and resources in ways that further deepen and institutionalize the partnership with each other and with local actors in the countries in which CCHI operates.

Partnerships between governmental public health agencies and nonprofit organizations working on health issues have the potential to enable both partners to better achieve their goals. Marrying the cultures of 2 very different organizations can be challenging, but the effort can pay significant dividends. As an initial attempt at developing a public–private partnership in global health, CCHI is a promising example from which future endeavors could learn. One of its strengths is that the CARE–CDC relationship is embedded within a broader set of partnerships with local communities, nongovernmental organizations, and governments. Advancing a common mission within such a web of partnerships and alliances can enable hundreds of thousands of families in poor communities in the developing world to have better, healthier, more secure lives.