Reflecting on a Decade of Work in Global Development
[Editor’s Note: This year marks Results for Development’s 10th anniversary. To kick off the celebration, I sat down with Gina Lagomarsino, president and CEO, to get her take on R4D’s growth and milestones over the years. In this interview, she also addresses how the organization has changed since it was first established and how it’s adapting to meet the demands of global development’s changing landscape.]
Can you share some insight into why and how R4D was established 10 years ago?
As you know, David de Ferranti founded R4D after a successful career at the World Bank. I first started working with him when we were at Brookings. In 2008, we decided to strike out on our own because we were hearing from people working in global development about the need for a different kind of partner — an organization that would help translate research and evidence into action.
And have you been you successful in doing that — translating evidence into action?
Yes. We’ve had some successes, though we are always trying to find ways to do this better. Within our first several years, we led several major technical and analytic exercises that influenced thinking globally, but that also laid the groundwork for our later work supporting progress in key countries.
One of our early programs was the Aids2031 initiative. The analysis we completed highlighted a path toward more efficient use of funds to fight AIDS in Asia and Africa. We then went on to directly support Cambodia and South Africa to apply these findings in their own contexts. And we are still supporting leaders in the South African National Treasury and Department of Health as they transition from donor assistance and integrate their AIDS funding and programming into the broader health system.
We also led work on the role of the private sector in health systems with in-depth analysis in Cameroon, Republic of Congo, Ghana, Madagascar and Senegal. The analysis showed that the private sector served the poor more than was officially recognized. Ultimately, I think this work helped shift thinking away from ideological public versus private debates to a more practical focus on how governments can engage private actors to achieve public health goals. We are now working with government leaders in many countries to develop health financing institutions that enable them to strategically purchase care from private providers in order to influence quality and increase access for the poor.
In 2008, R4D had about 10 employees and a budget of about $3 million — and, now in 2018, R4D has 130 employees and a budget of $30 million. What led to this growth?
We never really set out to grow or create any kind of growth targets. In fact, I remember actively talking about trying to remain small! But David intentionally recruited people who were entrepreneurial — and they were excited about pursuing new ideas.
That early team experimented with new approaches that combined rigorous analytic technical work with communities of practitioners and practical models for learning what works in different local contexts.
For example, we developed the Center for Health Market Innovations (CHMI), which to this day focuses on identifying innovations around the world, building information about which programs are achieving results, and then sharing that knowledge widely. CHMI also brings together sub-communities of innovators to think about how to improve their models.
One thing that our partners found appealing, was that we frequently co-created with them. CHMI was developed collaboratively with three funders (Rockefeller, Gates and DFID) and a network of local partners in places such as Kenya, the Philippines and India.
We initially applied our approaches mainly in health, but when they were successful, we started to get opportunities to apply them in education and nutrition. For example, we used the CHMI model when we later launched the Center for Education Innovations (CEI).
Also, as opportunities came to us, we were careful to hire highly committed, bright and driven people from a varied set of backgrounds at all levels of the organization. So, we were simultaneously growing our portfolio of work andbuilding a strong team of people to deliver.
Earlier, you mentioned co-creation. What does that mean, and what are some examples of initiatives you co-created with funders and partners?
We’ve always had a culture where we actively listen to partners to understand their issues and needs, and then work closely with them to design and implement practical solutions tailored to the specific context. It’s not that we don’t have our own ideas, but we try to enter situations with an open mind and a spirit of collective idea development.
In the early days, this co-creation was often done in partnership with key funders looking to launch global initiatives, where we served as a thought partner and a co-convener. For example, we co-led an early Universal Health Coverage (UHC) Task Force with the Rockefeller Foundation that brought together leaders from global institutions and prominent countries to bring more attention and greater commitment to UHC. Now, UHC is one of the Sustainable Development Goals.
Our early UHC efforts also spawned another co-created initiative — the Joint Learning Network for Universal Health Coverage (JLN), which continues to support reformers in 30 countries across the world to address the practical challenges of achieving UHC. The network was co-created and continues to be shepherded with leaders from a number of very committed countries and several local and international partners, including the World Bank, the Rockefeller Foundation and the Bill & Melinda Gates Foundation.
We’ve had the opportunity to play a convener role in additional partnerships, such as the Primary Health Care Performance Initiative (PHCPI) and the International Development Innovation Alliance (IDIA). In addition to technical skills, we’ve also developed facilitation and management skills that are helpful in the convening role.
We refer to “change agents” a lot here at R4D. Can you explain what we mean to our blog readers?
Change agents are the government policymakers, civil society leaders and social innovators who are driving systemic change in their countries — and they are at the heart of our mission.
For example, in Nigeria, we’re currently supporting leaders in a number of federal and state agencies with the design and implementation of the Basic Health Care Provision Fund. And for the past two years, we’ve been working with the Ethiopian ministry of health in strengthening their ability to track and better allocate financing flows for nutrition and to increase access to treatment for childhood pneumonia.
Even in our earliest days, we were working directly with leaders in countries. For example, the Transparency and Accountability Program worked closely with in-country civil society change agents to strengthen their capacity to conduct analysis and advocacy and empower citizens.
But those are just a few examples. As we have grown, we have built relationships and presence directly in about 25 countries, and we touch more than 50 countries through our networks. We now have a growing contingent of individuals or small teams based in six countries in Africa: Ethiopia, Ghana, Guinea, Mali, Nigeria and Tanzania.
While we expect to grow our presence in Africa and Asia, we’re also experimenting with new models for country engagement. We don’t plan to build large offices in countries. The models we are developing are designed to leverage and build local expertise and local organizations.
We also talk about “systems change” a lot. How do you define this and R4D’s role in systems change — despite our relatively small size?
We think of a system as the people, inputs, institutions, policies and processes and how they interact to deliver key results, such as moms and babies who are well-nourished, children who are learning and thriving, and high-quality, affordable health care for all. We believe that strong, well-functioning systems deliver many benefits across a population, especially the most vulnerable.
When we talk about systems change at R4D, we’re not talking about changing everything about a system at once. Instead, we look for entry points that can fundamentally change the way a whole system operates in a sustainable way. For example, helping change agents figure out how to mobilize funds and ensure they are used efficiently is one way we help to strengthen systems and make them self-sustaining. So is helping them introduce innovations into systems and supporting them to create better structures to engage community stakeholders.
We have several different cross-cutting practices that specialize in aspects of systems change, including sustainable financing, the adaptation and scaling of innovations, which are mentioned above — but also data for decision-making, citizen engagement and governance, market shaping, and the role of the private sector. We look for opportunities to apply this expertise to assist change agents in health, education and nutrition.
How do you engage with change agents in a way that’s meaningful, contextually-relevant and adds value?
As I mentioned earlier, R4D is brimming with people who are entrepreneurial. They’re always looking for ways to be more effective and do their work better. So many of the ways we engage with change agents have come about organically.
For example, our adaptive learning and evaluation practice formed when some of our mid-level staff were dissatisfied by the notion that that too little monitoring and evaluation work actually improved programs. They were interested in how to use the principles of evaluation and design thinking to improve program performance in real time. They invested their own time to meet and develop new ideas. This team later participated in a USAID BAA workshop (the agency’s innovative model for co-creating programs) and came away as leaders for the Rapid Feedback MERL (Monitoring, Evaluation, Research and Learning) program.
Now, the approaches they developed are increasingly being used across the organization. For example, we are currently working with partners in Tanzania to generate evidence about effective approaches to increase community engagement in education, and with private school operators contracted by the government of Liberia to design and test approaches for improving teacher capacity.
Similarly, we initially experimented with the concept of collaborative learning when we helped establish the Joint Learning Network for Universal Health Coverage (JLN). The JLN has evolved over the years, and, in the process, we and our partners have learned a lot about how to make collaborative learning networks succeed by facilitating the development of practical knowledge and tools that address commonly experienced problems, and supporting network members to apply those tools in their own situations. We are now applying those lessons in other networks, such as a learning network for Gavi transition countries (LNCT). We’ve also been laying the groundwork to create a practical learning network that will support countries with the planning and implementation of education systems reforms.
Looking forward, how do you see R4D evolving to meet the demands of a changing global development landscape?
We are certainly an organization that is evolving and changing, even as we work to deliver on ongoing initiatives. Many of my colleagues are now keenly focused on developing better models for supporting leaders in countries.
We are grappling with a key question: What is the right role for an international NGO when we all fundamentally believe that reforms must be driven locally, and that technical and implementation capacity needs to be strengthened in partner countries?
The change agents we work with tell us that they want a source of practical ideas, experience and evidence from other countries. They want to more efficiently solve challenges that others have faced before. And they want all of this support to be available at the moment they need it, in formats that are helpful. Sometimes this is a written toolkit. Sometimes this is a person with relevant experience. They also want to make sure their experiences and lessons learned are reflected in the growing global knowledge base.
We are thinking a lot about how to structure our future selves to respond to these needs. We increasingly envision networks of local individuals and institutions whose role is to support government leaders and other change agents with their reforms. This will require an infrastructure for structured learning and sharing of lessons across countries and between the country-level and global-level. We’ve been considering the inherently political nature of systems-change, and thinking about how to support countries to better engage all the stakeholders, including private sector and civil society, that need to be aligned for change to happen.
We’re focusing on building partnerships with local NGOs, think tanks, civil society organizations, and talented individuals in the countries where we work. We are also working to incubate several initiatives within African institutions. For example, our recently launched African Collaborative for Health Financing Solutions (ACS) and the Strategic Purchasing Africa Resource Center (SPARC) are focused on how to create and support local capacity in Africa to implement ambitious universal health coverage reforms.
As we celebrate our 10th anniversary this year, we are hoping to engage many others across the field of global development in a dialogue about models that best support local leadership.