Effective localization: case study of a faith-based health partnership in Sierra Leone and Zimbabwe

Faith-based organizations (FBOs) and faith-based service providers play a critical role in public health prevention, promotion, treatment, and community development. Effective capacity strengthening efforts through FBO partnerships can make a vital contribution toward effective localization. This case study details the efforts and results of a writing and publishing workshop provided in partnership with Corus International (IMA World Health) and the Africa Christian Health Associations Platform (ACHAP) in March of 2023. This case study also reports on workshop participantsʼ perceptions of the partnershipʼs approach to capacity strengthening. Three major and related themes emerged from the workshopʼs informal Focus Group Discussion transcription: 1) a safe and nurturing environment, 2) openness and shared decision-making, and 3) organizational humility.


Introduction
The understanding of local capacity strengthening has evolved significantly as the development sector increasingly prioritizes localization for sustainable development.Numerous capacity strengthening definitions exist, 1 with the majority describing some deliberate action taken to improve the ability of an individual, organization, or system to develop new knowledge, skills, and attitudes to achieve their mission, adapt to change, and function effectively. 2,3Health research capacity Cherian, Manuel, Waugh, Njeru, Mukandie, Chikari, Hooke, Crookston, West & Hall FEBRUARY 2024 -VOL 11 ISSUE 1 strengthening (HRCS) efforts in particular, ranging from informal and formal training programs to increasingly complex health systems approaches designed to increase the capacity of research institutions, are currently a major aim of international development actors and organizations. 1 The late Dr. Paul Farmer used the term accompaniment -a reciprocal partnership style characterized by intentional, collaborative, and respectful engagement -in defining the necessity of supporting mutual effectiveness, learning, and resilience throughout the capacity strengthening process.Farmer and others promoted this approach to bolster local and national capacity through the creation of long-term partnerships. 4Such partnerships can include ongoing mentoring and coaching, usually related to program-specific activities or interventions.The intention of the accompaniment is to strengthen individual and organizational capacities with a desire to increase self-reliance in preparation for future opportunities and challenges.
Capacity strengthening efforts can make a vital contribution towards effective localization through adapting programs to a communityʼs language, culture, context, and history to effectively meet their needs.The United States Agency for International Development (USAID) defines localization as the set of internal reforms, actions, and behavior changes undertaken to ensure public health efforts place local actors in the lead while being responsive to local communities and strengthening local systems. 5Successful localization allows community members to feel increased confidence and ownership in implemented programs. 6Localization begins with tailoring programs to community needs and ensuring local organizations are the primary program actors. 6,7Localization is more fully realized, however, with the transfer of ownership and management of programs into the hands of local organizations which are not only the most costeffective but are best positioned to understand and engage the community effectively.Effective localization allows programs to maintain momentum and continue sustainably benefiting communities. 7aith-based organizations (FBOs) and faith-based service providers play a critical role in development generally and in health promotion and healthcare specifically. 8There have been many contradictory estimates made related to the percentage of health care services delivered by FBOs and the number of faith-based service providers operating in Sub-Saharan Africa, 9 making it difficult to report an accurate percentage or number.What is increasingly agreed upon is that FBOs work to fill a significant gap in the provision of services and frequently remain under-recognized for their contributions. 8,10In many Sub-Saharan African countries, national networks of faithbased healthcare providers have been organized to help connect and resource these entities.The Africa Christian Health Associations Platform (ACHAP) is an umbrella organization of Christian Health Associations (CHAs) and other national-level faith-based networks in Sub-Saharan Africa.ACHAP is a coordinating, advocacy, and networking body for 43 member CHAs and faith-based associations in 32 countries.Collectively, ACHAP members support more than 8,000 faith-based, health facilities, including hospitals, clinics, pharmacies, training institutions, health outposts, and community health programs in their networks. 11MA World Health (IMA) is a founding partner of ACHAP, and the two organizations have worked closely since 2007 to strengthen the technical and organizational capacity of faith-based health networks in Africa.IMA was founded as Interchurch Medical Assistance in 1960 as an ecumenical enterprise to support church-related, health missions around the world.IMA has long recognized the inherent value of working with established or emerging Christian health networks, leveraging their existing strengths and contributing to their growth and capacity to do even more, even better, not only for immediate results but in the interest of sustainable solutions that these church-based national networks were best Cherian, Manuel, Waugh, Njeru, Mukandie, Chikari, Hooke, Crookston, West & Hall FEBRUARY 2024 -VOL 11 ISSUE 1 positioned to deliver.Over the decades, IMAʼs path would often be directed alongside the paths of these emerging Christian health networks, to the benefit of both.Today IMA continues to promote the visibility and influence of ACHAP and member CHAs as vital actors in achieving national and global health targets.
Corus International (Corus) was formed in 2019 through the merger of IMA, Lutheran World Relief, Ground Up Investing, and CGA Technologies, each with a long history of working with partners in their respective sectors to address development challenges.Specifically, Corus International organizations aim to grow productive and stable economies, develop scalable and sustainable technology systems, improve resilience in the face of climate change, and respond to natural disasters and humanitarian crises.Reflecting on the principles and practices of its legacy organizations, Corus believes that the traditional capacity-building framework has too often promoted Western models and failed to appreciate the ideas, skills, and resources of the Global South.To emphasize the value placed on mutual learning, co-creation, and leadership of underrepresented colleagues, Corus intentionally refers to its capacity strengthening approach as accompaniment.The accompaniment framework embraced by Corus has roots in IMAʼs long history of local partner engagement and development and is central to its capacity strengthening efforts.This approach aligns with renewed USAID guidelines for strengthening local capacity, particularly its updated Capacity 2.0 framework for understanding how USAID and its partners can most effectively strengthen organizations. 12his framework divides capacity into four interrelated and interdependent areas -the ability to Commit, Relate, Organize, and Deliver -and acknowledges that diverse capacities need to be strengthened using a range of approaches for optimal performance.Commit refers to a set of capabilities driving the success of an organization, network, or sectoral system.It specifically reflects USAID's Capacity 2.0 abilities and plays a determining factor in a partner's long-term viability and sustainability.Relate reflects an understanding of the importance of social capital and a partner's ability to form connections and collaborate with peers, communities, networks, and society at large in jointly achieving greater results.Organize refers to organizational development capabilities that focus on the processes and structures needed to organize work and implement projects, including the optimal allocation of resources and ensuring compliance with donor requirements.Deliver relates specifically to technical knowledge and skills a partner needs to carry out its work and that are critical for achieving results.
Through its accompaniment approach, Corus strives to leverage and elevate the existing capacity of local partners to drive innovation, achieve transformational change, and advance mutual learning -including the documentation and sharing of both successes and failures with the development community.In keeping with this aspiration, Corus has, among other things, strategically invested in local partners' ability to document and publish the results of their efforts.This case study details one such effort, a writing and publishing workshop held in early 2023 for IMA and ACHAP partners.Prior to the workshop, core members from all represented organizations analyzed baseline data from the project and drafted an overarching manuscript that described the study and basic findings.The four-day CoV-FaB Writing and Publishing Workshop was designed to further explore findings from the project's baseline data, discuss the project's impact on capacity strengthening generally, and increase participants' self-efficacy for preparing manuscripts for peer review and publication specifically.Instruction on research methods and manuscript development was delivered in person by the BYU team, with video presentations prepared as instructional "boosters" for review at later dates.Participants were organized into writing groups based on their role in the CoV-FaB project and personal interest in manuscript topics.Each writing group included individuals from IMA, ACHAP, ZACH or CHASL, and BYU.In addition, each writing group had a leader designated to oversee group progress and serve as the lead author of that group's manuscript.Two writing groups focused on epidemiology-based manuscripts using CoV-FaB baseline data, while a third group focused on understanding the strengths and weaknesses of Corus International's accompaniment approach.This effort included an informal Focus Group Discussion (FGD) led by the BYU team on the third day of the workshop, which began with participants responding to the following prompt: "How is the CoV-FaB project strengthening capacity among its partners?"Responses were transcribed and analyzed for major themes.

Methods
Writing groups met together over the course of the workshop to explore potential research questions, review available data, select and perform appropriate data analyses, outline writing responsibilities, and commit to writing deadlines.The progress of each writing team was analyzed six weeks after the conclusion of the workshop.This workshop component was objectively measured by the progress of each group's manuscript, together with an informal subjective assessment of the group's productivity and cohesion as reported by each writing group's leader.

Results
The CoV-FaB Writing and Publishing Workshop has resulted in the development of four manuscripts.The first focused on exploring SARS-CoV-2 vaccine acceptance in Sierra Leone and Zimbabwe and was drafted by key IMA, ACHAP, and BYU team members just prior to the workshop to serve as a template for the other manuscripts.The second manuscript explored the association between various chronic health conditions and SARS-CoV-2 risk perceptions in Sierra Leone and Zimbabwe.The third manuscript was a theory-based exploration of the factors associated with vaccine hesitancy and vaccine uptake.Finally, this case study is the fourth manuscript and details the capacity strengthening approach taken by CoV-FaB partners, as discussed by workshop attendees.The status of each manuscript six weeks following the event is an objective measure of the workshop's effectiveness.Assessment of group productivity and cohesion also provides an important gauge of the workshop's success.Writing group leaders noted several key challenges to the group writing process.First, writing team assignments and pursuit of manuscript completion represented work not prioritized or required by the donor, requiring additional work for group members who already had full-time responsibilities with either IMA, ACHAP, CHASL, ZACH, or Internews.Second, and related to the first challenge, was personal accountability among already busy group members volunteering to go above and beyond their normal, professional responsibilities.Third, scheduling weekly writing group meetings for groups spanning large time differences was challenging.This challenge was exacerbated on occasion by unreliable, internet connections and subsequent low-quality, conference call communication.Fourth, most participants had little to no experience developing manuscripts for peer review and navigating the peer review process.Such a lack of experience often leads to apprehension and a lack of confidence in writing ability.
Three major and related themes emerged from the informal FGD transcription: 1) a safe and nurturing environment, 2) openness and shared decision-making, and 3) organizational humility.Select comments supporting each theme are displayed in Table 1.

Major Themes
Supporting FGD Comments

Safe and Nurturing Environment
"The CHAs didn't have to impress IMA or ACHAP and act like they could do everything.They felt comfortable simply asking for help to progress toward greater self-reliance." "IMA focuses on the process and values the opportunity to connect -it's not only resultsdriven.The process is important, and the relationship is prioritized." "There is a shared vision that is not just funding driven." "IMA and ACHAP approach partners with humility.This is not just a CoV-FaB program approach; it is in their DNA." "IMA considers its partners to be family and sees them as equals on projects."

Discussion
This case study has two objectives.The first is detailing, reporting, and publishing the work that IMA and its partners are accomplishing.While technical reports are a staple among NGOs, peer reviewed reporting of programmatic progress and outcomes remains somewhat rare.The second is exploring the capacity strengthening efforts and interaction between IMA and its partners.While details of "what" programs have done or accomplished are essential, a nuanced examination and documentation of "how" programs do "what" they do can also be of great value.
Empowering and enabling public health practitioners and organizational partners in low-income and middle-income countries (LMIC) to engage in scholarly writing is often challenging.The obstacles reported generally in Sub-Saharan Africa include a lack of mentorship and institutional support, insufficient time for research activities, insufficient budget for research activities, and poor research infrastructure. 13Even when educational and training opportunities for scholarly writing have been offered, the optional task of writing for peer review is typically squeezed out by contractual and programmatic tasks which must be completed.Indeed, individuals and organizations are rarely required, compensated, or otherwise incentivized to pursue peer reviewed publications.Most writing courses detailed in the literature focus exclusively on training participants in preparing research protocols. 14The CoV-FaB Writing and Publishing Workshop is unique because it paired partners from multiple organizations, each bringing different experiences and skills to design, analyze, write, and publish scholarly work.Institutional support, specifically from IMA/Corus International and ACHAP, was key to the workshop's productivity.The time needed for continued collaboration and productivity among writing teams following the workshop did present an ongoing challenge.In some cases, writing assignments represented significant added workload to individuals already burdened with large and pressing work commitments, and while efforts were made to share writing responsibilities equitably amongst team members, some individuals did more than others.Ensuring that participants have the full support of managers who will help arrange participantsʼ priorities to allow sufficient time for their involvement is key.Similarly, incentivizing participation and providing compensation for the completion of activities would be beneficial.
While the CoV-FaB Writing and Publishing Workshop was a discrete exercise focused on developing specific skills, it demonstrated the capacity strengthening approach reflective of the long-standing relationship of the parties.Participants universally compared the relationship between IMA, ACHAP, and individual CHAs as a "family" collaboration fostering a safe and nurturing environment.It was noted that IMA has "built respect and mutual trust between organizations."In describing their partnership with IMA/Corus International, ACHAP leadership repeatedly detailed a long-standing relationship not influenced by, or reliant upon, funded projects.ACHAP greatly appreciates this unique feature of the partnership and noted that collaboration with most international partners is entirely dependent on available funding.In addition, ACHAP feels a strong sense of connection to IMA, in part due to the mutual faith-based identity, shared mission, and similar values.IMA appears to have been successful in establishing unity among its "household of faith" partners involved in the CoV-FaB project and sees this relational model as a non-negotiable pathway for all partnerships; an approach essential to addressing global challenges in health and development.ACHAP has, likewise, created an accepting environment where, as one workshop participant explained, "CHAs need not create or maintain a façade that they 'have everything under control and all is well' when it is not!" ACHAP partners know they will receive mentoring, which works to prevent "capacity gaps" among individual CHAs, increasing a spirit of belonging, collaboration, and equity.
Participants described the relationship between partners as void of hierarchy, where a pattern of openness and shared decision-making is the norm.IMA staff have fostered cordial and flexible relations aimed at connecting partners horizontally, described by one participant simply as "not the typical top-down approach."This has helped to create ownership locally and increased engagement and investment among partnership personnel.Openness and shared decision-making are key to IMA's commitment to localization and capacity strengthening principles.With the long view in mind, IMA's accompaniment approach acknowledges that local partners are the permanent stakeholders, rooted in their communities, and best positioned to address their needs in the most cost-effective and culturally appropriate ways.Similarly, ACHAP's open and cooperative approach sets the tone for member CHAs to be equally collaborative.CHAs are not territorial with one another and prefer to reveal, rather than conceal, best practices and successful approaches to their unique challenges.ACHAP has facilitated this collaborative environment among the various CHAs and facilitates the sharing of lessons learned and expertise from one CHA to another.ACHAP fosters this collaboration and exchange regularly in hosting the ACHAP Biennial Conference, rotated among the four regions of its membership; facilitation of technical working groups; and via the regional representation on its governing board.An Executive Directors Retreat for Christian Health Associations, jointly sponsored with IMA in December 2019, used a case study model to engage CHA leaders in sharing their expertise with one another and resulted in a commitment to develop more opportunities for strategic leveraging of knowledge and skills across the network, which the CoV-FaB project was also designed to do.
Participants identified humility as a fundamental characteristic of each partner organization.IMA appears to set the tone in Cherian, Manuel, Waugh, Njeru, Mukandie, Chikari, Hooke, Crookston, West & Hall FEBRUARY 2024 -VOL 11 ISSUE 1 this regard with its foundational belief that local organizations are best situated to address challenges when afforded autonomy and provided opportunities for capacity strengthening.It is not simply IMA's commitment to accompaniment that partners appreciate, but rather how this approach is executed.It is a modest tactic rooted in organizational humility and a deep understanding of sustainable development which may safely be described as "being the guide on the side" rather than the "sage on the stage." 15Mutuality of contribution and benefit is one of IMA's primary goals when working with partners and a key to strengthening capacity and ensuring sustainability.IMA's commitment to approaching partners with humility and executing programs with modesty has created an environment among partners where all programmatic successes feel mutual.Indeed, IMA and ACHAP both recognize that all partners offer mutually beneficial resources, expertise, connections, and contributions necessary for achievement.As current development trends aim towards more localization of projects, ACHAP leadership has proposed that the international partner continues to have an important role to play, with complementary strengths to offer the local partner.In this context, the accompaniment approach to capacity strengthening, based in trusting relationships, takes the long view and avoids the perception of instrumentalization that may dominate shorter-term, immediate-projectonly relationships; fosters a climate conducive to adaptive management, mutual learning, and innovation; and supports shared goals of effectiveness, efficiency, and sustainability of development achievements.
In summary, the CoV-FaB Writing and Publishing Workshop resulted in several specific lessons learned.First, bringing international and local partners together can be an incredibly meaningful and productive exercise.The faceto-face interactions, including both the formal professional technical working group meetings, presentations, and FGD, together with the informal discussions during health breaks, evening meals, and group excursions helped to establish trust, foster solidarity, and increase commitment to a shared mission.Although not a formal objective of the workshop, the time participants spent working with, listening to, and speaking together has proven to be vital in the months since, during which countless calls and emails have been exchanged and drafts of manuscripts have been created.The relationships among writing team members have progressed from colleagues and partners to life-long friends.Second, a commitment to localization and capacity strengthening using an accompaniment approach consistent with the USAID framework appears to foster partnerships characterized by safe and nurturing environments, open and shared decision making, and organizational humility.An alternative interpretation is that partnerships characterized by safe and nurturing environments, open and shared decision making, and organizational humility are well suited for the adoption and application of capacity building efforts consistent with best practices recommended by USAID.Either way, these three themes detailing "how" international and local partners work together is key.
Recommendations for FBOs and non-FBO international organizations include adopting and refining the accompaniment approach for capacity strengthening and prioritizing the telling of programmatic successes and failures.USAID has renewed its commitment to localization in pursuit of locally led action which is inclusive and places local partners front and center.There is little doubt that such an emphasis is necessary in finding sustainable solutions and driving lasting change.It is recommended that international partners ask the right questions of local partners and then listen with humility.Rather than assuming what is needed, international partners ought to work with local partners in identifying existing strengths and remaining needs in directing capacity strengthening efforts.Essential to this process is the establishment of, and investment in, long-term working relationships capable of outlasting funding cycles and project end dates.Finally, it is recommended that some amount of international and local project capacity and resources be earmarked for the peer reviewed publication of program findings.A great many local partners are capable of publication when the process is prioritized and time or other resources are afforded for this effort.Other local partners may require some level of assistance in accessing extant literature or mentoring in data analysis and manuscript preparation, but whatever the level of effort needed in this area of capacity strengthening, the inputs are worthy of the outputs.Enabling local partners to tell their own stories of success or failure and their own lessons learned should be at the heart of localization efforts.

Conclusion
This case study details an IMA/Corus International-sponsored workshop aiming to increase the writing and publishing capacity of its international partners.Also detailed herein are the findings of an informal FGD held at the workshop illuminating "how" IMA/Corus International and its do "what" they do.Findings largely indicate that the accompaniment approach adopted by IMA/Corus International positively influences partnerships and programs.In addition, the partnership model is consistent with the current and widely accepted public health principles of localization and capacity strengthening.
Early in the COVID-19 pandemic (March-June 2020), Corus partnered with ACHAP on COVID emergency response measures identified as most strategic and achievable by ACHAP and implemented initially by countrylevel CHAs in Kenya, Uganda, Rwanda, DRC, Cameroon, Ghana, and Nigeria, and at a later stage in Malawi, Zimbabwe, Chad, Nigeria, and Burkina Faso.Activities included local procurement of personal protective equipment (PPE) and medical supplies; health worker training; surveillance and referrals; water, sanitation, and hygiene (WASH) infrastructure for health facilities; and sensitization campaigns.In April 2022, Corus partnered with ACHAP and Internews, an international media support nonprofit organization dedicated to tackling misinformation and providing trustworthy news to individuals and communities, to launch the Cherian, Manuel, Waugh, Njeru, Mukandie, Chikari, Hooke, Crookston, West & Hall FEBRUARY 2024 -VOL 11 ISSUE 1 Promoting COVID-19 Vaccine Equity through Faith-Based Networks in Africa (CoV-FaB) project.CoV-FaB sought to increase vaccine uptake through CHA engagement in support of Ministry of Health vaccination priorities.In addition to the immediate objective of "shots in arms,ʼʼ CoV-FaB also focused on health emergency preparedness, identifying gaps, and strengthening the capacity of ACHAP and member CHAs to respond effectively in the event of a future pandemic or other health emergencies.The primary goal of CoV-FaB is to reduce the loss of life and spread of COVID-19 in Sub-Saharan Africa, contributing to global health security through the targeted capacity strengthening of Christian Health Association networks.Project objectives include: 1) empowering CHAs to work through their member institutions in delivering or promoting COVID-19 vaccines in their respective countries; 2) encouraging faith-based health providers and community and religious leaders to engage in the promotion of trusted and evidence-based communication (and countering misinformation) around COVID-19 vaccines; and, 3) ensuring that CHAs are recognized and resourced as critical partners with their national ministries of health in addressing global health security.Pursuant to objectives one and two, a baseline assessment seeking to understand and explore vaccine hesitancy and strategies to increase vaccine confidence and uptake was conducted in July and August 2022 in Sierra Leone and Zimbabwe.The baseline survey was created in collaboration with IMA and ACHAP.ACHAP worked with and supported the CHAs in administering the assessment through training and deploying local teams for data collection, organizing and analyzing the resulting data, and writing a baseline report.Pursuant to objective three, a writing and publishing workshop was held in Kenya in March 2023 for select individuals from the CoV-FaB partnership.This workshop was first conceptualized in July 2022 at ACHAPʼs 10 th Biennial Conference in Kigali, Rwanda.From the conference theme, Christian Health Associations in Pandemics: The Case of COVID-19, and subsequent proceedings came a "call to action" to further empower ACHAP and member CHAs to "tell their stories of impact" during the pandemic.ACHAP personnel from offices in Kenya and Uganda came together to host the workshop.Other participants came from Corus/IMA headquarters in Washington DC, the Christian Health Association of Sierra Leone (CHASL), the Zimbabwe Association of Church-Related Hospitals (ZACH), and Internews (with a participant from Chennai, India).Finally, a team of professors from Brigham Young University (BYU) in Utah, USA, worked closely with ACHAP counterparts to plan and facilitate the workshop.

Table 1 continued
Cherian, Manuel, Waugh, Njeru, Mukandie, Chikari, Hooke, Crookston, West & Hall "IMA asks, 'What are your needs?' and 'What are you best positioned to do?' As an organization, it is not heavy-handed with expectations.IMA says, 'Give us an outline, and we will help you!'" "IMA has developed great institutional humility and created a 'family' atmosphere.ACHAP has access to IMA headquarter leadership, and HQ leadership takes time with ACHAP personnel and shows genuine interest.""When relationships are approached with humility, reciprocal learning occurs because 'they' have some skills and information and 'we' have some skills and insights that can all be brought together."FEBRUARY 2024 -VOL 11 ISSUE 1