DIRECT IMPLEMENTATION BY THE INTERNATIONAL AID ORGANISATION

In this first scenario, an international aid organisation would enter the health district with the intention to implement projects or programmes itself, by means of its own

139 employees. These employees, who could be of foreign or Malawian origin, would deliver the personal or non-personal health services required to reach the objectives of the organisation’s engagement in the district. The internal managerial structure of this organisation is thus oriented at service delivery and employment, most likely on a temporary basis, at least for lower cadres deployed in certain projects. In this competitive situation for HRH, the ‘poaching’ of staff from governmental services is a risk. While it might not be actively pursued, it can just be a consequence of the salary gap.

It is possible that different types of organisations fill this position (IGOs, NGOs and even CBOs), provided that they have an international background and funding base.

The most common type in this position, however, is the international NGO. The organisation principally operates in parallel to the District health office, but the degree of collaboration may increase or decrease over time.

Collaboration or at least co-ordination is based on ‘voluntary’ mutual involvement. This might occur if overlaps of technical expertise and areas of responsibility between the District Health Office and the international aid organisation are recognised by both sides. Longer-term commitments would also foster such arrangements, which usually include the explicit objective of capacity development.

Institutional statements concerning HRH

Having outlined the [ATTRIBUTES] of the actors and the [CONDITIONS] of their interaction, the following sections are ordered by the [AIM] components of institutional statements found in this type of action situation. While each of these statements contains a [DEONTIC], i.e. an obligation, interdiction or permission for the actor, [OR ELSE] components are seldom found (see ‘grammar of institutions’ in chapter 3.3.3).

Statements aimed at scope and choice: The key actions or strategies that the aid organisation can pursue would be to recruit health workers and/or to develop members of their own organisation. If they recruit health workers who hold at least a basic qualification in the health field, they are competing with the District Health Office

140 for this scarce resource. While in-house HRH development might be possible for volunteers as well as other cadres, it is likely that basic or even academic entry qualifications are required, especially for more advanced positions. As a counter-measure in this competitive situation, it is possible to have a Memorandum of Understanding (MoU) at district level, regarding the poaching of government health workers:

NGOs must not poach staff from MoH.

While it is the employees' right to resign from government services first and then apply for other jobs, they cannot change employers directly under such a policy (If23:22-23, 74-76). Another option for an international aid organisation is to establish a ‘no-poaching policy’ as a voluntary and informal measure (Im3:85), to save the capacity of the governmental structures.

Writing a MoU can also serve as a learning point (If23:59). It is an opportunity to exchange about specific needs of the District Health Office on the one hand, and available resources of the international partner on the other hand as starting points of partnership (If22:81-82). Regarding the health services to be provided to the population, both sides should ideally work in a complementary manner, with the aid organisation at least ‘filling gaps’ that the District Health Office cannot cover in terms of geographical or technical areas. HRH should always be considered:

The District Health Office and the international aid organisation must include HRH as a cross-cutting issue of cooperation.

Such integration is required from the planning stage onwards (If21:78-83). HRH-specific fields of cooperation could be staff appraisal, training needs assessment, supervision or monthly joint meetings for all health workers, to discuss protocols and clinical chains. As supervision is the central HRH-relevant function of DHMT members, it lends itself to being an entry point for collaboration (If23:52). In the sense of capacity development, a shift over time needs to be agreed:

The international aid agency may gradually hand over core responsibilities and staff to the District Health Office.

141 As a prerequisite, the District Health Office would have to create new posts and taking staff on contract who have previously been employed by the NGO (If21:51).

Statements aimed at information and aggregation: Information flows constitute a particularly sensitive topic. For the international co-operation at health district level, this means providing mutual insights in the organisations’ activities. Most DHMT members mention the DIP planning and evaluation mechanisms as the appropriate frame for this exchange (Im10:53-56):

District Health Offices and international aid agencies must regularly exchange information on fields of work, targets, available resources, planning time-frames and impacts assessed.

Problems and delays often occur when the District Health Office has completed its internal routine analysis and has to incorporate data from the NGOs working in specific fields (If11:70-74). In fact, many of the DHMT members interviewed are complaining about NGOs which keep information about their work plans and resources for themselves (If11:73, Im10:62, Im19:85-86). This is also referring to the ‘packages’ that these organisations are offering - a term that is generally used for staff remuneration and incentives (If11:75). Some deplore that the NGOs would not even attend the planning meetings (Im10:66). A duplication of activities and waste of resources in the district are named as potential consequences; at least impact would often be limited.

It is stated that the co-operation of NGOs in this regard often slacks after the initial phase of coming to the district. However, repeating the same reporting requests year by year sometimes shows a positive effect (Im19:87-88).

District Health Offices and international aid organisations usually pursue different ways of planning (If23:61). For the District Health Office, ‘co-ordinated planning’ means setting priorities while remaining open for suggestions from their partners. If considered important, these issues should then also be integrated in the District Implementation Plan, and resources and activities would have to be shifted accordingly (If23:62).

142 By contrast, integrated management and planning (If22:84) has the effect that the partner cannot start any activity without communicating it with the District Health Office, which also is a mode of control. With regard to management decisions about the actual allocation of resources, both sides nevertheless remain separate entities (Im12:44):

International aid organisation and the District Health office may each decide autonomously about their use of resources.

The DHO is proclaimed as a steward for the health district, who is supposed to set priorities and guidance on MoH policy to other actors (Im7:153-160). He or she is supposed to coordinate the different actors and their resources but has no actual sanctioning powers (If11:86).

Statements aimed at payoff: The general strategy for an international aid organisation to directly implement their projects has immediate consequences in terms of payoff:

The international aid organisation must take over the managerial costs and salaries for project implementation.

The managerial input in relation to other personnel cost would thus be higher than in case of indirect implementation. The benefit, however, is relative decision-making autonomy from the MoH with its extensive bureaucratic procedures. Furthermore, the intervention is rather confined, and the link with its reportable results appears as more clear-cut.

Integrated planning and implementation of activities between the District Health Office and the international aid organisation is time-consuming and only appears likely under certain conditions. Joint efforts should start as early as possible in the process (If23:52). The benefit for the District Health Office would be optimum complementation of their own activities, in addition to enhancing their own skills.

In case that duplication can be avoided but the aid organisation is still working in isolation, the District Health Office might be relieved from particular tasks related to population health and save some of its resources for a certain period of time. On the

143 other hand, it might lose its competencies in this particular area in the medium run (If11:52).

On behalf of international aid organisations, a phase-out mechanism is usually justified with the ‘empowerment of partners’ and ‘sustainability of services’. However, programmes that are expected to be taken over might retrospectively interfere with the priorities for the district (If11:82). The chances for the programme to be continued are not very high under these circumstances: The District Health Office is likely to be faced with high expectations among the community to continue the service at a comparable level, but may not have the necessary financial or human resources.

The international aid organisation must seek the transfer of skills to the District Health Office at an early project phase, or else the activities will not be continued after its exit.

There are no strong sanctioning mechanisms in place that would back-up co-ordinated planning, especially the exchange of relevant information and the consideration of the overall workforce performance in the district as an outcome. It seems that NGOs are ready to take information and even advice on MoH policies away from the quarterly meetings, but communication appears to be mostly one-way (Im8:135-139). One interview partner states that internationals often only ask for advice when they are facing problems (Im13: 107-112).

However, it is also admitted that DIP review meetings are time-consuming for the NGOs. Usually, local members attend these meetings, who are based within the district (Im8:131). This arrangement does not disturb too much the operational procedures or the self-image on either side.

Conclusion

The cooperation of the District Health Office and non-governmental agencies at this level is characterised by weak or unclear institutional statements. Rules, which according to Ostrom (2005) are backed up by mechanisms for enforcement, are very rare. Also HRH-related outcome variables are largely absent from the action arena at the level of the health district – except for ‘availability’. The availability of qualified personnel, be it with regard to particular posts or from a geographical and population

144 perspective, stands in the foreground of the discourse about HRH in the various action arenas outlined here.

In the governmental sphere, the approach has historically been very much centralised and control-oriented, but there is increasing sensitivity for aspects of staff motivation.

The options that managers have in this respect depend on their own position within their organisation and its internal rules, but they range from staff development trough trainings via physical workplace arrangements to financial incentives. Intense collaboration on HRH with an international partner may deliver ideas, know-how and additional resources in this regard.