42 2.4 SHIFTS IN INTERNATIONAL DEVELOPMENT CO-OPERATION
International development policy in the health sector reflects the shifts that can be observed in development aid in general. Human resource development has always played a more or less overt role in it. Kuehl (2009) describes how the focus moved from vertical programmes and institution building in the 1950s, to general education and health measures in the 1970s. The latter were aimed at a broad human resource base of competent citizens, in an attempt to support more endogenous development.
Within a decade, however, this concept was again superseded by a New Institutionalism, which included ‘good governance’ as a conditionality for development aid. While the self-regulation of markets was increasingly doubted in this context, the importance of institutions for development is emphasised (Post-Washington Consensus in 1999, see Mols et al. 2006, p.366). The term ‘governance’ is related to a stronger involvement of the non-governmental and private sector, including public-private partnerships. These ideas are also reflected in the policies of major donors to Malawi, and they have informed the official decentralisation policy in the country.
They will therefore be further described in chapter 2.4.1.
The concept of Capacity Building / Capacity Development, which emerged in the 1990s, is now meant to combine approaches aimed at the individual with approaches targeting institutions at the organisational and systemic level (Kuehl 2009). Capacity development in the Malawian health sector is also a major objective of the Sector-wide Approach, which has dominated HRH policy at the time of the field research.
Chapter 2.4.2 describes sustainability and capacity development as two predominant concepts in the contemporary international development discourse.
43 for the health sector, global governance arrangements have clearly emerged within the scope of fighting HIV/AIDS, where broad alliances of actors from various sectors and countries, from the global to the local level, have been built to prevent the disease or enable medical treatment. The Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) stands for global governance in this field like no other global alliance (Hein et al. 2007). The containment of major communicable diseases such as HIV/AIDS and Malaria is only one out of three specifically health care-related Millennium Development Goals. However, the aims of reducing childhood mortality and maternal mortality have not managed to mobilise similar support.
At the same time, there has been increasing awareness of a lack of coordination and effectiveness of international aid provision to reach the MDGs. The High Level Forum in Paris 2005 was aimed at finding solutions to this problem. It was attended by a range of national governments, bilateral and multilateral agencies and other agencies.
These also included the GFATM and the Gates Foundation, representing a recently emerging type of financially strong agents in the global aid arena. The resulting ‘Paris Declaration on Aid Effectiveness’ is a commitment to the following principles (High Level Forum 2005):
• OWNERSHIP: Partner countries exercise effective leadership over their development policies, and strategies and co-ordinate development actions
• ALIGNMENT: Donors base their overall support on partner countries’ national development strategies, institutions and procedures
• HARMONISATION: Donors’ actions are more harmonised, transparent and collectively effective
• MANAGING FOR RESULTS: Managing resources and improving decision-making for results
Since the Paris Declaration is not health-sector specific, the OECD Development Co-operation Directorate has taken over the monitoring of the process. However, with WHO usually being a key partner in Global Health Initiatives or Partnerships such as GFATM, the WHO Health and Development Policy unit is looking at this issue in the context of the complex inter-linkages of global poverty reduction and health. One
44 example is the institutionalisation of health systems strengthening – in response to vertical, disease-specific programmes – by setting up a respective WHO department.
Another one is the launch of International Health Partnerships by the WHO in 2007, which gathers governmental and non-governmental agencies under the aid effectiveness agenda (WHO 2007a). In fact, various approaches to donor harmonisation, ownership and alignment have been tried out in the health sector even before the Paris Declaration. Most developing countries nowadays have some form of aid coordination mechanism with regard to health, in which the WHO is indirectly involved (WHO 2006a).
These initiatives indicate that there may be a number of side effects of Global Health Governance on health systems and on HRH in particular. Although the Paris Declaration aims at a stronger involvement (‘ownership’) of the receiving country’s government in regulation and resource management, civil society strengthening is a major goal pursued. Nation states and their governments might therefore be weakened in the traditional role by global governance mechanisms. Stubbs (2003) points to the fact that the emerging global development aid regime of “co-ordinated poverty reduction” (p.335) has largely incorporated the logic of ‘New Public Management’. This concept was mainly promoted by Anglo-Saxon authors starting from the 1980s. Besides the development of professional managerial roles, it also implies a shift from ‘management by hierarchy’ to ‘management by contracts’ (Segall 2000). The practice of contracting is meanwhile widespread in international aid.
Competition has been enforced by the practice of major donors to link grants and credits with technical assistance, and to make sub-contracts on the basis of competitive tendering. According to Stubbs (2003), this has led to rising number of internationally operating consultancy agencies, non-governmental organisations (NGOs) and other non-state actors, mostly in the North but increasingly in southern countries.
Also the international research network ‘System-wide Effects of the Fund’ (SWEF) has observed a fast growth of the NGO sector in many African countries receiving GFATM support. They partly attribute this to opportunities for partnerships and public/private arrangements offered by large funding agencies (USAID and Abt Associates 2005). The
45 implications for the job market in the health sector of developing countries may be substantial: Such organisation can often afford to pay much higher wages than local employers, including the ministry of health. At the same time, as NGO activities are usually externally funded, they follow short project cycles. The results-orientated terms of reference and short-term contracts are generally at the expense of sustainability and do not allow local communities much leeway to decide about the aims and modes of intervention (Pfeiffer 2003).
New types of actors in welfare are therefore emerging between the traditional state actors (governments, bilateral and multilateral agencies) and the purely private level, which is the household. The public-private dichotomy in social service provision appears to be dissolving. Stubbs (2003) explains that these new non-state actors can be civil society organisations, philanthropic foundations, consultancy agencies or private business. With mutual learning and knowledge exchange being an explicit aim of global governance structures in social development, individual experts may also play an important role as knowledge brokers. The boost of international consultancy and overseas operation of such non-state actors has also been made possible by the information technology revolution. Stubbs (2003) describes a “detraditionalization” of labour and a “new non-permanent Western professional labour force” offering
“intellectual services in real and virtual space” (p.326). He raises the question whether and how this phenomenon is now expanding to the workforce in developing and transitional countries. Similarly, he argues for more research on the role of sub-contracting within the aid and development sector: “subsub-contracting regimes need to be judged from a position that, rather than focusing on cost-effectiveness, focuses on ways in which to guarantee the incorporation of lessons learning and the preservation of institutional memories“(p.340). In other words, one major criterion is the ability of aid processes to really build local capacity.
Apart from facing the side effects of the global aid regime in the health sector, global governance mechanisms have also been actively embarked upon to improve the situation of the health workforce worldwide. As stipulated in the World Health Report 2006, nation states are still considered to be in the best position to develop effective strategies to meet the human resource crisis in the health sector. This is due to its
46 linkages with other areas of state responsibility, such as educational or economic policy (WHO 2006b). At the same time, the health sector in developing countries has traditionally been characterised by the large-scale involvement of public, faith-based, non-governmental and also private actors from abroad. The ‘Global Health Workforce Alliance’ (GHWA), simultaneously established in 2006, aims at bringing together the technical knowledge and political influence of this range of actors on a global scale, under the umbrella of the WHO. It has established various internet-based working groups and activities, and it regularly conducts international meetings. The first ‘Global Forum on Human Resources for Health’ was held in Kampala in 2008 and set up an agenda for global action (Global Health Workforce Alliance 2008).