IMPLEMENTATION THROUGH OTHER ORGANISATIONS/FREELANCERS

149 not mentioned in the interviews. They take risks as to how much effort they should invest to eventually ‘win the price’. Previous experience in managing international projects helps to be successful in proposal writing, since it invokes trust on behalf of the donors (If11:50).

Conclusion

The kind of contractual collaboration described here is prone to principal-agent-problems, meaning that agents at a lower hierarchy level are only passing on selected information to their principals. Information asymmetries even exist if both parties work in the same location. They increase if the reporting chain gets longer, involving national or even international headquarters. Given that the principals in this action situation would often be large multilateral agencies, this is likely to hamper adequate and timely decision-making on both sides. Even if consultants are working very close to the level of service provision and have extensive insights in the progress of the activities in question, they are at best catalysts for relevant decisions.

Shortfalls in the capacity of the MoH system may also be deliberately displayed in order to attract support. The DHMT just has to be flexible - up to the extent of adjusting its own plans to those of the aid organisation - to secure the aid flow.

(If17:38-39). However, programmes which are aimed at the local level and offer funding upon the initiative of the District Health Office might also foster creativity and trigger local initiative.

150 From the perspective of the District Health Office as a coordinating body, this action situation is most limited. With regard to the local partners of the international aid organisation, the relationship is very similar to action situation number one, and they normally should be included in the DIP procedures. The organisational structure of this partner might be weak or at least scattered, especially in the case of volunteer organisations, or temporary, in the case of consultancy and research teams.

Collaboration with the District Health Office is thus officially required, but would rather occur in the form of loose coordination than in the form of a contract. There might be demonstration of goodwill, however, to avoid open conflict and maintain an image of being open and collaborative. The attention of the international aid organisation would mainly be on its interaction with the local partner organisation.

Institutional statements concerning HRH

Given the actors’ [ATTRIBUTES] the [CONDITIONS] outlined above, the following kinds of statements might occur.

Statements aimed at scope and choice: Consultancies would normally be announced by an advertisement in the newspaper. These could include task such as surveys, water sample collection, or training impact assessment. The contractor would then be paid for organising staff and supervisors on the ground, while data analysis is usually done centrally (Im13:27-32, 73-78).

The international aid organisation may tender and contract out tasks to third parties, unless these tasks correspond to core functions of the District Health Office.

While such operations are often carried out from a distance, it is also possible to seek close cooperation with the District Health Office - at least in geographical terms. After all, this might offer advantages regarding the use of infrastructure and closeness to clinical and community-based activities, as in the case of the M&E officer working for the COM (If20:14). For the field of Environmental Health, one interviewee is telling about a failed proposal which aimed to establish a university study centre in a rural district (Im13:84-92).

151 HRH is unlikely to play a central role in the interaction between the District Health Office and these international aid organisations, even if there is an exchange of information about the resources being put into certain activities. This may be partly due to the greater role of volunteers or students/research assistants in such activities, who are not normally perceived as HRH.

The local partner would have to dispose of (or recruit) the necessary human resources to implement the envisaged activities. Some organisations might pursue the objective of enlarging the human resource base by training lay people and volunteers for their specific purposes, such as counselling or data collection (If4:41-43). If these human resources overlap with the cadres or professional groups employed by the MoH, there is a competitive situation for HRH. However, the international aid organisation is not directly affected in the sense of facing the short supply of HRH when trying to recruit qualified project staff. The contracting of local consultants makes an exception here:

The third party must assure that that its activities are not detrimental to the availability of core health staff to the District Health Office.

International aid organisations increasingly contract out smaller tasks within their larger programmes to Malawian health experts, different forms, e.g. carrying out studies and assessments, either as the consultant in charge or as member of a team from multiple organisations (Im5:36-43). For specialists in certain technical areas a short list is necessary. For such ‘competitive’ positions, they have to work with whoever is available at the required point in time. By contrast, 'non-competitive' short-term positions are advertised in the newspaper (Im5:44-53).

Statements aimed at information and aggregation: The decision of an international aid organisation to operate through non-governmental structures may have to do with their primary focus of work (e.g. research, counselling, advocacy), for which the DHO would not be the most suitable partner. They may also perceive the transaction cost of operating through the District Health Office as being too high, if administrative procedures tend to be obstructed. This may lead to the decision to ‘bypass’

governmental structures as far as possible.

152 Information exchange between the District Health Office and the international aid organisation in this action situation does not underlie any contract and has no respective sanctioning mechanisms. The international aid organisation and its sub-contractor in this situation might even perceive respective requests from the District Health Office as an illegitimate intrusion into their own affairs. However, information exchange appears as a centre piece in this action situation, given the rather lose linkages between the participants:

District Health Offices may actively seek information exchange with the intermediary international aid organisation or the third party, e.g. visisting each other’s planning meetings, accessing research findings.

Arrangements for the co-ordination of activities are possible, but would require mutual goodwill and investment of effort. Personal contacts need to be established and nurtured (If23:68-69). These tasks can also be delegated to the district coordinators who are in charge of the respective impact areas that the organisations are working in, e.g. home-based care, PMTCT, breast feeding, malaria or TB. The regular interaction after the initial phase is thus with programme managers (Im23:71, Im19:80-85). They would then compile reports which are shown to the DHO and then passed on to the MoH headquarters.

As for authority in decision-making, the situation of the District Health Office here is similar to the first action situation above. The ‘visitor’s status’ indicates that it can exercise even less influence on the international aid organisation or its partners, at least in terms of staff allocations. It can only try to adapt its own staff deployment to the activities of the other organisations. The office may instruct the other organisations on relevant MoH policies, which mostly refer to technical or clinical standards though (Im8:136-137).

However, CBOs may wish to make use of the extension workers that different sectoral ministries have in the communities, even if they have their own network of volunteers in the community:

Community-Based Organisations acting as third parties may seek to coordinate their community-based activities with the District Health Office.

153 The District Health Office could designate focal persons upon request, who would then participate in meetings and trainings, and they also follow up the project through the usual supervision mechanisms of the MoH (Im18:19).

Statements aimed at payoff: Voluntary co-operation may bring an image gain for the international aid organisation. The importance to align with government policies is being highlighted, which indicates the appreciation of such conduct by the membership of the organisation (Im18:11, 16-17).

The benefits for the District Health Office from maintaining close contact with such CBOs mostly lies in receiving additional information about what is happing in the communities. They may use this information to adapt their own activities and avoid duplication. At the same time they can demonstrate to the relevant authorities that something is being done, and that they are fulfilling their role as a link between the MoH and other stakeholders in the district. It may also be helpful for the fulfilment of DIP requirements, which include the comparison of HMIS data with other data – thus also research data would be of relevance (Im10:61-66).

For the District Health Office, leaving certain fields of work to other organisations does not necessarily have to mean that those are ‘filling the gaps’ which should normally be covered by public services. Emphasizing the complementarity of other organisations’

activities (while at the same time confining it as not being the major responsibility of the District Health Office) may bring moral relief.

On behalf of the CBOs, although volunteers would not receive salaries by definition, their longer-term engagement is usually remunerated in some form:

Community-based organisations must ensure that volunteers are adequately trained and motivated. This may include financial or in-kind incentives up to an agreed level.

Offering training to the volunteers can be seen as a sign of appreciation and an attempt to assure sustainability. It is recognised that volunteers usually stay in the community even after a project has finished and an organisation leaves (Im18:18).

However, this may also be a source of intra-organisational conflict, because people do not understand why there should be paid labour and unpaid volunteerism in the same

154 organisation. Building skills among volunteers could thus also be read as an approach to appeasement.

Volunteer structures assure direct links to beneficiaries and help mobilise communities more easily. However, it appears that there is also competition with regard to community mobilisation through offering incentive, e.g. for the attendance of health education sessions. The work of community volunteers in this case is backed up by further resources, which is a cost to the CBO. It has been argued that this area of competition among organisations should also be regulated by a policy (If4:64).

Finally, consultants make a special case with regard to the payoff. As they usually operate on a short-term basis and offer highly specialised services, they need to be particularly trustworthy for their contractors, in the sense of being a reliable partner and delivering good quality (Im15:103-105; 134-139).

Consultants acting as third parties must build a reputation not only based on quality delivered but also on conduct regarding HRH.

Interviewees in this study have not mentioned to what extent information generated through consultancies actually reaches the District Health Office or the local communities researched. Respective contracting arrangements could be considered to ensure a larger benefit of these activities.

Conclusion

The authority regarding international collaborations in the health district is no longer restricted to the 'technocratic line', from the MoH headquarters to the District Health Offices. DHMTs are now operating in two different strands of political accountability.

Most of the interview partners in this group are more comfortable with the hierarchical structures of the MoH, whereas the inter-sectoral collaboration at the district level (District Assembly/District Commissioner) bears uncertainties.

Apart from that, however, it has to be recognised that these coordination activities also require considerable managerial efforts. The common criticism that health workers spend too much time in meetings and carrying out administrative tasks should be taken seriously (Im15:174-184, Im5:78). It needs to be carefully considered whether

155 the improvements in general - and regarding HRH in particular - are really worth efforts that are required at district level. Given the general reluctance that can be observed in this regard, also the reporting and planning structures appear to be hindering better collaboration in the field of HRH.

With regard to consultancies, greater attention is to be given to the practice of issuing short-term contracts. For ‘competitive’ positions, these would normally be in addition to a regular work contract elsewhere. This is said to be a legal arrangement, if the contractors sign that they are available during the agreed time span (Im5:55-57). If these contracts come on top of an employment in the public sector for example, the competition is for human resources is obviously shifted to the level of the individual professional’s work-time.

On the positive side, contractual arrangements and agreements among actors in this third action situation also offer some innovative potential and learning opportunities.

It stems from the variety and the resources of actors working on health and social welfare in the broadest sense.

156 5.2 LINKS WITH OTHER ACTION ARENAS

The action arenas presented here are linked to the level of the health district in one way or another. The nature of this linkage will be examined, to identify arenas in which discussions about underlying norms and rules take place and where relevant rule changes might be initiated (collective-choice and even constitutional level).

The landscape of composite actors relevant for the resource system HRH in Malawi is visualised in figure 4. The action arena ‘co-ordinated planning’ at district level, which has been dealt with in chapter 5.1, is thus put into context. Different colours the different types of organisations: the different bodies of central government are kept in blue, while the District Assembly (DA) as a body of local government is distinguished.

The connecting lines and neighbouring clouds make clear that a number of decisions, which are of relevance to the action arena in question, are being made in other action arenas. Most organisations do not operate in one district only. The rules and norms within their respective organisation will thus determine the range of action that individual managers at district level have.

Figure 4: Actors and action arenas relevant to HRH in Malawi

157 According to the Local Government Act of 1998, the DA is supposed to receive a more active role within the scope of decentralisation, but councillors had not been elected yet in the year 2009. Malawi in fact has a history of emphasising rural development whilst taking an inter-sectorial approach. The installation of 'rural growth centres' to further decentralise the services available in the district, was also supported by German development aid. This support is being continued in technical assistance for building the local government structures. However, the recent decade has rather been characterised by sector-specific aid, e.g. within the scope of the health SWAp. This has also been very relevant for the District Health Offices in terms of financial and physical resources. Large numbers of HSAs have been recruited locally, as part of the EHRP.

Furthermore, the Zonal Health Support Offices (ZHSO) as an intermediary structure have been introduced (see map in Annex 7.1).

Potentials and limitations at the district level have been worked out in chapter 5.1. The following three sub-chapters will pick up these aspects: They will deal with different options to enhance HRH management and development in Malawi in a context of international aid. Each focuses on a particular arena, namely the health zones (chapter 5.2.1), local communities (chapter 5.2.2) and the DA (chapter 5.2.3).

In contrast to the preceding results sections, the following sections will also present some original quotes from the interviews. This is to acknowledge that in various instances, individual leaders have made up their minds regarding the changes that they consider necessary to improve the HRH situation at the operational level. Thereby they shift to the conditions of collective choice. However, these statements are not necessarily shared by the wider community of health workers.