Stakeholder perceptions of aid coordination implementation in the Zambian health sector

In this study, we analysed stakeholder perceptions of the process of implementing the coordination of health-sector aid in Zambia, Africa. The aim of coordination of health aid is to increase the effectiveness of health systems and to ensure that donors comply with national priorities. With increases in the number of donors involved and resources available for health aid globally, the attention devoted to coordination worldwide has risen. While the theoretical basis of coordination has been relatively well-explored, less research has been carried out on the practicalities of how such coordination is to be implemented. In our study, we focused on potential differences between the views of the stakeholders, both government and donors, on the systems by which health aid is coordinated.A qualitative case study was conducted comprising interviews with government and donor stakeholders in the health sector, as well as document review and observations of meetings. Results suggested that stakeholders are generally satisfied with the implementation of health-sector aid coordination in Zambia. However, there were differences in perceptions of the level of coordination of plans and agreements, which can be attributed to difficulties in harmonizing and aligning organizational requirements with the Zambian health-sector plans. In order to achieve the aims of the Paris Declaration; to increase harmonization, alignment and ownership – resources from donors must be better coordinated in the health sector planning process. This requires careful consideration of contextual constraints surrounding each donor.     

The implementation of a global fund grant in Lesotho: applying a framework on knowledge absorptive capacity

One of the biggest challenges in scaling up health interventions in sub-Saharan Africa for government recipients is to effectively manage the rapid influx of aid from different donors, each with its own requirements and conditions. However, there is little empirical evidence on how governments absorb knowledge from new donors in order to satisfy their requirements. This case study applies Cuellar and Gallivan's (2006) framework on knowledge absorptive capacity (AC) to illustrate how recipient government organisations in Lesotho identified, assimilated and utilised knowledge on how to meet the disbursement and reporting requirements of Lesotho's Round 5 grant from the Global Fund to Fight AIDS, TB and Malaria (Global Fund). In-depth topic guided interviews with 22 respondents and document reviews were conducted between July 2008 and February 2009. Analysis focused on six organisational determinants that affect an organisation's absorptive capacity: prior-related knowledge, combinative capabilities, motivation, organisational structure, cultural match, and communication channels. Absorptive capacity was mostly evident at the level of the Principal Recipient, the Ministry of Finance, who established a new organisational unit to meet the requirements of Global Fund Grants, while the level of AC was less advanced among the Ministry of Health (Sub-Recipient) and district level implementers. Recipient organisations can increase their absorptive capacity, not only through prior knowledge of donor requirements, but also by deliberately changing their organisational form and through combinative capabilities. The study also revealed how vulnerable African governments are to loss of staff capacity. The application of organisational theory to analyse the interactions of donor agencies with public and non-public country stakeholders illustrates the complexity of the environment that aid recipient governments have to manage.     

Managing external resources in the health sector: are there lessons for SWAps (sector-wide approaches)?

Drawing on the case studies presented in this issue, from Bangladesh, Cambodia, Mozambique, Zambia and South Africa, and examples from other countries, this paper asks what general conclusions can be drawn about the management of external resources, and specifically what lessons could inform the future implementation of sector-wide approaches (SWAps) in the health sector. Factors constraining the management of aid by ministries of health are grouped under three themes: context and timing, institutional capacities and the interplay of power and influence in negotiations over aid. Two factors, often underplayed, were found to be important in facilitating management of resources: the inter-relationship of formal and informal relationships, and the extent to which incremental changes are tolerated. The main conclusion is that coordination and management of external resources is inherently unstable, involving a changing group of actors, many of whom enjoy considerable autonomy, but who need each other to materialize their often somewhat different goals. Managing aid is not a linear process, but is subject to set-backs and crises, although it can also produce positive spin-offs unexpectedly. It is highly dependent on institutional and systemic issues within both donor and recipient environments. In promoting sector-wide approaches the key will be to recognize context-specific conditions in each country, to find ways of building capacity in ministries of health to develop and own the future vision of the health sector, and to negotiate a realistic package that is explicit in its agreed objectives. The paper ends with identifying crucial actions that will enable ministries of health to take the lead role in developing and implementing SWAps.     

Managing external resources in Mozambique: building new aid relationships on shifting sands?

The Mozambican health sector is recovering from war and general disruption. This massive endeavour is supported by several donor agencies, which contribute a substantial proportion of national health expenditure. The final years of the war and the transition period have seen an extreme fragmentation of the health sector. To correct it, serious efforts to coordinate the plethora of aid agencies and related external inputs have taken place. This paper reviews the actors present on the Mozambican health scene and their interactions. The existing aid management mechanisms are described and their effectiveness appraised. The factors affecting both the process and its outcomes are analyzed. Given the prevailing complexity, this research presents a number of tentative conclusions. First, the evidence suggests that coordination efforts have paid off. However, progress has required intense and sustained work. Incremental approaches, where donor demands are progressively raised as the system is strengthened, have been crucial. The initiative has come mainly from donors, with the Ministry of Health receptive and reactive. When the recipient administration has been able to take advantage of donor initiatives, success has ensued. Individual people have been crucial in shaping the process. Critical factors contributing to positive developments on both sides of the donor-recipient relationship have been frankness, risk-taking and a long-term perspective.     

Optimizing in-kind drug donations for Tanzania-a case study

A questionnaire survey (QS) among stakeholders in Tanzania had shown that in-kind drug donations (DDs) are important to boost the drug supply system. Major problems were their insufficient quantity for sustainable treatment and the discrepancy between the needs of the recipients and the donors' supply. Objectives in this study were to discuss these findings and to learn from key informants (KIs) how to improve the DD process. Data were collected through KI interviews in 2001/2002.A 30% gap in drug supply has to be bridged by DDs. KIs confirmed the importance of the World Health Organisation and Tanzanian DD guidelines as a tool for good donation practice and emphasized the role of the government in their implementation. They requested that donors meet the recipient country's regulatory requirements. In contrast to QS respondents, KIs did not view DD quality as a minor problem, and proposed that DD quality should be adapted to the national quality assurance procedures. DD processes could be improved through (a) effective implementation of DD guidelines as an aid for decision-making and for quality assurance, (b) availability of data to improve communication between donors and recipients, (c) transparency between recipients and donors and (d) clearly defined accountability.     

Small fish in a big pond? External aid and the health sector in South Africa

Since a new government was elected in 1994, South Africa has become a favoured nation for the many bilateral and multi-lateral agencies providing aid to developing countries. Despite several relatively large pledges of 'transition support', however, external resources constitute less than 2% of the annual government budget. This non-dependence has established a degree of equilibrium in a relationship normally regarded as highly unequal in other African countries. Although international donors funded the antiapartheid movement in South Africa prior to 1994, the new government inherited a chaotic administration that had little institutional experience of conventional development aid. Many of the new cadres entering government had not been exposed to the workings of government, let alone donor, bureaucratic processes. It is not surprising, therefore, that in the first few years after 1994, the aid relationship was characterized by low disbursements, unrealistic expectations and a degree of conflict. Since 1997, however, aid supported projects have started to become more visible. Within the broad objective of supporting transformation of the health system, one of the key areas of donor support is managerial capacity development, particularly of district, hospital and provincial health structures. These initiatives tend to be poorly coordinated, a problem compounded by a quasi-federal system in which provinces have large amounts of autonomy. The contribution of donor aid to strengthening the health system could be enhanced by the establishment of a clear national framework to guide the many externally supported projects building managerial skills and systems.     

Responses to donor proliferation in Ghana’s health sector: a qualitative case study

ObjectiveTo investigate how donors and government agencies responded to a proliferation of donors providing aid to Ghana’s health sector between 1995 and 2012.MethodsWe interviewed 39 key informants from donor agencies, central government and nongovernmental organizations in Accra. These respondents were purposively selected to provide local and international views from the three types of institutions. Data collected from the respondents were compared with relevant documentary materials – e.g. reports and media articles – collected during interviews and through online research.FindingsGhana’s response to donor proliferation included creation of a sector-wide approach, a shift to sector budget support, the institutionalization of a Health Sector Working Group and anticipation of donor withdrawal following the country’s change from low-income to lower-middle income status. Key themes included the importance of leadership and political support, the internalization of norms for harmonization, alignment and ownership, tension between the different methods used to improve aid effectiveness, and a shift to a unidirectional accountability paradigm for health-sector performance.ConclusionIn 1995–2012, the country’s central government and donors responded to donor proliferation in health-sector aid by promoting harmonization and alignment. This response was motivated by Ghana’s need for foreign aid, constraints on the capacity of governmental human resources and inefficiencies created by donor proliferation. Although this decreased the government’s transaction costs, it also increased the donors’ coordination costs and reduced the government’s negotiation options. Harmonization and alignment measures may have prompted donors to return to stand-alone projects to increase accountability and identification with beneficial impacts of projects.     

Living donor liver transplantation: the historical and cultural basis of policy decisions and ongoing ethical questions

Adult-to-adult living donor liver transplantation (LDLT) is in a state of flux. Technical innovations and demand have outpaced internal and external regulatory efforts. This has led to a wide array of centers performing LDLT for a variety of indications without clear evidence on the risks to the donor or recipient or the system as a whole. The birth from necessity of LDLT in Asia has led to the extrapolation of the technique in America and Europe that has not been sufficiently studied in the appropriate populations. While there is a clear benefit in some patients, the appropriate donors and recipients have not been defined. Regulatory and ethical consideration should be focused on minimizing acceptable risk in donors and recipients and expanding the investigation into the costs and outcomes of this challenging procedure. The recently funded adult-to-adult living donor liver transplantation cohort sponsored by the National Institutes of Health aims to answer some of these questions over the next five years.     

The “aid contract” and its compensation scheme: A case study of the performance of the Ugandan health sector

Current literature on aid effectiveness describes increasing use of a more contractual approach to the relationship between donor and recipient government in which a system of rewards and penalties for good and bad performance operates. The purpose of this case study of the Ugandan health sector was to understand the extent to which this approach is influencing processes and effectiveness. This qualitative study used a conceptual framework based on agency theory and ‘realistic evaluation’. Our results showed that the main official mechanism to assess and reward performance established through the Sector Wide Approach lacked objective criteria and was based on an unstructured system of discussions and agreements among donors. The achievement of a satisfactory performance rating was facilitated by the agreeing to undertakings that were under-demanding, vaguely formulated and lacking quantitative benchmarks against which progress could be measured. However, even when poor performance was readily observable, penalties failed to be applied by donors. This was always the case in relation to health sector performance and mostly so in relation to general governance and accountability. Funds continued to be disbursed despite the lack of progress made in achieving targets and undertakings and other evident performance problems (e.g. in the area of governance). A series of explanations of the failure to penalise were put forward by donor representatives in relation to this behaviour including the need to maintain long-term relationships based on trust and not to undermine health sector performance by withdrawing aid. Thus there are likely to be incentives to disburse funds and report success, irrespective of the realities of aid programmes in the context of large foreign aid volumes associated with increased political visibility of aid in donor countries.     

Transplantation-transmitted tuberculosis--Oklahoma and Texas, 2007

Approximately 28,000 organ transplants were performed in the United States in 2007. When infections are transmitted from donors, the implications can be serious for multiple recipients. Tuberculosis (TB), a known infectious disease complication associated with organ transplantation, occurs in an estimated 0.35%-6.5% of organ recipients in the United States and Europe posttransplantation. In 2007, the Oklahoma State Department of Health identified Mycobacterium tuberculosis in an organ donor 3 weeks after the donor's death. This report summarizes results of the subsequent investigation, which determined that disseminated TB occurred in two of three transplant recipients from this donor, and one recipient died. Genotypes of the donor and recipient TB isolates were identical, consistent with transmission of TB by organ transplantation. To reduce the risk for TB transmission associated with organ transplantation, organ recovery personnel should consider risk factors for TB when assessing all potential donors. In addition, clinicians should recognize that transplant recipients with TB might have unusual signs or symptoms. When transmission is suspected, investigation of potential donor-transmitted TB requires rapid communication among physicians, transplant centers, organ procurement organizations (OPOs), and public health authorities.     

Aid coordination for health sector reform: a conceptual framework for analysis and assessment

Recent widespread interest in health sector policy and institutional reform in lower income countries has coincided with heightened concern for aid coordination. Because the health budgets of many low income countries are highly aid dependent, donors are strongly placed to make aid conditional on health care reforms. However, given the growing number and heterogeneity of multilateral, bilateral and international non-governmental donors operating in many of these countries, there is concern that if external efforts are not coordinated, the aims of health care reform--namely improving efficiency, effectiveness and equity--will not be met. Evidence is mounting that without effective coordination arrangements, donors may weaken rather than improve fragile health systems, undermining attempts to reform those systems. This paper traces the factors fuelling current interest in coordination, in particular with reference to its contribution to the goals of health sector reform. Aid coordination is defined and its principles elaborated. A framework is developed by which to assess the variety of coordination mechanisms which are evolving at the county level. In light of this framework, a case is made for greater and more critical analysis of aid coordination arrangements. The paper concludes that if health sector reform is to be successful in low income countries, current enthusiasm for coordination needs to be harnessed. The framework offered here provides a way of assessing the variety of coordination mechanisms currently proliferating, which could be used to enhance health sector reform.     

Player or referee? Aid effectiveness and the governance of health policy development: Lessons from Viet Nam

Viet Nam is one of the brightest stars in the constellation of developing countries. Its remarkable achievements in reducing poverty and improving health and education outcomes are well known, and as a result it has enjoyed generous aid programmes. Viet Nam also has a reputation for taking a strong lead in disciplining its donors and pushing for more efficient and effective forms of aid delivery, both at home and internationally.

This article discusses how efforts to improve the effectiveness of aid intersect with policy-making processes in the health sector. It presents a quantitative review of health aid flows in Viet Nam and a qualitative analysis of the aid environment using event analysis, participant observation and key informant interviews.

The analysis reveals a complex and dynamic web of incentives influencing the implementation of the aid effectiveness agenda in the health sector. There are contradictory forces within the Ministry of Health, within government as a whole, within the donor community and between donors and government. Analytical frameworks drawn from the study of policy networks and governance can help explain these tensions. They suggest that governance of health aid in Viet Nam is characterised by multiple, overlapping ‘policy networks’ which cut across the traditional donor–government divide. The principles of aid effectiveness make sense for some of these communities, but for others they are irrational and may lead to a loss of influence and resources. However, sustained engagement combined with the building of strategic coalitions can overcome individual and institutional incentives.

This article suggests that aid reform efforts should be understood not as a technocratic agenda but as a political process with all the associated tensions, perverse incentives and challenges. Partners thus need to recognise – and find new ways of making sense of – the complexity of forces affecting aid delivery.     

Patterns of volunteerism, testing, and exclusion among potential living kidney donors

We found that in kidney transplantation, more females donate. We analyzed transplant recipients for patterns of potential donor exclusion and found that equal proportions of male and female potential donors existed among first-degree biological relatives. More male recipients were married and therefore had more spousal potential donors. Among friends and non-first-degree relatives, significantly fewer males offered to donate to females. Equal proportions of female and male potential donors were excluded from donating for medical comorbidities, blood type incompatibility, recipient refusal, and potential donor reluctance. We concluded that female transplant candidates had fewer potential donors among spouses and opposite sex volunteers from friends and non-first-degree relatives.     

Living Kidney Donor Decision Making and Communication

There is high demand for kidney donors in the United States, and it is widely accepted that living donation is optimal for individuals who need a kidney. Much research has focused on the potential recipient, but little has been studied about the communication and decision making of living kidney donors. Interviews assessed the communication and decision-making processes of 43 kidney donor volunteers. Almost all of the participants were not asked, but instead volunteered, to donate. The majority of donors reported having conversations with the recipient and speaking about their decisions with other individuals in their social networks besides the recipient. Some participants said that they stopped talking to others because of negative feedback. Future research should further examine the communication of donors with non-recipient others and potential methods of training recipients and donors to communicate effectively about the donation process.     

Living kidney donor decision making and communication

There is high demand for kidney donors in the United States, and it is widely accepted that living donation is optimal for individuals who need a kidney. Much research has focused on the potential recipient, but little has been studied about the communication and decision making of living kidney donors. Interviews assessed the communication and decision-making processes of 43 kidney donor volunteers. Almost all of the participants were not asked, but instead volunteered, to donate. The majority of donors reported having conversations with the recipient and speaking about their decisions with other individuals in their social networks besides the recipient. Some participants said that they stopped talking to others because of negative feedback. Future research should further examine the communication of donors with non-recipient others and potential methods of training recipients and donors to communicate effectively about the donation process.     

A review of health resource tracking in developing countries

Timely, reliable and complete information on financial resources in the health sector is critical for sound policy making and planning, particularly in developing countries where resources are both scarce and unpredictable. Health resource tracking has a long history and has seen renewed interest more recently as pressure has mounted to improve accountability for the attainment of the health Millennium Development Goals. We review the methods used to track health resources and recent experiences of their application, with a view to identifying the major challenges that must be overcome if data availability and reliability are to improve. At the country level, there have been important advances in the refinement of the National Health Accounts (NHA) methodology, which is now regarded as the international standard. Significant efforts have also been put into the development of methods to track disease-specific expenditures. However, NHA as a framework can do little to address the underlying problem of weak government public expenditure management and information systems that provide much of the raw data. The experience of institutionalizing NHA suggests progress has been uneven and there is a potential for stand-alone disease accounts to make the situation worse by undermining capacity and confusing technicians. Global level tracking of donor assistance to health relies to a large extent on the OECD's Creditor Reporting System. Despite improvements in its coverage and reliability, the demand for estimates of aid to control of specific diseases is resulting in multiple, uncoordinated data requests to donor agencies, placing additional workload on the providers of information. The emergence of budget support aid modalities poses a methodological challenge to health resource tracking, as such support is difficult to attribute to any particular sector or health programme. Attention should focus on improving underlying financial and information systems at the country level, which will facilitate more reliable and timely reporting of NHA estimates. Effective implementation of a framework to make donors more accountable to recipient countries and the international community will improve the availability of financial data on their activities.     

Patterns of Volunteerism,Testing, and Exclusion Among Potential Living Kidney Donors

We found that in kidney transplantation, more females donate. We analyzed transplant recipients for patterns of potential donor exclusion and found that equal proportions of male and female po tential donors existed among first-degree biological relatives. More male recipients were married and therefore had more spousal potential donors. Among friends and non-first-degree relatives, significantly fewer males offered to donate to females. Equal proportions of female and male potential donors were excluded from donating for medical comorbidities, blood type incompatibility, recipient refusal, and potential donor reluctance. We concluded that female transplant candidates had fewer potential donors among spouses and opposite sex volunteers from friends and non-first-degree relatives.     

Drug donations to developing countries

Developing countries often receive donations of drugs from corporations and governments during acute emergencies or as part of long-term development aid. However, donated drugs are often not relevant to the circumstances in the receiving country, many drugs arrive unsorted and under trade names with no international non-proprietary name, they may arrive in the wrong quantities, the quality of donated drugs does not always comply with donor countries' standards, and they often arrive without adequate package inserts or production information, and sometimes under a brand name unfamiliar in the recipient country. Local doctors often do not know how to use the drugs since they are not usually available in their country. The level and quality of communication between donors and recipients must be improved, and recipients advised on how they should specify the kind of help they need. Drug donations should benefit recipients as much as possible and be based upon receiving countries' expressed needs. Furthermore, only drugs of acceptable quality should be donated to other countries, no drugs should be donated which have been issued to patients or doctors and then returned to pharmacies for disposal, and after arriving in the recipient country, all drugs should have a remaining shelf-life of at least 1 year. In the acute phase of an emergency, it is better to send a standardized kit of drugs specifically designed for that purpose. Once the acute phase of an emergency ends, a donation in cash for the local or regional purchase of medical supplies will be more welcome than additional donations.     

Donor funding priorities for communicable disease control in the developing world

Prior research has considered donor funding for developing world health by recipient and donor country but not by disease. Examining funding by disease is critical since diseases may be in competition with one another for priority and donors may be making allocation decisions in ways that do not correspond to developing world need. In this study I calculate donor funding for 20 historically high-burden communicable diseases for the years 1996 to 2003 and examine factors that may explain variance in priority levels among diseases. I consider funding for developing world health from 42 major donors, classifying grants according to the communicable disease targeted. Data show that funding does not correspond closely with burden. Acute respiratory infections comprise more than a quarter of the burden among these diseases but receive less than 3% of direct aid. Malaria also stands out as a high-burden neglected disease. The evidence indicates that neither developing world need nor industrialized world interests explain all funding patterns, and that donors may be imitating one another in ways that do not take into account problems in the developing world. There is an urgent need for a major increase in funding for communicable disease control in the developing world, and for more balanced allocation of the resources already provided.     

Health sector development: from aid coordination to resource management

Aid coordination has assumed a prominent place on health policy agendas. This paper synthesizes the findings of research undertaken to explore the changing practices of aid coordination across a number of countries. It begins by reviewing the key issues giving rise to increased attention to aid coordination in the health sector. The second section describes, assesses and compares the strengths and weaknesses of the dominant mechanisms or instruments which were found to be employed to coordinate health sector aid in the case studies. From this analysis, four factors become clear. First, in many countries, coordination mechanisms have been introduced as a part of an incremental process of trying out different approaches--there is no one model that stands out at any one time. Secondly, some instruments function largely for consultation, predominantly coordinating inputs, while others are more directive and operational, and are used to manage inputs, processes and outputs. Third, many of the mechanisms have not excelled, although, fourth, it is difficult to judge the effectiveness or impact of aid coordination. It is therefore argued that concern with the effectiveness of aid coordination arrangements must give way to a broader analysis of the processes, outputs and outcomes governing the use of both external and domestic resources, focusing on institutional characteristics, the distribution and nature of influence among the actors, and the interests which they pursue through the aid regime. These factors varied considerably across the countries indicating that aid management is context dependent and subject to continuing changes. Finally, the paper looks at the findings in the light of the introduction of sector-wide approaches.