The Global Partnership’s work is guided by the principles of development effectiveness and supports countries on their unique paths to achieving the 2030 Agenda. Discover how Bangladesh, Tanzania, Kenya, Lao People’s Democratic Republic, Mexico, Uganda and Myanmar are leveraging the development effectiveness principles to realise the Sustainable Development Goals in their countries.
When we talk about “aid effectiveness,” what do we mean? Is it just jargon? It is, until we ensure that in the midst of all of our efforts to respond, our investments are not fleeting and that they don’t undermine the struggling public sectors and care delivery systems that are often already weakened. In the recent Ebola outbreak in West Africa, there was no mystery about how we got there: we got there because after the last crises in the region, too few resources were invested in building a health care system able to deliver on the promise of both prevention and care.
We have too often failed to link emergency responses—and there were many during the latter years of the past century and first years of this one—to building local capacity and professional training programs that draw on the world’s largest gold mine, which is its human capital. Over the last few decades, despite good-will efforts to accompany our partners in settings of poverty, we have too often failed to invest heavily in national institutions, sometimes skirting them altogether.
While numerous international policies such as the Paris Declaration and most recently the Busan New Deal encourage us to invest in national institutions, we’ve all heard why it’s “impossible” to partner with local authorities because of weak absorptive capacity and alleged corruption. In order to avoid risk, so goes the story, we build parallel systems to deliver and assess the impact of humanitarian aid. All too often, we worry about our own institutions rather than about the grotesque risks faced by those left behind by human progress. We whisper about “reputational” and “institutional” risk.
As a physician, I cannot resist inserting a little bit of clinical medicine that is pertinent certainly to the course of the Ebola virus but also the struggles that we all face in contemplating what we should do collectively when we are delivering aid: We’re familiar with the notion of a visual field defect. Basically it means that part of your visual field is obscured, and this is a major challenge before us: how do we see the entire field when we approach any development challenge? It’s difficult, for example, to have a conversation about aid effectiveness without asking ourselves some difficult questions about how we will ensure that we will, at every step of the way, make every effort to link our work to long-term strengthening of the public sector. Are we spending as much time ensuring our efforts add up to more than the sum of their parts as we are on divvying up the parts?
Those of us in the field of public health—or more broadly, those tasked by self or other with serving the poor—are quick express concerns about “sustainability” or “cost-effectiveness.”
With so many lives lost because of a lack of access to basic public health interventions such vaccines or adequate sanitation, how can we begin to think about using “scarce resources” to provide cancer treatment, or antiretroviral therapy for AIDs patients, or training new generations of nurses and physicians to address the ongoing crisis in human resources? Scarcity obscures our vision and we set our sights and our aspirations lower.
Yet it is important to remind ourselves that so much of what we consider as not being “cost effective” in places like Liberia or Haiti is rarely questioned as anything but a necessary facet of a functioning healthcare system when located in wealthier settings. Without these investments, without willing to accept anything but high-quality, comprehensive care for the poor, we are setting ourselves up for failure.
When we reject the low-ball aspirations, cynicism and defeat, that make it all too easy to accept business as usual approach, which in poor settings means providing only the most basic elements of modern medicine and moving on with no long-term plan to leave lasting public systems in place, there is no reason why we cannot make the investments needed to prevent the next epidemic before it occurs. The alternative truly is “unsustainable.”
We know that this can be done. Take the the Hôpital Universitaire de Mirebalais in Haiti as an example. The facility is a modern 205,000 square foot, 300 bed teaching hospital, owned by the Government of Haiti and operated in partnership with the NGO Partners In Health. Since opening its doors in 2013, the hospital has provided high-quality care to 250,000 people, most of whom never had access to modern medicine, while at the same time training new generations of Haitian physicians and nurses. If this is possible in Haiti’s Central Plateau, there is no reason it cannot be replicated in Liberia, Sierra Leone, Guinea, or any other resource poor setting. We need to reimagine what is possible.
Using country systems for the delivery of development assistance has the potential pay-off of increased investments and strengthening of public financial management and related procedures. It is also argued that using country systems leads to greater overall impact, improved co-ordination, and increased predictability and sustainability of donor programmes. It can also lower transaction costs. Likewise, damage can be done to country systems when development partners manage their assistance through parallel channels.
One of the principles of the Paris Declaration (2005) was that development partners would align to the policies of the partner countries and in doing so would make use of the country systems. The Accra Action Agenda (2008) commits to “more use of country systems for aid delivery”. The Busan Partnership Agreement (2011) committed development partners to increase the use of country systems as the default position, alongside the strengthening of financial management and related systems.
The work of the Collaborative Africa Budget Reform Initiative (CABRI) on use of country systems is focused on ways that development partners can shift towards the full or partial reliance on country systems to allocate resources, disburse funds, procure goods and services, and account and report. And at the same time, recognize the fiduciary risks of using such systems.
A CABRI study in 2014 found that most development partners place more emphasis on short-term fiduciary and performance risks than on long-term developmental risks. Development partners who use country systems forfeit some degree of control over their development assistance, which can be perceived to increase the risks of activities not being implemented, or of funds not being used as intended. As a result, development partners tend to mitigate risks by not using the country systems, especially where the diagnostic assessment is not favourable, instead of managing the risks in favour of longer-term development objectives.
In our collaboration with African governments, officials acknowledge weaknesses in their systems and capability gaps. And by doing so, also provide the evidence of where systems are strong and should be used for the delivery of aid, but are not. Apart from cases of un-earmarked sector budget support and general budget support, the least used systems are those for planning and budget preparation. There is some evidence that audit systems are the first to be used by development partners that traditionally use their own systems. Similarly, the CABRI study shows that when development partners use the budget execution, accounting and reporting systems of the partner country, audit safeguard measures are often in place.
As the dialogue between development partners and partner countries improve, and trust is built alongside the improvement in country systems, development partners ‘grow into’ the use of country systems. Across the cases reviewed in the CABRI study, there is evidence of a graduation from pooled funding mechanisms managed outside of the government to government-managed pooled funds, and to budget support arrangements.