Global Politics of Health Reform in Africa

Performance, Participation, and Policy

Amy Barnes, G. Brown, S. Harman

• Publisher: Palgrave Pivot
• Year: 2014
• ISBN:
  9781137500151
• Topic: Politique et relations internationales
• Subtopic: Politique africaine

Drawing on qualitative research with African actors and global health institutions, the authors explore the politics of how performance funding modalities and participation are used to shape health reform in African countries as well as the role of African actors, global policy elites and international donors within these processes.

1

Introduction: Global Politics of Health Reform in Africa

Abstract: Participation and performance have become two master concepts for wider health reform in Africa. These concepts were initially used in the delivery of HIV/AIDS and maternal and newborn child health programmes as part of the UN Millennium Development Goals; however, key international donors such as the World Bank and the Global Fund to Fight AIDS, Tuberculosis and Malaria are now seeing the potential of such concepts in mechanisms of wider health reform in Africa. This chapter introduces the context, aims, and argument of the book and provides a detailed account of the qualitative methods used to conduct research in South Africa, Tanzania, and Zambia and two global health hubs: Geneva and Washington, DC.

Keywords: Global Fund; health reform; HIV/AIDS; maternal and newborn child health (MNCH); qualitative research; World Bank

Barnes Amy, Garrett Wallace Brown and Sophie Harman. Global Politics of Health Reform in Africa: Performance, Participation, and Policy. Basingstoke: Palgrave Macmillan, 2015. DOI: 10.1057/9781137500151.0005.

The health of the population of sub-Saharan Africa has long been a pre-occupation of global health actors, policies, and spending. Over the last 20 years this pre-occupation has led to a surge in intergovernmental organisations, non-governmental organisations, and public–private partnerships and reconfigurations of government agencies in an attempt to throw money and research at a myriad of African health problems, from extensively drug-resistant tuberculosis (XDR-TB) to diarrheal diseases. Interest in and commitment to the health of Africans in many respects reached its zenith with the inclusion of three health-related goals – combat HIV/AIDS, malaria, and tuberculosis; maternal mortality; child mortality – in the United Nations 2000 Millennium Development Goals (MDGs). The MDGs opened the floodgates for new interventions and actors in response to the three health goals and presented a call to arms for the international community to combat HIV/AIDS in particular. In the period immediately following the MDGs for example, development assistance for HIV/AIDS rose rapidly from $0.8 billion in 2000 to $5.1 billion in 2007 (Ravishankar et al., 2009). Yet, despite significant progress in some areas such as HIV awareness and access to anti-retroviral therapy, and growing attention to issues such as maternal health, progress towards improving the physical and mental health of the population of Africa has been slow (African Union Commission et al., 2013; WHO, 2014a). The World Health Statistics 2014 show, for example, that the risk of a child dying before their fifth birthday remains highest in Africa (95 per 1,000 live births) and that people living in sub-Saharan Africa account for an estimated 70% of those newly infected with HIV (WHO, 2014a). Increasingly global health actors have come to realise that a major stumbling block to the realisation of better health for all Africans is the tricky issue of health system reform.

Health system reform in Africa is a difficult subject because of questions about who is responsible for the articulation of what reforms should exist (an elected government or the myriad of international donors and external agencies that fund the health system), what kind of reform is desired, who will pay for reform, and how reform should be implemented. Moreover to speak of health reform requires a greater engagement with health systems, a concept so broad it can apply to hospitals and medical centres, clinicians and their training, research and salaries, procurement and logistics, and mechanisms of health system financing. It has also created a whole body of research as to what the most effective and equitable health system would look like (see, e.g., Frenk, 2009; 2010; Sheikh et al., 2011). Actors within the global health community such as the World Bank entered these debates and initiated projects in the 1980s and early 1990s and were not thanked for their efforts. They were criticised, for example, for not fully engaging with the local populations for which the reforms were meant to serve, undermining the sovereignty of the state, under-funding health systems through cuts to public spending, and prioritising the private sector (Laurell and Arellano, 1996; Harman, 2009). Other global health actors such as the Bill and Melinda Gates Foundation have steered clear of health system reform altogether, cognisant of the politics of such efforts and the inability to make a measurable impact in this as a distinct area of reform. Health system reform since 2000 thus came to be a covert strategy: an issue that was not discussed or included as part of wider health strategies in Africa under the MDGs, but something that would occur in and through a multitude of vertical interventions such as national malaria plans and neglected tropical disease strategies.

Health system reform in Africa is, however, now back as a specific item on the agenda in global health politics. It is back on the agenda in a way that attempts to overcome the problems of state ownership and sovereignty, competing donor strategies, and how to measure success and impact, while managing health system reform in the wider context of the MDGs. The current framing of health system reform in Africa is the consequence of three trends in global health policy. The first is the need for measurement and performance as articulated by the MDGs and adopted as the norm of health development financing by Western donors. The second trend is the emphasis on collaboration and state-led initiatives rather than top-down donor-led projects. This was encapsulated by the World Bank’s Poverty Reduction Strategy Papers and Comprehensive Development Framework approach to working with African governments and the Paris Declaration on aid effectiveness that stressed ownership, results, and accountability. The third trend has been the changing position of what were ‘the big three’ diseases under the MDGs: HIV/AIDS, malaria, and tuberculosis. Efforts to combat these three diseases now need to stress the benefits for wider health systems and health reform more broadly, in order to justify continued investment and maintain relevance as debates in global health policy shift. Combined these three trends have generated two master concepts for health reform in Africa: participation and performance.

Participation is a key policy concept in global health, and has a long and varied genealogy in global development thinking and practice (Hickey and Mohan, 2004). In its most basic understanding, participation in global health relates to the ability of stakeholders to engage with and shape health policy at four intersecting levels: local, national, regional, and global. Such engagement continues to remain the main normative aim behind debates about furthering more equitable health diplomacy and, as a result, has been increasingly integrated into the agenda of global agencies. Participation has been integrated as a guiding concept in the World Health Organization’s (WHO) latest Programme of Work 2014–2019 (WHO, 2014a: 19). It is a guiding principle of the Global Fund to Fight AIDS, Tuberculosis and Malaria (hereafter the Global Fund, 2001), which rose to prominence on the back of the advocacy campaigns about universal access to anti-retroviral therapy to treat HIV/AIDS, and also an operational principle of the World Bank (2014). Participation is also the master concept underwriting the MDGs, specifically Goal 8: ‘To develop a partnership for development.’ Within policy statements and discussions, participation is often seen as having a normative value (something we ought to strengthen for moral reasons) as well as having practical relevance (a governance mechanism that will produce more equitable and effective outcomes for health). Yet, the role of participation in establishing more robust global health partnerships remains under-theorised and under-examined (Barnes and Brown, 2011), particularly in relation to how local and governmental actors can or should participate as effective participants in (1) the formulation of African health reform; (2) the conception and design of related health system interventions; and (3) their subsequent implementation.

In relation to performance, the greatest application of the idea in health system reform has been through results or performance-based funding, or PBF, specifically relating to the areas of maternal and newborn child health (MNCH), and HIV/AIDS, malaria, and tuberculosis programmes. PBF refers to the idea of transferring resources (money, material goods) on condition that particular actions are taken or specific, predefined performance targets are achieved (Eldridge and Palmer, 2009). The conditional transfer of money or material goods is believed to be key to PBF, as it provides the incentive for performance within health systems. It is because of this that PBF is increasingly promoted by leading global actors as a way to efficiently and effectively reform the way that health systems are planned, financed, co-ordinated, and steered, particularly in low- and middle-income countries. Key international donors such as the Global Fund and World Bank argue that PBF will promote reform in a way that is locally owned and accountable (Witter et al., 2012), given that performance targets will be developed or negotiated through active participation of local actors from the bottom-up, rather than being set by global agencies from the top-down. While the term PBF is used within the context of this research, it is important to highlight that a range of different terms are used to signify this type of health system intervention. These include:

performance-based funding

performance-based financing

performance-based contracting

pay for performance

results-based funding

results-based financing

output-based aid

value for money

buy-downs

PBF can apply to both supply-side and demand-side means of facilitating results and performance. Supply-side PBF programmes tend to involve giving health workers or health centres financial incentives to encourage the provision of services. For example, financial rewards might be offered if a specific number of women deliver their baby in a health clinic per month. Demand-side PBF programmes focus on the users of health services and tend to involve providing monetary incentives to attend and use services that are on offer. For example, ‘mama kits’ are offered as a way to incentivise pregnant women to deliver in health centres or hospitals. This book is principally interested in supply-side PBF programmes; however, PBF schemes will often involve elements of both. While there are variations in the way that PBF schemes are conceived, designed, and implemented, common to all is the idea that positive health system reforms can be incentivised and brought about by tying the transfer of resources to predefined performance targets.

It is these two concepts – participation and performance – that are the concern of this book. Participation and PBF have been increasingly used as models for HIV/AIDS and MNCH by international donors such as the World Bank, United States Agency for International Development (USAID), Cordaid, the Clinton Health Access Initiative (CHAI) of the William J Clinton Foundation, the Norwegian Agency for Development Cooperation (NORAD), and the Global Fund. However, there is now growing rhetoric from donors such as the USAID and countries such as Rwanda that such initiatives could hold the key to wider success in health system reform in Africa. The purpose of this book is to critically reflect on how participation and PBF have been applied to the management of health systems and what such application tells us about the future of health reform in Africa. The aim of the book is to investigate how and why PBF and participation have come to prominence as an ideational policy concept, to trace the history of PBF as a tool of health policy reform, to see how participation works at multiple levels of health governance, and crucially to identify the extent to which African actors shape health reform in African countries. It provides a critical examination of the application of these two concepts to health reform in South Africa, Tanzania, and Zambia. In so doing, the book investigates how different actors understand participation and performance, the evidence behind the policy rhetoric about PBF success, and the wider politics associated with how actors participate and measure performance. Existing debate in global health and development policy has shown a favourable bias to performance and participation by focusing on the positive externalities of these two concepts with little engagement with the agency of different people (including government ministries, health facilities, civil society) in these African countries. This book addresses this lacuna. It is about the politics of how participation and performance are used to shape health reform in Africa and the role of African actors in reforming health systems in African countries.

Analytical framework

The book takes a multi-level governance approach to exploring the use of participation and performance as tools of health reform in Africa. Multi-level governance refers to the sharing of authority and policy-making across sub-national, national, and supranational levels of government (Marks et al., 1996), as well as the public, private, and voluntary sector (Bache and Chapman, 2008). The state is still of paramount concern and multi-level governance has a statist core, but it is assumed that it does not have monopoly over decision-making and instead must share power (Eising, 2004). More specifically, it is assumed that sub-national decision-making exists beyond the scope or ‘nest’ of the state (Marks et al., 1996) and that shared sovereignty exists in that external actors (international agencies and donors) have influence over domestic authority (Mamudu and Studlar, 2009).

The use of a multi-level analysis allows for a conceptualisation of global health governance that does not isolate or ignore the state in the same way that regime-based or transnational understandings are said to do (Betsill and Bulkeley, 2006). At the same time, multi-level governance provides space for the inclusion of civil society both within and outside processes of global governance as an arena or ‘a space for critical reflection and affective expression’ (Brassett and Smith, 2010: 414). Different forms of multi-level governance, such as multi-sectoral governance that points to the inclusion of all aspects of society in decision-making, shift the focus away from a state-centred, institutional narrative of power and agenda-setting to allow for greater recognition of both deliberations w...

Table of contents

• Cover
• Title
• 1  Introduction: Global Politics of Health Reform in Africa
• 2  The Performance-Based Funding (PBF) Debate
• 3  The Politics of Performance-Based Funding (PBF)
• 4  The Politics of Participation in Health Reform
• 5  Conclusion
• Bibliography
• Index