Module 13: Partnerships

Challenges of Partnerships

As developed and developing countries are seen as donor and recipient, respectively, partnerships are often perceived as unidirectional. Strictly speaking, in terms of the flow of resources, this is often the case. The U.S. Agency for International Development (USAID), the main channel for the administration of U.S. foreign aid, periodically produces reports detailing the amounts of money transferred, and the measures implemented.(1)  From the perspective of a benefactor, this is perhaps the easiest way to track progress. The same report quantifies the success of the initiative in the countries where it is present.

The most relevant question with regard to partnerships, however, is whether healthcare interventions could be improved through more effective communication and collaboration with the cohort of interest.  In situations where cultural dialogue is absent, even the best-intentioned measures will fail to live up to their full potential.  For example, in Tanzania, one of the target nations of USAID’s PMI, the true efficacy of ITNs was uncovered. “Unfortunately, mosquito nets are fast finding a new role in African countries especially those endowed water masses and border the Indian Ocean. In remote Tanzanian villages mosquito nets are now used as fishing gear. According to Xinhua news agency, villagers living by the Lake Nyasa shores have found a better use of their United Nations- and government-subsidized mosquito nets: instead of covering people against malaria-spreading mosquitoes, they uncover fish with the nets from the lake.”(2)

But of course, developing nations are not so different from developed nations. They share the same interests, and ideally, common priorities, including the advancement of global health knowledge and the improvement of the human condition. It is for these reasons that parties with vastly different economic circumstances sign on to partnerships. Still, this monetary inequity, which lies at the heart of so many global health issues, naturally leads to medical paternalism, unequal relationships of power, and even biological stigmatization of one party. The resulting negative effects may ultimately counter any strides that are made in the realm of global health.

Development Cooperation

Development aid refers to the “international transfer of public funds” by a government or non-governmental organization to support the development of developing countries.  The World Health Organization (WHO) opts for the use of the term “development cooperation” to emphasize the importance of partnerships in such exchanges.(3) Unlike humanitarian aid which is mobilized only in the short term as a reaction to extenuating circumstances, development cooperation is meant to break the cycle of poverty in the long term. Aid effectiveness is the ultimate goal, but unfortunately crucial links are still missing from the “causality chain linking aid flows to development outcomes.” The empirical evidence is inconclusive, if not altogether contrary to previous literature.  It is clear, however, that aid is not as effective as it could be.  Bourguignon and Sundberg state that “much aid is lost due to instability and conflict.  Roughly half of aid to sub-Saharan Africa has gone to countries facing civil war and/or frequent military coups.  Much (though not all) aid has been wasted on poorly conceived and executed projects and programs, often fettered by debatable conditionality.”  Some of this is inevitable, though it often seems that partnerships are saturated with bureaucracy and outside interests that transform the chain of causality into a much more complicated web.  The paucity of reliable data stems from this complication. “From a statistical point of view, many technical problems arise, including distinguishing short-term versus long-term impact, problems with endogeneity of the aid-growth relationship, difficulty determining the direction of causality or controlling for country-specific characteristics, etc. […] Moreover, the multidimensionality of development objectives (mean income, poverty, literacy, access to sanitation, inoculations) further complicates empirical analysis.”(4)

Paris Declaration on Aid Effectiveness and the Accra Agenda for Action

How, then, can partnerships be responsibly incorporated into the framework of Effective Program Development?  Here, we defer to the Paris Declaration on Aid Effectiveness and the Accra Agenda for Action, the most universally recognized treatments of development aid and aid effectiveness to date.  The Paris Declaration was endorsed by more than 100 signatories in February 2005, and was followed up by the Accra Agenda in 2008, but both still have their critics who argue that they are “too narrowly defined.”(5)  A deeper knowledge of the barriers to partnership optimization, along with an understanding of individual circumstances, is necessary for proper implementation. The five principles of the Paris Declaration are helpful as a sturdy groundwork.(6)

• Ownership: Partner countries exercise effective leadership over their development policies, and strategize and coordinate development actions.

• Alignment: Donors base their overall support on partner countries’ national development strategies, institutions and procedures.

• Harmonization: Donors’ actions are more harmonized, transparent and collectively effective.

• Managing for Results: Managing resources and improving decision-making for results

• Mutual Accountability: Donors and partners are accountable for development results

Though the principles are all related, ownership, alignment, and harmonization in particular are important in light of the shortcomings of current global health partnerships. Ownership requires both partners to assume responsibility for the continued success and sustainability of development aid, which by definition requires long-term solutions that involve local engagement. Alignment and harmonization stress the importance of incorporating local priorities into any plan of action. No global health intervention can succeed without the support of the people. Popular support, however, can only be gained by learning what is important to the people, not only through the lens of public health, but also through the lenses of culture and society.

Effective Implementation

Sensitivity to the needs and wider perceptions of a population is perhaps the most important virtue in partnership facilitation, as each participant will interpret actions differently.  There is nothing more important than the proper interpretation of the facts, expressed and implied, when considering the most delicate issue of global health partnerships.  Cultural notions and local customs must not be dismissed nor downplayed, but rather incorporated in the pursuit of local and global health synergies.  Only when global health partnerships become characterized by trust and equality can they begin to advance those same ideals within the realm of global health and the international community.

Footnotes

(1) See, e.g. USAID. “Annual Performance Report” (2020). https://www.usaid.gov/results-and-data/progress-data/annual-performance-report.

(2) Sampao, P. (2010). Of fish and Mosquitoes. Malaria World. https://malariaworld.org/blog/fish-and-mosquitoes.

(3) “Development Cooperation.” World Health Organization.

(4) Bourguignon, F., & Sundberg, M. (2007). Aid effectiveness–opening the black box. American economic review, 97(2), 316-321.

(5) Wathne, C., & Hedger, E. (2009). Aid effectiveness through the recipient lens. Briefing paper, 55.

(6) “The Paris Declaration on Aid Effectiveness and the Accra Agenda for Action.” Organisation for Economic Co-operation and Development, 2008. https://www.oecd.org/dac/effectiveness/34428351.pdf.