Transcript Implication of the political-economy dynamics on donor

Donors and the political economy
of health sector reform in
Tanzania
A policy analysis perspective
Aziza Mwisongo
NIMR, 2008
Introduction
Consultancy for Irish Aid carried out in
Tanzania and Uganda
Objective: to understand the political-economy of
health sector reforms with a view of identifying
constrains and opportunities facing donors in supporting
evidenced-informed policy change and aid modalities
Mainly done through interviews and group
discussions with a range of stakeholders
and documentary review
Carried out collaboratively by ODI in UK
and NIMR in 2006
Presentation outline
Health reform challenges in Tanzania
Dimensions of stakeholders political
Feasibility of a proactive political –
economy approach to informing policy
dialogue and actions
Health reform challenges in Tanzania
The country context :Poverty Reduction Strategy Paper,
Health Sector Development Strategy, HSSP, political system is
hybrid of legal-Rational and patrimonial,UK inherited bureaucratic
civil service system, Tanzanian Assistance Strategy, political –
economy not documented
Progress in the health sector: some progress in
infant and child mortality, increased use of bednets, lowered
incidence of malaria BUT low family planning acceptor rate,
inadequate use of skilled birth attendants, low facility births, no
progress in MMR, good prioritization and managing resources BUT
no progress in fostering private –public partnership( HRH crisis)
Continued….
 Prioritization and coordination with constrained
resources: 1) per capita spending on health non sufficient for HSSP, 2) health
spending highly donor dependent, actual prioritization influenced by budgetary
processes and negotiations ( GHI), 3) lack of data on LGA spending, more weight on
political decisions ( presidents decision)
 Existence of SWAp related problems: rigid funding to districts, cuts
in OC, extensive system of allowances as salary top ups, ARV budget on expense of
basic immunization in MTEF, separate basket accounting, high central expenditure
compared to districts, high off budget,
 GHI problems: ignore official sector policy, strain in govt leadership,
balance accorded to few specific diseases, parallel systems, costly
commodities, lack of transparency, questionable sustainability
 Constraints to improving efficiency and efectiveness of
services: bifurcation of responsibility by MOHSW and LGA and
reemergence of projects rendering more power on managers
Dimensions of stakeholders political
 Powerful interactive set of political economy
constraints block reform processes;
 High politics of health sector policy: populist and
patrimonial initiatives, pet projects implementation through supplementary
budgets, using high level contacts to introduce expensive initiatives( ARVs),
policy making by health policy cabal
 The global and local aid architecture: several funding
routes fragments balance of power, finances confers some influence but
unpredictable, donors use of technical expertise in SWAP committees to
influence policies BUT unpredictable, use of allowances to attract officials
but deleterious, GHI and PEPFAR shifting balance of stakeholders interest
in SWAp, Donors disagreements, soft conditionalities off tracking key
issues, poor donor actions against poor government performance, fear of
challenging govt,
Continued….
The organization of interest and advocacy:
MOF silent opposition to some key health decisions , e.g. HRH
issues, weak professional group activism, restrictions to collective
bargaining, NGOs limited access and fear of being in odds with govt,
NGOs advocacy for advocacy is limited, LGA limited involvement in
policy discussions, middle class population is not affected by the
problems so lack of questioning,
Feasibility of a proactive political –
economy approach to informing policy
dialogue and actions
Constrains : limited use of political –economy,
translation of Paris declaration by accepting
government inadequacies or pulling out /cutbacks,
donors indifferences on how hard to push, lack of use of
opportunities on similar stands, limited networking,
health advisors are technical rather than brokers, undue
caution of some multilateral to work with CSO, culture of
mistrust of Govt and NGOs, leadership and capacity
problems, unsupportive of critical thinkers
Continued…
Opportunities: engage MOF, using evidence from PER and
NHA for dialoguing and alliances, using JAR for retrospective policy
analysis, empowering NGOs to influence priorities, SWAp
committees to look and discuss political –economy issues, mobilize
high profile support ( although could be knee jerk) but also use to
create synergies