Do Sector Wide Approaches for health aid delivery lead to ‘donor-flight’? A comparison of 46 low-income countries

Donor versus recipient preferences for aid allocation: A systematic review of stated-preference studies

As Official Development Assistance (ODA) tops 180 billion USD per year, there is a need to understand the mechanisms underlying aid effectiveness. Over the past decade we have seen some low- and middle-income countries become developed nations with record economic growth. Others remain in development purgatory, unable to provide their citizens with access to essential services. In an effort to improve aid effectiveness, the prescriptive nature of aid, where (typically) Western countries allocate funds based on perceived need or the strategic priorities of donors is being reconsidered in favour of locally-led development, whereby recipient governments and sometimes citizens are involved in the allocation and delivery of development aid. Meeting the preferences of donors (both governments and citizens) has been a longstanding priority for international development organisations and democratically governed societies. Understanding how these donor preferences relate to recipient preferences is a more recent consideration. This systematic review analysed 58 stated preference studies to summarise the evidence around donor and recipient preferences for aid and, to the extent possible, draw conclusions on where donor and recipient preferences diverge. While the different approaches, methods, and attributes specified by included studies led to difficulties drawing comparisons, we found that donors had a stronger preference than recipients for aid to the health sector, and that aid effectiveness could be more important to donors than recipients when deciding how to allocate aid. Importantly, our review identifies a paucity of literature assessing recipient perspectives for aid using stated preference methods. The dearth of studies conducted from the recipient perspective is perplexing after more than 30 years of 'alignment with recipient preferences', 'local ownership of aid', 'locally-led development' and 'decolonisation of aid'. Our work points to a need for further research describing preferences for aid across a consistent set of attributes in both donor and recipient populations.

Health priority-setting for official development assistance in low-income and middle-income countries: a Best Fit Framework Synthesis study with primary data from Ethiopia, Nigeria and Tanzania

BACKGROUND

Decision making process for Official Development Assistance (ODA) for healthcare sector in low-income and middle-income countries involves multiple agencies, each with their unique power, priorities and funding mechanisms. This process at country level has not been well studied.

METHODS

This paper developed and applied a new framework to analyze decision-making process for priority setting in Ethiopia, Nigeria, and Tanzania, and collected primary data to validate and refine the model. The framework was developed following a scoping review of published literature. Interviews were then conducted using a pre-determined interview guide developed by the research team. Transcripts were reviewed and coded based on the framework to identify what principles, players, processes, and products were considered during priority setting. Those elements were further used to identify where the potential capacity of local decision-makers could be harnessed.

RESULTS

A framework was developed based on 40 articles selected from 6860 distinct search records. Twenty-one interviews were conducted in three case countries from 12 institutions. Transcripts or meeting notes were analyzed to identify common practices and specific challenges faced by each country. We found that multiple stakeholders working around one national plan was the preferred approach used for priority setting in the countries studied.

CONCLUSIONS

Priority setting process can be further strengthened through better use of analytical tools, such as the one described in our study, to enhance local ownership of priority setting for ODA and improve aid effectiveness.

Critical evaluation of international health programs: Reframing global health and evaluation

Striking changes in the funding and implementation of international health programs in recent decades have stimulated debate about the role of communities in deciding which health programs to implement. An important yet neglected piece of that discussion is the need to change norms in program evaluation so that analysis of community ownership, beyond various degrees of "participation," is seen as central to strong evaluation practices. This article challenges mainstream evaluation practices and proposes a framework of Critical Evaluation with 3 levels: upstream evaluation assessing the "who" and "how" of programming decisions; midstream evaluation focusing on the "who" and "how" of selecting program objectives; and downstream evaluation, the focus of current mainstream evaluation, which assesses whether the program achieved its stated objectives. A vital tenet of our framework is that a community possesses the right to determine the path of its health development. A prerequisite of success, regardless of technical outcomes, is that programs must address communities' high priority concerns. Current participatory methods still seldom practice community ownership of program selection because they are vulnerable to funding agencies' predetermined priorities. In addition to critiquing evaluation practices and proposing an alternative framework, we acknowledge likely challenges and propose directions for future research.

Effects of donor proliferation in development aid for health on health program performance: A conceptual framework

Development aid for health increased dramatically during the past two decades, raising concerns about inefficiency and lack of coherence among the growing number of global health donors. However, we lack a framework for how donor proliferation affects health program performance to inform theory-based evaluation of aid effectiveness policies. A review of academic and gray literature was conducted. Data were extracted from the literature sample on study design and evidence for hypothesized effects of donor proliferation on health program performance, which were iteratively grouped into categories and mapped into a new conceptual framework. In the framework, increases in the number of donors are hypothesized to increase inter-donor competition, transaction costs, donor poaching of recipient staff, recipient control over aid, and donor fragmentation, and to decrease donors' sense of accountability for overall development outcomes. There is mixed evidence on whether donor proliferation increases or decreases aid volume. These primary effects in turn affect donor innovation, information hoarding, and aid disbursement volatility, as well as recipient country health budget levels, human resource capacity, and corruption, and the determinants of health program performance. The net effect of donor proliferation on health will vary depending on the magnitude of the framework's competing effects in specific country settings. The conceptual framework provides a foundation for improving design of aid effectiveness practices to mitigate negative effects from donor proliferation while preserving its potential benefits.

Has the Swap Influenced Aid Flows in the Health Sector?

The sector wide approach (SWAp) emerged during the 1990s as a mechanism for managing aid from the multiplicity of development partners that operate in the recipient country's health, education or agricultural sectors. Health SWAps aim to give increased control to recipient governments, allowing greater domestic influence over how health aid is allocated and facilitating allocative efficiency gains. This paper assesses whether health SWAps have increased recipient control of health aid via increased general sector-support and have facilitated (re)allocations of health aid across disease areas. Using a uniquely compiled panel data set of countries receiving development assistance for health over the period 1990-2010, we employ fixed effects and dynamic panel models to assess the impact of introducing a health SWAp on levels of general sector-support for health and allocations of health-sector aid across key funding silos (including HIV, 'maternal and child health' and 'sector-support'). Our results suggest that health SWAps have influenced health-sector aid flows in a manner consistent with increased recipient control and improvements in allocative efficiency.