By Matilda Nash, Lavinia Tyrrel and Graham Teskey
Over the past two years, Abt’s Governance and Development Practice (GDP) have worked with local partners in over 13 countries across the Pacific, Asia and Africa to apply Political Economy Analysis (PEA) approaches to sector programming (see briefing note for further detail).
The aim? To help us better understand the real politik of health and education systems, we asked the following questions: Why did upstream investments in particular, health or education policies and planning not translate into better services? What is the capacity and authority of the state and service delivery sectors to manage service delivery? How strong and organised are pro-/anti-reform coalitions or individuals? What is the salience of health and education outcomes for those in positions of authority and control over resources? How ‘institutionalised’ are the formal rules of the game? Who is excluded from decision-making regarding resource allocation and access to services and why? What did we learn? This blog summarises the lessons.
Four things stood out, regardless of sector or country:
Change needs to occur at many levels, but too often sector programs focus almost exclusively on the individual.
A common assumption is that if we can ‘support the right pro-reform health or education minister’, or ‘train enough staff’, health and education outcomes on the ground will improve. Such activities may produce worthy outputs in and of themselves – but they overlook the fact that turning individual competence into organisational capacity requires institutional change. Individuals need competence to do their jobs (e.g. training in procurement guidelines).
But this will make little impact on health outcomes unless individuals work within organisations that hold them to account to do their jobs. This process of turning individual capabilities into organisational capacity requires institutional change. Changes in the rules (formal and informal) that influence how individuals and groups in the health sector behave. The diagram above reflects how we think about this under one of the programs the GDP has worked on. The higher up the table, the harder it can be to influence change.
Many individual systems must function simultaneously for primary health care and basic education services to work.
Institutionally, this explains why primary health systems in particular are so resistant to improvement. For example, in order to perform surgery on patients suffering from trachoma, there must be in place a clinic with trained and incentivised staff, functioning equipment, patients informed and empowered to seek treatment. Institutionally, this complex (see diagram, below).
Yet sector programs (and we, as governance wonks, are absolutely guilty of this too) often work in silos, intervening at only one point in the health or education system or on a specific disease or set of education actors (e.g. parents or teachers). The (silent) assumption being that systemic issues (such as integration between upstream and downstream reform efforts, coordination, public financial management, hiring and performance management) will be addressed by another intervention or relegated to the ‘risks’ column of a logframe.
Purely technical fixes may not work.
This one will come as no surprise to most of our readers: purely technical fixes to problems which are also political or normative in nature will have limited impact. Health and education reform is no different; while specific elements of health and education service delivery are somewhat ‘politics free’ (e.g. selecting the most scientifically sound diagnostics and treatment plans) – change to the processes, institutions, incentives, systems and policies which shape – if not determine –the quality of service provision are not. When trying to understand outlier cases (e.g. why particular districts, provinces or countries functioned better than other), the answer, unsurprisingly, is not just about technical capacity; it is also about the political economy dynamics that govern how health and education systems work.
The donors’ dilemma.
Should donors intervene at the point of service delivery, ensuring short-term outcomes but with little guarantee of sustainability? Or should they invest in strengthening local systems, which may (or may not) deliver sustainable results but only in the long-term? In each of the 13 countries we looked at, donors oscillated between the two – and struggled to know how to strike a balance. Working in parallel to the state can hollow out what capacity and political commitment does exist, or – even worse – create perverse accountability and incentive structures (why should the cash-strapped national budget fund something we know donors will?). Alternatively, support for upstream reforms assumes that donors can influence organisational and institutional change, and that these changes will eventually benefit people (especially the most vulnerable) at the front line.
Despite the depth of insights surfaced through the PEAs we conducted; they are by themselves insufficient. PEAs are simply an analytic tool; and one which needs a far greater focus on drivers of exclusion and gender inequality (watch this space – we are soon to launch our approach to GESI responsive PEA. The challenge is to now convert the lessons from PEA into programming. In so doing, the fundamental question is how can education and health technical issues be sufficiently politicised to call forth changes in the institutional environment (I.e. the incentives and interests of key decision makers), rather than just leave donors fiddling around with a bit of training here and dumping a box of medicines or text-books there?