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Beyond the aid horizon

Findings from an ongoing research programme. Providing health care in severely-disrupted environments

Enrico Pavignani

on 6 April 2016

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Transcript of Beyond the aid horizon

Wrapping up:
Glimpses of the country case studies
Research background:
The research approach
On display is the Madaba mosaic, which presents a map of medieval Palestine, including adjacent portions of Jordan and Egypt. The Jordan river, the Dead Sea, Jerusalem and the Nile delta are all easily recognisable. Having grasped the subject of the image, the observer may also guess what the missing parts might portray. The Mediterranean Sea, for instance, lies at the bottom of the mosaic. Interestingly, some unreadable spots were deliberately effaced, because their original content was considered as offensive.
Accordingly, this research makes every effort to assemble available facts (and pointers to facts) into a meaningful image. Many tiles of the mosaic are irremediably lost, so the resulting picture is incomplete. But if the patient search for available pieces reaches an acceptable information threshold, the rough patterns of the missing parts may be reliably inferred. Additionally, some missing parts are purposefully hidden from sight, because of their sensitivity. Further fact-finding and analytical efforts are therefore needed.
Personal steps in conceptualising the research..
Fourth, reviewing the literature about healthcare provision in severely-disrupted situations, which was silent (or misleading) about the implications of state retreat or dysfunction
Second, finding a book titled "Somalia: economy without a state" (Little, 2003)
Third, reading a survey about health training institutions in Somalia, which presented a completely unexpected picture (and a vastly better one!)
Why this fringe research programme?
First, trying (unsuccessfully) to sketch the main features of healthcare provision in stateless contexts
Fifth, discussing the issue with colleagues, who confirmed that it is strangely (or deliberately?) neglected
Are these findings valid only for extreme situations, therefore not applicable to ‘normal’ poor countries?
Doubts about the country sample:
..is this a very instructive country set, which unambiguously exposes certain patterns partially hidden elsewhere?
Or rather,
Beyond the aid horizon:
charting poorly-understood health territories
Findings of a multi-country research programme
Enrico Pavignani and the research team
June 2013
University of Queensland and Danida
The multiple barriers conditioning the daily life of Palestinians also define their healthcare arena,..
Palestinians choose among many subsidised healthcare options, according to shifting conditions, in a fluid, reactive way.
..redundant health services, diverse delivery models, dispersed decision-making centres, informal power structures, multiple funding sources, assorted support systems, traditional as well as institutional safety nets.
Together, these intertwined health service delivery systems sport also a certain effectiveness and an extraordinary resilience,..
, a nation prevented from becoming a state
Another metaphor (about another map)
“If it looks like anarchy…you don’t understand what you’re seeing“
(Rackley, 2006, referring to the DR Congo).
A dynamic, well-resourced public health system cannot bootstrap itself above a doomed state-building project.
On the contrary,
trapped into their own technical discourses, health actors may remain detached from country developments.
The healthcare industry, accounting for a sizeable part of GDP in each country, might be better understood (and hence managed) on business, rather than on health or welfare grounds.
Selected over-arching research findings
Successful indigenous health governance and service delivery approaches may emerge at local level, never at central one.
Under the critical assumption that state withdrawal, country disruption and violence are permanent, many flaws affecting the healthcare arena may be interpreted as actual strengths.
Trans-border healthcare provision is a defining but neglected feature of most countries under severe stress.
Elegant mental models may be developed and perpetuated, as a way to embellish (and put at a distance) a reality grossly diverging from official narratives.
The pharmaceutical area, cause of large expenses and of health hazards, remains constantly under-investigated and under-managed.
The over-production of under-skilled health professionals, who in turn induce an over-supply of poor-quality care, is the rule.
the quintessential stateless nation (by choice)
Somalia might display
what the future prepares for other marginal countries.
Mirroring the country context, the healthcare arena is composite, cosmopolitan, and globalised.
Many Somalis travel within and outside Somalia, eclectically choosing from a variety of health services on offer.
In such a febrile fend-for-yourself workshop, crowded with healthcare providers, surprises abound.
Resource levels, service uptake, quality of care, safety nets, support systems are vastly better than expected,

...thanks to grassroots innovations blending traditional and modern, as well as local and international practices.
“The state is so present, but so useless”
(Trefon, 2009) and, we may add, often so harmful.
Geography and history make the DR Congo a constellation of peripheries with no core, ungovernable as a unitary state.
Since its creation, state deterioration, rampant privatization of the public realm, lawlessness, and wholesale pillage of the country assets have been its defining features.
Policies and plans issued by central health authorities with donor support fail to affect actual health service delivery. Likewise, central resources reach the periphery to an inadequate extent.
FBOs and NGOs deliver a large portion of health services.
'Public’ health services have been left to fend for themselves, so that business considerations dictate their operations.
...which is a jigsaw puzzle of assorted health service delivery systems, spanning the West Bank and Gaza, Israel, Lebanon, Syria and Jordan.
..made possible by the very features that make them wasteful, low-quality, aid-dependent and unsustainable:
Taking stock of the research results
For instance..
“To do the impossible you must see the invisible”
Looking ‘beyond the aid horizon’ induces the reappraisal of each studied healthcare arena,
..including the redefinition of its size and shape (often trespassing recognised frontiers),
..and the recognition of patterns previously ignored or misunderstood,

..in turn leading to unorthodox policy considerations.
These wild healthcare arenas are not empty spaces to be filled by outside interventions.
They are crowded with formal and informal private operators, who should not be ignored, but studied, and possibly engaged and managed.
In irreversibly commoditised contexts, incentives may work while coercion will not.
Efforts aimed at resuscitating derelict health authorities, or at bringing in external providers are bound to fail, or to have a modest impact at best.
The Central African Republic
a colonial cul-de-sac turned into a ghost state
“The State stops at PK 12”
- i.e., in the outskirts of Bangui, the capital (Biershenk and De Sardan, 1997).
Since the demarcation of its borders, the Central-African Republic has been unable to broadcast power to its periphery, ensure law and order, build institutions and provide services.
Colonial under-investment has been followed by internal violence and misrule, external meddling and heavy-handed French tutelage.
Country-wide, healthcare provision appears strikingly diverse, with regions served by public-turned-private facilities,others by international agencies, or by faith-based organisations, and some not at all.
The healthcare arena looks barren of ideas, initiatives, institutions and skills.Unimaginative donor-supported interventions fail to revive public health institutions, which seem beyond repair.
Private not-for-profit providers manage to fill only in part the huge gap left by the ghost state.
Informal provision remains the main or only (under-documented) healthcare option for poor and/or far-away communities.
The tormented triangle
"..on the one hand people in the region live unperturbed by the modern borders, which usually remain intangible in the desert sand, moving freely between the homes of their relatives scattered across different countries.

On the other hand the borders have to be respected by state institutions, so crossing the border to a neighbouring state therefore offers a certain protection for dissidents and rebels from persecution by the government of their home country.

With the end of the colonial era, the region was thus transformed from a transit area for nomads into a refuge for rebel groups.” (Berg, 2008)
the champion of resistance to assorted state-building efforts
The Democratic Republic of Congo
a failed state by design?
, "the apparent state"
Since 2002, a massive experiment in health service delivery is under way.
The country-wide contracting out of the delivery of a basic package of health services to NGOs has been hailed as an unqualified success.
Behind this reassuring screen, the unregulated, large-scale privatisation of healthcare provision has proceeded almost unnoticed (in international circles).
The advantage of relatively well-performing health services is gradually being lost amidst enduring conflict, state deterioration and territorial fragmentation.
The optimistic assumptions made in 2002 were more related to geopolitics than to a dispassionate assessment of the facts on the ground.

It was too good to be true (or to last for long)...
The research tries to read healthcare arenas as complex adaptive systems, which
"are more analogous to living organisms than they are to machines. They constantly adapt and change in the face of new circumstances in order to sustain themselves. This process of change is only partially open to explicit human direction and, importantly, cannot be predetermined”
(Land et al., 2009).
The incoherence, ambiguity and instability of these distressed healthcare arenas must be fully captured.
Wearing a complexity lens..
A continuing cycle of “routinized ruptures” compounds the insecurity that characterises the Haitian social and political context.
The multitude of actors present in an extraordinarily dysfunctional environment is unable to turn the sizeable resources they manage into positive healthcare developments.
A hapless Ministry of Health watches hordes of NGOs and FBOs deliver most health care, in a fragmented, deregulated way.
The acute awareness of the multiple ills affecting the Haitian healthcare arena does not ignite any concerted action.
Aid and remittances maintain alive (just) poorly-performing health services, in an apathetic, uninspired climate.
“Les résultats sont périssables”
(The results will not last).
This implies a tradeoff with the clarity and internal coherence of the analysis, which are inevitably affected.
Meanwhile, the law of unintended consequences is once more confirmed:
“An international medical NGO provided mosquito nets to a poor village in the Upemba region of Katanga. But this laudable action created a human and ecological catastrophe. As the mosquito nets were free and abundant, fisherman used them as fishing nets. Given their extremely fine mesh, not only were fish removed from the lake but all other forms of micro-fauna and micro-flora too. The lake gradually became covered with a black scum. Villagers lost their sources of livelihood and food supply. It took a Belgian priest two years to get the villagers, who believed they had been cursed, to realise what had happened and before the lake was able to regenerate.”
(Trefon, 2011)
What is the aid horizon?
A geographical metaphor
What does lie beyond it?
International agencies, research institutions and NGOs generate a wealth of data, studies and analyses.
Western aid-related aspects may be well studied, while the rest of the healthcare arena remains neglected.
Hence, the sector-wide picture generated by aid-related studies may be misleading.
Beyond the aid horizon
a fluid, fuzzy healthcare space populated by
informal and traditional practitioners,
private providers,
non-Western aid flows, diasporas, remittances,
political groups,
criminal rings
waits to be studied.
What does Western assistance look like, from
‘beyond the aid horizon’?
International actors are ill-equipped to understand the social processes triggered by state withdrawal.
The international crisis-control system, centred on states, deals poorly with regional instability complexes.
International diplomats promote the creation / revival of fictitious state configurations, which may lack legitimacy, credibility, capacity and clout.
Standard donor instruments premised on predictability and control (e.g. MDGs, MDTFs, PRS, logframes, quick wins..) look out of place in fluid, fuzzy environments.
In ungoverned, amorphous healthcare arenas, the aid industry becomes part of the problem, rather than of the solution.
In fuzzy contexts, where events can be
but not
, rational programming and managing by results constitute a delusion.
Strategic and operational fragmentation, international priorities displacing local ones, short-term engagements, frequent funding gaps, insensitivity to context, misplaced sustainability concerns, lofty state- and capacity-building ambitions...

...the list of flaws undermining aid effectiveness might be extended further.
Limitations of the research:
“As always in social sciences, the danger is to search where there is light”
(Challand, 2009).
Suggestive rather than demonstrative.
Scratching only the surface of a thick field.
Constrained by sensitive and in some cases dangerous factors.
Of uneven depth across the studied countries.
Pointing to arguable, even contentious conclusions.
Carried out mostly by health professionals.
In most studied settings health care has evolved into privatised, commoditised and largely unregulated services.
But managing healthcare actors by apportioning carrots is inherently difficult.

It is premised on knowledge, reputation, flexibility and freedom, a mix of assets no single actor is endowed with...
Central Africans access whichever health services are nearest to them, due to a severe lack of transport, long distances, impassable or insecure roads. Many people have no access to health care at all.
"..international officials in Somalia spent their office hours working on systems and procedures that they knew were a fantastical construction, and in the evening secretly read the papers of political analysts to find out what was really going on—like clandestine users of pornography“
(World Peace Foundation, 2014).
Full transcript