Health sector aid coordination in Zambia : From global policy to local practice

The volume of foreign aid to the health sector in low- and middle-income countries and the number of donors involved have increased in recent years. During the last two decades, more attention has been directed towards better coordination of donor resources and activities, particularly in the health sector. Models and agreements for how to improve the coordination of aid, such as the sector-wide approach (SWAp) and the Paris Declaration, have been launched. Significant effort has been invested in designing models for coordination, but comparatively little time has been devoted to studying how these models are implemented or what effects they have had. This thesis explores and analyses how health-sector aid coordination is implemented, from its definition in global policies to its practical application at the local level in Zambia. Aid coordination is analysed from the perspective of policy implementation. All four studies described in this thesis were conducted in Zambia, a country with extensive experience of coordination of activities and resources in the health sector. A case-study design was applied, which combined qualitative and quantitative methods for data collection. Nonparticipant observations, semi-structured interviews, document review and data on financial and administrative accounts were used. In total, more than 100 interviews were conducted with key actors: donor representatives and government officials. Findings were compared with nationally and internationally agreed indicators for efficiency in resource allocation and aid effectiveness. Findings showed that coordination is translated as it is adopted, being adapted to suit the existing administrative structures in different contexts. Translations varied more between actors than between different institutions. In general, actors were content with how healthsector aid was coordinated, although stakeholders had different ideas about how such coordination should be implemented. In Zambia, coordination efforts that started in the early 1990s have so far contributed little to the efficient allocation and use of resources in the health sector. Indicators for aid effectiveness showed that the coordination of resources at the district level is still a challenge since the number of external partners is increasing and the predictability of resources is not improving. Coordination of health-sector aid has led to changes in the ways that development aid is organized. In practice, however, the effects of these changes are still limited. The lack of effects is explained partly by observed decoupling between policy and practice, as processes are adjusted to match the actors needs and fit into the local context. The actors different understandings of how coordination is implemented and the fact that many resources are still uncoordinated weaken government ownership and are contrary to the global agreement of the Paris Declaration