The Return of the State

For the past few years, the pressure to demonstrate development results has grown. The adoption of the Millennium Declaration and the Millennium Development Goals (MDG) has placed even greater attention on low-income countries to articulate more clearly priorities and allocate resources to areas that will have the greatest impact in poverty reduction. There has also been much discussion, debate and movement on mobilising additional resources in support of low-income countries. Three of the eight Millennium Development Goals are related to the health sector (No. 4: Reduce child mortality; No. 5: Improve maternal health; No. 6: Combat HIV/Aids, malaria and other disease). This moved the health sector high on the international development agenda and has resulted in major changes in its aid architecture with the establishment of new foundations (e.g. Bill and Melinda Gates Foundation) and new Global Health Initiatives. In this respect, development aid to health has increased from about US$2 billion in 1990 to approximately $12 billion in 2004. The majority of the resources come from the new foundations and global initiatives.

The Paris Declaration: a call for more aid effectiveness

It has been estimated that there are approximately 75 to 100 Global Health Initiatives with 60% of their resources targeting the "big three" HIV/Aids, tuberculosis and malaria. Although the idea behind many of the global initiatives was to better target aid to areas which were perceived as being neglected, in a number of cases this has instead driven resources towards “diseases” (as opposed to system approaches) and created parallel mechanisms for financing, delivering and reporting. Most development actors would now agree that an average development country will need at least one generation to improve its health indicators. For this reason the focus of support should lie on strengthening the systems rather than on specific diseases and parallel implementation mechanisms. An answer to the call for enhanced coordination, coherence and especially increased aid effectiveness was the formulation of the Paris Declaration.

The Paris Declaration was adopted in March 2005 at a High Level Forum by over one hundred ministers, heads of agencies and other senior officials representatives. It represents a consensus about 56 concrete Partnership Commitments organised around the following five key principles: The Paris Declaration was formulated as a declaration of intent and an action-oriented roadmap on how to achieve more aid effectiveness as well as the Millenium Devolopment Goals in a process based on cooperation, mutual trust and accountability. In this system the country ownership and the formulation of national priorities as well as development strategies and associated operational frameworks is the precondition. Alignment of interventions to the national frameworks is the consequent answer of the development partners. Harmonisation of procedures, the establishment of common arrangements as well as coordination and mutual information should produce tangible results. Twelve indicators of aid effectiveness have been developed as a way of tracking and encouraging progress against the broader set of commitments.

The emergence of new aid modalities like general budget support (GBS) or sector baskets has changed the way how some donors are channelling their resources. In many countries, a number of donors are moving away from earmarked aid towards programming flexible resources in support of the priorities of the government. Many low-income countries are taking a stronger ownership and leadership role towards external assistance. However, the level and extent to which this is happening is very much dependent on the political will and the level of capacity in the country – as well as the participation of Non-State Actors. A pendulum movement as regards the strength and the implication of State and civil society in implementing development projects can be perceived since the structural adjustment programmes of the 80s. Today, the discussions are triggered by the worries of civil society that with the Paris Declaration their role as an independent actor in the development efforts could be undermined. In fact, the donor community assigns a leading role to the partner country and, more specifically, to the partner government. However, it has to be stressed that for Switzerland country ownership and strengthening of country systems refer to all the actors and not only to the government structures.

The importance of the Paris Declaration for Switzerland

Switzerland has actively contributed to the elaboration of the Paris Declaration. Following the adoption of the Paris Declaration Switzerland issued a high level policy statement. This statement was issued jointly by the responsible agencies, the Swiss Agency for Development and Cooperation (SDC) and the State Secretariat for Economic Affairs (SECO).

A joint SDC/SECO working group on "Harmonisation" has already achieved a series of concrete outputs, including Switzerland's active involvement in the OECD/DAC meetings and working groups, different regional SDC meetings, training activities and the dialogue which was started with Swiss civil society organisations on different levels, so as to ensure their involvement in the OECD/DAC processes. The latter is reflected in the fact that the last two SDC–Swiss NGO annual meetings have addressed the topic of the Paris Declaration and increased aid effectiveness through the discussion on the complementary roles.

A workshop of the civil society funded by SDC in Managua (November 2007) explored in-depth the role which NGO can – and are – playing in the development process in Central America. SDC undertook different dissemination and monitoring activities integrated in the formulation of the annual programmes of SDC priority countries. SDC also issued a reader with “Harmonisation Stories” in an effort to provide a more qualitative dimension of the realities on the ground. The joint SDC/SECO working group "Harmonisation" also formulated a stocktaking paper "Two years after the Paris Declaration: Where does Switzerland stand?", which was endorsed by SDC and SECO management.

Whilst the overall process of sensitisation has to be considered as exceedingly positive, the Paris Declaration also poses significant challenges for Switzerland. It effectively demands a new way of doing business which brings with it a need for new competences and adapted organisation structures. There are concerns regarding the loss of national visibility and "Swissness" of programmes that alignment and harmonisation inherently bring. This issue could be compensated by improved public relations and communication work in Switzerland. Other apprehensions relate to a more limited influence on individual projects and the risks related to its management. Finally, the "OECD/DAC 2006 Survey on Monitoring the Paris Declaration" has identified for Switzerland room for improvement, especially in the areas of alignment to national priorities, the promotion of improved national institutional capacities and the use of common arrangements or procedures. The latter point reflects the slow shift of Swiss development aid from a project to a programme approach determined by national development plans and the modest use of aid modalities such as Sector Wide Approaches and general budget support.

Implementing the Paris Declaration through SWAps in the health sector

The Sector Wide Approach (SWAp) is a form of development cooperation in which the most important donors active in a particular sector focus on a sectoral strategy defined by the recipient. The SWAp usually involves different forms of budgetary assistance. As an aid modality (as opposed to a financing mechanism) the SWAp can provide an answer to previously open questions and concerns regarding the lack of aid coordination and effectiveness. Through its involvement in SWAps in different parts of the world Switzerland sees itself playing an important role in implementing the Paris Declaration. SDC is active in approximately 30 countries, with health being a priority theme in more than a dozen – mainly in sub-Saharan Africa. SDC is involved in health SWAps in Tanzania, Mozambique, Kyrgyz Republic and Rwanda. Additionally, negotiations are under way with Burundi and Tajikistan. In all of these countries, in addition to participating in the SWAp, SDC also engages in project support. Overall, SDC invested 87 million Swiss Francs in health in 2005, with 47% being project funding and 11% provided through sector support. Sector support and budget aid are the smaller part of the general funding of activities in the health sector (cf also diagram). However, the proportion of sector support is expected to increase in the coming years.

In its efforts to increase awareness about different aid modalities, SDC conducted a Health SWAp capitalisation workshop in July 2007 to take stock of and share the institutional experience SDC has acquired through its role in health SWAps. The main identified challenges of working through a SWAp approach include the transaction costs needed to reach agreement on the common goals for which responsibility is shared and how to monitor the process. This situation is highlighted in the following quote by the Tanzanian Ministry of Health in an internal-used film of the Swiss Cooperation Office in Dar-es-Salaam: “In SWAps the good thing is that we have common objectives and agreed methods of following up. The challenge is that it takes a long time to agree on objectives, on the strategies and the methods of following up:”

The SWAp modality is highly relevant for achieving the Millenium Development Goal and for strengthening national health systems. For Switzerland, SWAps are important because knowledge gained in pilot activities can be up-scaled to national level. However, Switzerland advocates for a multi-stakeholder approach ensuring synergies between different aid modalities taking advantage of up-coming opportunities. This is not only because the respect which Switzerland gets for its context knowledge, continuity and participatory approaches is anchored in its experience with the local grassroots reality, but also because the project approach lends itself to piloting innovations and generating applied knowledge that can be fed into national policy debates. The link between the "field" and policy dialogue shall remain a distinctive feature of Swiss development cooperation. Technical assistance focuses increasingly on strengthening weak management capacities and facilitating the communication processes between State, NGOs as well as Civil Society actors. Nevertheless, the interaction between SWAps and Global Health Initiatives at the country level remains an ongoing challenge as does the harmonisation process with incoming new donors.

The role of the civil society

NGOs can make different contributions to the development agenda such as to influence the elaboration of partner country national development strategies. Furthermore many NGOs are engaged in implementation of sector strategies – generally via contractual arrangements. NGOs can also play an important “watchdog” function in the context of mutual accountability – both on the side of donors as well as on the side of partner countries. However, clarity regarding the role played by NGOs which they deem meaningful in the current aid environment is still urgently needed.

Engagement of civil society organisations in the aid effectiveness agenda may lead to some changes in aid practice. SDC is ready to support this trend. The possible changes include: creating a conducive environment for improved recognition of the important role played by civil society and collaboration between governments and civil society; defining new aid modalities aimed at strengthening civil society to better endorse its constructive role; assisting governments to become more capable in collaborating with civil society organisations.

SDC has concrete examples of support for NGOs and civil society networks in all the different roles mentioned above. In this way it is showing its commitment to involve NGOs and the civil society in the implementation of the Paris Declaration. Concrete measures towards this end include collaboration with civil society in SDC/SECO activities. SDC supports platforms for exchange and debate in Nicaragua, Burkina Faso and Tanzania. Additionally, SDC joined other donors setting up a common fund aimed at strengthening local civil society in Nicaragua and Tanzania. Another innovative way to strengthen decentralised government structures could be budget support for municipalities or SWAps at a regional/provincial level. As an agency, SDC is engaged in sensitising NGOs in the South on the importance of the Paris Agenda and of the key role they can play in counterbalancing and strengthening endeavours undertaken by the Government. Furthermore, SDC advocates the importance of civil society and its views as an irreplaceable element of accountable governance. However, it should not go unmentioned, that it will be a challenge for the donors to create instruments which are complementary to general budget support or SWAps, but are at the same time more innovative than the conventional projects. In the latter a donor agency also has the responsibility to push civil society actors to open themselves up to the paradigm shift – a task that is posing its specific challenges for us and our civil society partners as well as for other donors. In this respect, we depend also on ideas generated by civil society in order to build a country ownership which considers the strengths of the multitude of development actors on different levels of state organisation. The network of Swiss civil society maintained by Medicus Mundi Switzerland has the potential to play an important role in further engaging its members in this debate.

*This article summarises the presentation "Die Rückkehr der Staaten: Partner und Hoffnungsträger der internationalen Zusammenarbeit" held on 6th November 2007 at the Medicus Mundi Switzerland Symposium "Nichtstaatliche Gesundheitseinrichtungen und nationales Gesundheitssystem". Edita Vokral, Dr. phil., is since 2003 Deputy Head of the Department for Bilateral Development Cooperation of the Swiss Agency for Development and Cooperation. Since 2004 she chairs the SDC/SECO Working Group Harmonisation. www.deza.admin.ch/, edita.vokral@deza.admin.ch.