Full Terms & Conditions of access and use can be found athttps://www.tandfonline.com/action/journalInformation?journalCode=zgha20

Global Health Action

ISSN: 1654-9716 (Print) 1654-9880 (Online) Journal homepage: https://www.tandfonline.com/loi/zgha20

European aid and health system strengthening: ananalysis of donor approaches in the DRC, Ethiopia,Uganda, Mozambique and the global fund

Lies Steurs

To cite this article: Lies Steurs (2019) European aid and health system strengthening: an analysisof donor approaches in the DRC, Ethiopia, Uganda, Mozambique and the global fund, GlobalHealth Action, 12:1, 1614371, DOI: 10.1080/16549716.2019.1614371

To link to this article: https://doi.org/10.1080/16549716.2019.1614371

© 2019 The Author(s). Published by InformaUK Limited, trading as Taylor & FrancisGroup.

Published online: 28 May 2019.

Submit your article to this journal

Article views: 256

View Crossmark data

brought to you by COREView metadata, citation and similar papers at core.ac.uk

provided by Ghent University Academic Bibliography

PHD REVIEW

European aid and health system strengthening: an analysis of donorapproaches in the DRC, Ethiopia, Uganda, Mozambique and the global fundLies Steurs

Centre for EU Studies, Department of Political Sciences, Ghent University, Gent, Belgium

ABSTRACTBackground: In the field of international health assistance (IHA), there is a growing consensuson the limits of disease-specific interventions and the need for more health system strength-ening (HSS). European donors are considered to be strong supporters of HSS. Nevertheless,little is known about how their support for HSS translates into concrete policies at partnercountry level. Furthermore, as development cooperation is a shared policy between the EUand its Member States, it remains unclear to what extent European donors share a similarapproach.Objective: This article reviews a PhD thesis on European aid and HSS. The thesis investigated(1) the approaches of European donors towards IHA, and (2) the extent to which there aresimilarities or differences between them. An original analytical framework was developed tomake a fine-grained analysis of European donors’ approaches in the DRC, Ethiopia, Ugandaand Mozambique. In addition, the relation of European donors with the Global Fund wasinvestigated.Methods: An abductive research approach was used during which literature review, datageneration, analysis and research design mutually influenced each other. The research builton a wide range of empirical data, including semi-structured interviews with 123 respon-dents, policy documents and descriptive statistical analysis.Results and conclusion: Four ‘types’ of European donors were identified, which vary in theirfocus (issue-specific versus comprehensive) and their level of support to and involvement ofrecipient states. Despite this heterogeneity at a specific level, there is still a general degree of‘unity’ among European donors, especially compared with the US. Yet, there are signs that the‘transatlantic’ divide on HSS may be converging, as European donors tend to focus moreexplicitly on result-oriented approaches traditionally associated with the US and GlobalHealth Initiatives. Consequently, European donors play a limited role in bringing HSS moreto the forefront in IHA.

ARTICLE HISTORYReceived 26 October 2018Accepted 26 April 2019

RESPONSIBLE EDITORPeter Byass, UmeåUniversity, Sweden

KEYWORDSEuropean Union; Europeandonors; health systemstrengthening; globalhealth; developmentcooperation; internationalhealth assistance; globalfund

Background

Development assistance for health (DAH) has increasedsignificantly since 1990. However, as can be seen inFigure 1 the large majority of additional funding hasgone to the fight against specific diseases or themessuch as HIV/AIDS [1]. Furthermore, interventions haveoften been set-up with little involvement of the state,which led to the creation of so-called parallel systems.Consequently, little money and attention has been dedi-cated to strengthening the public health systems in devel-oping countries. The lack of a well-functioning publichealth system can have devastating consequences, as wasbrutally demonstrated during the 2014–2016 Ebola out-break in West Africa [2,3].

The importance of health system strengthening(HSS) has already been acknowledged for decades,with an important milestone being the Alma AtaDeclaration from 1978. This declaration aimed toreach ‘health for all’ by 2000 and stressed the impor-tance of primary healthcare and HSS to reach this

goal [4]. However, the principles of Alma Ata soonlost prominence and donors have provided muchmore attention and funding to fight specific diseasesrather than to HSS. This trend was reinforced by anunprecedented growth of so-called Global HealthInitiatives in the beginning of the new millennium,the most important ones being the Global Fund tofight HIV/AIDS, Tuberculosis and Malaria (hereafterthe Global Fund), the Global Vaccines Initiative(GAVI) and the US President’s Emergency Plan forAIDS Relief (PEPFAR). These initiatives have mas-sively increased the resources for global health, buthave been using rather disease-specific, parallelapproaches. Yet, since the mid-2000s, academicsand policymakers have increasingly stressed the lim-itations of these approaches, which led to a renewedconsensus on the need for HSS.

However, despite the increased attention for HSS,there is no common understanding on what the termexactly entails [5,6]. Consequently, donors have different

CONTACT Lies Steurs lies.steurs@gmail.com Centre for EU Studies, Department of Political Sciences, Ghent University, Universiteitstraat 8, 9000 Gent,Belgium

GLOBAL HEALTH ACTION2019, VOL. 12, 1614371https://doi.org/10.1080/16549716.2019.1614371

© 2019 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permitsunrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

interpretations and use different strategies to implementit. Moreover, the discursive importance attached to HSSin policy documents does not necessarily translate intoincreased support for HSS at country-level. Severalauthors claim that HSS is often interpreted and imple-mented in a very narrow, instrumental way, using well-targeted and specific interventions with clear, measurableoutcomes [7–9]. This is in strong contrast to a broaderconceptualization of HSS focused on social, societal andpolitical dimensions.

The European Union (EU) and its Member Stateshave been important donors, providing about a quarterof all DAH [1].Within their policy documents, Europeandonors tend to focus a lot on strengthening health sys-tems. The Council conclusions of 2010 on the EU role inGlobal health even explicitly stated that ‘the Council callson the EU and its Member States to act together in allrelevant internal and external policies and actions byprioritizing their support on strengthening comprehensivehealth systems in partner countries’ [10].

Nevertheless, little is known about how thisEuropean support for HSS in policy documents trans-lates into concrete policies at partner country-level.Furthermore, as development cooperation is a sharedpolicy between the EU and its 28 Member States, itremains unclear to what extent European donorsshare a similar approach on this matter. The limitedavailable research on European development coopera-tion seems to stress the differences between the indi-vidual European donors. An often made distinction isthe one between the more progressive Nordic andlike-minded countries and the more traditionalSouthern Member States [11,12]. Nevertheless,European approaches have not been systematicallyand comparatively analysed, neither in general norwith a specific focus on the sector level.

Another related theme is the level of ‘distinctive-ness’ or ’uniqueness’ of European donors. This relatesto the question to what extent there is – despite thedifferences among them – at least some degree ofsimilarity among European donors, making themdifferent from other donors. Certainly, there are dif-ferences with the emerging donors, which have chal-lenged the ‘Western’ consensus on international aidwhen it comes to issues such as political condition-ality [13,14]. In addition, European donors are said tobe inspired by normative principles and they havepaid more attention to the aid effectiveness principlesthan is the case for the US [15–17]. In health, inparticular, some authors referred to an Atlantic fault-line in thinking on health systems, which is linked tothe competing public health ideologies across theAtlantic ocean [9,18]. The US is generally consideredto be supportive of technology-oriented disease-specific solutions, providing funding through parallelsystems and NGOs. European donors on the otherhand are considered to promote coordinated publicsector aid models, favouring sector-wide approachesand budget support models. Yet, Storeng [9] claimedthat the transatlantic distinction is eroding in favourof a more narrow, technology-focused and market-based interpretation of HSS.

Building on these insights from the field of inter-national health assistance as well as EU-Studies, themain goal of the PhD research was to get an in-depthunderstanding of the approaches on internationalhealth assistance (IHA) of several European donors,with a specific focus on the partner country-level.

The main research question of my dissertation was:‘What is the European approach to internationalhealth assistance?’ In order to answer this question, thefollowing sub-questions were formulated:

Figure 1. Development assistance for health, distributed by focus area (IHME, 2018).

2 L. STEURS

(1) What are the approaches of European donorstowards international health assistance?

(2) To what extent are there similarities anddifferences between European donors inthis regard?

Empirical embarkation

It would have been unfeasible to research all Europeandonors’ health assistance approaches towards the wholedeveloping world through all channels and at all times.Consequently, I had to narrow down the focus.I analysed and compared the IHA approaches of 13European donors in six empirical settings (Table 1). Itconcerns EU itself, 10 EU Member States (France, theUK, Belgium, the Netherlands, Sweden, Denmark,Ireland, Italy, Spain and Germany), 1 Flanders (a feder-ated entity of Belgium) and Switzerland.2 These are theEuropean donors that have financed the most DAH overthe past years. However, not all Member States’approaches were discussed in every empirical setting.

The first setting concerns the European donors’approaches at headquarters level. Relevant documentsand aid figures at headquarters level were discussedto illustrate European donors’ vagueness and ambi-guity on HSS. While certainly important, this contextwas not the main focus of the PhD as it served asa broader context for the other two, more specificempirical contexts.

The second group of empirical settings was thecore of the PhD and concerned the bilateral coopera-tion of European donors in four partner countries inSub-Saharan Africa. I focused on Sub-Saharan Africaas this continent suffers the most from health pro-blems and receives most DAH from (European)donors [1]. Specifically, I examined European donors’approaches in the DRC, Ethiopia, Uganda andMozambique. These countries were selected becauseat least five European donors assigned health asa priority sector of their bilateral aid in these coun-tries. Consequently, by focusing on these four coun-tries, a maximum amount of European donors’approaches could be analysed. First, it could be ana-lysed how different European donors were reacting inthe same country. Second, it could be researched how

a certain donor was behaving in different partnercountries and to what extent some general trendsabout this donor’s approach can be observed acrossthese countries.

The last empirical setting concerned the multilateralcooperation via the Global Fund. The EU and several ofits Member States have played an important role in thedevelopment of the Global Fund and have been contri-buting considerable amounts of money to it. However,this seems to contradict with the European pleas for HSSas the Global Fund has a disease-specific approach andits efforts onHSS have been limited. During interviews inthe partner countries, several respondents referred to thisambiguous relation between European donors and theGlobal Fund. Consequently, I dedicated a separate articleto it [19] which was also included in the PhDdissertation.

Methods

The research for my dissertation was conductedthrough an abductive research approach. Abductionreasons at an intermediate level between deductionand induction [20]. Instead of following a linear ‘firstthis, then that’ logic, it implies a more cyclicalresearch process during which literature review, datageneration, data analysis and research designmutually influence each other [21]. Abduction stemsfrom the pragmatist research tradition [22] andallowed me to conduct problem-driven and practice-oriented research and to take a holistic perspective onthe European involvement in international healthassistance.

Empirical data were generated and analysedthrough a mixture of research methods. A firstmethod was semi-structured expert interviewing. Intotal, interviews were conducted with 123 respon-dents. While some explorative interviews were con-ducted at headquarters level (in 2014–2015), most ofthe interviews were conducted during four fieldworktrips in November–December 2015 (the DRC andEthiopia) and March–April 2017 (Uganda andMozambique), as well as additional Skype interviewsin early 2017 with respondents in the DRC. Thegroup of respondents included representatives from

Table 1. Overview of empirical settings.EU FR UK BE FL NL SE DK IE IT ES DE CH

Headquarters x x x x x x x x x x x x xBilateral cooperation in partner countries DRC x x x x x

Ethiopia x x x x x xMozambique x x x x x x xUganda x x x x x x

The Global Fund x x x x x x

1As the referendum on the Brexit took place in the middle of the research and as it is not clear yet what this will imply for the development cooperationpolicies of the UK and the EU, the UK is considered an EU Member State as any other in this dissertation.

2While Switzerland is not part of the EU, it was integrated in the analysis because it shares a similar history with the EU donors in the health sector ofMozambique and because existing research suggested that Swiss development cooperation policy is relatively ‘Europeanized’ [36].

GLOBAL HEALTH ACTION 3

European donor agencies, non-European donoragencies, the Ministries of Health, civil society orga-nizations and some local academic researchers. Thisbroad range of respondents allowed me to get bothinternal and external perspectives on European IHAapproaches. In May–June 2017, additional interviewswere conducted over Skype to obtain more specificinformation on the relations between EU donors andthe Global Fund. All interviews were recorded onaudiotaped, fully transcribed and analysed by usingNVivo software.

In addition to the interviews, policy documentsproved to be another important source of data.A variety of documents was consulted, whichfocused on the headquarters level (e.g. developmentcooperation or global health strategies) or on thespecific partner countries (e.g. donors’ country-specific development cooperation strategies, pro-gram documents or joint evaluation documents).Most of these documents were publicly availableon donors’ websites and other – more specific –documents were provided by interviewees. Thedocuments were analysed through a close and itera-tive reading. To complement the data from inter-views and policy documents, I also conducted somedescriptive statistical analysis on European donors’DAH, based on the ‘Development Assistance forHealth Database 1990–2017’ from the IHME [1].

Analytical framework

To analyse the European approaches in four partnercountries, an original analytical framework was devel-oped. This framework built on the often-made distinc-tion between so-called ‘vertical’ and ‘horizontal’approaches. The vertical approach implies that fundingand attention are mainly going to disease-specific inter-ventions, which often leads to quick, visible and measur-able results. The horizontal approach entails a focus onstrengthening basic health care and the wider healthsystem. This is claimed to be more sustainable in thelong term, but it is also more abstract, as the results aredifficult to measure. The past decades have showna continuous debate on the advantages and disadvan-tages of both approaches, e.g. [23–28].

However, while often used, the vertical–horizontaldichotomy is somewhat problematic. First, the termsare ambiguous, as they refer to a wide range of phenom-ena [29,30]. Second, by framing the debate asa dichotomy, one creates the impression that an IHAapproach is either ‘vertical’ or ‘horizontal’, while hybridapproaches are also possible. To allow for a more fine-grained analysis of the different European approaches, I,therefore, developed a framework which exists of twocontinuums (Figure 2).

The first continuum concerns the focus. This linkswith the more conventional interpretations of the

vertical versus horizontal debate as being specific,narrow and non-integrated versus comprehensiveand integrated. Given the problematic use of theseterms, I prefer to use the terms ‘issue-specific’ and‘comprehensive’, which are the two ends of the top-down continuum of the framework. The continuumis divided into five separate categories:

Targeted: Particular focus on a specific disease orhealth problem

Semi-targeted: Focusing on a particular disease orhealth problem, but taking into account the widersystem

Hybrid: Balancing a focus on specific diseases orhealth problems with a wider focus on the healthsystem

Semi-comprehensive: Focusing on the overall healthsystem, while still prioritizing certain diseases orhealth problems

Comprehensive: Holistic focus on the overall healthsystem

The second continuum, state involvement, links tothe deeply political question to what extent donorssupport the state and the existing country systems.Although the vertical-horizontal distinction mostlyconcerns the focus of IHA, some authors also use itto denote the extent to which donors make use ofexisting structures [24]. In addition, ‘the relativepower states and private sector actors should haveover the stewardship of health systems’ is also con-sidered to be one of the major fault lines in thedebate on HSS [6]. The dimension on state invol-vement thus refers to the extent to which donorssupport governmental policies (e.g. national healthstrategies), existing state structures (e.g. Ministry ofHealth, national procurement systems), or evenofficial policymakers (e.g. members of govern-ment). These dimensions of state involvement canbe conceptualized at both central and local levels.The state involvement is the left-right continuumof the framework and is divided into the followingfive categories:

Parallel: Working through parallel systems withoutinvolving the state

Semi-parallel: Working through parallel systemswhile involving the state to a limited extent

Pragmatic: Involving the state to the extent possibleand consulting the governmental institutions as ‘oneof the partners’

State-supportive: Using the existing system toa large extent and supporting the governmental insti-tutions in developing and/or implementing its plans

State-entrusting: Entirely supporting the state

4 L. STEURS

While it may seem plausible that both dimensions cor-relate, it is important to analytically distinguish betweenthem. First, this two-dimensional approach allows us toclarify the current conceptual confusion arounda donor’s IHA approach and to make a more preciseassessment of it. Second, one could imagine that, at leasttheoretically, donors have opposite approaches on bothdimensions. On the one hand, a donor could have anissue-specific focus while at the same time closely invol-ving the state through collaborating with the govern-ment and the existing public health system. This wouldfor example be the case if a donor supports the thirdcountry government to implement its specific HIV/AIDS policy. On the other hand, a donor could theore-tically have a relatively comprehensive focus which isnevertheless implemented entirely parallel withoutinvolving the state. This would for instance be the caseif a donor is supporting NGOs to provide primaryhealthcare services, without involving the governmentofficials and without taking into account the existingpolicies and structures.

The combination of these two continuums resultsin 25 different possibilities categories. Being idealtypes, all these 25 categories are not necessarilyexpected to occur in reality. Especially the categoriesat the extremities are thought to be less common inreality, as donors generally consider them to be eitherundesirable (entirely targeted or parallel) or

unrealistic (entirely comprehensive or state-entrusting). The European approaches will thusmainly vary between the middle nine approaches.

Results and discussion

Overview of the empirical settings

The analytical framework was applied to Europeandonors’ health assistance in the DRC, Ethiopia,Uganda and Mozambique. Figure 3 providesa summary of how the analytical framework wasapplied on European donors’ approaches in the fourcountries. The contexts differed quite substantially,which also impacted on donors’ approaches. In thenext paragraphs, I will provide a short summary onthe approaches in each setting.

Due to the fragile context of the DRC, high levels ofcorruption and the low level of trust in the Congolesegovernment and structures, the existence of and discus-sion on different approaches was the most prominentlypresent in this country. In principle all donors supportedthe idea of HSS, but there seemed to be different inter-pretations of it. While some donors wanted to collabo-rate with the state institutions and work as much aspossible through the existing structure, others weremore reluctant and thought that the system had to bebuilt first before it could be used. These different

Figure 2. Analytical framework.

GLOBAL HEALTH ACTION 5

interpretations featured prominently in the debate on theprocurement and distribution of medicines, with somedonors using the existing national system as much aspossible and others refusing to make use of it until itproved to be working more efficiently. Overall, theapproaches of European donors varied, with Belgiumand the EU having a state-supportive approach, and theUK, Sweden and France having a more pragmaticapproach. Also in terms of focus, approaches rangedbetween semi-targeted and semi-comprehensive.

In Ethiopia, there was a relatively good relation oftrust between donors and the Federal Ministry ofHealth. This was mainly due to the strong ownershipand leadership of the FMOH, which succeeded inmanaging the ‘aid jungle’ by aligning the donors withits own plans and priorities. All European donors werecontributing to the pooled MDG/SDG performancefund. Consequently, most European donors had a state-supportive approach. Differences in focus related tospecific objectives donors want to obtain, which canbe manifested by pushing for certain topics in discus-sions about the MDG/SDG performance fund, but alsoby funding additional-specific projects/programmesthrough which a specific theme is stressed. For example,the Netherlands focused a lot on sexual and reproduc-tive health and rights and transferred a relatively big

amount through NGOs, in addition to the MDG/SDGperformance fund (which also resulted in a more prag-matic approach than other donors).

In Uganda European donors used to be the strongestsupporters of the Sector Wide approach (SWAp) andSector Budget Support (SBS) in the late nineties and thebeginning of the 2000s, which implied a relatively com-prehensive focus and a high level of state involvement.However, over the years the relation between SWApsupporters and the government started deteriorating,due to a de-prioritization of health by the governmentand increasing concerns of corruption. At the same time,European domestic governments started to focusincreasingly on value-for-money and quick results,which led to less commitment to the principles of theSWAp and SBS. When a big corruption scandal at theOffice of the Prime Minister happened, all donors endedtheir direct support to the government. Consequently,the SBS in the health sector was also suspended, whichmade some donors change their approach. Belgium wasthe only donor that still applied a comprehensive andstate-supportive approach. Despite the fact that it alsosuspended the SBS, it has implemented programmeswhich aim to improve the entire health system andwhich are implemented in close collaboration with theMinistry of Health. The other European donors had

Figure 3. Summary framework.

6 L. STEURS

a more issue-specific focus with a lower level of stateinvolvement.

InMozambique, most European donors used to con-tribute to the pooled fund PROSAUDE. However, overthe years PROSAUDE encountered several challengeswhich led to severe discussions on its reform. However,this reform process was hampered by other factors. Dueto a big debt scandal in 2016, donors completely lost theirtrust in the government systems, which made mostdonors decide to suspend all aid that was provideddirectly to the government, including the funding forPROSAUDE. In addition, the Global Financing Facility(GFF) became an additional important initiative in thehealth sector of Mozambique and was regarded by someas an attractive alternative for PROSAUDE, given itsmore specific focus on women and child’s health andits attention for cost-effectiveness and results. Theongoing discussions on the reform of PROSAUDE andthe launch of the GFF made clear that different positionsexisted among European donors. While most donors(Ireland, Switzerland, Denmark, Flanders and Italy) con-tinued their support for PROSAUDE, the UK and theNetherlands decided to stop providing funding, whichimplied more issue-specific and pragmatic approaches.On top of that, there were also clear differences in termsof the relative importance attached to PROSAUDE, aswell as differences in focus and level of state involvementin the complementary programmes.

As mentioned earlier, I also investigated the relationbetween European donors and the Global Fund, witha focus on the debate on HSS. This research started fromthe puzzling observations during fieldwork, where inter-viewees at European agencies complained about thenegative effects of the Global Fund on countries’ healthsystems. As European donors themselves contribute sig-nificantly to the Global Fund, I wanted to better under-stand this relation. The findings indicated a ‘love–haterelationship’. European donors have loved the GlobalFund’s innovative institutional set-up and its ‘savinglives’ approach involving quick results. However, overthe years they have become more critical about theGlobal Fund’s narrow focus. Consequently, they haveincreasingly advocated a shift towards more HSS. Thishas been partly successful at the headquarters level, mostnotably the incorporation of concrete HSS commitmentsin the Global Fund’s strategic documents, but challengesat local level constrain the translation into funding andimplementation measures. The key tension is that ‘hor-izontalizing’ the Fund remains challenging, because the‘specificities’ that make the Global Fund so successfuland attractive, are precisely those that also impedemoves towards HSS.

As a detailed analysis of the European approaches ineach empirical setting can be found in the separatechapters of the dissertation, I will focus in the remainingpart of this PhD review on the overall findings.

Heterogeneity among european donors

A first important finding of the PhD research was theheterogeneity among European approaches. As canbe seen in Figure 3, individual donors’ approachescan differ geographically and temporally. Differencesbetween partner countries can be seen from the dif-ferent colours in Figure 3, which represent the fourpartner countries. While several European donorswere present in the health sector in two or morepartner countries, this did not mean that they hadexactly the same approach in all settings. For exam-ple, the UK was present in four partner countries andits approach has been classified differently in eachcountry. Furthermore, differences could also beobserved over time, as can be seen from the arrowson the summarizing framework. While theapproaches in the DRC and Ethiopia remained fairlystable, there has been a change in approach amongsome of the donors in Uganda and Mozambique overthe past years. For example, the Dutch approach inMozambique changed from hybrid and state-supportive to semi-targeted and pragmatic.

However, despite these geographic and temporaldifferences, certain patterns could be identified in theapproaches of each individual donor. Some donors staywithin the same ‘region’ of the framework and do notmove much. As such, their position in the frameworkremains relatively stable. For example, Belgium is typi-cally situated at the bottom right of the framework.Some donors display a certain pattern in how theymove within the framework. For instance, a numberof countries have typically moved towards the upper leftpart of the framework. Consequently, I distinguishedfour ‘types’ of European donors.

Belgium, the EU, Switzerland, Spain, Denmarkand Flanders are classified as type 1, which can bereferred to as ‘hardline health system strengtheners’.These donors were classified as either semi-comprehensive and state-supportive or comprehen-sive and state-supportive. The donors within thisgroup seem to apply this approach regardless of thegovernance situation. This implies that even ina challenging governance situation, they endeavourto have a comprehensive focus and to have a ratherhigh level of state involvement.

The second type of donors is the Netherlands, Swedenand the UK. Their approaches are in general more tar-geted and less state-supportive than the former type ofdonors. Furthermore, their approaches have also chan-ged over time in Uganda and Mozambique.Consequently, they can be considered to be ‘flexible’ inthe sense that the focus and level of state involvement islikely to change in light of the governance situation of thepartner country. When there is a favourable context, thistype of donors contributes to pooled funds or sectorbudget support, which implies a relatively

GLOBAL HEALTH ACTION 7

comprehensive and state-supportive approach. However,in case the context is (or becomes) less favourable, thesedonors work through other partners such as NGOs andUN agencies that are often implementing more targetedprograms. In the latter case, there is still a pragmatic levelof state involvement, but it seems to be more importantthat results can be made on specific focus areas.

Ireland and Italy can be considered a third type ofdonors. In general, these donors tend to be morestate-supportive than the flexible group but theyhave a less profound approach on it than the hard-liners. Furthermore, the group cannot be character-ized by a stable focus, as donors are sometimes moreissue-specific (cf. flexible group) and sometimes morecomprehensive (cf. hardliners).

France does not belong to any of the former types, asit is has a very particular stance. France is an importantdonor to the Global Fund and GAVI and has decided tocomplement its financial presence with an active pre-sence in the policy dialogue in these organizations, bothat the level of the board and at the level of partnercountries. Within this policy dialogue, France seems tobe advocating for a more comprehensive focus anda higher level of state involvement. While the Frenchapproachwas only investigated in theDRC, the empiricaldata on the engagement of France in the Global Fund aswell as policy documents at headquarters level and exist-ing (grey) literature proved to be relevant additional datato substantiate this finding.

European ‘unity’ in diversity?

The above-mentioned classification of Europeandonors shows that there is quite some heterogeneityamong European donors. Nevertheless, despite thesedifferences at the specific level, the research alsorevealed that there is still a certain degree of ‘unity’among European donors at a more general level,which contrasts with other donors such as the US.Consequently, while nuancing the existence ofa ‘European’ approach, this research also confirmsthe transatlantic divide discussed in literature.

The relative unity among European donors and itsdistinctiveness in relation to the US were prominentlydiscussed in the research on the Global Fund. The articleclearly showed the varying approaches on HSS betweenthe European donors and the US. Already in the initialstages of the Global Fund’s development, there seemed tobe different opinions on the matter. But since the GlobalFund was thought to provide ‘complementary’ supporton top of bilateral funding, this was not considered to beproblematic at that time. However, over the years, theGlobal Fund became a more powerful organization andits targeted and parallel approach increasingly got criti-cized. As the Global Fund appeared to have negative

effects on countries’ health systems which Europeandonors themselves have tried to build and strengthen,European donors increasingly tried to ‘horizontalize’ theGlobal Fund. The US on the other hand has never beena strong advocate of broadening the approach of theGlobal Fund.

The contrast between European approaches and theUS was also evidenced in the analysis of approaches inthe partner countries. Regardless of the capacity or lea-dership of the state, European donors in general werehaving a rather comprehensive focus and a relativelyhigh level of state involvement. In Ethiopia, Ugandaand Mozambique, European donors were the earliestand most generous supporters of, respectively, theMDG/SDG PF, the health SBS and PROSAUDE. In thefragile and challenging context of the DRC, Europeandonors acknowledged the importance of making use ofthe system as much as possible, which was manifestedmost clearly in the debate on the procurement and dis-tribution of medicines. On the other hand, the US didnot participate in any of the pooled funding arrange-ments in Ethiopia, Uganda andMozambique. And in theDRC, the US shared the opinion with the Global Fundand GAVI that the national system for procurement anddistribution of medicines had to be built first before itcan be used. Consequently, the general approach of theUS can be considered to be semi-targeted and semi-parallel. Compared to the US, all European donors’approaches are thus located more towards the right andbottom side of the framework.

However, this transatlantic divide also needs to benuanced as some degree of ‘convergence’ can be noticedbetween the approaches at both sides of the AtlanticOcean. On the one hand, European donors seem tohave become less profound supporters of HSS in recentyears. As clarified earlier that some European donors aremore ‘flexible’ and have moved away from HSS orientedapproaches. Importantly, evenwithin the so-called ‘hard-liners’, there are indications that HSS is increasinglycontested (e.g. in Belgium). The research on the GlobalFund also suggested that HSS may perhaps not be asimportant a political priority for European donors asoften thought/pretended, as they continue supportingthe organization even though it remains questionablewhether the proclaimed efforts for more HSS can besuccessful. On the other hand, the US seemed to haveopened up its approach a bit towards HSS. In all of thepartner countries, respondents of the US mentioned thatthere has been a gradual shift towards a more compre-hensive focus and a higher level of state involvement overthe years. At the same time, the recent, progressive moveof the Global Fund towards more HSS at headquartersalso implies that the US (which is a very important donorof the Global Fund) has also agreed upon a (limited)broadening of the approach.

8 L. STEURS

Towards an understanding of the findings

This dissertation provided an in depth analysis ofEuropean donors’ approaches and a full explanationwent beyond the scope of the research. Nevertheless,I can touch upon three majors factors that help tobetter understand the (evolving) approaches, differ-ences and similarities between European donors andopen avenues for further research.

First, the research clearly demonstrated the impor-tance of partner country-related factors. In particular,respondents often referred to the governance situationin the partner country when discussing (certain changesin) European donors’ approaches. The DRC andEthiopia could be considered to be two ‘extremes’ whenit comes to the governance situation. In the DRC, thefragile context, the high level of corruption and the lowlevel of trust in the Congolese government and structuresmade that none of the donors wanted to contribute topooled funding arrangements. In Ethiopia on the otherhand, the leadership of the Ministry of Health made thata relatively good relation of trust existed and thatEuropean donors have been contributing to the pooledSDG performance fund. The governance situation ofMozambique andUganda can be considered to be some-where between these two extremes. In both countries,there used to be a relatively high level of trust betweendonors and the government. However, over the years, thegovernance situation deteriorated. In a context in whichdonors have already been struggling for years, the occur-rence of certain corruption scandals became the decisivemoment for donors to change their approaches.

Second, the research showed the importance ofchanges in international thinking on development assis-tance the way European donors have reacted to these. Inthe 1990s and early 2000s, the international developmentcommunity paid increased attention to ownership, har-monization and alignment, which was manifestedthrough the development of the SWAps and the contri-butions to pooled funds and (sector) budget support.European donors attached great importance to theParis Declaration and soon became frontrunners in theaid effectiveness agenda [31]. This has also facilitateda certain level of unity among European donors’approaches in IHA. As was discussed in the dissertation,European donors were the earliest supporters of thepooled funds and SBS in Ethiopia, Uganda andMozambique. By the end of the 2000s, however, theinternational support for ownership, alignment and har-monization started to wane and increasingly got oustedby a strong focus on value-for-money and quick resultsthat can directly be attributed to individual donor activ-ities and which can be easily communicated to the public[32]. This tendency has very clearly manifested in thehealth sector, where practices are being measured andevaluated using quantitative indicators such as theamount of bed nets provided, the amount of people

vaccinated, and – ultimately – ‘the amount of livessaved’ [33,34]. As shown in this research, Europeandonors have not been immune to this internationaltendency to prioritize value-for-money and quick results.Especially in Uganda and Mozambique, donors seemedto have lost faith in the principles of ownership, harmo-nization and alignment, given the waning support for theUgandan SWAp and SBS, and the MozambicanPROSAUDE. Several respondents were referring to thefact that their headquarters increasingly focused onresults and accountability, which has pushed the princi-ples of ownership, harmonization and alignmentmore tothe background. Nevertheless, this tendency to focus lesson the latter principles and more on value-for-moneyand quick results appeared to be more apparent forcertain European donors than for others.

While the two above-mentioned factors certainly helpto understand why the preference for HSS amongEuropean donors is rather fragile and ambiguous, theyfail to explain the particular differences betweenEuropean donors. Consequently, I suggest that one alsoneeds to investigate the domestic factors of Europeandonors that differ between them and can explain thedifferent approaches on HSS. These factors can include(changes in) the composition of national governments,the (lack of) roomofmanoeuvre for local delegations, theinstitutional organization of development policy (and ofsocial and health policy), the power of national parlia-ments and civil society organizations, economic andforeign policy interests, etc..My research already revealeddomestic factors in Belgium, including the collaborationbetween and like-mindedness among several Belgianactors, which might explain the Belgian position asbeing a hardline health system strengthener [35]. Yet,the investigation of the domestic factors for all Europeandonors went beyond the scope of this research and willneed to be subject to further research.

Conclusion

The main goal of this dissertation was to get an in-depthunderstanding of the IHA approaches of Europeandonors. The systematic, fine-grained analysis showedthat there is significant heterogeneity of Europeanapproaches on international health assistance. Donors’approaches differ between partner countries and theycan change over time. Yet, certain patterns can be iden-tified that characterize individual donors. Consequently,four ‘types’ of European donors were distinguished,which vary in their level of support to and involvementof recipient states and in their level of focus on specificdiseases or health issues. Despite this high level of hetero-geneity at a specific level, the PhD research neverthelessalso showed that there is still a general degree of ‘unity’among European donors. These distinctive similaritiesbecome even more evident when comparing European

GLOBAL HEALTH ACTION 9

donors with the US. Yet, there are signs that the ‘trans-atlantic’ divide on the issue of health system strengthen-ing may be converging, as several European donors areincreasingly focusing on cost-effectiveness and directresults, which is traditionally more associated with theUS and global health initiatives.

In sum, this dissertation illustrated the heterogeneityof European approaches and the tendency to moveaway from state-supportive, comprehensive HSSinvestments. Consequently, the EU as a whole seemsto play a limited role in bringing health systemstrengthening more to the forefront in internationalhealth assistance. If European donors still want to‘walk their talk’ on HSS, they will have to reconsiderthe way they are providing health assistance in fragilegovernance contexts and find innovative ways tostrengthen the system. In addition, they have tobecome more involved in the follow-up of multilateralorganizations both at headquarters and local level.

This research has been one of the first studies thatbridged insights from the field of EU-studies with thefield of international health assistance, by thoroughlyinvestigating and comparing the European IHAapproaches. Throughout the empirical research, I alsomade an important analytical contribution, asI developed a new framework to analyse donors’ IHAapproaches, which consists of two continuums being thefocus of IHA and the state involvement. The applicationof the framework confirmed the relevance of the twoseparate continuums. The fact that not all the donors’approaches were classified in the diagonal from theupper left corner to the bottom right corner illustratethat there is no one-to-one relationship. Nevertheless, theapplication of the framework also showed that in mostcases, the position of donors on both continuums seemedrelatively closely related to each other. A high level ofstate involvement often involved a rather comprehensivefocus, as is the case when donors are contributing topooled funds or SBS. When donors have a rather prag-matic level of state involvement, for example, when theyare channelling funding through UN agencies, this oftenalso implied a more targeted approach. This frameworkcan be further developed by focusing especially on therelation between the two continuums.

The broad perspective on several European donorsand several empirical settings have had the downsidethat not everything could be investigated in depth.Furthermore, the focus of the research was mainly onthe donor side and less on the domestic factors in thepartner countries. Consequently, future research couldfocus more in depth on one or a few European donors,with more attention for the domestic politics and insti-tutions which might explain the preference for a certainapproach. For example, a closer look at the UK couldbe all the more relevant in the light of the Brexit. Also,the role of post-colonial influences on donors’ DAHcould be investigated more in depth. In addition,

ethnographic research could focus more on the partnercountry itself and investigate how the political, cultural,economic, geographical and societal factors are influ-encing the health system and the health assistance.

Acknowledgments

I would like to express my sincere thanks to my supervisorsJan Orbie and Sarah Delputte and the members of thedoctoral advisory committee Dries Lesage and GorikOoms for their support and advice which generouslyhelped improve my research project. I also wish to thankall respondents for making time to share valuable insightsand information on European health assistance. I gratefullyacknowledge the funding from the Flemish InteruniversityCouncil for University Development Cooperation (VLIR-UOS), who awarded me a PhD scholarship. Lastly,I express my gratitude to the members of the doctoralexamination board, for thoroughly reading my work andproviding critical, yet constructive comments.

Disclosure statement

No potential conflict of interest was reported by the author.

Ethics and consent

No patients were involved in this study. Respondents forthe qualitative interviews provided oral informed consentand were fully anonymized.

Funding information

This research was supported by the Belgisch DevelopmentCooperation through VLIR-UOS.

Paper context

While European donors are considered to be strong suppor-ters of health system strengthening (HSS), little is knownabout how this support translates into concrete policies atpartner country level. This research illustrated the heteroge-neity of European approaches and the tendency to moveaway from state-supportive, comprehensive HSS invest-ments. If European donors want to walk the talk on HSS,they will have to find innovative ways to strengthen thehealth system in fragile governance contexts.

References

[1] IHME. Development assistance for health database1990–2017. 2018. [cited 2018 Aug 15]. Availablefrom: http://ghdx.healthdata.org/record/ihme-data/development-assistance-health-database-1990–2017

[2] Gostin LO. Ebola: towards an international healthsystems fund. Lancet. 2014;384:49–51.

[3] van de Pas R, van Belle S. Ebola, the epidemic thatshould never have happened. Global Affairs.2015;1:95–100.

[4] WHO. Declaration of Alma-Ata: InternationalConference on Primary Health Care, Alma-Ata,USSR, 6–12 September 1978. 1978. [cited 2018 Aug

10 L. STEURS

15]. Available from: http://www.who.int/hpr/NPH/docs/declaration_almaata.pdf

[5] Hafner T, Shiffman J. The emergence of global atten-tion to health systems strengthening. Health PolicyPlan. 2013;28:41–50.

[6] Storeng KT, Prince RJ, Mishra A. The politics ofhealth system strengthening. In: Parker R, Garcia J,editors. Routledge handbook on the politics of globalhealth. Routledge; 2019. p. 273–287.

[7] van Olmen J, Marchal B, Van Damme W, et al. Healthsystems frameworks in their political context: framingdivergent agendas. BMC Public Health. 2012;12:1–13.

[8] Marchal B, Cavalli A, Kegels G. Global health actorsclaim to support health system strengthening - Is thisreality or rhetoric? PLoS Med. 2009;6:4.

[9] Storeng KT. The GAVI Alliance and the “Gatesapproach” to health system strengthening. GlobPublic Health. 2014;9:865–879.

[10] Council of the European Union. Council conclusionson the EU role in global health. 2010. [cited 2018 Aug30]. Available from: https://ec.europa.eu/europeaid/sites/devco/files/council-conclusions-eu-role-in-global-health-20100510_en.pdf

[11] Bué C La politique de développement de l’UnionEuropéenne. Construction et projection de l’Europepar le Sud. Phd Dissertation. Paris: Sciences Po -Institut d’études politiques de Paris; 2010.

[12] Carbone M. The European Union, good governanceand aid co-ordination. Third World Q. 2010;31:13–29.

[13] Carbone M. The European Union and China’s rise inAfrica: competing visions, external coherence and tri-lateral cooperation. J Contemp Afr Stud.2011;29:203–221.

[14] Kim S, Lightfoot S. Does “DAC-ability” really matter?The emergence of non-DAC donors: introduction topolicy arena. J Int Dev. 2011;23:711–721.

[15] Birchfield VL. The EU’s development policy: empiricalevidence of ‘normative power Europe?’. In:Whitman R, editor. Normative power Europe.London: Palgrave Macmillan; 2011. p. 141–160.

[16] Del Biondo K. The EU, the USA and partnership indevelopment cooperation: bridging the gap? J DevStud. 2017;53:1238–1252.

[17] Del Biondo K. Promoting democracy or the externalcontext? Comparing the substance of EU and USdemocracy assistance in Ethiopia. Cambridge RevInt Affairs. 2015;28:95–114.

[18] Brugha R. Global health initiatves and public healthpolicy. In: Carrin G, Buse K, Heggenhougen K, et al.,editors. Health systems policy, finance and organiza-tion. Academic Press; 2009. p. 128–137.

[19] Steurs L, Orbie J, Delputte S, et al. EU donors andhealth system strengthening: the love-hate relationshipwith the global fund. Dev Stud Res. 2018;5:S1–S1.

[20] Friedrichs J, Kratochwil F. On acting and knowing: howpragmatism can advance international relations researchand methodology. Int Organ. 2009;63:701–731.

[21] Schwartz-Shea P, Yanow D. Interpretive researchdesign. New York: Routledge; 2012.

[22] Cornut J Pluralism in IR theory: an eclectic study ofdiplomatic apologies and regrets. APSA 2009 TorontoMeeting Paper. 2009.

[23] Mills A. Mass campaigns versus general health ser-vices: what have we learnt in 40 years about verticalversus horizontal approaches? Bull World HealthOrgan. 2005;83:315–316.

[24] Travis P, Bennett S, Haines A, et al. Overcominghealth-systems constraints to achieve the millenniumdevelopment goals. Lancet. 2004;364:900–906.

[25] Mills A. Vertical vs horizontal health programmes inAfrica: idealism, pragmatism, resources and efficiency.Soc Sci Med. 1983;17:1971–1981.

[26] Atun R, Bennett S, Duran A When do vertical(stand-alone) programmes have a place in healthsystems? WHO European Ministerial Conference onHealth Systems. Tallinn, Estonia; 2008. p. 1–28.

[27] Uplekar M, Raviglione MC. The” vertical-horizontal”debates: time for the pendulum to rest (in peace)? BullWorld Health Organ. 2007;85:413–417.

[28] Gonzalez CL. Mass campaigns and general healthservices. Geneva: World Health Organization; 1965.

[29] Atun R, De Jongh T, Secci F, et al. Integration oftargeted health interventions into health systems:a conceptual framework for analysis. Health PolicyPlan. 2010;25:104–111.

[30] Ooms G, Van Damme W, Baker BK, et al. The “diag-onal” approach to global fund financing: a cure for thebroader malaise of health systems?. Global Health.2008;4:1–7.

[31] Carbone M. The European Union and internationaldevelopment: the politics of foreign aid. New York:Routledge; 2007.

[32] Koch S, Leiderer S, Faust J, et al. The rise and demiseof European budget support: political economy ofcollective European Union donor action. Dev PolicyRev. 2017;35:455–473.

[33] McCoy D, Jensen N, Kranzer K, et al. Methodologicaland policy limitations of quantifying the saving oflives: a case study of the global fund ’ s approach.PLoS Med. 2013;10:10.

[34] Kerouedan D. Chapitre 4. Les bonnes pratiques de laGlobal Health. Améliorer la santé ou bien gérer l’ar-gent?. In: Klein A, Laporte C, Saiget M, editors. Lesbonnes pratiques des organisations internationales.Paris: Presses de Sciences Po (P.F.N.S.P.); 2015. p.97–112.

[35] Steurs L, Orbie J, Delputte S. Belgium’s policy onglobal health: institutions, priorities and challenges.Stud Dipl. 2016;2015:59–72.

[36] Delputte S, Lannoo S, Orbie J, et al. Europeanization orinternationalization? A statistical analysis of EU mem-ber states’ aid policies. Paper presented at the 14thEADI General Conference, Bonn, 23–26 June 2014.2014.

GLOBAL HEALTH ACTION 11