Critical barriers to sustainable capacity strengthening in global health: a systems perspective on development assistance

Abstract

Background: Development assistance for health (DAH) is an important mechanism for funding and technical support to low-income countries. Despite increased DAH spending, intractable health challenges remain. Recent decades have seen numerous efforts to reform DAH models, yet pernicious challenges persist amidst structural complexities and a growing number of actors. Systems-based approaches are promising for understanding these types of complex adaptive systems. This paper presents a systems-based understanding of DAH, including barriers to achieving sustainable and effective country-driven models for technical assistance and capacity strengthening to achieve better outcomes Methods: We applied an innovative systems-based approach to explore and map how donor structures, processes, and norms pose challenges to improving development assistance models. The system mapping was carried out through an iterative co-creation process including a series of discussions and workshops with diverse stakeholders across 13 countries. Results: Nine systemic challenges emerged: 1) reliance on external implementing partners undermines national capacity; 2) prioritizing global initiatives undercuts local programming; 3) inadequate contextualization hampers program sustainability; 4) decision-maker blind spots inhibit capacity to address inequities; 5) power asymmetries undermine local decision making; 6) donor funding structures pose limitations downstream; 7) program fragmentation impedes long-term country planning; 8) reliance on incomplete data perpetuates inequities; and 9) overemphasis on donor-prioritized data perpetuates fragmentation. Conclusions: These interconnected challenges illustrate interdependencies and feedback loops manifesting throughout the system. A particular driving force across these system barriers is the influence of power asymmetries between actors. The articulation of these challenges can help stakeholders overcome biases about the efficacy of the system and their role in perpetuating the issues. These findings indicate that change is needed not only in how we design and implement global health programs, but in how system actors interact. This requires co-creating solutions that shift the structures, norms, and mindsets governing DAH models.

Critical barriers to sustainable capacity strengthening in global health: a systems perspective on development assistance

“…These syndromes reflect the views and perceptions of the co-creation participants 33 . We recognize that system syndromes vary based on country and/or donor context.…”

“…Zenodo: Critical barriers to sustainable capacity strengthening in global health: A systems perspective on development assistance. https://doi.org/10.5281/zenodo.6612438 33 This project contains the following underlying data:…”

Exploring system drivers of gender inequity in development assistance for health and opportunities for action

“…The work presented in this paper was conducted as part of a broader initiative led by the Inter-agency Working Group (IAWG) for Capacity Strengthening e to co-create a systems' understanding of capacity strengthening in the context of global DAH 47 .…”

“…A subset of six participants, h facilitated by a gender expert, explored dynamics and drivers related to gender and health inequities that are slowing or impeding progress in DAH. During the workshop, participants used a collaborative virtual whiteboard tool to capture and depict specific behaviors, dynamics, and characteristics of donor and country stakeholder group interactions that hinder progress to reduce gender and health inequities, as they experienced them in their context 50 .…”

“…The mapping and co-creation processes resulted in: 1) a series of conceptual maps of the drivers of gender inequities within the landscape of DAH, 2) diagrams describing potential change points, and 3) a graphic representing the participants' views on priority action steps by donors 50 . The six syndromes that emerged from the co-creation process reveal distinct yet interconnected system dynamics driving barriers to achieving gender equity and health outcomes.…”