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.

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 d to co-create a systems understanding of capacity strengthening in the context of global DAH 43 . The process was guided by System Acupuncture® e — a theory and method that enables the design of innovative, actionable, and synergistic interventions that drive deep and sustained transformation of system behaviors and outcomes 49 — and focused on the system diagnostic component of the System Acupuncture process.…”

“…This initial synthesis resulted in the identification of systemic challenges inhibiting progress on the critical shifts. This is explored in detail in a separate manuscript 43 .…”

“… d This approach combines multiple theories and concepts ranging from systems theory 43 , 44 , innovation and diffusion theory 45 , design thinking 46 , and resilience theory 47 . …”

Exploring equity in global health collaborations: a qualitative study of donor and recipient power dynamics in Liberia

“…[3][4][5][6] In global health collaborations, power imbalances from the onset of a collaboration could allow for outcomes that favour the higher-power, higher-resource group over the lower-power, lowerresource group, such as prioritisation of donor agendas, lack of intervention sustainability and fragmentation of national agendas, leaving those in the low-resource setting with less control and at risk of remaining dependent on outside resources. 7 In an effort to facilitate more equitable collaborations, global health practicioners and researchers have proposed new models for these types of partnerships and have called for funders to play a key role in addressing inequitable power dynamics. [8][9][10][11] Commonalities of these models include the need to focus on national priorities in the low-resource setting as well as emphasising the development of trust between partners.…”

“… 3–6 In global health collaborations, power imbalances from the onset of a collaboration could allow for outcomes that favour the higher-power, higher-resource group over the lower-power, lower-resource group, such as prioritisation of donor agendas, lack of intervention sustainability and fragmentation of national agendas, leaving those in the low-resource setting with less control and at risk of remaining dependent on outside resources. 7 …”