How do external donors influence national health policy processes? Experiences of domestic policy actors in Cambodia and Pakistan

Abstract

Although concerns have historically been raised about the influence of external donors on health policy process in recipient countries, remarkably few studies have investigated perspectives and experiences of domestic policymakers and advisers. This study examines donor influence at different stages of the health policy process (priority setting, policy formulation, policy implementation and monitoring and evaluation) in two aid-dependent LMICs, Cambodia and Pakistan. It identifies mechanisms through which asymmetries in influence between donors and domestic policy actors emerge. We conducted 24 key informant interviews—14 in Pakistan and 10 in Cambodia—with high-level decision-makers who inform or authorize health priority setting, allocate resources and/or are responsible for policy implementation, identifying three routes of influence: financial resources, technical expertise and indirect financial and political incentives. We used both inductive and deductive approaches to analyse the data. Our findings indicate that different routes of influence emerged depending on the stage of the policy process. Control of financial resources was the most commonly identified route by which donors influenced priority setting and policy implementation. Greater (perceived) technical expertise played an important role in donor influence at the policy formulation stage. Donors’ power in influencing decisions, particularly during the final (monitoring and evaluation) stage of the policy process, was mediated by their ability to control indirect financial and political incentives as well as direct control of financial resources. This study thus helps unpack the nuances of donor influence over health policymaking in these settings, and can potentially indicate areas that require attention to increase the ownership of domestic actors of their countries’ health policy processes.

Evidence and Policy in Aid-Dependent Settings

“…The analysis found that direct funding to preferred policy issues was the most common means of donor influence, but other means of influence arose from control over technical knowledge as well as more indirect influence -such as through financing particular research or evaluations (thus constructing evidence that could be seen as policy relevant), or through recipient country concerns over maintain a good reputation to avoid impacts on non-health areas of concern (e.g. tourism or trade) (Khan et al 2018).…”

“…In Cambodia, it was reported that the research agenda and the availability of routine data from the national health information system are driven by external funding, often focused on high profile diseases (such as malaria or HIV/AIDS), and this could result in the neglect of other important health concerns (with issues like hepatitis, road traffic accidents, or dengue fever mentioned). One interviewee further explained that mental health was another key priority in Cambodia, given the historical legacy of the genocide perpetuated in the 1970s; yet research and policy attention to mental health were said to be lacking due to dependence on donor agendas (see (Khan et al 2018) for more details). Similarly, a recent literature review found that few research reports on non-communicable diseases in Cambodia have been published, despite these accounting for the highest morbidity and mortality rates in the country (Goyet et al 2015).…”

Collaborations on blood transfusion research in sub‐Saharan Africa: who, what and where

“…This bias in research focus towards transfusion‐transmitted infections during the study period (2008‐2014) is not surprising as it coincides with the HIV epidemic in Africa. It may be related to asymmetries in influence in financial resources, technical expertise and indirect financial and political incentives between external donors and domestic stakeholders . The PEPFAR initiative focused on 14 countries with a high HIV burden, 12 in Africa, and aimed to provide development assistance rather than research funds .…”

Conclusion: Reflecting on Studying Evidence Use from a Public Policy Perspective

“…Similarly, the political dynamics through which evidence of certain topics was brought to political decision processes was seen in some places as a mechanism for donor influence; as was the influence that could result when donors shaped the processes through which evidence and data are brought to bear on policy decisions (see discussion in Chap. 10; also Khan et al 2017).…”