Cross-cutting themes across policy steps

The chicken and the egg: How to plan without funding? What to coordinate without a plan?

Another striking feature preventing coordination as a whole emerged from the various strategic plans and their attached financial plans – as each plan showed financial gaps. Each plan had a set of specific goals with a provisional budget attached to them, this latter being divided into ‗pledged amount‘ and ‗missing amount‘ (or ‗to be looked for‘). Therefore, depending on whether the ‗missing‘ funding was found or not, activities related to each goal were implemented – or not. Activities could be either cancelled, postponed, transformed or implemented as planned, depending on funding availability. This meant that a lot of

decisions were made in an ad hoc manner, depending on the funding available, with some funding arriving sometimes very late or unexpectedly.

Moreover, some financing was more predictable than others (e.g. GFATM and GAVI vs. UN agencies), as illustrated in the quote below:

“The funding from GAVI and MAP are easy to manage. If we have a multiannual plan, funding is planned against it and is made available. By contrast, funding from WHO is never planned ahead and comes out of the blue” (ITW6N09, group 2, local)

Given the short notice and the usual need to spend funds within a specific timeframe (before the end of financial year Y), there was no way to coordinate implementation. For instance, due to unpredictability of funding only 40% of activities planned for year 2007 were implemented (Unité de Lutte Sectorielle contre le SIDA 2008). This led the USLS to implement activities in an uncoordinated way, as illustrated in the following excerpts:

“The diversity of partners with whom USLS-health collaborates for HIV activities implementation leads necessarily to duplication. Due to donors‟ schedules, our unit is forced to work in a climate of rush and some activities need to be

rescheduled at the last minute.” (ITW6N09, group 2, local)

“USLS-health does not have its own funding for its annual action plan. The consequence is an unplanned implementation of activities, according to various donors‟ funding availability”. (ITW6N09, group 2, local)

The lack of predictability of disbursement and the uncertainty over the allocation of external funding are not new in the field of development aid, and have been well analyzed

elsewhere (Sundewall et al. 2009). However, the impact of these issues was aggravated in Burundi, where the conflict left the country exposed and extremely reliant on external aid such that government bodies did not have any leverage in decision-making or the

implementation of activities. This huge dependency on external aid explained the fact that a very good plan could remain in the drawer, if no funding was found. This lack of autonomy in terms of decision-making and implementation probably participated to the

discouragement of government to co-formulate or even formulate sound plans, since it was an energy- and time-consuming activity.

The functioning of programs and implementation of strategic plans slowed down

considerably or was suspended during the conflict and some resumed later than others. For the period considered here, 2002 to 2008, there was no annual planning within MoH, but only a five-year health plan (2006-2010) and a ten-year policy (2005-2015). The very first mid-term expenditure framework (2009-2011) and a national annual plan for the health sector were developed in 2009 as part of the IHP+ process. Before 2009, existing annual plans were the national strategic plans for HIV, developed by the PES-NAC and annual activities plan from the HIV unit of the MoH (2008). There were entire ‗holes‘ in the periods covered by these overarching policy and planning documents -– malaria, reproductive health and TB programs had no strategic plans.

National health plans were written for 2006-2010 and 2005-2015 but no annual health plan was developed before 2009. The first HRH policy document was only produced in 2009 (except for the specific P4P policy document of 2006). Therefore, in terms of HRH policies, before 2010, there was no reference document to form the basis on which to coordinate, for instance, a training plan.

In summary, except for the HIV ‗sector‘, there was no plan to use for coordination. This probably explains the pockets of coordination we found in HIV area (see case study 2 on partial coordination).

Funding makes policy

This finding was applicable to both the formulation and implementation steps. While some formulated policies were purely wishful without any practical details on implementation, other policies seemed to have been formulated exactly because funding was available that issue (e.g. P4P, see case study 1 above). Indeed, if one looks at the annual activity plan for the HIV sectoral unit for instance, only activities with funding available are actually planned as only those activities with available funding were translated into the plan, given the uncertainty of funding. Planning, therefore, did not necessarily reflect needs, so much as the availability and accessibility of funding - and drifted away from its initial objectives. This was also well illustrated in the comparison of the National Health Plan and vertical programs‘ plans. On one hand, the national health policy document exposed health challenges, in epidemiological terms but also in terms of the whole health system. On the other hand, the different program strategic plans and funding proposals seemed to have defined their lines of activities in a way that matched the funding available (e.g. provision of in-services training, supervision, M&E – source doc), not necessarily taking into account the national priorities with regard to public health. Sometimes this made planning documents look like shopping lists!

“Donors come with their ideas and usually there is no space for flexibility and integration to the health system….within GFATM-HIV for instance, there are two issues, „gender‟ and „HIV‟, to deal with. However, we need flexibility, even if we understand gender issue is a central question. There are pre-defined priorities at donors‟ level……” (ITW22N09, group 4, local)

“Because if you don‟t include HIV, gender, some donors don‟t fund anything…..(laughter)….” (ITW13N09, group 1, local)

Thus the planning process seemed to be a direct translation of funding into planning. This disjointed planning process did not allow for comprehensive planning, including and especially HRH, since funding for HRH was seldom available at both local and global levels.

This findings‘ chapter might have been relatively complex to follow, as it strives to both present the content of and analyze HRH policies, an essential step before moving to the analysis of the extent of HRH policies coordination. The main conclusion is that

few cases of partial coordination between ―like-minded‖ organizations. The process-related factors inhibiting coordination were then examined according to the policy steps. From issue identification to policy implementation, a common observation was that each organization acted for its own survival and had its own disbursement system and

functioning, putting a time-constraint on the recipient and implementers. Due to this finding, and to another finding that coordination is an extremely complex and time-consuming process, especially in the post-conflict context with its sense of emergency, many policies were precipitated in an uncoordinated way. The relative poor funding of health sector compared to the ‗HIV‘-sector at the beginning contributed to the non-emergence of MoH as possible coordinator and to a preeminence of HIV-related organizations.