Donors‘ own organizational structure and programmatic approach

The programmatic approach, as adopted by the National Health Plan, focused on programs indicators. The main donor and funding agencies based the program performance measurements on specific indicators and on disbursements ratios, usually included in a logical framework. Disbursements rules were the same from one country to another, set as a blue-print approach, as for GHIs. Program plans and funding proposals were developed around targets to reach, usually in a quantitative way and budget items were related to these targets.

While these issues were similar in many countries, consequences were more severe in terms of the disorganization of the health system in Burundi for instance, where the lack of HRH was an alarming issue and priorities were numerous (Cailhol et al. 2013). Government staff were overwhelmed in meetings, with each partner being willing to start working in the country at different moments.

The different programs‘ plans, the cooperation plans of different donors, the funding proposals and the national health policy document timelines did not coincide, either in terms of length or in terms of period covered (see Figure 3 on planning documents coverage). Donors were therefore unable to wait for each other to start their activity planning as they had to follow their country directives, as well as their own donors‘ exigencies, in an era where the levels of accountability has much increased. Even within the HIV sector, components and objectives of MAP1 projects and the HIV plan did not necessarily correspond, producing difficulties of coordination with projects other than the ones funded by the WB (SEP-CNLS 2005).

Even the different organizations within the UN system could not coordinate to have the same planning timelines, putting a strain on country-level coordination:

“Ban Ki Moon may say two years for everyone. But for the UNDAF [United Nations Development Assistance Framework] it is five years, for the UNIFEM [United Nations Development Funds for Women] it is three years, for UNAIDS it is two years - 2008-2009. It is treacherous because government does not have enough HRH. They would need one person for each UN organization, but it is impossible. The UN system will then

focus on one person and this person will be scattered and cannot work properly.” (ITW23N09, group 5, local)

Moreover, the planning procedures were different from one donor to another, adding work to the already constrained HRH at MoH level, and leaving no intellectual space for coordination ‗thinking‘. Some donors based their functioning on the performance of the country team and, for instance, assessed the timeliness of a grant submission, without waiting for other donors - thus undermining coordination (e.g. the WBG). 5.6 CREATION OF A CROSS-SECTORAL MINISTRY OF AIDS

HIV was considered not only a health-related issue, but an issue pertaining to all sectors. The existence of a specific strategic line corresponding to HIV in the PRSP (see Figure 2), justified the creation of the Ministry of AIDS - located in the

President‘s office so as to be hierarchically higher than other ministries so that it might play a cross-sectoral role.

[The creation of MoA] …was to make HIV predominant and visible. It was a political concern. This was even imposed by the WHO and UNAIDS so as to ensure the ownership of HIV issue by the government.

Nevertheless, the government was reluctant to accept this - as in many other countries. We were told that HIV is a multisectoral problem and it was advocated to the MoA should be linked directly to the Presidency. (ITW2N09, group 5, local)

When HIV was defined at global level as a priority and emergency, a large amount of funding became available, especially through GHIs (Samb et al. 2009). At the end of the war, Burundi applied for this funding, while the entire health system was in dire need of funding. Burundi was certainly willing to fit into the global discourse of HIV as an emergency; and indeed HRH and HSS were not yet set as a priority on the global agenda (Piva and Dodd 2009). The country therefore had to adapt to this discourse to obtain this funding, after many years of crisis and embargo. Presenting the HIV epidemic in Burundi as an emergency and as a fight against poverty (though justified to a certain point), could be seen as fitting in to the global political discourse in order to obtain funding.

This could be considered retrospectively as the starting point to the AIDS

exceptionalism which prevailed in the country for some years, following the end of the conflict. Subsequently, specific HRH policies were created which supported the implementation of HIV activities. This exceptionalism was further facilitated by the relative ‗void‘ of HRH policies and planning at MoH level (a legacy of the pre-conflict structure). Coordination of HIV activities by the health sector was thus difficult and perpetuated a parallel system for years.

Introduction of HIV activities, first focussing on prevention, marginalised the MoH and gave a strong role to the Ministry of AIDS. The curative activities came afterwards, first initiated by NGOs. Naturally, the first funds allocated to HIV

treatment were allocated to NGOs, which had accumulated experience, giving little space to the MoH to coordinate. There was to some extent a contradiction between the sector-wide approach and the intersectoral approach. MoH was considered as not having the capacity to deal with inter-sectoral coordination and was replaced by MoA and PES-NAC. MAP2 of the WB was negotiated to be channelled through MoH.

“We collaborate with various sectors and we are aware that the most crucial sector in the fight against AIDS is certainly the MoH. But the sanitary dimension is not the only one catered for. In the mobilisation of resources, we must also consider needs of other sectors, namely

vulnerable populations such as orphans of whom we are taking care for. […]This is a dimension not handled by the MoH, but related to other ministries, which need also to be supported by us [PES-NAC] or by other civil society actors. So, whatever the position of these ministries is, we, in our PES capacity must cooperate with all actors and each of them seems to have a well-defined place in the strategic plan. Otherwise whatever we said about being in line [with] the Paris Declaration etc. - all are good orientations for us. This will enable [us] to put together resources for a given sector at the level of the MoH, which deals [with] health business. And we are aware that is it the proper way, even for MAP 2….”

(ITW16N09, group 4, local)

This first findings chapter introduced the 19 main organizations involved in aid relating to health broadly, in the immediate post-conflict period in Burundi. It

highlighted the main features of the functioning of donors and recipients in terms of financial management and governance. This chapter set the complex scene of organizations, all with differing missions, governance, accountability, functioning. It is clear already that the MoH was left aside by NGOs and HIV-related organizations, purposefully or not, and this preliminary finding will be further developed in the following chapters (especially in chapters 7 and 8).

CHAPTER 6: FINDINGS PART 2, HRH POLICY CONTENT AND

PROCESS ANALYSIS

While an initial snapshot of the miserable landscape of HRH in the aftermath of the civil war was given in Chapter 2 on ‗context, the 19 organizations presented in the previous chapter all had, to a variable extent, explicit or implicit policies related to HRH – one on supply, another on salaries etc. We understand the detrimental effect that this multiplicity of HRH policies might have on HRH, in the absence of any coordination. This chapter will strive to analyse the existence and extent of coordination of HRH policies across organizations and will provide some key process-related factors contributing to explain its insufficiency.