Development Assistance for Health in Tanzania: Has the Sector Wide Approach achieved the principles of aideffectiveness?

Abstract

Increasing levels of development assistance have been coupled with increased attention to its effectiveness, resulting in a series of international declarations outlining an agenda of five principles of aid effectiveness: ownership, alignment, harmonisation, management for results and mutual accountability. This PhD thesis examines whether the Tanzanian health Sector Wide Approach (SWAP) has achieved these principles. It uses a case study approach, mixing quantitative and qualitative methods. It first maps out the health policy and financial landscape of Tanzania since the introduction of the SWAP. The thesis then explores the international aid effectiveness agenda and develops a set of indicators to assess its achievement in the Tanzanian health SWAP. This includes analysing external and domestic health financing flows over the last ten years; document review of key processes and in-depth interviews. The application of this indicator framework shows mixed results. Better progress is found towards indicators from international declarations, which are based on having aid-management processes in place, than towards those developed as defined by local stakeholders. Institutional factors, including the incentives of the institutions and individuals involved in aid relationships, as well as the political context within which aid relationships take place, are found to be key in explaining these results. A political economy approach is then undertaken to characterise and explore these factors further. Individual and institutional incentives are found to be unaligned with aid effectiveness principles. Furthermore, the structure of the SWAP is technocratic, excludes important stakeholders and does not fully reflect the political context and power dynamics of aid relationships. This thesis finds fatigue and disengagement with the SWAP and the aid effectiveness agenda, and recommends that the international community engage in SWAP as a process of institutional reform rather than just a technocratic solution to development assistance. Principles of aid effectiveness should allow for greater adaptation to national contexts. More research is needed to further integrate political and economic elements of frameworks to analyse aid relationships and deepen our understanding of how best to achieve institutional reform and improve aid effectiveness.