External Development Partners Research Articles

Using Health Systems and Policy Research to Achieve Universal Health Coverage in Ghana.

Ghana is positioned to become the first country in sub-Saharan Africa to implement universal health coverage based on nationwide expansion of geographic access through the Community-based Health Planning and Services initiative. This achievement is the outcome of 3 decades of implementation research that health authorities have used for guiding the development of its primary health care program. This implementation research process has comprised Ghana's official endorsement of the 1978 Alma Ata Declaration, leading to the institutionalization of evidence relevant to the strategic design of primary health care and national health insurance policies and services. Rather than relying solely upon the dissemination of project results, Ghana has embraced a continuous and systemic process of knowledge capture, curation, and utilization of evidence in expanding geographic access by a massive expansion in the number of community health service points that has taken decades. A multisectoral approach has been pursued that has involved the creation of systematic partnerships that included all levels of the political system, local development officials, community groups and social networks, multiple university-based disciplines, external development partners, and donors. However, efforts to achieve high levels of financial access through the roll-out of the National Health Insurance Scheme have proceeded at a less consistent pace and been fraught with many challenges. As a result, financial access has been less comprehensive than geographical access despite sequential reforms having been made to both programs. The legacy of activities and current research on primary health care and national health insurance are reviewed together with unaddressed priorities that merit attention in the future. Factors that have facilitated or impeded progress with research utilization are reviewed and implications for health systems strengthening in Ghana and elsewhere in Africa and globally are discussed.

The Mekong Subregional Cooperation Framework: A Geopolitical Dilemma and the Ways Forward

The Mekong Subregional Cooperation Framework:A Geopolitical Dilemma and the Ways Forward Charadine Pich (bio) In the current environment of regional security architecture dynamics, complex geopolitical dilemmas, and the congestion of subregional cooperation mechanisms, the Mekong is no longer just a river but also a core ground for competition in a broader context for power play among the major powers. Some observers have even highlighted that the issue of Mekong geopolitics could follow the trajectory of the South China Sea disputes in the near future if it is not taken seriously. For the riparian states of the Association of Southeast Asian Nations (ASEAN), successfully managing geopolitical contestation over the river and its resources is of critical importance. ASEAN and the Mekong: A Diverging Path? The Mekong River (known as the Lancang in China) begins in the Tibetan Plateau and passes through China, Myanmar, Laos, Thailand, Cambodia, and Vietnam before joining the South China Sea. The Mekong basin is one of the most biodiverse areas in the world, sustaining around sixty-six million people. This figure amounts to 10% of ASEAN's total population and includes "most of the population of Laos and Cambodia, one-third of Thailand's sixty-five million, and one-fifth of Vietnam's ninety million people."1 At stake in the river's management are issues such as water sharing, dams and hydroelectricity production, fisheries, irrigation, environmental conservation, and climate change mitigation. The ASEAN countries are mostly divided into two camps over issues pertaining to the river: mainland Southeast Asia and maritime Southeast Asia. States in the former put the Mekong River among their top priorities because of the river's importance to the livelihoods of their people as well as their vulnerability to changes in the water flow from upstream by virtue of residing in the Lower Mekong region. States in the latter group, on the other hand, do not have a share of the river and consider issues regarding [End Page 57] the Mekong not primarily as security concerns but more in terms of their technical and environmental aspects. The troubles over the Mekong River have been largely viewed through an environmental and socioeconomic lens and seen as affecting only the mainland countries of ASEAN rather than ASEAN as a whole. Hence, the river's linkages with the region's broader security and geopolitical considerations have been given less attention. In contrast, although not all ASEAN member states are claimants in the South China Sea disputes, this particular issue is largely considered a wider security dilemma in the broader region of Southeast Asia and beyond and a major threat to regional peace, security, and stability. Although it might not be entirely fair to compare Mekong geopolitics to those of the South China Sea, there is no better approach to understand the Mekong security dilemma than to look at it through that benchmark. The disputes have been widely regarded as an alarming security threat for all of Southeast Asia that could jeopardize regional peace and security if not cautiously monitored. This risk is due to the diverse military presence and, to a certain extent, the arms race surrounding the area. While the Mekong security dilemma has not yet warranted this same level of heightened concern, many regional analysts are cautious of unprecedented trends in the Mekong given the increasing involvement of external actors and development partners alike. The Mekong issue has not yet attained a regional status or posed "alarming" threats that encourage discussions at the regional level among all the ASEAN member states or priority placement on any existing ASEAN agenda. In fact, Vietnam tried to slot the Mekong agenda into the wider discourse within ASEAN platforms during its 2020 chairmanship but found "very limited success."2 In part, this omission was due to the Covid-19 outbreak, which disrupted traditional ASEAN practices and shifted regional attention to focus more on public health and economic recovery. Nonetheless, Vietnam's attempt to highlight the Mekong on the ASEAN agenda was met with reservations from both maritime and mainland members. The maritime ASEAN states see Mekong issues as only affecting the mainland states and thus believe they should be dealt with through existing frameworks at the...

Editorial: New conversations in development studies

Editorial: New conversations in development studies

Developing Feasible, Locally Appropriate Socioeconomic Support for TB-Affected Households in Nepal.

Tuberculosis (TB), the leading single infectious diseases killer globally, is driven by poverty. Conversely, having TB worsens impoverishment. During TB illness, lost income and out-of-pocket costs can become “catastrophic”, leading patients to abandon treatment, develop drug-resistance, and die. WHO’s 2015 End TB Strategy recommends eliminating catastrophic costs and providing socioeconomic support for TB-affected people. However, there is negligible evidence to guide the design and implementation of such socioeconomic support, especially in low-income, TB-endemic countries. A national, multi-sectoral workshop was held in Kathmandu, Nepal, on the 11th and 12th September 2019, to develop a shortlist of feasible, locally appropriate socioeconomic support interventions for TB-affected households in Nepal, a low-income country with significant TB burden. The workshop brought together key stakeholders in Nepal including from the Ministry of Health and Population, Department of Health Services, Provincial Health Directorate, Health Offices, National TB Program (NTP); and TB/Leprosy Officers, healthcare workers, community health volunteers, TB-affected people, and external development partners (EDP). During the workshop, participants reviewed current Nepal NTP data and strategy, discussed the preliminary results of a mixed-methods study of the socioeconomic determinants and consequences of TB in Nepal, described existing and potential socioeconomic interventions for TB-affected households in Nepal, and selected the most promising interventions for future randomized controlled trial evaluations in Nepal. This report describes the activities, outcomes, and recommendations from the workshop.

Primary healthcare implementation in practice: Evidence from primary healthcare managers in Ghana.

BackgroundPrimary healthcare (PHC) is a core part of healthcare in developing countries. However, the implementation of PHC since its inception in developing countries has been lethargic, inconsistent and marred by controversies.AimThis study investigates some of the controversies surrounding PHC implementation. It also examines how PHC is being implemented in Ghana as well as how the approaches adopted by PHC implementers influence PHC outcomes in developing countries.SettingThis study is set in Ghana and involves national, regional and district managers of PHC.MethodsA qualitative case study was used to gather information from 19 frontline PHC managers through semi-structured interviews. Interviews were recorded and transcribed. They were then qualitatively analysed using the thematic framework analyses approach.ResultsFindings uncover a lack of clear meaning of what PHC is and how it should be approached amongst key implementers. It also shows discrepancies between official policy documents and directives, and actual PHC practices. Findings also show a gradual shift from Alma Ata’s comprehensive PHC towards a more selective and intervention-specific PHC. Whilst donor and external stakeholders’ influence are the key determinants of PHC policy implementation, their support for vertical and other medicine-based interventions have gradually medicalised PHC.ConclusionThere is a need to pay more attention to understanding and addressing the gaps in PHC implementation and its inconsistencies. Furthermore, the role and control of donors and external development partners in PHC policy formulation and implementation, and their concomitant effects on community participation and empowerment, must be critically examined.

동남아 사회주의 국가의 여성연맹 연구를 통한 북한 여성 관련 개발협력 사업에의 시사점: 베트남, 라오스, 미얀마 여성연맹 사례를 중심으로 (A Study on Women’s Unions in Southeast Asian Countries and its Implications for North Korean Development Cooperation on Gender: Cases from Vietnam, Laos and Myanmar)

동남아 사회주의 국가의 여성연맹 연구를 통한 북한 여성 관련 개발협력 사업에의 시사점: 베트남, 라오스, 미얀마 여성연맹 사례를 중심으로 (A Study on Women’s Unions in Southeast Asian Countries and its Implications for North Korean Development Cooperation on Gender: Cases from Vietnam, Laos and Myanmar)

Determinants of stunting among children aged 0\u201359\u2009months in Nepal: findings from Nepal Demographic and health Survey, 2006, 2011, and 2016

BackgroundStunting is one of the most commonly used indicators of child nutrition and health status. Despite significant efforts by the government and external development partners to improve maternal and child health and nutrition, stunting is consistently high in Nepal. This paper assesses the potential determinants of stunting among children aged 0–59 months using the last three successive Nepal Demographic and Health Surveys (NDHS).MethodsWe used three nationally representative cross-sectional household surveys, known as the NDHS- 2006, 2011 and 2016. Logistic regression was used to identify the potential determinants of stunting. The sub sample for this study includes n = 5083 in 2006, n = 2485 in 2011, and n = 2421 in 2016.ResultsRates of stunting decreased from nearly 50% in 2006 to about 36% in 2016. The prevalence of stunting was higher among children from larger families (51.0% in 2006, 41.1% in 2011, 38.7% in 2016), poor wealth quintile households (61.2% in 2006, 56.0% in 2011, 49.2% in 2016), and severely food insecure households (49.0% in 2011, 46.5% in 2016). For child stunting, the common determinants in all three surveys included: being from the highest equity quintile (OR: 0.58 in 2006, 0.26 in 2011, 0.28 in 2016), being older (OR: 2.24 in 2006, 2.58 in 2011, 1.58 in 2016), being below average size at time of birth (OR: 1.64 in 2006, 1.55 in 2011, 1.60 in 2016), and being affected by anemia (OR: 1.32 in 2006, 1.59 in 2011, 1.40 in 2016).ConclusionsThis study found that household wealth status, age of child, size of child at time of birth, and child anemia comprised the common determinants of stunting in all three surveys in Nepal. Study findings underscore the need for effective implementation of evidence-based nutrition interventions in health and non-health sectors to reduce the high rates of child stunting in Nepal.

Implementation fidelity of provider-initiated HIV testing and counseling of tuberculosis patients under the National Tuberculosis Control Program in Kathmandu District of Nepal: an implementation research

BackgroundThere exists low uptake of Human Immunodeficiency Virus (HIV) testing among Tuberculosis (TB) patients through Provider-Initiated HIV Testing and Counseling (PITC) under the national TB control program in Nepal. The degree and quality of program delivery were explored through determining whether the PITC program is currently implemented as intended. This study aimed to assess three major components of the program’s implementation fidelity: adherence to PITC service, exposure, and quality of program delivery in order to optimize and standardize PITC implementation by exploring its barriers and enablers.MethodsThis research used a sequential explanatory mixed method design. Retrospective cross-sectional study of TB patients enrolled in five TB treatment centers of the Kathmandu district from July 1, 2016, to June 30, 2017 was done to assess PITC adherence to Direct Observed Treatment-Short Course (DOTS) protocols. The centers’ TB-DOTS readiness was assessed using the WHO Service Availability and Readiness Assessment checklist. A qualitative study was conducted to explore the barriers and enablers of PITC service implementation.ResultsFrom a total of 643 TB patients registered, 591 (92.1%) patients were offered HIV test counseling. Amongst those, 571 (96.6%) accepted and 523 (91.5%) were tested. Service providers’ HIV knowledge was found to be good although only 2/5 (40%) had participated in PITC training. The key barriers experienced by service providers were: patients feeling offended, stigmatization and lack of human resources in DOTS centers. The main enablers for PITC were national TB program commitment, health workers’ motivation, collaboration between stakeholders and external development partners’ promotion of program implementation.ConclusionIn the selected study sites, PITC services are well integrated into the routine TB control program with a high uptake of HIV testing among registered TB patients. This achievement should be sustained by addressing the identified barriers mainly in the quality of the PITC program delivery.

Foreign aid, Cashgate and trusting relationships amongst stakeholders: key factors contributing to (mal) functioning of the Malawian health system.

Malawi has a long history of receiving foreign aid, both monetary and technical support, for its health and other services provision. In the past two decades, foreign aid has increased, with the aim of the country being able to achieve its Millennium Development Goals by the end of 2015. It is currently moving towards achieving the sustainable development goals. Despite increased donor support, progress in the Malawian health service has remained very slow. This article discusses how trusting relationships amongst the stakeholders is vital in proper financial management, including of foreign aid and effective functioning of the health system in Malawi. This article is based on a qualitative study, using a range of research approaches: the in-depth case study of foreign aid funded Maternal and Child Health (MCH) projects (n = 4); Key Informant Interviews (n = 20) and reviews of policy documents to explore the issues around foreign aid and MCH services in Malawi. During the study period 2014-16, the country continued to face significant financial and other resource management challenges. The study has identified key factors, notably the issue of financial mismanagement, particularly Cashgate, news of which broke in 2013. This scandal has resulted in a great deal of mistrust amongst key stakeholders in health. The concomitant deterioration of working relationships has had a major impact on the health system resulting in further mal-distribution of resources and programme duplications. After highlighting key issues around foreign aid, Cashgate and trusting relationships amongst stakeholders, this article makes policy suggestions, with the aim of assisting donors and external development partners to better understand Malawian socio-political networks and relationships amongst key stakeholders. This understanding will help all those involved in the effective financial management and dispersal of foreign aid.

Conditional cash transfer policies in maternal health service utilization in Nepal: Analysis of safe delivery incentive program (Aama Surakshya Karyakram) using Kingdon's multiple streams framework.

Various factors limit access to and utilization of health services even when provided at subsidized cost. This results in poor utilization of services that contributes to further economic impoverishment and health care disparity. Many countries are experimenting with various approaches to tackle the poor utilization of health care services including demand-side financing policy. This paper explains the policymaking process during the formulation of safe delivery incentive program, a conditional cash transfer program in Nepal using Kindgon's multiple streams framework. Analysis of earlier policies and programs around safe motherhood concludes that high transportation cost was a major cause for poor utilization of institutional obstetric care, despite being provided at free of cost. Health was recognized as fundamental constitutional right in 2007. This assured societal support and political commitments for protecting health constitutionally. Furthermore, there was commitment from external development partners (EDPs) for investment in maternal health. Together, these problem, policy, and politics opened Kingdon's "windows of opportunity" for formulation of conditional cash transfer policy. This paper presents evolution of Aama Surakshya Karyakram and uses Kingdon's multiple streams framework to explain how problem, policy, and politics streams converged together to allow this program to be introduced in Nepal.

SUSTAINABLE RURAL DEVELOPMENT IN THE NORTHERN REGION OF GHANA: INNOVATIVE STRATEGIES FOR ENHANCING LEADERSHIP PARTICIPATION

Successive governments in Ghana have since the attainment of independence in 1957 initiated many programmes aimed at promoting sustainable rural development. The Northern Region of the country has benefited immensely from such initiatives. Many non-governmental organisations (NGOs) and International Development Agencies (IDAs) have augmented the efforts of government by making the region a focus of their developmental agenda. In spite of the profound commitment exhibited by the government and external development partners in bringing about sustainable development to the area, the Northern Region still remains one of the most deprived areas in terms of access to basic and necessary facilities and amenities. It can be argued that since rural leaders wield considerable influence over their people, their participation in rural development projects will go a long way to ensure the success of such projects. It is against this backdrop that this article sought to identify strategies for enhancing the participation of community leaders in the development of their communities in the Northern Region. The study was undertaken in the Sawla-Tuna-Kalba district of the Northern Region. It is the belief of the authors that the results from this study can be generalised to the entire region. This study employed the mixed methods research approach where 100 community leaders were selected for interviews. The study found amongst other things that community leaders in the district lacked basic literacy and numeracy skills, which hampered their active participation in the various stages of community development. It was recommended that the capacities of community leaders should constantly be built in order to promote their active participation in community improvement initiatives.

Prioritization in Somali health system strengthening: a qualitative study.

After years of decline and disintegration, the Somalia Federal Government alongside international and domestic partners is beginning the process of rebuilding its national health system. In this study, we aim to shed light on the current approaches to health system strengthening, as viewed by stakeholders closely involved in its development. Key informant interviews were undertaken with health and development professionals working within all three administrative regions of Somalia, as well as with Somali ministry of health officials, global health and policy specialists with interests in health system reconstruction in fragile states. A review of published and grey literature on Somalia, health systems, fragile and conflict-affected countries using PubMed and Reliefweb was also conducted. Technical documents designed for Somali health system building by external development partners were also reviewed. Key priorities identified by participants were, strengthening of local governance and management capacity, scaling-up efforts to structure a robust health financing mechanism, engagement with the burgeoning and dynamic private sector, as well as investing in the appropriate human resources for health. The study found that there was widespread agreement among participants that health system strengthening through a coordinated system would improve long-term capacity in Somalia's health sector. Future research should focus on the evaluation of the modalities by which health system strengthening interventions are implemented, on neglected topics such as mental health within the Somali health system, as well as on population-level barriers to accessing health systems.

Communicating the role of academia in the control of noncommunicable diseases: identification, involvement and institutionalization

DOI: http://dx.doi.org/10.3126/hprospect.v13i2.11886

External influence, policy transfer and national ownership: A case on primary education of Bangladesh

This paper aims to explain ‘how the development partners have worked to transfer policies in primary education of Bangladesh’, followed by an assessment of national policy ownership in context of external policy influence in the sector. The external development partners’ mode and nature of the policy influence has taken the form of ‘emulation’ in primary education sector. Emulation entails making, by the development partners, the funds and policy ideas available for reforms in educational development projects and programmes. They have tried down various modalities and by the way they have consolidated their position in directing primary educational development by introducing sector-wide approach. Together with this, they have imported many reforms from the outside in the education system. Empowering schools to prepare school improvement plans within the second primary education development program is an example of external policy transfer. This raises questions about government's leadership in educational development policies. Lack of national policy ownership weakens ministerial accountability to the government or the parliament. National capacity constraints, uncertainty of national education policy, and resistance of the domestic interest groups to local reforms are some of key bottlenecks towards promoting national stewardship in policy domain.

Central Asian Post-Soviet health systems in transition: has different aid engagement produced different outcomes?

BackgroundThe collapse of the Soviet Union in 1991 resulted in a transition from centrally planned socialist systems to largely free-market systems for post-Soviet states. The health systems of Central Asian Post-Soviet (CAPS) countries (Kyrgyzstan, Mongolia, Tajikistan, Turkmenistan, and Uzbekistan) have undergone a profound revolution. External development partners have been crucial to this reorientation through financial and technical support, though both relationships and outcomes have varied. This research provides a comparative review of the development assistance provided in the health systems of CAPS countries and proposes future policy options to improve the effectiveness of development.DesignExtensive documentary review was conducted using Pubmed, Medline/Ovid, Scopus, and Google scholar search engines, local websites, donor reports, and grey literature. The review was supplemented by key informant interviews and participant observation.FindingsThe collapse of the Soviet dominance of the region brought many health system challenges. Donors have played an essential role in the reform of health systems. However, as new aid beneficiaries, neither CAPS countries’ governments nor the donors had the experience of development collaboration in this context.The scale of development assistance for health in CAPS countries has been limited compared to other countries with similar income, partly due to their limited history with the donor community, lack of experience in managing donors, and a limited history of transparency in international dealings. Despite commonalities at the start, two distinctive trajectories formed in CAPS countries, due to their differing politics and governance context.ConclusionsThe influence of donors, both financially and technically, remains crucial to health sector reform, despite their relatively small contribution to overall health budgets. Kyrgyzstan, Mongolia, and Tajikistan have demonstrated more effective development cooperation and improved health outcomes; arguably, Uzbekistan and Turkmenistan have made slower progress in their health and socio-economic indices because of their resistance to open and accountable development relationships.

Evaluation of Gender and Equity Issues Under Sarva Shiksha Abhiyaan

In the last 50 years, India has made significant progress in the field of education. Yet, there are huge challenges, especially when it comes to bridging gender and equity gaps in education. In 2001, the Government of India (GOI) had launched Sarva Shiksha Abhiyaan (SSA) with the specific purpose of achieving universal elementary education (UEE). One of the main goals of SSA is to bridge gender and social gaps. Even though the SSA programme is primarily financed by the GOI, three external Development Partners (DP) also contribute funds towards SSA, namely: World Bank’s International Development Association (IDA), the United Kingdom’s Department for International Development (DFID) and the European Union (EU). Being a partnership programme, a six monthly review is carried out by the GOI and DP, which is known as the Joint Review Mission (JRM). This desk review was conceptualised with the purpose of doing a thorough review of monitoring and evaluation processes of SSA JRM reports in order to understand how gender and equity goals have been tracked and addressed by the government and donor partners. More specifically, this study also explores how equity and gender have been understood within the SSA framework; whether the SSA JRM mechanism focuses on input indicators, process indicators and/or output indicators; and what are the various gender-related issues that have been flagged in SSA JRM reports and recommendations made over the years?

Perceptions of government knowledge and control over contributions of aid organizations and INGOs to health in Nepal: a qualitative study

BackgroundAlmost 50% of the Nepali health budget is made up of international aid. International Non-Governmental Organizations working in the field of health are able to channel their funds directly to grass root level. During a 2010 conference, the Secretary of Population stated that the government has full knowledge and control over all funds and projects coming to Nepal. However, there are no documents to support this. The study aims to assess government and partner perceptions on whether Government of Nepal currently has full knowledge of contributions of international aid organizations and International Non-Governmental Organizations to health in Nepal and to assess if the government is able to control all foreign contributions to fit the objectives of Second Long Term Health Plan (1997–2017).MethodsA qualitative study was performed along with available literature review. Judgmental and snowball sampling led to 26 in depth interviews with key informants from the government, External Development Partners and International Non-Governmental Organizations. Results were triangulated based on source of data. Representatives of the Department of Health Services declined to be interviewed. Data collection was done until researchers felt data saturation had been reached with each group of key informants.ResultsWhile Ministry of Health and Population leads the sector wide approach that aims to integrate all donor and International Non-Governmental Organization contributions to health and direct them to the government’s priority areas, questions were raised around its capacity to do so. Similarly, informants questioned the extent to which Social Welfare Council was able to control all International Non-Governmental Organizations contributions. Political tumult, corruption in the government, lack of human resources in the government, lack of coordination between government bodies, convoluted bureaucracy, and unreliability of donor and International Non-Governmental Organization contributions were identified as the main reasons for difficulties in aid integration.ConclusionsDespite its commitment to coordinate and control development assistance to the health sector, and its leadership position of the Sector Wide Approach, complete knowledge and effective coordination of all international contributions remains a challenge and is hampered by issues within the government as well as among External Development Partners and International Non-Governmental Organizations.

Choices of health care financing schemes for resource poor country: An analysis of Nepal’s experiences

An appropriate health care financing scheme can improve the efficient, equitable, and effective use of health care resources; however, each popular health care financing scheme has some advantages and disadvantages. The designing of health care financing strategy to fit with the country specific features is not straightforward. In resource poor country, allocation of resources for health care services are always critical and frequently unstable due to nuances annual budget process, small fiscal space, uncertainties in contributions of external development partners. Considerable quantities of country specific researches require for the choice of an appropriate health care financing scheme. The paper illustrates possible better options for the government to pursue the goal of ensuring that the poor receive more benefits. The paper compares the benefit incidences and cost of services with different options purposed for primary health care services by utilizing recently collected data from different hospitals in Nepal. The paper offers an alternative policy such as a universal free care below the district level services; but in the district level which is top level of primary care, “extended targeted free health care” may be an efficient, fair, and relatively simple approach.

The Move from Institutions? Examining the Phenomenon in Africa

INTRODUCTION The recently issued National Security Strategy of the United States (March 2006), reaffirms the preference for informally created institutions or networks with selective membership increasingly favored in U.S. policy. It describes them as partnerships that emphasize international cooperation, not international bureaucracy; rely on voluntary adherence rather than binding treaties; and are oriented towards action and results rather than legislation and rulemaking. (1) Some commentators have concluded that these networks manifest a move away from institutions. One of my copanelists, Prof. Eyal Benvenisti, has described this trend in his presentation and in a forthcoming publication as thus: This new attitude toward international obligations reflects both the availability of novel ways for governments to interact across political borders, as well as new concerns about international legal tools, especially the formal international institutions. This preference for informal lawmaking suggests that international cooperation can be achieved without recourse to international legal tools and that the informality offers significant benefits to some governments. (2) The phenomenon of of the willing as an informal mechanism for circumventing the bureaucratic strictures and international rule-making or legislative processes of formal international institutions has become more pronounced lately with the proliferation of various coalitions of like-minded states led or inspired by the United States. Yet, the history of this phenomenon has a far longer and more complex life. (3) Most of these coalitions involve countries from the global North, but they are by no means limited to these states. Similar developments--albeit of a limited nature and scope, and of more recent pedigree--can be identified among states of the global South as well. My presentation focuses on the emergence of this phenomenon in the global South and is aimed at demonstrating that the move away from institutions may be occurring not only with respect to the universal or global institutions but also at the level of regional institutions, such as the African Union (AU). In my view, the New Partnership for Africa's Development (NEPAD) presents the closest example of this phenomenon in Africa. NEPAD: A MOVE FROM THE AU? NEPAD is nowadays commonly described as an integral program of the AU, the regional organization that superseded the Organization of African Unity (OAU) in July 2002. Yet, NEPAD originally was conceived as a separate framework for interaction and cooperation among a self-selected group of African states, operating as a parallel structure to the OAU. Although African political leaders subsequently decided to adopt it as a program of the OAU, I would argue that NEPAD was intended to be, and remains, an exclusive, voluntary coalition of like-minded states. From a structural and operational point of view, it remains a separate entity from the AU, notwithstanding the political rhetoric suggesting otherwise. The establishment of a separate small, core secretariat for NEPAD in Midrand, South Africa, away from the headquarters and international bureaucracy of the AU in Addis Ababa, Ethiopia, is itself a manifestation of this position. In addition, the different approaches taken by the AU and NEPAD leaders in presenting the two initiatives to African governments, civil society groups and Africa's external development partners, in particular the G8 countries, reinforces this view. Time constraints do not permit me to discuss in any meaningful detail the history, process and content of NEPAD or its relevance for solving Africa's developmental problems, etc. In any case, not all these issues are pertinent or relevant to the examination of the phenomenon of the move from institutions. …