Development Assistance for Health: Stakeholder perspectives on emerging donors in sub-Saharan Africa Inauguraldissertation zur Erlangung der Würde eines Doktors der Philosophie Vorgelegt der Philosophisch-Naturwissenschaftlichen Fakultät Der Universität Basel von Ashley Warren von Vereinigte Staaten von Amerika Basel, 2019 Originaldokument gespeichert auf dem Dokumentenserver der Universität Basel edoc.unibas.ch Genehmigt von der Philosophisch-Naturwissenschaftlichen Fakultät auf Antrag von Prof. Dr. Marcel Tanner, Dr. Don de Savigny, Dr. Devi Sridhar Basel, 13 Dezember 2016 Prof. Dr. J. Schibler, Dekan Table of Contents Acknowledgements ................................................................................................................... iii Summary .................................................................................................................................... v List of Tables ............................................................................................................................. ix List of Figures ........................................................................................................................... xi List of Abbreviations ............................................................................................................... xiii 1. Introduction ........................................................................................................................ 1 1.1 Changes in landscape of development assistance for health ...................................... 1 1.2 Private assistance ...................................................................................................... 11 1.3 Support from emerging economies .......................................................................... 20 1.4 The Global Fund ....................................................................................................... 31 1.5 Donor darlings and orphans ..................................................................................... 36 1.6 Rationale for thesis ................................................................................................... 38 2. Aims and Objectives ........................................................................................................ 39 2.1 Aims ......................................................................................................................... 39 2.2 Objectives ................................................................................................................. 39 3. Summary Methods ........................................................................................................... 41 3.1 Study areas ............................................................................................................... 41 3.2 Primary data collection ............................................................................................. 49 3.3 Analysis .................................................................................................................... 51 4. Stakeholder perceptions in sub-Sahara Africa of private assistance for health and principles of aid effectiveness .................................................................................................. 53 4.1 Abstract .................................................................................................................... 54 4.2 Introduction .............................................................................................................. 55 4.3 Methods .................................................................................................................... 57 4.4 Results and Discussion ............................................................................................. 60 4.5 Conclusion ................................................................................................................ 71 4.6 Key messages ........................................................................................................... 72 4.7 Acknowledgements .................................................................................................. 72 5. Engaging with emerging economies for health development: a case-study of four sub- Sahara African countries .......................................................................................................... 75 5.1 Abstract .................................................................................................................... 76 5.2 Introduction .............................................................................................................. 77 5.3 Methods .................................................................................................................... 79 5.4 Results ...................................................................................................................... 82 5.5 Conclusions .............................................................................................................. 95 5.6 Take-home messages ................................................................................................ 96 i 5.7 Acknowledgements .................................................................................................. 96 6. The Global Fund’s paradigm of oversight, monitoring, and results in Mozambique ...... 97 6.1 Abstract .................................................................................................................... 98 6.2 Introduction .............................................................................................................. 99 6.3 Methods .................................................................................................................. 103 6.4 Results and Discussion ........................................................................................... 105 6.5 Conclusion .............................................................................................................. 122 6.6 Take-home messages .............................................................................................. 122 6.7 Acknowledgements ................................................................................................ 123 7. Discussion ...................................................................................................................... 125 7.1 Synthesis ................................................................................................................. 125 7.2 Overall significance of research ............................................................................. 127 7.3 Limitations.............................................................................................................. 129 7.4 Recommendations and Future Research ................................................................ 130 8. References ...................................................................................................................... 135 9. Annex ............................................................................................................................. 151 9.1 Annex 1. Semi-structured interview guide (for health ministry officials) ............. 151 9.2 Annex 2. Non-BRICS emerging economies' activities in-country ........................ 153 10. CV .............................................................................................................................. 157 ii Acknowledgements First I would like to thank my supervisor, Don de Savigny, for his continuous and kind support without which this project would not have been possible. His welcoming support enabled me to overcome every obstacle and complete this work. Our dear Marcel Tanner. Our fearless leader. Thank you. Thank you for always taking the time to meet with me, to talk through my concerns, and for sharing your insights and resources at every opportunity. Thank you for your generosity, humor and levity. You taught me invaluable lessons about approaching every situation with an openness of mind and spirit. I cannot thank Christine Mensch enough for her support and friendship over the years. She became part of my family-away-from-family. Our Friday afternoon chats were something that I always looked forward to and missed whenever I was abroad. Margrith Slaoui and I spent more time on the phone in the past few years than I did with most friends. I thank her for all the laughs and her patience while we ironed out the details of project administration. She is an integral part of my Swiss TPH experience. I would like to thank my collaborators in this research Ilona Kickbusch, Shufang Zhang, Stephen Browne, Raymond Saner, and Lichia Yiu. Michaela Told and Roberto Cordon, I especially appreciate the time that you took to provide extra guidance. Michaela, thank you for your support and for the additional diplomacy lessons. Roberto Cordon, thank you for your dedication while I prepared manuscripts. I would like to thank our gracious hosts for their support in Chad, Ghana, and Tanzania, respectively: Dr Daugla Doumagoum Moto (Centre de Support en Santé Internationale; N’Djamena, Chad), Dr. Moses Aikins (University of Ghana; Accra, Ghana), and Dr. Honorati Masanja (Ifakara Health Institute; Dar es Salaam, Tanzania). I would especially like to thank Dr. Charles Mayombana for being such a helpful guide in the halls of the Ministry of Health and on the streets of Dar es Salaam. Malaba Haroun, thank you for