Moving to Government-Managed Technical Assistance

In the present phase of EC support to the health sector in the Philippines, the commission contracts TA personnel. This will change in 2011 when the government will take charge of recruitment and management of TA. The radical reform of TA delivery, proposed by government and welcomed by the delegation, poses a huge challenge to both parties who have to turn agreed reform principles into practice. Against this background, it turned out to be instrumental that  the formulation process was reinforced  by an additional  country support activity consisting of various learning events about the TC reform which followed in Manila from May 11-15th  (read more). Christopher Knauth and Nils Boesen, who facilitated the learning events, report from Manila.

The Health Sector and EC Support

The Philippines is a middle income country, however the health status of the population lags behind comparable countries in the region. The health system is characterised by huge inequalities and inefficiencies. In 1991 the country undertook a very radical politically driven decentralisation process where the delivery of health services was put into the hands of local government units, sometimes very small municipalities.  This devolution process resulted in a fragmented local health system, driven by local politics, in essence curative oriented and hospital based, with some protection of public health priorities from the national level. To address the various sector challenges, the government introduced a health reform agenda in 1999. In 2005 this was operationalised into a government-driven sector programme labelled "FOURmula One", the FOUR pillars being health financing, health regulation, service delivery and sector governance. The reform started in a subset of 16 out of 80 provinces who were the first to subscribe to the reform agenda.

The EC has been supporting the health sector in the Philippines since 2007 through a Health Sector Support Programme of € 33 m. In the first phase, the lion's share went through direct support to the 16 provinces, based on performance against agreed indicators. However, there was a separate TA component of € 8.5 m contracted by the EC. This TA - not less than 29 international and national advisers - supports the 16 provinces as well as the Department of Health (DoH) and central agencies like the national health insurance provider or the drug regulatory authority at national level.

"Embedded Technical Assistance"

The TA working in the present phase of the support is often referred to by delegation staff as "embedded TA". Technical assistants work within the structures of the DoH and other national organisations. There is no parallel implementation unit in the formal sense, and the TA does not manage EC funds (which are mainly provided as sector budget support). They do manage funds related to their work and the workshops they arrange.

The ownership of the partners is respected and promoted in close daily relations; the TA seeks to depart from what already exists; and to be mentors and coaches, rather than to teach. Proximity, availability and confidence are key values in the cooperation.

However, there is still a special relationship between the key TA staff (team leader, deputy team leader and advisers in key areas like public finance management) and the delegation. The TA does not only serve capacity development, policy advice and implementation objectives in the health sector, they also supply highly value information to the delegation about progress and challenges of the reform process.

While located within the offices they support, there are still elements of a parallel structure: The 29-person strong TA team is not only responding to national managers, but also to the hierarchy of the TA team, which again reports to both the government and the EC delegation.

The TA works with a clear results focus: Their work plans focus on a set of deliverables that they are solely responsible for. While this clarifies expectations, it was also observed that this narrow focus on what the TA delivers does not capture whether the TA deliveries feed into wider processes and thus deliver effective support to capacity development.   

Towards a Health Sector Policy on Technical Assistance: The TACT

The EC is not the only provider of TA to the health sector. Several other development partners and local partners are assisting in the health reform. As Under Secretary for Health, Mario Villaverde, explains in the video clip <embed video here>, the health sector has had difficulties with poorly coordinated support managed in parallel units, which were not producing sustainable results. Part of the response has been to form the Technical Assistance Coordination Team (TACT), which oversees the preparation of Terms of Reference, the selection of service providers, management of TA and evaluation of results (see the details of the TACT mandate here). In a further attempt to make TC and donor support more effective, the DoH is considering introducing a scorecard for assessing donor performance.

The consistent attempts of the DoH to align donors to the national agenda were an important backdrop for the decision of the EC to hand over TC procurement and management to the partner.

Government Procurement and Management of TA - and EC Sector Budget Support Only

The DoH has a very ambitious reform agenda, expanding the reform from an initial 16 provinces to all the country's 80 provinces. It faces the task of strengthening capacity of more than 1,000 Local Government Units, as well as a deconcentration process within the structures of the DoH towards the regional level locating technical assistance teams at the 16 regional offices of DoH, with other TA deployed at lower levels. The TACT will - unless its functions are devolved to lower levels - oversee the recruitment and performance of the TA. Consistent with the move to full partner implementation, the EC will from 2011 only provide one single Sector Budget Support to Government - and it is then up to the DoH to use part of the funds (and other funds) for procurement of TC. The EC delegation will no longer have any operative function in relation to TC.

This could of course be where the story ends - the TC reform promoted by the EC getting to the logical conclusion of full national management.  But, at least on some accounts, this may also be where the story begins again, both for the government and for the EC.

Central Government in the Donor Seat: How Can They Support Capacity Development at Local Level?

The decentralisation process in the Philippines gives considerable legal and financial autonomy to the local governments. They are responsible for delivering important health services - but they are not inclined to accept orders and instructions from the DoH in areas they consider under their purview. In the same vein, they may not necessarily see TA provided by the DoH as only a beneficial gift aimed at helping them - they may well fear that a "one-size-fits all" approach will be implemented, or that the TA are (also) controllers of the local investment funds that are part of the "reform package" that the DoH is offering.

This might sound conspicuously like accounts of the relation between donors like the EC and their partners - that ownership and demand for TA may not be strong, that supply-driven TA for capacity development is ineffective and that TA purportedly serving CD objectives may also be perceived as (and act as) controllers and implementers. So the typical questioning of the relations between donors and partners in relation to TA may now repeat themselves - this time between the DoH and the Local Government Units, (LGUs). In a coaching session where different government partners discussed the future management of TA, this "mutation" of a traditional donor-partner discussion to become an internal partner-discussion was very visible. Hopefully it can prompt a rich discussion of the capacity development strategies to be pursued, getting beyond the narrower focus on TA inputs.   

Donors Loosing Ears and Eyes: A Manageable Risk?

In the present "embedded" TA set up in the health sector, the TA is clearly as much the EC's as it is the governments'. This may be less optimal for ownership and long term effectiveness of CD support - but it certainly equips the EC delegation to be an informed dialogue partner. Therefore, there was an understandable ambiguity in relation to the bold move to let TA go: How would the delegation be able to follow developments sufficiently close without EC-contracted TA?

The details of alternative arrangements are still to be fleshed out. However, the preliminary discussions during the learning events in Manila included the following points:

• Seat in the TACT. The EC - as a major partner whose funds would be used among others for considerable amounts of TA - would become an observer of the TACT, thus effectively having a supervisory role regarding terms of reference, recruitment and management.

• A CD strategy and plan. The DoH should, as part of the reform strategy, develop a proper CD strategy and plan, in dialogue with development partners and as necessary with their support.

• Strengthening the sector dialogue mechanisms. At the moment, there is a sector working group meeting monthly, but the meetings - given their size and the fact that they span all reform issues - are not effective dialogue meetings regarding specific issues like capacity development.

A consequent approach to TC reform may well imply that a delegation (or donors in general) lose a direct channel into the workings of a sector. However, as discussed more generally by Nils Boesen in his related article, TA may not be the best way to gather information and may maintain fragmented TA delivery if each donor wants "their own" scouts. And TA is definitely not the only way to gather information and enrich the policy dialogue: Strengthening a Sector Wide Approach may provide a better joint solution.



How the EC delegation in the Philippines and the national stakeholders will shape events in the future remains to be seen and will be an interesting story to revert to, as and when it develops.