The precariousness of the franchise state. NGOs & health care in Tanzania

My latest paper – ‘The precariousness of the franchise state: voluntary sector health services and international NGOs in Tanzania, 1960s-1980s’ –  has just been published in Social Science and Medicine.

Here is the link to the article, which  will be free for all until mid-September, 2015, subscription only thereafter).

And here is a brief audio / slide presentation on the paper from the SSM site:

The paper continues my work on the structure, nature and significance of the voluntary sector in Tanzania (and sub-Saharan Africa more widely), and in many ways serves as the second part to the ideas I develop in my 2013 Development and Change article, ‘Common counsel, common policy: healthcare, missions and the rise of the voluntary sector in colonial Tanganyika.’

Much current writing on the voluntary health sector across sub-Saharan Africa sees it as a new creation, linked to the rise of the NGO as powerful development actor from the 1980s especially (indeed, in many texts, the terms ‘NGO’ and ‘voluntary sector’ are used synonymously). Building on this, there is a strong debate within health systems reform literature on the relative merits of private (voluntary) providers vs state-run facilities. In’Common counsel, common policy’, I show how, contrary to this perspective, the formal voluntary sector was the creation of an alliance between the colonial state and Christian missionary organisations in Tanganyika from the 1930s. In other words, it was created, and many of its fundamental characteristics (later ascribed to the impact of INGOs) were already established, by independence, and before the rise of the NGO.

From the 1930s, the colonial state gradually incorporated mission-run services into its own health system, so that by the 1950s we can see health system in Tanzania operating as a public-private partnership model. The state provided (limited) funding for voluntary sector services; and in return, those voluntary providers agreed to subject themselves to greater regulation and direction from the state.

My latest paper, ‘The precariousness of the franchise state’, takes the story into the post-colonial period, and specifically the period in which NGOs emerged as development actors.

I explore, in particular, the trajectory of a maternal and child health programme run by the Bulongwa Lutheran Hospital, in southwest Tanzania. Established in the mid-1970s, the idea was to establish a mobile clinic which would undertake preventive care of infants and children; offer treatment for parasitic infections, malnourishment and other conditions; and provide support for pregnant women and new mothers. It was initially funded by the British NGO, Oxfam. However, when Oxfam made its decision to focus their operations on a smaller number of regions (which did not include that in which Bulongwa was situated), it ended funding. Christian Aid was approached to take up the project, which they agreed to do. But as is the way with NGO grants, this was for a very limited period of time: just two years. And when funding stopped in 1981, the project collapsed through lack of resources. When, a few years later, Christian Aid sought to resuscitate the programme, it was too late: the doctor had left, and there was nothing there to allow for its re-introduction (especially on the short-term time-frame within which funding was allocated).

Bulongwa was not unusual. Across Tanzania in this period voluntary sector hospitals were seriously understaffed; operating theatres left unused where no qualified practitioner was based; equipment too expensive to run, maintain or repair; the heroic efforts of those who struggled to meet community health needs undermined by the incessant requirement to jump through the hoops of form filling, report writing, begging and pleading for the tiny amounts needed to keep them going.

Through this case study, and as with the earlier article, ‘Precariousness’ questions some of the standard critiques of INGOs that have become orthodox accounts of the NGO sector. In particular, it questions the idea that they are complict in the implementation of policies of privatisation and fragmentation under health sector reforms and the new institutional economics that rose to dominance from the late 1980s.

Borrowing from Geof Wood’s useful concept of the franchise state I argue that much of the instability, fragmentation, creation of parallel systems, and problems of accountability identified by the critics of INGO engagement in sub-Saharan Africa, were already in place by the time these organisations arrived on the scene.

However, whilst they may not have created the precariousness that characterised voluntary health services in this period, INGOs did exacerbate some of its worst features. Through their funding methods, the ways decisions affecting the future of much-needed services were made in the distant offices of NGOs rather than within the communities, and the demands INGOs placed upon the voluntary sector ‘partners’, voluntary health sector services were made increasingly vulnerable, unable to plan for the long-term, and at risk of sudden closure. What was lost in this mode of operating were the needs, wishes and voices of those whose lives were most affected, the communities themselves.

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The End of the Devolution Tour? What lessons from the Scottish Referendum?

One of the benefits of being one of the only Africanists in South Wales, during my time in at Swansea’s now (very sadly) defunct Centre for Development Studies, was my being wheeled out in front of visiting dignitaries from various African countries. The Welsh Assembly was one of the stops on the ‘Devolution Tour’, as governments under pressure from external funding agencies to decentralise were shown how it had worked in the UK. And in the absence of anyone else to call upon, I would be invited to come down to Cardiff. At one lunch I sat next to Raila Odinga, back when he was Minister for Roads, Public Works and Housing (the Welsh officials, understandably not au fait with Kenyan politics, sadly missed the undercurrent of power dynamics around the table). Another time I was brought in for a meal hosted by Rhodri Morgan for (then Vice-President of Sudan) Salva Kiir .

One diplomatic visitor (this time not from Africa) was clearly taking up the offer of a Devolution Tour to investigate opportunities for a holiday cottage on the Gower: which to be fair was possibly a better use of his time. I can’t believe any of these trips had any meaningful impact, other than boosting Wales’ presence on the international stage; and most of the VIPs shown around the Assembly, before jetting off to the Scottish Parliament, looked rather bemused as to exactly what they were supposed to take away from the experience beyond their goody bag and a decent meal.

The End of the UK

But what of the Scottish Referendum, which takes place tomorrow (Thursday 18th September)? Does this carry any lessons for African debates and processes of decentralisation, devolution and perhaps even the break-up of existing borders?

Attention will be being paid to the campaigns run by both sides for lessons on how to win or lose the argument. It has been clear over the past year or so that the Yes campaign has been the stronger. It has offered a positive model of what an independent Scotland could be, appealing to hearts, certainly, but also making the economic argument (and if there have been some weaknesses in that argument, so too has the No campaign fallen down in some of its arguments). The No campaign has appealed to heads over hearts, but has been largely characterised by a negative campaign of what divorce might mean rather than a positive view of what Union brings. But any aspiring secessionists take note: whilst you may be building on a sense of grievance, make sure you use the language of friendship and cooperation; make a strong case for economic stability, and preferably stability coupled with economic growth; remember that money – the actual hard stuff in your hands – matters, so be explicit about your currency plans.

For those looking for lessons on how to keep your country intact, the main lesson is that polling is much less certain in independence referendums than it is in legislative and executive elections, so don’t assume that any early indication that the No’s have it won’t change. The No campaign didn’t really get start going with any real passion until relatively recently (and perhaps too late?). Offer a positive reason to stay together. And if you have big beasts on your side, put them at the front of the campaign. Gordon Brown may come to rue his tribal instincts, given the dynamism, passion and power with which he has campaigned in recent days. A clash between Salmond and Brown in the televised debates would have been wonderful, and injected a much better sense of drama.

Inevitably, the campaigning has unleashed strong emotions on both sides. Stories of No campaigners being chased down the street by irate 5-year olds shouting ‘yes’, and journalists being intimidated (ITV’s Tom Bradbury perhaps rather unfortunately reflects on his experiences in Scotland compared to Northern Ireland). And of course there have been occasions where debate has turned nasty, and heckling has become intimidation. But a few (widely reported instances) should not detract from the fact that this has been a good and overall positive campaign. The leadership on all sides should be commended for trying to encourage respect and friendship across the independence divide. Secessionists, you might find that calling the media biased works well in mobilising support and the historical sense of neglect by the establishment. But remember you will have to rein in some of the passions unleashed after the referendum, so play these cards very carefully. Where politicians have routinely used violence, and stoked-up identity divisions, to secure victory, the language of campaigns, the allegations made, and the aspersions cast upon rivals, can have devastating consequences.

Another lesson is that the referendum is not actually an either / or process, no matter what it says on the voting slip. Indeed, Secessionist-in-waiting, it may be that you don’t actually want independence, but a lot more powers and resources for your region whilst remaining part of the country. An independence referendum, as Scotland shows, might be just the ticket. Alex Salmond’s charge that promises of greater devolved powers are a panicked response in the last days of the campaign are rather unfair: it has been clear over the past couple of years that should Scotland say No, its parliament is set to receive more powers (the UK government wanted a third option on the ballot, the so-called Devo-Max). It is probably true, however, that the closeness of the race has led to more concrete proposals than might otherwise have emerged. But, like a desperate lover trying to offer a reason, any reason, for the other to stay, presents are likely to be thrown at the party threatening to walk. More tax-raising powers? Of course, here you go. And did I say how lovely the Barnett Formula looks on you? So threaten, and perhaps actually hold, your referendum, but make sure you get more than ‘carry on as usual’ if the result is No.

Of course, for those of you wanting to make sure your country keeps its current borders, Scotland does show some of the dangers of devolution. By giving extensive powers to a region, you create a platform for secessionists to gain presence, power, and a platform for their demands. For one thing you can be sure, no matter how much power you give there will always be demands for more, and the moment you say no is the moment you can be characterised of seeking to dominate, colonise, and undermine regional government. Centralisation can look like an attractive option. Would the Scottish referendum have taken place without devolution in the late 1990s? Possibly not. But on the other hand, refusal to contemplate devolution may have created harder to control grievances, which would have led to a referendum on much worse terms. So in the place between the rock and the hard place, it’s probably best to try and make the best of the compromise. Devolution, when it works, can be good for all (and for all the flaws of the Devolution Tour, is probably where the best lessons can be noted). But make sure the transfer of power is real and substantial.

Whilst I’m not at all sure Scotland’s referendum holds any meaningful lessons for African countries, it does hold some for donors and international organisations who push the decentralisation agenda so heavily upon African (and other) countries. There is precious little evidence that decentralisation processes have made any real difference to economic and human development, democracy and transparency, availability of services and support, or any of the other promised miracles that will occur when decentralisation is put in place. This is partly because decentralisation can mean many things, not all of them leading to the outcomes donors expect, and some (many?) of which can actually concentrate power further at the centre. Malawi’s experience, for example, raises questions as to who the main beneficiaries have been. Where it has worked – and I would argue Scotland is an example here – it is because decentralisation was both real in terms of the power that was transferred (Welsh devolution has been markedly less successful for that reason); and because it was meeting an internal demand rather than the imposition of an externally-driven model (again, demand for devolution was much lower in Wales than in Scotland, although this might be changing). But I’m not sure that this is a lesson that one can only learn from Scotland. Kenya will be a very interesting country to look at, where its own decentralisation reflected long-standing internal debates rather than a donor-driven process. Researchers are already looking to see what difference counties and the established regional governance institutions will make to Kenyan governance and politics overall.

So are there any significant lessons from the referendum? Probably not. And if we’re looking for lessons, how about those for Scotland from similar processes in Africa and elsewhere? I’m sure that campaigners and politicians looked to experiences across the world, including Africa, for ideas for their own process.

What is probably much more important is what happens next, whatever the outcome. If Yes, how will the divorce process be managed? Will the bluster and obfuscation on both sides give way to reasoned negotiation? Will Westminster stop behaving like a spurned lover over the pound (you can’t have it, we had it first, look I’ve written my name on it) and come to a reasonable compromise? Will sharp barriers by set up, or a more relaxed sense of cooperation and collaboration?

If Scotland votes to stay, what changes to the devolution model will emerge, and how might that impact on the rest of the UK? Will my home of the South West be pushing for its own tax-raising powers or legislative assembly? Will English, of Welsh, or Cornish nationalism(s) rise, and will they do so in a positive rather than exclusive and exclusionary way? Will decentralisation be rolled out across the country as a whole?

So if it is lessons you are looking for, come back in six months to a year. But whatever the result, I’m sure we’ll see the continued flow of African government officials to London, Cardiff and Edinburgh. Whether they will be asking how devolution can work for them, or how separation can be made less painful, we’ll have to see.

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And we’re back to this again – politics, charities and Tory ministers

Look, Mr Cameron, please can you stop your colleagues banging on about why charities should be behaving like grannies rather than truculent teenagers. I keep telling myself not to return to this theme, and then someone says something that pulls me back in against my better instincts. I’ve got quite enough real work to be getting on with, really.

It’s hard to know where to start with a Minister for Civil Society who thinks civil society should “keep … out of the realms of politics”, before pontificating that “The important thing charities should be doing is sticking to their knitting and doing the best they can to promote their agenda, which should be about helping others.”

I’ve written on this twice now, and it’s getting a bit boring. The difference here is that this is actually a minister rather than just an MP seeking to make noise. More than that, it is actually the minister responsible for civil society, Brooks Newmark, who is saying this. Now I’m not saying ministers should be the world experts in their area of responsibility, but surely they should at least be a tiny bit aware of some of the issues.

I won’t rehearse the well-trodden issues with this statement. But perhaps, Mr Newmark, you could look to your own government’s policy elsewhere as a guide to what civil society should, or should not be doing. Why don’t you have a chat with Justine Greening about how DFID is supporting a very political role for NGOs and other civil society organisations in holding government to account in other countries. Or look here (if using a work PC to look things that might be a teeny bit political is OK – I’ve highlighted below the relevant bits):

“We work to support elections and help countries to develop fully functioning democracies including parliaments, civil society, the media and political parties.”

“In every country where we give aid directly to a government, we will spend up to 5% of the allotted aid on accountability. This will be done through projects to help the media to scrutinise the government, or by funding local organisations to feedback directly on government services

That sounds pretty political to me. Unless we’re now advocating a policy of civil society should be political for all those foreign chaps, but it’s not quite British is it.

Look, if you’re going to be the Minister for Civil Society, perhaps you could do some reading. Even a cursory glance at these basic texts should be enough to persuade you that civil society is necessarily political. How about starting with the classics, de Tocqueville’s Democracy in America (a very unthreatening book). Then you could move onto Robert Putnam’s ‘Bowling Alone’, and his other work on this subject. All easy and nothing to scare you. If you don’t mind being challenged a bit, try a bit of Gramsci –not the usual reading of choice for a go-getting Tory, but think how impressed colleagues will be if you can cite every student’s favourite revolutionary. Or try looking at the World Bank website for their understanding of civil society – surely that’s not full of untrustworthy Trots, and can be trusted?

I know you are pressed for time, so you could just look it up in a dictionary if you can’t do anything else. In case your department’s budget doesn’t stretch to one, here’s the Macmillan Dictionary definition:

The part of society that consists of organisations and institutions that help and look after people, their health, and their rights.

Again, looking pretty political to me, and precisely the kind of activity (looking after rights, health, etc) you aren’t very happy for them to be indulging in here in the UK.

But if you really want to know why your statement is nonsensical, and why civil society cannot be anything other than political, then why not come and study one our masters programmes in development studies at SOAS? We have lots of academics here who can explain what civil society is, what it does, and why it is important. We’re probably still accepting applications. If that doesn’t tempt you, why not take up knitting yourself?

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NGOs, Lobbyists and the Campaigning Blob

As the pre-positioning for next year’s UK election begins in earnest, one strand of the Conservative Party strategy appears to be becoming ever clearer: an attempt to undermine organisations whose campaigns, research, or focus might produce narratives that counter the government’s assertion that we are all in this together. Conor Burn’s attack on Oxfam’s campaign on UK poverty has become part of a broader attack on NGOs, think-tanks and other organisations whose work on poverty, inequality and the effects of government policy sits close to that blurred line where charitable status meets political campaign.

Last week, Tory MP Charlie Elphicke led a debate in the House of Commons on the political independence of charities, having the likes of Oxfam in his sights, but also the left-leaning think-tank, the Institute for Public Policy Research. In relation to the former, he denounced the campaign highlighting the impact of government policy on poverty and inequality in the UK as something that ‘could have been written by Labour Party HQ’. He followed this up with the intellectually lazy cliché of suggesting the NGO misleading ‘the hard pressed pensioner [who] donates to Oxfam … believing the money is going directly to help people in deep need – particularly overseas’ (many of the development-charity supporting ‘hard pressed pensioners’ I know have a better understanding of the politics of poverty that Mr Elphicke seems to display, and are entirely supportive of Oxfam’s campaigns overseas and in the UK).

In relation to the second focus of his attack – the IPPR – Elphicke criticised the Labour Party for out-sourcing its policy-making to the organisation; and highly conveniently fails to mention, in his criticism of IPPR links to the Labour Party, those of the right-leaning Policy Exchange to the Tory Party. Of course, there are great differences between the ‘political’ think-tanks which have always had close personal and intellectual links to whole parties, or elements within those parties, and development NGOs. But by conflating the two under an umbrella of the dangers of partisan lobbying, it becomes easier to attack all targets rather than engage in a nuanced debate.

In Sunday’s Telegraph we had another Conservative MP, this time recently-sacked Minister for the Environment, Owen Paterson moaning about the ‘green blob’ (borrowing from Gove’s own metaphor for those who disagreed with his education reforms): ‘lobbyists’, supported by ‘their industrial and bureaucratic allies’, whose sole purpose is not to improve environmental sustainability and protection, but to ‘enhance their own income streams and influence by myth making and lobbying’. Who are these core members of a Lobbyist-Industrial-Bureaucratic complex, reliant on European grants, representing no-one but their own self-interest, the ‘tangled triangle of unelected busybodies’? Why, it’s those ‘anti-capitalist agitprop groups’, Greenpeace and Friends of the Earth!

Now, Greenpeace has come in for some criticism over the past few months, and as campaigning organisations, both (as with any organisation who presents research and analysis on policy and practice) should have their claims and assertions tested and challenged. But their characterisaton here is deeply misleading, and, well, wrong. Patterson is not seeking to engage with their ideas and arguments, but chanting ‘I was right, I was right’ until he hopes we lose the will to challenge him on this. His assertion that green movement doesn’t believe in improving the environment, and only he did, is the political commentary equivalent of my four year old daughter yelling at me, ‘no, you’re wrong!’ and then sticking her fingers in her ears (actually, I do her a disservice – she has moved beyond that: shame the editors of this piece didn’t ask for something a bit more substantial).

Patterson’s article is really about defending a poor record, and as such is a rather unimportant footnote at the end of the government career. Except, what is interesting is the return to the language of lobbying, influence and ‘public funds’ being used (or misused) for political campaigns. Referring to Friends of the Earth and Greenpeace as ‘lobbyists’ is very deliberate. It is intended to muddy the waters that separate commercial lobbying firms, or the lobbying undertaken by particular industries for their own commercial advantage, with organisations who lobby and campaign for a social purpose. It will not be long before attacks on Oxfam, or whichever development charity next seeks to campaign on a UK-focused issue, refer to them as lobbyists rather than NGOs or charities.

Ironically, given the current Tory complaints about public money going to such organisations, it was under the neo-liberal reforms of the 1980s that NGOs came to be supported with public funds to an ever increasing degree. Seen as a way of bypassing the ‘governance blob’ of cumbersome, corrupt, inefficient and bloated public sectors and governments, and of bringing the efficiency of private (albeit non-profit) sector expertise to bear on issues related to poverty, support for marginalised groups, etc, governments began to channel ever more official aid spending via NGOs. Inevitably, this created tensions between organisations whose very existence was in effect a criticism of the government (for why would such organisations need to exist if government policy was working?), and those governments with whom they were now partners. It was a relationship that would inevitably, and frequently does, come back to haunt both partners: governments of all stripes who get cross at being criticised by those in receipt of official funds; NGOs who feel implicated by their linkage to those governments.

Of course, government attacks  on charitable campaigning are not new: remember Thatcher’s furious response to the Church of England’s Faith in the City report when published in 1985? However, they have been given teeth by the so-called anti-lobbying bill which is widely seen as a blunt instrument that fails to distinguish between the lobbying of, say, an oil company, and that of an anti-poverty NGO. But also by what looks to be becoming a concerted attack by Conservatives on any organisation that present a challenge to the government narrative of four years of economic success: charities, think-tanks, unions, etc.

So far the debate has been controlled by the critics of charitable campaigning, focused on the public funding aspect, or the potential misleading of hard-pressed (and presumably hard-working, to borrow another Tory mainstay) members of the donating public. The response needs to focus on the issues: on the illogicality of a politician suggesting poverty, or the environment, or social alienation, are not inherently political; on the pretence that the public-funding of charities is a left-wing policy; on the idiocy of suggesting that anti-poverty organisations can only focus on poverty ‘overseas’; and most importantly, that seeking to inform debates on poverty, environment, etc, is inherently, and must be political.

There are many legitimate and serious criticisms that can be levelled against NGOs: for the way in which they work; on their levels and processes of accountability; on their claims to represent particular constituencies; and yes, on the political influence they can bring to bear. But the current debate is not about challenging some real dilemmas of  and facing the NGO sector, rather it is about a political party seeking to limit the scope for public questioning of its own claims.

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It takes a village, revisited

So the UK government is facing a judicial review in the High Court for providing aid to Ethiopia without regard to its human rights record. As reported by the BBC and The Guardian (amongst others), an Ethiopian farmer who was forcibly resettled as part of a villagisation programme in Gambella Region in 2011, is arguing the UK government has acted unlawfully in supporting the Ethiopian government through aid payments.

The argument is that the aid provided through DFID has allowed the government to pursue its Commune Development Programme, which aims at resettling around one and a half million families in newly established ‘model’ villages. Although UK aid has not directly supported the CDP (according to DFID), the claimant accuses Britain of being complicit in the policy he says led to his violent eviction from his home, and the failure by the Ethiopian government to provide sufficient land, water or other resources to allow those evicted to survive. Failing to challenge the government on its human rights record, and by continuing to provide aid, the UK enabled the government to pursue this policy through the fungibility of aid.

I wrote about this almost exactly a year ago, when a US report criticised DFID and USAID for failing to act in the light of evidence of physical violence, intimidation and other abuses resulting from the villagisation campaign. I also noted the continued belief in resettlement as a development tool by national governments, donors and other development agencies alike, despite decades of evidence that should strongly advise caution.

This case has made the headlines (the pleasing image somehow reminiscent of Ealing comedies in which the Powers That Be are brought to book by the most unlikely of heroes). Its chances of success may be questionable (although whether that would be an appropriate finding is a very different matter). But the prospect of DFID defending its approach to monitoring good governance in the countries it supports, and in particular its rationale for why in some cases it chooses to be more forceful in making challenges against poor practice, is a juicy one.

The legal review might not tell us anything new, but it may force greater transparency on the decisions being made as to when to stay quieter than others. It will put pressure on DFID to clarify just how seriously it takes its ‘good governance’ mantra when deciding on its aid spending. We may have moved on from the Cold War years, when tyrants and dictators were endured provided they were ‘our’ dictators and tyrants. But there is no doubt that if you are considered to be a strategically important regional power, considerations other than respect for human rights, ‘good governance’ and constitutional niceties come into play (yes, I’m looking at both of you, Rwanda and Uganda).

But of course, as I noted in the last blog, it isn’t just donors who have been engaged in supporting large scale, and deeply controversial resettlement campaigns. Tanzanian villagisation drew into its orbit a host of otherwise impeccably liberal-credentialed NGOs and activists. Elsewhere, during the 1985-86 Ethiopian famine, money raised by NGOs and other charitable giving was used in a resettlement campaign that was highly political. Indeed, Band Aid (the organisation which dominated the headlines of the humanitarian response) supported some of the relocation camps, choosing to see the programme as developmental rather than part of the Derg’s war effort against Tigrayan and Eritrean rebels in the north. Here the result for tens, perhaps even hundreds of thousands, was not just violence and destitution (a bad enough outcome), but death.

These failures may be at the extreme end – support for interventions that culminate in human rights abuses, violence and deaths on a massive scale – but dark outcomes resulting from good intentions are not unusual, nor should they be unexpected. Development interventions have resulted in sufficiently frequent harm that they cannot simply be ignored as isolated cases.

This case raises the question as to whether development interventions can result from deals made between national governments and donors, or whether participation from those directly involved must be taken seriously. That would make policy formulation and implementation more of a challenge, but people cannot simply be treated as parts of a machine to be manipulated and moved about without regard to their own agency to achieve ‘Development’. For development without acknowledging the individual and communal human impact is not development at all. The legal challenge may not result in substantial change to DFID and broader donor policy, but it may add momentum to debates on how meaningful accountability can be improved, for all development actors, not just donors; and for how the voices of those who are forced to leave their homes as part of the Drive Forward can be better listened to and understood by all.

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