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:

http://audioslides.elsevier.com//ViewerSmall.aspx?source=1&doi=10.1016/j.socscimed.2015.07.018

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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About Mike Jennings

I am a Senior Lecturer in Development Studies at the School of Oriental and African Studies (SOAS), London. My work is on the history and politics of international development in sub-Saharan Africa. Research areas include: - The history of development in Africa, from the late nineteenth century to the current day - Politics of East Africa (Kenya, Tanzania and Uganda) - the role of non-state providers (NGOs, FBOs and self-help groups) in welfare service provision - Social aspects of health, including HIV and AIDS, and malaria
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