Picture credit: US Army Africa, via Flickr
What is the purpose of development aid in the health sector? In this post UnsettlingHealthcare leads Ben Hunter, Ramila Bisht and Susan Fairley Murray highlight findings from their recently published article in Critical Public Health: Neoliberalisation enacted through development aid: the case of health vouchers in India. They draw attention to a co-option of health aid within a wider and damaging neoliberal ideological project, but also the complications that arise when people are expected to implement this project.
Aid with neoliberal characteristics
The UN’s Millennium Development Goals proved a boon for an emergent ‘global health’ movement, with one prominent change being a dramatic increase in aid directed to the health sector. In 2000, USD 12 billion was committed to health causes (officially designated ‘development assistance for health’); by 2015 this had trebled to USD 36 billion. It was a period that one influential US-based research group described as a ‘golden age’ for global health financing.
Our concern is with the way in which this rapid expansion in health aid became part of a broader neoliberal political project to commodify public goods and services and to expand markets in social sectors. One feature of this in the healthcare sector has been a shift towards greater use of private sector operators to deliver public services. Public-private ‘partnerships’ have been presented by some parts of the global health community as a pragmatic, if not the only, option for addressing inadequate access to healthcare, with scant attention to the problems and costs associated with such arrangements.
Test sites for global replication
In our article, we examine attempts to use a health aid project to finance public-private partnerships and expand neoliberal policy approaches. Our case is the US Agency for International Development’s (USAID) Innovation in Family Planning Services Project (1992-2013). That project initially aimed to improve access to family planning in northern India, and then was extended to other maternal and reproductive health services for a second decade of implementation.
At the heart of the Innovation in Family Planning Services Project lay an emphasis on bypassing government systems and contracting private providers to deliver health services. This became increasingly explicit as the project proceeded, as the aim of its second decade was to ‘develop, design, demonstrate, document and disseminate’ a series of public-private partnerships which could be replicated elsewhere. The project formed part of USAID’s wider attempts to support and expand private healthcare globally, through its projects such as Private Sector Partnerships – One (2005–2008), Market-Based Partnerships in Health (2008–2012) and Strengthening Health Outcomes through the Private Sector (2012–2015).
The politics of aid
However, the Innovation in Family Planning Services Project’s five ‘Ds’ did not proceed smoothly. Funding for the Innovation in Family Planning Services Project, was provided jointly by USAID and the Indian federal government, yet programmes were to be enacted with state government support. There was scope for politicians and civil servants at the state level to re-interpret activities and they varyingly embraced, resisted, and distorted the project to suit their needs. In some cases they tried to expand programmes to offer a wider range of free health services; in other cases trying to divert funds to improve government provision and blocking programmes that were felt to undermine it.
Our close study of implementation in one of the project’s programmes – a voucher and contracting scheme – revealed further complications during enactment. Programme designers had sought to encourage ‘user choice’ by enabling people living in urban slums to use one of several private hospitals that had been accredited to accept vouchers. They incentivised community workers to support this by providing a payment in return for each voucher used.
However in practice, managers, supervisors, and community workers discouraged particular ‘choices’ by users when it became apparent this would undermine programme performance. Potential users of the voucher scheme were actively deterred from ‘choosing’ public healthcare to give birth (where they would receive a cash payment from the government); they were instead encouraged to use vouchers in private hospitals despite it being known that additional charges were levied by those hospitals. Two policy manifestations of neoliberal theory – user choice and individualised performance management – had quickly come into tension with one another.
Neoliberalisation enacted through health aid
A meta-level narrative around neoliberalism tends to obscure the processes, complexities and contradictions that have emerged as people experience and enact neoliberalisation in ways which ‘bring the political project to life, to make it real’. Our article further underlines the need to consider how neoliberal subject-making is pursued by paying particular attention to the state-forms and people involved, as officials, programme workers and users had ‘wiggle room’ to interpret programmatic features in unexpected ways in pursuit of their political and personal interests. Such tactics were used at times to reinforce public sector provisioning, and at times to weaken it.
This perspective sheds light on how development aid has been used in the health sector. What on the surface may seem a benevolent transfer of resources to improve health, can be part of a political project that exacerbates inequalities of health and wealth. It is important that we continue to balance our support for aid with critical perspectives on how it is designed and used.
Access to the full article in Critical Public Health is currently subscription only, and an open access version will be made available here once the publication embargo has ended.
This blogpost is based on doctoral research which aimed to examine the use of development aid to expand markets in healthcare. Data used in the research were drawn from texts produced by and for Innovations in Family Planning Services project funder, USAID, and fieldwork conducted in Uttar Pradesh during and following implementation of the Innovations in Family Planning Services project.