Below we present participant perceptions of TA in the DRC and Nigeria health sectors, beginning with how they defined and characterized TA. Then we report on the shortcomings of TA that were identified through the thematic analysis, and finally, we describe critical shifts needed in TA approaches and strategies to address the shortcomings.
Limitations and implications of existing TA practices
Donor-driven TA agendas and country needs and priorities. In both countries, participants stated that TA is usually initiated by donors. In many cases, donor agendas do not seem to align with the country’s priorities as described in its national health development or strategic plans. Because TA often does not address country priorities, participants reported that TA consumers often feel that their voices are not heard and their needs are not met. Participants noted that TA providers do not seem to have a genuine interest in partnering with them to address country-defined issues in ways that emphasize the long-term improvement of population health (e.g., building local knowledge and expertise, defining impact measures).
“A partner comes in, does his project, identifies the needs, hires the technical assistant in an attempt to work more closely with the government, and places this technical assistant within the MOH. That is the first problem: in the identification of needs, TA is externalized, it is not internalized.”
- TA Donor/Provider, DRC
Government participants shared that they often feel compelled to accept foreign aid, even if the proposed TA does not align with the country’s strategic objectives. They feel that their country is not in a position to refuse assistance that could improve any aspect of the health sector, even if the intervention itself is not deemed essential. To ensure that TA is aligned with country priorities, participants encouraged TA providers to collaborate with other TA actors, be flexible in allocating funds, and convey respect for the government’s authority. Government participants also acknowledged that, to build TA providers’ trust in the government’s ability to manage TA donors and providers, government actors should demonstrate leadership and direct, coordinate, and manage the TA delivered to their programs and agencies.
TA providers and consumers stated that misalignment between country needs and TA begins at the proposal stage when donors issue requests for proposals (RFP) that reflect partially designed projects. TA providers stated that because RFPs contain incomplete project designs and require a rapid submission of proposals, providers sometimes fail to fully research the country priorities or contexts, reverting to interventions, methods, and tools that have been effective in other settings. When TA providers conduct in-country research after their proposal is approved, they often believe they cannot refine the focus of the project at that point. Thus, direct TA support is often confined to the objectives in the TA provider’s terms of reference from the funder, with providers reporting being unable to pivot to respond to evolving situations and emerging needs. TA funders, providers, and consumers alike acknowledged that not permitting TA providers to modify their approach as needed is a critical flaw, and that steps are needed to improve how and when TA is tailored to a country’s context.
“As an implementing partner, we discovered we have designed programs that do not respond to needs and because the donor does not have flexibility, we are forced to implement the activity without change.”
- TA Provider, Nigeria
Participants also cited vertical programs like HIV/AIDS and immunization as examples of funder—rather than country—priorities dictating which health areas receive TA. They also noted that vertical programs result in the creation of duplicate data collection systems that do not strengthen primary health care and hamper program sustainability.
Short-term TA and static, one-size-fits-all solutions. Participants expressed the belief that TA projects are generally not designed to bring about meaningful, lasting change, given that donor funding cycles necessitate rushed TA implementation. Participants agreed that while emergency and humanitarian crises require quick-moving, nimble TA, non-emergency TA designed to strengthen systems requires a long-term vision. Nevertheless, most TA initiatives are three-to-five years long, which participants stated is too brief to effect sustained change.
Participants commented that the prevailing approach to TA emphasizes short-term measures of progress rather than systems building. They cited the emphasis on output indicators (e.g., the number of people trained to deliver a given service) as opposed to measures that indicate changes in a system’s capacity to provide services over time. TA consumers and providers alike expressed concern that individuals and organizations that fund or provide TA benefit more from short-term projects than TA consumers do, which further undermines country priorities.
When a TA provider meets short-term, donor-defined outputs, they may increase the probability of securing additional work from that funder. Pressure to implement TA rapidly encourages providers to implement one-size-fits-all solutions that are not responsive to the context. TA providers stated that they feel constrained to produce reports and demonstrate evidence of impact quickly, necessitating parallel data collection systems to substitute for slow-moving national information and reporting systems. This approach does not contribute to systems strengthening or enhance the capacity of country-led health sectors.
Participants also recommended that governments counter the short-term nature of TA by becoming directly involved in TA program design and implementation, thereby enhancing local institutional memory and increasing the likelihood of sustained impact, scale-up, or adoption of the initiative by the government. As one participant stated, governments should be engaged in and familiar with health programs, and thoroughly document needs assessments and rollout processes. This would result in more sustainable TA activities rather than being aligned with one individual in the health system and that are unaffected by changes in government leadership.
“[The time between] the formulation of the projects and their implementation can sometimes last years. At the central level, there can be some important changes. . . changes in ministers, etc. that mean that if we [TA donor/provider] do not have representation of TA at the central level, there is a loss of visibility. And the people who have participated at the central [government] level in the identification of needs are no longer there, and what is done locally is completely ignored by the incoming parties.”
- TA Donor/Provider, DRC
Insufficient skill transfer and dependencies. The practice of TA-supported interventions was described by participants as being “capacity filling” instead of “capacity building.” For example, when TA providers embed their staff in a MOH, they often neglect to allocate sufficient resources to strengthen the capabilities of MOH staff, which could enhance long-term sustainability. Many participants also criticized the attitude of certain TA providers who come to “do” the work themselves rather than assist, support, collaborate with, or learn from local partners. Participants concluded that this practice creates an over-reliance on donors and TA providers to conduct core government business and fails to leverage opportunities for local capacity development.
Participants explained that ideally, capacity building should be part of all TA contracts so that skills transfer is integrated into projects. They noted that an embedded approach, with TA providers working side-by-side and mentoring government staff, would ensure greater ownership by governments. Government staff would not feel excluded from learning the information and skills being used by TA providers and, consequently, would be better able to sustain the system after the TA ended. Participants also emphasized that capacity building is not a unidirectional effort and that TA providers would benefit from listening to the staff they train since staff often have a deep understanding of the nuances of the health system. Understanding these nuances would strengthen TA providers’ approach to capacity building, making their efforts more contextually relevant. Good TA through intentional capacity building signals an intent to invest in the system for long-term sustainability.
- TA Provider, Nigeria
Government representatives reported that they have lost talented civil servants who left to work for development agencies to benefit from opportunities for professional growth and higher salaries. This loss of talent diminishes governments’ ability to enhance and sustain leadership capacity and project management skills due to brain drain and overreliance on external TA. Furthermore, participants said that the motivation and morale of government staff often suffer when local capacity is compared to, pitted against, or replaced by private-sector TA providers. Respondents shared that some civil servants grow reluctant to engage fully in the work they share with TA providers for fear of relinquishing their responsibilities and assignments. This hesitancy to collaborate with TA providers can contribute to growing gaps in institutional capacity and perpetuate reliance on external support.
Short-term TA investments routinely divert attention from issues of government ownership, institutional capacity building, and systems sustainability. When capacity building is not emphasized and sustained, as new projects are funded, the government continues to rely on external expertise rather than leading from within.
Limited mutual accountability and uncoordinated TA. Government participants stated that there is limited or no obligation for TA funders or providers to interact and consult with governments, update them on progress, or share reports and evidence of their work. Government participants are often not informed about donors’ decisions related to selecting, funding, setting priorities for, and choosing a physical location for TA providers. In some cases, TA providers bypass national governments and contract directly with state or provincial governments, demonstrating their lack of accountability to national governments and further exacerbating government efforts to coordinate and manage TA.
Government participants acknowledged their critical role in coordinating TA, communicating their vision and expectations to TA providers and donors, and also highlighted the need for communication mechanisms through which they can receive updates on TA progress. They stated, however, that they are often unable to play a TA coordinating role because of competing priorities and their busy schedules. Government participants also felt that TA donors’ and providers’ rapid requests for input—when they do occur—are often not easy for them to meet as a result of their many job responsibilities. Participants representing governments also described the disconnect that occurs when donors and TA providers bring to bear resources that shift the balance of power and result in government staff feeling ineffectual and peripheral to the programs implemented in their country.
– Government representative, Nigeria
Government participants from the DRC and Nigeria described the challenges of coordinating different donor agencies, each with its own norms, financing processes, timelines, and expectations—especially given that many donors compete with one another and are reluctant to compromise or collaborate. With limited coordination and accountability among donors, at times, different TA providers implement projects with a similar purpose in the same location, using parallel data collection and reporting systems. In this situation, with multiple donors and TA providers intensely focused on a given health issue or geographic location, other health issues and locations are typically deprived of resources and expertise. TA providers emphasized the importance of governments closely reviewing TA providers’ terms of reference to coordinate TA and hold both funders and TA providers accountable.
Government participants also identified coordination mechanisms that frequently do not function as planned. For example, project approvals are often not communicated across government departments and at different levels of the government. Participants from the sub-national level shared that it is often unclear how funding decisions are made, with concerns that sub-national-level organizations receive a very small portion of TA funds for their programs. This causes mistrust about how resource-allocation decisions are made at the national level. In addition, according to sub-national level staff, the funding they received was insufficient to implement their programs. Participants noted the importance of government departments improving communication about TA funding streams and dollars allocated, along with the rationale for funding decisions.
In Nigeria, participants highlighted problems with coordination between state and federal governments that result from a decentralized health system and the growing autonomy of state governments. They did share the following best practice, which they hoped to scale to all partners: a memorandum of understanding that was signed between a funder, a TA provider, and the government to ensure mutual accountability and a more coordinated flow of information. Participants also mentioned the benefits of having technical working groups at the national level that coordinate strategies and activities for health programs.
Participants in the DRC highlighted several systemic accountability challenges, the first of which is the difficulty of tracking donor funds allocated and spent in the health sector. This lack of transparency contributes to TA providers’ distrust of the government. They also described a lack of clear communication and consensus on the TA to be done, the results and targets to be reached, and the benchmarks and deliverables to be met, suggesting the need for additional oversight and monitoring by the government and donors.
Budget management in the health sector. In the DRC, participants had differing perspectives on the management of and channels for donor health sector funding. Donors and TA providers expressed reluctance to allow funds to be channeled through the health department’s budget, fearing that funds would be disbursed at the central level without reaching provinces, zones, and communities. TA providers also felt that providing direct budgetary support requires them to relinquish some decision-making power regarding how, where, when, and for what purpose funds are allocated and distributed. TA providers said that they prefer to manage and disburse funds for salaries and activities or send funds directly to on-the-ground decentralized intermediaries, such as local NGOs. Participants suggested that if perceptions of the government’s reliability in managing health-sector spending improved, TA providers would be more inclined to equip, support, and trust a central-level mechanism for disbursing funds, which would help to reduce the fragmentation that comes with programs being implemented simultaneously by multiple TA providers.
Imbalances of power between government actors, TA providers, and funders. The findings above focus primarily on the mechanics of TA. Underlying these operational challenges are the cultural aspects of TA such as power imbalances—a fundamental driver of TA. The power dynamics between TA actors influence the way TA is managed, funded, designed, and implemented. This section draws on interviews and the Sonder DRC anthropological report21, which closely considered the power relationships between TA actors, among other themes. While power dynamics were not examined as exhaustively in Nigeria, the overarching theme of power appeared in multiple ways, including the influence of power on interactions, priority setting, relationships, and decision making within and among groups of TA actors.
Respondents commented that donors have power because they provide the funding for activities and determine who receives funding and who does not. In countries with limited resources, if a donor provides funding for a health area that does not align with country priorities, those funds will not be declined given the urgent needs. With the DRC’s heavy reliance on donor funding, government participants said they find it very difficult to express a difference of opinion about donor and provider priorities because of the acute need for financial and technical support.
“This situation puts the MOH in a situation of fragility because, since the technical assistance provider is the one bringing in the money, they end up being the one calling the shots. If the technical assistance provider says they do not agree, everyone changes their ways; if they say they agree, everyone else agrees too.”
- Government representative DRC
TA providers are considered powerful, either because funding is channeled through them or the acquisition of funding is contingent on drawing on providers’ expertise. In theory, governments should be able to approve or end TA activities. Respondents also noted that government actors’ sense of powerlessness is further exacerbated when decision making and money are inextricably linked—for example, when TA providers demonstrate their allegiance and accountability to funders, reporting to funders before communicating with the government.
Participants also commented that power dynamics manifest in the flow of information between TA actors. Provincial and state government staff felt they are typically not invited by the MOH and other national agencies to participate in critical discussions, which results in their being left out of decisions. This gatekeeping of information erodes trust among TA actors and creates inefficiencies in health systems operations.
Another result of this power imbalance driven by a lack of transparency in financial resource flows, information sharing, and work assignments was feelings of frustration and demotivation among TA consumers, particularly government employees who felt their efforts were futile or unappreciated.
Critically, navigating these power dynamics distracted TA actors from fully turning their attention to the communities that were intended to be the focus of health care services.
Summary of limitations of existing TA approaches. The leading TA issues that surfaced during interviews in the DRC and Nigeria included the focus on donor-driven agendas over country priorities, poor accountability within and among TA actors, inadequate transfer of skills from TA providers to governments, an emphasis on quick fixes and short-term thinking, and inadequate government mechanisms to oversee and manage TA—all of which combine to contribute to health systems that lack the authority, resources, and capacities to be resilient and function autonomously. Additionally, participants stated that it was unclear who benefits from TA and what the incentives are for TA actors to implement projects. The questioning of TA actors’ motivations, skewed power dynamics, and lack of accountability for TA result in a deficit of trust between TA actors and serve to intensify the challenges of working together in partnership.
Participants called for a shift in TA approaches and a redistribution of power so that governments can set their own health agendas, identify the issues that are of greatest importance to them, work with donors to design interventions, request TA support, and participate in the selection of TA providers. Additionally, participants also stressed the importance of establishing systems that allow governments to hold TA providers and donors accountable and government systems that promote transparency, responsibility, and a shared commitment to improving the health of communities.
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