5. How has Kuunika performed against aid effectiveness principles?

In this section of the report we apply a broader perspective, to consider Kuunika's inputs throughout the life of the project and the extent to which its inputs, intermediate outcomes and outcomes may have contributed to aid effectiveness. The 2005 Paris Declaration foregrounded the central importance of aid effectiveness principles being agreed, adopted and applied.

Reflections on Kuunika’s experience in the Districts against the benchmark of aid effectiveness principles

Aid effectiveness principle

1. OWNERSHIP:

Developing countries should be owners of their development

2. ALIGNMENT:

Development assistance should be aligned to country policies, institutions and local systems

3. HARMONISATION:

Developing countries and partners should

Assessment of Kuunika’s implementation experience

● Kuunika has throughout worked with the central MoH, which is the owner of the project. However, where should national ownership be sited? Only at the central level, or also at District and lower levels, where the great majority of health service delivery takes place?

● There is considerably less ownership in the Districts, where throughout the lifetime of the project issues have been raised of data extraction, multiple (and sometimes incompatible) reporting systems, vertical programs reporting to the national level, donor agendas sometimes outweighing District priorities in terms of data collection and use.

● Kuunika's position at central level has meant that its inputs have been aligned to MoH and by extension, GoM, policies and systems.

● Kuunika's support to the development of the 2020-2025 National Digital

Health Strategy reflects project commitment to alignment (but see e.g. section 2.4 for discussion of this Strategy)

● Major project technical, financial and human resource support to the development of the MoH Digital Health Division is another major benchmark of adherence to the principle of national alignment

● So too is the development of the Covid-19 digital data response, where

Kuunika, other development partners and the GoM (primarily but not solely the MoH through the Digital Health Division) have worked together

● But such achievements are less supportive of true alignment between central and lower levels of the health system, digital data collection and use at District, Health Facility and community levels.

● This begs the question: if Malawi has a highly centralized health system, including for digital data, what is the most effective role of any one intervention such as Kuunika in seeking to expand the definition of alignment, when there is evidence that in 2021 Districts are not yet full partners in the digital data ecosystem?

● Furthermore: aid effectiveness in the context of alignment specific to digital data systems should surely include focus on optimal alignment of sub-national and national structures - Kuunika has not yet optimally supported such work?

● Evidence indicates that a '[Health] Sector-wide Approach (SWAp) Revival' Concept Note is in development, an activity supported by the GoM + a number of partners; this must signal a degree of harmonization intent to

Aid effectiveness principle

harmonise their action

4. MANAGING FOR

RESULTS:

Developing countries and donors should focus on measurable results

5. MUTUAL

ACCOUNTABILITY

Developing countries and their partners are jointly accountable for development results

Assessment of Kuunika’s implementation experience

address the current stated 'extreme fragmentation' of donor partner inputs to health

● Kuunika support to the development and staffing of the MoH Digital

Health Division represents a springboard for greater GoM/donor partner harmonization specific to digital health; more effort is required to realize such potential

● Potentially: Kuunika may have generated added value that has enabled other partners to support digital data, e.g. the Global Fund.

● Digital data collection, analysis and use remains weak at District and lower levels, despite major inputs from Kuunika and other partners: evidence-based results management is nascent at best

● Knowledge culture: optimizing results in the digital data landscape requires genuine and sustained buy-in by individuals and institutions to the principle that data matter and their use can and should improve planning and service delivery. If Kuunika were able to support all health system levels to develop a results-centered data use culture, this could have substantial impact on performance

● This continues to be poor. As at the baseline, so too in 2021: data are vertically extracted by both MoH + donor partner projects from Districts +

Health Facilities, with too little discussion, feedback, wider dissemination

● Therefore, Districts and below appear to be the 'missing middle' in terms of accountability (in both respects, i.e. holding others to account + being held accountable - although for the latter, as ever Data Clerks bear the brunt of data entry accountability)

Of note here is that the aid effectiveness principles have been criticized for gender and equity blindness, as having a certain 'one size fits all' approach to such matters.

In the case of digital data and Kuunika (and indeed all other partners working in this area in Malawi), just one point is disaggregation of data - their collection, their identification, their analysis and their use. WHO, UN Women, many civil society organizations and others continue to press for greater equity of data disaggregation, greater acknowledgement that data are never neutral, and greater application of such principles in the context of digital data.