By Pierre Massat (ITM, Quamed)

Last Friday the Belgian Directorate General for Development Cooperation (DGD) organized a conference entitled “Development Cooperation in the Health Sector: Still the same approach ?” While the goal was mainly to discuss how the Belgian development cooperation in the health sector should adjust to the differences between low-income countries, fragile states and (a growing number of) middle-income countries, the conference protagonists also used the occasion to take a critical look at today’s development cooperation in general in Belgium.

Two speakers were invited: Dr. Georges Dallemagne, member of the Chamber of Representatives (CDH), former Director-General of Handicap International, former Vice-Director-General of MSF), and Prof. Dr. Bruno Gryseels, Director of ITM. Prof. Dr. Bruno Dujardin (ULB) was moderator and discussant, and gave the first of the three presentations.

All speakers started their presentation by mentioning the importance of the changes that occurred in the past 15 years, such as the sector-wide approach, the Paris declaration and the Busan forum, emphasizing a general move towards more partner country ownership and more effective cooperation. They also noted the recent shift from a purely economic, GDP-focused measurement of development towards more inclusive indicators (i.e. Human Development Index, Better Life index). They pointed out that the actors themselves have changed and are now far more diverse, with the emergence of the BRICs and their growing importance on the development cooperation scene, the creation of global initiatives for health, such as GAVI and the Global Fund (Prof. Dujardin said there were over 160 such initiatives in 2010!), and the increasing influence of private foundations such as the Gates Foundation.

Even if all speakers agreed that development cooperation should be finite, there was a shared concern about the future of development cooperation and the relative importance of health in it. All speakers referred to the current financial and economic crisis and considered the resulting budget cuts in the EU and Belgium as a major blow to development cooperation, even jeopardizing international aid as a whole. Tellingly, these significant budget cuts were met with practically no opposition. This shows, according to Dallemagne, an underlying “cooperation blues”. Against a backdrop of growing skepticism among the general public about the impact of aid, many development aid stakeholders probably also feel that if they criticize these budget cuts too fiercely, they’ll be instantly accused of a ‘conflict of interest’.

It was also emphasized that maintaining or increasing the relative importance of health with respect to other sectors will be an important challenge for the future, considering the fierce (and increasing) competition with other sectors (see the ongoing consultation and negotiations about the post-2015 development agenda for example). While a number of health related indicators have improved over the past years, in particular those linked to (some of) the MDGs, it has not been possible to clearly link these improvements to (Belgian) development cooperation. Dallemagne  also highlighted that there is quite some confusion in development cooperation circles about the concept of  ‘sustainability’: if there’s  cooperation with the state, actors often already have the feeling they’re ensuring sustainability. That is rather shortsighted. He argued that the starting point should rather be people’s own autonomy and capabilities. Too often, development cooperation remains too paternalistic, and is disconnected from the reality of the field (Prof. Dujardin used the term “virtual cooperation”). The great diversity of actors in Belgian development cooperation was also singled out as an obstacle – a shared, clear and consistent vision becomes more difficult due to the sheer number and variety of actors.

Gryseels agreed that current development cooperation is too paternalistic and advocated for a change of culture – development aid needs to be finite – and for thinking about new ways of collaboration with partner countries. When comparing the evolution of Ghana and South Korea over the past 50 years, it is not obvious that development cooperation works. Development cooperation policies are still too often decided in and by the Western countries, he also argued.

So according to Gryseels, the answer is “blowing in the wind”: we cannot escape the truth any longer. Partner countries and institutions come increasingly to Western countries for collaborations and relevant expertise, not for money (but see a recent ODI   publication (by Greenhill et al) which emphasized that ODA will still be critical in meeting post-2015 financing gaps, together with government spending by developing country governments).  In addition, the ITM director mentioned that the money available per poor person is bound to increase because the absolute number of poor people will decrease considering the progress made in countries like India, Indonesia, etc. It’s only in fragile states that the number of poor will stay the same, he argued.  Also, with the latest evolution in technologies, we should not be surprised if current development cooperation processes are bypassed or become irrelevant (i.e. the possibilities for direct cash transfers via mobile phones).

 

There are some opportunities too, though.  Dallemagne presented the MDG agenda as a great success, in spite of the excessive “verticalization” of health that resulted from it (Gryseels). For the first time ever, actors from all over the world shared an agenda based on common, operational and measurable objectives. This working method should be further developed, Dallemagne argued, and the same goes for the global public goods approach. As far as financing is concerned, better harnessing of remittances and increasing the ( often limited ) tax base in partner countries were mentioned as relevant options. Greenhill et al. point out that probably not too much should be expected from low-income countries when it comes to collecting additional domestic resources in the post-2015 era, but in other (especially middle-income  and/or resource-rich countries) there are opportunities.

Because the presentations took too long, there was practically no time left for debate. The conclusion by Dujardin was quite encouraging, though, calling for a “paradigm shift” in development cooperation: Belgium and other traditional donor countries should stop seeing themselves as ‘developed’ (as compared to so called ‘developing countries’) and accept that rich countries can be viewed as “ill-developed” too (Dujardin mentioned an increase of 60% in the consumption of antidepressants in the EU between 2000 and 2010), and therefore should not be used as benchmark. In addition, it’s vital to strengthen civil society without necessarily going via the State; to restore the confidence and self-esteem of actors (health care providers, communities, patients)  and to seek collaboration and “positive fertilization / reverse innovation” (the North can definitely also learn from the South). More generally countries in the North need to get their act together when it comes to solidarity with the world as a whole, Dallemagne insisted in his concluding remarks.

Prof. Dr. Bruno Gryseels put it somewhat differently: he said that, instead of “switching the poles”, we should start “ditching the poles”. We urgently need to rethink development aid and should no longer differentiate between developed and developing countries.

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