New Norms and Forms of Development: Brokerage in Maternal and Child Health Service Development and Delivery in Nepal and Malawi

Donors and international organizations involved in dispersing foreign aid now routinely employ contracts with service providers, both for-profit and non-profit, to carry out functions relating to international health service development and delivery. This outsourcing of foreign aid via contractual arrangements and partnerships is linked to a discourse on public sector reform in order to secure value for money, enhance aid efficiency and achieve the most impact with limited resources. These intermediaries include non-profits, private contractors, management consultancies, advocacy groups, research organizations, think tanks and educational institutions among others. They employ tens of thousands of expert professionals, operating within the state apparatus or as outside technical support, and advise, consult and serve in various official capacities and contribute to health service development and to the delivery of projects. They occupy and link the space between the funders and beneficiaries/target groups translating the meanings and processes of development.

Sceptics have argued that much of foreign development aid is actually a giveaway to large contractors and sub-contractors. However, these intermediaries are the key actors whose function is critical in bringing together innovation, expertise, resources and political networks from different institutions to contribute to global development objectives such as the Millennium Development Goals (MDG). Through its focus on the role and functions of different types of institutions and professionals who broker health sector development projects and programmes, the research aims to understand the nature of mediation and translation involved in that process and the difference these actors make in meeting the global health development objectives.

In this research we explore this phenomena for Maternal and Child Health, comparing the processes in the countries of Malawi and Nepal. Both of these countries have achieved strides towards achieving their goals for MDG 5 (focused on Improving Maternal Health by reducing by three quarters the maternal mortality ratio, and achieving universal access to reproductive health), and have been the focus of sustained resource input from both USAID and UKaid for these aims. To do this, first we will map the institutional terrain around this, and then explore - using ethnographic techniques and semi-structured interviews with those involved in the delivery of the MCH programmes - to compare and contrast this developmental landscape. A key aim is to use the research to inform policy makers in the donor community, and the respective governments, of the best institutional relations for this; in short, what works best, and what less well. To do this, we have brought together a team of researchers and in country research partners with significant expertise and experience in carrying out research and public engagement in the health sector development in Nepal and Malawi. Central to this research, we will run inception workshops in both countries to inform the aims of the research, and define the research direction. Continued engagement with the key stakeholders will culminate in dissemination workshops designed to inform policy and future direction in the arena of MCH.

The impacts that we are seeking to make with this research are of several kinds, and are emergent from the extensive
networks that the research team already have in Nepal and Malawi, and will further develop during the course of the
research. The PI has already run several workshops and conferences in Nepal, and with twenty years of programmatic and
research experience has contacts there that are extensive, with both UKaid and USAID, and numerous health sector
development organisations. Both Jeevan Sharma and Radha Adhikari also have extensive networks in the health and
development sector, having links with all nursing organisations, the Ministry of Health, National Planning Commission,
USAID, and other non-governmental organisations. The partner organisation, Social Science Baha, is also a well respected
and networked organisation, and the inception and dissemination workshops - which are central to the way the research is
conceptualised, and to involve key stakeholders in defining and refining the questions - will be run in conjunction with them.
In Malawi, Pam Smith has contacts with a range of institutions (both private not for profit and public) health
care professional training institutions, the Ministry of Health, and Nursing and Midwifery Council through the Scotland-
Malawi Partnership funded e-learning project, and doctoral studentships. Experience of running workshops with these
networks will be invaluable during the inception process, the research itself and dissemination.

Specifically the impacts will be of the following kinds:

1. First is for the donors to better relate to and work with these intermediaries and brokers. The increased knowledge and
perceptions around these organisations held by the governments in Malawi and Nepal (be this negative, or positive), and
on how these brokers work, will better inform UKaid, USAID and other donors on how best to interact with them in the future.

2. Our findings will bring a sociological perspective that will allow the intermediary organisations to reflect on their own
practice, and consider their impact and relations with government and donors differently.

3. Through a programme of targeted dissemination, information and knowledge will be used to improve public awareness
on the role and functions of these intermediaries beyond their negative media representations. For example, we will utilise
the websites and mailing lists of the national medical schools, nursing schools and related networks associated with the
Malawi e-learning project. The budget includes publication materials (in the form of policy briefs), and for the development
of an independent website. We will make our findings widely available for discussion and debate in various country level
forums such as donor coordination meetings in order to improve the understanding of the issues that arise in working with
intermediaries in setting up projects, mobilizing resources, monitoring and evaluating them.

4. The inception and dissemination workshops will include capacity building for the Nepal and Malawi partners, to undertake operational and qualitative research, and develop writing skills for policy briefs and research findings.

In addition, impact will be achieved by articles written for local journals, both local medical oriented journals (like The Nepal
Medical Journal, and the Malawi Medical Journal) and local academic humanities journals such as the Malawi Journal of
Social Science, and Studies in Nepali History and Society, and para-academic journals such as Himal, and locally widely
distributed newspapers such as the Kathmandu Post and Kantipur.