tentative thoughts on ownership: work-in-progress

i am road-testing a few ideas from the conclusion of my thesis, in which i try to bring out two themes recurring throughout the analyses on adoption and implementation of the phase I pilot of the amfm in ghana, between 2010 and 2012. these themes are ownership and risk-taking. i have already written a bit about risk-taking here. below, i share some of my tentative ideas and questions on ownership (slightly edited from the thesis itself, including removing some citations of interviewees for now).

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delighted for comments.

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one undercurrent running throughout this thesis is the idea of ownership of: the definition of the problem and solution at hand, the process of adopting the amfm, and of the program itself and its implementation.

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in chapter 4, i introduced stakeholder ideas of paths not taken, including how the program might have “develop[ed], not negate[d], local production capacity,” including through support to local manufacturers to upgrade to meet WHO prequalification and through work to bring local government and industry (rather than global industry) into closer partnership. both those ultimately receptive and resistant to the amfm acknowledged that all national stakeholders “would have preferred to have had quality, local drugs.” the very strength of the amfm design — high-level negotiations and subsidization — precluded local, structural changes.

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in chapter 5, i highlighted that several key stakeholders refused to take — that is, to own — a stand on whether ghana should apply to the phase 1 pilot. moreover, the key, institutional decision-makers in the country coordinating mechanism for the global fund (ccm) vacillated on whether or not to send the application while a variety of circumstantial stakeholders felt they had stake in the decision and worked to influence the process. in chapter 6, i analyze how global ideas and actors played a role in ghana’s adoption of phase 1. in chapter 7, i describe the way the amfm coordination committee (amfm-cc) was set up which, in composition and process, differs from the ccm.

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these points on alternatives not considered, on vacillation, on avoidance, and on outright resistance relate to conceptions of country ownership of development initiatives, as in the paris declaration. the absence of a national politics and aligned problem stream, in particular, neatly dovetails with the ideas of david booth that clarify what should be meant by country ownership (booth 2012). he proposes that it means an end to conditionality to “buy reform” and an end to channeling aid funding through “projects” as a way of by-passing country decision-making bodies, processes, and institutions (booth 2010). 

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the ccm represents an interesting example with which to examine country ownership. their explicit raison d’ětre is to foster ownership and they do indeed bring together representatives of government bureaucracy, business, and civil society, “representing the views and interests of grant recipient countries.” yet this structure allowed for vacillation within and strong views without. we must consider this and also juxtapose the make-up of the ccm versus the amfm-cc in terms of the stakeholders represented, the capacity and legitimacy to make relevant decisions, and a sense of ownership about the work ahead. having done this, it seems that, at a minimum, we must question whether the ccm composition when adopting phase 1 allowed for sufficient ownership. given the effort of ccm members to yield decision-making power to the minister of health, it seems that ccm members did not think so.

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however, it is not fair to critique apparent limited ownership without raising three additional questions:

• would ghana have tried out the amfm if political or bureaucratic actors had to take initial responsibility for the design?
• did limited national ownership of the design and adoption decision allow national stakeholders to better, “energ[etically]” implement the initiative, maximizing credit-seeking after minimizing risk for blame during adoption (while recognizing that policy entrepreneurs and others still felt this risk keenly)?
• how should we interpret ghana’s decision to continue with the global fund’s private sector co-payment mechanism?

these questions offer avenues for further analysis of the role of donors, the state, and the public.

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indeed, ownership is not only an issue for capital-based elites; Fox (2015) recently highlighted that “the current aid architecture deprives both african governments and african publics of agency.” in chapter 7, I introduce views of the citizens and businesspeople at the street-level of implementation. about 20%, during in-depth interviews, spontaneously said they wanted to see the amfm continued — a view that seems to have had no way of entering any debates about the future of the amfm and is absent from the academic literature on this initiative.

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though the minority, some respondents specifically voiced that they should have learned about the amfm through a government agency or professional association. two specifically raised their position as stakeholders. one, who heard from her supplier, said “i think it wasn’t fair because as major stakeholders, we should have been briefed before.” another, who heard first from the media, said “i felt this was wrong since we are a major stakeholder. we should have met as partners.” these concerns relate to relations between ghana and the global fund as well as between accra-based elites and tamale-based retailers.

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the events of both adoption and implementation of the AMFm suggest that ownership is important (in no way a novel claim). note, though, that there may be certain amounts of freedom to innovate accorded by being just an implementer, rather than having clear ownership of a new idea, decision-making power over adopting and implementing that idea, and, accordingly, more risk if the idea does not pan out.

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also, if we accept that ownership is indeed important, which seems a plausible lesson to draw from this thesis, we also learn that simply giving decision-making power to some national stakeholders is insufficient. the right national stakeholders and their existing decision-making structures need to be in play. we may glean something about relevant national stakeholders in this case through the composition of the amfm-cc and the committee characteristics raised as important (transparency, collaboration). but, given the views of some street-level implementers, ownership may require further consideration.