Health Policy 95 (2010) 122–128
Contents lists available at ScienceDirect
Health Policy journal homepage: www.elsevier.com/locate/healthpol
Stakeholder perceptions of aid coordination implementation in the Zambian health sector Jesper Sundewall a,∗ , Kristina Jönsson b , Caesar Cheelo c , Göran Tomson d a b c d
Division of Global Health (IHCAR), Karolinska Institutet, SE-171 77 Stockholm, Sweden Centre for East and South-East Asian Studies, Lund University, Sweden Department of Economics, University of Zambia, Zambia Division of Global Health (IHCAR) and Medical Management Centre, Karolinska Institutet, Sweden
a r t i c l e Keywords: Zambia Aid coordination Health-sector
i n f o
a b s t r a c t In this study, we analysed stakeholder perceptions of the process of implementing the coordination of health-sector aid in Zambia, Africa. The aim of coordination of health aid is to increase the effectiveness of health systems and to ensure that donors comply with national priorities. With increases in the number of donors involved and resources available for health aid globally, the attention devoted to coordination worldwide has risen. While the theoretical basis of coordination has been relatively well-explored, less research has been carried out on the practicalities of how such coordination is to be implemented. In our study, we focused on potential differences between the views of the stakeholders, both government and donors, on the systems by which health aid is coordinated. A qualitative case study was conducted comprising interviews with government and donor stakeholders in the health sector, as well as document review and observations of meetings. Results suggested that stakeholders are generally satisﬁed with the implementation of health-sector aid coordination in Zambia. However, there were differences in perceptions of the level of coordination of plans and agreements, which can be attributed to difﬁculties in harmonizing and aligning organizational requirements with the Zambian health-sector plans. In order to achieve the aims of the Paris Declaration; to increase harmonization, alignment and ownership – resources from donors must be better coordinated in the health sector planning process. This requires careful consideration of contextual constraints surrounding each donor. © 2009 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Coordination of health aid refers to actions taken by external donors and the national government to ensure that foreign contributions to the health sector enable it to work more effectively and in accordance with local priorities . Aid coordination has been on the development agenda since the late 1980s, but global interest in this topic has risen in recent years. The increased attention has largely been driven by donors and is associated with
∗ Corresponding author. Tel.: +46 70 717 2120. E-mail address: [email protected]
(J. Sundewall). 0168-8510/$ – see front matter © 2009 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.healthpol.2009.11.010
the quadrupling of the amount development assistance for health since 1990 and the fact that a signiﬁcant portion of funding for the health system1 in many low-income countries comes from external donors [2–4]. Cooperation between development agencies in health has also become increasingly complex. Large amounts of earmarked resources have been made available for disease-speciﬁc efforts through global health initiatives (i.e. initiatives targeted at one or more speciﬁc diseases,
1 In the 2000 World Health Report: Health systems – improving performance, the WHO deﬁnes the health system as “all the people and actions whose primary purpose is to improve health” (p. 1).
J. Sundewall et al. / Health Policy 95 (2010) 122–128
such as HIV/AIDS, tuberculosis or malaria). The number of international agencies and non-governmental agencies working in the health sector in low-income countries is growing . Effective coordination suggests that all actors and resources support a common plan for sectoral development and, ideally, that this support is reﬂected in national budgets. Thus, the increasing amount of resources and actors involved complicates implementation of aid coordination and raises questions about how to deliver aid programmes in an efﬁcient manner . Those interested in coordination, however, seem to concentrate more on the content of the policy than on its implementation, believing that by ensuring appropriate policies for coordination, the desired results will be achieved. Research has so far focused on the global level and been prescriptive in character, analysing managerial and administrative aspects of government and donors arguing for how coordination should be implemented and not describing how it is actually implemented [7–9]. The limited research at country level has described the intended rather than actual role and function of coordination structures [10,11]. Research has shown that when policies are implemented, difference between rhetoric and action, between formal plans and practice, are commonplace [12,13]. Yet government and donors, and in particular donors, both tend to underestimate the practical consequences of policy implementation and show less concern about this topic than it merits . Analyses of the implementation process are central to explain why the desired results are achieved or not. Policy implementation has been deﬁned as “the process whereby programmes or policies are carried out, the translation of plans into practice” . Implementation is the process that links the expectations of a policy to its (perceived) results . Zambia is often proposed as an example of a country where coordination in the health sector works particularly well . To explore if this is really the case, the aim of our study was to investigate donor and government stakeholders’ perceptions of the process of implementing coordination of health-sector aid in Zambia. We have analysed whether coordination of health aid is perceived to be undertaken in line with agreed plans for how it should be implemented. In particular, we explored differences in stakeholders’ view on how aid is coordinated. Based on the analysis, existing challenges of health sector aid coordination in Zambia are identiﬁed. 2. Methods This qualitative case study was based on nonparticipant observations, document analysis and literature review and interviews with stakeholders. Multiple data sources were used to increase validity and reliability and to be able to give an in-depth empirical account of the structures for, and perceptions of, aid coordination [18,19]. The interviews were semi-structured with open-ended questions.2 Semi-structured interviews allow a conversa-
Interview guide available from ﬁrst author.
tion to be developed around the area of interest and is a ﬂexible tool where the line of enquiry can be modiﬁed and interesting responses followed-up . Interviews also encourage the respondent to discuss the topic using their own words , an important feature in this study, which explored the stakeholders’ own perceptions. Questions were asked on how coordination of planning, implementation, monitoring and sharing of information was undertaken. By following an interview guide, respondents were encouraged to elaborate freely about their experiences and give concrete examples. Additional interviews were conducted until limited new information was extracted . Main government and donor stakeholders were identiﬁed through recommendations from key informants to make sure no important actors were omitted  and also through a review of ﬁnancial contributions to the health sector. Interviews were carried out with representatives of: – Government: the Ministry of Health (planning department), Ministry of Finance and National Aids Council; – Bilateral donors: Canada, Japan, Sweden, United Kingdom (UK), and the United States (US); – Multilateral donors: the European Commission, World Bank, World Health Organization (WHO) and United Nations Children’s Fund (UNICEF); – Global health initiatives: the President’s Emergency Plan for Aids Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis and Malaria. Together the donors’ organizations selected for inclusion in the study contributed about 75% of all external resources to the health sector in Zambia in 2007 . Respondents from the Zambian government were selected on the basis of their involvement in planning and implementation of health aid. All interviews were conducted by the ﬁrst author at the respondent’s place of work and for an average of 1 h. A total of 22 interviews were conducted, 16 between November 2006 and January 2007 and 6 follow-up interviews in October–November 2007. We reviewed general health-sector policies and steering documents from 2002 to 2007, including: health-sector strategic plans, annual action plans and the memorandum of understanding. Seven meetings were attended and observed between November 2006 and November 2007: three donor meetings, two policy meetings, the 2007 annual action-plan review meeting and the 2006 annual consultative meeting. During non-participant observations the researcher merely observed and did not actively participate or attempt to inﬂuence the study object. The data from documents and observations were used to explore and identify the formal structures for health-sector aid coordination. The observations also provided insight to which actors actually participated in the meetings and what were the typical issues discussed. The follow-up interviews were conducted to capture possible changes over time and to test preliminary ﬁndings. Owing to time constraints and availability of respondents, follow-up interviews could not be conducted with all respondents. Ten respondents agreed to electronic recording (which covered in total 13 inter-
J. Sundewall et al. / Health Policy 95 (2010) 122–128
views). These interviews were later transcribed. During the remaining nine interviews, the interviewer took notes. Interviews were initially analysed following the categories in the interview guide.3 After re-reading the interview transcripts, however, other key features of coordination emerged which then structured the analysis. Hence, the analysis took its point of departure in the interviews, while the written material and non-participatory observations were primarily used to verify interview statements and provide a deeper understanding of the case under study. The Ministry of Health endorsed the study and ethical clearance was obtained from the research ethics committee of the University of Zambia. 3. Background to the case study Zambia, a low-income country in sub-Saharan Africa, is a nation that is highly dependent on foreign aid. Donors contribute more than two-thirds of all the resources of the health sector . The health-sector is struggling to cope with a high disease burden, mainly due to diseases such as malaria, HIV/AIDS and tuberculosis. Despite its vast natural resources, Zambia ranks in 165th place in the Human Development Index . The country gained independence from the UK in 1964 and has had four multi-party elections since the republic’s ﬁrst president, Kenneth Kaunda, left ofﬁce in 1991. Aid has been ever present in Zambia since independence and it has increased dramatically over time. According to the First National Development Plan, in 1967 Zambia was expecting a total of about USD 3.85 million (USD 24 million in 2007 consumer prices) in foreign assistance . In 2007, total aid for health alone was estimated at USD 345 million. Since the 1980s, there have been ongoing discussions about how to improve the coordination of aid to improve its effectiveness . In the early 1990s, Zambia adopted a policy of extensive health-sector reform, with decentralization of planning and implementation of health services to the district level. With the reform came the introduction of a sector-wide approach (SWAp); this is now the main framework for coordination of health aid. The idea was to bring all external resources and stakeholders into one framework, which was implemented under government leadership [28,29]. It emphasized the preference for joint funding of health service implementation . Thus, Zambia has a comparatively long experience of aid coordination efforts. Government leadership and donor commitment to coordination has also reportedly been strong . The SWAp model was developed because of concern that lack of coordination increases the risk of duplication of activities carried out by different stakeholders [30,31]. It has been succeeded by other global models and agreements for more effective aid, such as the 2005 Paris Declaration on Aid Effectiveness and the UK Prime Minister’s International Health Partnership initiative [32,33]; to both of which Zambia is a signatory. The Paris Declaration, on the
3 The categories of the interview guide covered the following areas; development of common arrangements, simpliﬁcation of procedures, sharing of information and “ideal” coordination.
Fig. 1. Overview of the formal coordination meetings in the health sector .
one hand, aims to increase aid effectiveness by focusing on the principles of harmonization and alignment of external support through joint donor-government planning and funding. The International Health Partnership on the other hand is an initiative centred around the importance of all stakeholders agreeing on one strategic plan for the health sector’s development, guided by the Paris Declaration principles. A central component of coordination is government ownership, i.e. that the government leads the development process in consultation with major stakeholders [34,35]. The main responsibility for coordination of donor support thus lies with the Directorate of Planning and Development within the Ministry of Health and there is a formal structure for this purpose. Fig. 1 illustrates the hierarchy of structures and participating actors. At the annual consultative meeting, progress made during the previous year is reported and action plans and budgets for the coming year are reviewed. At the level below is the sector advisory group, convened twice per year, where performance indicators and release of funds for the sector are reviewed . The next level comprises monthly policy meetings addressing general health sector-related issues . Finally, a number of technical working groups and sub-committees deal with day-to-day administration and technical discussions on speciﬁc issues and areas (e.g. health ﬁnancing and child health). The external donors in Zambia have a separate coordination structure where most, although not all, organizations participate. Before every policy meeting, sector advisory group or annual consultative meeting, the donors meet to discuss issues they believe should be raised with the Ministry of Health. A “troika” consisting of Sweden, the UK and WHO, with rotating chairmanship during 2006–2008, leads the donor group. The lead donor is expected to speak and act on behalf of the donors on issues of com-
J. Sundewall et al. / Health Policy 95 (2010) 122–128
mon concern  and meets with representatives from the Ministry of Health on a weekly basis. For each sub-sector (e.g. Human resources, Procurement and Tuberculosis) one or more sub-sector lead agency/agencies have been appointed. Partners who are not leaders may take an active or a background role. The division of labour is by choice and determined by the speciﬁc interests of each agency. The coordination of health-sector aid in Zambia involves several different government agencies, bilateral and multilateral donors, global health initiatives and nongovernmental organizations. The coordination process is characterized as inclusive and all donors are offered a seat at the table, regardless of the size or type of their contribution. Cooperation in the health sector in Zambia is characterized by a consensus culture, in which the government encourages all stakeholders to participate in every decision.
4. Results 4.1. Coordination by plans and agreements Health-sector aid coordination in Zambia is outlined in the main policy documents: The National Health Strategic Plan and the Memorandum of Understanding. The National Health Strategic Plan 2006–2010 is the long-term strategy for health-sector development in Zambia and is thus the overarching policy document for all health-related activities . The Memorandum of Understanding is an agreement signed by the Government of Zambia and cooperating partners. The agreement is not legally binding, but reﬂects the “jointly agreed terms and procedures for support to the strategic plan and serves as a coordinating framework” between the Ministry of Health and the donors and outlines the roles and responsibilities of each partner . The main responsibility for coordination of healthsector aid lies with the Ministry of Health, although the Ministry of Finance and the National Aids Council are also important actors. The Ministry of Finance is responsible for ﬁnancial allocations and budgets for the Ministry of Health and the National Aids Council, which coordinates the national response to HIV/AIDS. In addition, approximately 15 donor organizations are regularly represented on health-sector committees and working groups; as some donors are imprecise with regard to their participation in the health sector, it is not possible to determine the exact number of partners in the sector. The interviewed representatives from government and donors were unanimous in their agreement that all activities undertaken should be in line with the National Health Strategic Plan. All donors interviewed asserted that all the support they provided, whether ﬁnancial, technical or inkind donations, were in line with this strategic framework. However, although all donors perceived their own support to be in line with national plans, they frequently considered support provided by other donors as unaligned. Government respondents also declared that some donors were providing support that was not in line with the National Health Strategic plan.
Of course we have concerns pertaining to the donors. . .especially the donors who are giving support without strict adherence to the sector plans. [Government respondent] Respondents from both sides voiced criticism of the way in which the action plan was constructed. Government respondents claimed that some bilateral donors and global health initiatives had very limited involvement in the consultations for the action plan, while some donors claim that the plan was not comprehensive. We found that several donor activities were not included in the Ministry’s annual action plan. According to government respondents, some activities were deliberately omitted from the action plans, as the Ministry of Health did not regard them as government activities. This included some speciﬁc HIV/AIDS activities, for which neither funds nor commodities are channelled through the government system. These different perceptions of the implementation of planning coordination seem to have persisted over time The biggest issue is predictability of the resources. It is difﬁcult to obtain all information from all partners regarding their future commitments to the sector. [Government respondent] A concern expressed by all donors interviewed was the struggle to merge the requirements and expectations of their directors at headquarters with the coordination agenda in Zambia. Difﬁculties covered a wide spectrum, from how resources are channelled, routines for procurement and reporting formats to accountability towards tax-payers. Donors also reported that it was sometimes difﬁcult to harmonize priorities; although all actors supported the National Health Strategic Plan, almost all donors gave examples of projects or activities being “forced on them from headquarters”. In interviews in 2006, two donor respondents expressed concerns about the fact that the lead donor in 2007, the UK, was not directly involved in aid to the health sector, questioning the capacity of the UK to address issues raised by other donors and the degree of inﬂuence the UK would have in negotiations with the Ministry of Health. By the end of 2007 and the UK leadership, most donors seemed to agree that the UK had taken a strong role in coordinating the donors and that the dialogue climate with the Ministry of Health was good. 4.2. Information sharing and the role of trust Donors and government considered that information sharing was an important aspect of coordination and both parties appeared to be satisﬁed with how it is conducted. The donors stated that the government was willing to respond to queries raised by cooperating partners, while government respondents perceived themselves as being proactive in their relationship with the donors. All donors interviewed also argued that the sharing of information between cooperating partners was good and that, in most cases, donors managed to speak with one voice.
J. Sundewall et al. / Health Policy 95 (2010) 122–128
I think there are a number of reasons why [it works well]. I think partly because it’s an established group – even when the people change the mechanisms are still there. For example, we [the donors] always meet the day before major government meetings. . . and at least some people carry on year by year. It’s friendly, it’s social, we do get on very well and I think that helps. [Donor] Generally, respondents were content with the openness of the meetings and committees. Donors, regardless of the size of their ﬁnancial contribution, had a seat at the table and could participate in discussions. One donor reported that this was not the case in other countries, where their agency was excluded from the coordination process because it did not provide direct ﬁnancial support to the Ministry of Health. Government and donors both raised the issues of trust and transparency as being necessary for effective coordination of health aid. By trust, respondents referred to trust in the system, but also in the leadership of the system. Transparency of the system was seen as an essential prerequisite for development partners to be willing to invest in the sector. We [the government] have to show that we can develop and implement these programmes. . .if there is no trust that is when parallel structures are developed. [Government] People are beginning to trust each other a bit more. . .there was a lot of suspicion before, you know people do these things and you’re wondering where is this coming from. . . what’s the agenda? [Donor] 4.3. Funding and ownership Much of donor resources are channelled outside government systems. Representatives of two donors argued that the channelling of large funds, in particular, funds for HIV/AIDS, outside government systems has negative implications for coordination and that the SWAp and service delivery was being undermined by the vertical approach of global health initiatives with speciﬁc implementation plans. Government interviewees agreed and urged donors to channel their support through the Ministry of Health, this being, in their opinion, the intention of the International Health Partnership initiative. Now it doesn’t need a rocket scientist to realize you’ve got a distorted story. You’ve got 150 [million dollars] for the whole health service and 270 [million dollars] for HIV/AIDS. [Donor] There had been worries from both the donor and government side that the move to budget support made by two of the main donors could lead to decreased funding for the health sector. So far, these worries had not materialized. Government respondents argued that how funds was channelled was less important than ensuring that all funds are reﬂected in the Ministry of Health budget, and reported positive developments in this regard. Most ﬁnancial support from global health initiatives, in particular PEPFAR and the Global Fund, is earmarked
for HIV/AIDS. Planning and priority setting for HIV/AIDS funds is outlined in a speciﬁc strategic plan, and is led by the National Aids Council. As the National Aids Council coordinates a comprehensive response to HIV/AIDS, the strategic plan does not include health-speciﬁc activities only. The health-related activities of the HIV/AIDS strategic plan are, however, supposedly integrated in the Ministry of Health strategic plan. Not all donors involved in HIV/AIDS participate in the health-coordination structures, although most of their support is directed towards health. For example, the main donor for HIV/AIDS, PEPFAR, has direct dialogue with the National Aids Council only. Several respondents raised the issue of ownership in relation to how funds are channelled. From the donor side, a few respondents emphasized that the Ministry of Health should take ownership over the health sector. Interviewees from the government, on the other hand, argued that government ownership was undermined by the nature of some donors’ support. If the money is outside it means you are still at the mercy of the ones who are holding the money. That also means you spend a lot more time in terms of negotiations/discussions and overall the time and transaction costs are increased. [Government] Follow-up of the health sector plans is coordinated by the Ministry of Health through a joint monitoring and evaluation process; the Joint Annual Review. The joint review process has signiﬁcantly reduced the workload of the Ministry of Health, according to government respondents, since all donors now collaborate to produce the joint annual review, rather than each donor carrying out multiple reviews during each programme or project. However, some leading partners still undertake additional reviews to meet their headquarters’ reporting requirements, while several partners require speciﬁc ﬁnancial reports concerning each item of support. If you go to the Ministry of Health. . .you’ll see that the chief accountant prepares a ﬁnancial report. . .but at the same time prepares a separate report for Sida, a separate report for the Netherlands, separate report for the [World] Bank. [Donor] During the last decade coordination has become more formalised as manifested by the development of policies and steering documents and the creation of formal forums. Government and donors agreed that the coordination of health-sector aid in Zambia largely works well and stressed that it is improving incrementally. Support for these assertions was provided by observations of meetings between the government and donors, which were well attended and characterized by the willingness of the participants to discuss, negotiate and compromise.
5. Discussion Understanding coordination implementation is difﬁcult. Just scratching the surface, coordination in Zambia
J. Sundewall et al. / Health Policy 95 (2010) 122–128
seemed to work well. Initial ﬁndings suggested that all the interview respondents representing government and nongovernmental and donor organizations were fairly satisﬁed with the implementation of coordination of health-sector aid in Zambia. However, at a closer look, these stakeholders held contrasting perceptions of the degree of coordination of strategic plans and agreements, which have an impact on government ownership. More importantly, donor interests to control resources and the limited coordination of HIV/AIDS funding, restricts Ministry of Health inﬂuence over coordination. The different perceptions of aid coordination which were found correspond well with experiences from health SWAps in Uganda and Bangladesh . In fact, such divergences in understanding are common when implementing policies as models for cooperation are often formulated in vague and general terms in order to be acceptable to all stakeholders . However, when donor and recipient priorities do not agree, the different understandings have also shown to be a potential source of conﬂict . The development of aid coordination in Zambia seems in line with the targets of the Paris Declaration on Aid Effectiveness, namely, to establish joint procedures for aidrelated funding, planning and activities . However, the existence of parallel procedures, as illustrated by separate coordination of funds for HIV/AIDS, was one of the respondents’ main concerns. Such parallel processes are perceived as negative for government ownership. Previous research on the Global Fund in Mozambique, Tanzania, Uganda and Zambia lends support to this ﬁnding, showing that there is widespread concern about the coordination problem and overlapping character of funding for speciﬁc diseases . It has been argued that parallel structures, are consolidated by the vertical nature of funds and commodities (e.g. drugs, laboratory equipment) supporting them . An increase in vertical funding is thus likely to promote the development of such structures and constrain the coordination of health-sector aid by the Government of Zambia at the national level. More vertical funding could also lead to a “polarization” between vertical and horizontal funding, a development that is likely to inhibit progress in coordination efforts . There are many actors with strong roles in the implementation of health-sector aid coordination in Zambia. Generally, the larger the number of stakeholders involved in a cooperation, the more difﬁcult implementation becomes as more actors have to agree . Thus the sheer number of strong actors involved in the Zambian health sector presents a challenge for successful implementation of aid coordination. Our study also showed that these actors have different perceptions of to what extent and how resources are coordinated. Our ﬁndings thereby reﬂect the difﬁculties of implementing coordination and reinforce the notion that a strong donor dependence can undermine government ownership [34,35]. It is established that the implementation of policy is inﬂuenced by the relative power of actors . Coordination is a tool by which actors can exercise powerful leverage over policy implementation . The power of individual stakeholders is determined by several factors, but the most obvious is the size of their ﬁnancial contri-
butions to the sector. The US Government is the largest donor in the health sector in Zambia, and they were by some respondents also criticised for poor coordination. Thus our ﬁndings propose that the power relationship must be taken into account when trying to understand why some aid seems more coordinated than other. As stated before, cooperation in the Zambia health sector is characterized by a willingness to reach consensus between all partners involved. However, results indicate that even though there seems to be consensus about adhering to national priorities and coordinate efforts, there exist in this case conﬂicting views between at least one of the main donors and the government about what this means in practice. Donors’ willingness and ability to coordinate is also restricted by rules and regulations of their own organizations and by the mandate by which they operate. This suggests that successful aid coordination must consider not only the context in which it is implemented, but also the context of each donor. Interviewees proposed the relatively long history of aid coordination in Zambia as an explanation for the reported increase in trust and good relationships between donors and the government. The efforts of the Zambian government to achieve consensus among stakeholders was also seen as positive. However, interviews with several key actors suggested that issues of trust and conﬂicting agendas still persist, although no respondent raised the issue of corruption speciﬁcally. In May 2009, the Anti-Corruption Commission in Zambia revealed suspicions of corrupt practices among Ministry of Health ofﬁcials, which further highlighted the importance of trust between the donors and the government [46,47]. The mere suspicion led to some donors suspending their aid disbursements to the health sector. This experience indicates that while time is important to build trust and good relationships, issues of trust and transparency are more important factors for building conﬁdence among stakeholders. Most of the actors interviewed in this study had been involved in the health sector in Zambia for many years. The results therefore represent an “insider’s” view, portrayed by the very actors that have been involved in setting up the structures described and analysed here. One of the limitations is the fact that the study was funded by one of the participating donors, which could have inﬂuenced the interviewees to, e.g. portray an overly positive or negative picture coordination implementation. Thus we used multiple sources of data to record multiple perceptions and thus clarify meanings . In meetings, the observer took note of whether the formal structure for coordination was implemented as described by interview respondents; for example, whether organizations that was supposed to attend actually participated. Although we acknowledge that the features of and group of actors in each context are unique, previous work has shown that differences in understanding of global aid models varies between institution, but these understandings are similar regardless of the context they are operating in . Therefore the approach adopted in this study is useful for similar analyses in countries with a comparable aid architecture and donor presence.
J. Sundewall et al. / Health Policy 95 (2010) 122–128
6. Conclusions The interests, actions and perceptions of the actors involved, which are expressed in their choice of processes and implementation, all inﬂuence coordination implementation. The Ministry of Health carries the ultimate responsibility for implementation of the health-sector strategic plan, which ideally should include all resources and activities. If the aims of the Paris Declaration – increased harmonization, alignment and government ownership – are to be achieved, resources from global health initiatives, particularly funds for HIV/AIDS, must be better coordinated in the health-sector planning process. Realizing such changes in coordination requires careful consideration of the contextual and institutional constraints surrounding each donor. It also requires shared trust in both systems and intentions between donors and the Zambian government. Conﬂicts of interest statement The study was funded by Swedish International Development Cooperation Agency (Sida). The funder did not in any way inﬂuence the study design, execution or presentation of results. References  Buse K, Walt G. Aid coordination for health sector reform: a conceptual framework for analysis and assessment. Health Policy 1996;38:173–87.  WHO. International development assistance and health. The report of Working Group 6 of the Commission on Macroeconomics and Health. World Health Organization; 2002.  International Development Association. Aid architecture an overview of the main trends in ofﬁcial development assistance ﬂows; 2007.  Ravishankar N, Gubbins P, Cooley RJ, Leach-Kemon K, Michaud CM, Jamison DT, et al. Financing of global health: tracking development assistance for health from 1990 to 2007. Lancet 2009;373:2113–24.  Pfeiffer J. International NGOs and primary health care in Mozambique: the need for a new model of collaboration. Social Science and Medicine 2003;56:725–38.  Chansa C, Sundewall J, McIntyre D, Tomson G, Forsberg BC. Exploring SWAp’s contribution to the efﬁcient allocation and use of resources in the health sector in Zambia. Health Policy Planning 2008;23:244– 51.  Aarnes D. Budget support and aid coordination in Tanzania; 2004. Report presented to the Norwegian Embassy in Dar es Salaam. Unpublished.  Dante I. Aid coordination and donor reform. In: Schmidt R, Beamish R, Shadid D, editors. Africa report, assessing the new partnerships. Ottawa: The North-South Institute; 2003.  UNDP. Aid coordination and management: considerations, lessons learned and country examples; 2002.  Lake S, Musumali C. Zambia: the role of aid management in sustaining visionary reform. Health Policy Planning 1999;14:254–63.  Pavignani E, Durao JR. Managing external resources in Mozambique: building new aid relationships on shifting sands? Health Policy Planning 1999;14:243–53.  Brunsson N. Organized hypocrisy. In: Czarniawska B, Sevon G, editors. The Northern lights: organization theory in Scandinavia. Copenhagen: Liber, Abstract, Copenhagen Business School Press; 2003. p. 201–22.  Sundewall J, Sahlin-Andersson K. Translations of health sector SWAps—a comparative study of health sector development cooperation in Uganda, Zambia and Bangladesh. Health Policy 2006;76:277–87.  Walt G. Health, policy: an introduction to process and power. London, Johannesburg: Zed Books, Witwatersrand University Press; 1994.
 Howlett M, Ramesh M. Studying public policy: policy cycles and policy subsystems. Ontario: Oxford University Press; 2003.  DeLeon P. The missing link revisited: contemporary implementation research. Policy Studies Review 1999;16:311–38.  Walford V. A review of health sector wide approaches in Africa. Technical Paper: HLSP Institute; 2007.  Eisenhardt K, Graebner M. Theory building from cases: opportunities and challenges. Academy of Management Journal 2007;50: 25–32.  Yin R. Case study research design and methods. Thousand Oaks: Sage Publications; 2003.  Robson C. Real world research. Malden, MA: Blackwell Publishing; 2002.  Dahlgren L, Emmelin M, Winkvist A. Qualitative methodology for international public health. Umeå: Umeå University; 2004.  Varvasovszky Z, Brugha R. A stakeholder analysis. Health Policy Planning 2000;15:338–45.  Ministry of Health. Survey of Donor Funding for Health (Unpublished). Lusaka: Ministry of Health; 2007.  Ministry of Health. Action plan 2007. Ministry of Health; 2007.  UNDP. Human development report; 2006.  Government of Zambia. 1st National Development Plan. In: Ofﬁce of National Development and Planning, editor; 1966.  Walt G, Pavignani E, Gilson L, Buse K. Health sector development: from aid coordination to resource management. Health Policy Planning 1999;14:207–18.  Foster M, Brown A, Conway T. Sector-wide approaches for health development: a review of experience. Overseas Development Institute, World Health Organization; 2000.  Cassels A. A guide to sector-wide approaches for health development—concepts, issues and working arrangements. World Health Organization; 1997.  Cassels A, Janovsky K. Better health in developing countries: are sector-wide approaches the way of the future? The Lancet 1998;352:1777–9.  Harrold P. The broad approach to investment lending. Sector investment programs. World Bank Discussion Papers 302: World Bank, 1995.  Alexander D. The international health partnership. Lancet 2007;370:803–4.  Paris Declaration. Paris Declaration on Aid Effectiveness; 2005.  Sundewall J, Forsberg BC, Tomson G. Theory and practice—a case study of coordination and ownership in the Bangladesh health SWAp. Health Research Policy System 2006;4:5.  Walford V. Deﬁning and evaluating SWAps. Institute for Health Sector Development; 2003.  Government of Zambia. National health strategic plan 2006–2011; 2005.  Government of Zambia. Memorandum of understanding between the Government of Zambia. Ministry of Health and Cooperating Partners; 2006.  Ministry of Health. Memorandum of understanding between the Government of the Republic of Zambia. Ministry of Health and Cooperating Partners, Government of the Republic of Zambia; 2006.  Strang D, Meyer J. Institutional conditions for diffusion. Theory and Society 1993;22:487–511.  Brugha R, Donoghue M, Starling M, Ndubani P, Ssengooba F, Fernandes B, et al. The Global Fund: managing great expectations. Lancet 2004;364:95–100.  Mayhew SH, Walt G, Lush L, Cleland J. Donor agencies’ involvement in reproductive health: saying one thing and doing another? International Journal of Health Service 2005;35:579–601.  Ooms G, Van Damme W, Baker BK, Zeitz P, Schrecker T. The ‘diagonal’ approach to Global Fund ﬁnancing: a cure for the broader malaise of health systems? Global Health 2008;4:6.  Pressman JL, Wildawsky A. Implementation. Berkeley: University of California Press; 1984.  Hill M, Hupe P. Implementing public policy. London: Sage Publications; 2002.  Buse K. Keeping a tight grip on the reins: donor control over aid coordination and management in Bangladesh. Health Policy and Planning 1999;14:219–28.  Lusaka Times. Police pick up Dr. Simon Miti. Lusaka, 2009.  Lusaka Times. Be patient, Dr. Simon Miti told. 2009.  Stake RE. Qualitative case studies. In: Denzin NK, Lincoln YS, editors. The sage handbook of qualitative research. Thousand Oaks: Sage Publications; 2005.