Decolonizing global health assistance through listening

French translation here.

Throughout the world, new doctors take the Hippocratic Oath, which is meant to remind them of their obligation to do good and cause no harm. While international development practitioners do not have a binding oath, we have a commitment to ensure that we implement and enact changes that are needed and wanted by their recipients by listening to and learning from the communities in which we work.

As development practitioners, many are familiar with the story of the women who had a well built by aid workers in their village but still preferred to walk for four hours to fetch water because that was the only time they had to be among only women. Or even the story of the Water of Ayolé that illustrates how a water pump initiative in Togo failed because project implementers made unilateral decisions without consulting key stakeholders in the community to understand what they wanted and needed.

The common denominator among these stories is that an external entity implemented a development initiative without assessing how it would be received in the local context. This raises an important question all international development organizations and practitioners should ask themselves: is my support desired? If yes, how should I go about it to meet recipients’ expectations?

The African Collaborative for Health Financing Solutions (ACS) project aims to facilitate collaborative and country-led processes in sub-Saharan Africa, to identify and address implementation challenges with policies and strategies designed to advance universal health coverage (UHC).  In the context of the ACS project, asking key stakeholders what they need and how they want to achieve it is called “Continuous Demand Assessment.”

Following the inception of the project, ACS published a blog that called for three shifts in the global health community’s support for health financing to advance UHC. The piece highlighted how supporting country-driven processes and paths is the keystone element to advancing UHC and building strong and sustainable health systems. As a follow up to the “Three shifts” blog, this post shares ACS’s experiences and learnings from the project’s demand assessment efforts in the countries it supports.

Deconstructing the concept: What does demand assessment mean and why is it important?

To understand demand assessment and its perceived strengths and weaknesses relative to its implementation, a total of six semi-structured interviews were conducted with project stakeholders. Two of the interviewees are part of ACS’s leadership team, two are part of the project’s implementation team, and the two remaining interviewees are country stakeholders from Benin and Botswana. Benin and Botswana were selected because they are the first countries where the project applied its full demand assessment methodology with contextualized tools to respond to a country ask.

In each interview, participants were asked “what does demand assessment mean to you and why is it important?” The main themes of the answers provided are displayed in the word cloud below. All respondents argued that demand assessment would allow the implementing organization to interact with local stakeholders to get an accurate representation of national priorities to align the interventions for the best possible outcomes, and create an environment conducive to an inclusive stakeholder dialogue as a first step to establishing reliable information-sharing channels for accountability and progress. Respondents also felt that it would allow national stakeholders to avoid having external priorities be imposed upon them.

When looking at the definitions of demand assessment provided by each participant, it became apparent that three components need to be present for a comprehensive assessment of country demands or priorities: 1. Inquiry, 2. Prioritization, and 3. Validation. The purpose of inquiry is to catalog the priorities identified by each stakeholder group at the country level. Prioritization consists of identifying the highest-ranking needs and establishing them as the national priorities with the meaningful contribution of critical national stakeholders. Once those priorities are identified, it is crucial to expose the highest-ranking needs to the scrutiny of all stakeholders for any amendments and final validation.

Plans for ambitious projects are often drafted without the involvement of the right mixture of voices and perspectives, which can have severe consequences – or at the very least, result in poorly implemented policies along with their ramifications. The process of demand assessment creates an environment conducive to collaboration, adherence of key stakeholders to the suggested process, and uses evidence to facilitate the implementing organization’s movement towards achieving the collectively sought-out objectives.

Continuous demand assessment à la ACS

When conducting a demand assessment exercise, the ACS project follows four steps:

1. Create an initial stakeholder map that contains a diverse set of stakeholders

Upon initial engagement with both the government and the U.S. Agency for International Development, ACS creates a key stakeholder map for that country, inclusive of a breakdown of the six stakeholder groups targeted by the ACS project. Stakeholders include: policymakers, development partners, public sector implementors, private sector implementors, civil society and academia. Additional stakeholders are added to the map as the project learns new and relevant information, much of which is captured through the project’s Process Documentation tool. This tool analyzes the context where the project operates in an effort to anticipate potential policy changes, or inform them, and to support national stakeholders to more effectively engage in policy processes.

2. Outreach to prioritized stakeholders and consultation

ACS’s overall goal is to listen to prioritized country stakeholders’ demands or priorities and formulate activities accordingly. Using the information provided, each ACS country engagement can be custom tailored to meet the needs and priorities outlined by the stakeholders.

3. Validation stage

Prior to implementation kick-off, ACS designs a set of support activities, in coordination with USAID, based on the prioritized needs identified during the consultation phase and validates the proposed activities with key national stakeholders for final refinement.

4. Implement activities, regularly reassess demand and adjust priorities accordingly

Throughout implementation, ACS country teams regularly re-assess demand with the initial set of prioritized stakeholders to understand current priorities and shifts and then adapts support accordingly, in coordination with USAID.

Demand assessment: Is it worth it?

Stakeholders were asked to delineate the advantages and shortcomings of the approach in an effort to improve its design and implementation. Their points of view are summarized in the sections below:

Pros of the approach

• It paves the way for a bottom-up approach to the design and implementation of development projects that leads to a more sustainable impact.
• It creates an environment where national voices are given a platform where their priorities are heard and addressed with the utmost consideration. Those national voices will guide the development organizations’ activities towards meaningful and contextually relevant results. There is research that looks at the impact of inadequate collaboration in public policy arenas and how siloed efforts hamper policy design and implementation. Addressing policy questions requires a multidisciplinary, multi-perspective, and collaborative approach to make it valid, relevant and sustainable.
• It sets up countries for success that will outlive the lifespan of the facilitating project or organization by creating a fertile national environment for meaningful collaboration. Demand assessment requires that national priorities are collectively identified, prioritization is transparent, and all stakeholders are given a voice in the process.
• Demand assessment gives stakeholders a taste of collaborative work and they are very likely to want to keep working that way.

Cons of the approach

• Demand assessment is a tedious and time-consuming endeavor because country actors can have varying opinions on their country’s needs and priorities. In cases where actors do agree, it can often be a challenge to have everyone articulate the priorities in the same way. In the case that country actors know exactly what they want and are able to articulate their needs, it is difficult to synthesize it all together.
• As a time-consuming exercise, if not properly managed, it could delay the actual start of activity implementation. Lack of proper time management might lead to a situation where the project is continually a step behind the process, thus proposing initiatives not necessarily aligned with a given country’s national priorities.
• The process is not as straightforward and can be a political exercise. Therefore, it comes down to impeccable facilitation, the ability to identify power struggles and establish equilibrating mechanisms to serve all stakeholders.

Demand assessment is an approach that breaks down the walls of siloed work and facilitates an open exchange among stakeholders. By systematically and regularly inventorying, assessing and prioritizing what stakeholders perceive to be critical needs, consensus and commitment are built amongst those in-country who have agency to address them. While not an easy process, it builds sustainable ownership to achieve those collective objectives. In the next blog, continuous demand assessment will be analyzed through the lenses of the ACS project’s experiences in Benin and Botswana to explore the feasibility of the concept’s theory and delineate learnings applicable throughout the international development field.

About ACS
The African Collaborative for Health Financing Solutions (ACS) is a five-year, USAID-funded project that supports sub-Saharan African countries to advance their UHC agenda. Learn more on the ACS web page.