Abstract
Health crises pose fundamental challenges to international relations and have been a major focal point of contests for global influence, particularly in the global South, where such crises are most acute. This necessitates a focus on the arenas of global health diplomacy and the power struggles that emanate from them, including the often-overlooked agency of African actors within these arenas. Drawing upon a total of 3 months of fieldwork in 2007 and 2014 that included 68 key-informant interviews, participant observations, and informal discussions, this article interrogates the mechanics of multi-stakeholder health diplomacy in Malawi, where a near-permanent state of health crisis and underdevelopment has generated extreme dependency on external health assistance. This article conceptualises shadow diplomacy as the informal networks and channels of influence that run parallel to, but are not recognised as part of, formal diplomacy. This concept reveals how health is key to struggles for leverage by both international and local actors, giving rise to informal and subversive manifestations of diplomacy in the ‘shadows’. It enables us to understand not only how Western powers consolidate and obscure their enduring power but also how the ‘shadows’ benefit African political elites as they leverage their dependency to subvert global power structures for their own ends. It disrupts the external/internal binary of international donors/African states and reveals that these are not monolithic actors but instead comprising complex individuals with multi-faceted motivations and divided loyalties.
Global health diplomacy has emerged over the past decade as a new area of diplomacy within the context of shifting donor–recipient relationships, novel types of health alliances and the rise of ‘south-south’ cooperation. 1 It is of importance because health crises – including the outbreaks of Ebola in West Africa and Zika in South America – pose fundamental challenges for International Relations (IR) and it is in arenas of health that battles for global influence are played out. 2 Global health diplomacy complicates understandings of diplomacy because it extends into new spaces with diverse actors and manifold forms of negotiation. 3 It encompasses different levels, including ‘core diplomacy’ with high-level inter-state negotiations over health (notably within the World Health Organization (WHO)) and ‘multi-stakeholder diplomacy’ where various bilateral and multilateral organisations work with national governments to develop, implement, and monitor national and regional health initiatives. It is the latter that is of interest here because it extends the gaze of International Relations to state and non-state actors that have not traditionally been recognised as participants in foreign affairs and to new forms of negotiations, including among technical experts within donor agencies and government ministries. 4
It is recognised that global health diplomacy is a nascent area and requires further conceptual development. 5 The concern here is what can be learned from rethinking based upon how it plays out in African realities. 6 This is important because the scholarship on diplomacy more generally – and global health diplomacy specifically – tends to be Western-centric in its concern and focus, to some extent obscuring African spaces, actors and forms of diplomacy. The dominant concern in work on global health that does engage with Africa is with perceptions of and reactions to Africa as a threat to global health and a site for diplomacy. 7 Typically, the continent is perceived as ‘acted on’ by the West 8 and, more recently, other powerful global actors, including China. 9 In recent years, there has been emerging interest in non-Western understandings of IR 10 and Africa’s place within the discipline. 11 This article contributes to scholarship that lays emphasis on Africa’s position as not merely ‘acted on’ but also as an ‘actor in’ global politics. 12 There is a small body of work within the global health scholarship on Africans as actors 13 and yet the focus of the health diplomacy scholarship remains on relatively powerful states and actors, notably South Africa. 14 Furthermore, there is a proclivity to apply Western conceptual frameworks to African cases. 15
Although multi-stakeholder health diplomacy is a phrase that is used in the global health literature and a useful descriptor, it lacks conceptual development. This article builds upon the existing literature to question what we can learn about multi-stakeholder health diplomacy within African contexts where there are highly asymmetrical donor-recipient power relations because of dependency on health assistance. Malawi is examined as an ‘extreme case’ 16 because it is dependent on external assistance for 81 per cent of the total health expenditure. 17 In this context, multi-stakeholder health diplomacy is useful for understanding the complexity of how diplomacy is not just occurring between states – there is also the crucial role of other actors including donors, non-governmental organisations (NGOs), private philanthropists and private-sector health providers. Moreover, it draws attention to the individual technical advisors, programme managers and consultants working within these organisations. The analysis interrogates the mechanics of multi-stakeholder health diplomacy – questioning what it looks like in practice, where and how it takes place, and how it is perceived by those individuals engaged in diplomacy. This focus is important because the precise nature of donor-government relations remains an undocumented black box on which political scientists have built political and economic models that assume great asymmetries of power between donors and recipient governments. This article shines a light into to this box and tests some of these assumptions using qualitative methods that allow for rich descriptions of the negotiation process.
The analysis takes an actor-oriented perspective 18 to fill gaps in our knowledge in IR, particularly in terms of understanding non-Western perspectives and locating Africans as actors in global politics. It draws upon a total of 3 months fieldwork in Malawi (during June–July 2007 and June–July 2014). Data were gathered from NGO, government and donor reports. A total of 68 semi-structured key-informant interviews were conducted with a broad spectrum of key players in health diplomacy – 44 in 2007 and 24 in 2014. These included civil servants in government, technical advisors from major international donors and private philanthropists working with and within the government, programme managers and technical assistants with major international donors, private-sector health providers, implementers, international NGOs, civil society organisations and consultants. Initially, the interviewees were approached through key organisations working in the health sector and high-level gatekeepers including the Attorney General and Minister for Gender. Further participants were identified through a process of snowballing, which extended the scope of the research beyond what was originally envisioned and enabled access to actors whose roles were confidential. Given the sensitivity of some of the issues raised, trust was established through these personal recommendations and building rapport during the course of the interviews. The interviews covered topics of the respondent’s role and background, their perception of the health priorities (how these differ between actors and changed over time), the response to those priorities, the challenges they face and the expectations on them in their role. The respondents are referred to here in the ways in which they themselves requested. In 2014, participant observations were also conducted of the ‘National HIV Prevention Symposium’ and HIV Technical Working Group meetings, and a series of informal discussions were also conducted. These rich data enable examination of the nuances of the ways that these actors negotiate and navigate the structural constraints and the complexities of their identities, perceptions, motivations and loyalties. The concern is with how power plays out and what it tells us about diplomacy, not with normative concerns about what is best in terms of health outcomes.
The article begins with the historical and political context of development assistance in Malawi to introduce the context of aid dependency. It is argued that despite limited power over domestic health policy-making, the spaces for diplomacy are in transition with shifting opportunities for negotiations. It then moves on to examine the mechanics of multi-stakeholder health diplomacy and develop the concept of shadow diplomacy. This extends from Reno’s conceptualisation of the ‘shadow state’, 19 to recognise the informal networks and channels of influence that run parallel to, but are not recognised as part of, formal diplomacy. This concept reveals how health is leveraged not only by external powers but also African political elites in ways that obscure, consolidate and extend their power. First, it enables us to understand how Western powers conceal their continued power over the global South, and it is argued that this takes three forms: (1) through directing health initiatives and the policy-making process in the shadows, (2) infiltrating the structures of the state by embedding external technical advisors within government ministries and (3) the use of diplomacy processes and instruments to extend their control. Second, it is argued that the shadows also benefit African elites as they leverage their dependency to subvert the global power structures, including for their own personal gain. This takes four forms: (1) through extraverting health issues, (2) playing more power actors off against each other, (3) strengthening their negotiating position through ‘evidence-based diplomacy’ and (4) subverting the health system for private gain. The final section argues that shadow diplomacy is useful for advancing how we understand ‘Western’ and ‘African’ actors in global health diplomacy.
The historical and political context of development assistance for health
In order to interrogate multi-stakeholder diplomacy in Malawi, it is important to briefly introduce the historical and political context of development assistance for health. External involvement in health in present-day Malawi dates back to missionary medical work and the establishment of hospitals and dispensaries in the late nineteenth century under British colonial rule. 20 Health care provision from the 1930s to the end of the 1980s comprised a public/private mix of mission hospitals coexisting alongside government district hospitals. From independence in 1964, there was increased state control and leadership of health provision under Hastings Kamuzu Banda with the expansion of government legislation and bureaucracy. 21 From 1981, the health system was hollowed out by structural adjustment policies: the underlying free-market ideology required the rolling back of the state and efficiency cuts, which had implications for the health services with the liberal registration of medical practitioners, the expansion of private-sector provision and the introduction of user fees. 22 Although, traditionally, Malawi performed well in terms of the World Bank requirements and has been considered a ‘strong liberaliser’, increases in foreign direct investment and economic growth failed to materialise. 23 While a number of other African states have experienced relatively high levels of economic growth – leading to the emergence of a narrative that ‘Africa’s rising’ 24 – Malawi remains among the poorest countries in the world with a gross national income of USD240 in 2014. 25 Economic growth reached 6 per cent but inflation was 24 per cent because of the continued depreciation of the kwacha and the withdrawal of donor budgetary support. 26
Despite 50 years of independence, foreign aid accounted for 40 per cent of Malawi’s national budget in the financial year 2013–2014, and 40 per cent of that came from the United Kingdom’s Department for International Development (DfID). 27 This dependency on external funds was particularly acute in terms of health assistance, which accounted for 89 per cent of the Ministry of Health budget and 81 per cent of total health expenditure. 28 The main donors were the Global Fund, World Bank, DfID and Norway, which had been resourcing a pooled fund for health through the Sector-Wide Approach (SWAp) (introduced in Malawi from 2004), and the US Government, particularly through the President’s Emergency Plan for AIDS Relief (PEPFAR). 29 Dependency on external funds was most apparent for HIV with 99 per cent coming from donors: USD705 million from the Global Fund and USD528 million from PEPFAR. 30 Although HIV prevalence remained high – only stabilising at around 11 per cent from 2011 – the prioritising of a single disease was disproportionate to its health burden and had warped the health sector such that local facilities lack the capacity to respond to other critical health issues. 31 This was fundamentally at odds with the priorities of local communities 32 but ultimately, donors are accountable to the taxpayers in their home countries, as donor and NGO representatives reflect. 33 For example, the policies and strategies of DfID are formulated in London and driven by the interests of the United Kingdom rather than those of Malawi. 34 The health system is highly fragmented with multiple parallel health systems where assistance comes from a coterie of donors who partner up with implementing partners. 35 Donors may engage with local partners, other donors or NGOs, and Watkins and Swidler describe how, with respect to AIDS funding, money ‘flows chaotically both downward and sideways’. 36 The team leaders are based in Washington and London, while technical advisors based at the country level are required to participate in donor grouping meetings and ensure the delivery of programmes.
By 2014, the health sector was in crisis because of the risk to donor funds. A 2012 audit revealed mismanagement of the Global Fund Grants 37 and the subsequent retraction of Global Fund resources had a knock-on effect and the other donors followed. 38 Furthermore, an audit of donor funds to the Government in 2013 revealed an estimated USD30 million was not accounted for – popularly known as the ‘Cashgate’ scandal. Although the Ministry of Health was not directly implicated, one donor technical advisor explains how the donors retracted their on-budget support because they could ‘not be seen to be supporting a government that is corrupt’. 39 One programme manager at a major donor pointed to systematic failures and explained that ‘Cashgate was the final nail following the decline in faith in governance’. 40 In 2014, DfID ended its bilateral funding (having already withdrawn support to the SWAp and the Central Medical Stores), the German Gesellschaft für Internationale Zusammenarbeit (GIZ) was withholding its funding and the Ministry of Health had a tenuous relationship with the Global Fund. 41 Resource mapping reveals that funding continues to be channelled to certain donor priority areas including disease-specific interventions (most notably for HIV/AIDS), while the majority of cross-cutting systems funding comes from the government and is underfunded because it is not attractive to donors. 42 A Programme Manager with a major donor highlights how ‘the decline in donor funding has led to the collapse of the health system for example there is a lack of the most basic drugs such as paracetamol’. 43 During the first months in office of the Democratic Progressive Party Government of Peter Mutharika (elected in May 2014), there were reports of shortages of blood, antiretroviral (ARV) drugs and condoms. 44 These were indicative of the incapacity of the major hospitals in Lilongwe and Blantyre and the health centres across the country, particularly those in more remote areas. And yet, shifts in the funding landscape – with the decline of ‘traditional’ donors and the increasing place of ‘non-traditional’ aid donors including China and new forms of private philanthropy such as the Gates Foundation – also provide new opportunities for negotiations. Within these broader shifts in development assistance, there are new relationships and novel forms of diplomacy that actors engaged in health diplomacy can capitalise on. 45
It is in this context of acute dependency on external health assistance and shifts in the health funding landscape that multi-stakeholder health diplomacy takes place in Malawi. The concern now is to interrogate what we can learn about the mechanics of multi-stakeholder diplomacy.
Obscuring Western power
When seeking to locate Africans as actors in global health diplomacy, an obvious place to begin is their role in developing global health initiatives and policies. Walt, Lush and Ogden argue that global health initiatives are not simply ideologically driven and imposed from the ‘top-down’ by international organisations. Rather, they often originate from the ‘bottom-up’ in low-income countries before forming global policies and over time, complex, context-specific policies become simplified into guidelines for global best practice. 46 The development of Option B+ as a modification of the WHO recommendations for Prevention of Mother-to-Child Transmission (PMTCT) programs 47 has been promoted as a major global health initiative originating from Malawi. Option B+ was the initiation of lifelong ARV therapy for all HIV-positive pregnant and breastfeeding women irrespective of their CD4 count 48 or clinical stage. 49 External stakeholders highlight that it was ‘government-led’ and conceived from the ‘bottom-up’ in response to the specific needs of Malawi, despite some international scepticism and concerns including about the cost of implementation. The rhetoric is one of ‘partnership’ through national consultations and decision-making with support of donor-funded technical advisors and international NGOs 50 The global roll-out has been promoted as a process of ‘south-south learning’, with Malawi showcased as a model for other countries. 51
However, it is well established within the literature on development assistance that the rhetoric of ‘partnership’ and ‘government-led’ conceals enduring Western power and the reproduction of asymmetrical aid relations. 52 The concern here is to develop greater nuance in understanding how multi-stakeholder health diplomacy takes place within contexts of acute dependency on external assistance. It is argued that shadow diplomacy enables us to understand how Western powers obscure their continued power in three ways: (1) through directing the process in the shadows, (2) embedding themselves into the structures of the state and (3) the use of diplomacy processes and instruments.
First, interviews and informal interviews discussions with representatives of international donors and NGOs in Malawi reveal that despite the rhetoric, they endeavour to ‘lead from behind’ in the shadows on the development of initiatives and policies across the health sector. 53 In the case of the development of Option B+, it is attributed to Malawi, and yet, the WHO update reflects earlier recommendations from major donors such as PEPFAR. 54 As Lie argues in his work on ‘developmentality’, donors make their policies those of the recipient in order to ‘govern at a distance’. 55 Participant observation of the development of national HIV policy and informal discussions reflecting on the process draw attention to some of the ways external actors seek to capture ostensibly participatory process and extend their control. The development of the National Strategic Plan for HIV and AIDS 2015-2020 was celebrated for taking a ‘highly participatory and consultative approach in which all the relevant stakeholders participated’. The plan highlights how this included bringing together international and national experts, programme managers, development partners and relevant stakeholders at the 2014 ‘National HIV Prevention Symposium’. 56 During the breakaway group discussions at the symposium, international experts and the national representatives of donors, NGOs, the Malawian government, National AIDS Commission (NAC), networks of people living with HIV (PLHIV) and Traditional Authorities signed to confirm their attendance. And yet, the facilitator was a representative of a major international donor and determined who spoke when and which contributions to the discussion were recorded on the flip chart from the discussions. The international experts and donor representatives dominated the conversation, while the PLHIV and Traditional Authorities mostly remained silent. Only those responses that were deemed by the donor representative to ‘fit’ were written down. 57 Moreover, in an informal discussion with one donor official working in infectious diseases, she highlighted that ultimately what mattered was working on the final draft and that she would leverage her position to ensure her role in that. 58 The identities of those involved in the final drafting of the policy are not provided in the published document (which is solely attributed to the NAC), and this obscures the fundamental role of external actors. Shadow diplomacy plays a fundamental role beyond the formal national consultation processes with the donors and their international implementing partners informally directing the process in the shadows. Echoing the arguments of Crawford on Indonesia, the rhetoric of ‘partnership’ serves to mystify enduring asymmetrical power relations between donors and recipient countries and how initiatives are externally driven. 59
Second, Western actors extend and conceal their power by embedding themselves into the structures of the state through their technical advisors in the Ministry of Health. In response to concerns over accountability – particularly in the wake of ‘Cashgate’ – a number of donor representatives reported how these technical advisors are working as their ‘eyes on the ground’ within ministries in roles that are shrouded in secrecy. 60 As one such technical advisor in the Ministry of Health explained, ‘Now the donors are taking a new path of bringing in independent persons in the systems whenever they are giving funds, as opposed to waiting to audit when things are done’. He explained that his role included acting as a fiscal agent to sign off payments and use third-party agents to verify the details of the training activities. 61 Interviews with these technical advisors revealed that there is a blurring of the roles and identities of these actors – some perceived themselves as part of ministries and had complex and, at times, conflicted loyalties. 62 There was a degree of silence around the nature of their work but what is of interest here is how this complicates health diplomacy. Shadow diplomacy reveals how negotiations do not simply occur between donors and national governments as clearly distinguishable external/internal entities where the donors are infiltrating the state. 63 The locus of multi-stakeholder health diplomacy is in the shadows within ministries between technical advisors, consultants and civil servants with complex identities and motivations. A point returned to in the final section.
Third, donors use diplomacy processes and instruments to extend their control over recipient governments. This is apparent in the case of the Malawi health SWAp, which was intended to pool donor resources to support the health system and place the government at the centre of health initiatives. Interviews with representatives of international donors and NGOs in 2007 revealed that they perceived the SWAp as problematic because it limits their ability to demonstrate their own impact and bring issues onto the agenda. As a technical advisor working with a major internal donor explained, the multilateral approach means that donors ‘do not actually have direct influence on indicators and so forth like you would have in a project’.
64
Likewise, where NGOs are incorporated within the framework, they lose the power to critique the government and push their own agendas.
65
The donors use the process of bi-annual reviews, district supervision systems and informal aide-memoires to strengthen their ability to hold the Malawian government to account on its commitments within the SWAp.
66
And yet, the SWAp is a weak mechanism that has been circumvented by the donors because it is based upon a memorandum of understanding that is modifiable and not legally binding.
67
A mid-term review by the Norwegian Agency for Development Cooperation (NORAD) reports that:
should any development partner offer to provide services outside the framework [of the national health strategy] … the Ministry is unable to say ‘no’, and must accept what is on offer. Such a viewpoint would indicate that Ministry of Health staff may not feel empowered to prioritise interventions and not hold development partners to account when they stray too far away from agreed strategies and work plans.
68
Shadow diplomacy draws attention to the more insidious and subtle ways that Western actors exert their influence through the bureaucratic structures, which serve to internalise aspects of neoliberalism. 69 As a result, donors construct the nature of the ‘partnership’ with the state and limit the very possibilities for manoeuvre. 70 Moreover, the ‘promise of incorporation and inclusion’ for adopting these structures produces modern, self-disciplined and rational agents. 71 However, this does not necessarily manifest itself in ways that the donors intended, as the final section considers.
This section examined how shadow diplomacy occurs beyond formal multi-stakeholder diplomacy over health initiatives and policies. In accordance with global commitments, 72 donors use rhetoric such as ‘government-led’ and ‘partnership’, and yet they continue to ‘lead from behind’ to ensure national policies and initiatives align with their own preferences. At a more insidious level, donors extend their control by permeating the forms and processes of the state. 73 The analysis of the mechanisms of multi-stakeholder health diplomacy reveals how donors embed their technical advisors within Ministry of Health and structure processes and use health diplomacy instruments to hold national governments to account (while thwarting them themselves). This not only shifts the locus of negotiations to the shadows within ministries but it also serves to produce rational, responsible agents. 74 And yet, despite the structural constraints of dependency and the enduring, embedded nature of donor power, African actors can also use the international actors to advance local agendas. 75 The next section examines how shadow diplomacy also entrenches and obscures the power of the African political elites.
Leveraging dependency
It is well established in work in African Studies that Africans have long resisted and even changed ‘what appears to be their structural fate’ 76 and exercised diverse agentic behaviours despite the powerful structures of (neo)colonisation and globalisation. 77 Traditional accounts of the continent’s marginalisation, Bayart argues, obscures how dependency has become a ‘mode of action’ to navigate and even exploit Africa’s unequal inclusion in the global order. 78 The concern here is how the concept of shadow diplomacy provides a more nuanced understanding of the ways in which African political elites leverage health dependency to obscure, consolidate and extend their power. Based upon empirical findings from Malawi, it is argued that this takes four forms: (1) through extraverting health issues, (2) playing more powerful actors off against one another, (3) strengthening their negotiating position through ‘evidence-based diplomacy’ and (4) subverting the health system for private gain.
First, African political elites leverage their dependency on external health assistance through ‘extraverting’ health issues. This draws upon Bayart’s argument that African states are outward-facing and responsive to how they can best exploit their situations to compensate for their limited power – what he conceptualises as ‘strategies of extraversion’.
79
The Malawian health sector is a site of extreme dependency on external resources. Civil servants working in the Ministry of Health reflect upon how they are outward-facing to the donors and must be responsive to shifting donor preferences (e.g. the preoccupation with issues of gender) and the new constraints that are placed upon them (including efforts to limit corruption).
80
Anderson and Beresford argue that precisely because of such dependency, health issues provide particularly effective leverage, and extraversion of crises in particular can mobilise support from the international community.
81
One Technical Advisor working with the Ministry of Health refers to strategies of ‘heart-string’ diplomacy when reflecting on the ways in which the government plays on emotive health issues in negotiations.
82
The extraversion of AIDS has long been particularly effective, as Swidler writes:
the cynic in me thinks that AIDS philanthropy, AIDS research and what might be called AIDS tourism have become Africa’s most successful ‘export’ and certainly a major source of foreign exchange. … AIDS crisis has focused the world’s attention on Africa.
83
Such strategies have mixed effects in terms of the actual health outcomes where it is ultimately about gaining and consolidating political power.
Second, the Malawian political elites play more powerful actors off against one another to advance their own interests, especially where there are a multitude of donors, each with competing health programs.
84
This is not a new phenomenon and there has been a long history of African leaders playing off external actors for foreign aid, including playing off the superpowers during the Cold War.
85
The rise of China has presented opportunities to African states,
86
and the recent Chinese interest in the Malawian health sector – including in the provision of medical expertise to Kamuzu Central Hospital and Mzuzu Central Hospital and Malaria eradication initiatives – provides opportunities for actors in the Ministry of Health despite the withdrawal of support of the traditional donors.
87
During an interview in the immediate aftermath of the announcement of the withdrawal of DfID support, one civil servant reflects on the potential of these new opportunities:
This Government has said that they are looking for other relationships. As long as we have got our priorities, and plans right whoever is funding and investing, and they are fairly flexible, so long as we are not paying vast amounts of interest on loans … we have the Chinese, the Indians, and a number of other potential people who are beginning to invest a bit more now – Turkey keep coming in and out. A number of countries are trying to invest in infrastructure and so forth.
88
This is situated within a broader strategy by the Malawian Government of ‘looking East’, with the strengthening of bilateral relations with China since 2008 under former President Bingu wa Mutharika, which provided his government with options in the wake of the retraction of traditional development assistance to his government in 2011. 89 This has continued under the current President, Peter Mutharika, and in his Inaugural Speech in June 2014, he stated that the traditional donors are ‘welcome to stay’ but Malawi will look to ‘new friends’, including Russia and China. 90
These neoteric health actors have very different relationships with the government as compared with the traditional donors and diplomacy takes on new forms. A civil servant working with the Ministry of Finance reflected a popular sentiment that ‘with the European donors (particularly the UK) it is like a parent-child relationship but with China it is like a brother-brother relationship’. 91 The ‘Beijing Consensus’ of non-interference and respect for sovereignty is attractive to African governments such as Malawi as a break from ‘tied aid’ of traditional donors that includes prerequisites of political liberalisation or economic reforms (except for the ‘one China policy’). In the health sector, China provides technical support including the provision of medical personnel, medicines, equipment and training, and prevention and treatment for malaria and HIV. 92 These new forms of involvement are attractive because as one civil servant in the Ministry of Health explains, ‘with an aid relationship you keep receiving money but it can go nowhere but the money will keep coming – it maintains dependency’. 93 And yet, it also presents novel challenges, and one civil servant reports that the Ministry of Health faces ‘issues of knowing what activities are undertaken – new issues of tracking the funding from the non-traditional donors’. 94 A civil servant in the Ministry of Finance highlighted problems with Chinese representatives thwarting the recently introduced Government reporting mechanisms. 95 Where health diplomacy is fundamental to China’s soft power, 96 shadow diplomacy also enables us to understand how these newer global actors utilise global health diplomacy to consolidate their influence in Africa.
Third, African actors strengthen their negotiating position through the use of ‘evidence-based diplomacy’. In Malawi, private-sector international consultants and technical advisors work with and within the Ministry of Health to build its capacity to produce quantitative evidence and comply with donor demand for evidence-based policy-making. This is important because, as Rottenburg and his colleagues argue, the emphasis on quantitative knowledge ‘privileges the perspectives of those with infrastructure, financial and professional resources and experience in the production of large-scale numerical knowledge’; and yet, ‘indicators have become powerful advocacy tools’, including for grassroots and advocacy groups. 97
In a context of competition for retracted donor funds, the capacity building in the Ministry of Health bolsters its negotiating position through ‘evidence-based diplomacy’. One private-sector technical advisor explains how previously the Ministry:
resorted to lots of ‘heart-string pulling’ advocacy for resources for health but now we have them being able to show clearly what their needs are, what the resources available are and a compelling reason for what they can do with more money.
98
The Ministry was working with the Clinton Health Access Initiative (CHAI) between 2010 and 2014 on annual resource mapping to challenge donor control of information. One civil servant reports that they are now generating data to make better decisions and effectively navigate the opportunities, or, as they put it:
getting all the ducks in line – this is what we want to do: these are our gaps and who is funding what … so we have got a better picture of what the costs are, what the gaps are, what resources are coming in, where they are going to and where the gaps are in terms of diseases and the health system as well.
99
A CHAI report considers how the increased visibility on planned investments and interventions has ‘informed the allocation of US$300 million to high-impact interventions, and strengthened national ownership and coordination of the HIV response’. 100
Strengthening ‘evidence-based diplomacy’ also empowers the government to hold the donors to account. Aid mapping is a useful advocacy tool to reaffirm international commitments to aid effectiveness. Of course, better reporting and mapping of aid is in part about donors extending their control where transparency reduces the ability of the government to misallocate resources, duplicate resources or use resources strategically. However, one civil servant in the Ministry of Finance explains how they use comparative tables on the performances of each of the donors to publicly shame those that are underperforming.
101
Resource mapping by the Ministry of Health with the support of CHAI provides weight to their criticisms of the fragmented parallel health systems and has influenced the allocation of resources. A CHAI report argued that:
Results illustrated that harmonization of these systems could save over US$11 million per year. This informed DFID’s decision to donate drugs directly to the government’s supply chain agency, rather than distributing them through a third party contractor. The change contributed to an estimated reduction of US$3 million in supply chain costs between 2013 and 2014.
102
The government can also hold donors to commitments to aligning their work with the government’s priorities, which in practice tends to only be where there is already goal convergence.
103
Typically collective work towards defining domestic health priorities and commitments to health systems strengthening are overshadowed by dominant themes at the global level including those set out in the Alma Ata Declaration, Ouagadougou Declaration, Millennium Development Goals (MDGs), Poverty Reduction Strategy Papers and the Sustainable Development Goals (SDGs). This includes the diffusion of international norms of gender equality, human rights and community participation.
104
However, one private-sector technical advisor working with the government explained how the National Strategic Plan for HIV was being revised in 2014 so that there is a clear framework to hold donors accountable ‘making it robust so it is costed and prioritised’ which:
allows for first of all, coordination around the governments priorities and second it allows for better tracking on a biannual basis of what we have achieved against our outputs, accountability for what we said we would achieve and then comparing that to how much money has been spent.
However, they recognise that it will be hard to implement – ‘redirecting them to other priorities takes a lot of guts. So they try to do it with evidence but there may be battles they do not want to fight’. 105
This shift in Malawi reflects a broader rise of ‘evidence-based diplomacy’ whereby advocacy groups are ‘playing the numbers game’ and use scientific evidence to augment their negotiating position with more powerful actors. And yet, Storeng and Béhague highlight that this can have profound impacts on how evidence is produced, ambivalence and a technocratic narrowing of the policy agenda. 106 Participant observation of the formulation of the HIV Policy reveals some of these impacts in Malawi. During an open discussion at the ‘National HIV Prevention Symposium’ in 2014, one Western consultant raised the issue that there was not sufficient data to determine priority districts, and yet, his objection was met with silence because it conflicted with the requirement to produce ‘evidence-based policy’. 107 The emphasis on evidence-based policy-making impacts on how evidence is produced, and participant observation of one stakeholder meeting about the development of the policy revealed that during the process of compiling sufficient data about key populations, it violated ethical procedures and led to infringements on the rights of people who participated in the study. 108 Finally, the emphasis on quantitative knowledge impacts on what counts as evidence, and the emphasis on measures leads to the silencing of certain perspectives. In an informal discussion after the gender breakaway group at the HIV Symposium, one woman living with HIV representative explained that she did not know how her contributions about gender-related stigma could be included after the facilitator raised the issue of measuring in relation to the discussion of gender – so she remained silent. 109
Moreover, there becomes a façade of evidence as Malawian actors align their actions and rhetoric with donor assumptions to advance their position.
110
Swidler notes with respect to reporting on HIV interventions for children how:
personnel are rewarded for turning in reports without much scrutiny from the home office staff. So in the long run, what these organizations really need to provide in order to survive is enough children; so that when the infrequent visitor comes, local relationships can be used to mobilize an acceptable number of children or adults to demonstrate that something is happening on the ground.
111
Where there is a mutual (albeit unequal) dependency between donors and recipients, 112 this façade is not brought into question because there is often a shared benefit. The international community need to point to ‘success stories’ such as the government-led development of Option B+. 113 The performance of a ‘partnership’ masks donor control but Malawian political elites can also claim political capital. In this sense, ‘dependency has been a joint venture’, 114 and donors rely on local actors to achieve their goals, which has enabled African actors to also benefit. 115
Fourth, Malawian political elite subvert health assistance for their own private gain. Shadow health systems of informal commercially orientated networks between global and local actors and general rent-seeking behaviour exist alongside the formal structures of the health sector. 116 State resources are exchanged for political loyalties, and public office provides the opportunity to support one’s own clients through privileged access to public goods. 117 Political elites at multiple levels engage in ‘gatekeeper politics’, which Beresford defines as the ‘political and social structures through which authority and power are cultivated, disseminated, and contested’. 118 This has been one of the main means of mobilising political support in Malawi since independence and the state continues to be a primary means for accumulating wealth despite the rhetoric of democracy since the shift to multiparty elections in 1994. 119 Gatekeeper politics is especially pronounced in the health sector with the sheer scale external resources and the legacy of a lack of Monitoring and Evaluation. Positions within the health sector provide key opportunities for controlling resources and channelling them for personal ends. The Ministry of Finance controls the gate to donor resources, and the Ministry of Health responds by lobbying formally within state apparatus but also through interconnections of these elite through patronage ties and personal networks (including extended family and past experience studying or working together). Informal networks serve to subvert the health sector for personal gain and severely undermine healthcare provision. With the sheer extent of resources into HIV, control of this gate is particularly lucrative and there have been reports of scandals of corruption within NAC. 120
Patronage networks permeate society and, as Swidler considers, ‘local people at all levels, at least initially, inevitably regard an international organisation as a potential source of money, goods or contacts that are otherwise unavailable’. 121 Interviews with actors across the health sector reveal the strong pressure on them to support their own dependents, including their extended families, communities, employees and clients within their patronage networks. 122 However, it is important to recognise that these expectations extend to ‘western’ actors who settle in Malawi, 123 some of whom are married to Malawians and incorporated into their patronage networks, as some of these actors reflect. 124
Corruption is a feature of patronage distribution and throughout the health sector has implications for infrastructure, drug procurement and service delivery. As a representative of the Anti-Corruption Bureau (ACB) explains:
[Where] money is siphoned off it means there isn’t enough money to deliver enough infrastructure but also the money that is available to build the infrastructure sometimes in the end the infrastructure is not up to the standard because government officials that are meant to insure the standards have been paid off and low quality is delivered [and] … at an even higher cost.
125
In this resource-scarce context, medical resources are particularly amenable to fraud because of the demand in a context of shortages. One representative of the ACB points to the Drug Leakage Survey and how ‘the procurement process is marred by issues of corruption’.
126
While another reflects upon the broader phenomenon:
If I go to the hospital and I am prescribed drugs, for me to access it I have to pay something. I am told the drugs are not available … because they know that the demand for the drugs is higher than the supply.
127
Despite the tight corners for health diplomacy, the concept of shadow diplomacy sheds light on the ways in which Malawian actors are resisting and changing what appears to be their structural fate. They are employing their differing situations of dependency as a means for agentic behaviour – leveraging health issues, taking advantage of shifts in the funding landscape (particularly looking to new opportunities from China), strengthening their negotiating position through ‘evidence-based diplomacy’ and using shadow health systems of patronage to divert resources and opportunities for private gain.
‘Western’ and ‘African’ actors in global health diplomacy
This final section turns to a concluding discussion of what this interrogation of the mechanics of multi-stakeholder diplomacy in Malawi tells us about seemingly ‘Western’ and ‘African’ actors in global health diplomacy. It is argued that the conceptualisation of shadow diplomacy complicates our understanding in five ways.
First, shadow diplomacy disrupts the external/internal binary between international donors and African states because, as Harrison argues, donor power is not simply an external force but in more insidious ways they have become ‘part of the state’. 128 The analysis here reveals how donors are ‘leading from within’ the state by embedding their technical advisors within government ministries such that negotiations occur in the shadows within ministries. There is a plethora of diverse actors working within government ministries: transnational African elites and Western actors working as consultants and experts in civil servant roles, and transnational African elites and Malawians working as donor ‘eyes on the ground’. Donors are also structuring the very processes of health diplomacy.
Second, and connected to the first point, shadow diplomacy reveals that these are not simply monolithic actors and there are crucial power hierarchies within them, shifting the locus of diplomacy to within donors, the state and other actors. The Government of Malawi is not simply a monolithic ‘Malawian’ actor. The Ministry of Finance is a key gatekeeper between the various Ministries and the external donors. During the interviews, civil servants in the Ministry of Health focused their responses on their efforts to lobby the Ministry of Finance for resources and directed the researcher to key actors in the Ministry to include in the research. 129 For the case of administrative reform in Tanzania and Uganda, Harrison highlights how the ministry of Finance is a ‘hegemonic ministry’ that regulates budgetary expenditure and is a conduit between the Government and Donors. He notes that ‘All bilateral donors negotiate their aid programmes with the Ministry of Finance, many referring to it as the “point of entry” regardless of the nature of the aid programme’. 130 There are also tensions within the donors, and some representatives were highly critical of the organisation that they worked for. For example, one respondent (who wanted to be identified as an employee of a major international donor to distance himself from the organisation) criticised the ways in which the Head Office had overruled the work the in-country team had done in developing initiatives and had recalled them to bring their work in line with ‘best practice’. 131
Third, shadow diplomacy is useful for advancing how we understand the complex identities of these Malawian and Western actors who have multi-faceted motivations and divided loyalties. The interviews shed light on the complex history of these actors: many had previously worked for other organisations in the health sector – some of the interviewees in 2014 had been previously interviewed in those former roles with other organisations in 2007. Malawian actors working for international donors juggle their own individual interests, beliefs and commitments. 132 One Technical Advisor reflects on the withdrawal of budget support following Cashgate that ‘a lot country representatives working for those organisations are upset with that decision they have been forced to pull their money out’. 133 For example, one Malawian technical advisor had been working with a major international donor for 3 months and was responsible for working with government, participating in the donor grouping meetings and engaging with NGOs on programming and implementing of health programmes in the country with that international donor. She had experience of participating in those meetings for almost 3 years as a representative of another international donor and previously worked for almost 3 years at a consortium of NGOs that included NGOs she is now working with. This complex history means that she has a conflicted sense of her own identity and loyalty, with a strong sense of empathy with the other organisations she is negotiating with. 134
Fourth, shadow diplomacy also complicates our understanding of African actors because it draws attention to the disciplinary power of neoliberalism in producing rational, responsibilised agents. 135 The interviews and informal discussions revealed how Malawian actors in various ways are balancing their own personal aspirations including for material goods, social mobility and career advancement. Typically, the Malawian elite working in Government have aspirations to work in more lucrative positions for donors or NGOs, undertake university study and to further their careers. 136 Malawian Programme Managers and Technical Advisors working with the major donors typically had lengthy experience in health and were progressing in their career by working with multiple actors including government, faith-based organisations (FBOs), NGOs and other donors. 137
Fifth, shadow diplomacy draws attention to the nuances of the agency of these actors despite the power hierarchies. It highlights how Malawian actors are employing their differing situations of dependency as a means for agentic behaviour: leveraging health issues, taking advantage of shifts in the funding landscape, strengthening their negotiating position through ‘evidence-based diplomacy’ and using shadow health systems of patronage to divert resources and opportunities for private gain. Similarly, the donors and NGOs are not simply ‘Western’ actors: the Programme Managers of donors and Western NGOs include Malawians, transnational African elites, ex-pats who were Malawian residents and other Westerners who were married to Malawians or intimately connected in other ways to the country due to the long time they had resided there. How these diverse actors understand their roles in health projects and their goals and motivation for participation differs from those understood by donors – as Swidler and Watkins argue with respect to Malawians working on AIDS projects. 138 This understanding is important because it is well established that donor–local agent relationships tend to be personalised and dynamic. 139 Health systems need to be understood as relational, and the fundamental challenges are relationship problems. 140
Conclusion
Over the past decade, there has been mounting criticism of Western hegemony within the discipline of IR and the marginalisation of non-Western theory. 141 The necessity for re-orientating and redefining IR 142 is brought into stark focus when we consider the realm of global health. 143 As contemporary health crises emerge as issues of ‘high politics’, 144 they lay bare some of the limitations for understanding and responding to them. The epicentres of these crises lie outside of the West with HIV in Southern Africa, pandemic influenza in South East Asia, Ebola in West Africa and Zika in South America. This highlights the necessity to better understand those regions and actors that are marginalised, particularly the African continent and African actors. As Acharya and Buzan argue, IR theory can be ‘enriched with the addition of more voices’ and ‘periphery perspectives’. 145 So what can we learn about diplomacy from African spaces, actors and forms of diplomacy?
Multi-stakeholder health diplomacy is useful for extending our understanding of the complexity of health diplomacy beyond monolithic state and donor actors to the crucial role of other actors – including donors, NGOs, private philanthropists and private-sector health providers; and the individual technical advisors, programme managers and consultants working within these organisations. It is significant in African contexts such as Malawi where there is acute dependency on resources and health is an important point of leverage to exert influence, which can readily be framed as benevolent. The contribution here is through developing the concept of shadow diplomacy – the informal networks and channels of influence that run parallel to, but are not recognised as part of, formal diplomacy. This is useful for understanding how health is an effective point of leverage giving rise to informal and subversive manifestations of diplomacy in the shadows, not only for external powers but also African political elites.
Shadow diplomacy enables us to understand some of the nuances of how Western actors strengthen and conceal their continued power through the use of rhetoric while ‘leading from behind’, embedding their external technical advisors within government ministries such that diplomacy comes from within and the duplicitous use of diplomacy processes and instruments to extend their control. Furthermore, shadow diplomacy locates Africans as actors in diplomacy: the shadows also benefit African political elites as they leverage their dependency to subvert the global power structures. African political elites develop diverse agentic behaviours that include extraverting health issues, playing off the donors against one another, strengthening their negotiating position through ‘evidence based diplomacy’ and subverting the health system for private gain. As such, donors aim to impose external agendas on African societies through health assistance, and yet, although this leads to change, this is not necessarily in the ways that were intended by the donors. 146
Shadow diplomacy disrupts the external/internal binary understanding of the relationship between international donors and African states. The locus of diplomacy has shifted from between these actors to negotiations within donors, the state and other actors. Critically, these are not coherent, monolithic entities but instead comprise of complex individuals with multi-faceted motivations and divided loyalties. These actors may have been produced as rational, responsible individuals but this can have unintended consequences and they exhibit agency despite the structural constraints within which they operate. This highlights the importance of future research into the complex relations between these heterogeneous global health actors.
Footnotes
Acknowledgements
The author would like to thank Alexander Beresford, Sophie Harman, the editorial team of International Relations, the anonymous reviewers and the School of Politics and International Studies (POLIS) reading group at the University of Leeds for feedback on this article.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The author received financial support from the POLIS ‘Strategic Research Investment Fund’ (SRIF) at the University of Leeds for the research of this article.