When a low-income country emerges from a devastating crisis like Ebola, how do you go about rebuilding services? How do you ensure that citizens’ urgent needs are met — that children catch up on lost schooling, that sick people get the treatment they require, that water sources are safe — while simultaneously ensuring that, at some point, international assistance will no longer be required for this purpose?
Enter capacity building, a long-time bastion of development policy and practice.
Capacity building is about using foreign aid to strengthen the ability of recipient governments to do stuff better. That might be service delivery, law enforcement, security provision or private sector development, to name a few. At its most basic, capacity building is — or at least should be — about development agencies doing themselves out of a job.
The problem is, that doesn’t look like it’s going to happen any time soon.
Some argue that capacity building has the potential to drive social emancipation, but it is often approached in a narrow, reductive and overly technical way. In a new report from the Secure Livelihoods Research Consortium, we argue that this limited operationalization of capacity support helps account for why the Ebola virus was so hard to control in Sierra Leone — just as other public health problems, like undernutrition, have been for many years.
Drawing on more than 130 interviews since 2013, our analysis suggests that external capacity support to the country’s health sector has ignored (at least) four important issues. In our report we call these blind spots, because they refer to the areas dominant capacity building models fail to see. These range from the complexities of behavior change programming and the messy realities of life in a plural health system, to the all-important connections between organizations and the question of whether communities actually trust the formal health service.
Taken together, these four blind spots suggest there have been limited attempts to work at the systems level — and that’s what often prevents quality health care from emerging.
The Ebola crisis is an opportunity for better health systems strengthening, not only in West Africa, but around the world. Several major aid agencies have called for greater investments in health. We agree. But we also think that the dominant approaches to capacity building need to change.
As things stand, they are failing to reflect the messy realities of what it means to strengthen a health system — and failing to understand what it takes to deliver quality services in a sustained way.
Here are three key ideas for how capacity building might smarten up:
1. Drop the training fetish.
“Training, training, training … how much training does one person need?”
These were the words told to us back in 2013 by a health worker based in Freetown, frustrated with the amount of resources funneled into training programs and the lackluster returns they generated. Too often, capacity building is synonymous with training. It’s easy to deliver, ticks the right boxes, and has observable outputs.
But so much evidence suggests that, when not properly conducted or followed up on, it just doesn’t work very well (and not just in health). This is about systems: What’s the point in following instructions when the right incentives aren’t in place?
2. Work with nongovernmental providers.
Whether you like it or not, governments aren’t the only provider of services — and they’re not always the first port-of-call for users.
Part of what it means to think and work “systemically” is understanding how a system actually works on-the-ground. There are several health providers beyond the government in Sierra Leone, the legitimacy of whom varies locally. If those providing capacity support are interested in shaping community behavior, then getting a clearer sense of who the locally influential providers are is a must.
3. Focus on the invisible dimensions of capacity.
Being able to get stuff done depends on things you can’t always see. Technical know-how, resources and equipment all matter for a functioning health system. But so does the manner in which a nurse relates to patients, the influencing power a district nutritionist may (or may not) have over the annual budget, and the degree to which a government prioritizes health sector development.
Issues like this are harder to see, but no less important. The funders and implementers of capacity building need to find ways of working that enable them to build toward outcomes that aren’t always obviously measurable. The delivery of quality health care, not just in West Africa’s Ebola-affected countries but around the world, depends on it.