GIZ Professional Forum Health & Social Protection, 13-14 January 2011

Title page: Forum Report

'Health and Social Protection: The Political Economy Dimension'

Dates: 13 & 14 January 2011
Place: Gustav-Stresemann-Institute, Bonn

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The objectives of the forum are:

  • Explore concept and practical relevance of a political economy perspective for sector reform, improved services and better outcomes;
  • Discuss different types of analysis, ways of engagement at policy level and operational entry points in the social sectors, incl. supply and demand side;
  • Exchange on case examples and experience from participants, on the lessons learned so far with political economy approaches;
  • Reflect on how to strengthen GIZ’s and GDC’s contribution by better defining its role in the political context of its work, and how to develop, adapt and improve its tools accordingly.

Main topics and guiding questions

This forum will examine the three main topics that are listed below. For each of them, we have formulated guiding questions that will guide the respective sessions and the group work.

1. The political economy of reform processes in partner countries

  • From a political economy perspective, how can we understand reform processes in health and social protection in partner countries?
  • Which forces and actors promote them, which resist them, and why?
  • How can these issues be addressed in the context of policy dialogue?
  • Which incentives/ disincentives within GDC constrain policy dialogue and an effective response to political economy challenges?

2. The relevance of political economy analysis for the approaches of German Development Cooperation

  • From a political economy perspective, how do GDC's health and social protection approaches work - in theory and in practice?
  • How do these approaches impact on the interests, resources and power relations of the different stakeholders?
  • How could we better take account of this in our work?

3. Political economy from the users' perspective

  • From a political economy perspective, how do approaches work that strengthen the power of users and citizens - in theory and in practice?
  • How do these approaches impact on the interests, resources and power relations of the different stakeholders?
  • How could we better take account of this in our work?


Over the past few years political economy issues have come increasingly to the forefront of the discourse within the international community. The way how political power is secured and exercised in partner countries is regarded as a key issue for understanding how development processes evolve, and how incentives are generated which enable or block development oriented behaviour of actors. Also, development partners have been recognized to be political actors who - by providing resources to selected groups - change the dynamics of the political process.

This type of political thinking also influenced the ‘good governance’ agenda. Newer types of governance analysis place greater emphasis on understanding the core governance issues in a country, such as interests, resources and power of actors and their relations. They adopt incremental approaches in fostering governance, thus focusing more on ‘good enough governance’ and on the change feasible under given political circumstances. Thus, newer approaches to governance take into account political economy issues.

More recently, there is growing recognition that political economy is also an important dimension of sector work, both at policy and operational levels. It is crucial for the articulation of policy goals, their implementation and the outcomes of a particular sector.

Progress in pro-poor health reform has not been encouraging. The analysis shows that this is only partly a function of the technical complexities but rather one of specific political economy issues, in particular the asymmetries of power and the particular incentives and disincentives facing the winners and losers, including service providers, politicians and the bureaucrats who often dominate policy-making (Batley, 2004).

With regard to public service delivery for the poor, the WDR 2004 drew attention to the accountability relationships between citizen, policy makers and service providers. Re-aligning these accountability relationships has since been a popular operational entry point for better governance and service delivery. Approaches to strengthen the demand side of governance, the ability of citizens and clients to demand better policies from their governments and better services from their service providers have increasingly come into focus. In Uganda for example, communities routinely monitor the service quality of their health centers and give feedback to the staff. This initiative was evaluated with ‘robust’ methods. The results indicate that this intervention did not only significantly improve the quality but also the results of the health services that were delivered (Björkmann, Svensson et. al. 2007).

With the change in aid modalities towards SWAP, PBA and budget support, the spectrum for working on governance issues has widened, ranging from high-level political dialogue, conditionalities, investments in better institutions or capacity development of demand side actors. Donors and think tanks have developed a whole arsenal of methodologies and instruments to guide this work.

Still, there are many open questions: How can donors meaningfully and without intrusion engage with partner countries on these issues? How do we, working in a partner country as an advisor of an international development organisation, act in a politically intelligent way? Which entry points to chose for a politically informed sector programme: sector policy reform, supply side interventions or strengthening citizens’ demand for good governance? Where is the space for improvement within the given circumstances and which rhythm of change should be adopted?

As for many other actors, the potentials and limits of the the political economy paradigm as well as the newer governance frameworks are not yet fully explored for German DC. To date, there are a number of promising experiences and practitioners claim that they have always managed the political dimension of their work. However, in the fields of health and social protection, GDC has not yet engaged in a systematic reflection on the relevant terminology, frameworks, assessment methodologies and intervention areas.

This is why the forthcoming professional forum on political economy shall provide an opportunity for exchanging views and experiences for GIZ and German DC more broadly.

Programme Overview and Keynote Presenters/Discussants

Thursday, 13 January

8:30 – 9:00


9:00 – 9:30

Welcome and opening Franz von Roenne, Head of Section Health, GIZ Matthias Rompel, Head of Section Social Protection, GIZ

9:30 – 11:00

Plenary session 1: The political economy of reform processes in partner countries

Keynotes: Alex Duncan, Principal, The Policy Practice; Senior Associate Member, African Studies Centre, University of Oxford: "Making development cooperation work better by using political economy analysis. What has been done and what have we learned?" Nadia Molenaers, Lecturer at the University of Antwerp at the Institute of Development Policy and Management: "Coping with Clashes: A Political Economy Perspective on Policy Dialogue"

Discussants: Joachim Schmitt, Health and Population Policy Division, BMZ Klaus Hornetz, GIZ Kenya

Panel discussion and plenary discussion

11:00 – 11:30

Tea break

11:30 – 13:00

Working Groups

  • Javaid Khan: Hospital Autonomy Reforms in Pakistan: Why more than legislation is required for alternative management mechanisms to improve hospitals
  • Klaus Hornetz: Social Health Insurance Legislation in Kenya: Why did it not go through?
  • Franz von Roenne: Social Protection Reform in Indonesia: What is holding the process?
  • Elena Zanardi: The challenges of decentralisation in Malawi's health sector

13:00 – 14:00

Lunch break

14:00 – 15:00

Plenary session 2: The relevance of political economy analysis for the approaches of German Development Cooperation

Keynotes: Jean Bossuyt, Head of Strategy of the European Centre for Development Policy Management (ECPDM): "Deepening governance and political economy analysis Sector Operations: The EC Governance Analysis Framework" Inke Mathauer, Health Systems Development Specialist, WHO: "Political economy issues and systems capacity development - illustrated for health financing" Andreas Kalk, GIZ, Cameroon: "About pilots and their destiny"

Questions & Answers

15:00 – 16:30

Working Groups

  • Alexandra Plüschke: GIZ’s approach to Human Resources Development in the health sector: theory and practice
  • Susanne Lein: Conflicting interests in a socialist market economy – the case of capacity development in health in Vietnam
  • Nishant Jain: Smart Cards for Health Expenses/RSBY health insurance in India: the challenges of implementation
  • Bergis Schmidt-Ehry/Meinolf Kuper/Gerd Eppel: Special Fonds in Cameroon: which political conditions have ensured their success?

16:30 – 17:00

Tea Break

17:00 – 18:00

Conclusion of the day

Panel Discussion: Nishant Jain, GIZ, India Alexandra Plüschke, GIZ, Pakistan Jean Bossuyt, ECPDM Nadia Molenaers, University of Antwerp Inke Mathauer, WHO


Meeting in front of GSI for joint walk to restaurant


Joint dinner-buffet at the  "Rheingarten" restaurant

Welcome address by Joachim Prey, Deputy Director General, Planning and Development Department, GIZ

Friday, 14 January

9:00 – 9.15

Review of day 1, presented by selected participants

9.15 – 10.15

Plenary Session 3: Political economy from the user’s perspective

Keynotes: Kirsten Havemann, DANIDA, Mozambique: "Bridging the divide, using Social Accountability as entry point for improving Health" Alain Ahawo-Komi, GIZ, Guinea: "An analysis of two examples from Cameroon: - The Aunties as sexual health Advocates - Micro Health Insurance (MHI) to improve quality of care"

Questions & Answers

10.15 – 10.45

Tea Break

10:45 – 11:45

Working Groups

  • Franz v. Roenne: Community Based Health Insurance in Guinea
  • Kirsten Havemann: Empowering communities for better nutrition and health in Kenya
  • Chhom Rada: Patients Rights Charter in Cambodia
  • Ute Jugert: Worker/Citizens Facilitation Centers in India

11:45 – 13:00

Buzz groups: Participants reflect on key lessons learnt, challenges and the way forward

13:00 – 14:00

Lunch break

14:00 – 15.30

Plenary session 4: How can a political economy perspective inform our work? What does it mean for our roles and approaches in technical cooperation?

Talk show: Simon Koppers, Division Head, Health and Population Policy, BMZ Alex Duncan, Principal, The Policy Practice, Oxford Matthias Rompel, Head of Section Social Protection, GIZ Franz v. Roenne, Head of Section Health, GIZ

Questions & Answers

15:30 – 16:00

Closing remarks

Ralf-Matthias Mohs, Division Head, Millennium Development Goals, Poverty Reduction, Social Protection, Sectoral and Thematic Policies, BMZ Hedwig Petry, Division Head, Health, Education & Social Protection, GIZ

Mr Alex Duncan; Principal, The Policy Practice; Senior Associate Member, African Studies Centre, University of Oxford. Alex Duncan began his career as an agricultural economist, but much of his work since 2002 has been on the political economy of development.  He has had a particular long-term interest in eastern and southern Africa, though in recent years he has also worked in west Africa and south Asia.  His work has included policy and institutional analyses of subjects including governance, public expenditure management, strengthening the private sector and markets, agriculture, rural development, land reform and food security.  Inter alia, he has been closely involved with initial thinking on the ‘Drivers of Change’ approach to understanding development issues, and has been involved in applying it in several countries of Asia and Africa. He is by origin South African, finishing his education at Oxford and Reading Universities.  He has worked for FAO, the World Bank, and Oxford University and as a consultant, living mainly in the UK, but also in southern Sudan and Lesotho.  He is a Principal of the Policy Practice, a Senior Research Associate of the African Studies Centre in Oxford, and a Senior Associate Member of St. Antony’s College, Oxford.  He is a trustee of Save the Children UK.


Dr. Nadia Molenaers, PhD in political science. Lecturer at the University of Antwerp at the Institute of Development Policy and Management. She teaches ‘Politics of Aid’, ‘Politics of Development’, ‘Governance’. Her research focuses on Aid under the New Aid Approach (Paris Declaration and AAA). More particularly she has worked/published on civil society participation in PRSPs, the EC Governance incentive tranche, conditionalities, Northern NGOs and the Paris Declaration, Budget Support and political crisis, Policy Dialogue.


Jean Bossuyt (1959), a Belgian national, is Head of Strategy of the European Centre for Development Policy Management (ECDPM), an independent foundation, based in Maastricht and Brussels, which seeks to play the role of an ‘honest broker’ role in ACP-EU cooperation processes. For the last twenty years, he has facilitated dialogue between ACP-EU actors and done extensive practical (field) research on a variety of topics such as the political dimensions of partnership, (sector) governance, civil society development, decentralisation processes and recently on issues related to domestic accountability. He has been involved in programmes of institutional development, including with the African Union Commission. He has been team leader of several major evaluations, including on EC support to governance (2006) and on the use of civil society as an EC aid delivery channel (2008). He has published extensively on these topics and been involved in training seminars both in Europe and in Africa.  Prior to joining ECDPM, he worked at the Centre for Third World Studies at the University of Ghent (Belgium), the Brussels Delegation of the UNHCR and as a civil servant in the Belgian Parliament.


Dr. Inke Mathauer is a health systems development specialist, holding a MSc and PhD from the London School of Economics. She is working in the Department of Health Systems Financing of the World Health Organization (WHO) in Geneva. Her work involves health financing policy advice to ministries of health, tool development and conceptual work on health financing performance and the role of organizations and institutions, as well as social health insurance financial/technical feasibility assessments. Her particular interest lies in health financing system reviews with an institutional-organizational focus. Prior to WHO, she worked several years for the German Technical Cooperation (GTZ) both at  Headquarters and in Kenya, where she headed the quality management as well as health financing project activities of the GTZ supported health sector program. She provided policy and technical advice to the Kenyan ministry of health and the National Hospital Insurance Fund. Inke Mathauer has also undertaken several institutional analysis consultancies for the World Bank in the field of health and social protection. Earlier, she worked in Benin and Uganda at local and district level. She has published articles and written book chapters on various health systems and health financing issues.


Dr. Kirsten Havemann is a social and public health specialist with interest and expertise in health and social sector analysis, design and systems development. She has extensive knowledge and skills in participatory and action oriented research and operations. After her more than 20 years of field experience in Africa and Asia where she held substantive posts, such as Senior Adviser for the Danish Government, she moved to the World Bank’s Social Development Department working on social accountability. She thereafter worked for WHO as governance research officer and now work for the Danish Government as Senior Adviser for Health, currently posted to Maputo in Mozambique.


Joachim Schmitt: Master Degree in Political and Administrative Science; Joined BMZ in 1996; Until 2000 in charge for the "political dimensions of German development cooperation" within the General Policy Division; 2005 until 2008: Counsellor for Development Cooperation at the German Embassy in Accra/Ghana, coordination German development cooperation activities in Ghana as well as co-chairing the Multi-Donor Budget Support Group in 2007/2208; Since 2009 division for health and population policy in BMZ, in charge especially of MDG 4 and 5, the right to health and population dynamics. I have always been very interested in factors driving or hampering the development of societies and do believe that official development cooperation still too often falls short of taking all of these into account.


Dr. Klaus J Hornetz is the current Sector Coordinator of the Kenyan - German Development Cooperation in Health Care and Program Leader of the GTZ Health Sector Programme Kenya. A medical doctor with a postgraduate degree in health social policy, planning and financing he has many years of experience in public health and health systems development, in the areas of Social Health protection, Health and Social Systems Policy. Klaus H. has worked as manager and advisor in various position for German Federal and State Governments, multilateral donors, the German Development Bank (KFW) and GTZ on short- and longer-term missions both in the German health care system and abroad. His international experience covers about 40 countries in Europe, Middle East / Asia, Africa, Latin America and the Caribbean, with a particular focus on Africa. Most of his assignments took place at the interface between health systems and the political level.   During his tenure in Kenya Klaus H. initiated and supported a number of innovations and initiatives aimed at strengthening health systems and improving equitable access to good quality healthcare. Among these initiatives include the formulation of the health financing strategy, the establishment of the Health Network of NGOs in Kenya (HENNET) and the Private–for-Profit Health Care Consortium.   Klaus Hornetz is currently serving as the chair of the Development Partners in Health in Kenya (DPHK) and is representing development partners in Kenya in the focal areas of health Financing, Public Financial Management and Sexual and Reproductive Health.


Dr. Simon Koppers: Bundesministerium für wirtschaftliche Zusammenarbeit und Entwicklung - Federal Ministry for Economic Cooperation and Development (BMZ); Head of Division Education, Health, Population Policies. - Economics at University of Bonn and UC Berkeley; - Ph.D. 1994, University of Bonn; - Feb. 1994 - Nov. 1996 KfW, Project Manager, mainly on Central Africa; - Dec. 1996 - March 2009 BMZ, German Federal Ministry for Economic Cooperation and Development, Advisor (West Africa; Evaluation; Controlling; Organisation; Infrastructure; Southern Africa); - April 2009 BMZ, Head of Division; Health, Population Policies.


Dr. Andreas Kalk: General and orthopedic surgeon in Germany,  Mozambique and Nigeria 1985-1997; Public Health studies in Liverpool, than Medical Director of German Leprosy Relief 1990-2002; Health Sector Coordinator German Cooperation in Rwanda 2003-07; Head of GTZ Health Sector 2008/09; since 2009 Regional Director GIZ in Yaoundé, responsible for TC with Cameroon, Tchad, CAR, Gabon and S. Tomé. Particular interest in health financing.

Background Reading

1. The political economy of reform processes in partner countries

Policy Dialogue under the New Aid Approach: Which Role for Medium-sized Donors ?

Theoretical Reflections and Views from the Field by Nadia Molenaers and Robrecht Renard
Institute of Development Policy and Management, June 2008 Adobe PDF file (44 pp. 575 kB)

Good governance, aid modalities and poverty reduction From better theory to better practice
The Advisory Board for Irish Aid, 2008 Adobe PDf file (76 pp. 760 kB)

Overseas Development Institute (2009): Analysing governance and political economy in sectors Workshop Report ODI 2009 Booth, D. (2006): Drivers of Change and Development in Malawi Adobe PDF file (93 pp. 992 kB) Kossof, S., Booth, D. (2009): Uganda roads. A problem-focused political economy exercise using a ‘layered’ approach. Presentation to Joint Donor Workshop

2. The relevance of political economy analysis for the approaches of German Development Cooperation

Mathauer, I., GTZ (2009): Capacity Development in the Health Sector: Better Health through healthy Governance Adobe PDF file (32 pp. 2.9 MB)

Leadership and effective government Chapter 5: World Health Report 2008 - Now more than ever pp. 81 - 98 World Health Organization, Geneva Full report - Adobe PDF file (148 pp. 3.2 MB)

3. Political economy from the users' perspective

Jaffré, Y. et Olivier de Sardan, J.-P. (2003):  Une médicine inhospitalière. Les difficiles relations entre soignants et soignés dans cinq capitales d’Afrique de l’Ouest Moore, M. and Unsworth, S. (2010): An upside down view of governance Bangura, S. (2010): Rethinking Accountability in Africa - a practitioner's perspective


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