Development assistance, donor-recipient dynamic, and domestic policy: a case study of two health interventions supported by World Bank-UK and Global Fund in China.

Background: This study views sustainability after the exit of development assistance for health (DAH) as a shared responsibility between donors and recipients and sees transitioning DAH-supported interventions into domestic health policy as a pathway to this sustainability. It aims to uncover and understand the reemergent aspects of the donor-recipient dynamic in DAH and how they contribute to formulating domestic health policy and post-DAH sustainability.

Methods: We conducted a case study on two DAH-supported interventions: medical financial assistance in the Basic Health Services Project supported by the World Bank and UK (1998-2007) and civil society engagement in the HIV/AIDS Rolling Continuation Channel supported by the Global Fund (2010-2013) in China. From December 2021 to December 2022, we analyzed 129 documents and interviewed 46 key informants. Our data collection and coding were guided by a conceptual framework based on Walt and Gilson's health policy analysis model and the World Health Organization's health system building blocks. We used process tracing for analysis.

Results: According to the collected data, our case study identified three reemergent, interrelated aspects of donor-recipient dynamics: different preferences and compromise, partnership dialogues, and responsiveness to the changing context. In the case of medical financial assistance, the dynamic was characterized by long-term commitment to addressing local needs, on-site mutual learning and understanding, and local expertise cultivation and knowledge generation, enabling proactive responses to the changing context. In contrast, the dynamic in the case of HIV/AIDS civil society engagement marginalized genuine civil society engagement, lacked sufficient dialogue, and exhibited a passive response to the context. These differences led to varying outcomes in transnational policy diffusion and sustainability of DAH-supported interventions between the cases.

Conclusions: Given the similarities in potential alternative factors observed in the two cases, we emphasize the significance of the donor-recipient dynamic in transnational policy diffusion through DAH. The study implies that achieving post-DAH sustainability requires a balance between donor priorities and recipient ownership to address local needs, partnership dialogues for mutual understanding and learning, and collaborative international-domestic expert partnerships to identify and respond to contextual enablers and barriers.