African health diplomacy: obscuring power and leveraging dependency through shadow diplomacy

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 discussio ns, 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 comprised of complex individuals with multi-faceted motivations and divided loyalties. 1 The author would like to thank Alexander Beresford, Sophie Harman, the editorial team of IR, the anonymous reviewers and the POLIS reading group at the University of Leeds for feedback on this article.

Stakeholder engagement in the health policy process in a low income country: a qualitative study of stakeholder perceptions of the challenges to effective inclusion in Malawi

“…Yet, it is common in policy consultations for some stakeholders to have greater power, knowledge and resources to affect the policy content, particularly in LMICs with highly centralised policy-making and where a significant proportion of the national budget often comes from other national governments or donors [ 1 , 2 , 22 , 23 ]. The donor dependency of the Malawian health sector means that through donor-government partnerships international development agencies can ‘lead from behind’ to ensure national policies and initiatives align with their own preferences [ 24 ]. It was suggested in our study and in literature on high and low income countries that the extent of the influence possible in centralised policy-making is relative to the financial contribution made by the stakeholder [ 25 – 27 ].…”

Global health diplomacy—reconstructing power and governance

“…The concept of shadow diplomacy came from criticism of Western hegemony within the discipline of international relations, and suggests how international donors obscure structural power by subtly directing health initiatives, processes, and instruments. 71 More analyses of global health diplomacy from these critical perspectives, especially from a decolonisation perspective in international relations that puts into question the whole concept of global health, would help make these power relations explicit.

Examples of key international relations concepts applied to the analysis of global health diplomacy Sovereignty 55 State sovereignty signifies the existence of an independent political community that has juridical authority over its territory.

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Public Servants as Development Brokers: The Shaping of INGOs’ Reducing Teenage Pregnancy Projects in Malawi’s Primary Education Sector

“…The repeated shifting between aid modalities has not improved the situation. Withdrawals and redirection of funds have resulted in public sector funding crises (Anderson 2018;Anderson and Patterson 2017;Dionne 2018:69;Khunga 2018). It is within this context that the RTP project is implemented.…”

“…Robinson (2017) argues that Malawi's patterns of response to population control, HIV, and maternal mortality are strikingly similar: relatively late response and demonstrating the capacity to implement donor-supported technical solutions. However, as Anderson (2018) shows for Malawi, Western donors have considerable influence on national policies and priorities; but try to conceal their influence through "shadow diplomacy". He ruled through an ideology of unity, loyalty, obedience and discipline, and exiled, imprisoned or killed people who opposed his regime, including many intellectuals who could have provided technical leadership to the ministries or played a role in building an active civil society (Robinson 2017).…”