La indignitas

From the previous chapters, it is clear that measuring country ownership and attempting to link it health outcomes, comes with challenges. These challenges ask two fundamental questions: is there value in measuring country ownership and what do we expect this ownership to do or affect?

Albert Einstein once said “Not everything that can be counted counts and not everything that counts can be counted”. This study establishes that country ownership ‘counts’ and that even though there remain questions, a credible attempt at ‘counting’ country ownership in Lofa

County was undertaken. What does this attempt at accounting for country ownership tell us? It tells us five things.

First, it tells us measurement is possible. It is possible in very structured and clearly defined circumstances. The value of this exercise, of measuring country ownership, is the clarity of description and the limited measurement scope. Does this mean that where there is no clarity or limitation there can be no measurement? No it does not. As with any measurement activity, lack of clarity makes the exercise challenging. Researchers usually have to take a step back, discuss with stakeholders their objectives before the measurement activity can begin. It is no different with measuring country ownership.

Second, this measurement exercise unmistakably demonstrated the ‘capacity dilemma’ that came from the literature. The capacity to own the PBF scheme and how capacity is applied

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to the PBF scheme to engender greater ownership is a multifaceted notion. What this capacity dilemma does as well is confirm the essential nature of all four dimensions of the country ownership. Capacity is needed for relationships, governance, communication and feedback and to implement the initiative. Further, relationships, governance, communication and feedback are all individually affecting capacity and as a collective. Therefore, when discussing capacity in the context of country ownership, it is important to see it as one of the dimensions of country

ownership, while bearing in mind its role as facilitator of country ownership.

Third, the measurement of country ownership raises the question of the usefulness of the decision rule for determining country ownership. For study purposes, dichotomizing country ownership was done to provide a frame for the theory building exercise of determining

intervening variables for linking country ownership of PBF scheme to selected health outcomes. But is dichotomizing country ownership into ‘exists’ or ‘doesn’t exist’ useful for stakeholders to take action? Would it not be better to have a range or continuum where stakeholders can gauge progress and continue to refine their actions and interventions to improve health outcomes? It seems to be more suitable, in future, to describe an aid funded initiative as having different levels of country ownership and focus on actions to move stakeholders from one level to the next.

Fourth, the measurement approach assumed that only a small number of people knew enough about the PBF scheme to respond to the statements in the tool and to think though the nuances of how country ownership of the PBF scheme influences health outcomes. This assumption was correct. But should conclusions about institutional influences be drawn from small number of actors within each institution? If the actors are well positioned, know the initiative and can see many of the angles of how the initiative functions, why not? Who but the key stakeholders have the knowledge required to draw these conclusions? Are there other

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perspectives that could be sought from others in the same institutions? Would these perspectives be an added value or more voices? For any health funded initiative such as a PBF scheme, there will be a small number of people who have detailed knowledge about the initiative. Their perspectives on institutional influences of country ownership are appropriate for drawing actionable conclusions.

Fifth, this measurement exercise tells us it is important to accept unsurprising findings. Certain ‘truths’ will hold; donors will believe they are participatory and recipients will believe the power is imbalanced, recipients will believe they are being responsive and accommodating and donors will believe further accommodations should be made. That the measurement approach confirms these ‘truths’, does not diminish the value of the tool, it instead adds to the richness of the conversations that result.

One final thought. The assumption of this study and much of the literature is that country ownership has a connection to or influences development outcomes, in this case health

outcomes. This study demonstrates that the description of country ownership considers many of the process elements that influence health outcomes. But are outcomes a step removed in the results chain and we should instead focus on process outputs? Is it reasonable to expect the donor and recipients’ interactions and what those interactions produce to directly affect the knowledge and behaviors of targeted populations? Or is the effect more distal? Does it matter if the

influence is distal or proximal in an exercise that is qualitative and aimed at generating action oriented conversations? What value would it add if it were one or the other? It seems that the work of thinking on the influences of country ownership has just begun and while further thought is needed, this study makes a contribution to both the frame and content of that discussion.

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