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INTRODUCTION
Monitoring the effectiveness of official development assistance (ODA) is the only way to determine the influence of aid on achieving development goals. Although this is a basic concept, it only became a focus of the international community in the late 20th century (1). Previously aid was often uncoordinated, based on the self-interests of donor countries and administered in a manner that undermined the effectiveness of recipient country systems and capacity (1). In 2005 the Paris Declaration on Aid Effectiveness established five principles for making aid more effective and holding partners accountable for their commitments (Table 1) (2). The declaration was endorsed by over 100 signatories and established indictors for monitoring aid effectiveness. The Republic of Korea (ROK) is an endorser of the declaration and has remained committed to the principles in concept, but has struggled to achieve them in reality.
At the time of endorsing the Paris Declaration on Aid Effectiveness, the ROK was in a period of great transition. Only five years prior, in the year 2000, the ROK was removed for the final time from the recipient list of the Organization for Econimic Cooperation and Development (OECD) Development Assistance Committee (OECD-DAC) (3). The ROK quickly developed into a donor country and in 2010 it became the 24th member of the OECD-DAC, marking the first time that a country transitioned from aid recipient to DAC member since the OECD was established in 1961 (45). However, the rapid progress from recipient to donor came with inherent challenges. Around the time of its induction in DAC, several international evaluations identified the ROK as being one of the weakest countries at providing good aid. For example, a 2010 report by the Center for Global Development found that the ROK ranked either last or second to last among DAC member countries in the following donor dimensions: maximizing efficiency, reducing burden, and transparency and learning (6). Additionally, the 2011 Survey on Monitoring the Paris Declaration found that the ROK was one of only two countries in the analysis that had not achieved any of the Paris Declaration on Aid Effectiveness donor targets (78).
To overcome these negative findings, the ROK Prime Minister's Office (PMO) initiated a review of the country's national system for administering ODA for health. Following a call for proposals, a research team at Seoul National University College of Medicine was selected to conduct an external review of the national system. This manuscript reports the results of one component of the review, a survey that was administered to government officials based in partner countries' Ministries of Health (MOH). The survey sought to evaluate respondents' perspectives about ROK health ODA governance based on principles of the Paris Declaration on Aid Effectiveness.
MATERIALS AND METHODS
A survey was conducted to assess partner countries' perception of the ROK's health ODA governance. The survey was administered to government officials based in the partner countries' MOH and the target respondents were identified with help from two ROK agencies that administer health ODA. The ROK agencies were made aware of the purpose of the survey and were informed that the survey was part of an evaluation being conducted by the ROK's PMO. The agencies were asked to submit the names and email addresses of their contact person at every partner MOH. In total, 29 email addresses were received. Two of the email addresses were determined inactive and 1 email address was received twice, once from each agency; resulting in a final list of 26 potential respondents from 22 countries (Table 2).
The survey was conducted anonymously using an online survey program. Potential respondents were informed about the survey through an advanced notice email on 24 October 2013. This email also helped to test the validity of the email addresses. The survey link was sent on 25 October 2013, reminder emails were sent on 29 and 31 October 2013 and the survey closed on 1 November 2013. Because some countries work with both ROK agencies, respondents were asked to complete the survey separately for each agency that they work with and the survey settings were customized so that individuals could complete the survey more than one time. During the course of the survey, some individuals reported that they did not have sufficient computing capabilities to access the survey via the survey website. Because of this, all individuals were also given the opportunity to complete the survey through a fillable portable document format (pdf) form that could be opened directly from their email. The respondents who chose this method then emailed their completed forms back to a researcher in the ROK and the researcher entered the data into the survey system.
The survey questions were developed based on the Paris Declaration Partnership Commitments of: Ownership, Alignment, Harmonization, Managing for Results, and Mutual Accountability. The authors of this study worked collaboratively to develop relevant questions and adapted several questions from the United Nation's survey of program country governments (9).
RESULTS
The total response rate was 13 responses out of 26 individuals who received the email request (50%). The regional disbursement of respondents was: 54% South-Eastern Asia, 31% Africa, 8% Central Asia, and 8% Western Asia.
Ownership
All respondents reported that their country has a national system for collecting vital health statistics and 92% of respondents reported that their country has a strategy for health. When asked about the average frequency of meetings with someone from the ROK agency 58% reported one time every month, 8% reported one time every other month (total of 6 times per year), and 33% reported one time every quarter (total of 4 times per year). Respondents were also asked about the supportiveness of the ROK agency when their country wants to make a change in an area that is supported by ROK health aid and the highest percentage reported very supportive (Table 3).
Alignment
When asked about the activities of the ROK agency and their country's development needs, the majority of respondents reported closely aligned (Table 3). Respondents were then asked about change in alignment over the past four years and the majority reported became somewhat more relevant (Table 3). Respondents were also asked questions about the types of support that they actually receive from the ROK agency and the types of support that they would like to receive from the ROK agency. As shown in (Fig. 1), partner countries would like to receive more support from the ROK in all areas except providing equipment, vehicles, supplies and services.
Questions about the ROK agency's operation within the country were also asked and 73% of respondents reported that the ROK agency operates well within their country's policies and procedures, 100% reported that the ROK agency meets the commitments it agreed to in the memorandum of understanding it signed, and 90% reported that the ROK agency's commitments match with its disbursements. The ROK agency's use of partner country national systems was also assessed but a less positive result was identified, as shown in (Table 3). Additionally, when asked if funding from the Korean agency is predictable, the greatest percentage of respondents selected somewhat agree (Table 3). Respondents also reported that they collaborate in a range of activities with the ROK agency, in which the most common included planning and monitoring (Fig. 2).
Harmonization
Respondents were asked one question related to harmonization and 63% reported that the ROK agency coordinates well with other agencies working in the country (18% reported no, 9% reported I don't know, and 9% reported not applicable).
Managing for results
Respondents were provided a list of items and were asked to select up to three that the ROK agency should work on to become more effective in their country. The responses are as follows: 82% reported improve the design of programs and projects, 64% reported become more engaged in program-based approaches, including sector-wide approaches (SWAPs), 46% reported make better use of results-based methods, 46% reported improve the monitoring and evaluation, 36% reported focus on areas where South Korea has a clear comparative advantage, and 0% reported do fewer things.
Mutual accountability
Questions about mutual accountability were asked and 70% of respondents reported that the Korean agency follows the MOU commitment schedule, 30% reported that it partially follows the MOU commitment schedule, and 0% reported that it does not follow the MOU commitment schedule. Respondents were also asked if the Korean agency uses funds carefully and avoids waste and 91% strongly agree (Table 3). In regard to funding accountability activities that take place between the partner country and the ROK agency, 11% reported auditing, 67% reported training or workshops, and 44% reported development of policies and/or procedures. Lastly, respondents were asked if the ROK agency has an exit strategy for their country: 27% reported yes, 18% reported no, and 55% reported I don't know.
DISCUSSION
The ROK has a remarkable development history, including its status as the first country to transition from aid recipient to DAC member (5). However, the country has struggled to achieve internationally accepted agreements related to aid effectiveness and several international evaluations have identified the ROK as being one of the weakest DAC countries at providing good aid. In response, the ROK Prime Minister's Office commissioned an evaluation to: 1) assess the ROK's health ODA system and 2) recommend interventions for improvement. As one of the component of the evaluation, this study uncovered some areas that the ROK should strive to improve based on the internationally-accepted Paris Declaration on Aid Effectiveness.
According to the Paris Declaration on Aid Effectiveness, partner countries should have effective leadership and coordination of their own development policies, strategies and actions (2). Partner countries that the ROK collaborates with appear to be on target regarding this principle but the ROK should take steps to improve facilitation of ownership. For example, some respondents reported that the ROK agency is somewhat not supportive when they want to make a change in an area supported by ROK health aid and one-third of respondents only meet 4 times per year with the ROK agency, indicating weak collaboration. The ROK should address these issues by striving to consult fully with partner countries when developing ODA strategies and respect partner countries' leadership capacities. These suggestions are consistent with the Paris Declaration on Aid Effectiveness and recommendations made in DAC's 2012 Peer Review of Korea (210).
The country of Denmark is a good example of how a donor can support the ownership of its partners. Of all donor countries, Denmark has achieved the greatest number of Paris Declaration on Aid Effectiveness donor targets and is particularly respected for enhancing its partners' ownership (811). Denmark does this in many ways, including incorporation of ownership principles in the Programme Management Guidelines provided to all staff and enhancement of partner ownership through capacity development efforts. Additionally, Denmark's default aid modality is sector budget support, which intrinsically requires substantial ownership on the part of recipients (11). The ROK should consider adopting strategies from Denmark and other leading donor countries.
The Paris Declaration on Aid Effectiveness calls on donors to achieve alignment by centering their support on partner countries' national development strategies, institutions and procedures (2). Unfortunately only a small percent of respondents reported that the activities of the ROK agency are very closely aligned with their countries' development needs. However, progress is being made, as evidenced by all respondents reporting that alignment over the past 4 yr has become more relevant.
ROK agencies can continue to improve alignment by ensuring that the types of support they provide match partner needs. For example, the majority of respondents reported that they would like to receive support from the ROK with strengthening national capacities for policy and strategy development for health, but less than 10% reported that they actually received this type of support from the ROK. This pattern in which countries would like to receive more than they actually received is true for all of the services listed except for providing equipment, vehicles, supplies and services, in which respondents actually received more than they wanted to receive (Fig. 1). This discrepancy may be explained by the fact that provision of capacity-development services requires a donor itself to have a very high level of capacity, which in the case of a new donor like the ROK, may still be developing. The provision of supplies requires less donor capacity and also results in an immediately tangible result that may help to garner public support, which is important in countries that are new to providing international aid. As the ROK continues to develop its own identity as a donor, it should learn from the experiences of other donor countries on this topic. Strengthening capacity by coordinated support lends itself well to benchmarking because it is the only Paris Declaration on Aid Effectiveness indicator that was achieved by the 2010 target year. Therefore, several countries can serve as models for best practices (78).
Similar is true of program management activities. According to the survey results, most respondents conduct planning and monitoring together with the ROK agency but only around half conduct budgeting and collect/analyze data together (Fig. 2). This is a concern because the Paris Declaration on Aid Effectiveness emphasizes that: "The capacity to plan, manage, implement, and account for results of policies and program, is critical for achieving development objectives..."(2). As the ROK continues to enhance its own capacity related to ODA, it also needs to strive to empower the capacity of its partners.
The survey results indicate that the ROK is performing well in regard to meeting its commitments and operating within partner countries' policies and procedures, but it is not doing as well in terms of funding predictability and use of partner countries' national systems (Table 3). These findings mirror the results of the DAC Peer Review of Korea that was published in 2012 (10). The review stated that the ROK "is lagging behind in implementing the aid effectiveness principles, particularly those on aid predictability and use of partner country systems." The peer review identified that part of the problem is that the ROK has not embedded the Paris Declaration on Aid Effectiveness principles in aid management procedures and cooperation strategies (10).
Aid predictability is an ongoing challenge for the ROK and many other DAC members (10). Predictable aid is important because it facilitates the partner countries' smooth implementation of programs and also results in more efficient use of funds. One analysis calculated that financial losses related to unpredictable aid from European Union donors alone is between 2.3 to 4.6 billion EUR annually (1213). In the ROK, short-term disbursements are reasonably predictable but multi-year commitments are the bigger challenge in terms of predictability (10). The ROK is currently working to address this issue by forecasting funding amounts through a multi-year rolling plan and, in some cases, creating multi-year framework arrangements (10). Additionally, a budget-support trial has been initiated, but in general, budget support has yet to gain popularity by the ROK.
Harmonization is also an important principle of the Paris Declaration on Aid Effectiveness. It refers to conducting activities that are "harmonized, transparent and collectively effective" (2). Respondents were asked questions related to harmonization and some reported that the ROK agency did not coordinate well with other agencies working in the country. Anecdotal evidence suggests that ROK agencies can improve harmonization in partner countries by increasing collaboration with other donors and reducing the amount of aid they administer indirectly through non-government organizations (NGOs) via improvement of aid fragmentation.
Another Paris Declaration on Aid Effectiveness principle is to manage resources and improve decision-making for results (2). Although there is not a donor-focused Paris Declaration on Aid Effectiveness indicator related to managing for results, a survey question was included to reveal if the ROK could be doing more to support the management and implementation of aid in a way that focuses on results (2). The most frequently mentioned items were: improve the design of programs and projects (82%) and become more engaged in program-based approaches, including sector-wide approaches (64%). Notably, less than half of the respondents selected: make better use of results-based methods and improve monitoring and evaluation.
The ROK should also be sure to use partner systems to monitor outcomes and provide partners with capacity-building support related to data collection and results management. The ROK is well positioned to provide capacity support in this area. Its own national statistics portal was launched in 1976, during the heart of the ROK's development, and now compiles data on over 500 subjects from over 120 national and international agencies (14). Evidence suggests that capacity-building efforts can be effective for results management, but that countries should avoid efforts that are tied to specific donor needs and are piecemeal in nature (715). The ROK has good potential but needs to expand its effort in this area.
The last Paris Declaration on Aid Effectiveness principle is mutual accountability, which means that donors and partners are accountable for development results. The survey focused on the ROK's accountability to the partner country and the majority of respondents reported that the ROK follows the MOU commitment schedule and uses funds carefully. However, the ROK should also increase transparency regarding funding accountability. Only a few respondents reported that they audit and develop policies or procedures together.
Based on the 2011 Survey on Monitoring the Paris Declaration, we know that the ROK did not achieve this indicator by the 2010 target date. However, the fact that the ROK PMO commissioned this analysis would signify high-level understanding about the importance of partner perspectives. We recommend that such evaluations should be conducted on a regular, ongoing basis and become embedded in all levels of ODA programming. We also recommend that the ROK continues to monitor the work of its own government agencies that administer health aid. Healthy competition between the two aid agencies in Korea deserves to be encouraged to improve aid effectiveness such as KOICA (Korea International Cooperation Agency) and KOFIH (Korea Foundation for International Healthcare).
This research includes a few weaknesses that should be acknowledged. One weakness is that we cannot distinguish time trends because only one question asked about change over time. Future surveys should ask additional time-bound questions and/or collect data that can be compared with the outcomes of this baseline survey. The total number of responses is also a limitation of this survey. Although the survey received a 50% response rate, this only represents 13 responses.
CONCLUSION
The ROK is a relatively new donor in the field of health ODA and is committed to achieving a quality system that meets international expectations and helps partner countries achieve the best possible outcomes. This survey helps to inform future strategies by understanding the perspective of recipients related to the ROK's governance of health aid.
This survey confirms that the ROK is continuing to develop its capacity as a good donor, a final stage in the country's overall development process. Although the survey results indicate that progress has been made since earlier international evaluations, it is clear that the ROK has not overcome all areas of concern. A commitment to regular evaluations and parallel strengthening of two agencies (KOICA and KOFIH) will help the ROK achieve optimum ODA governance. Analysis and documentation of the ROK's process may also help other countries that are in earlier stages of transition from recipient to donor.
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