“Life can only be understood backwards, but it must be lived forwards”
S
Ø ren Kierkegaard 1813-1855
File no.: 104.A.1.e.21
November 2000
Royal Tropical Institute (KIT)
COWI, Consulting Engineers and Planners

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BBREVIATIONS
IV
XECUTIVE
UMMARY
NTRODUCTION AND
ETHODOLOGY
1.1
1.2
1.3
1.4
1.5
Why this evaluation? ................................................................................................... 1
Methodology ................................................................................................................ 2
Outputs ......................................................................................................................... 4
Structure of the report ................................................................................................ 4
Acknowledgements ..................................................................................................... 5
EVELOPMENT IN
NTERNATIONAL
EALTH
2.1
2.2
A changing world ........................................................................................................ 7
Changing international health policies ..................................................................... 9
ANIDA
UPPORTED
EALTH
CTIVITIES
4.1
4.2
4.3
4.4
4.5
4.6
4.7
4.8
4.9
3.1 Danida’s health policy ............................................................................................... 13
3.2 Overall Danida support to the health sector ......................................................... 15
3.3
3.4
Priority areas ............................................................................................................... 15
Recipient countries .................................................................................................... 16
3.5 Project duration ......................................................................................................... 17
3.6 Channels of support .................................................................................................. 17
3.7 Changes in time - Danida support to the five countries studied ........................ 18
CHIEVEMENTS
ERCIEVED
MPACT AND
ARGETING
Achievements - impact ............................................................................................. 21
Achievements - utilisation of health services ........................................................ 22
Achievements - providing essential services ......................................................... 23
Achievements - health systems - health sector reform ........................................ 24
Achievements - health systems - resource allocation ........................................... 26
Achievements - health systems - human resource development ........................ 28
Achievements - health services infrastructure....................................................... 28
Achievements - social mobilisation ........................................................................ 30
Targeting ..................................................................................................................... 32 i

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4.10 Good practices, lessons learned and recommendations ...................................... 34
OLICY AND
TRATEGI
EVELOPMENT
5.1
5.2
5.3
The appropriateness of assistance........................................................................... 39
Supporting national health policies and strategies in the five countries ............ 40
Good practices, lessons learned and recommendations ...................................... 44
MPLEMENTATION AND
ERFORMANCE
6.1
6.2
6.3
6.4
6.5
6.6
6.7
6.8
6.9
6.10
Channelling through the public sector ................................................................... 47
Channelling to the private sectors........................................................................... 48
Synergy of interventions through different channels ........................................... 49
Complementarity and donor co-ordination in the health sector ........................ 49
Joint management arrangements ............................................................................. 51
Stakeholder participation .......................................................................................... 52
Inter-sectoral collaboration ...................................................................................... 52
Role of technical assistance ...................................................................................... 53
Role of health research ............................................................................................. 55
Good practices, lessons learned and recommendations ...................................... 57
USTAINABILITY AND
OST
FFECTIVENESS
7.1
7.2
7.3
Sustainability ............................................................................................................... 59
Cost-effectiveness...................................................................................................... 61
Good practice, lessons learned and recommendations ....................................... 62
OVERTY AND
ROSS
CUTTING
SSUES
8.1
8.2
8.3
8.4
8.5
Poverty ........................................................................................................................ 65
Cross-cutting issues ................................................................................................... 66
Gender ........................................................................................................................ 67
Environment .............................................................................................................. 69
Good practice, lessons learned and recommendations ....................................... 70
ONCLUSIONS
ESSONS
EARNED AND
ECOMMENDATIONS
9.1
9.2
9.3
Overall conclusions and lessons learned ................................................................ 73
The transition to Sector Programme Support ....................................................... 75
Specific conclusions and lesson learned ................................................................. 77
9.4 Conclusions and lessons learned from the five countries ................................... 81 ii

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9.5 Summary recommendations .................................................................................... 82
9.6 Developments 1998-2000 ........................................................................................ 84
iii

A
BBREVIATIONS
NGO
ODA
OECD
PANS
PHC
PRA
RUF
SAP
SPS
SWAp
SWOT
DBL
DHMB
DFID
DKK
DMO
EDP
ENHR
ENRECA
EPI
ET
EU
FAMS
GDP
GIS
GoI
HIS
HIV
HMIS
HSR
HSPS
IEC
IMF
KIT
MCH/FP
MIS
MoH
A BBREVIATIONS
AIDS
AMREF
CBNP
CMAZ
DAC
DALYs
DANLEP
DANPCB
Acquired Immune Deficiency Syndrome
African Medical Research Foundation
Community Based Nutrition Programme
Christian Medical Association of Zambia
Development Assistance Committee
Disability Adjusted Life Years
Danish Assistance to the National Programme for Control of
Leprosy in India
Danish Assistance to the National Programme for Control of
Blindness in India
Danish Bilharziasis Laboratory
District Health Management Board
Department for International Development
Danish Kroner
District Medical Officer
Essential Drugs Programme
Essential National Health Research
Enhanced Research Capacity Programme
Essential Programme for Immunisation
Evaluation Team
European Union
Financial Administration Management System
Gross Domestic Product
Geographical Information System
Government of India
Health Information System
Human Immunodeficiency Virus
Health Management Information Systems
Health Sector Reform
Health Sector Programme Support
Information Education & Communication
International Monetary Fund
Royal Tropical Institute
Maternal & Child Health/ Family Planning
Management Information System
Ministry of Health
Non-Governmental Organisation
Official Development Assistance
Organisation of Economic Corporation Donors
Participatory Approach to Nutrition Security
Primary Health Care
Participatory Rapid Appraisal
Council for Development Research (in Danish)
Structural Adjustment Programme
Sector Programme Support
Sector Wide Approach
Strengths Weaknesses Opportunities & Threats iv

TA
TASO
TB
ToR
TORCH
UNAIDS
UNDP
UNFPA
UNHCR
UNICEF
UWR
VHC
WDR
WHO
WID
A
BBREVIATIONS
Technical Assistance
The AIDS Support Organisation
Tuberculosis
Terms of Reference
Tororo Community Health Project
Joint United Nations Programme on HIV/AIDS
United Nations Development Programme
United Nations Population Fund
United Nations High Commission for Refugees
United Nations International Children’s Emergency Fund
Upper West Region (Ghana)
Village Health Committee
World Development Report
World Health Organisation
Women in Development v

A
BBREVIATIONS vi

E
XECUTIVE
S
UMMARY
E XECUTIVE S UMMARY
This report concerns the first overall evaluation of Danish bilateral assistance to health. It covers a ten-year period (1988-1997) involving over 400 health interventions and over
DKK four billion in support. The main objective of the evaluation was: “to compile relevant ‘lessons learned’ in order to improve the quality of Danish bilateral interventions in the field of health and contribute to the strengthening of health care systems and improved health care status in the developing countries.” During the period evaluated
Danida shifted its policy from project to sector programme support. A major focus of the evaluation was directed towards this policy shift.
The evaluation was carried out in three phases: desk studies; field studies in five selected countries (Ghana, India, Kenya, Uganda and Zambia); and a synthesis and analysis of the findings. This executive summary discusses the overarching findings and main recommendations. A more detailed summary can be found in Chapter 9, with conclusions, lessons learned and recommendations.
Declining health indicators despite donor support to health. Health indicators in most recipient countries show currently a downward trend; amongst others, life expectancy is decreasing, vaccination coverage is decreasing and major preventable diseases such as tuberculosis and malaria are on the rise. The AIDS pandemic is raging in all (Sub-
Saharan) countries receiving Danish health sector support and impinges on the measures of effectiveness of aid interventions.
Danida support to the health sector grew rapidly in the evaluation period. Assistance to health has been steadily growing during the period under evaluation, in particular in the latter half of the period when more than 10% of total bilateral assistance was devoted to health. In
1997, the share was exceptionally high at 15.6%, equivalent to DKK 815 million. Since then the share of health has come down to 11.4% (DKK 618 million) in 1998 and 12.6% in 1999. In addition, Danida devoted a further 9 to 13% of its budget to health-related multilateral organisations. The ‘top ten’ recipients of health assistance 1 received about 90
% of total health expenditure in 1988, while in 1995 it was around 65%. Despite this concentration, there are over 40 countries that receive health sector support of some kind. Among these are ‘transitional’ countries and countries recovering from conflict. A major share of the allocations is channelled through the Embassy Appropriation Facility and through NGOs.
Danida’s health sector policy became more poverty focussed. Strategy 2000, adopted in 1994, establishes that poverty reduction is a fundamental principle of Danish assistance to developing countries. Strategy 2000 made explicit that development assistance must be organised in a manner that promotes development of the social sectors .
2 The Evaluation
1 The 'top 10' countries are the nine countries with Danida supported HSPSs: Bhutan, Ghana,
India, Kenya, Mozambique, Tanzania, Uganda, Zambia and Zimbabwe, and number 10,
Bangladesh, which does not have a HSPS.
2 The three 'legs' of Danish development assistance are: 1) sustainable economic growth, in which distribution policy constitutes an integral element of economic policy, 2) development of the social sectors, including concentration on education and health as prerequisites for developing vii

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UMMARY of Poverty Reduction in Danish Development Assistance, 1996, confirmed that of the eight Sector Policy Strategies analysed, the health sector policy had the most explicit poverty orientation. Overall growth in allocations to the health sector after 1994 are in line with the principle set out in Strategy 2000. However, the current evaluation has not been able to establish a systematic attention to the poverty reduction principle in interventions. Poverty orientation was implicitly followed in the actual interventions with emphasis on delivery of Primary Health Care (PHC) services, including essential drugs programmes, to the poorest segments of the community in the poorest countries. The successful support to fight leprosy and blindness (in India) demonstrates Danida’s concern for poverty. Also, Danida has become more explicit in its concern to improve the health status of the population, especially for the most vulnerable groups, with emphasis on women and children. However, operationalising and integrating a gender strategy with health sector support has not been systematically pursued. Given the gender focus, a greater focus in terms of allocation of funds, to develop adequate interventions to tackle the problem of maternal and child malnutrition, could have been expected. Maternal and child malnutrition remains a considerable problem in most
Danida-supported countries.
Danida has been successful in addressing priority public health problems. The main entry point for
Danida support to the health sector has been focussed on the health systems of partner countries. In addition, special attention in the period under evaluation has been directed to specific health problems such as leprosy, TB and HIV/AIDS. Danida has been successful in promoting the PHC principles and has contributed to bringing health closer to the people. Major achievements resulting from Danida-funded activities have been the much needed expansion of PHC services (India, Kenya) resulting in improved access to care, the development of the Essential Drug Programmes (Kenya, Uganda), the support of immunisation programmes (Kenya) and training of health personnel (all countries).
Provision and/or renovation of infrastructure such as rural clinics, training schools and workshops (all countries) has accounted for around 50% of Danida’s health expenditures. By far the best returns for small flexible budgets were derived from Danida investments in innovative pilot projects in India (blindness, leprosy) that were scaled up with funds from loans or large donors.
Danida has been a front runner and has taken risks in shifting from project support to sector programme
support (SPS). In the late 1980s, a number of weaknesses related to piecemeal project and programme support detracted from the efficiency of assistance to health. Poor health management capacity, problems of accountability, lack of ownership and sustainability prompted donors, with Danida up-front, to pursue the philosophy of health sector support. As a consequence, in the mid-1990s, SPS became the focus of Danida’s support in the health sector. This support was given through the Health Sector Programme
Support (HSPS). Increased financial support to the health sector facilitated this shift.
Danida’s approaches have been complementary to the developments in international health policies, and Danida has often provided significant inputs to the international debate on health. In doing so, Danida has taken risks to support potentially important and innovative approaches. It has made significant contributions by operationalising new concepts, such as health sector reforms (HSR) and sector-wide approaches (SWAp),
(Ghana, Uganda, Zambia). human resources, and 3) popular participation in the development process, building a society based on the rule of law and good administrative practices as prerequisites for stability in economic, social and political development. (Strategy 2000, Danida 1994). viii

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S
UMMARY
The ’time factor’ required to prepare for sector support and reform of the health sector has not always been
taken sufficiently into consideration. Due to Danida’s ambition and enthusiasm to achieve results in the implementation of the new concepts, the time requirements to build trust and capacity have in some instances been overlooked. The balance between donor conditionalities and dialogue is delicate. Disagreement between Danida and governments about formulation and implementation of macro policies has turned enabling environments into suspicious or antagonistic climates at short notice (Kenya, Zambia).
National reform policies (e.g. decentralisation, civil service reforms, introduction of user fees) necessary for reforming the health sector have not been sufficiently considered in the planning and implementation of Danish assistance to health.
Stakeholder participation is still a subject of concern. There are many groups of stakeholders concerned with health, public authorities, civil society, private sector, individual users and donors. Stakeholder participation, in particular of health systems managers and communities, was initially managed successfully in places where Danida was provided the space for joint experimentation and pilot testing (India). The need for stakeholder participation is even more vital for a successful SPS approach. While Danida has strategy papers and guidelines for many issues, there are none concerning participation.
Systematic approaches to community participation and documentation of experience and lessons learned on this issue are few.
The rapid pace of sector reforms has diverted attention from the quality of care at the peripheral level.
SPS has focussed Danida’s assistance to mainly the MoH at central level to support the necessary health reforms. However, in this process the quality of patient care at the peripheral level has suffered. Early gains from project support that focused on capacity development and quality control of disease control programmes have, in some cases, been lost (Zambia). Although quality assurance was a component in some HSPSs in others it did not feature prominently. With an exception of Ghana, where it was on the agenda, the operationalisation of quality assurance proved to be a problem.
Sector wide approaches have in practice been sector narrow. Danida’s prioritisation of support to the public sector, at the central level of the MoH, tends to become sector narrow.
Although hospitals consume a major part of the national health budgets, they received little attention by Danida. Of similar importance, little attention, with an exception of
Ghana, has been devoted to the private-for-profit sector and the informal sector. More attention could have been devoted to other sectors that influence health. Health is a cross-cutting concern and demands inter-sectoral linkages. The challenge of HIV/AIDS is a dramatic example. While Danida policies acknowledge the interaction between health and other sectors such as education, environment, agriculture, energy, transportation and food security, collaboration in the field hardly materialised.
The effectiveness of any support is strongly influenced by two factors: the degree of political commitment
and ownership at the country level, and capacity within the health sector. Health system development and improved performance require long-term thinking and planning, a willingness to change, and a capacity to absorb change. Reform implies significant, often fundamental change, and there is no blueprint for successful support. Danida has been flexible in its support to developing national programmes in some countries (Ghana,
Zambia), but more rigid in others where it tried to “push” reform (Kenya, Uganda). ix

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UMMARY
Health systems managers, being the implementers of health interventions, and communities are vital to the success of health policies and SPS. It has continued to prove difficult to translate the need and demand for institutional capacity building at the district and community levels in the formulation and implementation of Danida supported programmes.
Danida has had difficulties in achieving the careful balance between trust and control that SPS demands.
Trust, expressed in a shared vision, and transparency of operations, is the most important pre-requisite for long-term partnership. Conditionalities and earmarking of funds reflect differences between donor and national priorities and management capacities. Tight programme frames of objectives and activities often leave the issue of conditionalities unresolved, or irresolvable. Danida’s strict application of conditionalities, even when initially patience has been practised, led to a freeze in Danish disbursements, resulting in the on/off implementation of HSPSs or their components (Kenya, Uganda and Zambia).
The effects this has had on service delivery in countries highly dependent on donor aid were aggravated by the fact that no alternative strategies existed. This strict application has had a significant impact on trust and mutual understanding, making future dialogue even more difficult.
Having access to information is the key to rational decision-making both by Danida and by country level
partners. The existence of a well-defined health policy and information on the state of existing health problems and systems is essential for successful reforms. Danida has had mixed success in supporting systems that produce the necessary information. Many reforms run faster than the production of information that is necessary for rational planning, monitoring and evaluation of implementation activities. Lack of information continues to be a problem when making an informed sector analysis and evaluating
Danida support. This includes also information on political processes, institutional and legal frameworks.
SPS requires different Technical Assistance (TA) than project approaches. In the beginning of the period under evaluation, when projects predominated, the role of TA was clear, as it was mostly of executive and technical nature and confined to the objectives of the project.
However, within the context of SPS, the relationship between Danida and the recipient country demands both technical and policy advice. As a consequence, the shift from project support to SPS has implications for TA. Since the introduction of SPS, the different roles (technical and political) of the technical advisors have not always been clarified nor have the division of responsibilities within the Danida hierarchy been clearly defined. Finally, SPS requires also a new demand for donor co-ordination. This has been successfully met in some countries (Ghana, Zambia), but co-ordination under the leadership of national governments needs reinforcement.
There is a general tendency in north-south research collaboration that the research agenda is determined
more by the northern research partners than by southern partners. The health research network is actively promoting the integration of health research and development assistance to health. Yet the research agenda is insufficiently oriented to support the implementation of HSPS and operation of the health sector reforms. x

E
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S
UMMARY
To improve the quality of Danish bilateral interventions in the field of health, to contribute to strengthening health care systems and the improved health status of communities in developing countries, the following recommendations are made:
1.
Establish long-term partnerships to be built on long-term financial commitments. Subsequent phases of the SPS process, including a framework for financial commitments, should be elaborated between Danida and the recipient country, before SPS is initiated.
Long-term budgets could include fixed and variable (performance-related) components. A trade-off needs to be made between target contracts and relational contracts. Although this might conflict with Danida's specific annual budgetary targets, it increases the flexibility and trust between partners.
2.
Enhance the focus on quality of patient care at the peripheral services. Efforts to improve the quality of care need also include the non-technical aspects of quality, such as affordability, counselling/interaction, supervision, safety, efficiency, and service environment. The understanding of client needs and priorities is, besides functioning of staff, a key to better quality. In areas with few qualified staff, establishing a supportive enabling environment and creating internal incentives will help foster quality of patient care. The issue of staff incentives are crucial with regard to good services. Establishment of Quality Assurance and Monitoring and Evaluation mechanisms should be prioritised in Danish support to HSPSs.
3.
Use semi-flexible conditionalities, with clear fall-back positions and realistic milestones based on
local capacity and demonstrated commitment to implement changes. Preconditions for entering health sector support need to be carefully assessed. A joint government-donor (risk) analysis needs to be conducted to identify elements of TA for the design and implementation of national plans. In this respect, donor co-ordination is of vital importance. While using a phased implementation of SPS, earmarking of successful projects may be retained, in addition to budget support to the overall health sector.
Such projects may be innovation-oriented or projects of vital importance. Processoriented monitoring tools need to be strengthened for better monitoring of the process and outputs of the support compared with the original plans and component expenditures.
4.
Be sector wider. To improve the efficiency of allocation within the health sector, more attention should be paid to the hospital level. Similarly, alternative entry points through NGOs or the private-for-profit sector may be considered through the creation of umbrella mechanisms.
5.
Mobilise broader representation of all stakeholders, including those who are otherwise likely to be left
out (private sector, NGOs, vulnerable groups, women’s groups). Constructive dialogues will help building mutual trust as a precondition for successful partnership and participatory development in health programmes. Care should be taken that ownership remains with national stakeholders; it must not be taken over by outside agencies. The principle of community participation needs to be reinforced - involving communities in decision-making, particularly in cost-recovery mechanisms to strengthen the operationalisation of adequate health interventions, including quality of care. Danida should strengthen support to test different 'models' of stakeholder participation. xi

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UMMARY
6.
Enhance the research capacity and the application of research results for operational purposes.
Danida should explore opportunities with local research institutions and academicians to get them more involved in a research agenda that supports the operation of the health sector. Subjects for further research are for example: costquality interactions; exemption modalities; provider payment schemes; social and other health insurance systems; subsidy targeting; user fees; assessments of AIDS interventions in Sub-Saharan countries; tightening the links between health and environment; studies on different determinants that influence quality of patient care; gender issues and improvement on equity. Initiatives for research need to come as much from the HSPSs as from the ENRECA-supported Health Research Network.
It is essential to document key lessons learned from past interventions to establish an institutional memory, as this allows dissemination of experience (good and bad) to various partners.
7.
Give sufficient attention to AIDS. In those countries where HIV is epidemic, Danida should treat AIDS as a cross-cutting issue. Given its impact on development in general, attention to AIDS should be mainstreamed across the sectors where Danida is active (e.g. agriculture and food security, education, transport, etc.).
Developments 1998-2000
The above mentioned conclusions and recommendations are reflecting the evaluation period 1988-1997. It should be noted that beyond this period some important developments have been taken place in Danida’s strategy for health support, notably:
 A shift has taken place on the importance of comprehensive and realistic health policies as a precondition for SPS, to a more process oriented approach, where SPS is seen as a conducive environment for change.
 Instead of instigating on “radical” HSR, approaches have been incorporated that allow gradual shifts towards HSR, including e.g. transitional phases. More space has been created to allow persons and institutes time to develop, taking into account lessons learned from the past.
 A shift has taken place from the rational model of planning to a more comprehensive and realistic model of planning and decision making. Besides technical
(epidemiology/economic) paradigm also political and organisational views are considered in the planning process, as well as proper staff incentives.
 More emphasis is given to relational “contracts” rather than conditions.
 Instead of giving emphasis to the primary PHC level, more attention is given to the private sector and hospital sector in health sector support.
 Rather than sticking to the essential health package, the use of public subsidies is seen in a broader context. xii

1 I
NTRODUCTION AND
M
ETHODOLOGY
1 I NTRODUCTION AND M ETHODOLOGY
Poverty reduction is the overriding objective of Danish development co-operation. To achieve this objective, Danida aims to promote sustainable growth, develop social sectors and foster popular participation in the development process. Health is a priority issue and is defined both as a development goal and as a means to achieve development.
“Health is more than just absence of disease; it is vital to human well-being and as a goal in its own right, it is central to social and economic development.
Equally it is a means to achieve and maintain development.”
Source: Danida Sector Policies, Health (1995)
Danida has been at the forefront of many of the international debates about effective strategies for improving health. The specific objectives and strategies guiding Danida’s assistance have changed and evolved over time to reflect the changing international environment and changes in broader development policies as well as changing priorities within Danida itself.
Danida contributes more to the health sector than to any other sector through bilateral assistance. In 1997, Danida contributed DKK 815 million in bilateral assistance to health, equivalent to 15.6% of the total bilateral assistance budget, the highest proportion to date.
There have been several specific evaluations of Danish assistance to projects and programmes within the health sector but no overall evaluation of Danish bilateral assistance to health. In view of the priority given to health, Danida decided that an evaluation of its bilateral assistance was necessary. The main objective of the evaluation was: “to compile relevant ‘lessons learned’ in order to improve the quality of Danish bilateral interventions in the field of health, and to contribute to the strengthening of health care systems and to improved health care status in developing countries.”
(See Annex I: Terms of Reference).
The evaluation was carried out by The Royal Tropical Institute (KIT) and COWI
Consulting Engineers and Planners, Copenhagen, in collaboration with institutes and consultants from the countries selected for field studies (see Annex II: Composition of
Evaluation Teams). The team leader of the overall evaluation was Maarten van Cleeff.
This report is based on five country working documents which were authored by Jane
Kusin, Britha Mikkelsen, Alanagh Raikes and Jurrien Toonen. Drafts of the report were regularly screened by Claus Rebien, quality co-ordinator and Pieter Streefland, general advisor.
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The evaluation covers the period 1988-1997, involving over 400 health interventions and over DKK 4 billion in support. The evaluation includes support to health research and support offered through NGOs. Danida’s evaluation questions, as outlined in the terms of reference, were grouped into five clusters:
Cluster I Overview of Danida-supported bilateral assistance to health
Cluster II Policy and Strategy Development
Cluster III Institutional Framework - Channelling, Implementation and Performance
Cluster IV Targeting, Achievements and Perceived Impact
Cluster V Sustainability including cost-effectiveness
The clustered evaluation questions, indicators, means of verification and activities are presented in matrix form (see Annex III: Cluster Matrices). The evaluation was conducted according to Danida Guidelines for Evaluation (1994 and 1999). The evaluation criteria were relevance, efficiency and effectiveness, perceived impact, sustainability, and quality. The term health sector is used broadly and refers to the entire network of public, private and voluntary institutions. The evaluation also includes activities outside but related to the health sector, such as water & sanitation and environmental issues.
Multidisciplinary and consultative approach
The evaluation was carried out by a multidisciplinary team. Close contact was maintained with the Evaluation Secretariat as well as with Danida's technical department. A quality plan was drafted to assist monitoring and ensure transparency.
In order to maximise opportunities, enable a shared analysis and learn from the experience of various partners, a consultative approach was developed and adopted. This involved a broad range of stakeholders, including government officials, representatives of
NGOs, private health providers, community representatives, and beneficiaries. The team encouraged open communication with all of the partners. Special attention was paid to women, children and underprivileged social groups, such as minorities and illiterate people. Altogether more than 500 people were interviewed or took part in workshops related to the evaluation.
Throughout the whole evaluation period, a total of nine workshops were held (three in
Denmark and six in the countries visited) with the aim of sharing and discussing results reached up to that point and adjusting the plans for the next evaluation phase.
Selection of countries and interventions
Of the 55 countries and 400 interventions that received Danida assistance to health, five countries were selected for evaluation: Ghana, India, Kenya, Uganda and Zambia. These countries absorb a major proportion of the total aid. They were chosen as Danida had been providing health sector support for sufficiently long to learn lessons about the transition from the project approach to sector wide approach (SWAp).
During the preparatory workshop, a total of 25 projects (five from each country) were selected for desk studies according to specific criteria, such as: the size of the financial allocation, area of interventions, and channel of intervention.
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1 I
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ETHODOLOGY
Danida has worked for more than 20 years in India, a country that proportionally has minimal donor support. It has operated for over 20 years in both Uganda and Kenya, which receive substantial donor assistance, and was present when the sectoral orientation approach started to emerge. Danida became a donor in Zambia and Ghana fairly recently, after the sector wide approach had already been established.
The evaluation was carried out in three phases: Phase 1 consisted of a desk study; Phase
2 of field studies in the five selected countries; and Phase 3 of the synthesis and report preparation. A preliminary phase, prior to the desk study, was important to specify the evaluation methodology and to refine some of the conceptual elements. In addition, thorough preparation was required for the desk study and to plan the field studies and finalise arrangements with partner organisations and stakeholders.
Phase 1: Desk study
A range of relevant background papers, project reports and evaluation reports were studied. Interviews were conducted with Danida staff and personnel of partner institutions in Denmark. The results appeared as five “Desk-study country documents” which provided the background material for a workshop in Copenhagen. A computerbased database was made, containing all of Danida's bilateral health projects in the period under evaluation. An overview of Danida supported health activities over the period
1988 till 1997 is presented in Chapter 3.
Phase 2: Field studies in five countries
A multidisciplinary team of 4-5 people visited each country for a four-week period, and a selection of Danida-supported projects as well as ‘non-Danida’ projects were visited for comparison. A range of open and structured interviews were held with essential personnel, government authorities, representatives of the different health providers, as well as the target groups. Checklists guided these interviews.
Debriefing notes were discussed at the embassy, and working documents (one document per country) were developed to bring together information from the country studies. In addition to the field visits, local institutions were contracted to carry out a total of 15 small-scale studies. They included Stakeholder Participation, Human Resource Situation,
Public/Private Mix, Health Financing, Perceived Impact Study, and Impact and
Performance Indicators.
Phase 3: Synthesis
All of the material collected was compiled into one draft synthesis report and discussed during a workshop at Danida, Copenhagen, in November 1999. The themes of the workshop included consensus about the “lessons learned” and recommendations for future directions for Danida assistance to health.
Limitations
Like any study this evaluation has its limitations. Quite some literature has been read, nevertheless it is unavoidable that some relevant reports or documents have not been studied, while some persons may not have been interviewed. Observations in the field are based on visits to five countries. Although these five countries have been well selected, according to sample criteria, it remains a sample. Conclusions drawn from these countries may be challenged by experiences from other countries where Danida operates. This may even be the case among the selected countries themselves. The synthesis intends to present an "average" impression of Danida's assistance to health.
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1 I
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ETHODOLOGY
Observations or conclusions may be more outspoken in one country and less so in another. The synthesis represents as much as possible the "average" opinion of people interviewed, as well as the opinion of the entire evaluation team, but nuances between individuals always exist. Some topics gave more subject for discussion. Five of these topics have been selected and are being dealt with in separate papers, the so called "Issue
Papers". In accordance with the ToR, the evaluation team has been asked to stick to the timeframe 1988-1997. After this period certain developments within Danida and within countries have taken place, which make some recommendations less relevant today.
This synthesis report is one of the outputs of the evaluation. Other outputs include: a computerised database (see phase 1); country working documents (see phase 2); smallscale studies (see phase 2) and five issue papers 3 .
These issue papers were prepared as an input to the planned revision of the booklet “Danida Sector Policies of Health”. They concern themes that were ambiguous in terms of policy and for which no clear guidelines existed for translating the policy into action. The papers place specific emphasis on
Sector Programme Support (SPS) and Health Sector Reform (HSR) and are presented separately from this report.
The synthesis report brings together the work of the evaluation team and is structured as follows:
 Executive summary.
 Chapter 1 outlines the methodology used in the evaluation.
 Chapter 2 describes the international context and some of the main changes and influences on donor support.
 Chapter 3 gives an overview of Danida policies, strategies and interventions in health during the 10-year period.
 Chapter 4 gives an overview of the main achievements of Danida support, of targeting of interventions, mobilisation of stakeholders and target groups.
 Chapter 5 discusses how changes in Danida policy have been translated at the operational level in countries receiving bilateral support.
 Chapter 6 examines the institutional framework and the channelling of funds. It looks at the role of different actors and discusses complementarity and donor coordination. It also discusses the role of research.
 Chapter 7 examines issues relating to sustainability and cost-effectiveness.
 Chapter 8 focuses on poverty and cross-cutting issues including gender and environmental health.
 Chapter 9 summarises and discusses the overall conclusions, lessons learned and highlights areas which require particular attention; it recommends topics for further research and identifies some tools which could be developed.
3 The following issues were selected: 1) The operationalisation of SWAp; 2) Public/Private mix;
3) Economic Appraisal/Evaluation of Danida Assistance; 4) Gender and Health: 5) Stakeholder
Participation.
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ETHODOLOGY
Chapters 1-3 provide the background to the evaluation. Chapters 4-8 contain the main findings of the evaluation and a discussion of the findings. Each of these chapters finishes with good practices, lessons learned, and recommendations. Chapter 9 provides a summary of good practices, lessons learned and recommendations.
We would like to express our sincere thanks to the Governments of Ghana, India,
Kenya, Uganda and Zambia and their respective Ministries of Health for the assistance, hospitality and support in meeting so many people. We would also like to take this opportunity to extend our thanks to Danida Staff in Copenhagen and at Embassies for the time they spent on interviews, workshops and reviewing our drafts and for their support in logistics and arrangements.
We would like to thank local research institutions who performed the small-scale studies:
Management Service Group, India; Health Service Research Unit, Ghana; Institute of
Economics and Social Research, Zambia; the Department of Public Health, University of Nairobi, Kenya; and The Makerere Institute of Social Research, Uganda.
Our appreciation also goes to all the stakeholders, including country representatives,
NGOs, unilateral and bilateral donors and community members, and the staff members of the different projects for making documents readily available and guiding us through the projects and last – but not least – to the patients, with whom several interviews were held.
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2 D EVELOPMENTS IN I NTERNATIONAL H EALTH
During the period under evaluation (1988-1997), the world changed substantially, not only in terms of the epidemiology of diseases, but also in terms of the underlying determinants of health and the policies which address them. In this chapter, the broader context of health policy development will be outlined, followed by the developments in international health policies. This provides the context for the evaluation and provides a basis to assess the relevance of Danida’s policies and strategies.
Poverty has always been closely related to health. People living in absolute poverty have a five times higher probability of dying between birth and the age of five years, and a 2.5 times higher probability of dying between the ages of 15 and 59. Today, over 1.3 billion people still live in absolute poverty, particularly in Africa and Asia (Graph 2.1) Although, over the past decade, large parts of the world have experienced economic growth and improved living standards, at the same time the regions of Sub-Saharan Africa and
Eastern Europe have suffered a decline, which have often directly reflected in deteriorating health indicators. As a result, gaps still exist, both in income and in health
(Graph 2.2), between regions. The health disparities between high and low income countries, and within individual countries are substantial. In particular, disparities exist between different social groups, men and women, different ethnic groups and geographic areas.
Graph 2.1 Population living on less than US$1 a day in developing economies
1987
600 1993
500
400
300
200
100
0
South Asia East Asia and the Pacific
Sub-Saharan
Africa
Latin America and the
Caribbean
Middle East and North
Africa
Eastern
Europe and
Central Asia
Source: Lerer, LB et al. Health for all: analysing health status and determinants, World
Health Statistics Quarterly, 51 (1); 7-20 (1998).
The world is currently undergoing substantial economic change. The process of globalisation has direct consequences for health. It can enhance the dissemination of infectious diseases and unhealthy lifestyles. In addition, economic reforms in many countries have promoted the rapid expansion of the private sector and the privatisation of services that were traditionally provided by the public sector.
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Graph 2.2 Maternal mortality (1990)
1000
800
600
400
200
0
Africa Asia Latin America Europe North America
Source: Revised 1990 estimates of maternal mortality. A new approach by WHO and
UNICEF, WHO (1996 Geneva).
The world is currently facing both a demographic and an epidemiological transition. The demographic transition is being caused by a decreased death rate and with some lead time, a reduction in the birth rate. As a result, the number and proportion of old people are increasing sharply, in both high- and low-income countries. In 1995, the world population stood at 5.7 billion and was growing at about 1.6% a year. Though there is some decline in the growth rate, this decline is slowest in the poorest countries. Hence, in these countries populations are still steadily growing, which is also reflected in a rapid urbanisation. The demographic transition and the changing lifestyles are major contributors to the epidemiological transition. While previously infectious diseases were the major cause of death, currently non-communicable diseases (cancers, cardiovascular diseases, degenerative diseases) have become dominant, a trend which looks set to continue (Table 2.1). This transition also affects the least developed countries, where funds may be increasingly channelled to treating non-communicable diseases and expensive health facilities.
Table 2.1 Diseases causing highest burden in 1990, projected for 2020 (mortality)
5
6
7
8
1
2
3
4
R ank 1990
Ischaemic heart
Cerebro-vascular diseases
Lower respiratory
Diarrhoeal diseases
Perinatal disorders
Chronic obstructive pulmonary
9
10
11
12
Tuberculosis
Measles
Road traffic accidents
Malaria
Self inflicted injuries
Trachea, bronchus & lung cancers
2020_________________________
Ischaemic heart
Cerebro-vascular diseases
Chronic obstructive pulmonary
Lower respiratory
Trachea, bronchus & lung cancers
Road traffic accidents
Tuberculosis
Stomach cancer
HIV
Self inflicted injuries
Diarrhoeal diseases
Cirrhosis of the liver
Source
: Murray CJL, Lopez AL. The Global Burden of Disease, Harvard University
Press (1996).
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The control of communicable diseases is, however, still far from being achieved. In most developing countries, childhood illnesses, infectious diseases, and poor maternal and nutritional conditions are still responsible for a substantial proportion of the burden of disease: about 42% of deaths in all developing regions, and about 65% in Sub-Saharan
Africa. These countries are suffering, or will soon suffer, from a double burden of disease, having to face both the unfinished agenda of communicable diseases, while at the same time being confronted with an increasing burden of non-communicable diseases.
There have been successes over the past decade in the combat of infectious diseases, e.g. in relation to onchocerciasis control and the eradication of polio. However, at the same time, diseases that were thought to be on the decrease have re-emerged, such as tuberculosis and malaria. In fact, they may be more persistent than ever, as a result of the resistance that micro-organisms have developed to available drugs. Moreover, the introduction of the HIV virus, causing AIDS, has had a devastating impact on health, particularly in Sub-Saharan Africa (Table 2.2). AIDS particularly affects vulnerable groups such as women and the poor.
The AIDS epidemic also illustrates the close relationship between health and socioeconomic development, particularly by its negative impact on the growth rates of GNP in several African countries. The consequences are reflected in the health status of these countries: while health indicators such as life expectancy and age-specific mortality rates have improved globally, they have not improved in countries that are most severely affected by HIV/AIDS.
Table 2.2 AIDS in the world (in millions)
New HIV infections
People living with HIV/AIDS
AIDS deaths
Cumulative HIV/AIDS deaths
Adults Children Total
1996 1999 1996 1999 1996 1999
2.7
21.8
1.1
5.0
5
32.4
2.1
12.7
0.4
0.83
0.35
1.4
0.57
1.2
0.47
3.6
3.1
22.6
1.5
6.4
5.6
33.6
2.6
16.3
Source
: UNAIDS/WHO, AIDS epidemic update (December, 1999)
In the 1980s, national health policies and donor support focussed on the concept of
Primary Health Care (PHC). The PHC strategy became central to health care in developing countries after the Alma-Ata conference in 1978, at which Health For All, emphasising equity in health and health care, was promulgated as the ultimate goal. The
PHC strategy was based on experience from several countries (China, Tanzania) which had shown that better health for more people was possible, if the right approach was pursued. This approach was operationalised through four principles and eight elements
(Box 2.1). PHC proved a unifying conceptual framework for improving health and shifted the focus from curative to preventive care, from hospital care to community care and public health. It linked health to its determinants, often outside the health sector, and emphasised the responsibility of people for their own health.
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Box 2.1 Principles and Elements of PHC
Principles of PHC:


Striving for universal access and coverage in relation to need
Enhancing community involvement and self-reliance
 Promoting intersectoral action for health
 Matching appropriate technology and cost-effectiveness to the available resources
____________________________________________
Eight elements of PHC:
 Education concerning prevailing health problems and the methods of preventing and controlling them
 Promotion of food supply and proper nutrition
 Adequate supply of safe water and sanitation
 Maternal health and child health care, including family planning
 Immunisation against major infectious diseases
 Prevention and control of locally endemic diseases
 Appropriate treatment of common diseases and injuries
 Provision of drugs
PHC proved difficult to operationalise. It was undermined by the adoption of selective interventions that attempted to apply technological solutions to health problems without addressing the real underlying causes. Some donor-supported interventions, such as vaccination campaigns and disease control programmes, were implemented in an isolated, vertical and top-down fashion.
Hence, by the end of the 1980s, it had become evident that much of the support given was not sustainable, as relatively little change had occurred outside these programmes and the development of comprehensive health systems. Moreover, the vertical nature of some of the support meant that governments had difficulties in co-ordinating fragmented donor inputs and in developing coherent health policies.
A comprehensive approach was necessary, in which all aspects, including human resource development, financial arrangements and priority setting, were dealt with in a more systematic way. As a result, since the mid-1980s, the focus has moved to strengthening the district health system as the basic organisational unit for the planning and implementation of health care interventions.
The economic recession in the 1980s, which eroded funding for health care services in many countries, highlighted the difficulties in achieving sustainable health services. The recession also illustrated the close relationship between economic development and health. Economic reforms in response to the recession and increasing debt burdens focused on reductions in public expenditure. These expenditure reductions in social sectors particularly affected the health of the poor and most vulnerable groups in society.
Later reforms included a social component: “Structural Adjustment Programmes (SAPs) with a human face”, in which multilateral organisations, including the World Bank, and bilateral donors emphasised the mutual relationship between health and poverty/socioeconomic growth, highlighting that health and education are important inputs into socioeconomic growth and human development.
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Graph 2.3 Health and economic growth
Economic growth policies that benefit the poor
Poverty reduction Human resource development
Investing in schooling and health
Source : World Development Report. Investing in Health, World Bank (1993)
The concept of health as an investment was expressed in an influential publication on health care by the World Bank: World Development Report (WDR) 1993: Investing in
Health. The ideas were later operationalised in publications such as “Better health for
Africa” (Graph 2.3). The WDR stressed that improvements in health can only be enhanced through economic growth policies that benefit the poor and that investments in schooling are necessary, particularly for girls. It emphasised that government spending should be improved by reducing government expenditure on tertiary facilities, specialist training and interventions that provide few health gains for the money provided. Instead, cost-effective packages of public health and clinical services should be developed and the management of government health services improved. A new concept for the burden of disease was introduced, the Disability Adjusted Life Year (DALY), to facilitate priority setting in health and the development of cost-effective health care packages. The WDR also promoted diversity and competition in the provision of health services, particularly for those services that are not included in the packages.
The concept of health as a basic human right also received much attention in the 1990s.
This was particularly highlighted by organisations such as WHO and during international conferences which were directly or indirectly related to health (Box 2.2). These conferences reflected a growing consensus that health, socio-economic development and fundamental human rights are interdependent and mutually reinforcing. The
International Conference on Population and Development in Cairo, for instance, made the conceptual linkage between human rights, reproductive rights and health, moving away from a narrower concept of reproductive health as mainly consisting of population control.
Box 2.2 World Conferences - Health on the International Agenda
 World Summit for Children 1990 – New York
 International Conference on Nutrition 1992 – Rome
 United Nations Conference on Environment and Development 1992 – Rio de Janeiro
 World Conference on Human Rights 1993 – Vienna
 International Conference on Population and Development 1994 – Cairo
 World Summit for Social Development 1995 – Copenhagen
 Fourth World Conference on Women 1995 – Beijing
 Second United Nations Conference on Human Settlements (Habitat II) 1996 – Istanbul
 World Food Summit 1996 – Rome
 International Conference on SWAp 1997 – Copenhagen
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The concept of mutually reinforcing social sectors, socio-economic health and human rights was reflected in the 20/20 initiative. Donors agreed to spend at least 20% of their support on social sectors, if recipient countries would also devote a minimum of 20% of their expenditure to these areas.
In the early nineties, the emphasis on strengthening district health services to improve health began to broaden. Increased international attention was given to the economic, institutional and political functioning of health systems. Any enhancement of effectiveness and efficiency would require fundamental changes across the health sector, or Health Sector Reforms (HSR). The introduction of HSR was further facilitated by the perception of the poor quality of health services and by fundamental political and socioeconomic changes occurring in many countries (democratisation, abolition of communism, marketisation, public service reform).
New mechanisms needed to be developed to ensure sustainable funding and adequate distribution of financial and human resources. They are centralised around five different themes:
 Changing the role of the government and MoH within the health sector.
Government and MoH should be more involved in the organisation, policy development and regulation of the sector and less in the process of provision of health services.
 Improving the performance of the civil service, e.g. through restructuring, new incentive schedules, and improved human resources management.
 Introducing new financial mechanisms in order to broaden the financial base for health care and to enhance its sustainability. User fees, new insurance schemes and community financing mechanisms were established in many countries.
 Promoting decentralisation to enhance the involvement of communities, to reduce bureaucracy and to bring the responsibility for planning and implementation closer to the beneficiaries.
 Stronger involvement of partners, such as the private sector, e.g. through the contracting out of certain activities.
The recognition of the importance of health and HSR, also led donors to reassess the way in which development assistance was managed. In the early nineties, governments and donors began to explore sector wide approaches (SWAp). These involve all partners in development in a more systematic way than the previous project approaches.
Government adopts a central role and becomes increasingly responsible for the management of aid. There is a strong emphasis on donor co-ordination and communication often focused around national health plans. The objective of the approach is to strengthen national health policy, institutional development and programme implementation. This change in approach to aid management has been supported by most multi-lateral and bilateral donors and has dominated the discussions and interactions between donors and recipient countries in the second half of the 1990s.
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3 D ANIDA S UPPORTED H EALTH A CTIVITIES , 1988-1997
3 D ANIDA S UPPORTED H EALTH A CTIVITIES , 1988-1997
Denmark has endorsed the PHC approach as adopted at the Alma-Ata conference in
1978. It therefore subscribes to the main principles of equity, community involvement, focus on prevention, appropriate technology and a multi-sectoral approach. During the
1980s, Danida was instrumental in operationalising the principles and elements of PHC, it focused on primary and public health essential services and developing the health systems to provide them. It pioneered the new concept of Essential Drug Programme
(EDP) and placed strong emphasis on the principles of equity and the utilisation of health services by poor and vulnerable groups. It advocated community participation and stimulated community-based health care by supporting the training of community health workers and the construction of community health centres.
Most of Danida’s support was managed through projects, as elaborated in the Danida documents “Project Guidelines, Appraisal and Planning” (1985) and “Guidelines for
Project Preparation” (1992). Projects were designed and managed primarily in three-stage planning cycles (project preparation, implementation and completion) with support given to a range of providers, including governmental health services and NGOs.
The first half of the nineties was a period of rapid change in Danida’s support to health.
Danida was one of the first donors to recognise that project and provision based assistance often led to fragmentation and was unable to tackle the organisation and management of health systems. Consequently, Danida began to focus more on comprehensive health system projects, particularly on initiatives in relation to district health systems. At the same time, it remained focused on public health and watched for specific new emerging health problems. Danida was among the first to recognise the broad impact of HIV/AIDS on different aspects of life and on different parts of the society. In particular, it supported interventions which dealt with the prevention and consequences of the AIDS epidemic by continuously exploring new avenues, such as home care and counselling activities.
The policy development in health was complementary to an overall change in strategy in
Danida. “Strategy for Danish Development Policy towards the year 2000” (1994), outlined Danida’s objectives and strategies for the latter half of the nineties. Poverty alleviation was established as the fundamental goal of Danish assistance to developing countries. Four principles were stressed (equity, sustainability, effectiveness and efficiency), and three strategies were formulated to achieve this goal (Box 3.1). Danida also identified three cross-cutting themes: women’s participation in development, environmental protection, and the promotion of democracy and human rights.
Box 3.1 Danida's poverty reduction strategy
 Promotion of sustainable economic growth, including redistribution policies
 Development of social sectors, including health and education
 Promotion of popular participation in the development process and development of a society based on the rule of law and good governance
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3 D ANIDA S UPPORTED H EALTH A CTIVITIES , 1988-1997
Fundamentally, Danida reoriented its bilateral aid by advocating a move from project assistance towards a more sectoral approach. To increase its impact, it decided to concentrate its assistance on three or four sectors in its priority countries, incorporating a long-term perspective. This approach enabled Danida to support HSR in developing countries in a more substantial way. It often took the lead in the donor co-ordination necessary to improve the dialogue between donor and recipient countries and to establish an overall health sector policy. Danida emphasised that health policies should be executed through the host country and that separate or parallel structures should be avoided. However, within the framework of Sector Programme Support (SPS), specific activities could still be supported, particularly if they were designed to promote crosscutting themes.
The “Guidelines for Sector Programme Support” (1996, revised in 1998) facilitate the operationalisation of sector support. The guidelines cover the entire process from identification through implementation to evaluation. Nevertheless, it is recognised that they depict an “ideal process” and that the sector development process in any given country should be adjusted to the context in which it operates. Danida has stressed that this process should not be donor-driven. The ownership should lie with the recipient country, which requires of the donors a more supportive and advisory role than an implementing one. This applies to the technical assistance (TA) provided as well.
The international policy emphasis on essential services (including reproductive health) and HSR as reflected in WDR ‘93 and several global conferences substantially influenced
Danida health policies during the 1990s. Danida invested considerable time and effort to adapt to these conditions by formulating new policy frameworks. Danida’s health sector guidelines from 1995 outlined the policies and strategies in the health sector for the latter half of the nineties.
Box 3.2 Health Policy Areas (Danida’s health sector guidelines from 1995)
(Essential) Health services
Child Health
Sexual and Reproductive Health and Rights
Immunisation
Essential Drugs
AIDS
Health systems
Health Financing
Health Planning and Management
Health Manpower Development
Health Research
Community development
Health Education
Safe Water Supply and Sanitation
Gender Perspectives and Empowerment of Women
Nutrition
Health Infrastructure and Equipment
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3 D ANIDA S UPPORTED H EALTH A CTIVITIES , 1988-1997
The main aim is to improve the health status of the population, especially for the most vulnerable and poorest sections. Specific emphasis is placed on women and children. The importance of health systems and the provision of good quality service is stressed in order to increase the utilisation of basic health services. In addition, individual, household and community control over their own health should be strengthened, through enhanced participation in the planning and provision of health services and more appropriate health-related behaviour. A more comprehensive approach to sexual and reproductive health and rights, also highlighted in the Cairo meeting, has been emphasised.
Danish assistance to health has been steadily growing during the period under evaluation, in particular in the latter half of the period with more than 10% of total bilateral assistance being devoted to health 4 . In 1997, the share was exceptionally high at 15.6% equivalent to DKK 815 million. Since then the share of bilateral aid devoted to health has come down to 11.4% in 1998 and 12.6% in 1999. In addition, Danida devotes a further 9-13% of its budget to health-related multilateral organisations and activities.
The document ‘Strategy 2000’ has the clearly stated aim of moving the focus of support away from the project to the sector level. This has been achieved to a large extent in the health sector. This is reflected below in the support to health systems and infrastructure
(Graph 3.1).
Graph 3.1 Danish Bilateral Health Assistance divided into main areas, 1991-1997
500
450
400
350
300
250
200
150
100
50
0
1991 1992 1993 1994
Year
Source: Evaluation Database 1988-1997
1995 1996 1997
AIDS Prevention and
Treatment
Medical Supplies
Preventative Health
Care
Disease Control
Health Systems and
Infra Structure
Health Education
Health Research
4 This overview is derived from Danida's Annual Reports and from a database established for this evaluation in which the ET entered all health interventions (over 400) during the evaluation period 1988-1997.
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3 D ANIDA S UPPORTED H EALTH A CTIVITIES , 1988-1997
Three points are worth noting:
1.
The ‘health systems and infrastructure’ component of bilateral assistance has grown
(due to SPS), reflecting Danida’s large increase in funding to health sector. Other commitments have in fact remained relatively constant or grown slightly. Only
‘medical supplies’ aid has declined significantly in the period for which reliable data are available (1991–1997).
2.
Health sector programmes and projects whose funds are not earmarked are included in the ‘health system’ category. Some of these funds may still end up being spent in areas such as AIDS or health education.
3.
While bilateral government to government channelling (i.e. SPS) has increased in countries with health sector support programmes, e.g. in Uganda since 1994, so too has the funding through Danish NGOs (in this case, the Danish Red Cross and the
Ugandan Essential Drugs Programme).
The SPS strategy focuses aid on a limited number of countries as well as a few sectors. In fact, the ‘core countries’ have remained relatively constant during the evaluation period
(Bangladesh (not an HSPS country), India, Kenya, Mozambique, Tanzania, Uganda, and
Zimbabwe). More recently, Ghana and Zambia and to a lesser extent Bhutan – but lower expenditures are perhaps mainly due to its small size have joined the group. Even before
“Strategy 2000”, a large proportion of Danida expenditure in health was devoted to a relatively small number of countries. The ‘top ten’ recipients of health assistance accounted for approximately 90% of total health expenditure in 1988; by 1997 this was reduced to about 75%. However, the concentration is not immediately seen in the number of countries, as more than 40 receive some form of bilateral health assistance, although the non-HSPS countries receive much smaller allocations than the HSPS countries. Numerous factors have played a role in maintenance of a considerable large number of recipient countries of health assistance. Most important is the Embassy
Appropriation Facility, which has increased since 1989 with allocations of up to DKK 3 million allocated directly from Danish embassies to health projects. Also the increasing number of new ‘transitional’ countries and countries recovering from conflict account for much of the allocation to other than countries with HSPSs.
Graph 3.2 The "top ten" against total Danida health expenditure
900
800
700
600
500
400
300
200
100
0
Top ten
Total
1988 1990 1992 1994 years
1996 1998
Source: Evaluation Database, 1988-1997
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3 D ANIDA S UPPORTED H EALTH A CTIVITIES , 1988-1997
The SPS guidelines emphasise a longer time frame for broader based Danish assistance to a sector rather than the time-bound project approach. However, since 1987, the average duration (as defined in project documents) of newly conceived projects shows a marked shortening, a trend that has continued even after the new guidelines for SPS were implemented. This reflects the planning of HSPS in distinct phases, particularly initially.
Phases of HSPS are planned as individual projects with their own budget allocations, i.e. longer planning time frames were not translated into longer term financial commitments.
Negotiating new terms of financing after each phase may encourage a stop/go relationship. The experience from Kenya, Uganda and Zambia provides an illustration.
Bilateral Health Assistance
"Strategy for Danish Development Policy towards the Year 2000", builds on the principles that that the overall volume of ODA be maintained at one percent of GDP with approximately even distribution between bilateral and multilateral assistance. The principle need not be reflected in individual sectors. The relative share of bilateral health assistance has increased quite substantially during the evaluation period: while it exceeded the relative share of multilateral assistance by 4% in 1989, the figure was 14.7% in 1998.
Since 1991, Danida has classified its bilateral assistance according to DAC ‘sector’ codes.
These facilitate comparison with assistance from other OECD countries. While seven sectors of assistance exceeded the health and population sector in 1991, allocations have grown since then to make it, in 1997, the largest sector for Danish bilateral assistance.
The increase was particularly high (64%) between 1996 and 1997, but fell again in 1998 and 1999. Only the DAC sector “other social infrastructure” increased more during the evaluation period (See Chapter 6: Channelling, Implementation and Performance)
Multilateral assistance to health
In 1998, more than 50 multilateral and international organisations received contributions from Danida, amounting to a total of DK 4,779 million. Approximately 10 of these organisations can be characterised as health-related, namely UNICEF, WHO,
International Planned Parenthood Federation, UNFPA, UNDCP, Health Action
International, the Population Council, the International Disability Foundation,
Management Sciences for Health and UNAIDS. Some of the other multilateral organisations supported by Danida are partly or indirectly involved with health issues, such as UNDP, UNDCP, and UNHCR. It is, however, impossible to estimate how much of Danida's support to these organisations is spent on health.
During the 1990s, annual health-related contributions amounted to approximately 10% of Danida's total multilateral assistance. In 1996, the figure had increased to 13.4%, primarily due to a significant increase in contributions to UNFPA. This increase in funding to UNFPA since 1994 is mainly a result of follow-up on the Cairo Population
Conference. In 1997, UNFPA was the fourth largest multilateral recipient of Danida funding, only exceeded by UNDP, International Dispensary Association and UNHCR.
Contributions to WHO have decreased considerably since 1994, but it is expected that they will increase significantly in coming years given the newly appointed general
17

3 D ANIDA S UPPORTED H EALTH A CTIVITIES , 1988-1997 secretary, Dr. Brundtland. UNAIDS, founded in 1995, has only received support from
Danida since 1996.
In 1988, Danida supported health sector activities in three of the five countries evaluated
(Kenya, Uganda, and India). The support reflected the priorities of the time: in Uganda in
1988, the priority was still post-emergency aid; in Kenya and India, the focus was on
PHC strategies. The universal availability of basic health care services has formed the foundation of international thinking in health policy and development since the Alma
Ata Conference in 1978. In practice, this was typically translated into diffuse individual projects targeted at specific geographical areas (health districts) and specific diseases, for example TB, leprosy or blindness. While these national intervention projects often, but not always, offered immediate relief, they tended to be isolated from the country context in which they operated. However, overall administrative and implementation difficulties in nation-wide policy formation and the donor’s own needs for quick and tangible results continued to justify this fragmented approach.
Graph 3.3 Total Danida expenditure by country
90
80
70
60
50
40
30
20
10
Ghana
India
Kenya
Uganda
Zambia
1988 1989 1990 1991 1992 1993
Year
1994 1995 1996 1997
Source: Evaluation Database, 1988-1997
In the early 1990s Ghana and Zambia also requested Danida to join sector-level initiatives in their countries.
5 Today the five evaluated countries are major recipients of
Danida health sector assistance (Graph 3.3). Although it is still too early to draw solid conclusions, their experience during this period of transition is significant for Danida.
India
India has been a major recipient of Danida health support since the 1970s. Aid has focussed on a limited number of geographical areas (Madhya Pradesh, Tamil Nadu) and a number of national disease programmes (blindness control, leprosy eradication, polio immunisation, and TB control). This has changed only marginally with the introduction of SPS. Since the mid-1990s, support for the integration of vertical programmes for blindness and leprosy in the regular health system has been provided. This has largely taken the form of capacity building in management and information tools for the respective national programmes, maintenance, and capital investments. In recognition of
5 The nine countries with Danida supported HSPSs: Bhutan, Ghana, India, Kenya, Mozambique,
Tanzania, Uganda, Zambia and Zimbabwe
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3 D ANIDA S UPPORTED H EALTH A CTIVITIES , 1988-1997
India’s stable commitment to health, its clear strategy for the sector, and the proportionally small contributions donors make to the sector as a whole, Danida’s programme support aims at the facilitation of India’s health sector reform through innovative, experimental and relatively high-risk projects. The most important aspect of this facilitation process has been the development of the area support programme (a sort of state-wide HSPS). In turn, this has been significant for the development of decentralisation, integration and local management. The leprosy programme was an early example of introducing the concept of channelling public funds through district societies, which are private bodies. This concept was later followed by the blindness prevention programme. The initiative has now been incorporated in the national policy and is partly financed through a substantial World Bank loan.
Uganda
Danida started to contribute significantly to the health sector in Uganda after the end of the civil war in 1986, with a clear post-emergency focus. The majority of the resources was channelled through international NGOs. Support to the Essential Drugs
(Management) Programme, as managed by the Danish Red Cross, constituted the largest part of this assistance. The introduction of SPS in the mid-1990s led to the establishment of an HSPS that integrated the previously separate health projects, but did not support the national health programme. A two-pronged approach emerged, with assistance offered to the central policy-making level and operational support in selected districts.
Recently, phasing out of the involvement of international NGOs (in particular, the
Danish Red Cross involvement in the procurement and management of essential drugs at the central level) has begun.
Kenya
In Kenya, the transition from project to SPS followed a similar path as in Uganda. In a reasonably stable political environment, the Danida projects and programmes that existed in the late 1980s were executed through and alongside the national government and to a lesser extent through NGOs. Support to the Kenya Expanded Programme on
Immunisation, the Preventive Maintenance Implementation Unit, the Essential Drugs
Programme and the Community Based Nutrition Programme, previously called the
Family Life Training Programme, were important components. Separate management units for the components worked out of the central ministry. With the establishment of
HSPS, the essential drugs, immunisation and maintenance components were amalgamated under one management structure. The Danida HSPS team was instrumental in the development of a coherent national health policy in the mid-1990s.
This policy has been translated into a plan which has yet to be operationalised due to conflicting interests within the Kenyan government. Disagreement over conditions for support led to freezing of Danish funds at the time of the evaluation. Support to health research has not been integrated with the reform process.
Zambia
The MoH in Zambia embarked on a process of far-reaching HSR back in the early
1990s. While endorsing PHC principles, the reforms focussed on the decentralisation of responsibilities, cost-sharing, leadership, and partnership. In 1993, the MoH agreed on the modalities of the HSR and invited donors to subscribe and contribute towards the
National Health Policies and Strategies as defined at the end of 1992. Subsequently,
Danida assisted the government in formulating strategies to implement the national health programme. Differing from the technical interventions in the countries above,
HSPS in Zambia provided technical assistance for components of the HSR process. The
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3 D ANIDA S UPPORTED H EALTH A CTIVITIES , 1988-1997 stringent donor government co-ordination and strengthening of accountability resulted in the establishment of a donor “common basket” financing mechanism for the districts.
Between 1993 and 1998, Danida also supported the Christian Medical Association of
Zambia in their AIDS interventions for home-based care. This support accounted for approximately 10% of total Danida sector support to Zambia.
Ghana
Ghana initiated a reform of the health sector in 1991. The central ministry was reorganised, and 14 different technical divisions were transformed into 7 functional units.
Concurrently, the Government of Ghana pursued a civil service reform as part of the
Economic Recovery Programme. Danida selected Ghana as a country for health sector support, and a project formulation mission was carried out in 1992. Through dialogue and at the request of the Ghana MoH, this mission resulted, in 1993, in the start of a support programme which included assistance to the less developed Upper West Region, the National Tuberculosis Programme, institutional strengthening, and the establishment of an HSPS Steering Unit. Danida supported the preparatory phase to establish a national health account, through budget support and support to the development of a financial management system. Recently, donor government co-ordination has led to the establishment of a “Health Account” in which both government and donor resources are pooled. During the period 1991-97, some small projects were executed through NGOs and research was carried out with Danida support including a district PHC project, a project addressing the rehabilitation of the blind, and the maintenance of buildings.
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4 A CHIEVEMENTS , P ERCEIVED I MPACT AND T ARGETING
4 A CHIEVEMENTS , P ERCEIVED I MPACT AND T ARGETING
This chapter presents the main achievements of Danida support to the health sector over the ten years evaluated in the five countries selected for the field studies. First it examines the impact in terms of health status of Danida support. Then it looks at a major intermediate objective, changes in the utilisation of essential services. Both changes in impact and utilisation are difficult to attribute to Danida support. The chapter moves on to discuss the achievements of Danida in its main policy areas as outlined in Danida
Sector Policies, Health (1995). These include essential health services, health systems, community development/participation and infrastructure. These achievements are then analysed with respect to targeting of the poor, women and children.
It is virtually impossible to attribute changes in health status to Danida assistance.
Neither baseline data nor a system for monitoring the achievements of Danida supported projects have been developed. One may ask if such a system would have been useful.
Many factors influencing the health status (such as macro-economics, other donors, food security) are beyond Danida's influence. (It is futile to try to separate the effects of the overall development process and its impact on health.) It should be realised that Danida does not provide health care services itself. It creates conditions, it enables national institutes/persons to provide services.
All five countries will fail to reach the health targets of the Health for All in the Year
2000 strategy. The five countries represent a range of developing countries differing in population size, level of socio-economic development, epidemiological profile and health status, service delivery systems, donor support, and health policies and strategies. In
India, combined donor support for health expenditures amounted to less than 5% of the overall budget on public expenditures for health, compared with over 40% in some of the African countries (Zambia). Danida supported large vertical programmes, short-term projects and sector-wide support with a variety of implementation modalities to facilitate
HSR when appropriate. Given the difficulty of obtaining reliable data on the health status and trends in the five countries, the following observations discuss selected achievements based on data collected from interviews, documents and observations in-country.
Health status of the population
In general, improvements in health are reflected in broad (outcome) indicators such as reduced infant and child mortality rates and a falling crude death rate with a concomitant increase in life expectancy (Table 4.1). Modest reductions in maternal mortality rate and the prevalence of low birth weight and malnutrition among children under 5 were reported, but all indicators remain unacceptably high in the five countries visited, although differences in health status between the countries exist. Significant improvements in infant mortality took place in all countries except Zambia. In the last two decades, positive trends in mortality have stagnated in the African countries included in this evaluation, in some countries largely due to the economic crises and political unrest. Such positive trends were actually reversed in the countries affected severely by the AIDS epidemic. This particularly counts for Zambia, where all major health indicators show a downward trend.
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4 A CHIEVEMENTS , P ERCEIVED I MPACT AND T ARGETING
Table 4.1
Trends in health indicators (1970-1998) for countries visited.
Country Life expectancy Infant mortality rate /
1000 live births
1970 1989 1997 1988
Uganda 46 49 40 110
Kenya 50
Ghana 49
59
55
52
60
96
111
Zambia 46
India 49
55
59
40
63
109
130
1998
86
57
68
112
71
Under-5 mortality rate/ 1000 live births
1989 1997
198 137
159
105
119
125
87
107
202
108
Source : World Development Report (1991, 1999) The World health Report, WHO
(1997).
Minor changes were observed in the morbidity profile of countries still dominated by infectious diseases. Exceptions include the more developed states of India (e.g. the
Danida-supported state of Tamil Nadu) where they have entered a transitional epidemiological phase with increasing morbidity from chronic, non-infectious and behaviour-related diseases. Reproductive health service indicators show a positive trend, with a reduction in crude birth rate and total fertility rate and an increase in contraceptive prevalence rate. Population growth still far exceeds economic growth and increases in food production.
Indicators
Given that large outcome measures such as mortality/morbidity are difficult, costly and time-consuming to estimate
6
, and that country demographic and health status statistics are of questionable quality and limited use to assess the impact of health policies and programmes on health
7
, it has been suggested that more attention be directed to intermediate indicators in relation to Danida inputs. Considering that Danida has designed projects and programmes according to the LFA, which requires identification of indicators, it was surprising to see how limited the use of indicators is for monitoring achievements and impact of health interventions. Danida’s more recent attempt to establish an Output and Outcome Indicator System (1998) 8 was generally met with scepticism in the HSPSs, and by Danida technical staff. The system was seen as neither relevant, practical nor tallied with national statistical preferences. Considerable work needs to be put into impact monitoring before a clear picture stands out regarding targeting and derived benefits for the target groups.
As with health status, it is difficult to attribute changes in general to utilisation of Danida assistance alone. Nevertheless, a few observations can be made. The impact of Danida-
6 Reasons for the lack of data on adult mortality and morbidity for African countries are
7 described by Timaeus, 1991.
While World Fertility Surveys and Demographic and Health Surveys have been conducted recently in most countries, including those evaluated here, according to Directorate of Health services staff, the quality of the data has been variable and the error severest in Sub-Saharan
8
Africa. See also Cohen, 1993.
The system was meant for measuring output and outcome and was not developed as a monitoring system.
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4 A CHIEVEMENTS , P ERCEIVED I MPACT AND T ARGETING supported programmes on the utilisation of services by the general population varies according to the type of services. For example, while coverage of vertical programmes improved substantially, notably of EPI and to a lesser extent of disease control programmes, the actual utilisation of public health services (both curative and maternalchild health) remained low, indicating that there is a long way to go in providing essential services.
From the perspective of the user, there are still substantial problems with essential services in the five countries visited. Reasons for the low utilisation of government services differed per country but were related to the perceived quality of the services offered and the other services available. According to field observations and interviews, the following list outlines some of the problems with perceived quality:
 absence of qualified health staff;
 indifferent attitude of health service providers;
 long waiting time;
 overcrowding of facilities;
 lack of drugs, materials and equipment;
 lack of water supply and electricity;
 general poor access and physical infrastructure.
Along with low client expectations of service quality, the clients’ lack of awareness and indifferent attitude may also contribute to under-utilisation of the services. Strong IEC and advocacy activities can go a long way to counter negative perceptions about or a lack of awareness of existing services. In India, when IEC and advocacy were part of the
DANLEP and later DANPCB programmes, the quality of the programmes was perceived to improve. Ghana is strongly pursuing quality assurance, too.
The best indications of Danida’s contribution to health development in India are the many promising interventions that have been scaled up and replicated. In the national
DANPCB and DANLEP programmes these include, for example, the involvement of
District Societies, private-public mix, MIS and Geographical Information System and blister packs for leprosy; while in District or Area Health Care Projects noted examples are the regional training schools, joint responsibilities in the construction and maintenance of facilities, essential drug policy, management, procurement and production. It also concerns the training of traditional birth attendants and supply of safe delivery kits. Danida-supported pilot projects frequently had a catalytic effect, the value of which far exceeded the money spent.
In the African countries, national programmes such as EPI and EDP have featured prominently in the earlier periods of bilateral and Danida support (Kenya, Uganda). Even following the transition period to HSPSs, they remain important components of health sector support in all four case countries. Danida’s support to EPI in these countries has assisted the government to largely achieve its goal of providing equal access to immunisation nation-wide. EPI services were usually expanded hand-in-hand with the expansion of public health services through government-run institutions, NGOs, the private sector and mobile clinics. The coverage rate of completed immunisation rose on
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4 A CHIEVEMENTS , P ERCEIVED I MPACT AND T ARGETING average by 20-30% in a decade. The relatively recent introduction of cost-sharing may affect these gains, especially where there is no workable exemption policy.
In EDP important achievements have been made in policies and strategies, exemplified in Uganda by the establishment of a national body: the National Drugs Authority. The
EDP has also ensured that drug availability is greatly improved at the rural health facilities. The introduction of the drug kits has facilitated the distribution of the drugs and may have reduced pilferage. However, the vulnerability to irregularities remains too pronounced and has not been sufficiently counteracted through an efficient health management information system. Lack of transparency in price-setting and the distribution of essential and other drugs, poor quality control, and increasing ‘leakage’ of drugs are all factors that hamper efforts to ensure more equitable access to drugs. The ongoing decentralisation process further complicates the transfer since the managerial capacity at district level to run the programme is either incomplete or requires further strengthening.
Integrating vertical programmes is an essential part of HSPSs. In India, the integration of two large vertical programmes (leprosy and blindness) has been initiated. In the short term, the outputs of such programmes may be diluted as it will be difficult for the much weaker routine health system to maintain the quality of well-targeted, staffed and managed vertical programmes. The long-term prospects for sustainability, however, are clearly improving, despite an environment of constrained resources.
In Zambia, the operational strategy changed abruptly, with considerable adverse effects.
Various disease control programmes, although not ones supported by Danida, are on the verge of collapse within the process of health reforms. In the other three countries, the integration process existed mostly on paper, and as a result planning, training, HMIS and supervision are still predominantly programme-based. Traditionally, the regular health system is weaker than the centrally managed programmes, and thus reported performance and achievements may be anticipated to be lower than under vertically managed interventions.
Of the five countries visited, India with its strong hierarchical structures, cultural diversity and size, and relative independence of donor funding has so far been the least involved in HSR. The change in health policy to SPS was mainly reflected in two Danidasupported national programmes (DANPCB and DANLEP) and the shift in focus from districts to an area (state)-wide approach for bilateral co-operation in health. The government stands by its policy to provide free, quality health care through the public sector and has been cautiously supporting the decentralisation movement. It also advocates several components of HSR such as transparency in planning and resource allocation, accountability, appropriate administrative and financial management, monitoring of prioritised outcomes and impact. Both the government and the international donor community respect Danida as a constructive partner in these processes.
Since 1995, Danida has played a central role in the transition to SPS in Kenya and has been instrumental in the development of the Health Policy Framework Implementation and Action Plan (issued in February 1996). However, this plan has still not been
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4 A CHIEVEMENTS , P ERCEIVED I MPACT AND T ARGETING implemented, most likely due to insufficient ownership by the MoH and a lack of clearly defined priorities in health on the one hand, and a lack of basic trust in the government's accountability on the other. The government-to-government agreement covered the end of 1998 and renewal depends on an agreement acceptable to both Danida and the government.
Uganda has undergone tremendous reform, thriving on active support from national and local authorities, and has benefited from consistent Danida support in this area.
Although Danida is strengthening capacity to implement the health sector reform at the district level in three northern districts, most mechanisms for managing and financing the health sector are being transformed or finding their own local modalities. Financial irregularities in some components of the HSPS have led to delays or to a general freeze in disbursements to the detriment of overall progress. In this regard, the national authorities have requested more flexibility from Danida’s side, and the delicate trustcontrol balance between donor and government reportedly needs to be strengthened.
In Zambia, Danida was considered a forerunner in its strong policy support to health sector reforms, in particular decentralisation and de-linkage of an executive authority,
(the central board of health) within the MoH. Following the election of a new government in 1991, Danida supported the rapid channelling of funds to the district. It also helped pilot basket funding and invested in improved financial and health information management systems. Danida further contributed to pilot testing of certain aspects of the health sector reforms in three districts. These efforts have resulted in a strengthening of national capacity and growing donor trust in the reform process of the
MoH. Nevertheless, the de-linkage process has recently been halted and the reform process has proved difficult to sustain at its early pace. A contributory factor has been the failure of the HSR to show any observable improvement in health services and health status.
In Ghana, reforms (particularly financing reforms) were underway before the period of
Danida support. Danida used a somewhat different approach than in Zambia. In the early part of the period evaluated Danida supported the development of district services in a region. In the mid-nineties, Danida provided substantial support to the preparation of a national health plan and a SPS to support it. While it directed strong policy assistance to HSR and piloted the shift from project to sector support (in the Upper
West Region) much like in Zambia, this piloting of strategies came with flexible budget support and almost completely without conditionalities for aid. The national plan is currently on track, although questions still remain on how to co-ordinate deconcentration in the health sector with local government decentralisation.
Looking across the five countries, the success of Danida’s support to HSR seems dependant on the national ownership and the capacity to implement reforms, (for further discussion on ownership see Chapter 5 Policy and Strategy Development). Any reforms initiated in the health sector usually pertain to larger overall reforms in the governance of the country involved. Without stability in this area, radical reforms become a high risk investment compared to incremental developments. It is evident that some basic prerequisites for a smooth implementation of a jointly developed health sector reform programme were not adequately met in Kenya, Zambia and Uganda. Such factors include a clear understanding and agreement around the key elements of the support, trust and credibility of partnership, modalities for monitoring and evaluation, and pre-agreed timeframes for co-funding and phasing out of support.
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4 A CHIEVEMENTS , P ERCEIVED I MPACT AND T ARGETING
The second key determinant of success is the capacity to implement reforms
(acknowledging that the purpose of many reforms is to strengthen capacity). SPS focuses support at the central level. However, there is a tendency for the centre to move faster than the periphery in the development and implementation of decentralisation and other reform policies. The situation varies widely among the countries. In Kenya, decentralisation has not materialised despite a national decentralisation policy, but in
Uganda decentralisation is actively encouraged through the central level. The limited capacity of the peripheral government to absorb changes has often caused a fragmented approach towards local initiatives.
There is a central dilemma on how to reconcile immediate needs with a reform-oriented approach. There is history of centralised management in Uganda and Kenya, very much built around vertical, externally funded interventions. At the end of the war in Uganda, there was an obvious need for the provision of essential drugs. Not surprisingly, to be quick and efficient, the Danish Red Cross retained the management of this programme.
The management of the various vertical programmes often decided the priorities for health services. To exchange these parallel-planning mechanisms in favour of sector-wide planning with far less opportunity for centrally located institutions to implement them means surrendering control over reasonably successful programmes and the associated resources. The integration currently in process is hampered by lack of managerial capacity within partner agencies.
Health sector reforms often take place within the context of general civil service reform.
In some circumstances, incongruent development of the two processes has caused conflicts. In Zambia, the public sector reform programme made it difficult to appoint new staff, and the payment of staff has been problematic. In Uganda, there seems to be a discrepancy between the centralised health sector planning and the ongoing political, administrative, and financial decentralisation. For example, a MoH directive to districts to upgrade the health infrastructure could not be incorporated in the district budgets.
The proportion of government expenditure allocated to health is a basic indicator of the government commitment to financing health. This increased or remained constant in
Danida-supported countries, indicating little fungibility of Danish aid at the sectoral level.
In the four African countries, the level of spending varied between 4% and 8% of total public expenditure on health, while in India it was around 3%. In Zambia, there was a marked increase in the proportion allocated to health. In Ghana, Uganda, Kenya and
India (broadly), the trend is more sporadic, but in general the proportion allocated to health remained constant or only rose slightly. During the evaluation period, both Kenya and Uganda experienced cuts in the amount of total public expenditure. In the mid- to late 1980s, the IMF identified the health sector as being most vulnerable to public expenditure cuts in Africa (UNICEF, 1987). Therefore, maintaining constant levels of health expenditure in Kenya and Uganda indicates a relatively high level of commitment.
It was difficult to assess whether financing increased to essential services during the period evaluated. In all the countries visited, resource allocations to different levels changed over time and many did not indicate where resources were used. Nevertheless, the record of government commitment to allocating more money to essential health
26

4 A CHIEVEMENTS , P ERCEIVED I MPACT AND T ARGETING services has clearly been mixed (in absolute and relative terms). Of the five countries,
Uganda has been the most successful: in recent years, the government has made significant increases in the financial contributions to the district level. Other countries have also increased the proportions allocated to basic services (Kenya, India, and Ghana in the late 1990s), but these have been relatively small. While official Zambian government figures are difficult to interpret, the evaluation team did not observe increased allocations to basic health services. The combined effect of little growth in national allocations and simultaneous growth of donor support has in financial terms increased the reliance on donors, including Danida, to develop district health services.
Danida has typically invested in capital or non-salary recurrent items rather than salaries.
Although prioritised primarily for reasons of sustainability, these items were also seen as relatively under-funded and vulnerable to public expenditure cuts. Danida made considerable investments in drugs and repair/maintenance. However, in all the countries visited, the proportion of government expenditure allocated to salaries has remained high and allocations to non-salary areas, such as drugs, low (including financing raised from direct payments). With the exception of Zambia, salaries form the largest part of health service costs. In Kenya and Uganda, the bulk of Danida's financing was spent on drugs; in Zambia and Ghana on non-salary district items such as repair and maintenance, drugs and training and capital items such as infrastructure; and in India on non-salary support to programmes. By and large, it was found that national governments have not managed to increase their funding to these areas; for example, it has been difficult to obtain domestic financing for the drugs programme in Kenya. Exceptions arise when governments manage to establish successful financing schemes. For example, in Ghana, user fees have substantially increased the funds available for fuel and medicines, although the main increase preceded Danida's investment.
There are early indications that the process of a SWAp to health has the potential to address some of the necessary reallocations to basic health services. In Ghana, for example, it allowed donors to negotiate down the level of commercial loans for building new hospitals. However, to date there is no example of a government successfully addressing inefficient allocations to salaries expenditure, that allows for motivation and equitable geographic distribution of health staff.
Danida has provided project support to specific areas of health such as TB and leprosy and to specific regions. In most cases, when specific areas were financed, government financing also increased. Donor funding to specific areas can make them more attractive in terms of employment and investment opportunities. For example, investments made in Ghana in the Upper West Region attracted increased government resources. In India,
Danida’s support has resulted in increased government commitment to specific diseases and, in some cases, promoted national expansion of the programme. However, there is little evidence that this increased commitment can be sustained once a donor ceases its investment. Ghana forms an exception here as negotiations during the SPS preparations managed to secure some continuation of funding from the government. Here the government expenditures to the health sector in UWR has not declined after withdrawal of Danida support.
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4 A CHIEVEMENTS , P ERCEIVED I MPACT AND T ARGETING
Danida considered human resource development, and training in particular of all health workers, a key strategy of its HSPSs to improve the quality of public health care. Thus, extensive support was given to the development and upgrading of training institutions
(regional and district level) for community health nurses, midwives and rural health workers and to training activities. In Ghana, training included pre-service training for health personnel at the operational level; in Uganda, support was offered to basic training; and in India the area programmes supported training of auxiliary nurse midwives and other categories. In the other countries, human resource development involved on-the-job training for staff in new concepts and technical aspects of interventions and management. In general, Danida made important contributions to the development of training curricula, modules, manuals and other material. It also promoted the advanced training of trainers. In particular, the Danida-supported training of newly recruited primary level health workers (village health workers and traditional birth attendants in African countries, multi-purpose workers in India) allowed for the necessary expansion of peripheral service delivery. Most notably, in the vertical/national programmes (India, Kenya), it was reported and observed that training has helped ensure a better quality of care.
A number of observations can be made regarding Danida’s approach to human resource development and specifically training:
1.
The need for training was usually centrally determined following national programmes with donor funds for training and was insufficiently based on a needs assessment leading to a plan of “who will be trained, when and in what” as part of an overall resource development plan (except for Ghana).
2.
Training programmes were often designed with limited active involvement of the state (India), regional or district level administrations, and thus usually resulted in lack of ownership. This, in turn, caused difficulties in the phasing out of support to the training institutions and programmes at the termination of donor funding.
3.
Much emphasis was directed toward increasing knowledge and capabilities in planning and management. Although training in important areas like information, education and communication (IEC) and community mobilisation took place, they were rarely applied by health personnel or followed up with implementation.
4.
More sensitive aspects of human resource management and deployment policies were either not, or not adequately, integrated into overall resource development plans.
Despite the investments in human resources, many vacancies in health centres or subhealth centres/health posts exist, which is partly attributable to a lack of funds available for salaries (see previous section on resource allocation). Other reasons include a lack of motivation to reside in the assigned posts, no living quarters for staff, and lack of security for female health workers. In Ghana and India, Danida has successfully responded to these problems by building staff quarters and improving the living conditions.
Danida (and other donor) support has improved the geographical accessibility of public health services at the peripheral level through the physical expansion and upgrading of the health service delivery system and the provision of logistics. Provision of infrastructure such as rural clinics, training schools and workshops has accounted for
28

4 A CHIEVEMENTS , P ERCEIVED I MPACT AND T ARGETING around 50% of Danida's health expenditures to the recipient countries. In all four case countries, the buildings were appropriate in design and of good quality (although in
Zambia there was no specific support for infrastructure). In Kenya, current attempts to establish mechanisms for raising maintenance funds and establishing participatory maintenance systems are only being piloted and could not be assessed in this evaluation.
Renovation of training schools in Uganda and Ghana were of excellent quality and were carried out with the participation of future users.
In the African countries, Danida has focussed on the maintenance of the facilities provided. The main obstacles to successful maintenance are ownership, availability of funds and an organised maintenance system. In India a serious problem exists with the maintenance of rural clinics. There, uncertain ownership and low motivation in the
Public Works Department (common in all countries) threaten to limit resources spent on buildings owned by MoH. A process towards local ownership has been initiated in the countries visited, and this should continue to be supported. The successful introduction of joint community responsibilities in the construction and renovation of buildings, as in
Uganda, will undoubtedly increase local ownership and enhance prospects for sustainability within the limits of local funds.
In all countries (except Ghana), it was observed that the responsibility for maintenance was unclear. Where a responsible person was found, practical planning tools were lacking. This emphasises the need for an appraisal of maintenance needs, the knowledge of how to apply for funds for preventive maintenance or repair at the central level and how to generate local funds for maintenance. In Ghana, Danida supported the introduction of an Estate Management Unit which is presently being decentralised to the regions. The regional estate managers and hospital estate managers, who are responsible for construction and preventive maintenance, are in place and well motivated, a promising situation. The involvement of the users in renovating training institutions and hospitals has resulted in a greater awareness of the necessity of maintenance and improved the feeling of ownership of the facilities.
Where Danida's support has included means of transport (minibuses, trucks, motorbikes), the simultaneous establishment of maintenance workshops resulted in better maintenance and consequently increased durability of the equipment. Examples of support to maintenance units include the Biomedical Engineering Units that are awaiting staff and the Estate Management Unit in the Upper Western Region of Ghana. The latter unit is being decentralised, and the regional estate managers and hospital estate managers are motivated and equipped with the necessary tools to maintain training institutions and hospitals. Another excellent example is the well functioning workshop for maintaining hospital equipment in Uganda. Only in Uganda and Ghana did Danida finance solar battery power for appliances (fridge, lamps and other essential equipment). This form of energy is becoming more reliable and a good example of locally appropriate technology.
The implementation of a preventive maintenance policy for all investments in transport, building and hospital equipment is essential for sustainability. Ghana (UWR) provides a successful example. Workshops for hospital equipment in Uganda were found to be functioning well and performing a very important task. The Biomedical Engineering Unit in Ghana was still awaiting staff, but the idea of a combined workshop for trucks and motorcycles is very promising.
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4 A CHIEVEMENTS , P ERCEIVED I MPACT AND T ARGETING
Danida’s shift from project to programme support and later to SPS implicitly redirected the targeting exercise back to health planners and managers at MoH, more than to the regional and district levels, and health care providers at the peripheral levels, as observed in the five case countries. Danida’s role in working with and reaching the ultimate beneficiaries, e.g. communities, was thus largely limited to its contribution to the development of appropriate, cost-effective, equitable and sustainable national health plans and programmes. Danida did, however, earmark funds to enhance community involvement and decision-making, with only limited experience to date in its operationalisation. In India, and to a certain extent in Uganda, Danida also took the lead in incorporating gender issues in its health activities.
The degree to which the ultimate beneficiaries actually benefit from HSRs and SPS depends to a large extent on their role in determining needs, co-management of health services and budget allocation. Since Alma Ata (1987), community participation has been an essential component in national governments’ and donors’ health and development policies. In India, local health authorities and health workers were extensively involved in planning in the 1970s, which probably contributed to later success.
In practice, an array of factors accounts for the generally limited success of communitydeveloped and -led activities in health. For the five countries visisted, these included: a recent start and slow process of democratisation; a preoccupation with purely technical, administrative and financial matters; limited skills in social mobilisation of the health service managers and providers (local and technical assistance); and a lack of real participatory planning. The team noted that community consultation and needs assessment did not routinely feature in the planning phase of externally supported programmes. Public health problems and subsequent interventions were generally identified at the central level (although there is a recent shift to the district level as part of the ongoing devolution and decentralisation processes).
There are examples in which a rapid appraisal or baseline survey preceded priority setting in Danida-supported health packages. However, this does not necessarily mean that community needs were taken into account, as the information was analysed and interpreted by outside professionals. Nor does it mean that the community was involved in the subsequent steps of priority setting, planning, resource allocation and management.
Danida's support has helped improve community participation in some respects.
Communities usually participated in the construction of the peripheral health units, in maternal-child health activities, and most successfully in disease control programmes
(leprosy, blindness, AIDS). Accompanying IEC activities aimed to mobilise the community for these programmes by asking them to share some of the costs through contributing labour/time, materials and sometimes money. In essence, this type of semivoluntary participation only marginally affected the utilisation of health services. Many projects selected community representatives on the basis of traditional group formation and establishments, rarely guided by leadership skills, gender or other such considerations.
Communities are being heard through PRA studies in Zambia and Ghana, and in the three northern districts included in the Danida-supported HSPS in Uganda. Otherwise, the health sector planning process is generally awaiting operationalisation of district and
30

4 A CHIEVEMENTS , P ERCEIVED I MPACT AND T ARGETING community mobilisation. Efforts to mobilise stakeholders at the national and local government levels through human resources capacity building and training had come to a standstill in the Uganda HSPS due to the premature departure of the responsible Danish
TA.
Co-operation between different categories and groups of health providers is desirable, if not essential, to strengthen the coverage and utilisation of available services. Most donor- and Danida-supported programmes have established or improved the relationship with community-based (traditional) health care providers, most notably traditional birth attendants. While training traditional birth attendants formed part of human resources development, depending upon the relative importance and level of utilisation of these birth attendants in the population and the (non-)existence of alternative providers to ensure safe deliveries, the observed weakness lay in the ineffective management and inadequate linkage of such community-based health workers to other (higher) sources of care. Observations from the field confirmed that community health volunteers and workers were hardly supervised, monitored, or supported in their activities and rarely involved in local planning.
Democratic election mechanisms have been put in place and the formation of village health committees (VHCs) has been completed in many places, sometimes reflecting local preferences for multi-sector committees such as joint water and health committees in parts of Uganda. Yet the output of VHCs has frequently been ambivalent, in India as well as in the African countries. A variety of reasons exist: false expectations of service delivery by other donors mean that many health committees do not function properly; confusion as to the involvement of communities in the management of funds coming from user fees as experienced in Zambia and India. Finally, it should also be noted that the elected partners in discussion not necessarily represent the community concerned.
The equal representation of men and women tends to decline over time. A more elaborate discussion on this subject can be found in the issue paper “Stakeholder participation”.
Women in all five countries are regarded as care providers for the family, but their formal involvement in health remains marginalised. It is encouraging to note that the representation of women in health management teams, in district, sub-district and village assemblies and councils has increased, partly as a result of Danida’s preoccupation with gender. Although important, this development represents merely a first step in the process toward gender equality and the promotion of gender awareness and sensitivity in health programmes.
Involvement of local health authorities
Over time, Danida’s consistent policy in support of devolution of authority has played an important direct or indirect role in empowering district and sub-district level health staff.
Such staff became increasingly involved in and responsible for planning and management, eventually providing the prospect of community based planning and management.
Decentralisation and devolution of technical, fiscal and managerial responsibilities greatly differ across countries, but in general are still in the initial stages. It will take time before all stakeholders will have an equal opportunity to participate in planning, selection of priorities and resource allocation. A key constraint to the more rapid and meaningful inclusion of stakeholders in the countries included in this evaluation relates to the
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4 A CHIEVEMENTS , P ERCEIVED I MPACT AND T ARGETING traditional hierarchical structure of society, which respects and values position, seniority and kinship more than merit. The higher echelons and the medical doctors dominate the process, leaving a marginal role for those near to the grassroots (paramedical personnel, health assemblies). One key stakeholder, the lower level administrative units (district, sub-district and village assemblies or councils), was excluded most often from the planning and implementation processes (except in Uganda).
Another barrier is that micro-level planning will have little relevance to district and subdistrict level stakeholders if there is limited or no room for change in centrally determined inputs or activities with budget ceilings. This was certainly the case in India, although less so in Ghana and Zambia. In the latter two countries, system tools to facilitate and encourage local ownership and participation (HMIS and financial administrative management) have been developed but are still in the process of defining locally feasible (resources, infrastructure), cost-effective health packages.
Support through NGOs
Danida's experience with NGOs were probably as varied as its experience with the various MoHs. An example of successful Danida support to a local NGO is the AIDS
Support Organisation in Uganda (TASO). HIV/AIDS patients and affected dependants have learned to live with AIDS and have experienced improvements in their quality of life through home-based care. Danida was instrumental in assisting TASO to obtain more basket funding and maintain uniform management, implementation and reporting systems. Danida-supported capacity building has allowed TASO to cope adequately with the transition from a small NGO to a large multi-donor-funded one with new demands on management approach, monitoring and quality assurance of activities, staff policy, transparency, co-ordination with other AIDS programmes and adjustment of its intervention strategy. The support to CMAZ represents an example of assistance to an umbrella network of national NGOs. Danida's contributions were earmarked to AIDS interventions and mostly oriented to the provision of (medical) care. While CMAZ’s vertical organisation may hamper integration in a sector-wide approach, its approach may lend itself well to future operational research.
There were also examples of less successful collaboration with local (national and international) NGOs such as with AMREF in Kenya. Participatory planning, clear understanding of roles and responsibilities, and good (donor) co-ordination might have prevented crisis management and premature termination of the contract in this case.
The reduction of poverty is the overriding aim of Danida development assistance. Over the last decade, targeting of ‘the poor’, vulnerable groups, ethnic minorities, women and children has become more explicit in Danida’s policies and strategies and in country programmes. Selected requirements to achieve improved targeting are:
1.
Attention to how particular target groups can be addressed in programme design, implementation practices, and not least in terms of monitoring and evaluation of effects and ‘perceived’ impact, - (where long-term impact assessment is not realistic considering time perspective to measure impact and the resources required).
2.
Shared understanding and willingness by all stakeholders – Danida, advisors and recipient agencies – that targeting is necessary and desirable.
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4 A CHIEVEMENTS , P ERCEIVED I MPACT AND T ARGETING
3.
Knowledge of better practices, approaches and tools for targeting and monitoring targeting – including establishment and utilisation of indicators.
The evaluation found that the necessary requirements have rarely been fulfilled, and achievements in terms of better targeting and improved conditions for specifically targeted groups therefore difficult to establish. Particular effects on specific target groups, e.g. women and children, appear to be incidental rather than planned.
The governments of the four African countries included in this study have always placed a high priority on the improvement of the health of the general population, rather than specific groups. Five-Year National Development Plans or National Health Plans did not specify target groups for the interventions. General health policy and service delivery strategies focussed on providing the population with equal access to health care of acceptable quality. In contrast, India’s Health-for-All national policy was later changed to
Health-for-Underprivileged and does emphasise the need to address the health of women, children, scheduled castes and scheduled tribes.
As a result of differing national contexts and priorities and international trends in health,
Danida-supported projects before 1995 reflected the need for strengthening the peripheral health service delivery (Ghana, Uganda, Zambia, and India) and/or vertical programmes addressing diseases of public health magnitude (India, Kenya). The various district health projects reflected efforts to strengthen health care at the lower levels. At that time, Danida had not yet made poverty reduction the explicit basic principle of aid.
Women in Development, while an explicit cross-cutting issue since adoption of the WID policy in 1993, was only slowly reflected in specific targeting of women and children.
Women were indirect beneficiaries rather than a specific target population. Their participation in project design, implementation and evaluation was limited. The selection of districts reflected socio-economic and geographical targeting, reaching the most under-served districts (Ghana, Uganda) or districts with a large socio-culturally deprived population (India). Although Danida support to strengthen primary health care services did not specify gender concerns or include target groups, it did address the needs of primary users of maternal-child health and family planning services.
The Danida-supported vertical programmes complied with its policy to increase access and coverage of essential health care or to address health problems that disproportionately affect the poor or are a heavy burden on them. Particularly in the
African countries, EDPs made drugs available at rural health facilities and improved the vaccination coverage. Data have clearly indicated that TB and AIDS are major health problems particularly affecting the poor. In Uganda, AIDS clients belong mostly to the absolute poor, and programme support provided much needed welfare and material support to single mothers and other women. The main argument for retaining the CBNP in Kenya was that it was the only programme aimed specifically at the very vulnerable group of young, malnourished children. Although, maternal health and malnutrition has been a subject in training, Danida didn’t address this issue with adequate interventions, while the prevalence of both reaches two digit percentages in all the countries reviewed.
This problem, however, is a difficult issue to tackle which cannot be solved by one donor alone. Danida’s support to leprosy and blindness control in India also closely follows its overall goal to improve the health of the poor. Leprosy is mainly a health problem of the poor, and while adult blindness hardly affects the population at large, it has considerable economic implications for the poor.
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No quantifiable information was available to assess the impact on the overall economic access to essential health services. However, there are indications that the introduction of user fees and inadequate targeting of the poor may have negative repercussions on the access to public health care for vulnerable groups. Current targeting practices, based on geographic location and known vulnerable pockets of the population, appear insufficiently refined to reach the hard-to-reach groups and the hidden poor. Danida has recognised this, in Ghana, by earmarking funds within the HSPS to support the development of exemption systems. Similar to economic access, there was no information from the African case countries regarding socio-cultural access. In India, cultural barriers were reported and observed for selected minority groups and lower castes. Health providers were not motivated to serve these groups due to the difficulties in reaching them. Attempts to train men or women from the target population as village health providers have not yet been successful. This was partly because the recruitment criteria were reportedly too high (few of the potential candidates had finished primary school).
Good practices:
 The influence of those (including Danida) who have emphasised the importance of the social sectors in the international policy arena has enabled the maintenance of levels of health expenditure by countries facing substantial macro-economic difficulties.
 The move from project support to SPS in the Upper West Region of Ghana provides a good example of a sector wide approach. In 1992, a Danish identification mission visited the region and presented specific areas, which qualified for support, to a small group of decision-makers at the regional level. This group too requested funding.
The priorities were essential drugs and support to the hospital level. Neither were honoured. Instead the HSPS office in Accra retained the management of the funds, but the different district programmes received support in the consultation process with regional stakeholders. The district plans for the Upper West Region, resulting from these processes, were then financed through the common health account, as part of the national health programme. Danida now supports the sector as a whole, instead of financing earmarked micro projects.
 While community participation appeared inadequate at times or not as effective as desired, Danida-supported interventions did help to establish certain community-led and -owned activities, such as the construction of health posts/sub-health centres and District Societies in India.
 In India and Ghana, Danida financed the construction of staff quarters. This contributed significantly to increased enthusiasm to work in remote areas and higher job satisfaction.
 Provision of physical facilities of good quality has strongly motivated health projects.
The concurrent support to maintenance workshops (facilities and transport) improved the durability of hardware. The creation of an estate management unit, which is now being decentralised in Ghana, is very promising.
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4 A CHIEVEMENTS , P ERCEIVED I MPACT AND T ARGETING
Lessons learned:
 In some countries, the difficulties in continuing support under SPS to previously effective vertical programmes may have had a negative effect on health. Danida, historically one of the most important donors for vertical inputs, finds it difficult to transform separate projects into a sector-wide policy. For example, HSPSs in Kenya and Uganda still show distinct project characteristics. The challenge remains to maintain the existing experience and capacity with pragmatic solutions.
 There are early indications, from countries like Ghana, that SPS has a positive effect by supporting HSR and resource allocation, that ultimately is necessary for sustainable essential services.
 Within the health sector there has been limited success in increasing domestic funding to non-salary and basic level services. Significantly, recipient governments have not managed to deal with the level and allocation of the salaries and hospital expenditures adequately. As a consequence, the large increases in donor financing to health, particularly to basic health services (sometimes including substantial contributions by Danida), have inadvertently reinforced financial dependence on external aid. The shift to sector wide approaches intends to overcome this problem.
 Political and capacity requirements to enable a smooth process of HSR were somewhat underestimated in some countries. The political processes necessary to implement important changes are often slow. Many five-year plans were too ambitious. Timing and modalities for phasing-out of project/programme support were not sufficiently guided by the knowledge of what works. The relative absorption capacity of the different parties involved at the national, state and local levels were not sufficiently considered. In particular, the managerial absorption capacity for guiding the decentralisation process at the peripheral level has been overestimated.
Lack of guidance and supervision from the centre has resulted in a fragmented approach. The autonomy of the districts to manage public services needs extensive capacity building.
 Not all stakeholders in the health sector have the same understanding of HSR.
Similarly, not all actors have been optimally involved in the formulation of policies and strategies. This has led to the patchy implementation of reforms and fragmented, non-transparent health service delivery. With varying degrees of success, Danida has established mechanisms for dialogue with different stakeholder groups, but the participation has been insufficient.
 Despite their important position in the health system, grassroots level stakeholders
(paramedical personnel, health assemblies) are not often consulted in the planning or prioritising phases but are more involved in the actual implementation. Consequently, the national programmes do not reflect the needs and priorities of the operational level. Given their importance in deciding on the allocation of local taxes and future decentralised budgets, their sense of ownership in health and social sector activities will have an obvious influence on the subsequent sustainability of interventions.
 Human resource development, although successful in upgrading the knowledge and skills of district level health staff, needs the support of a broader human resource development plan and adequate financing for staff providing essential health services.
 Inadequate explicit targeting of the poor resulted in less attention being paid to the development of appropriate strategies to increase poor people's access to health services (except perhaps for the Upper West Region of Ghana). An example is the indication that in Uganda and Kenya the system for the provision of drugs has
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4 A CHIEVEMENTS , P ERCEIVED I MPACT AND T ARGETING become more inequitable over the period under review. Application of indicators to monitor interventions at targeted groups has never been put in place.
 The lack of ownership and the local Department of Public Work's inability or indifference to spend resources on MoH buildings (in all countries except Ghana) were reported as serious threats to the sustainability of maintenance efforts.
Recommendations:
1.
Blueprint policy shifts may turn out to be inappropriate if the absorption capacity of the recipient country is over-stretched. The pace of the implementation of the policy shift needs careful co-ordination with the pace of national HSR. The capacity of the different levels of the health pyramid to absorb new functions demands consideration. With respect to the implementation of SPS, it is recommended that
Danida follows a flexible process approach based on each country's requirements, with substantial attention being paid to the institutional, economic and political risks.
2.
It may be more meaningful to integrate vertical programmes by designing comprehensive packages for nationwide implementation that are often cross-cutting in nature, such as for Reproductive and Child Health, Disease Control, and
Integrated Management of Childhood Illnesses, as recently proposed by WHO.
3.
While Danida support did concentrate on serving poor communities in rural areas and underprivileged population groups in India and Ghana, actual targeting should be more refined toward vulnerable groups. This is a matter of concern after the shift to SPS.
4.
It is recommended that in future Danida should attempt to gather information based on available or additional data sources to assess the impact of Danida supported programmes on beneficiaries. While measuring the impact on health status and other outcome indicators may remain too cumbersome, pilot projects and operation research in the catchment areas may help to ascertain changes in health-seeking behaviour, access, coverage and utilisation rates, quality of care and client satisfaction.
They are essential, for example, to explore ways to reach the poor, to assess the impact of user fees on health-seeking behaviour, to strengthen women’s and local health authorities’ involvement in the design and implementation of health interventions, and to design and provide appropriate packages of health interventions at the different levels of care.
5.
Danida should support studies investigating local needs and the socio-cultural acceptability of services. Results of these studies will help to ensure that communities will not view participation as an imposition but as an expression of genuine interest in their involvement. It is also recommended that more research be conducted on strategies to reach selected minority groups and provide support through the formal and non-formal health sectors
6.
To help ease possible inequitable effects of user fees, Danida should consider taking the lead in the deliberations on health financing, looking into differential user fees
(how much and what for), exemption criteria (who are the poor and how to reach them without stigmatising them), and community involvement in the utilisation of user fees/cost recovery mechanisms (like for example already done in Ghana).
7.
Increasing resources (recurrent budget financing) is one method of providing incentives for trained staff to stay in the sector. Increasing resources do not necessarily imply salary support. The options for increasing non-salary benefits are also considerable (e.g. housing, transport, career structures). How to move forward with respect to this common problem is difficult. Danida should facilitate that
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4 A CHIEVEMENTS , P ERCEIVED I MPACT AND T ARGETING experiences of creative local solutions be shared and mechanisms established for this to happen, e.g. through regular consultations.
8.
In India, Danida has taken the lead in incorporating gender issues in its health interventions through collaboration with women’s groups. It is recommended that
HSPS in the African countries look for opportunities to introduce similar approaches to gender.
9.
The provision of workshops for transport equipment and for hospital equipment is essential and should be expanded and support should be continued.
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5 P OLICY AND S TRATEGY D EVELOPMENT
P OLICY AND S TRATEGY D EVELOPMENT
This chapter examines policy and strategy development from two perspectives. In the first section, the appropriateness of Danida’s assistance to the economic, political and institutional context of the five countries visited. The second section assesses whether
Danida has been successful in achieving its objectives at policy and strategy level within countries. In particular, it focuses on the move from project support to sector support.
At the end of the eighties, most of the African countries supported by Danida were facing reductions in public sector expenditure, including the social sectors. Some had not achieved macro-economic stability, but were showing potential to do so. The case of
Zambia provides an illustration. At the time when Danida began its support to the health sector, Zambia was in the midst of economic uncertainty. On the one hand there was a situation of high inflation, instability in GDP and a substantial reliance on foreign financing, on the other a relatively new government embarking on a programme of rapid economic and public sector reforms. In this situation Danida’s response of SPS support can be seen as appropriate to the macro-economic circumstances, protecting the social sectors in time of instability, consistent with SAP with a human face.
Macro-economic instability can, however, present serious hurdles to governments' own commitments to the social sector and may therefore threaten the effectiveness of SPS. In the countries visited government financial support to the health sector remained constant or increased within the evaluation period. This indicates that the judgement on commitment and stability that Danida made at the time of initiating SPS was correct and that in these conditions, (Zambia, Ghana, Uganda and Kenya) SPS was an appropriate tool, given the macro-economic context. Nevertheless, although the signs during the evaluation period are encouraging, the future remains uncertain. In 1998, Zambia failed to keep its budgetary commitments to the health sector resulting in a temporary suspension of Danida support. In Ghana, the recent pattern of growing tax revenues, expenditure control and growth in Ghana is encouraging, but it is still a long way off generating a domestic fiscal surplus. It remains to be seen, if the government can generate the optimistic growth rates (8% target) and stability to ensure the ambitious increase in allocation to the health sector.
In countries emerging from a conflict situation, such as Uganda in the mid 1980s,
Danida’s focus on rehabilitation and infrastructure can be seen as appropriate. The focus on the provision of drugs and vertical programmes was also highly appropriate.
Danida’s support has on the whole been complementary to public sector reforms, focusing on organisational reforms and strengthening management systems. There are, however, some notable exceptions. In Ghana, Danida followed the national policy in supporting the deconcentration of health services and the management systems to support this, but at present it is still not clear how this fits in with the decentralisation of all government services. In Zambia, the de-linkage of the MoH created different employment conditions from the rest of the civil service and staff have not been
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5 P OLICY AND S TRATEGY D EVELOPMENT rewarded to date. This has proved difficult to achieve focussing on the health sector alone.
Danida's assistance was thus largely appropriate to the guiding principle elaborated earlier. In general, projects achieved their objectives. However, after the introduction of
SPS there are also examples where Danida support was not sufficiently addressed by national policies or sufficiently dealt with in annual/five-year action plans. Examples of problems include:
(a) training of health staff isolated from national human resource management (recruitment, emoluments, career development, allocation), which in itself was weak in all countries;
(b) strengthening of the physical infrastructure without inter-sectoral collaboration with, amongst others, the Public Works Department.
From project support to sector support
Danida’s HSPSs are based on a process of health policy, strategic development and institutional strengthening. There are five main areas of support as described in Danida’s
Sector Policies, Health, January 1995 (Box 5.1).
Box 5.1 Development and institutional strengthening
 Support to develop well-defined national policies and strategies for developing the health systems, with a focus on equity (defined), efficiency, and effectiveness.
 Securing ongoing dialogue on health policies and strategies with ministries of health, finance and planning.
 Securing ongoing dialogue with major donors in supporting health sector development (and assistance in developing mechanisms for the coordination of donor support).
 Assistance in setting priorities and sector analysis, for the revision or further development of health policies and strategies.
 Assistance to develop a practical and operational implementation plan for reform of the health sector.
Support to develop well-defined national policies and strategies
The importance of well-defined national health policies is internationally recognised, also by Danida. However, there are considerable problems in identifying what a well-defined policy is, for two main reasons:
 Although there is considerable evidence as to what constitutes ‘well-defined’ or good health policy in a broad sense, no universal solutions (blueprints) apply.
 Even if a ‘well-defined’ policy is realised – results depend to a large extent on country-specific implementation strategies and contexts.
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5 P OLICY AND S TRATEGY D EVELOPMENT
Despite these provisos, at a minimum a “well-defined” policy can be defined as a policy that moves beyond identifying broad issues, to identifiy the constraints, strategies and resource implications of the policy. In supporting health policies, Danida has become a partner in the gradual and continuous process of sector development. Reform implies significant – often fundamental – change. HSR which is often part and parcel of general
(governance) reforms, requires a willingness to change and a capacity to absorb change.
In Ghana and Zambia, clear national policies existed at the time Danida was asked (along with other donors) to contribute to the policy process through an HSPS. In these two countries, developing sector analysis and developing practical and operational plans were the principal policy needs. The invitation to join an already existing process of changing health policy facilitated the smoother introduction of HSPS. However, in Zambia, the donors' overly stringent focus on health systems and over-ambitious planning fuelled a radical health sector reform that has proved politically difficult to sustain. The reforms appeared to ignore a clear downward trend in the quality of health service provision, which made maintaining political support difficult.
Danida has only had limited success where it has tried (sometimes with other donors) to lead reforms. The experience during the transition period from project to SPS in Kenya and Uganda is instructive. In Kenya, donor (World Bank) ‘pull’ strategies did produce a well-defined health policy on paper. However, translation into action with Danida support proved difficult, due to a lack of ownership and a lack of basic trust in government accountability. In Uganda, the Essential Drugs Programme, Human Resource
Development Program and district support were similarly ‘pulled’ into a HSPS. As a result, these programmes experienced difficulties in maintaining the expected outputs. In both cases, Danida's (and other donors') assessments of the environment for change were perhaps too optimistic.
SPS aims to empower national policy ownership by reducing the fragmentation resulting from project support. In some circumstances, however, earmarked support might still be an option, in particular when the intervention concerns an urgent problem or still lacks political support (AIDS, TB, gender). However, when it imposes donor preoccupations at the cost of national priorities, it may undermine the feeling of ownership. Examples of earmarking related to previous Danida interventions can be found in all the country
HSPSs. The risk exists, however, that continued earmarking will eventually hinder sustainable integration. In Kenya and Uganda, Danida has supported large vertical programmes. The importance of these to the general functioning of the existing sector is evident. Furthermore, for example, the EDP in Uganda, through its role as a source of supplementary, informal income for clinical staff, has made change problematic.
System development, and particularly reform, demands patience, and is not a linear process. In an international context, the USA is the most recent of many countries to fail to reform its health sector. In other countries, fundamental reforms have taken decades to instigate, implement, and assimilate. Linking conditionalites to such a process and then applying them constructively relies, in practice, on a carefully balanced judgement, not a sole indicator. Tight programme frameworks of objectives and activities often leave the issue of conditionalities unresolved, or irresolvable.
The strict application of conditionalities, even when initially patience had been exercised, led to a freeze in Danida support, resulting in the on/off implementation of HSPSs or its components (Kenya, Uganda and Zambia). In some circumstances, conditionalities may
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5 P OLICY AND S TRATEGY D EVELOPMENT replace dialogue (this seems to have been true for Kenya). The effects of applying conditionalities on service delivery in countries highly dependent on donor aid were aggravated by the fact that no alternative strategies or fall-back positions existed. This has had a significant impact on trust and mutual understanding, making future dialogue even more difficult. Technical assistants and consultants have frequently been a useful but also problematic source of expertise and have provided a buffer between Danida and its incountry counterparts. Conditionalities of a more political nature (India) may hamper the dialogue, but are nevertheless necessary for clarity.
Although conditionalities and their timing must be based on transparent, ‘objective’
priority-setting procedures, this may be problematic in practice. These procedures require transparent financial, service and epidemiological data. Systems to obtain these data can take many years to develop. The experience of Zambia highlights the importance of transparency in both donor and recipient country accounting. Both donors and recipient governments need to be able to provide each other with the relevant expenditure information in useful breakdowns.
Securing on-going dialogue with national ministries (authorities)
Country experience of dialogue with Danida varies. Two questions emerge: Who should be the actors in the dialogue? And how and on what basis should the dialogue take place?
With respect to the first question, Danida is one and the recipient health sector another.
Danida is represented by the respective Danish embassies, which in turn are frequently advised by local technical advisors and sector specialists from Copenhagen as well as the regional office in Denmark representing the political point of view. All are important but may not share the same vision on the programme, conditionalities or approach to be financed under the health sector support. The lack of a clear and consistent position has been an additional obstacle to progress in Uganda and Kenya.
The recipient side of the negotiation table should be broader. In practice, it has often been narrow. Negotiations are conducted mainly with the public health sector, and often with the central level only. Other important stakeholders such as peripheral authorities and representatives of NGOs, the profit sector and not least the communities are only marginally involved, negating the evidence that these organisations supply the lion’s share of health services. Other sectors like the Ministry of Finance should also have a place at the table. In the context of Danida’s wider development goals, stakeholder participation in the planning phase is particularly important. A good example is provided by Ghana, where Danida bound relationships by being a major contributor to the sector review, including national meetings of stakeholder representatives.
By focussing on the health sector to improve health, Danida has implicitly adopted a narrow perspective of public health. The complexity of factors influencing health but covered by other sectors is not taken sufficiently into account (environment, food security and nutrition, water & sanitation, and gender, to name a few). Examples of intersectoral dialogue are scarce. Uganda offers some good examples, particularly with respect to gender issues and water and sanitation and political and administrative decentralisation.
Securing an ongoing dialogue with major donors
A lack of co-ordinated donor procedures places a considerable burden on the local administration. Donor co-ordination was organised most adequately, comparatively speaking, in Ghana and Zambia. In these countries, this resulted in the ‘health account’
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5 P OLICY AND S TRATEGY D EVELOPMENT and the ‘common basket’, respectively. However, though in the long term the local burden may lower, setting up these systems may present a substantial short term burden.
Although arrangements between donors exist, there are still differences between donors with regards to operational procedures and monitoring or financial information systems.
In Uganda and Kenya, donor co-ordination was weaker and in this sense SPS has yet to represent an improvement in project approaches. (See further discussion Chapter 6:
Channelling, Implementation and Performance).
Co-ordination also creates challenges for Danida’s (and other donors') in-country administration. This will require some central co-ordination (i.e. at the Danida
Copenhagen level) to help in preparing the ground.
Assistance in setting priorities and sector analysis
It is clear that national health system development is a national undertaking, particularly where universal access is a stated aim. Building system development on rational and politically relevant decision-making involves all actors in the health care system at all levels. In turn, actors require the tools to analyse and monitor and subsequently improve the performance of that part of the system for which they are responsible, by setting clear and systematic priorities. Since the mid-1990s, Danida has clearly prioritised capacity building in policy and management in the health sector in all the evaluated countries (Box 5.2).
In building capacity in policy development and health sector management, a distinction can be made between ‘tools’ (data collection, information management and analytical techniques, and equipment) and ‘tool-users’ (training for data analysts and decisionmakers with quantitative skills). Danida has invested extensively in both, in all countries.
In Zambia, support has been given at the central level to change the Health Information
System (HIS) to Health and Financial Management Information Systems (HMIS and
FAMS). In India, extensive support was provided for the development of MISs, particularly in the two large, vertical programmes (blindness and leprosy).
Box 5.2 Policy and management capacity building in the health sector
 Increasing knowledge and in-country capacity.
 Transfer of practical experience.
 Increasing the availability of international experience.
 Short and long term training in relevant disciplines (public and business administration, accounting, statistics, economics, epidemiology, law, behavioral and social sciences).
 Increasing resources.
 Strengthening collaboration.
 Refining techniques in burden of disease and priority setting.
 Improving methods for the effective distribution of health technology.
 Developing methods for information gathering and monitoring.
At the sector level, little use has been made of ‘objective’ tools for decision-making.
Burden of disease exercises, sponsored by Danida, have not been carried out except in
Zambia. One may dispute the usefulness of extensive data collection that absorb scarce resources, as political issues often play a more important role in decision-making.
Moreover, one primary problem is the difficulty in collecting even basic cost and epidemiological data. Distinguishing between plan budgets and expenditures is an almost
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5 P OLICY AND S TRATEGY D EVELOPMENT universal problem. Danida’s own expenditure data until the early 1990s provide a further example.
Despite the investments supporting prioritisation, there is still work to be done in information provision. This applies as much to Danida’s own investments as to the investments countries make in their own health sectors. SWAp and decentralisation affect the type of information required. Priority setting in a project is relatively straightforward, but the increased number of actors and increased number and remoteness of issues make priority setting in a sector-wide set-up more difficult. The information needs, demands, and processing capacity of different actors at different levels in health service vary substantially. Although gathering of evidence is indisputably necessary to make informed choices, it should be stressed that the mere presence of appropriate tools and skilled users is not enough to set priorities and make a system work.
Assistance to develop practicable and operational plans for reform of the health sector
Danida has supported the translation of broad policies into workable operational plans.
Danida has assisted all the evaluated countries in formulating sector development plans and developing practicable and operational plans for reform of the health sector at the national level. In some countries, this planning proved rushed and optimistic (Zambia), in others, Danida supported comprehensive sector analyses (Ghana) which informed the development of programme of work. In India, this was done at the state level. However, the changes and reforms in the health policies of these countries are, in many cases, as fresh as the change in Danida’s own development policy. The experience is therefore too brief to make firm predictions about the realisation of these plans in the future.
Good practices :
 Whereas the broad objectives of health policy are clear, realistic operational goals are in practice frequently far more modest. Clear, mutually prepared and agreed HSPS perpetration documents, as in Ghana Phase II, helped to establish realistic frameworks for the likely time-scale (long) and scope (modest) of effective realisable health sector goals.
Lessons learned:
 Over the years, Danida has played a constructive role in the dialogue with recipient countries on health development. The shift in focus from project to SPS automatically redefined the role of Danida from a partner in the provision of health services to a partner in health policy, its development and planning. However, as the example of India illustrates, the share in decision-making is primarily dependent on the relative scale of participation. In the four African countries, the significant role of
Danida in the sector, in effect, buys a place in the national policy dialogue. A delicate balance results between recognising a country’s right to self-determination in setting and implementing policy (ownership) and the donor’s entitlement to accountability for, and returns on, its investment.
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5 P OLICY AND S TRATEGY D EVELOPMENT
 The withdrawal of support when agreed national targets and conditionalities were not met by the recipient country (Zambia, Kenya, Uganda) has resulted in the interruption of the implementation of programmes in the periphery. This has discredited the appropriateness of Danida support measured against its stated goal to assist the poorest of the poor.
 Fixed conditionalities (Kenya, Zambia) and earmarking of funds (Uganda) within SPS have the potential to frustrate the development of national policies and strategies.
Inadequate time was spent on gathering evidence on which to base these conditionalities and to allow the national governments to understand the implications. But also the limited insight in technical and political problems compounded by lack of experience with the SPS modality of assistance contributed to this problem.
 The division of roles and responsibilities between the different hierarchical levels
(political and technical) of the Danida organisation itself hampers, to a certain extent, constructive dialogue with the recipient country.
 Rational management requires trained staff. Such staff are very scarce, particularly in social sectors such as health. Experience demonstrates that this scarcity persists, even with well thought out training programmes, due to brain drain.
Recommendations
:
1.
Danida should have a clear and formal view of what it perceives to be a ‘well-defined’ health policy in its programme countries. This would provide a reference point against which a perceived need for reforms can be measured and against which prospective recipients could set their expectations.
2.
Danida should keep an open eye for emerging windows of opportunity and adopt incremental approach to policy support, i.e. strict time-frames and strategies need to be made subservient to sensing the right time, person, place, etc. Much effort needs to be devoted to understand the mechanisms at work. To learn from experience, reporting requirements should include a chapter on these contextual factors.
3.
Long-term commitments are necessary to support HSR. This offers some income security to the recipient and at the same time some room for donors to match performance incentives. At the time reliable partnership exists and the environment is conducive, it is recommended to introduce fixed and variable (conditional) components to HSPS transfers. Clear agreements should be reached between the partners on the evolution of the fixed/variable mix. Ideally, this process would eventually aim at budget support.
4.
The strict enforcement of target-oriented conditionalities should not affect Danida’s support to the underprivileged. Projects, programmes and specifically SPS should incorporate alternative strategies. Phasing or a transition period is important as a strategy for the introduction of SPS. Flexible HSPSs should insist on processoriented phase-in periods and fall-back scenarios.
5.
Internal agreement based on informed sector analysis and consistency with other incountry development goals would seem an appropriate starting point to set realistic goals and time-frames for the introduction of SPS. Where data are scarce or analytical skills limited, a first phase should focus on building capacity and developing ‘tools’ to facilitate decision-making. Areas of specific importance include: National Health
Accounts, National Human Resource Plans, Epidemiological data and Micro- and macro-economic indicators (see issue paper entitled Economic Appraisal Evaluation)
6.
Danida should support the mobilisation of a broader representation of all stakeholders, both from within and outside the health sector, to enhance the social
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5 P OLICY AND S TRATEGY D EVELOPMENT basis for newly developed policies. Public debate within countries may be an important resource in terms of articulating and creating support for activities.
7.
The fact that Danida has often been at the forefront of organising dialogue between donors puts it in a good position to spearhead the development of collaborative administrative donor procedures. Danida should make sure that the procedures are known and transparent to the relevant stakeholders.
8.
Teams of just two donors (more is better) lend credibility and momentum to the process of SPS. Incorporation or the encouragement of others to join a so-called
SWAp will increase the leverage and reduce donor duplication and ‘gaming’ between donors. Initiatives at the EU or OECD level may expedite progress in in-country cooperation.
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6 C HANNELLING , I MPLEMENTATION AND P ERFORMANCE
This chapter discusses the channelling of Danida funds through the public and private sectors. The level of synergy and complementarity between the different health related institutions is discussed. Furthermore the mobilisation of stakeholders with respect to the channelling of funds is assessed as well as the issue of inter-sectoral collaboration and implementation of technical assistance. Finally, the role and relevance of Danida’s research assistance, including ENRECA is assessed.
Danida’s support to the health sector in the five visited countries has been largely restricted to the public (through government to government and multi-lateral channels) and the not-for-profit private sector (NGOs). The shift from programme aid to SPS resulted in relatively less money being channelled to the NGO (national and international) sector, while more funds were streamed through the HSPS working with the different levels of government (See Annex V, p. 126: Selected Indicators & Statistics:
Channels of funding for health interventions).
In principle, HSPSs commit Danida to a very simple structure for the further channelling of funds. Funds are transferred to a national government (to the Ministry of Health through the Ministry of Finance), that then commits to allocating these resources within the health sector according to a sector work-plan. Although the work-plan is mutually agreed upon, responsibility for ensuring that funds are indeed channelled as intended rests with the recipient government.
Graph 6.1 Sector programme support
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In India, Kenya and Zambia, special counterpart implementation units were instituted within the MoH. In fact, in all five countries, implementation units have effectively become ‘clearing houses’ for Danida funds. While this may not contradict the letter of the policy, it perhaps contradicts the spirit. The SPS ‘concept’ has come to resemble an organisational structure (Graph 6.1). Work-plan components are matched with ministry functions. Departments within ministries then come for the ‘approval’ of funds for work-plan activities. Hence, while the implementation units were intended to provide technical assistance to the health sector development process, they sometimes become the auditors and accountants of the conditionalities attached to Danida’s sector support work-plans.
In all cases, Danida has actively supported the promotion of deconcentration as one of the components of HSR. The focus on the national level and district level has resulted, in some cases, in a lack of co-ordination in the provision of different services. Independent donor support to the district level is still continuing (actively promoted by the government in Uganda). A positive exception may be found in Zambia, where Danida used the experience of the Dutch in HMIS for nationwide scaling up.
Within the five countries visited, the ongoing decentralisation of health service management and the resulting autonomy (to various degrees) at the implementation level have provided the opportunity to develop interesting intra- and inter-sectoral initiatives.
A good example is the revitalisation of the Rakai Joint AIDS Conference, which is housed in the district's social welfare department and serves as a platform for information exchange and co-ordination of both private and public AIDS activities
(counselling, home-based care services, income generation, etc.).
The government commonly finances and provides only a part of all available health services. The ‘public-private mix’ for health service provision should be carefully considered in terms of public and private goods and service provision and financing. As stated in the Danida Sector Policis, Health (1995): “Health care, beyond its immediate role in preventing and curing disease, also serves to express communal consideration for, and extend care to, individuals and population groups that would not be cared for under pure market conditions.”
The Sector Policy Paper does mention the possibility of supporting the for-profit and the not-for-profit private sectors. Danida’s track record here is relatively positive in comparison with other bilateral donors. Danida’s support through international NGOs is a little less than 20% of total expenditures. For example, the provision of essential drugs to Uganda has been channelled through the Danish Red Cross. Danida also supported a study in Uganda to review the laws and regulations towards the private sector. The HSPS in Kenya commissioned a study on private-public mix, and initiatives have been taken to work with NGOs at district level in Kenya. The appraisal of Danida support to Ghana
(HSPS II, 1997) contains a private sector component.
NGO health facilities in Uganda have a good reputation and funds channelled to them tended to have a positive effect. However, Danida’s efforts to strengthen the collaboration between the Ugandan government and the private health sector are as yet inconclusive. Several NGOs in Uganda also expressed fears that Danida’s SPS in practice
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6 C HANNELLING , I MPLEMENTATION AND P ERFORMANCE implies that their funding will dry up when all disbursements are controlled by government decision-makers.
The differentiation of channels of funding to the private, public, for-profit and not-forprofit sectors provides Danida with an important tool to influence health financing and health provision within a country. Issues of what should be funded publicly or privately are not straight forward. The private financing of health services far outstretches public finances, but the role of the private sector towards public goods and services is often limited. In practice, over the period reviewed, Danida was little involved in policy development towards public private partnerships, in strengthening collaboration between the public and private sectors, or in developing regulatory instruments to improve the quality of the private sector. A more elaborate discussion on this subject can be found in the issue paper “The Public/Private mix”.
Complementarity and synergy are important for the provision of a comprehensive health care package, the reduction of duplication and the mutual enhancement of activities.
Before the introduction of the SPS concept, these were largely left to ad-hoc arrangements. Interventions were decided on by preoccupation and comparative advantage of donors and/or pre-existing needs in the country. E.g. Danida, already experienced with a nationwide EDP in Kenya, could similarly support Uganda after the virtual collapse of the health system in 1986, while UNICEF used its experience to set up a national immunisation programme at the same time.
The philosophy of SPS is to provide a platform for planned synergy and complementarity. The reality is found more complex and fraught with different political, cultural and economical stakes of the different actors. There is a risk that when SPS focuses too much on the governmental sector, possibilities to forward the development of the health sector through other agencies are not sufficiently considered.
Different types of organisations have their own strengths. In terms of resources (loans, manpower and materials), the economic scale of the multi-lateral organisations is apparent. NGOs have a spearhead function in the development of innovative ideas, being close to the communities and understanding their needs, they can react quickly and adequately. The bilateral organisations, with their own specific identity, are able to address local problems and give support (grants) with tailor-made interventions. When asking about the best method of channelling funds, a mix seems to be the most appropriate reply, as done by Danida.. Lack of involvement of the NGOs and the private for-profit sector in the policy debate can result in fragmentation of the delivery of health services.
Complementarity and synergy in a SPS requires strict co-ordination between all different actors in the health sector. This entails flexibility and compromises not only in programme planning, but also administratively. Potential conflicts between various funding and implementing agencies can occur at different levels of the health sector. In all of the countries studied, Danida is an outspoken proponent of SPS. Within the donor
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6 C HANNELLING , I MPLEMENTATION AND P ERFORMANCE group it is often Danida which fosters the process of donor co-ordination and insists on and negotiates HSR. This front-running position of Danida is sometimes seen by other donors as too imposing. On the other hand, the close collaboration with DFID in the front line of the reform in Ghana has significantly contributed to the momentum of what seems to be a successful SWAp. Particularly the presence of (Danish) technical assistance allowed a continuous dialogue between different actors. In general, this dialogue led to mutual trust and positive attitudes in coming to agreements. It is obvious that the more powerful the donor, the more likely it will take the lead role (for example WB). Focusing on a selected number of sectors in a selected number of countries has allowed Danida to play a significant role in countries receiving substantial health sector support.
Each organisation (bilateral, NGO, multi-lateral) has its own agenda, mandate and procedures for operation. Most organisations are in agreement with the principle of
SWAp, but there are various degrees of overlap and contradictions in implementation.
This makes negotiations a tedious process. Although the review of the five countries has shown that the discrepancies were relatively minor and secondary (administration), this often had a significant impact on co-ordination; for instance the importance of different financial years among donors and governments for the pooling of funds, as is the case in
Uganda.
Nevertheless, SPS has been instrumental in the improvement of donor/government coordination. It enhanced the dialogue between donors and recipient central governments in most of the countries visited (except perhaps for Kenya). Strengthened collaboration has culminated in Ghana and Zambia in a “common basket” which finances the health sector (district only in Zambia). In the other two African countries, preparations are underway, based on this experience, to develop systems along the same lines once accountability is ensured. This has more chance of success when there is an effective platform for inter-donor and donor-government co-ordination. This has now been established among donors, but effective government leadership is lacking.
However, cross-fertilisation, using the experience of peripheral interventions, still hardly takes place between donors. Examples include the different Health Management
Information Systems initiatives by different donors in Ghana. Even within the same donor aid portfolio such problems can arise, for example, lessons learned from the
African Medical Research Foundation district project in Uganda were not sufficiently documented to be of significant use for the newly opened district programmes in the north of the country. The impression exists that at the national level, donor coordination has now been sufficiently developed into efficient mechanisms, but at the peripheral level further evolution is required.
Co-ordination at the sector level can be difficult with agencies that have a mandate for an intersectoral or intrasectoral objective. Earmarking finances for proven technical interventions has shown to be efficient and effective, particularly when it concerns urgent health matters, as exemplified by the different UN funds (UNICEF: immunisation, growth monitoring, oral dehydration and breastfeeding; UNFPA: birth control, reproductive health; WHO: polio and small-pox eradication). Participating in a SPS is often seen as surrendering some of their independence and risking their gains. The challenge remains to maintain the existing experience and capacity with pragmatic solutions.
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A major part of the HSR in Zambia has been the introduction of basket funding and the development of management systems to support it. Danida played a key role in this process. Danida worked closely with the government to develop the concept of basket funding and was the first donor to agree to give sector support. It also provided technical and financial support to establish a system to channel, account and monitor donor and government monies to the districts, known as FAMS (financial administrative management system). These FAMSs were satisfactory to most donors. However, a number of donors, particularly the multi-laterals, have had some problems in adapting their procedures to allow for sectoral and basket support. However, most of the bilaterals felt that the auditing and reports were satisfactory and have been able to channel funds.
The development of FAMS as a broader resource management system has been slower.
Since 1996, it has been decided to narrow the focus to financial management to ensure quality in systems development, given local capacity constraints. When the FAMS first began, grants were already going to the districts and there was a rush to ensure a basic system was in place with basic accountancy skills at the district level. By 1996, it was realised that it was essential not only to build the capacities at the district level, but also to improve the capacity of those who were to supervise, manage and develop the system.
However senior staff have proved difficult to recruit and maintain, given that there is a narrow resource base of management accountants available in Zambia. In addition, it has been difficult to institutionalise the systems management and supervisory staff.
In a decentralised system, donors are faced with the choice of whether to channel money directly to districts, through project offices, or through other layers of government.
Giving money directly to the districts and through projects can result in dual reporting systems at the district level. At one extreme these can be two entirely different systems, at the other they can be parallel, identical systems using the same formats and accounting rules. In Ghana, Danida moved from the former position to the latter, supporting the region to develop similar accounting rules, building on existing financial systems. This capacity support was essential to the successes of the project in the Upper West Region.
After five years of trial and error, it has provided an integrated financial management system which can support further donor inputs. Furthermore, it has provided the basis in the Upper West Region to benefit from the continued support to integrated donor and government financial systems, (the Ghana Health Account) at the national level. This should result in a fully integrated national system, whereby donors are able to channel funds through the MoH and account to their own population whether funds are being used to meet health sector objectives. It should not result, however, in a new and totally
Danida dependent financial system as observed in Zambia.
However, although the support has been successful in developing systems, the development of skills in financial management has been less successful. The localised development of financial management capacity for the disbursement of funds, although useful in the short term, has proved frustrating and difficult to sustain if national systems are not being developed simultaneously, (as was the situation in the early years of the project). Unlike other management systems development, such as HMIS’s, pre-existing financial management systems are usually deeply entrenched and are often outside the control of the MoH. In Ghana, the high degree of rotation of accountancy staff, controlled by offices outside the MoH, illustrates this point. Therefore, it could be argued that, if poor financial management is identified as a major constraint to the
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6 C HANNELLING , I MPLEMENTATION AND P ERFORMANCE achievement of programme objectives and sustainability serious consideration must be paid to capacity development both at national and local levels, in and outside the MoH.
Stakeholder participation is vital to Danida’s approach to health sector support and important in the implementation of project and sector support. Danida has had various degrees of success in establishing mechanisms for dialogue with different stakeholder groups. Good examples can be found in Ghana and India. In Ghana, early participatory assessments were undertaken. The follow-up to these are less evident. In India, Danida provided the space for joint experimentation and pilot testing. In general, however, attempts to define stakeholder groups are rare, possibly because the importance of power relations between stakeholders for successful interventions is not fully appreciated. Nor is it fully appreciated which participatory methods are more successful in communication with different stakeholders. ‘Participation’ tends to be interpreted as synonymous with community participation.
Facilitation of the establishment of health facility committees and of community participation in the maintenance of health facilities are two examples of participatory approaches with different degrees of coercion involved. There have been scattered attempts at participatory identification processes in HSPS using Participatory Rural
Appraisal methods (e.g. Uganda) and at transformation of the Community Based
Nutrition Programme in Kenya using the Participatory Approach to Nutrition Security
(PANS). Internal reviews of HSPS progress may be interpreted as participatory monitoring involving officials, but rarely involve health care providers and even more rarely male and female users. Few advisors and health care providers distinguish clearly between participation as a means to improve activities and participation as an end in itself and the many modalities for participation which lie between the two interpretations.
In the African countries, the intention has been there, but vibrant, participatory, social mobilisation is less apparent (see Section 4.8: Achievements – Social Mobilisation), with a few important exceptions (PANS, selected DHMBs in Kenya). Community mobilisation has been easier in response to crisis (Uganda), but the enthusiasm tends to wear off once the emergency is over.
While Danida has strategy papers and guidelines for many other issues, there are none concerning participation. How stakeholders are represented, who should participate, in which activities, how and when, is indeed subject for discussion. The issue paper
“Stakeholder Participation” elaborates more on this issue.
In the Danida Plan of Action: a Strategy for Human Health (1989), the following is included in the guidelines for Danida-supported projects:
 Take the health aspect into account in all development efforts which interfere with the environment.
 Emphasise preventive measures rather than cure in dealing with environmentally determined health hazards.
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 Integration of environmental control of communicable diseases with PHC.
 Impact assessment of environmentally related health aspects for all development projects.
These guidelines are highly relevant for the five countries visited, as many of the most pressing health problems are related to environmental conditions. The most obvious examples are:
 Malaria, which is related to agricultural practices and the location of homes close to
Anopheles breeding sites.
 Respiratory diseases, which are related to crowding and cooking indoors.
 Intestinal diseases, which are related to water and sanitation.
The team observed some good examples of collaboration with the water and sanitation sectors. (see Section 8.4: Environment). General knowledge (staff, patients) about the relation between water and sanitation-related hygiene and health appeared to be good.
There is, however, great potential in all five countries for more collaboration and coordination between these (and other) sectors. The water and sanitation projects have developed further than health projects concerning the creation of demand-driven projects.
However, there is a lack of co-ordination between the health sector and the agricultural, energy or transportation sectors, while, for example, within all these sectors, projects can lead to a considerable increase in mosquito breeding sites and thus contribute to the spread of malaria. The potential impact on human health appeared of little concern in these other sectors. It is noteworthy to observe that human health is not mentioned as an environment-related factor in Danida's evaluation report: Environment and development
(1996). Nevertheless, Danida's guidelines on environmental assessments for sustainable development (1994) include "impact on people’s health" as an indicator. Health assessments are not practised as part of environmental impact assessments. This observation was confirmed in the field; for example, the project: Strengthening of Primary
Health Care in the Upper Western Region (Ghana) included reducing the mortality and morbidity from malaria as an immediate objective. However, Danida appears not to consider the possible increase of malaria from its activities in transport and energy projects.
The role of technical assistance (TA) has changed over time from project to sector-wide approaches. In projects, the role of TA was clear, it was technical and confined to the objectives of the project, like TB, leprosy, blindness or PHC. TA at this time was appropriate and was expected to provide technical skills on the subject, to bring in new knowledge and international experience and to propose innovations. Advisors also played the role of broker, both for Danida and for national project officers; they were meant to be the eyes and ears for Danida and to be aware of what was happening at the different levels, they often had a say, if not the overall responsibility, on the spending of
Danida’s budget. Advisors played a role in arriving at different innovative interventions.
External consultants, be they national or international, may introduce new knowledge and experience from elsewhere, they may question ongoing activities, facilitate local
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6 C HANNELLING , I MPLEMENTATION AND P ERFORMANCE professionals in their process of decision-making and provoke reflection in local decision-makers.
The relevance of TA was acknowledged and appreciated to varying degrees, with Indian and Ghanaian officials being most aware of the key roles that Danish TA has played. In
India, the advisors played a pivotal role in keeping the project within the boundaries of
PHC principles. Providing TA to the Upper West Region of Ghana for management, training and institutional strengthening was recognised as appropriate, as it facilitated the region’s shift from project- to- programme to sector-wide approach.
A constraint in each of the countries was that government's human resources were limited in quantity and quality. Furthermore, foreign TA runs the risk of replacing national health personnel in a project approach. Where shortcomings in TA were reported (Zambia, Uganda, Kenya), different reasons and explanations were offered to the Evaluation Team they included:
 high turnover and delays in replacement (Uganda, Zambia);
 lack of Danish nationals (Uganda, Zambia);
 lack of clarity in their roles (Kenya, Zambia and the Ghana TB programme).
The relationship between Danida and the recipient country within the context of SPS has to do with technical as well as with political issues. As a consequence the role of the technical advisor within the Danida structure and within the national programmes has to change. Since the introduction of SPS, this has not always been the case. As national programmes are decided upon at national level, TA is also concentrated on that level, bypassing the operational peripheral level, where management and planning capacities are often weak. In Zambia, for example, TA was mainly provided at national level and became too academic, with little feeling for what was happening in the field. SPS supports health programmes and national plans based on national priorities. TA was considered here as honest, open and critical and as having clear principles on policy development; but at the same time as having only one-direction communication and as trying to be (too) influential.
The recipient country’s leadership should be guaranteed in developing such a programme and in decision-making. The advisor is meant to play a facilitating role. Conflicts may arise when the roles of political negotiator and manager of funds are merged with technical and facilitating roles. The Kenyan case appeared the most controversial. This related mostly to confusion between the role of TA, on the one hand, and financial controller on the other. In the past, the role of TA in projects was acknowledged and appreciated, but HSPS has led to a more comprehensive and proactive role in policy, strategy and systems development. This has not always been well received or accepted by the MoH. In the transitional phase towards SPS in Ghana, a steering unit was established for the HSPS. Within the context of sector wide approaches TA should not steer, but rather provide technical support within the framework of the MoH. A danger exists that such a unit, when physically and institutionally outside the MoH as happened later in
Ghana, will function in an isolated way.
The role of the Embassy is pivotal in the context of SPS and may require technical advice. This advice may be provided by both the technical advisor of the respective country, but also by the TSA unit in Copenhagen. However, past experience demonstrates that the TSA is often overloaded and therefore not always able to provide
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6 C HANNELLING , I MPLEMENTATION AND P ERFORMANCE the required support, when this is needed. Moreover, direct contact between the advisor and TSA is not allowed (all contacts should pass the Embassy, which contacts the regional/country office in Danida Copenhagen), which results in delayed support. Even if direct contact would be possible, TSA support may sometimes fall short. Of course, much depends also on personal relationships.
TA is given through technical advisors. In most instances these advisors are recruited individually and not as part of a contract with a knowledge institute. Institutional support is certainly a subject for discussion. As a Zambian MoH official expressed it:
“Institutional support enables institutional capacity building, long-term institutional partnership and easy access to multidisciplinary expertise”.
Danida's policy for research support in the area of health was first formulated in 1995. It focuses on the production of knowledge on health issues, which is "a critical means of empowerment… and (the) search for solutions to unresolved problems." Secondly, the policy aims to strengthen research capacity in the partner countries by "establishing strong linkages between research and action agencies". Exclusive biomedical research with little or no regard for contextual significance is not encouraged.
The institutional basis for health research in the developing countries is seen as particularly weak compared with, for example, agricultural research. Denmark has contributed in a variety of ways to health research and capacity building in research; the major initiatives have been the following.
Aid-related research integrated into the plan and budget for particular aid interventions
Budget lines for research in the HSPSs are supposed to be directed at specific health sector support issues. The distinction between 'studies' related to the project cycle and
'aid-related research', sometimes commissioned as the need arises, has not always been clear. Utilisation of research funds in the HSPSs has also been slow; in some cases it has not yet even been initiated (Uganda). In Kenya, for example, several research studies on financing mechanisms and public-private sector mix have been commissioned by the
Danish-supported HSPS, but with little involvement or support from the national authorities and stakeholders, who have sometimes taken an antagonistic position toward the research community.
Funds for enhancement of research capacity in developing countries and in
Denmark
From the early 1990, research on health issues has been concentrated more and more in the Enhancement of Research Capacity in Developing Countries, ENRECA,
Programme. Of 40 ENRECA twinning programmes between research institutions in
Denmark and in the co-operating countries, 12 are active health-related projects in Asia and Africa. The education of PhD and Master students and support to research infrastructure have been successful in all five countries under study. The programmes are at different stages of phasing-out after a maximum of three times three years, and responsibility is being handed over to the national partners. The focus of ENRECA being on research isolated from the development of the health sector may have contributed to a predominance of exploratory and ‘basic’ research rather than applied
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6 C HANNELLING , I MPLEMENTATION AND P ERFORMANCE research. For example, HSR and decentralisation have not been researched. Many
ENRECA programmes have addressed priority public health problems such as maternal and child health, immunisation and essential drugs, and malaria.
ENRECA supported health research programmes displayed a tendency in north-south research collaboration that the research agenda is determined more by the northern research partners than by southern partners. In some programmes, however, e.g.
TORCH in Uganda, there was considerable awareness of the need for a shared definition of research priorities and objectives, not only between the research institutions but also between researchers and practitioners.
From twinning arrangements between Danish and South research institutions based on the rather ad hoc character of many research projects, the ENRECA programme has increasingly contributed to the creation of wider networks. Throughout the decade the demand has been increasing for applicability of research to the benefit of development assistance in general and to the improvement of the health status in particular. The establishment in 1996 of a co-ordination unit for a multi-disciplinary Health Research
Network is a most pertinent facility for promoting the objective of enhanced dialogue and integration of research into the HSPSs. Thus, the Health Research Network provides a forum for discussion and sharing of information and aims to provide a mechanism for dialogue between ‘policy’ and ‘research’, especially for Danish Technical Advisors, sector advisors and embassy staff. The secretariat facilitates contacts between the research community and development practitioners in Denmark and elsewhere.
The Health Research Network’s priority for the next years is to involve more Danida
Sector Specialists. However, it must be emphasised that the prospects of better integration between the Health Research Network, ENRECA, and health research in general with the HSPSs require mutuality. They must be prompted by similar initiatives taken by the Sector programmes towards better integration of health research and practice, need more attention by the HSPSs. Moreover, research objectives and questions which need to be better mutually defined, if research is to increase its relevance for HSPS interventions.
Grants from council for development research
These grants are mostly provided to individual researchers and for larger framework programmes. As part of this, a professorship in "International Public Health" was also established in 1996. Furthermore, RUF finances a professorship at the State Serum
Institute.
Larger scale research programmes financed by special health research frameworks have addressed key areas such as malaria (multi-country), nutrition (Bangladesh), overcrowding and health (Guinea Bissau), etc. Such programmes may correspond to Essential
National Health Research as defined by the Commission on Health Research for
Development, but generally speaking, research topics have been defined by the research community, relatively independently of the aid agency and national authorities. This has been largely true throughout the period under evaluation. It should be noted that consent to research is not the same as integration into national research programmes and priorities.
When research financed by any of these sources has been directed at particular diseases, the focus has often been on 'the poor and at-risk group ailments', e.g. TB, malaria,
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HIV/AIDS, diarrhoea, blindness and leprosy. These are relevant research-cum-aid areas, but the opportunities for establishing synergies have not been fully utilised. The limited research on malaria which was supported by individual research grants from the RUF early in the decade, e.g. impregnated bed-nets, was relevant but incidental. A larger health network programme is now addressing primary health care and malaria-combating strategies in Ghana, Tanzania, and Uganda. However, this is not directly integrated with existing aid interventions.
A separate research-related activity is the provision of scholarships for staff employed in
Danida-supported programmes. The majority of these scholarships are intended for managerial and administrative capacity building rather than research. Danida finances
Danish Bilharziasis Laboratory (DBL), which is responsible for many scholarship courses. DBL has contributed to bridging the health and water sectors with substantial environmental health research. In addition to bilateral health research, Denmark has also supported a variety of multilateral health research facilities.
Good practices:
 Focussing on selected sectors and selected countries provides Danida with a key role in donor co-ordination. SPS has been largely successful in supporting donor coordination at the country level.
 Although sometimes slower to initiate, where joint resource management systems have been built on existing government financial systems, they have facilitated government led donor co-ordination.
 Intra- and inter-sectoral initiatives, rather than hierarchically organised co-ordination by the district health authorities, are better suited for networking. A case in point is provided by the Rakai district in Uganda, where NGOs and district authorities work together in an ad hoc and pragmatic fashion (the Rakai Joint Conference), rather than through a top heavy co-ordination body.
 Genuine community participation in the implementation of programmes is possible and rewarding and contributes to the sustainability of the programmes, as exemplified by the Danida-supported disease control programmes in India.
Lessons
learned:
 SPS and SWAp have enhanced the collaboration and co-ordination mechanisms between donors. However, on the implementation level, there is not enough exchange of experience between donors to make learning from experience and avoiding pitfalls a reality.
 There is a risk that by concentrating aid in the public system, access to operational innovative experience, which is often pursued by small-scale (NGO) projects outside the mainstream of health service delivery, will decrease in the future.
 Upgrading financial administrative systems and the responsiveness to national programme development helped shape Danida’s success story in Ghana. It is noted that in the formulation of HSPS, earmarking occurred together with budget support.
 Danish TA has been appreciated and well received in the majority of cases. Where this is not the case, the lack of clarity of the role(s) of the TA typically lies at the root of the problems.
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 Twinning between a few research centres, for example, the Child Health
Development Department of Makere, in Uganda, and medical anthropologists at the
University of Copenhagen and epidemiologists in Aarhus is beneficial. The Tororo
Community Health Project programme enhances the internal dialogue and involvement of local authorities. In larger set-ups, such as the Kenyan-Danish Health
Research Programme, involving five Kenyan and five Danish research institutions in health, the co-ordination and administration are overly demanding. Dialogue with the
HSPSs has not happened or is very embryonic, possibly due to the programmes’ laudable and legitimate concentration on research capacity enhancement.
Recommendations:
1.
Danida's involvement with and understanding of the private-for-profit sector is limited. Further study is needed of health-seeking behaviour and the role of privatefor-profit health care providers. Danida should develop a more comprehensive approach towards the private sector, and select criteria on which basis funds may be channelled to private sector providers.
2.
There is ample opportunity to strengthen collaborative efforts in-country. Danida is not consistent in its policies on health impact screening or assessments in its support to sectors other than health. It is recommended that health impact assessments be included as a routine component of all development sectors that impact on health.
3.
Due to the discrepancies in understanding HSR concepts and implementation modalities between the centre and the periphery, more analysis is necessary on what works and what does not. In particular, the process of “scaling up” experience needs attention. Danida’s HSPSs work at both the central and peripheral levels. This provides an excellent opportunity for Danida to take on the role of mediator to facilitate the dialogue between different levels of the sector. In addition, this would build capacity, not only in the implementation, but also in the policy and strategy levels in the periphery.
4.
The lessons learned from small-scale projects on health, water and sanitation should be disseminated broadly and inter-sectoral collaboration actively encouraged where opportunities exist.
5.
Lack of community involvement in the HSR process is a missed opportunity for mobilising community support for critical aspects of the reforms (e.g. Zambia).
Danida should facilitate the testing of different approaches to stakeholder participation, appreciating that there are many different stakeholder groups and significant power relations at stake. Participation should not be limited to the implementation phase but also include the identification phase.
6.
Providing appropriate TA requires a re-examination of the delineation between the roles and functions of the technical advisors, the diplomatic/political branches of the embassies, and the country/TSA departments of the Ministry of Foreign Affairs in
Copenhagen.
7.
A shortage of Danish TA was noted. To avoid this problem, the programme of funding fellowships should be strengthened and upgrading of local staff is recommended. Also the contracting out of TA to institutions rather than using individual consultants may be given more emphasis.
8.
Operational health research should be better balanced with research capacity enhancement. Research objectives and questions need to be better defined to increase their relevance for HSPS interventions. Initiatives towards better integration of health research and practice through utilisation of the ENRECA Health Research
Network need more attention by the HSPSs.
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This chapter examines the sustainability and cost-effectiveness of Danida’s interventions.
The first section evaluates financial sustainability. Danida’s evaluation guidelines, (1999, p60) see sustainability as “an indication of whether the positive impacts of an investment are likely to continue after external assistance has come to an end”. This chapter assesses the long-term relationship between revenues and expenditures to determine whether the benefits can be sustained. The second section examines Danida's investments. The evaluation methodology used in this section is different for sector-wide investments and micro-level investments in specific activities, areas, or institutions. For sector investments, the analysis of changes in government expenditure (Section 4.5:
Achievements- Health Systems - Resource Allocation) indicates whether the sector is becoming more cost-effective. For micro-level investments, cost–effectiveness was analysed by examining Danida’s investment choices and the degree to which the interventions chosen were implemented at the lowest cost.
In the five countries visited, most of the essential health services that Danida has supported are unlikely to be sustainable in the near future. In ‘Better Health in Africa’, the World Bank calculated the cost of a basic package of health services at $13 per capita.
This package includes the costs associated with health centres, district hospitals, water and sanitation, and national management. In four of the five countries visited (Zambia,
India, Kenya and Ghana), the domestically financed government health expenditure ranges typically between $4 and $8, of which 50% or more is allocated to regional or central hospitals. On average, between $2 and $4 are currently available for basic health services from domestic public sector funds, implying a shortfall or ‘financing gap’ of $9 to $11 per capita. The likelihood that the financing gap can be filled from increased public sector revenues, even in the medium term, is very low. Increasing proportional public expenditure allocations to the health sector may provide some of the required resources, but given declining government revenues, actual growth or reallocations remain insufficient.
Danida has had limited success in improving the financial sustainability of the health sectors, but has created some of the conditions and systems necessary to make the sector more sustainable in the future. Danida has successfully prepared the ground for future reallocations, namely through sector support and decentralised management/financial information systems for sound financial planning. As mentioned above, in Ghana, sector support, together with the development of channelling systems to the districts, is showing promising signs of reallocations to basic district services. Uganda is now contributing increasing proportions of the essential drugs expenditure and has a system of district grants in place. In Zambia, the district grant basket system is helping to channel government money.
However, Danida has not made a consistent approach in addressing the sustainability of
HSPSs, and in most of the cases examined, the financial analysis in the early stages of the projects was overly optimistic. In Zambia, and during the first phase of the health sector support programme in Ghana, sustainability was anticipated to be fulfilled at the end of
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FFECTIVENESS the programme period. Sustainability was mainly mentioned as an issue to be dealt with when phasing-out. Where it was included as a start-up consideration, the economic assessment appeared overly optimistic and failed to take into account issues outside the health sector. In addition, in the early stages of the evaluation period, Danida did not include an explicit costing of the recurrent implications of capital investments. The appraisal of Phase II SPS to Ghana is an important exception to this finding and reflects progress in Danida’s approach to financial sustainability.
Over the evaluation period, there has been a growing recognition within Danida that encouraging the adequate resourcing of basic services requires both institutional change and political support, rather than technical solutions. Many of the required reallocations demand difficult political decisions. In countries where there were initially encouraging signals of willingness to take these decisions, such as Zambia, there can be problems further down the line too as it becomes difficult to sustain politically in the absence of visible results. In the EDP in Uganda, Danida was more successful and helped to build political support for increased allocations as reflected in the adoption of a national drugs policy.
Opportunities to develop or improve financing systems have not been fully explored by
Danida. The Upper West Region project in Ghana provided an opportunity to illustrate how a community-based approach could improve the national financing scheme, but work in this area was limited. In Zambia, the national financing policy initially supported by Danida has run into difficulties, and Danida has not been involved in reviving the process. As a result, little money is being raised, and experiments with prepayment schemes have petered out. In Kenya, the maintenance project relies on fees, but the fees are often used for medicine and salaries rather than improved maintenance.
There has been mixed success with the sustainability of micro-investments. Many of the benefits from technology transfer have been sustained, for example, support for maintenance and estates management, and technical support to disease control programmes in India. The exception appears to be projects aimed at strengthening management capacities at the district level where there is often a problem with a high turnover of staff. It has, on the whole, been much more difficult to sustain services directly supported by Danida. For example, government funding for both EPI and EDP has been difficult to obtain in Kenya. However, in Uganda, increased government contributions to essential drugs have now been secured. Moving to health sector support may provide Danida with the opportunity to sustain essential services. In the Upper West
Region Project in Ghana, sector negotiations increased government allocations to this region. However, lower priority programmes such as the TB programme may encounter more difficulties in receiving increased domestic allocations than under the earlier project approach.
A satisfactory solution to the sustainability of NGO-provided services has not yet been found. The team observed evident problems with the financial sustainability of NGOs.
Many NGOs are providing services to the very poor, and opportunities for private financing are negligible. Most of the services provided are public goods. The feasibility of substantial private financing for this type of service is limited. Indeed, many NGOs provide services precisely because the government does not.
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Danida has a strong implicit investment portfolio that promotes cost-effectiveness.
Danida has been involved in investing in many areas and projects that are considered cost-effective according to international health experts. Examples include: EPI in Kenya;
EDP in Uganda; TB and blindness in India; and outreach services in the Upper West
Region in Ghana. Although Danida has supported many innovative and cost-effective technologies, it has not provided the resources or capacity to evaluate the costeffectiveness. It therefore missed an opportunity to allow others to gain from this experience. The notable exception is India. Here partners participated in an economic evaluation of different interventions and have been successfully promoting their methods to the Indian authorities and to other donors.
Through project support and technical assistance, Danida has been successful in promoting technical efficiency. Examples are: estates and maintenance, resulting in the better use of capital resources; the development of district management systems; and support to specific disease areas such as TB. NGOs supported by Danida have also often shown impressive results, for example, home-based care for AIDS in Uganda. The rehabilitation of severely malnourished children in Kenya has improved in connection with restructuring of the assistance. Some areas of concern remain. For example, the supply of drugs kits in Kenya and Uganda, which may be appropriate in emergency situations, can lead to wastage, and infrastructure investments may not lead to improved access and utilisation.
To date, there is little evidence to help determine whether Danida’s SPS has increased the cost-effectiveness of the health sector in recipient countries. This conclusion is supported by two observations. First, the reorientation of health sectors toward providing basic health services has been marginal. This observation is perhaps not surprising given that the evaluation covers a period of mainly project support and the early stages of sector assistance. An evaluation of the next ten years of support will provide a more appropriate time-frame for establishing a measure of success. Second, there is little evidence that some of the HSRs supported by Danida have led to improvements in cost-effectiveness. In the countries visited, there was little capacity to evaluate the reforms from an economic/financial perspective. Without baseline information and capacity development, there is a real risk that reforms will not be based on evidence.
While investing in cost-effective areas enables Danida to show that its funds are being used to the fullest, this does not guarantee that the cost-effectiveness of the entire health sector improves. Low prioritisation of the hospital sector, like for example, in Zambia, means that perhaps large sources of inefficiency have not been addressed. However justifiable investment in PHC may be on allocative efficiency grounds, the hospital sector accounts for the majority of expenditures (both public and private). Danida’s focus on
PHC and district services failed to address one of the most significant ways to improve efficiency.
The concept of an essential package of health services has proved difficult to implement.
Danida has encouraged governments to address the resource requirements of districts by promoting the concept of an essential packages. Later, Danida has criticised this concept, as an essential package defines the limits of the public provision of health care. The actual package often corresponds to basic or PHC services. Once defined, a package can
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Uganda, Danida supported the government in defining the package for the district level.
In both countries, this process was found to be complex and time-consuming, and the package has not yet been implemented.
Several factors were observed:
 In very low income countries, the results of ‘packaging’ are difficult for health professionals to accept. In Zambia, a standstill was reached between those who wanted to implement an affordable basic package and those who would not accept such a reduction in the health service. The process can be very complex and requires large amounts of data. This makes it easy for critics to undermine (delay) the process.
 The ‘packaging’ process was initially applied to district health services. Applying it to the hospital sector was considered far too complex. However, without considering tertiary care facilities, necessary reallocations cannot occur. As a result, addressing the financing gap of the essential services becomes a matter of looking for more external funds.
 In identifying priority areas, the package provided a useful focus for other activities such as producing technical guidelines.
 Packaging still does not relate to the principle of priority setting at the operational level. Although packages may be largely similar across districts in terms of costeffectiveness, local needs and preferences vary. Prioritisation within the package is an essential tool for decentralisation.
Good practice:
 The joint economic appraisal and the capital investment appraisal of the second
Ghana HSPS provide a good example of the economic analysis necessary for SPS.
The total sector was considered, and a balance was sought between capital and recurrent costs.
Lessons learned:
 In most cases the health services that Danida wishes to support are not likely to be sustainable in the near future. For most of the basic government and NGO services that were given project support, the benefits were not sustained after the support ended. Although sustainability can be improved by encouraging low-cost practices and financing from service users, political support seems to be the main determinant of success as many basic services in low-income areas require a degree of permanent subsidy from the government.
 In general, Danida has a strong, implicit policy and investment portfolio that promotes cost-effectiveness. However, for most of the investments in the evaluation period, it has proven difficult for Danida to monitor and evaluate cost-effectiveness.
This can in part can be attributed to the complex nature of such tools, particularly in the area of essential packages, but is also due to lack of capacity or priority within
Danida.
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Recommendations:
1.
Danida should explore the work being done on national health accounting, which could provide the comprehensive information necessary for SWAp approaches and for developing national plans. In addition, appraisals of financial management systems should include an assessment of whether key economic and financial indicators can be produced. These indicators should be sector-wide, not only for basic/district level services.
2.
Danida should develop a framework for sustainability for SPS. It should include guidance on: the dimensions of sustainability, (defining time frames, definition of areas requiring public financing, identification of key determinants of sustainability, key policy, institutional and financial milestones); basic economic analysis of sustainability in investment appraisals; risk analysis: emphasising political and institutional risks.
3.
It is recommended to explore ways to support the policy on health care financing as outlined in the Danida Sector Policies, Health (1995); to identify key strategies to support the development of alternative financing systems; to explore new ways to ensure the financial sustainability of NGOs, including mechanisms for government financing of NGOs.
4.
Danida should develop an approach towards cost-effectiveness at the sector level and focus policy negotiations on SPS at the key areas that affect cost-effectiveness. For example, balance allocations between primary and hospital sector rather than concentrate on inefficiencies between interventions within primary services
(packages). Ensure that these allocations are included in developing financial systems.
5.
Danida should develop capacity in health economics. Few initiatives have taken place to date with the exception of a seminar in health economics and training in India.
However, there appears to be no systematic approach to capacity development in this area.
6.
Explore alternative ways to support the use of health research within government and NGOs. For example:
7.
 Support research institutions in making evaluations of specific areas, particularly to evaluate aspects of health sector reform.
 Where technical assistance is being given to develop new interventions, such as in
India, support economic evaluations of the new interventions.
 Support the establishment of units/institutions/committees to undertake regular studies of specific interventions and diseases, rather than one-off comprehensive exercises (these types of units could be established nationally/regionally).
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This chapter describes the extent to which three issues, namely poverty reduction, gender and environment, have played a role in Danish bilateral assistance to health. The issues have been discussed in specific connections in the previous chapters and will be discussed separately in the following sections. Poverty reduction is the overriding principle of Danish foreign assistance. Gender and environment are in line with the 1994
Danida Strategy 2000 as cross-cutting issues that affect all development activities, including health.
The global revival of the poverty debate that followed the WDR on Poverty in 1990 and the subsequent Poverty Reduction Handbook (World Bank 1992) resulted in several policy changes in Danish development assistance which focussed the role of aid on health. The poverty debate in the 1990s highlighted poverty as a multi-facetted phenomenon, where causes and effects are closely intertwined. Health, or ill health, is both a cause and a symptom of poverty and well-being. This 'double-edged' sword makes it more essential but also more difficult to operationalise and to address poverty reduction effectively. New concepts of entitlement and access to services (Sen 1992; Ul
Haq 1995) such as health, water and sanitation have come to complement static poverty and well-being measures like Gross Development Product and Gross National Product per capita (see Annex V: Selected Indicators & Statistics).
Poverty reduction became an explicit principle of Danish development assistance in
1994. Implementing the poverty reduction objective was further spelled out in the threepronged strategy of 1996 that aimed at: promoting sustainable economic growth; supporting the development of human resources where health plays a vital role; and promoting popular participation and good administration practices.
Danida's Poverty Evaluation of 1996 clearly identified poverty concerns at the macro- and micro-levels as measurable and experienced phenomena of vulnerability. It further applied a working definition: “poverty is the deprivation of basic human and social needs and rights.” This definition placed the social context and rights at the forefront of
Danida’s aid agenda. A second analytical tool was introduced to differentiate between poverty alleviation, i.e. addressing the short-term effects of poverty, and poverty reduction, i.e. addressing the root causes of poverty. Consequently, for health interventions a choice must be made between short-term curative services and a preoccupation with the deeper causes and prevention of ill health and poverty. Danida's support to the primary health care strategy and related preventative health services has placed Danish aid to health in line with the longer-term poverty reduction objective. At the same time, some interventions such as AIDS counselling clearly fit a short-term alleviation perspective.
The Evaluation of Poverty Reduction in Danish Development Assistance, 1996, confirmed that of the eight Sector Policy Strategies analysed, the health sector policy had the most explicit poverty orientation. Overall growth in allocations to the health sector after 1994 are in line with the principle set out in Strategy 2000. However, the current evaluation has not been able to establish a systematic attention to the poverty reduction principle in interventions. Poverty orientation was implicitly followed in the actual
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SSUES interventions with emphasis on delivery of Primary Health Care (PHC) services, including essential drugs programmes, to the poorest segments of the community in the poorest countries. The successful support to fight leprosy and blindness (in India) demonstrates Danida’s concern for poverty.
Poverty has appeared on the national policy agenda in all of Danida's partner countries during the last decade. Poverty assessments have been undertaken to examine both relative and absolute poverty, skewed geographical distribution (Northern Uganda and
Upper West Region, Ghana) and predominance of poverty 'pockets' (India). Findings have been documented and reflected in Danida's priority areas for HSPS. Danida has helped create awareness of the pervasive effects of poverty, of the exclusion, isolation and indignity, and the strong bias against women and ethnic minority groups. So far though, implementation of Poverty Alleviation Action Plans is not universal, and the actual priority given to addressing the root causes of poverty varies greatly.
Annex V: ‘Selected Indicators & Statistics’ highlights differences in poverty for the five countries under study and indicates that poverty is context- and culture-specific. The total population without access to health services varies between 15% in India and 51% in Uganda, while as much as 71% of the Indian population is without access to proper sanitation compared with 23% in Kenya and 43% in Uganda. Behind these figures is hidden the fact that poor people, more than others, are forced to cope with health privately in the so-called 'popular sector'. Services are often of questionable efficacy and quality, and many poor people end up spending much of their savings on ineffective care.
This situation is believed to be exacerbated by the way user fees for health services are being applied. Exemption schemes meant to help ensure improved access for the poor, which have been instituted in the five countries, were not functioning satisfactorily.
In the late 1980s, Danida initiated activities in three specialised areas of concern: women in development (1987), environment (1988), and human rights (1990). The idea was to direct Danish foreign assistance along the lines of its broader agenda for social justice and community well-being. While initially these three issues were not part of Danida health planning, they were subsequently identified for development aid and prioritisation.
In the early 1990s, international health experts, including Danida, decided that the basic concept of PHC was subject to re-orientation. Following a series of workshops and issue papers, several cross-cutting issues; e.g. financial sustainability, cost recovery, women in development, environmental health, human rights, and AIDS, were considered for achieving sustainable development and were first identified as such in Danida policy documents in 1991. Poverty reduction firmly remained the fundamental principle of all
Danish assistance to developing countries.
These issues were reviewed and refined, and eventually Danida’s Strategy 2000 was adopted in 1994, which identified three cross-cutting issues: women’s participation in development was never included; environment; and democracy and human rights. It is worth pointing out that AIDS was never included as a cross-cutting issue which affects all development activities, including those of health.
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Danida gender policy development
To date, Danida upholds a Women in Development (WID) policy that uses tools such as gender analysis to make women and their role in development visible, to facilitate their empowerment as partners in development, and to strengthen their access to resources. In
1988, Danida developed a plan of action for development assistance to women that set forth strategies for integrating women’s participation in three sectors: water, health and agriculture. In 1992, a Danida discussion paper proposed WID strategies for the year
2000, and subsequently, a WID policy was developed in 1993. A major evaluation of
Danida’s WID policy was carried out soon thereafter (1994). The 1994 evaluation revealed that of 28 reviewed health projects presented to the Danida Board for approval, women were only mentioned as the target group in 14 of them, and there was little discussion on gender issues. The evaluation further pointed out that while women were not mentioned in the project documents, project evaluation reports usually did contain information on whether or not the projects had benefited women. Using the results from this evaluation a Sector Plan for development assistance to women was developed
(1997).
Danida has become more explicit in its concern to improve the health status of the population, especially for the most vulnerable groups, with emphasis on women and children. However, operationalising and integrating a gender strategy with health sector support has not been systematically pursued. Given the gender focus, a greater focus in terms of allocation of funds, to develop adequate interventions to tackle the problem of maternal and child malnutrition, could have been expected. Maternal and child malnutrition remains a considerable problem in most Danida-supported countries.
Gender and women’s health policies at the national level
At the policy level, the five countries visited have included gender or women’s concerns in MoH policy documents. Policy shifts in these countries, from a focus on maternalchild health and family planning to broader sexual and reproductive health, following the
1994 Cairo Conference on Population and Development, have had little visible impact on the provision of services under bilateral aid agreements. Only in 1999 did Danida produce a policy document on reproductive health. Danida funds to multi-lateral aid, mostly to UNFPA, for sexual and reproductive health and rights did increase considerably.
It has been noted in recent reviews of the Cairo+5 process that very few countries have been able to move from rhetoric to action in operationalising reproductive health.
Among our examples, India has made some progress in its efforts to integrate vertical programmes and reorganise its health sector, as have Ghana and to a lesser degree
Uganda and Zambia. It is too soon to demonstrate the impact and effectiveness of more comprehensive reproductive health programmes and policies, as few relevant models exist.
Although gender is mentioned in the planning documents reviewed in three African countries (except for Ghana HSPS I), its inclusion does not imply that a gender analysis has taken place or that the planners were aware of or sensitised to gender. In fact, the term gender often appeared in one or two sentences in health policy papers, but was noticeably absent in departmental policy and strategy papers. In some cases, gender has been included in the MoH policy documents as part of a preconceived package of
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SSUES activities negotiated with donor agencies. In general, the ET noted that the process of incorporating a gender or WID perspective into planning documents appeared difficult, especially at the lower levels.
Danida has stimulated the incorporation of gender and has supported the five countries by using different modalities or combinations thereof. These included: the appointment of a focal person in the MoH (Zambia, Ghana); technical assistance to support the development of a gender strategy for health (Ghana); technical assistance in gender from embassy staff together with considerable support from the Ministry of Women’s Affairs
(Uganda); and screening of health projects for inclusion of gender issues (India).
The different modalities of Danida support to Women in Development helped dictate the extent to which gender was an apparent issue in the health sectors, at both the policy and implementation level. For example, India, Bangladesh, Kenya and Tanzania have national gender desk officers, Danish embassies in all programme co-operation countries have appointed WID Counsellors.Uganda received support to establish a Ministry of
Women’s Affairs. Kenya received considerable support when the World Congress on
Women was held in Nairobi in 1985. Most recently, in India the Danish Embassy made gender the theme of the Annual Technical Advisor’s Meeting. Danida support was instrumental in the establishment of a Gender Core team, consisting of eight Danish and
Indian technical assistants. Moreover, the Government of India is now calling for an equity approach to health, and the majority of the Indian states has an official state policy for the advancement of women. It should be mentioned that the inclusion of gender and
WID in the health sector policy in India is mainly the result of the strong women’s NGO movement, rather than the restricted influence of donors at the state level.
Providing support through Danida, WID desk officers, embassy staff and in-country technical assistance has been the main thrust of the Danida-supported WID and gender strategies to decrease gender and inequity constraints in access to health care. Good examples of this support were found in India in DANLEP, in the initial planning for the construction of new health centres in the District Area Projects (and more recently in their general plans) in the Upper Western Region of Ghana, the NGO-supported AIDS project in Uganda (TASO), and the District Development Plan in Rakai, Uganda.
Collection of sex-disaggregated health statistics
At the national level, sex-disaggregated data for diseases patterns and client care were not easily available in all five countries. It appeared that not much has improved over the last ten years, although in Ghana, for example, the Gender Strategy for Health does clearly spell out the need to collect and analyse sex-disaggregated health data. Such data were collected in the Core Welfare Indicators Survey (1997). Moreover, a few states in India have made progress in integrating gender indicators in their HMIS (Tamil Nadu), but others have not yet started this process (Madhya Pradesh). In Zambia, the only gender indicator analysed in the HMIS is the number of women serving on Health Boards. The
1994 Danida WID Evaluation found that 14 of the 28 vertical health programmes did not collect or present data in a sex-disaggregated manner, except for AIDS and
TB/leprosy programmes. Most of the integrated projects did include selected data on women’s health needs and male and female literacy rates.
Women as beneficiaries
In the earlier years of Danida assistance, EDPs and immunisation programmes (Kenya,
Uganda, and Tanzania) improved access to basic drugs and vaccination coverage for
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SSUES women and children. It is generally agreed that this gain has eroded during the recent ten-year period (1987-1997) due to political unrest, a deteriorating economic situation, and structural adjustment programmes that have all seriously affected household livelihood. Especially in the four African countries, there has been a marked deterioration in the health service (availability and access to care and quality). These problems have been aggravated by the cutbacks in trained/qualified staff and the introduction of user fees. While exemption guidelines have been introduced to support impoverished and vulnerable groups, reports from all the African countries, except Ghana, indicated that these are not having the desired results. Focus group discussions with beneficiaries in
Zambia, for example, revealed that Health Reform had made things worse for the poorest inhabitants with fees for services and a lack of drugs.
An additional major setback for women and the poor during the period 1987-1997 has been the HIV/AIDS epidemic, mostly in the four African countries and in selected areas of India, and its devastating impact on household income and labour and community livelihoods. The havoc of the epidemic is most noticeable perhaps in the disruption of the social and economic patterns and safety networks and as such has even more severely disadvantaged women than men. Most of the Danida-supported HIV/AIDS projects
(Zambia and Uganda) appeared sensitive in targeting the poor by offering free testing and counselling and access to subsidised drugs (TASO, Rakai). NGOs have also been instrumental in recognising the gender implications of the epidemic, as HIV-infected women are heavily stigmatised (culturally, socially and economically), female-headed households are on the increase, and women are burdened with additional care-taking roles including raising large numbers of orphans. Governments in these countries are seriously lagging behind in providing support services to women.
The strategy of advocating community participation and including women as members of health committees has been attempted in all five countries with varying degrees of success. Where the decentralisation process is fairly well advanced (Uganda) and where legislation concerning women’s participation has been passed (Zambia), women are now elected members of health committees. In Kenya, where women have played an important political role and have a long history of successful mobilisation and women-led projects, women are now running community pharmacies and water projects. Their representation on health committees needs reinforcement. In India, community participation has been very successful at times, an example being the Tamil Nadu community mobilisation programme on female infanticide.
Danida has, in its support to the health sector, included a number of initiatives directed at environmentally determined diseases. In Africa (Uganda and Ghana), co-operation and co-ordination with water & sanitation projects have been successfully attempted. One important activity has been Danida support to Schools of Hygiene and the
Environmental Health Division at the MoH in Ghana. These schools and divisions
(Uganda and Ghana) would not have been established without Danida’s support, and they represent a substantive contribution to the prevention of ill health. The School of
Hygiene in Mbale, Uganda, is an excellent example of creating a linkage between the health and water environment sectors. Here students are trained in a school by the MoH, do fieldwork through the Danida-financed RUWASA project, and finally are employed by the District Director of Health Services. There is, however, a tendency to transfer
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SSUES these preventive-orientated institutions to other ministries like local government, which might alienate these institutions from the health sector.
Several examples of co-operation between the health and the water & sanitation sectors were seen in the African countries (Uganda, Ghana). In Mbale (Uganda), the environmental health inspector responded to outbreaks of cholera in a village by improving the water and sanitary conditions (Danida project). In the Volta region
(Ghana), the health sector was represented on the village water and sanitation committees. The team noted that a good opportunity for co-operation exists in Tamil
Nadu, but so far no real action has been taken.
Placing emphasis on hygiene in rural clinics and training schools for nurses/midwives has proven successful. Training programmes stressed increased awareness of the importance of the provision and maintenance of water & sanitation facilities. At training institutions and even at heath facilities in all five countries, the awareness of the students and health staff, as well as the information material on personal hygiene was consistently good. The water supply and sanitation functioned well at the clinics visited (India, Ghana, Uganda) except for Kenya where the water supply to clinics remains a problem. The handling of hospital waste, however, is an environmental issue that still needs attention. Included in the issue of handling hospital waste is the handling of outdated medicine. In Uganda, outdated medicine is taking up enormous space in the medical stores facilities. In Tamil
Nadu, on the other hand, it is now a condition that suppliers take back outdated medicine before bringing in new supplies.
Good practice:
 Danida has played an acknowledged role in both improving the situation of women and integrating a gender perspective in the health sector. Danida has supported the introduction of WID policies at the national and, to a lesser extent, the project level but may need to be more attentive to ensure actual translation from policy to action.
Danida’s flexible support to NGOs has been much appreciated and has helped to achieve broader gender awareness.
Lessons learned:
 As indicated, operationalising a gender strategy and meeting women’s reproductive health needs have proved very challenging in the five countries, and a longer timeframe is necessary to demonstrate measurable results. Care should be taken that the shift from Project Support to HSPS will not threaten gains made for women, both in terms of their own health and their true participation in health policy and programmes. More attention may be directed at community participation and intersectoral collaboration, ensuring the inclusion of gender in all development-related sectors.
 The HSPSs that have been included in this evaluation do comply with Danida's overall principle of poverty reduction at the policy level. However, in their operationalisation, the attention paid to poverty reduction tends to wane.
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Recommendations:
1.
Danida has a mission to ensure that its partners and its own staff pay continuous attention to equity in access to health services. It is important that this effort be sustained while the shift to a sector-wide approach is being initiated. Danida is well placed to facilitate integration of mechanisms for introducing poverty reduction measures in health services. Co-operation with NGOs has shown positive results for reaching the poor, and such partnerships should be encouraged and expanded.
2.
The evaluation team strongly encourages Danida to maintain its catalytic role with regard to gender during the transition to sector-wide programmes.
3.
Mere inclusion of gender in policy documents is not enough. Gathering sexdisaggregated data will aid in better assessing the degree to which activities are benefiting women.
4.
A greater attention to adequate interventions to tackle the problem of maternal and child malnutrition is recommended.
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9 C ONCLUSIONS , L ESSONS L EARNED AND R ECOMMENDATIONS
This chapter summarises the lessons learned from the findings of this evaluation. It also presents some summary recommendations. The first section concerns general findings and highlights the evolution of Danida's assistance to health with a special focus on SPS.
The second section discusses findings referring to the respective chapters of the report.
The third section describes findings from the five visited countries. The last section contains a list of recommendations to guide future assistance.
In the ten-year period evaluated (1988–1997), Danida was broadly successful in targeting public health problems of magnitude and those affecting the poor. Limited quantifiable information is available for a true impact assessment of Danida's specific inputs in terms of health outcomes. Moreover, many factors influencing the health status are beyond
Danida's control and are not or cannot be supported by Danida. Nevertheless, the immunisation rates and access to essential drugs improved significantly in Danida supported areas and there are signs that sector support can result in improved health services. There are also indications that poorer sections of the community benefited from better access to selected health services supported by Danida.
Danida has continually focused on essential health services and health systems development. In the early period of the evaluation, Danida’s two-pronged approach through PHC and disease prevention programmes was intended to improve access to and utilisation of services for the poor and vulnerable groups. Danida's support in the fight against leprosy and blindness and later tuberculosis and AIDS demonstrates this concern. In addition, Danida promoted district level activities through capacity building, improved logistics and infrastructure, and supporting structures that complement PHC, such as EDP and EPI.
A fundamental shift during the evaluation period has been from project support to SPS.
Three important developments have enabled this change: 1) There was an international shift away from piecemeal projects to more comprehensive approaches in health and development; 2) Danida experienced an increase in its budget for the health sector, which created room to pursue new policies; and 3) Some interventions proved to be unsustainable in-country. Internationally this change in strategy has meant that Danida has been able to provide important inputs to the debate on international health.
In-country, the shift in focus to SPS has redefined the role of Danida from a partner in the provision of health services to a partner in health policy, its development and planning. This shift could be facilitated by the increased allocation of funds and policy focus on health within Danish bilateral aid. The increased emphasis on health sector reform has shifted attention from the immediate users and beneficiaries to stakeholders at higher levels, policy-makers and health management staff, on the assumption that national ownership of health sector policies and strategies in the long run will improve the performance of the health sector.
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The following list summarises the experience of Danish assistance from the context to the eventual results:
Context
 Health and health service indicators show a downward trend, major preventable diseases (AIDS, tuberculosis and malaria) are on the rise, vaccination coverage is decreasing and public health service utilisation is declining.
Policy
 Macro-policy levels are fragile and volatile, turning ’enabling environments’ into suspicious or antagonistic climates at short notice.
 There has been an increased interest in national reform policies and health sector reforms. The broader reforms have often not been sufficiently considered in the planning and implementation of Danish assistance to health (e.g. macro-economic reforms, decentralisation, civil service reforms).
 Stakeholder participation is vital and has proved important for gaining support for health sector reforms and therefore for the effectiveness of SPS that supports them.
There are dangers in promoting reforms that rely on a small group of central government health officials. There are many groups of stakeholders concerned with health; public authorities, civil society/private sector, and individual users. In particular, the promotion of a public debate of health sector reforms has received insufficient attention.
Impact
 The achievements and donor-related impact on health status are difficult, or even impossible, to measure and are therefore not well documented in Danida supported interventions.
 The AIDS pandemic and macro-economic problems are raging across (Sub-Saharan) countries receiving Danish health sector support. This impinges on the measures of effectiveness of perhaps all aid interventions.
Danish
Support
 Danida support to disease control and vertical programmes was on the whole effective, but may prove difficult to sustain within the context of SPS. In some countries, rapid transition to SPS may have damaged gains previously made under project support in other countries. More consideration has maintained those gains.
 Health system development and improved performance require long-term thinking and planning, a willingness to change, and a capacity to absorb change. Reform implies significant, often fundamental change, and there is no blueprint for successful support. Danida has been flexible in its support to development of national programmes in some countries (Ghana, Zambia) but more rigid in others (Kenya,
Uganda) where it tried to “push” reform.
 As the implementers of programmes and reforms, health systems managers and communities are vital to the success of health policies and SPS. Participation of these groups was initially managed successfully in places where Danida was provided the space for joint experimentation and pilot testing (India). However, in general, systematic approaches to involving stakeholders from different levels are few. It has continued to prove difficult to translate the need and demand for institutional capacity building at the district and community levels in the formulation of Danida support programmes.
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 Considerations of quality of care, poverty focus and targeting, and community participation are often not adequately reflected in SPS or have proved difficult to implement. For example, community initiatives are expanding in many places but are often neither reflected nor considered in many health sector policies supported by
SPS.
 SPS focuses inherently on one sector. However, the complexity of factors influencing health but covered by other sectors are in practise not taken sufficiently into account
(environment, food security and nutrition, water & sanitation, and gender, to name a few). Examples of inter-sectoral dialogue are scarce.
 Danida has had difficulties in finding the appropriate balance between conditionalities and dialogue in SPS. Given the volatile nature of policy environments, in some countries there has been insufficient time spent building trust, and identifying risks prior to SPS. But also the limited insight in technical and political problems compounded by lack of experience with the SPS modality of assistance played a role.
 The new demands for donor co-ordination have been successfully met in selected countries (Ghana, Zambia), but co-ordination under the leadership of national governments needs reinforcement.
 SPS health sector approach requires health advisors with different skills. The shift in demand for those with skills to manage project funds to those who are able to be involved in national policy has not always been considered in the selection of technical assistance.
 There has been limited dialogue and possible integration between health systems research and sector programme planning. Research objectives and questions have been insufficiently focussed on needs with respect to SPS implementation.
Danida
 The division of roles and responsibilities between the different hierarchical levels
(political and technical) of the Danida organisation itself hampers constructive dialogue with the recipient country to a certain extent. This applies particularly to the division between technical and political roles.
Useful lessons emerge from Danida’s experience with the transition from project support to SPS:
 The move from project support to sector support is a process not a one time event.
In preparation for SPS, Danida was often overly optimistic in its assessment of the climate in which far-reaching reorganisation and changes in donor strategies were to be introduced. Timing and modalities for support were not always designed to minimise risks. The complexities of the political and economic climate were perhaps also underestimated in some cases (Kenya, Uganda). Danida did not sufficiently adhere to incremental planning exercises and use realistic financial assessments in guiding national partners. This over optimism later created impasses and jeopardised otherwise promising conditions. Ambivalent government commitment and lack of a sense of ownership to health sector reforms, on the one hand, and the issue of conditionalities, on the other, created disruption and stop-go situations regarding
Danida’s support. This experience indicate that a planned transitional phase between
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ECOMMENDATIONS project and SPS is important including more emphasis on promoting public debate and significant stakeholder consultation in joint government led planning.
 SPS demands a careful balance between trust and control. Achieving this balance has been difficult and has been a process of trial and error for Danida. Trust, expressed in a shared vision and transparency of operations, is the most important pre-requisite for long-term partnership. Conditionalities and earmarking of funds reflect differences between donor and national priorities and management capacities. To date conditionalities have been based on inputs rather than outputs or outcomes.
Conditionalities on inputs may be required in the short term, but have been seen as a sign of mistrust. When conditionalities have not been met, Danida’s response has been inconsistent. There have been different levels of adherence to conditionalities by Danida, partially due to different contexts, but also to differences between Danida decision-makers. In some countries fall back conditionalities are in place, but it remains to be seen whether this is a successful approach.
 Having access to information is vital to rational decision-making both by Danida and by country level partners. The existence of a well-defined health policy and data influencing the state of existing health problems and systems is essential for successful reforms. Danida has had mixed success in supporting systems that produce the necessary information, with many reforms running faster than the production of data to inform them. Lack of information continues to be a problem when making an informed sector analysis and evaluating Danida support. This includes also information on political context and institutional and legal frameworks.
 The effectiveness of Danida's support is strongly influenced by the degree of political commitment and ownership at the country level. This relies, in part on how Danida is perceived. Technical support and mechanisms for collaboration were most successful in Ghana. Here national counterparts defined Danida's assistance from a
“country owned, country led” perspective. Similarly, in Zambia, Danida was invited by the government to join the policy dialogue and co-ordinate aid with other donors through a common basket. In these circumstances, where Danida's support has been seen as a support to the domestic impetus for reforms, SPS has been fruitful.
 SPS has focussed Danida support to the public sector of the Ministry of Health, and mainly to health reforms at the central level, concentrating on district health services.
This may mean that other significant areas were overlooked. In the formulation of
SPS, Danida directed relatively little attention to the private sector, hospitals, community participation and safeguarding the quality of care. To expand on the latter, in a devolving health system, regardless of the modality in which assistance is provided, quality of care will take on increasing importance for donor and health authorities. Although quality assurance was a component in some SPSs in others it did not feature prominently. Where it was on the agenda, the operationalisation of it proved to be a problem. Only Ghana has begun introducing quality assurance mechanisms.
 Finally, the changes and reforms in health policies of many countries are, in many cases, as new as the shift in Danida’s own development policies. Experience is too limited to make firm predictions for the future. Given that HSR is in its earliest stages, careful documenting and joint learning from existing initiatives are essential.
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Achievements, perceived impact and targeting
In the main, the evaluation relied heavily on the perceived impact of Danida-supported health programmes. This was mostly positive among the managers of health services and was exemplified by the strengthened technical skills of the health providers. The ultimate beneficiaries, i.e. the communities, were also positive about Danida’s contribution to the infrastructure and availability of drugs. Danida's contribution to the decentralisation of health planning and management structures, improved local/regional capacity for planning, financial and administrative management has been well appreciated.
In terms of essential health services, Danida has been successful in addressing priority public health problems (infrastructure, EDP, TB, leprosy, AIDS). It has not been able, however, to develop adequate interventions to address maternal and child malnutrition, while the prevalence of both reaches two digit percentages in all the countries reviewed.
Perhaps Danida’s main achievement was its contribution to a much needed expansion of and improved access to primary health care services through the strengthening of outreach activities and the availability of drugs, training, and construction or upgrading of the physical infrastructure. By far, the best returns for small flexible budgets derived from Danida investments in innovative pilot projects in India that were scaled up with funds from loans or large donors.
There are early indications, from countries like Ghana, that SPS can have a positive effect by supporting health sector reforms and resource allocation that is ultimately necessary for sustainable essential services. Nevertheless, in some countries, the difficulties in continuing support under SPS to previously effective vertical programmes may have had a negative effect on health. Danida, historically one of the most important donors for vertical inputs, finds it difficult to transform separate projects into a sector-wide policy.
Although Danida has a strong poverty focus policy, it has proved difficult to implement.
Danida has often concentrated investments on the poor regions within countries. While the activities benefited the general population, it has proved significantly more difficult to reach the very poor sectors of the community. While attention to community participation was not always evident, selected Danida-supported interventions did help to establish community-led and -owned activities (e.g. construction of facilities, communitybased nutrition and disease prevention). This was not the case for the management of the health services nor the planning of Danida support. Staff at the peripheral level expressed the view that they were not sufficiently involved in the planning process of national plans.
Policy and strategy
There have been several key dimensions to Danida's policy and strategy in the ten years evaluated. Firstly, Danida has focused on three key areas of the health sector: the provision of essential or priority services; the strengthening of health systems planning and management; and finally, community development. Within these there has been an increasingly explicit poverty focus and the inclusion of cross-cutting issues such as gender and the environment. In the 1980s, Danida was successful in promoting the PHC principles and contributed to bringing health closer to the people through infrastructure expansion, development of the EDP concept, and support for immunisation
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ECOMMENDATIONS programmes. Danida supported control programmes of 'poor man's diseases' such as tuberculosis, leprosy and blindness, community-based health, and nutrition.
In terms of strategy, Danida has aimed to be flexible and responsive to the national context, needs and priorities. A key strategy has been the move from project to sectorwide support. Danida has been one of the leaders in this change. In doing so, Danida has taken risks to support potentially important and innovative approaches. Partners in most countries have acknowledged the constructive role Danida plays in donor deliberations and national policy development.
The example of India illustrates that even where the relative scale of donor dependence is low, project support can be relevant, if governments decide on their strategies. In the four African countries visited, the significant role of Danida in the health sector has, in effect, bought a place in the national policy dialogue, and sector support remains the strategy of choice, where external financing is a large part of health sector financing.
Finding the balance between recognising a country’s right to self-determination in setting and implementing policy and the donor’s entitlement to accountability for and returns on its investment remains a challenge.
In sector support, maintaining essential/priority services, community involvement, health systems development and poverty focus is dependant on establishing these priorities in national health plans. Danida was directly involved in supporting the formulation of national health plans to prepare the way for the SPS. Establishing these priorities nationally is a process of policy dialogue and to date ( in the early stages of SPS) has met with mixed success. In the context of HSR, Danida’s consistent support of decentralisation and devolution of authority has helped to strengthen the capacity at the local level, although the policy needs reinforcement. Nevertheless, in some cases Danida has still felt it necessary to earmark funds for community involvement and participatory rural appraisal studies (Ghana, Uganda, Zambia). In India, with project and programme approaches social mobilisation was more vibrant.
Tight programme frames of objectives and activities often leave the issue of conditionalities unresolved, or irresolvable. The strict application of conditionalities, even when initially patience has been practised, led to a freeze in Danida disbursements, resulting in the on/off implementation of HSPSs or its components (Kenya, Uganda and
Zambia). The effects this has had on service delivery in countries highly dependent on donor aid were aggravated by the fact that no alternative strategies or fall-back positions existed. This has had a significant impact on trust and mutual understanding, making future dialogue even more difficult, and has discredited the appropriateness of Danida support as measured against its stated goal to assist the poorest of the poor.
Channelling, implementation and performance
Danida channels funds through three major channels: multilateral organisations; nongovernmental organisations (NGOs); and government to government bilateral support.
The focus of this evaluation is bilateral government to government and NGO support.
Channelling is not simply a question of where resources come from, but also where they go. Danida's bilateral support to the health sector has focussed on the public sector and, within this sector, on the primary service level. Other options exist: hospitals, which consume a significant part of the public health budget and often inefficiently, were, on the whole, excluded. The for-profit private sector can provide high quality and efficient services. The informal sector is often community driven and may provide alternatives
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ECOMMENDATIONS where public services are breaking down. Neither have been within the range of Danida support to health.
SPS can channel large amounts of funds relatively quickly. It was found that in many cases implementation plans were too ambitious and that the timing and modalities were not sufficiently guided by knowledge of what works and what does not, not taking the relative absorption capacity of the different parties involved at the national, state and local levels sufficiently into account. Danida's (and other donors') assessments of the environment for change were too optimistic in Kenya and Uganda. Here a phased transition period, based on Danida’s earlier support to vertical programmes, might have been more appropriate.
Danida seeks synergy among and between its development activities. Danida has had the opportunity to capitalise from supporting different levels of the health service. However, examples of synergy of interventions at the national, district and community levels and between Danida-supported sectors in country aid portfolios are few. Complementarities between support from different agencies - private/public and bilateral/multi-lateral donors - have also been difficult to establish, particularly where government commitment or donor co-ordination has been weak or ambivalent.
Health is a cross-cutting issue and demands inter-sectoral linkages. The challenge of
HIV/AIDS is a dramatic example. However, inter-sectoral linkages in the field and within Danida itself have not been optimised for health. While Danida policies acknowledge the interaction between health and other sectors such as education, environment, agriculture, energy, transportation and food security, collaboration in the field hardly materialised. Health and health impact assessments did not feature prominently in the planning and implementation of activities in sectors other than health.
Integration of health and water and sanitation was most successful (Uganda, Ghana).
As Danida has moved from project to sector support the requirements for TA have changed. While on the whole, Danish TA has been well received, where this was not the case, it has been due to the lack of definition in the role of the TA. The TA requirements for a constructive policy dialogue in order to reach health sector objectives are different from those required to manage and support projects. There is still a problem in finding sufficient and appropriate Danish TA.
The health-related research capacity has been enhanced increasingly. Danida has facilitated linkages between health researchers and health practitioners through the
ENRECA supported HRN. Nevertheless, research has played a limited role in supporting policy and strategy development and operationalisation of SPS.
Sustainability and cost-effectiveness
In most cases, the health services that Danida has supported are unlikely to be sustainable in the near future. This is almost certainly a consequence of the fact that
Danida targets the poorest of the poor and some of the most intransigent health problems. Increasing proportional public expenditure allocations to the health sector may provide some of the required resources, but given constant or declining government revenues allocations remain insufficient to provide essential services in most of the visited countries. In the few cases evaluated where support had ended it was observed that on the whole benefits had not been sustained.
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Although sustainability can be improved by encouraging low-cost practices and financing from service users, political support is a first essential step to determine future sustainability as many basic services in low-income areas will require a degree of permanent subsidy from government. The maintenance of levels of health expenditure by countries facing substantial macroeconomic difficulties can be seen as an indication of success for those in the international policy arena, (including Danida) who have emphasised the importance of investment in the social sectors. Within the health sector there has been limited success in increasing domestic funding to non-salary and basic level services. Importantly, recipient governments have not managed to adequately confront the level and allocation of the salaries and hospital expenditures. As a consequence the large increases in donor financing to health focused on basic health services (sometimes including substantial contributions by Danida) have inadvertently reinforced financial dependence on external aid. The shift to sector-wide approaches intends to overcome this problem.
In general, Danida has as a strong implicit policy, an investment portfolio that promotes cost-effectiveness. There has been a strong focus on interventions that are among the most cost-effective, for example, the project support for PHC, EPI, and TB Control.
The move from project support to programme support has shown potential to maintain this focus, if given specific attention. Initial indications in countries such as Ghana are that SPS may be successful in encouraging increased expenditure allocations to essential health services. This success can be partly attributed to an emphasis on priority services in the preparation and appraisal phase of sector support and the dialogue surrounding national health plans. A second contributory factor is the transparency in both donor and recipient country accounts. The case of Zambia illustrates that both donors and recipient governments need to be able to provide each other with the relevant expenditure information in useful breakdowns in order to negotiate allocations to essential services.
Where technical (economic) tools have been used for priority setting, such as packaging methodologies, there has been limited success. This is primarily due to the application of the tools. Firstly, economic tools inform priority setting by illustrating optimal allocations of resources. However, priority setting is essentially a political process and unless this process is also addressed, the tools will have little benefit. Secondly, the tools are complex and there is often little domestic capacity in health economics. This can result in a lack of sustainability and domestic ownership. The example of Zambia illustrates this point where, after the technical assistance finished, the packaging process ground to a halt.
As with the measurement of effectiveness, the measurement of cost-effectiveness has also proved difficult for project managers and health advisors. Tools for economic evaluation of project interventions are well established, yet implementation proved to be difficult. This is in part due to the complex nature of the tools, but also due to lack of capacity or priority for health economics within Danida during the period of evaluation.
Sector support brings new challenges in assessing cost-effectiveness. In particular, it demands more attention to the assessment of allocative efficiency at the sector level.
Assessing allocations in resources between inputs (i.e. salaries, buildings etc.) is relatively easy, but assessing allocations in resources between levels and services is more problematic and relies heavily on the development of financial management systems.
Attributable improvements in effectiveness (outputs and outcomes) present even greater difficulties.
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Poverty alleviation is an overriding principle of Danida support. In the health sector, it has been addressed from the beginning in the form of targeting the poor areas in the poorest countries, and support to PHC and the essential drugs programmes. In these areas considerable achievements have been made. The shift to SPS may mean that targeting of the poor and selecting national programmes that benefit the poor (TB, leprosy, blindness prevention) are at risk. This has often not been explicitly considered and successfully implemented in SPS. One exception is Ghana, where funds remained earmarked for the development of an exemption scheme for user fees.
The cross-cutting issues of gender and the environment showed both achievements and constraints. Although Danida stimulated the process of incorporating gender into health planning through in-country technical expertise, experiences with operationalising gender strategies was limited. In terms of the environment, Danida was most successful in coordinating health and water and sanitation activities, but less successful in other sectors
(transport, food security and energy).
In India, it was observed that, although SWAp is not a national policy and Danida's financial contribution to the health sector is small in relative terms, Danida has had a significant influence on health sector development. There has been a mix in channelling interventions through the governmental sector as well as the NGO sector. Danida contributed successfully to “vertical programmes” (blindness, leprosy, TB). Different stakeholders have been supported to reach the poor elements of the society. Gender is high on the agenda. Co-ordination with other donors occurred in a pragmatic way.
Through this flexible approach, Danida was able to develop innovative policies, strategies and intervention modalities. Some of these could be upgraded (cataract campaigns, blister packs for leprosy, integration of vertical programmes). Elements of SWAp
(transparent information systems, decentralisation, and uniformity of drug management systems) have been established within the area programmes.
The major lessons to draw are: i) long-term partnership (20 years) is required for building up trust, and to learn about the environment and local culture; and ii) a partnership stands a better chance of success when it is based on equality and not on dependence.
Kenya and Uganda have also received long-term assistance but are financially dependent and have experienced economic hardship. The initial interventions concerning vaccination and essential drugs were very much needed, and Danida's role here was clear.
When SWAp was initiated, the HSR began, and Danida shifted from project to sector support. The role of the donors, including Danida, became less obvious and was also not clearly spelled out. Who should do what and how?
The main lessons are i) time factor and trust. There was probably a miscalculation about the time required before such a huge undertaking as HSR can be realised. This is certainly true when the countries experience economic recessions and political upheavals. Distrust in each other’s intentions hampered constructive dialogue; ii) the process of support to the health reforms is not a one-way street. While a project may have clear targets and one
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ECOMMENDATIONS can use “logical frameworks” to develop intervention plans, support to an entire sector needs process-oriented support, including fall-back positions.
In Zambia and Ghana, Danida was invited to support the reforms through a SWAp.
Clearly, the country itself was in control. The expectations were nevertheless too high in
Zambia. The merging of specific programmes (e.g. vaccination and TB) in the reforms has not been well addressed, as the focus was too much on the organisation of the reforms and too little on the quality of the services. There is a need for incremental planning. Specific targets, as used in log frames, can be suffocating. In contrast, incremental process-oriented planning, with milestones instead of ‘fixed’ targets, boost moral. In Zambia, the developments were initially very promising, and this positive spirit can now be appreciated in Ghana. Caution is, however, required. The process is very fragile, as recent experience in Zambia has shown.
The major lessons are: i) there is a need for incremental planning, using a processoriented approach, with milestones instead of fixed targets; ii) too great a focus on health systems developments detracts from quality of patient care; and iii) an institutional memory should be kept to learn from each other's experience.
1.
A joint government-donor (risk) analysis needs to be conducted to identify capacity, economic and political risks to SPS. The capacity appraisal should propose how to integrate existing elements of technical assistance into national plans. Integration of project elements (human resource development, capacity building, costing studies, and data management) should be gradual.
2.
Long-term partnerships and support for major reforms have to be built on long-term financial commitments. Therefore, subsequent phases of the SPS process, including a framework for financial commitments, need to be elaborated between the donor and recipient country before the SPS is initiated. Long-term budgets could include fixed and variable (performance-related) components. A trade-off needs to be made between risk management and unconditional support. Although this might conflict with Danida's specific annual budgetary targets, it increases the flexibility and trust between partners. Danida should develop a framework for sustainability, emphasising the dimensions of sustainability such as, realistic time frames, key milestones.
3.
Preconditions for entering health sector support need to be carefully assessed. Semiflexible conditionalities are essential, with clear fall-back positions and realistic milestones based on local capacity and demonstrated commitment to implement changes. Alternative entry points through NGOs or the private sector may be considered through the creation of umbrella mechanisms. This includes earmarking of successful smaller (innovation-oriented) projects in addition to budget support to overall health.
4.
Danida should establish an approach towards cost-effectiveness at the sector level.
This should begin with internal capacity development within Danida. Sector programmes should include support to improve the efficiency of allocation across the health sector and, where appropriate, more attention should be paid to the hospital level. SPS should also include the development of a policy towards the
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ECOMMENDATIONS private sector. Existing private provision is an essential consideration when deciding the allocation of resources to government services. Useful starting points could be support for national health accounting or for private sector development units within
MoHs.
5.
To facilitate support to the health sector, process-oriented monitoring tools need strengthening for better monitoring of process and outputs against original plans and component expenditures. The recently introduced indicator system may be useful in this regard but needs critical review.
6.
Danida can help mobilise broader representation of all stakeholders including those who are otherwise likely to be left out (private sector, NGOs, vulnerable groups, women’s groups). Care should be taken that ownership remains with national stakeholders; it must not be taken over by outside agencies.
7.
The principle of community participation needs to be reinforced in Danida's support to sector programme support - involving communities in decision-making, particularly in cost-recovery mechanisms to strengthen the operationalisation of adequate health interventions, including quality of care.
8.
Efforts to improve the quality of care need to reflect the non-technical aspects of quality better, such as affordability, counselling/interaction, supervision, safety, efficiency, and service environment. Understanding client needs and priorities is the key to better quality and should be more actively supported by Danida. In areas with few qualified staff, establishing a supportive enabling environment and creating internal incentives will help foster quality.
9.
In addressing poverty and cross-cutting issues that impact on health, Danida needs to take a more active leadership role to search for robust strategies and operationalise the lessons learned.
10.
In those countries where HIV is epidemic, Danida should treat AIDS as a crosscutting issue given its impact on development in general. This concerns not only the health sector but also other sectors (economy, agriculture, food security, human resources, etc.).
11.
Macro- and micro-nutrient deficiencies in women of reproductive age contribute to four of the five major causes of maternal mortality. Maternal malnutrition is a major cause of low birth weight that increases the risk of infant mortality, poor growth and stunting. Danida should stimulate the development of adequate interventions to tackle these problems
12.
There is ample opportunity to strengthen collaborative efforts in-country. Danida is not consistent in its policies on health impact screening or assessments in its support to sectors other than health. It is recommended that such assessments be included as a routine component of all development sectors that impact on health.
13.
To avoid shortages of TA, funding fellowships and upgrading local staff and/or the contracting out of TA to institutions rather than using individual consultants should be reinforced.
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14.
Health system research and small-scale pilot projects should be supported, to help identify entry points for appropriate intervention strategies that seek to improve equity and gender equality. Earmarking funds for NGO activities remains necessary and relevant. Danida should continue to push both the enhancement of research capacity and the application of research results for operational purposes. Danida should further explore opportunities with local research institutions and academicians to get them more involved in a research agenda that supports the operation of the health sector. Topics of studies could include: cost-quality interactions; exemption modalities; provider payment schemes; social and other health insurance systems; subsidy targeting; user fees; assessments of AIDS interventions in Sub-Saharan countries; tightening the links between health and environment; and studies on different determinants that influence quality of patient care.
15.
It is essential to document key lessons learned from past interventions to establish an institutional memory. This allows dissemination of experience (good and bad) to various partners. Danida should actively support the process.
Above mentioned conclusions and recommendations are reflecting the evaluation period
1988-1997. It should be noted that beyond this period some important developments have been taken place in Danida’s strategy for health support, notably:
 A shift has taken place on the importance of comprehensive and realistic health policies as a precondition for SWAp/SPS, to a more process oriented approach, where SWAp/SPS is seen as a conducive environment for change.
 Instead of instigating on “radical” HSR, approaches have been incorporated that allow gradual shifts towards HSR, including e.g. transitional phases. More space has been created to allow persons and institutes time to develop, taken into account lessons learned from the past.
 A shift has taken place from the rational model of planning to a more comprehensive and realistic model of planning and decision-making. Besides technical
(epidemiology/economic) paradigm also political and organisational views are considered in the planning process, as well as proper staff incentives.
 More emphasis is given to relational “contracts” rather than conditions.
 Instead of giving emphasis to the PHC level, more attention is given to the private sector and hospital sector in health sector support.
 Rather than sticking to the essential health package the use of public subsidies is seen in a broader context.
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Evaluation of Danish bilateral assistance to health
Health is more than just the absence of disease; it is vital to human wellbeing and, as a goal in its own right, it is central to social and economic development. With increasing life expectancy the quality of human life has become at least as important as its length.
Health expectancy can thus be defined as life expectancy in good health. This represents a shift from previous emphasis on reduction of mortality to renewed focus on morbidity reduction.
In most developing countries the pattern of health is changing. Infections and parasitic diseases continue to kill 17 million people per year and afflict hundred of millions of others. At the same time 24 million people per year now die of chronic diseases such as diseases of the circulatory system, cancer, diabetes, and diseases of the respiratory system outnumbering the number of such deaths in the developed world. In addition they suffer from other lifestyle diseases such as the ill effects of tobacco, alcohol, drugs, violence and traffic accidents.
Health problems can be grouped as follows:
1. Health problems for which methods of prevention and/or cure are well known but where lack of economic resources and/or political will hamper access for those who need it most. Examples are: vaccine preventable diseases, malnutrition, maternal deaths, neonatal deaths, mental disorders and some infectious disease.
2. Health problems where preventive and/or curative methods are either difficult to apply (politically, culturally or administratively) or too expensive for low income countries. Examples are HIV/AIDS, cardiovascular disease, diabetes, cancer, substance abuse related disease, traffic accidents and consequences of violence.
3. Health problems which could previously be controlled, but where the previous measures are no longer effective due to improper use. Examples are: drug resistant malaria, drug resistant tuberculosis, and some sexually transmitted diseases.
4. Finally, health is increasingly influenced by social and economic circumstances over which the individual has little control and over which the conventional health sector has little influence.
Denmark has subscribed to “Health for All by year 2000” as well as the principle of
20/20
8
as agreed at the Social Summit in Copenhagen, 1995. It is, however the Danish understanding that the 20/20 principle shall not be a new conditionality for assistance to the sectors.
Poverty orientation constitutes a fundamental principle of Danish development assistance and one of the main points of the “Strategy for Danish Development Policy towards the Year 2000” (March 1994) is:
 That the development of the social sector, including the promotion of education and health services are prerequisites to the development of human resources.
8 On average 20% of ODA and 20% of the national budget shall be allocated to basic social programmes: health, education, drinking water and sanitation
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Within this framework, assistance to health has been and will remain an important element in Danish development co-operation. At present, the health sector is the largest recipient of Danish bilateral assistance receiving DKK815 million (15.6%) of the total bilateral assistance in 1997. As a part of the bilateral assistance in 1997 DKK 123.9 million (19.7%) of the NGO frame has been used for health, whereas the Programme for
Enhancement of Research Capacity in Developing Countries (ENRECA) has used DKK
19.6 million (37.8%) of its budget for research i health.
The magnitude of the assistance to health is also reflected in the section of priority sectors in the 20 Danida Programme countries. The health sector is now a priority sector in nine Programme Countries, namely, Bhutan, Ghana, India, Kenya, Mozambique,
Tanzania, Uganda, Zambia and Zimbabwe.
Since January 1995, Danish bilateral assistance to health has been provided within the framework of “Danida Sector Policies for Health”.
Although several Danish assisted health projects/programmes have been evaluated (see
Annex I: Terms of Reference) an overall evaluation of the Danish bilateral assistance to health ahs never been done. It has therefore been decided to carry out such an evaluation during 1998/99.
In order to facilitate the planning and implementation of the evaluation and to ensure utilisation of “lessons learned” from the evaluation, an Advisory Group has been established. The members of the Advisory Group are Danida staff and external advisers.
Advisory Groups will also be established at country level in connection with the field studies.
The main objective of the evaluation is to compile relevant “lessons learned” in order to improve the quality of Danish bilateral interventions in the field of health, and contribute to the strengthening of health care systems and to improved health status in developing countries. Furthermore, the evaluation will present an overview of the results of Danish bilateral assistance to health. The evaluation may also provide input to revision of the paper “Danida Sector Policies for Health”.
The evaluation will result in:
An overview of Danish bilateral assistance to health over the last ten years including an assessment of its quality and its contributions to improving health conditions of the target groups (e.g. women and children) as well as health care systems.
Issue papers relevant to future interventions in the field of health, with emphasis on
Sector Programme Support e.g. input of a revision of the paper “ Danida Sector Policies for Health”.
A synthesis report for publication.
The evaluation will cover Danish bilateral assistance to health during the period 1988-97 including support to health research and through NGOs. The evaluation will be carried out within the framework of the Danida Guidelines for Evaluation (1994) and Danida
Evaluation Policy (1997).
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From an operational point of view the evaluation will embrace activities defined as
“health” under the DAC code no. 12. The evaluation will be concerned with the health sector broadly defined, and thus the entire network of public, private and voluntary institutions. The evaluation, will however, at field level include other health related activities e.g. water supply and sanitation and additional contributions to health made by
Danish assistance through multilateral organisations.
The evaluation will be carried out in three phases:
Phase 1: desk study
The primary objective of phase 1 is to provide an overview of the results of Danish bilateral assistance to health in the developing countries. In this, the evaluation will assess the relevance, effectiveness, efficiency, impact and sustainability of the Danish assistance.
Phase 1 will comprise of a desk study of relevant background papers and reports etc. and interviews with representatives from Danida, Danish NGOs, Danish health researchers, the Danish resource base, the international health community and other relevant informants.
A one day workshop on the findings, conclusions and recommendations of the desk study will be held in Copenhagen before the start of Phase 2 in order to adjust the scope of the field studies, if needed.
Phase 2 : field studies
The purpose of the field study is to further explore issues identified in Phase 1 and to validate preliminary findings and conclusions from Phase 1. The field studies will therefore address the same issues as the desk study, but also additional issues, which best can be explored at field level.
Phase 2 will comprise of field studies in several Danida Programme countries. The field studies will include: a) consultations with senior Government officials, staff members of the Danish
Embassies and NGO representatives; b) interviews with persons responsible for health activities e.g. technical advisers, representatives from ministries, local authorities and communities, local NGOs, researchers and relevant donors; c) surveys of and/or interviews with representatives from target groups e.g. women and children as well as private health care providers e.g. private doctors and sellers of drugs; and, d) visits to a representative sample of districts representing different health problems and levels of socio-economic development.
The identification of countries for the field study will be based on the following criteria:
1) They will be Danida Programme countries where the health sector has been selected as a priority sector in the present Danida country strategy, and
2) Danish assistance should over the last ten years have been considerable.
Furthermore, countries from both Asia and Africa will be represented. Health has not been selected as a priority sector for any Programme countries in Latin America.
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Based on these criteria the following countries have tentatively been selected for the field visits: Ghana, India, Kenya, Uganda and Zambia. Ghana and Zambia only partly fulfil the second condition, but have been included in the field studies due to the joint donor approach on Sector Programme Support to health in these countries. The final selection of countries for the field study will be based on the findings of the desk study.
Two country specific health evaluations in Tanzania and Bhutan will also be carried out during 1998-99. Although these two evaluations will have their own objectives and scope of work, they will to the greatest possible extent cover the same issues as this evaluation.
In order to contribute to the development of evaluation capacity in the Programme
Countries, local institutions will be involved in the evaluation at country level. The local institutions will conduct surveys and tracer studies as well as prepare issue papers relevant for the evaluation. Advisory Groups will also be established at country level in connection with the field studies.
The findings, conclusions and “lessons learned” from the field studies will be presented during one day workshops at country level and in Copenhagen, where the outline for the synthesis will also be discussed.
Phase 3: synthesis
Phase 3 will synthesise the findings of the first two phases and compile relevant “lessons learned” and “best practices” in order to improve the performance of future Danish bilateral interventions in the field of health. Furthermore, the synthesis will include an overview of the results of Danish bilateral assistance to health over the last ten years. The findings, conclusions and recommendations from the country specific evaluations will be included in the synthesis. Special attention will be given to issues identified during the field studies. “Lessons learned” and “best practices” shall address both basic issues concerning the health care services in the developing countries and specific issues related to Sector Support Programmes.
The evaluation shall comprise of, but will not necessarily be limited to the following:
Desk study:
The desk study will:
1. describe the changes over time in the concept of health and the main strategies used for health improvement during the period 1988-1997, with emphasis on significant changes in both national and donor strategies;
2. describe the relevance of Danida’s policies and strategies for health both in relation to international trends and to the political, economic and social setting in developing countries;
3. assess any shift/ change in the main internal strategies for health improvement in the selected developing countries, their relevance for the political, economic and social settings and how Danida has adapted to these shifts;
4. analyse how targeting of the poor was taken into account in the Danish support to health;
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5. analyse how targeting of women and children was taken into account in the Danish support to health;
6. assess to what extent adequate inputs have been incorporated to counteract, and if possible redress gender constraints to the equitable delivery of health care services;
7. assess the relevance of achievements of ENRECA and other Danish supported health research programmes with regard to research capacity building both in Denmark and developing countries.
8. assess the co-ordination and integration of health research within ENRECA and the
Danish research base and in relation to Danish project/ programme interventions;
9. assess the synergy and complementarity to be found between interventions implemented by Danida and NGOs;
10. describe measurable achievements (outputs) of Danish assistance to health;
11. assess the perceived impact of Danish assistance on health status of special target groups, particularly women and children;
12. assess the perceived impact of Danish assistance on health policies and strategies planning and implementation at national and international levels;
13. analyse the transition between a sector programme approach in relation to Danida financed health programmes;
14. assess the conflict between the Sector Programme Support approach and the desire for visibility, recognition, special audit and reviews; and,
15. identify key issues, constraints, problems, strengths and facilitating factors which have had major influence on implementation of Danish assistance to health.
Field studies:
The field studies will tentatively ( field studies in each country will not necessarily cover all tasks):
1. assess any shift/ changes in the main internal strategies for health improvement in selected developing countries, their relevance for the political, economic and social setting and how recipient countries have adapted to these shifts;
2. assess the relevance of Danish supported health research for strengthening of the health care system and an improved health status;
3. assess the co-ordination and integration of health research within ENRECA and the
Danish research base and in relation to Danish project/ programme interventions;
4. assess the commitment of the Government to support health and priorities given to the different health sub sectors e.g. support to primary health versus secondary, curative versus preventive etc.;
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5. describe the proportional roles of the public sector in financing, planning and implementing of health activities;
6. describe the roles of the private sector and NGOs in financing, planning and implementing of health activities;
7. assess joint management arrangements (Government/donors/user) e.g. “Health
Fund” or similar arrangements of health services;
8. assess the involvement of the stakeholders, in the particular local communities and the target groups, in planning and implementation of health activities;
9. assess the synergy and complementarity to be found between interventions implemented by the public sector, private sector and NGOs;
10. assess the appropriateness (technical, economic and social) of Danish assistance in relation to the current health needs and overall patterns in both the public and private sectors of the health system;
11. describe the role and assess the relevance of technical assistance;
12. assess how Danish assistance has contributed to capacity building within the health sector as a whole (public, private and voluntary institutions);
13. assess the Danish supported activities in relation to social mobilisation with and emphasis on the involvement of local government authorities and communities;
14. assess the access of the target groups to the health care services (public, private,
NGO) and describe conditions (e.g. knowledge, access, cost) preventing the target groups from using the health care systems;
15. assess to what extent Danish assistance has improved access of the poorest sectors of the population to health care services;
16. assess the cost efficiency and sustainability of Danish assistance to health;
17. assess the synergy and complementarity of the Danish support to health sector and health related activities e.g. water supply and sanitation;
18. assess the synergy and complementarity of additional contribution to health made by
Danish assistance through multilateral organisations;
19. assess the potential conflicts between the bilateral Danish Sector Programme
Support, Danish NGOs and support through multilateral organisations; and,
20. assess complementarity and co-ordination of donor assistance to the health sector.
The evaluation is planned to take place during 1998-99. The anticipated time schedule is as follows:
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Desk study: October- December 1998 workshop on desk study: December 1998
Field Studies: January- March 1999
Draft issue Papers: March- April 1999
Workshops on field studies: April- May 1999
Draft report (synthesis): August 1999
Workshop on draft report: August 1999
Final report: November 1999-10-12
The evaluation team should have a wide range of expertise in the field of health and
Sector Support programmes. The evaluation team should cover the following areas of expertise:
Public Health planning; experience from planning in government programmes in developing countries;
Health and social systems development (institutional and human resources);
Medical sociology or medical anthropology; experience in community development and participatory methods;
Health economics;
Health education, communication and behaviour change in health, water and sanitation;
Gender issues especially in the health sector;
Health care facility construction and maintenance.
Each person involved in the evaluation should preferably be in a position to manage more than one area. Furthermore, the evaluation team should include a professional language editor (copy editor).
Evaluation Secretariat, July 6, 1998
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A NNEX II C OMPOSITION OF E VALUATION T EAMS
Management Team
Maarten van Cleeff
Britha Mikkelsen
Alanagh Raikes
Jurrien Toonen
Jane Kusin
Team Members
Chifumba Chintu, Zambia
Fatima Mohamedali, Kenya
Dileep Mavalankar, India
Tony Dogbe, Ghana
David Moore
Jan Borg
Jes Clauson-Kaas
Ulla Kou
Annelise Boysen
Anna Vassall
Jan Visschedijk
Welmoed Koekebakker
Hanne Overgaard Mogensen
Joost Hoppenbrouwer
Other Experts
Jacques van de Broek
Louise Engberg
Jean-Marc Guimier
Peter Lever
Marti van Liere
Grant Rhodes
Peter Petit
Bert Schreuder
Robert Soeters
John Griffiths
Derek Baker
Derek Brander
Carl Hugod
Reference Group
Prof Dr P Streefland
Prof Dr Lex Muller
Quality Assurance
Claus Rebien
Speciality
Public Health
Sociology
Anthropology,
Public Health
Public Health
Nutrition
Speciality
Public Health
Reproductive Health
Public Health
Sociology
Anthropology
Public Health
Construction
Health Economics
Construction
Health Economics
Public Health
Gender
Anthropology, Data
Management
Health promotion
Disease Control
Data Management
Health Economics
Disease Control
Nutrition
Health Economics
Public Health
Public Health
Public Health
Data base construction
Health Economics
Health Economics
Public Health
Task
Team leader
Task manager Desk study and
Country Co-ordinator, Kenya
Country Co-ordinator Uganda
Country Co-ordinator Zambia and Ghana
Country Co-ordinator India
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Field Study Teams
Kenya Country Co-ordinator
Zambia
India
Uganda
Ghana
Britha Mikkelsen
Fatima Mohamedali
Jan Borg
Ulla Kou
Peter Petit
Bert Schreuder
Carl Hugod
Annelise Boysen
Maarten van Cleeff
Jurrien Toonen
Chifumba Chintu
Anna Vassall
Alanagh Raikes
Annelise Boysen
Joost Hoppenbrouwer
Maarten van Cleeff
Jane Kusin
Dileep Mavalankar
Derek Baker
Erik Brander
Henk Eggens
Welmoed Koekebakker
Jes Clauson-Kaas
Maarten van Cleeff
Alanagh Raikes
Jan Borg
Britha Mikkelsen
Jan Visschedijk
Jes Clauson-Kaas
Ulla Kou
Maarten van Cleeff
Jurrien Toonen
Tony Dogbe
David Moore
Anna Vassall
Jes Clauson-Kaas
Maarten van Cleeff
Country Co-ordinator
Country Co-ordinator
Country Co-ordinator
Country Co-ordinator
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A NNEX III C LUSTER M ATRICES
MATRIX II: POLICY & STRATEGY DEVELOPMENT
Cluster II: Matrix of Research Questions, Indicators, Means of Verification and Methodology/Activities
Research questions
1. Describe the changes over time in the concept of health and the main strategies used for health improvement during the period
1988-97, with emphasis on: significant changes in both national and donor strategies; the relevance of Danida’s policies and strategies for health both in relation to international trends and to the political, economic and social setting in the developing countries
2. Assess the appropriateness (technical, economic and social) of Danish assistance in relation to the current health needs and overall patterns in both the public and private sectors of the health care system
3. Analyse the transition from a project approach to a sector programme approach in relation to Danida financed health programme, including an assessment of the
(potential) conflict between a Sector
Programme Support approach and the desire for visibility, recognition, special audit and reviews
Indicators selective versus comprehensive approach community based and basic health care community involvement decentralisation project versus programme approach public/private mix health care financing options and capacity health needs - gender, age and social group specific, expressed by different stakeholders, in quantitative and qualitative terms
Danida financed interventions' compliance with national health policies and practices in the public and private sectors. burden of disease 'accommodated' by project/programmes supported by Danida areas of support in relation to technical capacity of health staff at different referral levels correspondence with other donor interventions correspondence with national available human, financial and material resources
Transition methodology
Danida/TA support to local planning process
"demand of receiving country" considerations financing mechanisms focal point /receiving structure of support limits to or positive selection in Danish Sector
Programme Support monitoring and auditing systems - application and conflicts
Means of verification
Policy documents (Danida, recipient countries, multilaterals), health sector reviews, strategy papers, annual reports produced by Danida and multilateral organisations.
Interviews with Danida Board members and politicians, key staff members of Danida, field staff, recipient countries officials, representatives of NGOs
Policy documents (Danida, recipient countries, multilaterals), health sector reviews, strategy papers, annual reports produced by Danida and multilateral organisations.
Interviews with politicians, key staff members of Danida, field staff, recipient countries officials, representatives of NGOs, health specialists, stakeholders and users/non-users
Institutional self-assessments
Observations
Annual project/programme reports produced by Danida
Interviews with key staff members of Danida, field staff, recipient countries officials, representatives of NGOs, stakeholders and users/non-users
Examples of auditing reports
Institutional self-assessments
Observations
Methodology/ Activities
Analyse policy documents with respect to health strategies for improving health : how and why do strategies change? What does the problem analysis look like from donor and recipient countries perspective, and how does it change over time ? Do their strategies correspond to the problem analysis?
Interview key staff on policy development and the concept of health over time
Analyse project documentation
Initiate institutional assessments in cooperation wit local institutions
Organise individual and group interviews
SWOT analysis
Application of provocative statements on appropriateness of Danish assistance
Descriptive analysis (from historical perspective) of the fields of change organise SWOT analysis
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MATRIX III: INSTITUTIONAL FRAMEWORK - CHANNELLING, IMPLEMENTATION AND PERFORMANCE
Cluster III: Research Questions, Indicators, Means of Verification and Methodology/Activities1 - Channelling
Research Questions Indicators Sources of verification Methodology
1.1 Describe the proportional roles of : the public sector the private sector, and
NGO’s
In financing, planning, implementing and monitoring of health activities
1.2 Assess the synergy/ complementarity between interventions implemented by Danida and by
NGO’s
Private sector
Public sector
Multilateral organisations and
Health related activities e.g. water supply and sanitation
1.3 Assess the potential conflicts between the bilateral Danish Sector Programme Support,
Danish NGO’s and support through multilateral organisations
1.4 Assess the complementarity/ coordination of donor assistance to the health sector
1.5 Assess joint management arrangements
(Government / donors/ user) e.g. “Health
Fund” or similar arrangements
% of budget of HC programmes
Proportion of total number of projects executed
Proportion of decision-makers
Cost-effectiveness per channel qualitative indicators (sustainability, risks, accountability, sense of ownership, quality of work, impact on national policy)
Spreading of Danida aid:
Geographical
Thematic in place and time phase in the planning cycle
Structures of co-ordination
Spreading of Danida aid:
Geographical
Thematic in place and time phase in the planning cycle
Structures of donor co-ordination (regularity, quality,....) concerted actions (number, quality, importance, ..);
Qualitative indicators (approach national involvement, perceived quality, sustainability) variety of joint management arrangements institutional framework legal framework accountability
Implementation arrangements (decision making power, distribution of responsibilities, ..)
Qualitative indicators(perceived quality, sustainability, )
Project documents
Expenditure reviews
National Investment Plans
Key persons in the donor community.
Of 5 selected countries: all contracts of Danida aid;
Of selected project / programme here: all relevant documents.
Of 5 selected countries: all contracts of Danida aid;
Of selected project / programme here: all relevant documents.
Project documents
Key persons in the donor community.
Project documents
Key persons of Danida- and government representatives.
Desk studies
Individual in depth interviews
Based on comprehensive project-list: select activities supported by Danida;
Mapping of Danida support
Multi-level analysis (national, region, district,
HCentre) :analysis of selected items of who's doing what in which phase
Based on comprehensive project-list: select activities supported by Danida;
Mapping of Danida support
Multi-level (national, region, district, HCentre) analysis of selected items of who's doing what in which phase
Desk study in Copenhagen
In 5 selected countries: interviewing key persons of Danida and in the donor community.
Desk study in Copenhagen
In 5 selected countries: interviewing key persons of Danida and government representatives.
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2 - Implementation
Research Questions
2.1 Assess the Danish supported activities in relation to social mobilisation with emphasis on the involvement of local authorities
2.2 Assess the role and relevance of technical assistance (TA)
2.3 Assess health research/ ENRECA with respect to : co-ordination and integration in relation to
Danish project/ programme interventions relevance for strengthening the health care system and an improved health status
Indicators number of projects with some form of social mobilisation legal- and institutional framework of the social organisations methodology of social mobilisation; representation of community members in their organisations;
Implementation arrangements (involvement in planning cycle, decision making power, distribution of responsibilities, ..)
Qualitative indicators (perceived quality, sustainability,
....)
Number of Danida financed projects without TA
Phase in development of projects/ programmes TA involved
Administrative versus technical TA-tasks
Institutional framework
Implementation arrangements (involvement in planning cycle, decision making power, distribution of responsibilities, ..)
Performance (perceived quality, sustainability, ....)
Discipline of the assistants versus tasks TA
Outputs (technical reports, policy papers, ....)
TA-budget as proportion of the total project budget
Research questions studied versus specific objectives of Danida financed projects/ programmes
Sources of verification project/ programme documents key persons of Danida, local authorities and community representatives.
Initial field surveys/studies observations
Interviews and observations during field studies will be more relevant than documentary studies project/programme documents key persons of Danida, field staff
(TA), and their counterparts observations project/programme documents key persons of Danida, Danida and national researchers, MoH officials, health professionals observations
Methodology
Desk study Copenhagen
Undertake preliminary surveys/studies:
Community based study in 5 selected areas
Interview key staff and stakeholders
Assess level of involvement of local authorities by means of "Rifkin spider net"
Analyse project documentation
Organise individual and group interviews
SWOT analysis
Application of provocative statements on role and relevance of TA
Analyse project documentation
Organise individual and group interviews
SWOT analysis
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MATRIX IV: TARGETING, ACHIEVEMENTS AND PERCEIVED IMPACT
Cluster IV: Research Questions, Indicators, Means of Verification and Methodology/Activities
Research questions
1. Analyse targeting of the poor, of women and children, and assess constraints and counteracting measures to redress gender constraints to equitable delivery of health care services.
Indicators
Quantitative: poverty lines, poverty pockets, income/consumption data
Qualitative: poverty and gender/age assessments
Context specific access/ exclusion indicators on: Livelihoods, Resources, Knowledge,
Rights
2.Describe achievements (outputs) and perceived impact of Danish assistance to health in terms of impact on:
Health status of special target groups, particularly women and children,
Health policies and strategies, planning and implementation at national and international levels
Capacity building in the health sector (public, private and voluntary organisations)
3. Assess social mobilisation of stakeholders:
Local communities and target groups, and
Local government authorities, for involvement in planning and implementation of health activities
Gender, age and social strata sensitive indicators in selected areas:
Public health exp. in relation to GDP and population
Health System Accessibility
Curative Health Interventions
Preventive Health Interventions
Morbidity / Mortality
Maternal Mortality
MCH nutritional status
Contraceptive prevalence rate
Institutional capacity - quantitative and qualitative
Passive participation
Training and information
Active participation sessions
Participation by subscription
Participation on local request by stakeholder group
Means of verification
Project documentation compared with international/ national/local socioeconomic/ health studies and statistics
Interviews/ group discussions with stakeholders and users/non-users
Observations
Project documentation compared with international/ national/local socioeconomic/ health studies and statistics
Tracer studies
Interviews/ group discussions with politicians, heath specialists, stakeholders and users/non-users
Institutional and beneficiary self-assessments
Observations
Initial field surveys/studies
Interviews and observations during field studies will be more relevant than documentary studies
Methodology/ Activities
Analyse project documents with regard to application of gender sensitive poverty data.
Interview key staff on poverty and gender awareness and remedial measures
Observe/analyse the poor's access to/exclusion from health services and gender-sensitive remedial measures to inequity constraints
Analyse project documentation
Initiate tracer studies, institutional and beneficiary assessments in co-operation wit local institutions
Organise individual and group interviews
Adjusted SWOT workshops
Application of provocative statements on achievements and impact
Undertake preliminary surveys/studies
Interview key staff and stakeholders
Assess level of community participation in planning and implementation by means of
"Rifkin spider net"
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Research questions
4.Assess access and constraints on access to health services, for the target group, including changes in access for the poorest sections of the population.
Indicators
Access indicators to be defined in local context. National and/or international definitions will be used.
Relevant indicators on access, and constraints on access, to be specified at the different levels in question: National, policy/sector, community, group and individual user level.
Means of verification
Project documents
Interviews and focus group discussions with stakeholders and users/non-users
Observations
Methodology/ Activities
Analyse project documentation with regard to measures initiated to improve access to health services
Organise individual and group interviews with the aim of identifying key constraints on access, i.e. costs of transportation, user fees on health services, lack of medical supplies and drugs, etc.
Analyse any changes in access to health services during the project period.
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MATRIX V: SUSTAINABILITY AND COST-EFFECTIVENESS
Cluster V: Research Questions, Indicators, Means of Verification and Methodology/Activities
Research questions Indicators Means of verification
Assess overall commitment of the
Government to support health
Assess the priorities of the Government given to different health sub-sectors, i.e. tertiary versus primary health care.
Quantitative:
Trend in Gov. health exp. during the last 10 years, in nominal as well as real prices.
Trend in Gov. exp. on health in % of GDP during the 10 year period.
Trend in Gov. exp. on health in % of total
Gov. exp. during the 10 year period.
Trend in Gov. exp. on health per capita during the 10 year period
Qualitative:
Assessment of policy initiatives, such as formulation of, and commitment to, national health planning system, human resource planning system, decentralisation process, cost recovery scheme for public health services, collaboration with private sector and
NGOs, and donor co-ordination.
No. of work groups active in the public health administration, working on issues such as health sector reform and donor coordination.
Quantitative:
Recent trend in percentage distribution of
Government health expenditures divided into primary, secondary and tertiary health services.
Qualitative:
Policy statements on priorities
Quantitative:
National policy documents
National budget and expenditure estimates
Donor reports, such as World Bank Staff
Reports
Qualitative:
Interviews/group discussions with
Government officials and the donor community
Ministry of Health Annual Report
Organogram of Ministry of Health
Policy papers
National health plan
Policy documents
National Health Plan
Government expenditures estimates, national as well as regional
Existing surveys/studies on the subject
Methodology/ Activities
Analyse expenditure estimates with regard to trend in Gov. health expenditures during the last 10 years. Explain any significant changes in financial allocations to the sector and compare figures with similar indicators in other countries.
Interview Government officials and other relevant stakeholders on policy initiatives in the health sector and the commitment to these.
Observe actual changes followed by a policy initiative i.e. any increase in actual revenue generation followed by a cost recovery reform? Any real increase in budgetary allocations to districts followed by a decentralisation reform?
Analyse project documentation with regard to the priority given to primary health care.
Analyse expenditure estimates and divide actual expenditures into primary, secondary and tertiary care. If expenditure estimates on different levels of care are not directly available, existing studies on the subject should be referred to.
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Research questions
Assess sustainability of Danida assistance to health
Assess the cost-effectiveness of Danida assistance to health
Indicators
Qualitative:
Approach used when phasing out projects
Strategy for health care financing included project or programme
The extent of training activities for local staff and the use of counterpart staff
Level of programme sector support measured by the existence of budget support and Danida funds reflected in Government budgets
Community participation measured by needs assessment, leadership, organisation, resource mobilisation, management
Danida health assistance divided into primary, secondary and tertiary health care
Means of verification
Project documents
Government budgets
Policy documents
Interviews/field studies to assess community participation through "Rifkin Spider net"
Project documents
Danida Country Strategy
International studies on cost-effectiveness of relevant interventions
Methodology/ Activities
Analyse project documents and interview key stakeholders to assess approach used when phasing out projects and whether any strategy for health care financing has been developed
Analyse project and policy documents to assess the degree of sector programme assistance
Estimate the importance of budget support
Undertake preliminary surveys/studies using the "Rifkin Spider net" framework
Divide Danida health expenditures into primary, secondary and tertiary care. estimate the percentage distribution.
Assess cost-effectiveness of selected interventions by comparing to international standards
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113

A
NNEX
V S
ELECTED
I
NDICATORS
& S
TATISTICS
A NNEX V S ELECTED I NDICATORS & S TATISTICS
HDI rank
High human development
Medium human development
Low human development
133 Ghana
137 Kenya
139 India
146 Zambia
160 Uganda
All developing countries
Least developed countries
Industrial countries
World
Human Development Index
Life expectancy at birth
(years) 1995
73.52
67.47
56.67
Adult literacy rate
(%) 1995
Combined first-, secondand thirdlevel gross enrolment ratio
(%) 1995
95.69
83.25
50.85
78.68
65.61
47.09
57
53.8
61.6
42.7
40.5
64.5
78.1
52
78.2
61.8
44
52
55
52
38
62.2
51.16
74.17
63.62
70.44
49.2
98.63
77.58
57.49
36.42
82.81
61.59
Real
GDP per capita
(PPP$) 1995
16241
3390
1362
Adjusted real GDP per capita
(PPP$) 1995
Life expectancy index
6193
3390
1362
0.8087
0.7078
0.5278
Education index
0.9002
GDP index
0.9809
Human development index (HDI) value 1995
Real GDP per capita
(PPP$) rank minus
HDI rank
0.8966
-
0.7737
0.496
0.5297
0.2032
0.6704
0.409
-
-
2032
1438
1422
986
1483
3068
1008
16337
5990
2032.45
1437.73
1421.99
986.46
1482.91
3068
1008
6194
5990
0.5333
0.4805
0.6098
0.2945
0.2585
0.62
0.436
0.8195
0.6437
0.5755
0.6928
0.529
0.6955
0.5393
0.6612
0.4494
0.9336
0.7225
0.311
0.215
0.213
0.143
0.223
0.4778
0.1462
0.9811
0.9482
0.473
0.463
0.451
0.378
0.34
0.5864
0.3439
0.9114
0.7715
-8
2
1
11
-23
-
-
-
-
115

A
NNEX
V S
ELECTED
I
NDICATORS
& S
TATISTICS
Gender-Related Development Index
High human development
Medium human development
Low human development
133 Ghana
137 Kenya
139 India
146 Zambia
160 Uganda
All developing countries
Least developed countries
Industrial countries
World
Genderrelated developme nt index
(GDI) rank
Life expectancy at birth
(years) 1995
Female
Life expectancy at birth
(years)
1995 Male
Adult literacy rate
(%) 1995
Female
Adult literacy rate
(%) 1995
Male
-
-
-
121
122
128
134
146
-
-
-
-
76.79
69.68
57.46
58.85
55.07
61.76
43.42
41.44
63.67
52.3
77.9
65.37
70.27
65.35
55.9
55.21
52.49
61.41
41.85
39.59
60.78
50.03
70.36
61.92
95.23
76.93
38.34
53.55
70.02
37.69
71.27
50.18
61.82
39.3
98.5
71.48
96.16
89.53
62.96
75.88
86.3
65.5
85.64
73.71
78.86
59.19
98.76
83.71
Combined first-, secondary- and third-level gross enrolment ratio
(%)1995 Female
79.03
63.67
39.51
38.07
50.94
46.46
48.5
34.16
53.06
30.85
83.98
58.07
Combined first-, secondary- and third-level gross enrolment ratio
(%) 1995 Male
75.51
64.93
52.22
48.58
51.79
60.08
55.03
41.92
58.9
40.32
81.57
62.51
Share of earned income
(%) 1995 Female
34.41
36.38
28.64
43.296
41.785
25.366
39.278
40.562
32.42
34.29
38.02
33.71
Share of earned income
(%) 1995 Male
GDI value
(1995)
HDI rank minus GDI rank
65.59
63.62
71.36
56.704
58.215
74.634
60.722
59.438
67.58
65.71
61.98
66.29
0.8604
0.6559
0.388
0.466
0.459
0.424
0.372
0.331
0.564
0.3324
0.8879
0.7365
-
-
-
-
-
-
-
2
5
1
2
4
116

High human development
Medium human development
Low human development
133 Ghana
137 Kenya
139 India
146 Zambia
160 Uganda
All developing countries
Least developed countries
Industrial countries
World
A
NNEX
V S
ELECTED
I
NDICATORS
& S
TATISTICS
Gender Empowerment Measure
Gender empowerment measure
(GEM) rank
..
95
81
..
-
-
..
-
-
-
-
-
Seats in parliament held by women
(%)
14.1
..
Female administrators and managers
(%)
..
..
7.9
..
..
..
..
7.3
9.7
..
8.6
..
15.3
11.8
..
2.3
6.1
..
..
..
..
..
Female professional and technical workers
(%)
..
..
Women's share of earned income
(%)
35
36
..
..
25
..
..
20.5
31.9
..
..
..
..
..
..
25
39
..
32
..
37
33
GEM value
..
0.228
0.304
..
..
..
..
..
..
..
..
..
117

A
NNEX
V S
ELECTED
I
NDICATORS
& S
TATISTICS
Human Poverty Profile and Index
HDI rank
High human development
Medium human development
Excluding China
Low human development
Excluding India
133 Ghana
137 Kenya
139 India
146 Zambia
160 Uganda
All developing countries
Least developed countries
Industrial countries
World
People not expected to survive to age
40 Human poverty index (as % of total
(HPI-1) value
(%) 1995 population)
1995
Adult
Illiteracy rate
(%) 1995
Population without access to safe water (%)
1990-96
Population without access to health services (%)
1990-95
..
..
..
..
..
8.3
9
11.5
21.5
26.8
10.49
19.59
21.44
49.01
50.31
17.69
31.23
28.67
29.43
40.79
..
12.53
13.43
30.41
47.95
Population without access to sanitation
(%)
1990-96
21.53
60.5
37.48
64.6
57.59
31.8
27.1
35.9
36.9
42.1
..
..
..
..
14.2
28.8
5.4
12.7
23
27
16
42
44
35.5
21.9
48
21.8
38.2
29.55
50.8
1.4
22.4
28.93
42.87
..
..
35
47
19
73
54
20.15
50.89
..
..
40
23
15
25
51
57.81
63.93
..
..
45
23
71
36
43
Underweight children under age five
(%)
1990-97
11.5
19.4
23.2
45
37.3
Children not reaching grade 5
(%)
1995
Real
GDP
Real
GDP
Refugees by country of asylum
(thousands)
1996 per capita per capita
(PPP$) (PPP$)
Poorest Richest
20%
1980-
94
20%
1980-
94
Population below income poverty
(%)
1$ a day
(1985 PPP$)
1989-94
21.2
10.9
209.3
2781.8
1236.9
847.7
19705.7
5750.1
17
25.9
14.7
35.6
31.5
2491.7
5565.3
5332
1108.2
531
..
7068.3
2883.8
..
..
43.8
..
30.3
39
..
30
27
23
53
24
26
..
32
35.617 790 4220
223.64 238 4347
38 233.37 527 2641
16 131.139 216 2797
.. 264.294 309 2189
22.4
36.2
8556.4
767.9
6195.3
3424.4
..
..
1.1
3889.8
4811 32273.3
20.6
12446.2
1758.5
12584.3
..
50.2
52.5
84.6
50
32.2
..
..
..
Population below income poverty
(%) national poverty line
1989-94
21.6
15
..
..
..
..
..
..
..
31
37
..
86
55
118

A
NNEX
V S
ELECTED
I
NDICATORS
& S
TATISTICS
Population Trends
HDI rank
High human development
Medium human development
Excluding China
Low human development
Excluding India
133 Ghana
137 Kenya
139 India
146 Zambia
160 Uganda
All developing countries
Least developed countries
Industrial countries
World
Estimated
Population
(millions)
1970
310.125
1309.042
Estimated
Population
(millions)
1995
514.767
2081.624
Estimated
Population
(millions)
2015
650.614
2613.303
Annual population growth rate
(%) 1970-1995
2.05
1.87
Annual population growth rate
(%)
1995-2015
Population doubling date (at current growth rate)
1995
1.18
1.14
2044
2047
Crude birth rate
1995
Crude death rate
1995
21.5
21.6
6.3
7.2
Dependency ratio
(%)
1995
57.8
56
Total fertility rate
1995
2.47
2.5
Contraceptive prevalence rate, any method
(%)
1990-95
68.64
71.77
478.367
996.893
441.982
861.4
1797.67
868.665
1204.177
2628.214
1416.552
2.38
2.39
2.74
1.69
1.92
2.48
2033
2028
2022
27.8
32.7
39.6
7.2
11.2
13.1
69
76.1
89.1
3.47
4.26
5.42
54.01
30.97
18.87
8.6
11.5
554.9
4.2
9.8
2616.06
285.661
1043.536
3659.596
17.3
27.1
929
8.1
19.7
4394.061
542.486
1233.064
5627.125
29.4
43.2
1211.7
13.2
34.8
5892.131
873.726
1294.742
7186.873
2.84
3.5
2.08
2.66
2.83
2.1
2.6
0.67
1.74
2.67
2.35
1.34
2.48
2.88
1.48
2.41
0.24
1.23
2019
2026
2038
2023
2021
2037
2022
2223
2046
39.28
37.32
26.33
43.26
50.96
26.1
39.2
12.6
23.2
11.03
11.54
9.4
17.88
21.39
8.7
14.1
10.1
9
91.55
95.94
65.45
101.92
103.9
63.9
88.8
50.5
60.8
5.49
5.13
3.23
5.74
7.1
3.16
5.3
1.72
2.85
20
33
41
25
15
55.87
21.56
70.16
58.49
119

A
NNEX
V S
ELECTED
I
NDICATORS
& S
TATISTICS
HDI rank
High human development
Medium human development
Excluding China
Low human development
Excluding India
133 Ghana
137 Kenya
139 India
146 Zambia
160 Uganda
All developing countries
Least developed countries
Industrial countries
World
Health Profile
One-yearolds fully immunized against tuberculosis
(%)
1995-96
94.6
93.5
One-yearolds fully immunized against measles
(%)
1995-96
81.1
90.8
AIDS cases
(per
100,000 people) a1996
8.6
..
Tuberculosis cases
(per
100,000 people)
1995
Malaria cases
(per 100,000 people) 1994
Cigarette consumption per adult
(1970-
72=100)
1990-92
Doctors(per
100,000 people) 1993b
Nurses
(per 100,000 people) 1993 b
People with disabilities
(as % of total poeople)
1985-92c
Public expenditure on health
(as % of GNP)
1960
46
52
187.3
201.1
99.5
206.2
122.2
99.1
84.3
100
..
3.9
1.2
0.9
Public expenditure on health(as % of
GDP)1990
2.2
2.1
90.4
84.3
85.4
68.6
2.3
2.5
86.9
93.6
633.5
2152.1
129.5
133.4
70.7
36.2
122.3
..
1.8
1
0.8
0.6
2.1
1.5
76
65
56
96
100
96
88.9
80
91.6
89
59.9
53
38
81
93
66
78.5
60.4
85.7
79.4
5.9
3.9
6.49
22.38
0.09
46.86
13.75
3.5
7.4
5
52.7
23.83
103.65
130.77
157.7
129.39
68.6
69.9
27.6
59.7
5682.8
..
23067.56
243.34
44497.91
..
953.5
6764.9
..
..
137.2
115.1
60.98
119.05
236
86
100
160.3
156.2
90.2
21.4
4
15
48
..
4
76.4
13.9
286.7
121.7
44.6
..
23
..
..
28
84.9
25.5
780.1
240.5
..
..
..
0.2
1.6
..
2.6
..
..
..
0.8
1.1
1.5
0.5
1
0.7
1
..
..
..
1.6
2
1.9
..
..
1.7
1.7
2.7
1.3
2.2
120

A
NNEX
V S
ELECTED
I
NDICATORS
& S
TATISTICS
Child Survival and Development
HDI rank
High human development
Medium human development
Excluding China
Low human development
Excluding India
133 Ghana
137 Kenya
139 India
146 Zambia
160 Uganda
All developing countries
Least developed countries
Industrial countries
World
70
61
73
112
88
64.76
109
13.03
60
Infant mortality rate
(per 1,000 l ive births)
1996
29.28
40.42
34.7
51.8
Under-five mortality rate
(per 1,000 live b irths)
1996
..
..
Pregnant women aged 15-49 with
Births attended by trained health anaemia
(%)
1975-91 personnel
(%)
1990-96
84.6
74.6
9.4
10.7
Low- birth- weight infants
(%)
1990-96
42.53
90.02
102.11
56
139.3
159.4
..
..
..
61.6
32.1
30.1
12.3
26.1
20.8
110
90
111
202
141
95
171
15.8
88
..
40
88
..
..
..
..
..
..
44
45
34
51
38
57.8
29
99.1
57
7
16
33
13
..
18.4
22.2
6.5
17.4
Maternal mortality rate
(per 100,000 live births)
1990
Mother exclusively breast-feeding at three months
(%)
1990-96
148.2
209.7
34.1
53.2
..
80.7
Oral rehydration therapy use rate
(%)
1990-97
310.6
763.4
901.1
40.5
40.1
31.4
75
75.3
83.5
740
650
570
940
1200
487.6
1100
29.5
430
19
17
51
13
70
44.6
45.6
..
..
93
76
67
99
49
76
80
..
..
Source all tables: UNDP Development Report 1998
27
23
53
24
26
30.3
Under-weight children under age five
(%)
1990-97
11.5
19.4
23.2
45
37.3
39
..
30
121

A
NNEX
V S
ELECTED
I
NDICATORS
& S
TATISTICS
4 5
4 0
3 5
5 5
5 0
7 0
6 5
6 0
1 9 8 5 -9 0
2 0 0 0 -0 5 1 9 9 0 -9 5
1 9 9 5 -0 0
Ug a n d a
Ke n y a
Gh a n a
In d i a
Za mb i a
122

A
NNEX
V S
ELECTED
I
NDICATORS
& S
TATISTICS
30,00
20,00
10,00
0,00
60,00
50,00
40,00
1988 1989 1990 1991 1992 1993 1994 1995 1996 1997
Year
123

A
NNEX
V S
ELECTED
I
NDICATORS
& S
TATISTICS
700000
600000
500000
400000
300000
200000
100000
0
1988 1989 1990 1991 1992
Year
1993 1994 1995 1996 1997
Bilateral
NGO
Multilateral
Embassy allocations
Research/ Educational institution
124

A
NNEX
V S
ELECTED
I
NDICATORS
& S
TATISTICS
30
20
10
0
50
40
1988 1989 1990 1991 1992
1993 1994 1995 1996 1997
125

A
NNEX
V S
ELECTED
I
NDICATORS
& S
TATISTICS
90
80
70
60
50
40
30
20
10
0
1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997
126

127