ACRONYMSCIPDACDFAFHSPFMGFMOHGDPGNPHAPSSHFSHHRAAIMFIPCKHCFKNHLGAMCHMOHMOPHMOPHSANHIFNHSSGNPHCSP/PHCPHCSRSALSAPSDATCSPUNICEF<strong>USAID</strong>WHOCommodity Import ProgramDevelopment <strong>Assistance</strong> CommitteeDevelopment Fund for AfricaFamily Health Support <strong>Project</strong>Federal Military GovernmentFederal M<strong>in</strong>istry of HealthGross Domestic ProductGross Nati<strong>on</strong>al ProductHealth and Populati<strong>on</strong> Sector Support Program (Togo)Health F<strong>in</strong>anc<strong>in</strong>g and Susta<strong>in</strong>ability <strong>Project</strong>Health and Human Resources Analysis for Africa <strong>Project</strong>Internati<strong>on</strong>al M<strong>on</strong>etary FundInterim Program of C<strong>on</strong>solidati<strong>on</strong>Kenya Health Care F<strong>in</strong>anc<strong>in</strong>g ProgramKenyatta Nati<strong>on</strong>al HospitalLocal Government AuthorityMaternal Child HealthM<strong>in</strong>istry of HealthM<strong>in</strong>istry of Public HealthM<strong>in</strong>istry of Public Health and Social AffairsNati<strong>on</strong>al Hospital Insurance FundNiger Health Sector Support GrantNigeria Primary Health Care Support ProgramPreventive and Primary Health CarePrimary Health Care Subsector Reform Program (Camero<strong>on</strong>)Structural Adjustment Lend<strong>in</strong>g Program (World Bank)Structural Adjustment ProgramSocial Dimensi<strong>on</strong>s of Adjustment ProgramTogo Child Survival and Populati<strong>on</strong> ProgramUnited Nati<strong>on</strong>s Children’s FundU.S. Agency for Internati<strong>on</strong>al DevelopmentWorld Health Organizati<strong>on</strong>v
EXECUTIVE SUMMARYAt the request of <strong>USAID</strong>’s Africa Bureau and the Health and Human Resources Analysis forAfrica <strong>Project</strong>, the Health F<strong>in</strong>anc<strong>in</strong>g and Susta<strong>in</strong>ability <strong>Project</strong> exam<strong>in</strong>ed the experiences of the UnitedStates Agency for Internati<strong>on</strong>al Development (<strong>USAID</strong>) us<strong>in</strong>g n<strong>on</strong>-project assistance (NPA) to supporthealth sector objectives <strong>in</strong> sub-Saharan Africa. This paper summarizes the design, implementati<strong>on</strong>, andevaluati<strong>on</strong> experiences of NPA programs <strong>in</strong> Niger, Nigeria, Kenya, Togo,, and Camero<strong>on</strong>. All fiveprograms were submitted to <strong>USAID</strong>; however, <strong>on</strong>ly three were authorized.The overall goal of these programs was to use NPA with<strong>in</strong> the health sector to achieve specificpolicy reform objectives and to provide f<strong>in</strong>ancial resources to programs and activities with<strong>in</strong> the sector.The purpose of this paper is to <strong>in</strong>itiate a discussi<strong>on</strong> with<strong>in</strong> <strong>USAID</strong> of the effectiveness of us<strong>in</strong>g NPA asa reform tool <strong>in</strong> policy development. This will, it is hoped, also promote a discussi<strong>on</strong> of the wider questi<strong>on</strong>of how to best support the development of health services and promote desired health outcomes <strong>in</strong> Africa.The experiences of the health sector NPA programs are exam<strong>in</strong>ed us<strong>in</strong>g sec<strong>on</strong>dary <strong>in</strong>formati<strong>on</strong>sources (PAIPS, PAAPS, project reports and documentati<strong>on</strong>, and evaluati<strong>on</strong> reports).All NPA programs transfer d<strong>on</strong>or resources to a host county to support ec<strong>on</strong>omic development.The NPA programs <strong>in</strong> the health sector <strong>in</strong> sub-Saharan Africa have all been developed as sector assistanceprograms. Sector assistance programs have two objectives: the direct transfer of f<strong>in</strong>ancial resources to thehost government and the support of sector specific host country <strong>in</strong>itiatives result<strong>in</strong>g <strong>in</strong> predef<strong>in</strong>ed policyreforms or implementati<strong>on</strong>. Sector assistance programs attempt to def<strong>in</strong>e reform agendas that addresspolicy and resource c<strong>on</strong>stra<strong>in</strong>ts to sector productivity, performance and output.All of the countries <strong>in</strong> this study experienced significant decl<strong>in</strong>es <strong>in</strong> their annual GDP growth ratess<strong>in</strong>ce the early 1980’s. Policy reform and development of the health sector <strong>in</strong> each of the countries hasbeen made more difficult by political <strong>in</strong>stability. In most sub-Saharan Africa countries, the public sectoris the primary source of the delivery of health care. This currently leaves many (and perhaps <strong>in</strong>creas<strong>in</strong>g)populati<strong>on</strong>s with limited access to services, decreased quality of care, and poor health outcomes. Facedwith this decl<strong>in</strong>e <strong>in</strong> services, d<strong>on</strong>or agencies and m<strong>in</strong>istries of health <strong>in</strong> many countries are attempt<strong>in</strong>g toimplement reforms and projects <strong>in</strong> the areas of health f<strong>in</strong>ance, primary care services, and plann<strong>in</strong>g andmanagement of health care services decentralizati<strong>on</strong>. The NPA programs discussed <strong>in</strong> this paper weredeveloped to support reforms <strong>in</strong> these areas.Health services <strong>in</strong> Niger are provided by the M<strong>in</strong>istry of Public Health and Social Affairs(MOPHSA), which emphasizes primary health care through vertical disease specific <strong>in</strong>terventi<strong>on</strong> programs.The Niger Health Sector Support Grant (NHSSG) was designed to complement and be implemented <strong>in</strong>collaborati<strong>on</strong> with other d<strong>on</strong>or (primarily World Bank) efforts <strong>in</strong> the sector to facilitate policy reform <strong>in</strong>the follow<strong>in</strong>g areas: cost recovery, cost c<strong>on</strong>ta<strong>in</strong>ment, resource allocati<strong>on</strong>, pers<strong>on</strong>nel, health sectorplann<strong>in</strong>g, and populati<strong>on</strong> policy and resources. The program was judged by evaluators as be<strong>in</strong>g toocomplex for the <strong>in</strong>stituti<strong>on</strong>al (<strong>in</strong>clud<strong>in</strong>g human resources) and fiscal resources available. In additi<strong>on</strong>, fundswere not directly transferred to the <strong>in</strong>stituti<strong>on</strong>s resp<strong>on</strong>sible for the reforms and, due to delays <strong>in</strong> theaccomplishment of certa<strong>in</strong> reforms, were not disbursed with<strong>in</strong> the assigned time frame. However, manyof the predef<strong>in</strong>ed health sector reforms have occurred s<strong>in</strong>ce the sign<strong>in</strong>g of the grant agreement.vi
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