Evaluation of Finnish Health Sector Development Cooperation 1994 - 2003 (PDF, 1,08 MB)
REPORT 2005:3
ISBN: 951-724-493-2, ISSN: 1235-7618
Euro Health Group: Riitta-Liisa Kolehmainen-Aitken, M.D., Dr.P.H., Tom Barton, M.D., Hope Chigudu, M.A., Ulrika Enemark, M.Sc., Ph.D.
by e-mail eva-11@formin.fi
by phone +358 9 1605 6256
Evaluation reports are free of charge.
“Somehow, health seems to be at the bottom of the drawer for Finland.” (Senior respondent at the WHO)
This first-ever evaluation of Finland’s health development cooperation covers the years 1994-2003. Finland considers health to be one of its main development cooperation sectors and its new Development Policy focuses on poverty reduction and the Millennium Development Goals. Both are areas for which health is very important.
Policies and strategies: Finland has no health development cooperation policy or strategy. The White Papers and policies governing development cooperation in general make little specific mention of health. The absence of a health policy or strategy made it difficult for the evaluation team to review and compare Finland’s achievements in health development cooperation. To compensate, the evaluation team examined public domain documents on key Finnish positions. Our aim was to see whether these would provide a clear expression of a unified position by the government of Finland. We found the statements neither comprehensive nor focused enough for this purpose.
Resource allocation: The examination of multilateral funding levels over the evaluation period shows that UNFPA, UNAIDS, UNICEF and WHO (excluding membership contribution), which are the major multilateral partners, received a relatively stable percentage of the annual allocation to health-related contributions (approximately 11%). The absolute amount increased, particularly to UNFPA and UNAIDS. This is in line with Finland’s commitment to follow up on the ICPD conference.
The bilateral funding of health sector development contains direct state-to-state health sector programmes/projects, projects financed through local cooperation funds and bilateral programmes implemented through multilateral organisations, such as PAHO or UNFPA. The share of bilateral funding to long-term partner countries decreased continuously during the evaluation period. A significant increase occurred both in the number of non-long-term partner countries receiving bilateral health support and in the quantity of small projects. This trend runs counter to the government’s stated priorities. The growth in projects was mainly due to concessional credit schemes, particularly in China. Within the NGO financial frame, both the resources allocated to health and the number of NGO health projects increased significantly, notably between 1997 and 2001.
Involvement in key areas: The main thematic areas that the evaluation team could identify in Finnish multilateral and bilateral health cooperation are very appropriate. They include strengthening health systems, capacity building, population and reproductive health, disability and HIV/AIDS. Finland has been a leading donor in supporting disability internationally. Its active role in promoting women’s rights and a broad perspective on sexual and reproductive health is particularly important at a time, when some other donors are reducing their support to these areas.
The MFA has no official HIV/AIDS strategy, but there is ample evidence that HIV/AIDS is understood to be a multisectoral problem, with strong causal and outcome linkages to national poverty. There do not, however, seem to be any ‘White Papers’ with thorough analyses of the implications of HIV/AIDS for development cooperation and the less developed countries. There is no collection of all the position statements by Finnish spokespersons (in all sectors and international arenas) regarding HIV/AIDS. No intersectoral or interministerial networks focused on HIV/AIDS could be identified. In spite of its multisectoral scope, programming for HIV/AIDS is left to the health sector. The Ministry for Foreign Affairs does not have an HIV workplace policy, a surprising finding for a ministry that sends its staff overseas on a regular basis.
Aid mechanisms: Finnish funding to multilateral organisations is principally provided as non-earmarked ‘core funding’ with some additional thematic support. The share of core funding appears to be declining, but the amount has increased in absolute terms. The mechanism the MFA uses for discussion and engagement in active dialogue in relation to the multilateral funding programmes is not clear. An increasing amount of funding has been earmarked for themes of particular relevance to the Finnish development assistance in the health sector. While the selected themes are important, the criteria and strategic considerations that led to the choice of these thematic areas are not obvious.
Finland’s bilateral state-to-state grant assistance is shifting from a project approach to a SWAp approach. While the move to a SWAp is a positive one, steps must be taken to ensure that gains made by past programmes are not lost. One option is to maintain earmarking of a smaller part of the Finnish support for areas of particular concern to Finland. Finnish assistance has been in line with the needs and priorities of the recipient countries - although not necessarily at the core of them. Finland’s flexibility and ability to provide some un-earmarked support has provided it with much influence beyond what its level of financial support justifies. By its choice of sub-sectors, Finland has supported those quarters of government that are willing to put slightly contentious health-related issues on the agenda and work for changing the health of vulnerable groups. Several informants in Nicaragua credited Finland for helping keep important issues, such as the disabled people, reproductive health and family violence, higher on the agenda than they would otherwise have been.
Non-government organisations (NGOs) are a varied group from large Finnish and international organizations to small local ones. About two hundred Finnish NGOs implement over 500 projects in almost 70 countries. The MFA has partner agreements with eight large, experienced NGOs; they receive approximately 50% of the total NGO support. No data base lists all NGOs working in the health sector, which makes it difficult to assess NGO funding as an aid mechanism toward better health. Anecdotal information on the value of their contribution in health is quite positive, as they are often in a better position to address critical and potentially controversial issues than government authorities. The evaluation team is concerned, however, that NGO work appears to be isolated from the mainstream work of the MFA’s other Departments.
Local Cooperation Funds (LCFs) are a good mechanism to reinforce health development assistance at a country level. The availability of a LCF could also be an avenue for empowering civil society to engage meaningfully in the SWAp discussions. The evaluation team supports allowing embassies to plan the use of LCFs as part of a country specific plan. The team found a great deal of apprehension regarding the use of Concessional Credits (CCs) in the health sector. Consistency between social impact and the use of CCs will have to be ensured through careful preparation and monitoring of projects. CC could also be an instrument for gradually withdrawing from countries, where health sector support is being phased out.
Key implementation strategies: The evaluation team found little evidence of mainstreaming, either in relation to gender or HIV/AIDS. A process toward participatory ownership has been initiated, though stakeholder participation is still limited. Capacity building has long been considered an important part of development cooperation in Finland. Namibia represents Finland’s most consistent experience with both health system strengthening and capacity building. Many valuable lessons can be learned from Namibia, but the evaluation team was unable to find any evidence that these ‘lessons learned’ would have been applied to Finnish health development cooperation efforts elsewhere. Finland is generally poorly prepared for any form of transition, be it a phase-out from countries or from sectors. Guidance on phaseout is thin on the ground and there appears to be no collection of relevant MFA experiences with phasing-out in various situations.
Management capacity: The evaluation team is very troubled by the seeming incongruence between Finland’s stated importance of health in development cooperation and its current lack of systems and processes to assure appropriate attention to health within the government structures. The team members were surprised – frankly, even startled – by the extent of weakness in the MFA’s management capacity as it relates to Finland’s health development cooperation. Many of the management issues are not specific to the health sector nor is the MFA unaware of them.
The evaluation team found it difficult to identify what management systems and processes Finland uses now to define its health sector cooperation policies and priorities and operationalise them through its aid modalities. No department or unit in the Ministry for Foreign Affairs maintains a comprehensive picture of Finland’s health development cooperation. There is no Finnish health development cooperation policy or strategy to guide strategic and resource allocation decisions. There are no clearly defined health sectoral or thematic goals that would be commonly understood and accepted by the MFA staff managing multilateral, bilateral and NGO support to health in their separate departments and divisions. And there is no easily accessible repository of key documents on health to inform these staff (as well outside consultants and evaluators) about the government’s stance regarding issues of health development.
The approach to approving new health projects is haphazard and unstrategic. The Sectoral Policy Unit of the MFA has no statutory role in enforcing sectoral policies. The sectoral health adviser has very little influence on bilateral funding decisions. The MFA’s information system is totally inadequate for evidence-based decision making about health development cooperation. It does not allow for the identification of all projects with health as a component. It focuses on funding, not outcomes or results, and appropriate disaggregation of data is not possible without considerable additional manual effort. The documentation of achievements and lessons learned is also very weak.
A disconcerting finding of this evaluation is the unsystematic manner in which Finnish bilateral health projects and programmes are monitored and evaluated – or not! Guidelines on management and evaluation are not complete, and the process for reviewing and updating them is unclear. Baseline studies have, in general, not been a feature of bilateral projects. Where they were undertaken, they do not appear to have been followed up. Even mid-term reviews are sometimes ad hoc decisions and tend to yield information only about project processes and not outcomes. End-of-project evaluations are rarely done.
The evaluation team was struck by the extreme vulnerability of the MFA’s and embassies’ staffing situation in regard to health expertise. The technical skills of both present health advisers are highly praised, but the fact that required skills and experience lie in only a few individuals, overloaded with work, makes Finland’s capacity to competently address the myriad health-related issues most precarious.
The evaluation team is very concerned about the apparent lack of planning for “growing” the next generation of Finnish health development expertise. Most of the experienced health and development experts are likely to retire within the next 10-15 years. The Ministry for Foreign Affairs does not consider building capacity in health development cooperation to be its role. In fact, it appears that no ministry or institution sees this as their responsibility.
Measurable achievements: The evaluation team was expected to examine measurable achievements of Finland’s health sector support. Putting it quite squarely, this part of the Terms of Reference proved unrealistic and unachievable, given the state of information management in the MFA. Relevant information to measure achievements was simply not available – not just to the evaluation team, but even to the MFA itself. The evaluation team heard complaints about the absence of statistics and data bases from a number of senior officials in various departments of the MFA, and from officials in the field. We fully agree - all members of the evaluation team were shocked to find that there is no data base of evaluations, not even a register of them that would go back ten years.
The evaluation report includes an analysis of gaps in information about achievements and a listing of significant (but not necessarily measurable) achievements that were highlighted during the evaluation.
Faced with the dearth of data and documentation, the evaluation team struggled to assess the relevance, effectiveness and impact of Finland’s health sector development cooperation. In reference to relevance, the Finnish development assistance to health is generally in line with the objectives in the general development principles and related statements of Finland. The relevance of the portfolio mix at a more detailed level is, however, difficult to assess due to the absence of a health policy. Regarding specific bilateral programmes, the ones examined were found to be relevant to the country needs and priorities. The effectiveness of Finnish multilateral development assistance to health is difficult to assess and cannot easily be distinguished. At the bilateral programme level, the evaluation team assesses the programmes as having been fairly effective overall in reaching their objectives. The effectiveness in mainstreaming gender and HIV/AIDS has, however, been low. Finnish assistance has probably made an impact on the lives and health of target beneficiaries. The absence of documentation, however, makes it difficult to assess in which health areas and target groups such impact would be most notable.
Finland’s strengths: This evaluation calls attention to a number of challenges facing Finland, as it seeks to strengthen its development cooperation in the health sector. But the evaluation also revealed several areas of particular strength. These include Finland’s choice of thematic areas of support; its focus on often marginalised but important areas, such as disability and sexual and reproductive health and rights; the dependability of Finland’s ‘core support’ to multilateral partners and the good alignment between Finnish bilateral support and recipient countries’ priorities. These are valuable strengths to build on, as Finland tackles the challenges confronting the operationalisation of its new Development Policy with respect to the health sector.
Recommendations and opportunities analysis:The evaluation report concludes with a detailed list of recommendations, as well as an opportunities analysis. Many of the most vexing issues affecting health development cooperation require action at a government level higher than the MFA. The opportunities analysis is presented as an input to the debates and discussions – within the MFA itself and between the MFA and its partners - on priority actions to improve the focus and management of Finland’s future health development cooperation.
