The Pan American Health Organization
Promoting Health in the Americas

 Safe Hospitals

Health Surveillance & Disease Prevention & Control — Communicable Diseases: 
Acute Respiratory Infections - Anthrax - Antimicrobial Resistance - Campylobacter - Chagas -
Cholera - Dengue - Diarrheal/Enteric Diseases - Disease Outbreak News -
Emerging/Reemerging Diseases - Filariasis - Hantavirus - InfluenzaAvian |  Pandemic |  Seasonal - International Health Regulations - Leishmaniasis - Leprosy - Malaria -
Neglected Diseases - Parasitic Diseases - Rabies - Research - Salmonella - Shigella - Smallpox -
Tuberculosis - West Nile Virus  - Yellow Fever  -
Health Analysis & Statistics - Chronic Diseases - Veterinary Public Health


Health Surveillance and Disease Management / Communicable Diseases / Chagas Disease

Capacity Development under Program-Based Approaches:

LENPA Spring Forum 2005: Synthesis Report (Washington, DC, 25–27 April 2005)

LENPA Forum 2005

Full Text
(PDF, 54 pp, 477 Kb)
- Abbreviations & Acronyms
- Acknowledgements
- Executive Summary (excerpts)

I. Introduction
- Introductory Comments
- From Berlin to Washington via Tokyo
- Links to the Learning Network on Capacity Development

II. Approaches to CD under PBAs
- A Systems Approach to Capacity Development
- Promoting CD Under PBAs—Elements of a Conceptual Framework

III. Lessons from Africa and from current efforts in PFM and Procurement
- Building State Capacity in Africa
- Capacity Development in Public Financial Management—Good Practices
- Strengthening Procurement Capacities—DAC Good Practice Paper (GPP)

IV. Highlights from Case Studies
- Africa Forum
- Honduras Chagas Eradication
- South Africa Water and Sanitation
- Nicaragua Education
- Uganda Water
- Ghana Water and Decentralization
- India Health
- Senegal Health
- Tanzania Agriculture
- Bolivia Water
- India Education
- Honduras Education
- Nepal Capacity Development of Local Bodies

V. From Diagnosis to Results—Lessons from the Case Studies
- False Starts
- Strategies and Approaches
- Roles of External Partners
- Results Achieved
- Challenges Ahead

VI. Principles of Effective Support to CD under PBAs
VII. Closing Session

- Concluding Summary
- Closing Comments
Annex 1: Agenda
Annex 2: Documents and Links

PAHO Chagas Links:
- Chagas Page
- Chagas Activities Honduras
- IPCA Subregional Initiative

Case Studies from the Americas
   - Honduras Chagas Eradication
   - Honduras Education
   - Nicaragua Education
   - Bolivia Water

Honduras Chagas Eradication

The case study titled "Capacity Development via Program-Based Approaches: Chagas Disease Control in Honduras" provided an example of a program-based approach (PBA) with some unusual features. It is novel first of all in that it is a "vertical" program, rather than a sectoral one. It addresses a single disease, caused by a type of beetle (Triatomines, or 'kissing bug') that invades people's homes. As such, it is particularly susceptible to concerted action aimed at eliminating the vector that carries the disease. The initiative operates in the context of a region-wide initiative in Central America. This PBA also involved an interesting mix of partners, including the Canadian International Development Agency (CIDA-Canada) and the Japan International Cooperation Agency (JICA) as bilateral donors, but also the Pan American Health Organization (PAHO) and the international NGO World Vision, each operating according to its comparative advantage. PAHO provided leadership in creating a program out of previous experience with Chagas in Latin America.

Presenters described Chagas eradication as a "quick win" for the health sector in Nicaragua, that could be organized in PBA mode along project lines, in support of the country's National Strategic Plan on Chagas Disease Control, 2003–2007. Strong political commitment and support was secured after initial results were seen. The success of the initiative has raised interest in extending the PBA experience to other areas of the health sector. This PBA was also described as having developed "organically" while conscious efforts to establish SWAps in other sectors (i.e. education) have been less successful.

This PBA has made considerable and systematic efforts in the area of capacity development (CD).

Such efforts included initial identification of CD needs of national stakeholders across a wide range of areas, including:

  • Strategic planning
  • Technical dimensions
  • Program planning
  • Control planning, execution, monitoring and evaluation
  • Information management
  • Financial management
  • Community participation

Donor support was provided in all these areas, and involved multi-layer CD targeting at all administrative levels, from the central government level down to the community level.

Achievements include the establishment of technical norms for Chagas disease control, the standardization of planning, monitoring and evaluation methods, skills acquisition, and community participation in vector control activities.

Stakeholders harmonized their approaches to CD to cover the CD needs of different administrative levels. One difficulty was reaching the communities effectively. This was solved by working with NGOs that had good local connections.

Honduras Education

The case study on "Capacity Development in the Honduran Ministry of Education," applies an analytical framework developed by Boesen and Therkildsen (2004)1 to identify constraints to successful capacity development in the Honduran education sector.

In 2002, Honduras became on of the several developing countries selected to participate in the Education for All Fast-Track Initiative (EFA-FTI). The EFA-FTI proposal for 2003–2015 aims to achieve a 100% primary school completion rate along with improved learning outcomes in math and Spanish, and increased operational efficiency in the educational system. Ten multilateral and bilateral aid agencies and development banks support the plan.

A structural feature of the EFA-FTI program-based approach (PBA) is its focus on very specific goals involving only portions of the education sector. This PBA thus has features of a mega-project that has resisted donors' calls to mainstream it into the Ministry of Education. From the beginning, participants in EFA-FTI have attended to institutional capacity issues in the Ministry of Education, by conducting studies and drafting institutional strengthening plans. However, many of these efforts were thwarted or otherwise failed to improve capacity.

Efforts to promote capacity development (CD) are analyzed using a two-by-two table that distinguishes the functionalrational and political dimensions of organizational change along the horizontal axis, and internal and external organization factors on the vertical axis.

The case study points to ongoing internal political forces spurred by a lack of incentives that reduced the effectiveness of reforms aimed at the decentralization of the Ministry, improved educational statistics, more rational decision-making and improved work environments. A number of external political factors identified in the study also undermined progress in CD. These included the 2005 election, the influence of teachers unions, and weak demand for accountability by civil society.

The case study closes with an insightful analysis of several key issues having to do with donor support for CD:

  • How to develop capacity without creating dependency.
  • How to buffer the negative effects of "big money" on existing incentive and management systems.
  • Addressing when and how it is appropriate for donors to provide direct technical support in a PBA environment.

1 Nils Boesen and Ole Therkildsen, "Between Naivety and Cynicism: A Pragmatic Approach to Donor Support for Public-Sector Capacity Development" In Capacity Development Evaluation, Step 4 (June 2004), published by Danida, Foreign Ministry, Copenhagen, April 2005.

Nicaragua Education

The case study titled "Education Sector Policy Support Programme in Nicaragua (PAPSE)" addresses sector-wide educational needs of a very large school age population of 2.2 million school-age children (out of 5.1 million inhabitants) in an effort to reach the education Millennium Development Goals (MDGs). In 2002 and 2003, prior to PAPSE, the Nicaragua Ministry of Education, Culture, and Sports and donor partners developed a National Education Strategy and Education Sector Policy, working with The World Bank, Inter-American Development Bank, European Commission, Finland, Spain, and Luxembourg.

In 2004, several donors, including the EC, World Bank, Denmark, and Canada, developed PAPSE as an education sector-wide approach (SWAp) to improve ownership, alignment, and harmonization of efforts in providing for the needs of the sector. PAPSE covers four program activities:

  1. Decentralization of the sector.
  2. Reform of secondary education.
  3. Support to teachers.
  4. Support to education in the Atlantic coast area.

In its first year of operation, PAPSE received budget support from the EC, WB, Denmark, and Canada. Funding consists of a fixed annual tranche plus variable tranches that are set annually after a joint review with the host government of performance on educational indicators.

Indicators for the variable tranche include enrollment and drop-out rates, and an indicator of actual allocations and expenditures at the decentralized level. Capacity development has been a central focus of PAPSE activities, as the line ministries adjust to their roles in management of budget support financing to the sector.

Bolivia Water

The presentation and paper entitled "Bolivia: New Approach in the WSS Sector Fosters Capacity Development at National and Subnational Levels," compare Bolivia's earlier efforts at capacity development (CD) in the water supply and sanitation (WSS) sector to the more recent effort to broaden and sustain CD on a more sustainable basis. In the 1990s, the Bolivian government neglected CD in the WSS sector in the belief that infrastructure investments alone would suffice. As a result of this and other factors, the sustainability of their WSS investments was threatened.

In 1997, the state-run water utility for the capital, La Paz, was given over to an international private-sector concession, and in 2000, the utility in Cochabamba, the third largest city, was also contracted to an international concession. These reforms produced some improvement in efficiency and sustainability to the WSS programs in urban areas, but in 2001 and again in 2004–2005, civil unrest led the national government eventually to cancel these two private concessions.

Since 2002, the Bolivian government has pursued a reform agenda for the sector that is constrained to function in a policy environment in which the Bolivia WSS sector which the authors described as, "an anti-globalization battlefield by international NGOs," while dealing with inefficiencies and corruption under more traditional models of service provision.

This agenda has focused on three core issues:

  1. Identification of New Financial Policies to guarantee higher coverage and sustainability of WSS investments.
  2. Creation of a Foundation for Technical and Management Advisory Services (FUNDASAB) to support improved investments and capacity. More on FUNDASAB
  3. Adoption of a new Sector Investment Funding Approach (SIFAp) to channel donor investment funds to the sector.

To address the needs for CD in the WSS sector, the government and donor partners have pursued the three reforms listed above plus two others:

  1. Development of a sector information system.
  2. A structural adjustment credit (SSPSAC), which offers donors and government a platform for sector policy dialogue and helps to manage the risks of inappropriate political influence on sector policies.

Remaining challenges to address CD problems include:

  • The need for good financial management and technical know-how to structure and implement the New Financial Policies and the SIFAp.
  • Slow progress in institutionalizing CD requires good communications between the technical foundation (FUNDASAB) and New Financial Policies steering committee.
  • The need for the water utilities to take ownership in reengineering their operations and attracting donor financial support for technical assistance (TA) and investment funds.
  • The need to build up shared ownership in the stakeholder community (including the national government, local water utilities, donors and other partners), based on quality assurance, monitoring, evaluation, and feedback on mid-term outputs, milestones, and impacts.
  • The sectoral approach, as the authors state, "depends to a high degree on the government's political ability to manage and—even more importantly in the medium term—to prevent conflicts about water issues in a prudent but also a sustainable manner."

Excerpts from Executive Summary

This report synthesizes key ideas and conclusions emerging from the Forum on Capacity Development Under Program-Based Approaches (PBAs) sponsored by the Learning Network on Program-Based Approaches (LENPA) in Washington, DC from 25–27 April 2005.2

Background

This was the fourth such LENPA forum. Previous forums were organized in Ottawa (June 2002), Berlin (November 2003), and Tokyo (June 2004). All LENPA forums have dealt with capacity development (CD) to some degree in the past, but LENPA members had identified the topic of CD under PBAs as meriting concentrated attention.

A central premise behind the organization of this forum was that PBAs and CD are intimately linked. Whereas prior approaches to development cooperation have often had the effect of undermining host-country institutional capacities in a number of ways, PBAs are expected to have a number of positive effects, by:

  • Strengthening host-country ownership.
  • Working through—rather than around—local institutional structures.
  • Shifting attention towards more strategic issues, including policy and institutional reforms, rather than upon the details of project implementation.

Furthermore, PBAs themselves can only succeed to the extent that local institutions have the capacity to deliver. This considerably raises the incentive for all parties to promote CD processes in those institutions.

However, PBAs also raise new challenges regarding how best to combine efforts and how best to catalyse and support change at the program level. These challenges have yet to be fully understood. Furthermore, there is an almost total lack of empirical material on this subject. The forum aimed to address these challenges and begin to fill the empirical gap.

Don't Walk away from Fragile States

Strategies on how to promote or support capacity development efforts need to be adapted to contextual realities. Participants identified four sorts of situations that could condition donor approaches to working with governments depending upon the capacity and commitment of those governments to engage in development reforms: low capacity/low commitment; low/high; high/low and high/high. Under PBAs, the situation is often one of low capacity but high commitment and most of the lessons identified in this report can be said to apply.

The situation changes when lack of commitment is manifest. Where commitment is weak, donors will have to use a flexible, and political economic approach in order to identify windows of strategic opportunity. This is likely to involve working with groups that are perceived as legitimate, and attempting to develop a critical mass of momentum for change over time.

A variety of potential stakeholders may be involved, including the Diaspora, and the private sector.

Efforts should be made to help establish checks and balances in society and to promote multistakeholder dialogue. This sort of approach requires patience and persistence, but may produce significant results over the long term.

Conclusions

To conclude, the Washington forum allowed LENPA members to advance both their conceptual understanding of the CD/PBA challenge, and their knowledge of how CD is actually being promoted under PBAs. Much remains to be done. One of the reasons for organizing the fourth LENPA forum on this topic was because of the absolute dearth of empirical information on capacity development under PBAs. The case studies produced for the Washington forum have helped to fill that gap, but they are only a start. Further work is clearly needed, both in deepening our understanding and knowledge and in putting that understanding into practice. The fact that Indicator 4 of the Paris Declaration bears directly on the coordination of capacity development efforts should hopefully provide some impetus for more vigorous and coordinated efforts to promote CD processes under PBAs.

2 Detailed information on this and other LENPA forums, including all of the papers and presentations, is available on the LENPA extranet site. This is a password-restricted site, so new users will have to register before they can access the site (follow the links from the home page). Information on the LENPA network is also available on the site.


Regional Office for the Americas of the World Health Organization
525 Twenty-third Street, N.W., Washington, D.C. 20037, United States of America
Tel.: +1 (202) 974-3000 Fax: +1 (202) 974-3663

Pan American Health Organization. All rights reserved.