2008
EC DEVELOPMENT ASSISTANCE
TO HEALTH SERVICES IN SUBSAHARAN AFRICAEUROPEAN COURT 
OF AUDITORS
Special Report  No 10SPECIAL REPORT ‘EC DEVELOPMENT ASSISTANCE TO HEALTH SERVICES IN SUB
SAHARAN AFRICA’ EXAMINES WHETHER THE FINANCIAL AND HUMAN RESOURCES ALLOCATED TO THE HEALTH SECTOR REFLECTED THE EC’S POLICY COMMITMENTS, 
AND WHETHER THE COMMISSION HAS SPEEDED UP THE IMPLEMENTATION OF 
THIS AID AND USED THE VARIOUS TYPES OF FINANCING EFFECTIVELY. THE REPORT MAKES A SERIES OF RECOMMENDATIONS AIMED AT IMPROVING THE EFFECTIVENESS OF EC ASSISTANCE IN CONTRIBUTING TO IMPROVING HEALTH SERVICES IN SUBSAHARAN AFRICA.
EUROPEAN COURT OF AUDITORS
EN
QJ-AB-08-010-EN-C
ISBN 978-92-9207-095-3
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EC DEVELOPMENT ASSISTANCE 
TO HEALTH SERVICES IN SUBSAHARAN AFRICASpecial Report  No 10   2008
EUROPEAN COURT OF AUDITORS(pursuant to Article 248(4), second subparagraph, EC)
2
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan AfricaEUROPEAN COURT OF AUDITORS
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Special Report  No 10   2008
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Cataloguing data can be found at the end of this publication.
Luxembourg: Office for Official Publications of the European Communities, 2009
ISBN 978-92-9207-095-3
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Reproduction is authorised provided the source is acknowledged.
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Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan AfricaCONTENTS
Paragraph 
 GLOSSARY
IVI  EXECUTIVE SUMMARY
13 INTRODUCTION
46 AUDIT SCOPE AND APPROACH
729   OBSERVATIONS ON ALLOCATION AND DISBURSEMENT OF RESOURCES 
TO THE HEALTH SECTOR
720 RESOURCES ALLOCATED BY THE COMMISSION TO THE HEALTH SECTOR
817 FINANCIAL RESOURCES
1820 HUMAN RESOURCES
2129 SPEED OF EC FUNDING TO THE HEALTH SECTOR
2223 EDF HEALTH SECTOR INTERVENTIONS
2425 GENERAL BUDGET SUPPORT
2629 GLOBAL FUND
3072  MANAGEMENT AND EFFECTIVENESS OF INSTRUMENTS
3146 BUDGET SUPPORT
3134 THE USE OF BUDGET SUPPORT BY THE COMMISSION
3546 EFFECTIVENESS OF GENERAL BUDGET SUPPORT IN IMPROVING HEALTH SERVICES
4755 PROJECTS
4849 EDF PROJECTS
50 INTRAACP PROJECTS
5155 GENERAL BUDGET LINE HEALTH PROJECTS
5662 GLOBAL FUND
5658 THE COMMISSION’S MANAGEMENT OF ITS SUPPORT TO THE GLOBAL FUND
5962 EFFECTIVENESS OF THE GLOBAL FUND
6372 COHERENT USE OF INSTRUMENTS AND INTEGRATION IN SECTORWIDE APPROACHES
6467 COHERENT MANAGEMENT OF INSTRUMENTS BY THE COMMISSION
6872 INTEGRATION OF INTERVENTIONS INTO SECTORWIDE APPROACHES
7383  CONCLUSIONS AND RECOMMENDATIONS
7378 RESOURCES
7983 MANAGEMENT AND EFFECTIVENESS OF INSTRUMENTS
 ANNEX I  MILLENNIUM DEVELOPMENT GOALS: 2007 PROGRESS CHART
 ANNEX II   EXTRACT FROM BRUSSELS DECLARATION BY ACP MINISTERS OF HEALTH, 
OCTOBER 2007
 ANNEX III  COUNTRY SUMMARIES ANNEX IV  LIST OF PROJECTS EXAMINED
 REPLY OF THE COMMISSION
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan AfricaGLOSSARY
ACP : African, Caribbean and Pacific States
ACT : artemisinin-based combination therapy (for malaria treatment)
ARV : anti-retroviral
CCM : country coordination mechanism
DOTS : directly observed treatment short course
EC: European Community
ECHO : European Community Humanitarian Office
EDF : European Development Funds
EuropeAid : EuropeAid Co-operation Office
Global Fund : Global Fund to fight AIDS, tuberculosis and malaria
HIPC : highly indebted poor countries debt initiative
HIV/AIDS : human immunodeficiency virus/acquired immune deficiency syndrome
IMF : International Monetary Fund
ITN : insecticide treated bednets (for malaria prevention)
MDGs : Millennium Development Goals
OVC : orphans and vulnerable children
PEPFAR : United States President’s Emergency Plan for AIDS Relief
PMTCT : prevention of mother to child transmission
PRBS : poverty reduction budgetary support
SRH : sexual and reproductive health
SWAp : sector-wide approach
USD : United States dollars
VCT : voluntary consulting and testing (for HIV/AIDS)
WHO : World Health Organisation
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan AfricaEXECUTIVE 
SUMMARY
I.
The objective of the audit was to assess  
how effective EC assistance has been in  
contributing to improving health services  
in sub-Saharan Africa in the context of the 
EC’s commitments to poverty reduction and 
the millennium development goals (MDGs). The audit examined whether the finan-
cial and human resources allocated to the  
health sector reflected the EC’s policy com-
mitments and whether the Commission had accelerated the implementation of this aid. The audit also assessed how effectively the 
Commission had used various instruments  to assist the health sector, notably budget support, projects and the Global Fund to  fight AIDS, tuberculosis and malaria (Glo-
bal Fund).
II.
Overall, EC funding to the health sector has 
not increased since 2000 as a proportion  
of its total development assistance despite 
the Commission’s MDG commitments and  
the health crisis in sub-Saharan Africa. The 
Commission contributed significant funding to help launch the Global Fund but has not 
given the same attention to strengthening 
health systems although this was intended 
to be its priority (paragraphs 8 to 17). The 
Commission has had insufficient health  expertise to ensure the most effective use  
of health funding (paragraphs 18 to 20).
III.
The Commission has accelerated the health assistance it manages itself. While the  
Global Fund has mobilised a large volume  of funding, its rate of disbursement has been 
slower than for the European Development Funds (EDF). There is scope for improving  the predictability of the flow of funding from all instruments to enable countries to bet-ter budget the resources available for their health sectors (paragraphs 22 to 29).
7
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan AfricaEXECUTIVE 
SUMMARY
IV.
The Commission has made little use of Sec-
tor Budget Support in the health sector  
although this instrument could make an  
important contribution to improving health 
services. It has used General Budget Support 
much more widely but its links to the health sector are less direct and the Commission  
has not used it very effectively (paragraphs 
32 to 46). Overall, projects have proved rea-
sonably effective although sustainability is often problematic (paragraphs 47 to 55). The Commission played a key role in setting up 
the Global Fund, which has already produced significant outputs, but greater involvement by the Commission in Global Fund activities in the beneficiary countries could have made 
it more effective (paragraphs 56 to 62).
V.
The Commission has not paid sufficient  
attention to ensuring the different instru-
ments are used together coherently. When 
choosing which instruments to use, it could 
also take more account of the situation in  
individual countries, in particular whether  they had a well-defined health sector pol-
icy. Given their importance to the effective-
ness of each instrument, there is a need for 
the Commission to contribute more to the  
development of such policies and to ensure its interventions are integrated into them  
(paragraphs 63 to 72). VI.
The report’s main recommendations are that 
the Commission should:
consider increasing its aid to the health  –
sector during the 10th EDF mid-term  
review to support its commitment to the health MDGs;
review how its assistance to the health  –
sector is distributed to ensure it is pri-marily directed to its policy priority  of health systems support;
ensure each delegation has adequate   –
health expertise either in the delega-tion or through drawing on the resources of other partners;
make more use of Sector Budget Support  –
in the health sector and focus its Gen-
eral Budget Support more on improving 
health services;
continue to use projects, especially   –
for support to policy development and  capacity building, pilot interventions  
and assistance to poorer regions; 
work more closely with the Global Fund  –
in beneficiary countries;
establish clearer guidance on when each  –
instrument should be utilised and how  
they can best be used in combination;
make greater efforts to contribute to the  –
development of well-defined health sec-tor policies in beneficiary countries.
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan AfricaSpecial Report No 10/2008 — EC development assistance to the health services in sub-Saharan AfricaINTRODUCTION
 1.  Good health is a major factor in economic growth and development while 
ill health is both a cause and an effect of poverty. The central place 
which health occupies in poverty reduction has been recognised in the MDGs which, over the period 2000–15, are intended to be the  
focus of international development cooperation. Thus three of the 
eight MDGs directly relate to health: MDG 4: Reduce child mortality; 
MDG 5: Improve maternal health; MDG 6: Combat HIV/AIDS, malaria 
and other diseases. However, the United Nations 2007 mid-term  
review of progress towards the MDGs
1 reported that the projected 
shortfalls for their achievement are most severe in sub-Saharan Africa 
as shown in Annex I . ACP ministers of health at their summit in 2007 
also expressed grave concerns about other health issues outside the MDGs and the huge challenges faced by health services in addressing them (see Annex II ).
 2.  In 2000 the Commission made poverty reduction the overarching goal 
of its  development policy2 and also committed itself to assisting  
developing countries achieve the MDGs. The 2005 ‘European con-
sensus on development’ continued to emphasise these priorities. The 
Commission’s health policy in the context of poverty reduction and 
the MDGs has been set out in two key initiatives.
In 2000 it launched a policy to accelerate action targeted at HIV/ (a) 
AIDS, malaria, and tuberculosis3. The Commission stressed that its 
main long-term response to improving health, including tackling 
these diseases, was ‘intensified support to strengthen health sys-
tems to ensure improved access to prevention and treatment for 
the poorest.’ But it also emphasised that ‘the global and national emergency created by these three diseases will not wait for the 
improvement of health systems; there is also a need for simul-
taneous actions beyond the traditional health sector’. Hence,  
the Commission proposed new partnerships and faster delivery 
mechanisms and this initiative contributed to the creation of the Global Fund in 2001.1 The Millennium Development 
Goals Report 2007. United Nations, 
New York 2007.
2 Declaration by the Council and 
the Commission on the European 
Community’s development policy, 
13458/00 of 16 November 2000.
3 ‘Accelerated action targeted 
at major communicable diseases 
within the context of poverty 
reduction’. Communication of the 
Commission to the Council and the 
European Parliament, COM(2000) 
585 final of 20.9.2000.
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa9
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan AfricaWhile the 2000 policy initiative was focused on HIV/AIDS, malaria (b) 
and tuberculosis, in 2002 the Commission established a new over-
all health policy to reflect the poverty reduction objectives of its development policy
4. It maintained the country programmes as 
the major focus of EC investment in health and prioritised actions 
in the areas of promoting public health, strengthening health  
systems, pro-poor systems of health financing, communicable  
diseases, and reproductive and sexual health and rights.
These two policies have remained the main basis for Commission (c) 
interventions in the health sector with the 2000 communication 
being updated in 2004 to cover the period 2007–11. The main addi-tional initiative, directed at health systems strengthening, was  the establishment in 2005 of an EU strategy to address the human 
resource crisis in the health sector in developing countries.
 3.  The main sources of EC funding for health assistance, the channels for 
this funding and the instruments for its implementation are set out in Table 1 .
4 Communication from the 
Commission to the Council and the 
European Parliament: ‘Health and 
poverty reduction in developing Countries’, COM(2002) 129 final of 
22.3.2002.
Source : ECA.
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa10OVERVIEW OF FUNDING MECHANISMS FOR EC HEALTH ASSISTANCETABLE 1
unds Dna Europe  evelopment F General budget lines
Sources Channels Instruments
NGO co-
financingHealth 
assistance
Country programmes 
are established between
ACP States and the 
Commission for the 
duration of each 
European Development 
Fund. An overall 
allocation is decided by
the Commission and 
generally two focal 
sectors are selected on
which to concentrate 
assistance. Regional programmes 
work in the same way as 
country programmes but 
cover several countries 
within a specific region. 
However, regional 
programmes have been 
little used to provide 
health assistance and 
only for financing projects.Intra-ACP funding is 
defined in the Cotonou 
Agreement (Annex IV 
Article 12) as funds 
‘earmarked for regional 
operations that shall be 
set aside for 
operations that benefit 
many or all ACP 
States’. In particular: Regulation 
(EC) No 1568/2003 of 
15 July 2003 on aid to 
fight poverty diseases 
(HIV/AIDS, TB and 
malaria) in developing 
countries and 
Regulation (EC) No 
1567/2003 of 
15 July 2003 on aid for 
policies and actions on 
sexual and reproductive 
health and rights.Council Regulation (EC) 
No 1658/98 on co-
financing operations 
with European non-
governmental 
development 
organisations (NGOs) in 
fields of interest to the 
developing countries. 
From 1998 to 2006 this 
regulation funded 
projects in different 
sectors including health.
Global Fund Projects Sector Budget 
SupportGeneral Budget 
SupportCountry 
programmesRegional 
programmesIntra-ACP 
funding
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa11
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan AfricaAUDIT SCOPE AND APPROACH
 4.  The Court’s audit sought to assess how effective EC assistance has been 
since 2000 in contributing to improving health services in sub-Saha-
ran Africa in the context of poverty reduction. The audit focused on four key questions:
Has the amount of resources allocated by the Commission to the (a) 
health sector reflected its policy commitments?
Has the Commission accelerated its funding of assistance to the (b) 
health sector?Has the Commission used the individual instruments available  (c) 
effectively to contribute to improving health services?Has the Commission used the range of instruments available coher- (d) 
ently to effectively contribute to improving health services?
 5.  The main audit work carried out to answer these questions was as  
follows:
a review of documentation on EC health assistance policy; (a) 
a review of EDF, general budget line and Global Fund health sec- (b) 
tor commitments and disbursements;
on-the-spot missions to Kenya, Lesotho, Malawi, Mali and  (c) 
Swaziland;
desk reviews of health interventions in Burundi, Côte d’Ivoire  (d) 
and Ethiopia;
a survey of all 41 EC delegations in sub-Saharan Africa on EC  (e) 
assistance to the health sector5. 
 6.  The audit was limited to sub-Saharan African countries which receive EDF 
financing since these are the countries facing the worst health crisis. 
The audit did not include an examination of how other sectors, for 
example, water and sanitation, were used to improve health nor how 
health issues were mainstreamed into interventions in other sectors. 
It also excluded the audit of health interventions by the European  Community Humanitarian Office (ECHO).5 Due to the good cooperation 
of the Commission, replies to 
the questionnaire were received 
from 37 of  the 41 Commission delegations in sub-Saharan Africa.
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan AfricaSpecial Report No 10/2008 — EC development assistance to the health services in sub-Saharan AfricaOBSERVATIONS ON ALLOCATION 
AND DISBURSEMENT OF RESOURCES TO THE HEALTH SECTOR
RESOURCES ALLOCATED BY THE COMMISSION 
TO THE HEALTH SECTOR
 7.  This section addresses the question whether the financial and human 
resources allocated by the Commission to the health sector reflect its 
policy commitments. The Court examined Commission policy state-
ments and European Parliament targets, the allocations made, and 
the causes and consequences of the level of allocations.
FINANCIAL RESOURCES
The Commission has made strong policy commitments to the health sector 
 8.  The Commission has made strong commitments to the health sector in its 
health assistance policies. In its ‘programme for action’ for the 2000 ‘accelerated action’ policy the Commission stated it would ‘prioritise 
within the total development cooperation budget, health, AIDS and 
population interventions over the next five years (2002–06)
6. Sub-
sequently, the 2003 progress report on the programme for action7 
referred to a target of 15 % of ninth EDF programmed aid being allo-
cated to health. The 2002 health and poverty reduction policy stressed 
that far greater efforts had to be made by the international community to support the health sector and that the EC had an important role 
to play in this.
 9.  In 2004, in order to show the priority it attached to EC assistance being 
directed to the health and education MDGs, the European Parliament introduced a specific allocation target in its budgetary remarks for all 
areas of development cooperation, including the African, Caribbean 
and Pacific (ACP) States: ‘(as) the purpose of development coopera-
tion under this heading is primarily its contribution to achieving the 
MDGs… a minimum of 20 % of total annual commitments will be allo-cated to activities in the sectors of basic health and education’
8. In 
2006, the Commission formally committed itself to prioritising these sectors in the country programmes covered by the new Development 
Cooperation Instrument and to meeting the 20 % target
9 taking into 
account budget support linked to these sectors. Such an approach is 
difficult to apply in the context of the EDF where, in contrast to the 
Development Cooperation Instrument context, most budget support is provided through General Budget Support for which there is no  
recognised method for attributing the assistance to specific sectors. 
While the Commission did not make a similar undertaking for the EDF, 
the Parliament nevertheless said that the Commission’s undertaking 
‘should apply to all European development policy spending including the EDF in order to be coherent’
10. 6 Programme for action: 
accelerated action on HIV/AIDS, 
malaria and tuberculosis in the 
context of poverty reduction, 
COM(2001) 96 final of 21.2.2001.
7 Update on EC programme 
for action: accelerated action on 
HIV/AIDS, malaria and tuberculosis 
in the context of poverty 
reduction, COM(2003) 93 final of 
26.2.2003.
8 General budget of the European 
Union for the financial year 2004 
(OJ C 105, 30.4.2004, p. 1169).
9 Communication from the 
Commission to the European 
Parliament concerning the common position of the Council on 
the adoption of a regulation of the 
European Parliament and of the 
Council establishing a financing 
instrument for development cooperation. Annex on Article 
5 of Development Cooperation 
Instrument, COM(2006) 628 final 
of 24.10.2006.
10 European Parliament ‘Report 
on the implementation of the programming of the 
10th European Development 
Fund’. A6-0042/2008 dated 
February 2008.
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa13
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan AfricaOverall Commission funding to the health sector is below policy 
commitments and benchmarks, despite significant new support 
for the Global Fund
 10.  As Table 2  shows, ninth EDF assistance committed directly11 to the health 
sector in sub-Saharan Africa represented 5,5 % of total EDF commit-
ments, well below the 15 % target (see paragraph 8). This was despite 
an increase from 4,4 % under the eighth EDF due to significant new 
funding for intra-ACP health interventions, principally in contribu-tions to the Global Fund.
EDF COMMITMENTS TO THE HEALTH SECTOR UNDER EIGHTH 
AND NINTH EDFS AS A PERCENTAGE OF TOTAL EDF COMMITMENTS IN SUBSAHARAN AFRICA MILLION EURO AT 31.12.2007
Eighth EDF Ninth EDF
Total EDF commitments 9 787,0 13 930,7
Type of health supportAmount 
of EDF health 
commitments% of total EDF 
commitmentsAmount 
of EDF health 
commitments% of total EDF 
commitments
Health in country 
programmes369,3 3,8 % 351,2 2,5 %
Health in regional 
programmes13,1 0,1 % 19,7 0,1 %
Health in intra-ACP funded 
interventions47,6 0,5 % 399,7 2,9 %
Total 430,0 4,4 % 770,6 5,5 %TABLE 2
 11.  As Table 3  shows, commitments directly to the health sector in country 
programmes in sub-Saharan Africa have been very low compared with 
the target set by the European Parliament (see paragraph 9), falling 
from 5,1 % under the eighth EDF to 3,6 % under the ninth EDF while 
under the 10th EDF allocations were programmed for just 3,5 %. This was inspite of it being the Commission’s policy to use country pro-
grammes as its main channel of assistance to the health sector (see 
paragraph 2). Low health commitments were not compensated for  
by higher education commitments: combined health and education 
commitments in country programmes fell from 7,5 % under the eighth 
EDF to 6,2 % under the ninth EDF and were programmed to remain 
at this level under the 10th EDF.11 Excluding General Budget 
Support (see paragraph 12).
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa14
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa 12.  Apart from the direct funding to the health sector, an assessment of the 
Commission’s support to the health sector in sub-Saharan Africa  should also take General Budget Support into account, although in practice it is very difficult to quantify.
Under the seventh and eighth EDFs, 3 240 million euro were com- (a) 
mitted by the Commission to budgetary support programmes.  
Up until 2000, counterpart funds arising from the programmes  were directly allocated to national health and education budgets, 
an estimated 800 million euro (80 million euro per annum; 35 % 
of counterpart funds) being provided to the health sector over  
the period 1990–99.
Under the ninth EDF, General Budget Support commitments  (b) 
amounted to approximately 2 000 million euro but was no longer 
earmarked for specific sectors. Although it is not possible to state 
how much funding was allocated to the health sector, it is esti-
mated that it was lower than under the two previous EDFs. If  
it is assumed that countries spend the General Budget Support they receive in line with the relative shares of sector budgets,  
this would mean that approximately 200 million euro was used 
for health (33 million euro per annum) since health budgets on 
average make up 9–10 % of total national budgets in sub-Saharan 
Africa. This percentage is much less than the 35 % previously ear-
marked for health by the Commission. Moreover, as shown by a 
2007 International Monetary Fund (IMF) evaluation of budgetary support to sub-Saharan African, countries on average save up to 
70 % of such assistance to reduce their budget deficits
12. This indi-
cates that the ninth EDF General Budget Support actually used for 
national health budgets was rather less than 200 million euro.
For the 10th EDF, General Budget Support of approximately  (c) 
3 300 million euro has been programmed. While this represents 
an increase compared with the ninth EDF, it is unlikely to lead  to as much resources being channelled to health as under the  seventh and eighth EDFs.EDF COMMITMENTS TO THE HEALTH SECTOR UNDER EIGHTH AND 
NINTH EDFS AS A PERCENTAGE OF TOTAL EDF COUNTRY PROGRAMMES IN SUBSAHARAN AFRICA MILLION EURO AT 31.12.2007 
Eighth EDF Ninth EDF
Total EDF country programmes 7 268,6 9 793,8
Health in country programmes 369,3 5,1 % 351,2 3,6 %Education in country programmes 175,5 2,4 % 255,8 2,6 %Total health and education 
in country programmes 544,8 7,5 % 607 6,2 %TABLE 3
12 The IMF and Aid to sub-Saharan 
Africa. Independent Evaluation 
Office of the IMF, 2007.
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa15
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa 13.  A further source of funding for health assistance are the general budget 
lines (see Table 1 ). The amounts increased significantly over the period 
2003–06, averaging 109 million euro per annum, of which approxi-mately one third was directly committed to sub-Saharan Africa. This 
compared very favourably to the 22 million euro per annum allocated 
over the period 1997–2002, but the budget has fallen back to 84 mil-
lion euro per annum for the period 2007–13.
 14.  Overall, while it is extremely difficult to calculate a precise figure and 
recognising the limitations of a purely input based approach, the  
Court’s analysis pointed to an indicative figure of 1 100 million euro to 1 200 million euro being allocated to the health sector in sub-Saharan Africa over the period of the ninth EDF including General  
Budget Support and general budget line funding. This is estimated 
to represent an increase in absolute terms of up to 30 % compared 
with the period covered by the eighth EDF. However, given that there was a more than 40 % increase in total commitments for the ninth 
EDF compared with the eighth EDF the percentage of EC funding  
committed to the health sector in sub-Saharan Africa declined. While 
the 10th EDF represents a 60 % increase compared with the financial 
allocations of the ninth EDF, health allocations to sub-Saharan Africa 
are estimated at approximately the same amount as for the ninth  
EDF. The low country programme allocations to country programme direct health sector interventions in sub-Saharan Africa are in sharp 
contrast with EC allocations to countries in Asia, where 14 % of the 
2007–10 multiannual indicative programme funds were allocated to 
basic health. This is despite the fact that Asian countries were sig-
nificantly further advanced towards the health MDGs.
There is a shortage of international assistance 
for strengthening health systems
 15.  Starting from the ninth EDF, the Commission and EU Member States 
sought to find an appropriate division of labour between themselves 
based on their traditional expertise and perceived comparative advan-tage. While the division of labour between donors is a sound man-
agement principle, it does not ensure that adequate resources are  
allocated to sub-Saharan African countries to achieve a minimum level 
of health services and make significant progress towards the health 
MDGs. Analyses by the Commission, EU Member States and the World Health Organisation (WHO) have identified key issues in the overall 
level and distribution of health funding which the international com-
munity must address (see Box 1).The relative absence from the sector 
of such a major donor as the Commission
13 has contributed to these 
shortfalls, and the European Parliament has taken the view that the division of labour principle is not a valid reason for the Commission 
not to play a key role in the health sector
14. 13 The European Commission is one 
of the five largest donors to sub-
Saharan Africa along with France, 
the United Kingdom, the United States and the World Bank.
14 European Parliament resolution 
of 24 April 2007 with observations 
forming an integral part of decision on discharge for 
implementation of the budget 
for the sixth, seventh, eighth 
and ninth EDFs for the financial 
year 2005. Paragraph 29.
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa1616
BOX 1
EU Member States and Commission health experts concluded in 2006 both that health’s share in overall EU overseas 
development assistance was insuﬃ   cient at 6,6 % and that EU health assistance was not correlated to countries’ needs 
in terms of their health ﬁ  nancing gap.
DG Development has estimated that, if they were to deliver minimal health services16, 32 sub-Saharan African coun-
tries would have a total ﬁ  nancing gap of 9 767 million euro, even if they met the target set by African Heads of State 
at their 2001 Abuja Summit to allocate 15 % of their national budget to health.
A WHO study on health assistance identiﬁ  ed a number of ‘health donor orphans’ and concluded that there was no 
clear correlation between a country’s health situation and the amount of health assistance it received. More health aid is given to countries with high HIV/AIDS prevalence rates, even if the overall health situation in other countries 
is as bad or worse
17.KEY ISSUES IN THE OVERALL LEVEL AND DISTRIBUTION OF HEALTH FUNDING 16.  The 2007 EU Code of Conduct on Complementarity and the Division 
of Labour in Development Policy15 stresses the need to address the 
problem of donor orphans, which are often fragile States and post-crisis countries. An EC comparative advantage, recognised in both  
the 2000 and 2005 development policies, was the role it could play 
in such countries. This is both because it is more frequently repre-
sented in these countries than EU Member States and also because 
of its role in supporting rehabilitation and development after the  
end of relief operations managed by ECHO. Since a significant part of ECHO’s interventions are health-related, there is a particular need 
to assure follow-up health interventions. In only a limited number  of such countries was health selected as a focal sector under the  10th EDF (Angola, Burundi, Côte d’Ivoire, Democratic Republic of the 
Congo, Liberia and Zimbabwe).
16 According to the 2001 Commission on Macroeconomics and Health, 30 USD per capita per year is needed to deliver very 
minimal health services. It does not include key elements such as family planning, tertiary hospitals and emergencies.
17 Sub-Saharan African countries classified by the WHO study as health donor orphans are: Central African Republic, Cote 
d’Ivoire, Democratic Republic of the Congo, Ethiopia, Nigeria, Sudan, Togo and Zimbabwe. 15 Council of the European Union 
Note 9558/07, Brussels, 
15 May 2007. 
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa1717
STAFFING ISSUES IDENTIFIED DURING THE COURT’S AUDIT MISSIONSBOX 2
In Burundi, although health was an important sector under the ninth EDF and a focal sector under the 10th EDF, 
the delegation had no health expertise. In Kenya, aft  er the departure of a Member State national health expert in 
August 2006, the delegation was not able to obtain a replacement because no post was available. In Swaziland, the delegation had an oﬃ   cial with health training but he had been working on other sectors as health had not been a focal 
sector in Swaziland under the ninth EDF. 17.  The relatively large Commission funding for disease-specific interventions 
compared to that for health systems (see paragraph 10) reflected the 
fact that over the period 2000–05 it invested significant efforts in drawing up and implementing action programmes for its HIV/AIDS, 
malaria and tuberculosis policy initiative. On the other hand, it has paid 
less attention to implementing its broader health policy. The decline 
since 2000 in Commission assistance to country programmes (see para-
graph 11) is part of a wider tendency on the part of the international 
community to focus on disease-specific interventions at the expense of strengthening health systems
18. In the Court’s survey of Commission 
delegations in sub-Saharan Africa, 23 out of 27 delegations considered that there was too much disease-specific funding. The Court found that in Ethiopia and Mali, although the two countries had relatively low HIV 
prevalence rates
19, the external assistance they received for tackling 
HIV/AIDS was greater than their entire national health budget. The 
UNDP 2007 mid-term review of the MDGs stressed that weak health systems are a serious obstacle to their achievement.
HUMAN RESOURCES
The Commission does not have adequate health expertise
  18.  While the Commission itself recognised its lack of health expertise in 
2004, citing it as a reason for its limited financial allocations to the 
health sector20, the Court found that this problem persists and a  
human resource strategy to address it has not been developed. Of the 
37 delegations in sub-Saharan Africa which replied to the Court’s  survey, 13 delegations have in total 18 staff with university-level  
qualifications in health-related fields
21. Only four of these are per-
manent officials, of which just one works full-time on health22. The 
Court identified several issues during its on-the-spot audit work (see 
Box 2). Not only is it essential for delegations in countries where  health is an EDF focal sector to have health expertise, but it is also important for other delegations to have access to health expertise for the following reasons:
to manage the health aspects of General Budget Support  (a) 
programmes;
to support and monitor Global Fund operations in the country; (b) 
to better supervise the health general budget line and intra-ACP (c) 
projects;
to ensure HIV/AIDS issues are integrated into all EC interventions. (d) 18 In particular, the United States 
President’s Emergency Plan for 
AIDS Relief (PEPFAR) was launched 
in 2003 to provide 15 billion USD in assistance to combat HIV/
AIDS over a five-year period in 
15 focus countries, of which 
12 were sub-Saharan African 
countries (including the Republic of South Africa). 
19 According to the demographic 
and health survey conducted in 
2005, the HIV prevalence rate in 
Ethiopia is 1,4 %. In Mali it is 1,9 %. 
20 Second progress report on 
the EC programme for action, 
SEC(2004) 1326 final of 26.10.2004. 
21 Four permanent officials, five 
local agents, seven contractual 
agents and two junior experts. 
22 In addition, five local agents 
(all full-time), seven contractual 
agents (three full-time, four part-
time) and two junior experts (both part-time) also worked on health.
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa18
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa 19.  Commission headquarters does not have sufficient expertise to provide 
adequate backup to the delegations in sub-Saharan Africa. In DG  
Development three officials (only one with a health background) and three detached national/multilateral experts work on health policy 
issues relating to all developing countries and programming issues 
in ACP countries. In EuropeAid there are just two health professionals responsible for providing support to all 41  delegations in sub-Saharan Africa.
 20.  One positive recent measure taken by the Commission to address the 
lack of health expertise at delegation level was the appointment  of a regional HIV/AIDS advisor for southern Africa based in its del-egation in Pretoria, but this is an isolated case. There is also scope for delegations to cooperate more in post-conflict countries with  ECHO’s regionally-based health advisers. Some delegations have also sought to draw on the health expertise of other donors, including EU Member States but such cooperation is still limited and generally not formalised, with the result that mandates given by the Commission to Member States are not adequately defined and do not ensure that the Commission retains its responsibility.
SPEED OF EC FUNDING TO THE HEALTH SECTOR
 21.  An important aspect of the Commission’s health policy since 2000 has 
been its commitment to accelerate assistance to the health sector, 
notably to combat poverty-related diseases (see paragraph 2). Predict-
ability of funding has also become a key issue if beneficiary countries 
are to improve budgeting and implementation of external aid. This section examines the disbursement rate of the different instruments 
and identifies factors affecting their speed and predictability.
EDF HEALTH SECTOR INTERVENTIONS
EDF assistance to the health sector has accelerated under 
the ninth EDF
 22.  The speed of implementation of ninth EDF health sector interventions 
in sub-Saharan Africa has significantly increased compared with the eighth EDF (see Table 4) . A major factor explaining the accelera-
tion in disbursements is devolution. According to the Court’s survey, 
77 % of delegations considered devolution had increased the speed 
of implementation of EDF projects.
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa19
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa 23.  Since the Commission allocates funds for the full period of its country 
strategy papers, this provides a good basis for predictable funding. 
However, the Court found that, despite devolution, the complex pro-
cedures for procuring inputs (works, services, supplies) and approving and implementing work programmes still reduce both the speed and 
the predictability of the flow of funding to EDF health interventions.
GENERAL BUDGET SUPPORT
Disbursement by the Commission is quick but predictability 
is an issue
 24.  Under both the eighth and ninth EDFs General Budget Support proved 
to be a fast-disbursing instrument as shown in Table 5 . The fact that 
programmes are generally for three years and indicative allocations are set out in country strategy papers for six years also contributes 
to their predictability.TABLE 4
COMPARISON OF PERCENTAGE OF EDF HEALTH INTERVENTIONS IN SUBSAHARAN 
AFRICA DISBURSED OVER FIRST FIVE YEARS OF EIGHTH AND NINTH EDFS 
Cumulative percentage of EDF health commitments disbursed 
during ﬁ  rst ﬁ  ve years of EDF
Eighth EDF Ninth EDF1
Year 1 0 % 0 %
Year 2 1 % 3 %
Year 3 3 % 13 %
Year 4 8 % 25 %
Year 5 18 % 39 %
1 Excluding transfers to Global Fund (see paragraph 26).
GENERAL BUDGET SUPPORT COMMITMENTS DISBURSED 
OVER FIRST FIVE YEARS OF EIGHTH AND NINTH EDFS 
Cumulative percentage of general budget support commitments 
disbursed during ﬁ  rst ﬁ  ve years of EDF
Eighth EDF Ninth EDF
Year 1 12 % 5 %
Year 2 22 % 18 %
Year 3 31 % 38 %
Year 4 55 % 57 %
Year 5 71 % 74 %TABLE 5
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa2020
 25.  However, the Court found that speed and predictability were reduced 
by:
delays in countries making eligible payment requests, mainly due (a) 
to their problems in collecting data for the performance indicators 
(e.g. Burundi, Kenya, Mali);some countries losing their eligibility for General Budget Support, (b) 
with the result that it is suspended, thus reducing assistance avail-able for health budgets. This was the case in four of the six coun-tries covered by the Court’s on-the-spot audit and desk reviews (Ethiopia, Kenya, Lesotho, Malawi) although the Court found that in Ethiopia the international community had found an effective alternative mechanism to ensure a continued flow of funds to the health and other key sectors (see Box 3). One advantage of using Sector Budget Support in parallel with General Budget Support is that, in some circumstances, the former can still be used when the latter has been suspended.
GLOBAL FUND
The Global Fund has disbursed a large volume of funds but the 
rate of disbursement has been slower than the EDF
  26.  One of the objectives of setting up the Global Fund was to establish a 
faster delivery mechanism (see paragraph 2). While the Commission’s 
contributions to the Global Fund, which began under the ninth EDF, 
have accelerated the speed with which the Commission disburses  overall EDF health commitments (see Table 6) , disbursement to the 
Global Fund is only the first step in channelling this assistance to the final beneficiary.
BOX 3
In Ethiopia, General Budget Support was suspended in 2005 because of the political situation. However, to ensure 
that external assistance to key services, including health, was maintained the international community put in place a 
new multisectoral ‘basic services protection programme’ providing support directly to regional authorities. Such an 
approach represents a means of reducing the risk that long term eﬀ  orts to improve health services may be disrupted 
by the suspension of General Budget Support.BUDGET SUPPORT TO ETHIOPIA
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa21
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan AfricaEFFECT OF GLOBAL FUND DISBURSEMENTS ON  RATE OF DISBURSEMENT 
OF EDF HEALTH COMMITMENTS 
Cumulative percentage of EDF health commitments disbursed 
during ﬁ  rst ﬁ  ve years of EDF
Eighth EDFNinth EDF Ninth EDF
(excluding Global 
Fund)(including Global 
Fund)
Year 1 0 % 0 % 22 %Year 2 1 % 3 % 24 %Year 3 3 % 13 % 31 %Year 4 8 % 25 % 46 %Year 5 18 % 39 % 55 %TABLE 6
 27.  In terms of increasing the overall volume of disbursements for combating 
HIV/AIDS, malaria and tuberculosis, the Global Fund has been effec-tive, its disbursements in sub-Saharan Africa amounting to 2 931 mil-
lion USD from 2002 to 2007. However, as Table 7  shows, the rate at 
which the Global Fund disburses in sub-Saharan African countries  
does not compare favourably with EDF health interventions. For the 
first round of grants launched in 2002, at the end of their five-year 
implementation period only 73 % of the budget had been disbursed. 
The Court’s analysis did not indicate an improvement in the disburse-ment rate of Global Fund grants approved in subsequent years.
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa22
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa 28.  Besides the Global Fund’s legitimate emphasis on performance-based 
funding, which means it reduces disbursements to less effective  
grants, two further factors affecting the rate of disbursement have been:
difficulties of some recipients of Global Fund support in estab- (a) 
lishing financial, procurement and monitoring systems of the  
standard required by the Global Fund and in quickly disbursing 
the funding; 
new funding sources such as PEPFAR entering countries dur- (b) 
ing Global Fund grant implementation, which has reduced their 
absorption capacity.
 29.  Unlike the EDF, Global Fund grants are approved on the basis of annual 
funding rounds. Countries do not know if their applications for fund-
ing will be approved and for what amount. Thus, over the first six  
years of the Global Fund only 39 % of grant applications submitted for financing were actually approved. TABLE 7
COMPARISON OF CUMULATIVE RATE OF DISBURSEMENT OF GLOBAL FUND 
AND EDF HEALTH INTERVENTIONS IN SUBSAHARAN AFRICA 
Global Fund EDF health interventions
Year 1 2 % 1 %Year 2 13 % 25 %Year 3 26 % 36 %
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa23
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa 30.  The Court examined the three main instruments used to improve health 
services: budget support, projects, and the Global Fund. This sec-
tion assesses both how well the Commission has managed them and how effective they have been and how coherently the Commission 
has used the instruments together. Annex III  contains an overview 
of interventions in the five countries visited by the Court.
BUDGET SUPPORT
THE USE OF BUDGET SUPPORT BY THE COMMISSION 
Budget support has the potential to play a key role in improving health services
 31.  Budget support has the potential to play a key role in improving health 
services by increasing funds available to governments for their  
health budgets, thus allowing them to scale up services, a necessary 
 prerequisite for achieving the MDGs. In addition, it can strengthen 
the policy and institutional framework through policy dialogue and 
technical assistance. The Commission, which is one of the biggest  providers of budget support, defines it as ‘the transfer of financial 
resources of an external financing agency to the national treasury  
of a partner country, following the respect by the latter of agreed  
conditions for payment’
23. Although it classifies budget support as 
General Budget Support or Sector Budget Support, in practice the  
distinction is less clear:
   ‘Budget support can best be described as a spectrum. At one extreme 
is General Budget Support with dialogue and conditions focused on macro and cross-sectoral issues. At the other extreme is Sector Budget Support focused only on sector specific issues. In between is General 
Budget Support with sector conditions and dialogue and those Sector Budget Support operations which include some macro and cross-
cutting conditions and dialogue’
24.
Sector Budget Support has been little used and the role 
of General Budget Support in improving health services has not been clear
 32.  Sector Budget Support, with its focus on one sector, has particular poten-
tial for assisting the health sector. However, although it has been  
Commission policy since 2000 to increase its use, in practice only two 
sub-Saharan African countries (Mozambique and Zambia) received  
health sector budget support under the ninth EDF. One reason for  this is that the Commission has generally only used health sector  
budget support in a country if it has health as a focal sector, which 
is the case in only a limited number of countries. A second reason is 
that one of the eligibility criteria is the existence of a well-defined 
health sector policy, which is still not the case in some countries.MANAGEMENT AND EFFECTIVENESS 
OF INSTRUMENTS
23 European Commission General 
Budget Support Guidelines 2007 
(Page 10). 
24 Note on Sector Budget Support 
from November 2005 Dublin 
Workshop of the Strategic 
Partnership for Africa, a group 
of bilateral and multilateral 
donors. 
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa24
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa 33.  General Budget Support has been used much more widely than Sector 
Budget Support by the Commission, 21 sub-Saharan African countries 
having received it under the ninth EDF. It has been the Commission’s preferred form of budgetary support and, in contrast to sector budget 
support, the Commission allows its use in addition to funding two  
focal sectors. Furthermore, more countries are eligible for General Budget Support since an overall national policy, rather than a spe-cific sectoral policy, is an eligibility requirement even though the  
effectiveness of national policy to a considerable degree depends  
on the strength of sectoral policies. While General Budget Support has a broader range of objectives than Sector Budget Support, it can 
also contribute to improving health services if its design includes a 
sectoral dimension (see paragraph 31). This has traditionally been  
the case in the Commission’s General Budget Support programmes 
since it has prioritised the health and education sectors and included health sector conditionality and provisions for health policy dialogue with governments.
 34.  The Court nevertheless found that views varied within the Commission 
services, particularly between macroeconomists and health profes-
sionals, as to how far General Budget Support should have a sectoral 
dimension. The Court’s survey indicated that most delegations per-ceived improving health services as a key objective of the instru-
ment (see Table 8 ). On the other hand, the revised 2007 General  
Budget Support manual considerably reduced the instrument’s sec-
toral dimension compared to the previous 2002 manual, lessening its 
focus on improving health services.
TABLE 8
DELEGATIONS’ PERCEPTION OF THE IMPORTANCE 
OF GENERAL BUDGET SUPPORT OBJECTIVES 
12345 N / O Average GBS objectives
1 1 1 7 18 2 4,43 Reducing poverty 1 0 1 10 16 2 4,43 Improving public ﬁ  nance management
1 1 3 11 12 2 4,14 Providing macroeconomic stability1 2 4 14 7 2 3,86 Harmonising aid procedures1 0 8 12 7 2 3,86 Increasing predictability of funding
1458 1 0 2 3,79 Improving health services
14689 2 3,71 Improving education services
3 5 0 9 10 3 3,67 Reducing aid transaction costs
(1 = Not important, 5 = Highly important, N/O = No opinion)
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa25
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan AfricaEFFECTIVENESS OF GENERAL BUDGET SUPPORT 
IN IMPROVING HEALTH SERVICES
 35.  It is widely recognised that it is very difficult to assess the effectiveness 
of General Budget Support. While a joint donor evaluation of Gen-
eral Budget Support issued in 2006 represented an important step in evaluating the instrument, it was not without its limitations and the Commission is still working to establish an appropriate evaluation  
methodology. In its assessment of the instrument’s effectiveness the 
Court focused on the following aspects
25:
whether the financial inputs provided were associated with  (a) 
increased allocations to and disbursements from national health 
budgets and whether the inputs were likely to be used for the  
intended purpose; whether the policy and institutional framework in the health sec- (b) 
tor was conducive to the effective delivery of services;whether delegations were involved in health sector policy dia- (c) 
logues which would contribute to the more effective use of Gen-
eral Budget Support; 
whether health performance indicator targets selected as part  (d) 
of the General Budget Support conditionality were achieved and appropriate.
Financial inputs: in most countries examined General Budget 
Support has not been associated with an increase in health 
budgetary resources 
 36.  The Court found that in most countries examined General Budget Support 
did not lead to increased resources being channelled through the  national health budget (see Box 4). One important reason for this is that in some cases beneficiary countries decide not to increase budg-
etary expenditures in a given fiscal year by the same amount as the 
budgetary support received but instead use the funds to reduce their fiscal deficits (see paragraph 12(b)). Moreover, the Commission has 
not systematically sought to encourage countries to increase national 
health budgets through the use of performance indicators targeting 
such increases in its General Budget Support financing agreements. Thus in only five of the 12 countries examined were health budget allocations included as a performance indicator.25 The Court’s assessment is based 
primarily on General Budget 
Support programmes in Burundi, 
Ethiopia, Kenya, Lesotho, Malawi 
and Mali. It also takes into account 
relevant audit work carried out in 
other countries in the framework of its statement of assurance on 
the EDF In particular relating to 
Ghana, Guinea Bissau, Madagascar, 
Mozambique, Niger and Sierra 
Leone. 
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa26
GENERAL BUDGET SUPPORT AND ITS EFFECT ON HEALTH BUDGETSBOX 4
In Burundi, while the health development national plan for 2006–10 foresaw an increase in the national budget allo-
cated to health from 3,6 % to 15 % in 2010, the budget allocations for health in 2007 decreased to only 2 %.
In Ethiopia, health budget allocations and expenditure remained low for the period reviewed (2002–07) leaving 
health services seriously underfunded. While PRBS 2 targeted an increase in the health budget from 6,8 % in 2003 to 
7,3 % in 2004, in fact health’s share of the budget actually fell to 6,5 %. Although, overall, poverty-related recurrent 
expenditure in Ethiopia increased signiﬁ  cantly aft  er 2000, this was not the case for health, its share of such expenditure 
being only 15 %. 
In Mali, while the ﬁ  nancing agreement for General Budget Support required the share of health in the national recur-
rent budget to increase from 10,5 % to 11,5 % over the period 2002–05, it did not do so and in 2005 fell to 10,2 %.
In Kenya, the health budget allocation increased to 9 % in 2005–06 compared to 7 %–7,5 % in previous years, but 
expenditure in 2005–06 was just 5,7 % having declined each year since 2001–02 when it was 9 % of total government 
expenditure.
In Malawi, for the ﬁ  rst two years (2005–07) following the resumption of General Budget Support, the government 
prioritised paying oﬀ   internal debt and the health budget was only maintained at a level of 10,7 %, lower than in some 
previous years. However, a signiﬁ  cant increase in the budget was planned for 2007–08.
In Lesotho, health expenditure was maintained at previous levels despite the growing health crisis.The Commission’s ‘dynamic interpretation’ of eligibility 
for General Budget Support puts at risk the effective use 
of funding for improving health services 
 37.  The effectiveness of General Budget Support in improving health serv-
ices depends not only on how much is channelled to health spending but also on the soundness of public financial management systems covering its use. As a result of what the Commission terms a ‘dynamic 
interpretation’ of eligibility, although sub-Saharan African countries 
generally have weak public finance management capacity, they may still be eligible for General Budget Support, leading to a high risk  
of inefficient and ineffective public spending. Funds channelled to 
the health sector are at particular risk since resource flows to front-
line service providers are complex, generally passing through sev-
eral administrative layers. The Court found that public expenditure tracking surveys or audits tracking public expenditure, although sel-dom used, have identified public resource leakages on a significant scale in relation to non-wage health expenditures which could have 
serious consequences for health service delivery
26. In addition, drug 
procurement through central medical stores is widely recognised to 
be a high-risk area.26 See, for example, ‘Public 
expenditure tracking surveys — 
quantitative service delivery 
surveys in sub-Saharan Africa: 
a stocktaking study’. Bernard 
Gauthier. HEC Montreal. September 2006, commissioned by 
the World Bank. 
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa27
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa 38.  General Budget Support programmes have not adequately addressed 
these risks. The 2002 General Budget Support manual foresaw finan-
cial audits and compliance tests, particularly in the social sectors,  during the course of programme implementation, in addition to the 
initial appraisal of the quality of public finance management. Such 
controls are particularly necessary where the capacity of national  supreme audit Institutions is low, as is generally the case. However, in practice controls of this kind were not carried out and the Commis-
sion dropped the requirement to perform them from its 2007 manual. 
This states that once the Commission has transferred resources to  the national treasury, it will not follow up on how they are used. This 
is in contrast to the Commission’s policy for Sector Budget Support 
to examine the use of inputs much more closely ‘paying attention to 
the results chain from ‘inputs’ to ‘outputs’ to ‘results/outcomes’
27. 
The Court shares the view of the European Parliament that this is  another advantage of Sector Budget Support in terms of its potential effectiveness compared with General Budget Support
28.
Insufficient attention has been paid to strengthening the 
policy and institutional framework when using General Budget 
Support to improve health services 
 39.  The Court found that in two countries visited, Malawi and Mali, the 
effectiveness of General Budget Support channelled to the health  
sector was likely to be increased by the existence of a sound health 
sector policy which was supported by donors through a sector-wide 
approach (SWAp). However, according to the audit survey, in approxi-
mately half of the countries which had received General Budget Sup-
port under the ninth EDF or were programmed to receive it under the 10th EDF, a health SWAp had not yet been established. This points to 
the insufficient attention given by the Commission to the importance of ensuring SWAps are established in order to make General Budget Support effective in improving health services.
 40.  Ministries of health tend to be among the weaker ministries, particularly 
at regional and district levels, to which extensive decentralisation has taken place in some countries. This limited institutional capacity is 
a constraint on both the development and implementation of sound health policies. It has been Commission policy to provide technical assistance to strengthen priority sectoral ministries as well as minis-tries of finance, approximately 10 % of General Budget Support fund-
ing being reserved for this purpose
29. However, in the 12 countries 
with General Budget Support examined by the Court, in only one case 
(Niger) were funds allocated for specific technical assistance to the 
Ministry of Health. The 2007 General Budget Support manual no longer 
foresees the use of technical assistance to sectoral ministries.27 European Commission support 
to sector programmes guidelines, 
July 2007. 
28 European Parliament 
resolution of 22 April 2008 
with observations forming an 
integral part of the decision 
on discharge in respect of the 
implementation of the European Union general budget for the 
financial year 2006, Section III — 
Commission, point 225. 
29 ‘Community support for 
economic reform programmes and 
structural adjustment: review and prospects’. COM(2000) 58 final. 
Brussels 4.2.2000.
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa28
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan AfricaThe Commission has not taken full advantage 
of the opportunities for health sector dialogue to improve 
the effectiveness of General Budget Support
 41.  One of the potential advantages of budget support is the opportunity it 
provides to improve effectiveness through policy dialogue between 
donors and beneficiary governments. While, according to the Court’s survey, the great majority of delegations directly participated in a health sector dialogue, the Court found weaknesses in the quality  and depth of this dialogue:
the limited health expertise in delegations (see paragraph 18) is (a) 
not conducive to contributing to high-quality dialogue. The Com-
mission has sought to find economic expertise to work on General 
Budget Support but has not formed wider teams for such pro-grammes which would also include health (and education) experts. 
While representation by other donors may, in some circumstances, 
be used, this was only the case in two delegations and was not 
covered by a formal written mandate (see paragraph 20);
it is unclear what depth of sectoral dialogue delegations are  (b) 
expected to go into in the context of General Budget Support  
(see paragraph 34);discussions on the achievement of performance indicator targets (c) 
are intended to be a means for establishing a wider health sector 
dialogue, but the Court found that there was a tendency for the 
dialogue to be overly focused on the specific indicators, rather 
than wider health issues, as well as on the amount of the variable tranche to be paid for each indicator rather than on the under-lying factors affecting performance.
Only half of the performance indicator targets were met and there are weaknesses in the mechanisms for their use
 42.  A commendable part of Commission policy on General Budget Support 
since 2000 has been the focus on results. Thus approximately 30 % 
of General Budget Support is disbursed through so-called variable-
tranche payments depending on the achievement of targets for per-
formance indicators. The indicators have increasingly been selected 
from beneficiary governments’ poverty reduction strategy papers to 
improve their relevance and national ownership. The need to meas-
ure results has also led to significant efforts to strengthen national statistical systems. 
 43.  The Court examined how far the health sector performance indicator 
targets contained in the Commission’s financing agreements had  
been achieved. It found that overall only 50 % of the health indi-cator targets had been met. This raises issues about the effective-
ness of General Budget Support programmes in helping bring about 
improvements in health services.
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa29
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa 44.  The Court found several factors concerning the way health performance 
indicators were used which also reduced the effectiveness of Gen-
eral Budget Support in contributing to improvements in health  services.
The incentive value of performance targets may be reduced both (a) 
because of the relatively small amounts attached to each indicator and the Commission’s policy of making unspent funds available for other EDF assistance to the country, in cases where variable tranches have not been disbursed because targets had not been 
met.
Governments also had less incentive, and the link to General  (b) 
Budget Support was reduced, when indicators were selected over 
which governments did not have sufficient control.
Data used were often not reliable so that it was sometimes difficult (c) 
to be sure whether a target had been achieved or not, particularly 
when indicators were measured over relatively short 12-month  
periods, which meant changes were sometimes hard to detect.
Targets set were sometimes under- or overambitious. (d) 
Indicators did not sufficiently address qualitative aspects  (e) 
of healthcare.
 45.  The Court also examined whether General Budget Support had been spe-
cifically effective in improving health services for the poorer sections 
of the population. Analysis by the WHO of health policies contained 
in poverty reduction strategy papers has shown the generally limited 
poverty focus of national health policies. This view was also confirmed by the wider evidence gathered by the Court, which showed the high concentration of health personnel and health services in urban areas. Moreover, the Commission’s health performance indicators rarely  
included a poverty dimension, which would have focused improve-
ments in health services on poorer sections of the population and/
or poorer regions of the country.
 46.  The Court’s survey asked delegations how they perceived the effective-
ness of General Budget Support in improving health services and in 
meeting other objectives. Their replies confirmed the Court’s con-
cerns about the effectiveness of General Budget Support, as currently 
implemented, in improving health services. On a scale of 1 (low)  
to 5 (high), Delegations rated its effectiveness in improving health 
services at only 2,77, the lowest effectiveness rating of eight General Budget Support objectives (see Table 9 ).
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa30
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan AfricaSUBSAHARAN EC DELEGATIONS’ PERCEPTION OF THE EFFECTIVENESS 
OF GENERAL BUDGET SUPPORT IN IMPROVING HEALTH SERVICES 
12345 N / O Average GBS objectives
11589 5 3,96 Providing macroeconomic stability
0 0 6 15 3 5 3,88 Improving public ﬁ  nance management
1 1 5 13 5 4 3,80 Harmonising aid procedures2 1 6 10 5 5 3,63 Reducing aid transaction costs15793 4 3,32 Increasing predictability of funding
17662 7 3,05 Reducing poverty 
17842 7 2,95 Improving education services
38452 7 2,77 Improving health services
(1 = Not important, 5 = Highly important, N/O = No opinion)TABLE 9
PROJECTS
 47.  The project has traditionally been the main instrument used by the Com-
mission for implementing its development assistance. However, since 
2000, the Commission has made Budget Support its preferred form 
of aid implementation. This has led the Commission to adopt a posi-
tion in its aid manuals where the project is de facto to be used as an 
instrument of ‘last resort’, when other instruments are not feasible. The Court examined a sample of projects to assess their effectiveness in terms of whether they had met, or were likely to meet, their objectives. The effectiveness of projects was classified as ‘satisfactory’ where they 
have been, or are likely to be, successful in reaching their objectives, 
‘partially satisfactory’ where they have experienced some problems 
and have achieved only part of their objectives and ‘unsatisfactory’ 
where they have experienced significant problems and have achieved, or are likely to achieve, few of the planned objectives.  Annex III  briefly 
presents the projects examined during the on-the-spot missions while 
Annex IV  contains the full list of projects covered by the audit.
EDF PROJECTS
Overall EDF projects have been reasonably effective but 
in most cases their sustainability is in doubt
 48.  EDF projects can combine the provision of technical assistance, infrastruc-
ture and equipment. The Court reviewed the effectiveness of 12 EDF 
health projects in 12 countries. Project effectiveness was assessed as 
satisfactory or partially satisfactory in two thirds of the countries despite 
the relatively complex nature of health sector interventions. The Court’s assessment of the effectiveness of EDF projects largely corresponded 
to the view Commission delegations. In the Court’ survey, delegations ranked their effectiveness at 3,11 on a scale of 1 (low) to 5 (high). Posi-tive features of EDF projects were their contribution to improving the 
quality of policies and service delivery. On the other hand, the projects 
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa31
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africaexamined by the Court in most cases did not specifically target the 
poorer sections of the population, although they had the potential to 
have an impact at regional and district level. For most projects the prospects for their sustainability were also not good.
 49.  The main factors negatively affecting the performance of EDF health 
projects identified by the Court’s audit, some of which are common to EDF projects in other sectors, are set out below.
Projects tended to be too ambitious, particularly in post-conflict (a) 
situations, both because of the wide range of activities and geo-
graphical coverage of some projects and because too much was 
expected of what projects could achieve without the support  
of other instruments. 
The project implementation timeframe was generally too short, (b) 
firstly because of long procurement and approval processes  
(see paragraph 23), and secondly because time was required for 
changes introduced by the projects to take hold in beneficiary  
organisations and become sustainable.
The quality of the technical assistance contracted for these projects var- (c) 
ied greatly and this had a considerable influence on project results.
Capacity both to deliver health services and work with EDF projects (d) 
also varied, especially at provincial and district level. 
The lack of a sound country health policy reduced project effective- (e) 
ness, and particularly the prospects for achieving sustainability.
Delegations often did not have the health expertise and, more  (f) 
generally, were frequently under too much pressure to ensure the level of supervision required to maximise the project’s prospects of success.
INTRAACP PROJECTS
Complex design and implementation arrangements make intra-ACP projects less effective than other types of projects
 50.  Each intra-ACP project covers a range of countries in different regions 
of sub-Saharan Africa, and under the ninth EDF they were most fre-
quently being implemented through United Nations agencies. Of the 
five projects audited, in one case effectiveness was assessed as sat-
isfactory, in two cases as partially satisfactory and in two cases as  
unsatisfactory. Factors in the management of this type of project  which led to their generally modest performance included:
the design of the projects, which generally involved a large number (a) 
of countries each receiving relatively small allocations for a sub-
stantial number of activities. This reduced their potential impact;the low involvement of Commission delegations in these centrally (b) 
managed projects and the difficulty Commission headquarters  
had in adequately monitoring projects which frequently cover  
numerous countries;difficulties in agreeing planning and reporting modalities between (c) 
the Commission and UN bodies and subsequent problems for the 
UN bodies in complying with these modalities.
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa32
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan AfricaGENERAL BUDGET LINE HEALTH PROJECTS
General budget line projects have mainly been effective, 
with the exception of centrally managed projects, but sustainability is often in doubt
 51.  General budget line health projects are mainly implemented through NGOs 
and other non-State actors. The Court examined nine such projects 
in Kenya, Malawi and Mali. The effectiveness of three projects was  
assessed as satisfactory and of the other six as partially satisfactory. Commission delegations also had a relatively positive view of such 
projects since in the Court’s survey they ranked their effectiveness at 
3,52 on a scale from 1 (low) to 5 (high). Four NGO co-financing projects 
in Lesotho, Malawi, Mali and Swaziland that were also examined were 
found to be similarly effective: in one case project effectiveness was considered to be satisfactory, while in the other three cases it was 
partially satisfactory. 
 52.  Particularly positive aspects of these types of project were:
they were targeted on poverty-related issues and often provided (a) 
basic services in remoter areas where government services were less present;
in sensitive areas such as HIV/AIDS many people, particularly  (b) 
youth, preferred to be assisted by NGOs rather than visit govern-
ment health services;
these projects were easier than larger EDF projects for the Com- (c) 
mission to supervise, and hence less prone to delay, since all  project activities came under one NGO contract;the projects provided high visibility for relatively low funding. (d) 
 53.  In general, as noted in a recent evaluation of the health budget lines30, the 
weak point of such projects is their sustainability and wider impact 
because:
although the regulations governing the health general budget  (a) 
lines were intended to promote innovative projects, the fact that 
Commission procedures do not foresee the involvement of national 
health officials meant that projects were less likely to be taken 
up into national policies;
the Commission has not established a system to ensure that  (b) 
the lessons learned from successful projects are systematically  disseminated;although successful projects could have been scaled up using EDF financ- (c) 
ing, this relied on health being selected as a focal sector and delegations 
and national officials being well-informed on the project at the time of programming, none of which has generally been the case.
 54.  A further concern is that while the projects themselves have a poverty 
focus, the award of projects does not adequately take into account the poverty levels of different countries. The NGO co-financing regu-
lation has increasingly sought to address this issue by reducing the 
number of eligible countries. 30 Appraisal of the two legal bases 
on health, AIDS and population, 
Ecorys Research and Consulting, 
November 2006. 
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa3333
 55.  The Court also examined five centrally managed health general budget 
line projects. Each of these projects covered at least two, and gener-
ally several, countries and the countries did not border each other. As for intra-ACP projects, they were assessed as performing less well 
than projects carried out in a single country. The projects suffered 
from both the difficulty NGOs had in implementing often complex  
projects across several countries in different regions and the difficulty the Commission headquarters had in monitoring these projects.
GLOBAL FUND
THE COMMISSION’S MANAGEMENT OF ITS SUPPORT 
TO THE GLOBAL FUND 
The Commission played an important role in the setting up 
of the Global Fund but has done little to support 
or monitor it at country level
 56.  In the framework of its ‘accelerated action’ policy (see paragraph 2), the 
Commission has made a significant contribution to the establishment of the Global Fund. It is represented on the Board and is consequently 
in a position to influence the overall principles according to which 
it operates (see Box 5). The Global Fund has quickly become a major 
player in tackling HIV/AIDS, tuberculosis and malaria and by 2007 it 
had approved grants of 8 947 million USD for 136 countries, of which almost 60 % has been for sub-Saharan Africa.
GLOBAL FUND OPERATING PRINCIPLESBOX 5
Operate as a ﬁ  nancial instrument, not an implementing entity. • 
Make available and leverage additional ﬁ  nancial resources. • 
Support programmes that reﬂ  ect national ownership. • 
Operate in a balanced way in terms of diﬀ  erent regions, diseases and interventions. • 
Pursue an integrated and balanced approach to prevention and treatment.• 
Evaluate proposals through independent review processes.• 
Establish a simplified, rapid and innovative grant-making process and operate transparently, with • 
accountability.
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Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa 57.  Over the period 2001–07, the Commission disbursed a total of 622,5 mil-
lion euro to the Global Fund from the EDF intra-ACP funds (330 mil-
lion euro) and the health general budget lines (292,5 million euro). This represented 8,1 % of total contributions to the Global Fund,  
making the Commission the fourth biggest contributor. However, a 
recent evaluation of the management of the Global Fund has noted that the Global Fund may experience difficulties in absorbing the  increased contributions pledged by donors
31. This reflects both the 
lack of capacity of some countries to translate their need for assist-
ance into grant proposals of an acceptable standard and also their subsequent inability to disburse grants received. 
 58.  The significant role played by the Commission headquarters in the set-
ting up of the Global Fund, as well as the considerable resources it 
has allocated to it, are in contrast to the limited role played in rela-tion to the Global Fund by most Commission delegations. Guidance notes issued by Commission headquarters did not instruct but only ‘encouraged’ delegations to support Global Fund operations. In none 
of the three main areas earmarked by Commission headquarters for 
delegations’ involvement have they played an active role:
 (a) actively participating in Global Fund country coordinating mecha-
nisms (CCM) and help strengthen them : according to the Court’s  
survey, only 35 % of delegations participate in the CCMs. The most 
common reasons given for not attending were insufficient staff 
in the delegations and the fact that the health sector was not a 
focal sector for the Commission; (b) reporting on aspects of the Global Fund functioning in country : 
according to the Court’s survey, just 8 % of delegations reported regularly to Commission headquarters, 59 % reported occasion-ally while one third had never reported. While the Commission  is on the Global Fund board, its lack of feedback on Global Fund operations from delegations has reduced its capacity to act at this 
level to improve the effectiveness of operations; (c) providing technical assistance for developing grant proposals  
and assisting implementation:  in the face of the lack of capacity 
of national bodies to draw up grant proposals and then implement 
them (see paragraph 57), the Global Fund has particularly stressed the need for the international community to provide technical  assistance in sub-Saharan Africa to address this problem, but the Commission has not responded to this need.31 Evaluation of the organisational 
effectiveness and efficiency 
of the Global Fund to fight AIDS, tuberculosis and malaria’. 
October 2007 (Macro Consultancy). 
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Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan AfricaTABLE 10
GLOBAL FUND PERFORMANCE INDICATORS 
FOR ITS THREE SUBSAHARAN AFRICAN REGIONS AT 31 DECEMBER 2007 
HIV/AIDS% 
of targetActivities
Anti-retroviral therapy 93 % 1 100 000 people on ARV therapy
HIV counselling and testing 101 % 16 million people reached
Prevention of mother to child 
transmission (PMTCT)64 %100 000 HIV positive pregnant received a 
full course of prevention of mother-to-child transmission
Support to orphans 116 %2 million orphans provided with care and 
support
TuberculosisDOTS treatment 86 % 800 000 people on treatmentMalariaInsecticide treated nets (ITN) 63 % 35 million nets distributedAnti-malarial treatment (ACT) 43 % 37 million malaria treatments deliveredOther indicators
Care and support 107 % 1,7 million people received care and support
People trained 105 % 1,8 million people trained to deliver services
Source : Global Fund.EFFECTIVENESS OF THE GLOBAL FUND 
The Global Fund has made a significant contribution to tackling 
HIV/AIDS, malaria and tuberculosis but it depends on 
complementary long-term health system support from donors 
to become more effective
 59.  One key measure of the effectiveness of the Global Fund is the output 
indicators used by the Global Fund to cover what it terms ‘Global Fund 
supported-programmes’.These indicators include outputs not only  from programmes financed solely by the Global Fund but also from 
programmes which the Global Fund co-finances along with national 
governments and other external assistance. This makes it difficult to 
determine what outputs can be specifically attributable to the Global 
Fund
32. Nevertheless, it is clear that the Global Fund has made a major 
contribution to the outputs set out in Table 10 . In the five countries 
visited, the Court noted in particular the Global Fund’s contribution to scaling up anti-retroviral (ARV) therapy and HIV/counselling and testing, but prevention of mother to child transmission (PMTCT) was proving difficult because of staffing shortages and cultural issues. Some malaria grants experienced procurement delays for ITNs and ACTs. More details of Global Fund interventions examined by the  audit are given in Annex III .32 Similarly it is difficult to 
determine from the grant 
performance reports on the Global Fund website for each grant 
financed what is the Global Fund 
contribution’s specific contribution 
to the outputs reported. 
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa36
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa 60.  The Global Fund has been faced with the issue of whether it should fol-
low a narrow interpretation of its mandate and focus exclusively on 
the three diseases or take a broader view and also provide funding for health systems support. In 2007 the Global Fund established a new 
policy position by which it would ‘provide funding for health systems 
strengthening within the overall framework of funding technically sound proposals focused on the three diseases’
33. However, it is not yet clear 
how this concept will be implemented in practice, given the difficulty of isolating specific parts of health systems. The Global Fund has, how-ever, emphasised that the main support for health system strengthening should come from other donors: ‘There is an urgent need for their strate-gies to prioritise substantial long-term health system and infrastructure strengthening with additional finance’
34. Such finance is important both 
to achieve a better balance between health systems and disease-specific 
interventions and to make Global Fund support more effective since weaker health systems can be a bottleneck which reduces countries’ absorption capacity for Global Fund grants.
 61.  The fact that the Global Fund’s mandate is to tackle the three diseases 
means that the amount of support it provides to specific countries 
reflects more the disease burden in these areas than the overall  
income poverty levels in the country. That said, the Global Fund has had a poverty focus within countries. Particularly through its exten-
sive use of community-based organisations, it has sought to intervene 
in the poorer regions of countries which are less well-covered by  
government health services. 
 62.  The role of the Global Fund in health system strengthening and poverty 
reduction are issues which have not received adequate attention from the Commission, at either board or country level. This reflects the  
limited overall involvement of delegations in Global Fund operations and the insufficient priority Commission headquarters has given to ensuring delegations’ involvement (see paragraph 58).
COHERENT USE OF INSTRUMENTS AND INTEGRATION 
IN SECTORWIDE APPROACHES
 63.  The Commission’s overall health policy gave budget support a leading 
role in its strategy for assisting the health sector but stressed too  the continuing relevance of other instruments. It also underlined the importance of there being a sound national health policy framework and of working within it:
  ‘Budget support, social sector support, programme and project support 
can be complementary as long as they support a nationally defined 
policy framework. Where budget support is not appropriate, Commu-nity funding will support programmes and projects within the context 
of a national framework and will focus on capacity building. Where 
a national framework is not in place, the Community will facilitate 
the evolution towards a sector-wide approach. In most developing 
countries, the Community will, during a period of capacity and con-
fidence building, maintain a mixed portfolio’
35. 33 Minutes of November 2007 board 
meeting of the Global Fund. 
34 Global Fund ‘Partners in 
impact — Results report 2007’. 
35 Communication from the 
Commission to the Council and the 
European Parliament: ‘Health and 
poverty reduction in developing countries’, COM(2002) 129 final of 
22.3.2002.
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BOX 6
LINKS BETWEEN EDF HEALTH PROJECTS AND GENERAL BUDGET SUPPORT
Th e Court found that in Mali the eighth EDF health sector support project (PASS) increased the eﬀ  ectiveness of General 
Budget Support by strengthening Ministry of Health capacity even if the PASS project was not speciﬁ  cally designed 
to complement General Budget Support. On the other hand, a lack of coordination between the two instruments 
led to the Commission not extending an eighth EDF project in Lesotho on health management information systems 
although weaknesses in health data were one reason for stopping General Budget Support to Lesotho under the eighth and ninth EDF.COHERENT MANAGEMENT OF INSTRUMENTS 
BY THE COMMISSION
The Commission has not developed guidance for coherently 
managing the different instruments in the health sector
 64.  The Commission has not developed guidance on when it would be more 
appropriate to use General Budget Support or Sector Budget Support, or a combination of the two, to respond most effectively to the situ-ation of a given country. While the Commission’s manual on Sector Budget Support does point to the benefits of using General Budget Support and Sector Budget Support in combination, the very limited number of health Sector Budget Support programmes financed by  the Commission in sub-Saharan Africa has reduced the effectiveness of its General Budget Support (see paragraphs 36 to 46).
 65.  Guidance is also lacking as to how projects at sectoral level can be linked 
to General Budget Support to make Commission interventions more 
effective. The Court found cases where EDF projects had strengthened 
General Budget Support programmes, even if the two interventions 
had not been coordinated, and also cases where improved coordina-
tion with EDF projects would have benefited General Budget Support interventions (see Box 6).
 66.  The 2002 health policy, while emphasising the complementary role of dif-
ferent instruments, does not actually make reference to the links  
between the Global Fund and the instruments managed by the Com-
mission. The Court found that the lack of involvement of delegations 
in Global Fund operations (see paragraph 58) had led to the Com-mission continuing to finance EDF projects in the area of HIV/AIDS. 
Leaving the Global Fund to finance such projects would have allowed the Commission to allocate its support to wider health system issues which lay outside the mandate of the Global Fund.
 67.  The Commission’s General Budget Support and the Global Fund have 
certain areas of common interest, notably the use of health sector per-
formance indicators and improving related monitoring and evaluation 
systems, but also in relation to financial and procurement systems. However, the General Budget Support instrument has not worked  with the Global Fund in these areas and its financing agreements do not generally make reference to the Global Fund. 
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa38
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan AfricaINTEGRATION OF INTERVENTIONS INTO SECTORWIDE 
APPROACHES 
Integration of Commission interventions into SWAps 
is a key factor for their effectiveness but the Commission 
has not sufficiently supported SWAps 
 68.  A major factor in deciding which combination of instruments will best 
suit a particular country is whether it has a well-defined sector policy. 
The Court’s survey found that the situation varied considerably from country to country: 10 countries already had SWAps, 10 countries  
were preparing SWAps, while in 14 countries delegations found health 
policies to be inadequate. 
  69.  Despite the importance of SWAps in improving the effectiveness of Gen-
eral Budget Support (see paragraph 39) and as one of the eligibility criteria for Sector Budget Support (see paragraph 32), the Commission 
has not prioritised assisting in their preparation. Thus, according to 
the Court’s survey, in only eight delegations (22 %) had ninth EDF  
technical assistance projects been used to contribute to the prepara-
tion of a health SWAp. 
 70.  While countries with a health SWAp are still a minority, the number has 
grown since 2000. Thus there are more opportunities for providing 
sector budget support in the framework of SWAps under the 10th EDF 
than under the ninth EDF, but this has not led to a significant increase 
in Sector Budget Support being programmed for this period. 
 71.  A key concern with the project approach is projects’ sustainability (see 
paragraphs 48 and 53). Given that this is dependent on their inte-gration into well-defined and adequately financed sectoral policies, this also points to the need for the Commission to prioritise capac-
ity building projects through the EDF in order to help establish such 
policies.
 72.  A major challenge in relation to the Global Fund is to align its procedures, 
particulary for performance-based funding, with national procedures. 
At the end of 2007, the Global Fund was participating in health SWAps in just two countries, Malawi and Mozambique but its 2007 strat-egy signalled its intention to engage more in such funding where  adequate national health strategies exist. The frequency with which 
this approach can be followed depends on how ‘adequate’ is defined 
and the support given by the international community, including the 
Commission, to help countries develop such strategies. 
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa39
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan AfricaCONCLUSIONS 
AND RECOMMENDATIONS
RESOURCES
THE LEVEL AND BALANCE OF FINANCIAL RESOURCES 
ALLOCATED TO THE HEALTH SECTOR DO NOT ADEQUATELY 
REFLECT THE COMMISSION’S POLICY COMMITMENTS, 
WHILE HEALTH EXPERTISE IS INSUFFICIENT
 73.  Financial allocations to the health sector in sub-Saharan Africa have not 
increased since 2000 as a proportion of its total development assist-
ance despite the Commission’s MDG commitments and the health  crisis in sub-Saharan Africa. They also fall short of the European Par-
liament’s benchmark of allocating 20 % to basic health and primary 
and secondary education in country programmes. 
 74.  The Commission has mobilised significant additional funding to con-
tribute to the Global Fund against AIDS, tuberculosis and malaria.  However, the Commission has focused on tackling these three dis-
eases rather than on support to health systems, which is its policy 
priority. 
 75.  The Commission does not have sufficient health expertise to adequately 
implement its health policy and has not made systematic arrange-ments to draw on alternative sources of expertise. 
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa40
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan AfricaRECOMMENDATIONS ON RESOURCE ALLOCATIONS
No 1 : In the context of its policy of supporting the achievement of the 
Millennium Development Goals, the Commission should consider  
increasing its support to the health sector during the 10th EDF mid-
term review, particularly in:
(a)  fragile States, as the Commission is considered to have a com-
parative advantage in these countries;
(b)  countries where ECHO has had operations in order to strengthen 
the link between the relief phase and rehabilitation and develop-ment (LRRD) in these countries;
(c)  countries which have been found to be health donor orphans.
No 2 : The Commission should review the balance of its funding to  
ensure that this reflects its policy priority of focusing on health system 
support.
No 3 : The Commission should ensure it has sufficient health expertise 
to adequately implement its health sector policies and interventions 
and play an effective role in health sector dialogue. To this end it  
should, as a minimum, ensure that all delegations where health is a focal sector have health specialists. It should assess how far the fol-
lowing options are feasible for ensuring adequate support to other  
delegations:
(a)  establishing health expertise in regional delegations to support 
delegations without health specialists;
(b)  working more closely in post-conflict countries with ECHO health 
advisers;
(c)  forming closer partnerships with World Health Organisation  
country offices to draw on their expertise;
(d)  entering into formal agreements with EU Member States to use 
their expertise, such agreements to be based on a mandate which ensures the Commission retains responsibility and clearly defines 
the operating modalities.
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa41
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan AfricaTHERE HAS BEEN AN INCREASE IN THE SPEED 
OF IMPLEMENTATION OF EDF HEALTH RESOURCES. 
THE GLOBAL FUND HAS DISBURSED LARGE AMOUNTS BUT ITS DISBURSEMENT RATE IS RELATIVELY SLOW. 
THE PREDICTABILITY OF AID FLOWS REMAINS A CHALLENGE 
FOR ALL INSTRUMENTS
 76.  There has been a significant improvement in the implementation rate 
for EDF interventions, at least partly because of devolution.
 77.  The Global Fund has succeeded in disbursing a large volume of funds 
but the actual rate of disbursement has been relatively slow mainly 
because of low absorption capacity in most beneficiary countries.
 78.  Predictability of funding remains a problem of all instruments, includ-
ing General Budget Support because countries whose eligibility for this instrument is suspended have less resources available for their 
health budgets.
RECOMMENDATIONS ON SPEED AND PREDICTABILITY
No 4: The Commission should work more closely with the Global  
Fund to accelerate the implementation of its programmes by provid-
ing technical assistance support to beneficiary countries, both in the 
preparation of grant applications and in the implementation of grant contracts.
No 5:  The Commission should make its budget support for health more 
predictable by ensuring that it is prepared to intervene with alternative 
instruments in cases where countries lose their eligibility for budget 
support.
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Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan AfricaMANAGEMENT AND EFFECTIVENESS OF INSTRUMENTS
BUDGET SUPPORT HAS NOT YET MADE AN EFFECTIVE 
CONTRIBUTION TO IMPROVING HEALTH SERVICES, PROJECTS 
CAN PLAY AN IMPORTANT ROLE IN SUPPORTING THE HEALTH 
SECTOR, WHILE THE GLOBAL FUND HAS PROVIDED SIGNIFICANT OUTPUTS
 79.  While the current design of General Budget Support includes links to the 
health sector, its implementation has not sufficiently exploited these links. Thus, while it has the potential to be an important instrument 
for improving health services, it is not at present proving effective 
for this purpose and has not focused on addressing the needs of the 
poorer sections of the population. Sector Budget Support, which  
focuses on the health sector, has been little used by the Commis-sion in sub-Saharan Africa.
 80.  Although weaknesses exist with the project instrument, notably in rela-
tion to sustainability, projects have made a useful contribution to  
assisting the health sector. Generally, the more problematic projects 
have been those which cover a number of countries, because of the 
management difficulties this entails.
 81.  The Global Fund has made a significant contribution to the fight against 
AIDS, tuberculosis and malaria. However, despite the Commission’s 
important role in the creation of the Global Fund, it has done little 
to contribute to its effectiveness at country level.
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Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan AfricaRECOMMENDATIONS ON MANAGEMENT  
AND EFFECTIVENESS OF INSTRUMENTS
No 6:  Greater use should be made of Sector Budget Support. The gen-
eral requirement that it can only be used if health is a focal sector  should be reviewed and the Commission should reconsider its current distribution of resources between Sector Budget Support and General Budget Support.
No 7:  The sectoral dimension of General Budget Support should be  
strengthened by:
(a)  using performance indicators and health sector dialogue to  
encourage countries to respect their commitment to move  
towards allocating 15 % of their national budget to health and 
to fully implement their national health budget;
(b)  carrying out operational and financial reviews to establish  
whether health budget resources are being used for their  
intended purpose;
(c)  financing technical assistance with budget support to strengthen 
health sector policy, institutional capacity in the health sector, 
and address specific public finance management and procure-ment weaknesses in the health sector;
(d)  improving the quality of input into the health sector dialogue 
by increasing the level of health expertise in the Commission  
services or by using other donor expertise based on clear written 
mandates;
(e)  giving greater attention to ensuring that performance indica-
tors are based on sound statistical systems, reflect government’s capacity to influence performance and take into account poverty 
reduction and quality objectives.
No 8:  The Commission should take on greater ownership of the Global 
Fund at country level. As well as giving beneficiary countries more  support in the preparation and implementation of Global Fund grants, 
delegations should report back to headquarters to allow the Commis-
sion to intervene more effectively at board level.
No 9:  The Commission should make greater use of the project instru-
ment to provide policy and technical support and advice (EDF projects), to finance pilot interventions (health general budget line projects)  
and to provide healthcare in poorer regions not adequately covered 
by healthcare services (NGO budget line projects). The role of general 
budget line projects covering a number of countries and intra-ACP  
projects should be reconsidered.
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Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan AfricaTHE COMMISSION HAS NOT ESTABLISHED GUIDANCE 
FOR ENSURING THE COHERENT USE OF THE DIFFERENT 
INSTRUMENTS TO ASSIST THE HEALTH SECTOR, NOR HAS IT SUFFICIENTLY INTEGRATED ITS INTERVENTIONS INTO 
SECTORWIDE APPROACHES
 82.  The Commission has not adequately defined the role that each instru-
ment can play in the health sector and how they should be combined for maximum synergy.
 83.  Given the importance of sound sector-wide approaches to the effec-
tiveness of all instruments, there is a need to reinforce the efforts  
to support contributing to the design and implementation of such 
approaches.
RECOMMENDATIONS ON COHERENT USE OF INSTRUMENTS
No 10:  The Commission should establish and disseminate clear guid-
ance on when each instrument should be utilised and how they can 
be used in combination to maximise synergy, including:
(a)  defining in what circumstances General Budget Support should 
be used, when Sector Budget Support should be used and when 
the two instruments should be used together;
(b)  providing for increased and more effective use of the project  
instrument to support Budget Support and Global Fund interven-tions in the health sector;
(c)  taking account of Global Fund operations whenever the Com-
mission plans a health sector intervention, including through  
General Budget Support.
No 11: The choice of instruments to be used should take more specific 
account of the situation of the country and in particular whether it  has a well-defined sector policy.
No 12:  The Commission should more closely align its health sector  
interventions, including Global Fund interventions, with SWAps. In  
countries where SWAps do not yet exist, it should work towards estab-lishing them.
  This Special Report was adopted by the Court of Auditors in Luxembourg 
at its meeting of 19 November 2008.
  For the Court of Auditors
Vítor Manuel da Silva Caldeira
President
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa45
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa
Source : ECA.
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa46
ANNEX I
MILLENNIUM DEVELOPMENT GOALS: 2007 PROGRESS CHART 
Goals and targetsAfrica Asia
Northern Sub-Saharan Eastern South-eastern Southern Western
GOAL 1 | Eradicate extreme poverty and hunger
Reduce extreme poverty by half low poverty very high poverty moderate poverty moderate poverty very high poverty low poverty
Reduce hunger by half very low hunger very high hunger moderate hunger moderate hunger high hunger moderate hunger
GOAL 2 | Achieve universal primary education
Universal primary schooling high enrolment low enrolment high enrolment high enrolment high enrolmentmoderate 
enrolment
GOAL 3 | Promote gender equality and empower women
Equal girls’ enrolment in primary school close to parityalmost close to 
parityparity parity close to parity close to parity
Women’s share of paid employment low share medium share high share medium share low share low share
Women’s equal representation 
in national parliamentsvery low 
representationlow representationmoderate 
representationlow representation low representationvery low 
representation
GOAL 4 | Reduce child mortality 
Reduce mortality of under-ﬁ  ve-year-olds 
by two thirdslow mortality Very high mortality low mortality moderate mortality high mortality moderate mortality
Measles immunisation high coverage low coverage moderate coverage moderate coverage low coverage high coverage
GOAL 5 | Improve maternal health
Reduce maternal mortality 
by three quartersmoderate mortality very high mortality low mortality high mortality very high mortality moderate mortality
GOAL 6 | Combat HIV/AIDS, malaria and other diseases
Halt and reverse spread of HIV/AIDS low prevalencevery high 
prevalencelow prevalence low prevalencemoderate 
prevalencelow prevalence
Halt and reverse spread of malaria low risk high risk moderate risk moderate risk moderate risk low risk
Halt and reverse spread of tuberculosis low mortality high mortality moderate mortality moderate mortality moderate mortality low mortality
GOAL 7 | Ensure environmental sustainability
Reverse loss of forests low forest covermedium forest 
covermedium forest 
coverhigh forest covermedium forest 
coverlow forest cover
Halve proportion without improved 
drinking waterhigh coverage low coverage moderate coverage moderate coverage moderate coverage high coverage
Halve proportion without sanitation moderate coverage very low coverage very low coverage low coverage very low coverage moderate coverage
Improve the lives of slum-dwellersmoderate 
proportion 
of slum-dwellersvery high 
proportion 
of slum-dwellershigh proportion 
of slum-dwellersmoderate 
proportion 
of slum-dwellershigh proportion 
of slum-dwellersmoderate 
proportion 
of slum-dwellers
GOAL 8 | Develop a global partnership for development
Youth unemploymentvery high 
unemploymenthigh 
unemploymentlow unemploymenthigh 
unemploymentmoderate 
unemploymentvery high 
unemployment
Internet users moderate access very low access moderate access moderate access low access moderate access
Source : United Nations.
Target already met or very close to being met.
Target is expected to be met by 2015 if prevailing trends persist, or the problem that this target is designed 
to address is not a serious concern in the region.
Target is not expected to be met by 2015.
No progress, or a deterioration or reversal.
Goals and targets
GOAL 1 | Eradicate extreme poverty and hunger
Reduce extreme poverty by half
Reduce hunger by half
GOAL 2 | Achieve universal primary education
Universal primary schooling
GOAL 3 | Promote gender equality and empower women
Equal girls’ enrolment in primary school 
Women’s share of paid employment
Women’s equal representation 
in national parliaments
GOAL 4 | Reduce child mortality
Reduce mortality of under-ﬁ  ve-year-olds 
by two thirds
Measles immunisation
GOAL 5 | Improve maternal health
Reduce maternal mortality 
by three quarters
GOAL 6 | Combat HIV/AIDS, malaria and other diseases
Halt and reverse spread of HIV/AIDS
Halt and reverse spread of malariaHalt and reverse spread of tuberculosis
GOAL 7 | Ensure environmental sustainability
Reverse loss of forests
Halve proportion without improved 
drinking water
Halve proportion without sanitation
Improve the lives of slum-dwellers
GOAL 8 | Develop a global partnership for development
Youth unemployment
Internet users
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa47
OceaniaLatin America and 
CaribbeanCommonwealth of Independent States
Europe Asia
— moderate poverty low poverty low poverty
moderate hunger moderate hunger very low hunger high hunger
moderate 
enrolmenthigh enrolment high enrolment high enrolment
close to parity parity parity parity
medium share high share high share high share
very low 
representationmoderate 
representationlow representation low representation
moderate mortality low mortality low mortality moderate mortality
low coverage high coverage high coverage high coverage
high mortality moderate mortality low mortality low mortality
moderate 
prevalencemoderate 
prevalencemoderate 
prevalencelow prevalence
low risk moderate risk low risk low risk
moderate mortality low mortality moderate mortality moderate mortality
high forest cover high forest cover high forest cover low forest cover
low coverage high coverage high coverage moderate coveragelow coverage moderate coverage moderate coverage moderate coverage
moderate 
proportion 
of slum-dwellersmoderate 
proportion 
of slum-dwellerslow proportion 
of slum-dwellersmoderate 
proportion 
of slum-dwellers
low unemploymenthigh 
unemploymenthigh 
unemploymenthigh 
unemployment
low access high access moderate access moderate access
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa48
ANNEX II
EXTRACT FROM BRUSSELS DECLARATION 
BY ACP MINISTERS OF HEALTH, OCTOBER 2007
‘N. Recognising  current challenges of health management in ACP 
States including, inter alia, the lack of human resources, weak-nesses of disease alert and surveillance systems, inadequate health information management systems for decision making, poor qual-
ity of healthcare, especially universal precautions, blood transfu-sion and laboratory capacity, low level of indigenous/operational 
research and development (R & D) in endemic, and communica-
ble diseases such as HIV and AIDS, tuberculosis and malaria, and 
chronic diseases such as diabetes, hypertension, asthma, as well as 
those arising out of violence, trauma and accidents, limited prepar-edness and management of epidemics such as Ebola among others, exorbitant prices of drugs and pharmaceuticals and the need to  adequately finance the health sector from annual budgets;
O. Stressing  the importance of health systems in ACP States to  
address the prevention, treatment and management of neglected 
tropical diseases within the epidemiological context, such as human 
trypanosomiasis (sleeping sickness), dengue, leprosy, filariasis,  
onchocerciasis (river blindness), schistosomiasis (Snail fever), and 
trachoma; chronic and lifestyle diseases, such as hypertension, can-cer, sickle cell anaemia and diabetes, emerging and re-emerging dis-
eases, such as Buruli ulcer, haemorrhagic fever, Monkeypox, plague, rabies, as well as mental illness, neurological illnesses, human cer-ebral meningitis, intestinal worms, and infantile diarrhoea, among others;’
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa49
ANNEX III
COUNTRY SUMMARIES
SWAZILAND
OVERVIEW OF HEALTH SITUATION
Swaziland has the worst HIV/AIDS prevalence rate in the world at 
34 % of the population. Closely related to this, it also has the high-est TB prevalence rate, cases rising from 856 per 100 000 people in 
2000 to 1 182 per 100 000 in 2006. Life expectancy has fallen from 
60 years in 1998 to just 31 years in 2004. There are an estimated 
130 000 orphans and vulnerable children (OVC) in a total popula-
tion of one million.
Both infant and under-five mortality have increased since 1997, ris-
ing from 78 and 106 per 1 000 live births respectively in 1997 to 85 
and 120 in 2006. HIV/AIDS is the cause of 47 % of under-five deaths. 
There has been a rapid rise in maternal mortality from 230 deaths per 100 000 live births in 1999 to 370 in 2006, the principal causes 
being not only HIV/AIDS but also the limitations of the health  
system. Health services are increasingly struggling to cope with  
the huge new disease burden which is added to by a rise in non-
communicable diseases which receive little attention. 
EDF PROJECTS
HIV/AIDs prevention and care programme (HAPAC)
HAPAC I (2001–05; 2,25 million euro) largely achieved its objectives 
in relation to developing new VCT services, building up the home-
based care network in one of Swaziland’s four regions and support-
ing measures to strengthen the treatment of STIs. The main result of HAPAC II (2006–08; 2 million euro) has been to maintain services 
set up under HAPAC I but the modest further expansion of services 
foreseen for this follow-up project have only been achieved to a 
limited degree. HAPAC II was financed because the sustainability 
of HAPAC I had not yet been assured but sustainability remains a 
major problem and some VCT centres were expected to close at the 
end of the project, in 2008. Better coordination by the Commission 
with the Global Fund could have allowed the Global Fund to take over operations covered by the project at the end of HAPAC I.
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa50
NGO COFINANCING GENERAL BUDGET LINE
Integrated HIV/AIDS and livelihood project
This project is intended to assist persons living with HIV/AIDS 
and orphans and vulnerable children through home-based care and helping them increase food security through growing their own  food. The project was still at an early stage. While very relevant, 
the objectives appeared to be too ambitious for a project of little more than three years. 
GLOBAL FUND
Swaziland has so far received the highest per capita support from the Global Fund in the world (105 million USD, approximately 100 USD 
per capita). The great majority of the funding has been for HIV/
AIDS.The low amount of funding for tuberculosis does not reflect 
the scale of the problem. 
The results of Global Fund-supported programmes are rather mixed. 
Care and support to families and communities affected by HIV/
AIDS, VCT services and home-based care components have gener-ally progressed well. On the other hand, parts of the components on 
ARV treatment and monitoring, PMTCT support, and prevention work amongst youth have been less effective. Global Fund reporting requirements have been a catalyst for improving monitoring and evaluation systems and data reliability.ANNEX III
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa51
LESOTHO
OVERVIEW OF HEALTH SITUATION
Lesotho’s HIV/AIDS prevalence rate of 23 % is one of the high-
est. Closely associated with this is the extremely high prevalence of tuberculosis. HIV/AIDS and TB are the main reasons why life expectancy has plummeted since the mid-1990s from 60 years to 
just 41 years. There are an estimated 180 000 orphans and vulner-able children, approximately 10 % of the population. While malaria 
does not exist in Lesotho, other concerns include the growing level 
of non-communicable diseases.
Partly as a result of HIV/AIDS, infant mortality has considerably 
increased, from an average of 75 per 1 000 live births over the  
period 1995–99 to 91 over the period 2000–04. At the same time, 
maternal mortality has risen dramatically from 282 per 100 000 live 
births in 1993 to 762 in 2004. The deterioration of health indica-
tors also reflects the decline in health services, which are struggling to cope with the higher disease burden. Budgetary resources have 
not increased to address this situation and are allocated dispro-
portionately to secondary and tertiary care and to urban areas.  
The country is losing health workers to other countries and due to 
HIV/AIDS-related deaths.
GENERAL BUDGET SUPPORT
General Budget Support has not been an effective instrument for improving health services. The eighth EDF programme was halted by the Commission because of the government’s lack of commitment 
to public finance management reform and the programme also faced 
difficulties in providing reliable data for performance indicators. 
For these reasons support under the ninth EDF, although originally programmed, was not granted.ANNEX III
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa52
EDF PROJECTS
The eighth EDF project ‘Support to health sector reform’ (1,8 mil-
lion euro) made an important contribution to the health sector  
decentralisation process in Lesotho, both in its support to the over-all planning of the process and its piloting of decentralisation in three districts, even if the pilot phase of nine months was too short. 
The Government of Lesotho has subsequently extended decentrali-
sation to all 10 districts, although serious capacity and resource constraints exist.
NGO COFINANCING PROJECT: HOMEBASED CARE 
FOR PEOPLE LIVING WITH HIV/AIDS OR TERMINAL ILLNESSES AND OVCS
Overall, this is a successful project with 600 people trained as care 
providers, each with an average of 10 clients although only limited 
support is delivered to orphans and vulnerable children. A follow-
up project has been launched which addresses food security and income-generating activities to make the project sustainable, but 
the three-year project duration may be too short to achieve this. 
GLOBAL FUND
Under the main grant implemented so far (HIV/AIDS, Round 2) more than 15 000 people are receiving ARV treatment, compared 
with a target of 12 500, as a result of approximately equal shares of Global Fund and government financing. However, the monitor-ing system may include people who have dropped out of treatment and those who have died whilst on treatment. Only approximately 30 % of those needing ARVs are receiving them. There has been a large expansion of VCT sites but the number of people being tested for HIV is 20 % less than foreseen. This reflects general problems in the implementation of Lesotho’s ‘Know your status’ campaign. For the care and support for OVCs it was not clearly defined what the support package would include and it was difficult to establish what the OVCs had received. Condom distribution targets have been exceeded but only partly due to Global Fund financing and there was a need to ensure that the condoms distributed to and available in health centres were then actually obtained and used by the youth. Some progress has been made on youth education for HIV/AIDS prevention. PMTCT support was the most problematic area, with only one of the six indicator targets being achieved. This is in part the consequence of shortages of health personnel.ANNEX III
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa53
KENYA
OVERVIEW OF HEALTH SITUATION
All the major health indicators declined in the 1990s and health 
indicators continued to show a downward trend under the first  national health sector strategic plan (1999–2004). Thus, there was an increase in under-five mortality from 11,2 % to 11,5 %. While it is 
difficult to establish the maternal mortality ratio, indicators do not point to an improvement. The only area of clear improvement was 
in HIV prevalence, which fell from 13 % in 1994 to 6 % in 2005.
The deterioration in major health indicators reflects declining use 
of services in public health facilities, shortages of health workers 
and their uneven distribution between urban and rural areas and 
public and private sectors, as well as stagnating contributions from 
the national budget to health. The second national health sector stra-
tegic plan (2005–10), supported by donors through a ‘joint planning 
of work and funding’, is attempting to reverse this decline.
GENERAL BUDGET SUPPORT
In view of the still relatively low expenditure on health, weaknesses in health and general public finance management systems, and the fact that only one of the four performance indicator targets was achieved, General Budget Support cannot be considered to have  been very effective in Kenya in improving health services. 
EDF PROJECTS
The eighth EDF project ‘District health services and systems devel-opment programme’ (DHSSDP) has made a significant contribution in the central and eastern regions to improving the access and qual-
ity of the public and non-public services, with a particular focus on 
the people more at risk and on the communities. However, had the 
project timeframe been longer than the three years foreseen and not 
reduced by delays, results would have been still better. ANNEX III
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa54
GENERAL BUDGET LINE PROJECTS
Adolescent sexual and reproductive health (ASRH) initiative
This project was making significant progress in improving the access 
to HIV/AIDS prevention and care services for the most vulnerable and marginalised youth by the use of youth-friendly mobile VCT service delivery and increasing community awareness about this 
initiative.
Access to and use of quality basic and comprehensive 
obstetric care services
The project seeks to improve access for women and children to  
obstetric and neonatal care in 10 target districts. Project indicators 
point to increases in the proportion of direct birth complications in 
the target districts being treated at emergency obstetric facilities and 
an increase in the proportion of deliveries attended by midwives.
Comprehensive approach to reaching those most at risk from 
and affected by HIV/AIDS
The project seeks to build the capacity of Marie Stopes Kenya to 
contribute to the Kenya national AIDS strategic plan (2005–10). Initial progress has been good. 
Uzazi Bora — Mother and infant services — HIV activities
The aim of the project was to improve PMTCT, antenatal, intra-
partum and postnatal care services in two districts. The project  
objectives were partially achieved, the main shortfall being in rela-tion to postnatal services.
GLOBAL FUND
Although Kenya is a major beneficiary of the Global Fund, grants 
have been implemented with serious delays, with the result that the most targets will not be reached and budgets have been reduced 
after Phase I.ANNEX III
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa55
MALAWI
OVERVIEW OF HEALTH SITUATION
Malawi has one of the highest HIV/AIDS prevalence rates (approxi-
mately 14 %) in the world. The high HIV/AIDS prevalence rate has led to a major increase in tuberculosis, the number of cases doubling from 1994 to 2004. It also suffers greatly from malaria, it being 
the most commonly reported cause of mortality both in adults and children. Even if there has been an improvement since 2000, Malawi 
still also has one of the highest maternal mortality rates in the  
world at 984 per 100 000 live births. Similarly while some progress 
has been made in relation to child mortality, which has fallen to 
76 per 1 000 live births, this too remains a major area of concern. Malawi health services have been grossly under-resourced to cope with these problems, with the very limited number of health staff heavily concentrated in urban areas. 
GENERAL BUDGET SUPPORT
General Budget Support was not considered to have had a significant effect on improving health services by mid-2007. Since 2005, when 
General Budget Support was restarted, the government had focused 
on using budgetary support to help build up a sound track record in fiscal management rather than expanding pro-poor budgetary 
expenditure. However, through the leverage of General Budget Sup-port, the Commission has contributed to ensuring that the govern-ment maintains its health budget allocation at a minimum of 10,7 % of the overall national budget. With the HIPC completion point now reached, greater discretionary expenditure, including for health, 
will become possible. 
EDF PROJECTS
The eighth EDF project had created a national blood transfusion 
service which was covering between a third and a half of national 
needs. While this was less than what was specified in the financing 
agreement, it still represented considerable progress given the dif-
ficult cultural, as well as organisational, challenges which have had 
to be overcome by the project.ANNEX III
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa56
GENERAL BUDGET LINE PROJECTS
Scaling up of sexual and reproductive health (SRH) and HIV/
AIDS services for young people
The project aims to increase the utilisation of youth-friendly SRH 
services and the adoption of safer sex practices by working through 
NGOs and youth clubs. Given initial delays, it may not be possible 
to achieve all project objectives.
Promotion of behaviour change and increase of access to SRH 
services in Thyolo district
The project was making a valuable contribution, particularly in  
improving access to a continuum of HIV care, support and treat-
ment, PMTCT services and VCT services in this poor district  
of southern Malawi.
Youth and children’s health in the central and southern regions 
of Malawi
The project is producing good results, with an increase in the number 
of youth undergoing VCT in the targeted youth and health centres 
and a decrease in pregnancies among school girls. 
GLOBAL FUND
Overall, the Global Fund is producing significant results, most nota-bly in enabling a huge scaling-up of ARV provision, from just a 
few thousand in 2004 to 110 000 by mid-2007. Most other compo-nents of the Round 1 HIV/AIDS project, after some delays, were on their way to important achievements, including the health systems support component, which was assisting in training large numbers of personnel, particularly at the level of community health workers. The main problem area was the PMTCT component.ANNEX III
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa57
MALI
OVERVIEW OF HEALTH SITUATION
Mali has a very high maternal mortality ratio (1 200 per 100 000 
live births) and child mortality rate (219 per 1 000 in 2004). The HIV/AIDS prevalence rate is relatively low (1,9 %) but tuberculosis is widespread (578 cases per 100 000 population) and malaria con-tinues to be one of the main causes of child mortality. Other major 
illnesses include acute respiratory infections, diarrhoea, Guinea 
worm, schistosomiasis as well as growing problems with chronic 
illnesses such as diabetes and heart disease.
While significant investments have been made in health infrastruc-
ture and access to health services has globally improved, serious 
problems remain. There is no adequate human resource policy,  
resulting in low availability, inappropriate geographical allocation, 
and inadequate skills, motivation and ethical standards of staff. 
The decentralisation process has not been accompanied by a suffi-cient transfer of human and financial resources. Overall, the quality 
of health services remains low and health services are unaffordable 
for the poorest. 
GENERAL BUDGET SUPPORT
Contrary to the commitment made in the General Budget Support financing agreement, the government did not increase the share 
of the health budget, while public funds continue to be inequitably 
allocated between regions. In addition, public finance management remains weak, with a high fiduciary risk and low efficiency and  
effectiveness of public spending.ANNEX III
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa58
EDF PROJECTS
The eighth EDF PASS project has contributed to its objective  
of strengthening the capacity of the Ministry of Health but not to 
its other objective of improving the quality of health services. The project was not in a position to bring about such improvements since this required the adoption of major structural reforms.
GENERAL BUDGET LINE PROJECTS
Improvement of women’s reproductive health in northern Mali
The project contributed significantly to improving training of health 
workers and providing equipment but the project was too short to make a real impact on maternal mortality. 
Action Biomali
This project to improve the detection of HIV/AIDS, TB and malaria 
in Mali has led to the setting up of a network of laboratories although 
there were delays in training personnel on how to use the equip-ment supplied. Monitoring of the increase in detection rates was 
problematic. 
Participatory approach to improving access to healthcare 
for TB patients
This regional project, also covering Benin, Burkina Faso and Sen-
egal, was contributing to an improvement in the detection of TB and subsequent follow-up.ANNEX III
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa59
Strengthening local capacity to fight HIV/AIDS
This project, which is still at an early stage, aims to reduce sexual 
and mother-to-child transmission in poorer regions of northern 
Mali through greater involvement of civil society and by improving the quality of health services.
GLOBAL FUND
The malaria grant had contributed to the supply of bednets and training to health personnel. The HIV/AIDS grant contributed to the number of people on ARVs increasing from 600 to 12 800 over the period 2005–07. For the TB grant, the treatment component was more successful than the prevention one. The health systems strengthening component was experiencing some difficulties, nota-
bly in relation to the construction and equipping of the national 
laboratory.ANNEX III
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa60
LIST OF PROJECTS EXAMINEDANNEX IV
Country Project title Project amount Rating
EDF PROJECTS
Angola Support programme to the health sector 25,0 Unsatisfactory
Benin Support to the health sector 10,2 Partially satisfactory
Burundi Transitional support to the health sector (PATSBU) 4,1 UnsatisfactoryChad Support to health policy 42,0 UnsatisfactoryCôte d’Ivoire Emergency and rehabilitation programme Phase 1 34,0 Satisfactory
Kenya District health services and systems development 15,0 Satisfactory
Lesotho Support to the health sector reform 1,8 Partially satisfactoryMalawi Malawi blood transfusion service 9,4 Partially satisfactoryMali Support programme to the health sector 10,5 Partially satisfactorySierra Leone Health sector support programme 28,0 Unsatisfactory
Swaziland HIV/AIDS prevention and care programme 4,3 Partially satisfactory
Uganda Development of human resources for health 17,0 Satisfactory
INTRA-ACP PROJECTS
8 countries EC/ACP/WHO partnership on health MDGs 25,0 Partially satisfactory
14 countries WHO polio eradication programme 26,8 Partially satisfactory
41 countries EC/ACP/WHO partnership on pharmaceutical policy 24,6 Unsatisfactory22 countries EC/ACP/UNFPA/IPPF sexual and reproductive health 32,0 Satisfactory3 countries Development of malaria vaccine multi- centre trials 7,0 Unsatisfactory
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa61
Country Project title Project amount Rating
HEALTH GENERAL BUDGET LINE PROJECTS
Kenya Adolescent sexual and reproductive health initiative 2,6 Partially satisfactory
KenyaIncreased access to and use of quality basic and comprehensive 
obstetric care services2,2 Satisfactory
KenyaComprehensive approach to reaching those most at risk and aﬀ  ected 
by HIV/AIDS4,4 Partially satisfactory
Kenya Uzazi Bora — Mother and infant services — HIV activities 1,3 Partially satisfactoryMalawiScaling up sexual and reproductive health and HIV/AIDS services for 
young people 2,25 Partially satisfactory
MalawiPromotion of behaviour change and increased access to sexual and 
reproductive health services1,35 Satisfactory
Mali Improving reproductive health services in northern Mali 1,6 Satisfactory
Mali ‘Action BioMali’ 3,6 Partially satisfactory
MaliParticipatory approach for improving the quality and access to health 
care for TB patients4,5 Partially satisfactory
Burundi, Kenya, 
MozambiqueFight against AIDS programme 2,0 Unsatisfactory
Burundi, Guinea,
HaitiMutual strengthening of front line private and public players in the 
ﬁ elds of protection of rights, prevention of infections and provision 
of complete healthcare for people living with HIV/AIDS3,9 Partially satisfactory
Benin,
Dem. Rep. of the CongoProgramme to develop integrated HIV care for TB patients living with 
HIV/AIDS4,3 Unsatisfactory
Zambia, South AfricaBuilding local capacity and ownership of HIV vaccines in southern 
Africa3,0 Unsatisfactory 
Malawi, South Africa Increasing prevention and treatment of TB 4,5 Partially satisfactory
NGO CO-FINANCED BUDGET LINE HEALTH-RELATED PROJECTS
LesothoHome-based care for people living with HIV/AIDS or terminal illnesses 
and for orphans0,7 Partially satisfactory
Mali Strengthening local capacity to ﬁ  ght HIV/AIDS 1,0 Partially satisfactory
MalawiYouth and children’s health in the central and southern regions 
of Malawi0,75 Satisfactory
Swaziland Integrated HIV/AIDS and livelihood project 0,75 Partially satisfactoryANNEX IV
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan AfricaREPLY
OF THE COMMISSION
EXECUTIVE SUMMARY
I.
The Commission thanks the European Court 
of Auditors for its work on the EC devel-
opment assistance to health services in  sub-Saharan Africa (SSA). It provides an  interesting analysis with findings and les-
sons learnt that gives an opportunity for the 
Commission to clarify a number of issues  stemming from the Court audit work.
II.
The Commission policy recognises that sup-porting progress towards better health out-comes calls for a comprehensive strategy  tackling existing constraints through the  most appropriate instruments and division 
of labour with other donors. Thus ‘at coun-
try level the Community will employ a range 
of complementary interventions including: 
macroeconomic support linked to improved health outcomes; support to sectors that  
have a wider impact on health outcomes and 
direct support to the health sector’ (health 
and poverty reduction communication).
In line with its policy commitments the  
Commission has remained sensitive to the 
importance of health systems strengthen-
ing by maintainingd its direct financing to 
health at country level, increased general  
budget support and its contribution to glo-
bal initiatives.
Health expertise in the Commission is kept 
within the limits of resource allocation  decisions. However, mechanisms such as,  at country level, the ‘Technical cooperation fund’ (TCF) or, more specifically at Headquar-ters level, ‘external technical expertise’ (ETE) might, for specific tasks, provide technical support to the Commission services.
63
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan AfricaIII.
The Commission continues its effort to  
improve the speed and the predictability  of its assistance to the health sector: this  includes privileging sector-wide approach  (SWAp), Sector Budget Support (SBS) where conditions allow but also a more predict-able longer-term type of General Budget  Support (GBS) (‘MDG Contract’) in perform-ing countries.
IV.
The Commission shares the Court’s view on the potential role of SBS, a relatively new  aid modality of which the Commission is the largest user in Africa, according to available evidence. The Commission has already used SBS to support health sectors in Mozam-bique, Zambia and South Africa.
The Commission views GBS as a comple-
ment to health focal or non-focal interven-tions and is committed to further enhance 
this tool’s effectiveness in general and  
in relation to sectoral issues. However,  
the Commission notes that the effective-ness of general budget support is better  
assessed in the longer term since progress 
in outcomes at national level takes time as 
it requires improvements in large systems  
and thus cannot be compared to progress  
in outputs in smaller and targeted groups  
of the population.
V.
In a country strategy paper related to a  country in which health is supported, the  Commission articulates different types  
of support, foreseen in its policy to improve 
health outcomes, in response to country  
specificities. The Commission will continue to strengthen synergies between different  
interventions at country level.The health policy / strategy framework has 
improved a lot in SSA countries over the  last decade, with the support of the WHO  (World Health Organization) and of all other major development partners (Commission  included). However, these policies need to be constantly reviewed and improved. As an example, joint annual health sector reviews in which the Commission is often involved, is an exercise which brings new developments to the policy.
VI.
The Commission will consider sectoral  allocations according to the guidelines to  be established for the 10th EDF mid-term  review. These will stress country-level objec-tives, results achieved and the principles  of country ownership and division of labour. They will also take into account the fact that results on the health MDGs can be attained through various ways, including investments outside the health sector (water and sanita-tion, education, rural development, govern-ance) and not solely through direct support to health services.
The Commission will continue to support  
health systems, where possible with support 
to sector programmes. Development and  
retention of ‘human resources for health’  
(HRH) as well as health system financing are 
issues that the Commission will follow care-
fully and assist.
64
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan AfricaThe Commission agrees that adequate   —
expertise is important for those delega-
tions which have an active donor role in the health sector. Where health is a focal 
sector, the Commission will explore ways 
to provide the delegation with the ade-quate expertise. In other cases, including for general budget support, silent part-
nerships and delegation of responsibili-
ties to other donors could be envisaged in the context of the division of labour. 
Pragmatic ways such as EU pooling  
of experts might also be considered.
SBS will increase from nearly 9% under  —
the ninth EDF to 16% under 10th EDF  
across all sectors of cooperation. When 
conditions are satisfied it will be the  
preferred modality in countries that  
have programmed support to the health 
sector. The Commission will continue  
to strive to make its GBS instrument  more effective in its achieving its goals, 
including through the launch of the MDG 
Contract.
The Commission will continue to   —
use projects in order to develop and  strengthen health systems, especially  in countries affected by situations  of fragility.
In countries with a SWAp environment, sup-
port to policy development is also given  through sector policy dialogue (involvement 
in specific working groups; participation  
in joint government–donor health sector  
reviews) as well as projects.Capacity building, according to the ‘Accra  
Agenda for Action’ (September 2008), should 
increasingly be implemented through pooled funds to strengthen national capacities,  
maximising the use of local expertise.
Following the Court’s audit a specific   —
Inter Service Group has been established to define what the Commission should  do at country level to ensure a more effi-cient use of the Global Fund’s financial resources.
This guidance on the specific use of the  —
various instruments in relation to the  health sector, including on their use in 
combination, will be reviewed in the  
‘health programming guidelines’ which 
are currently being updated to better  
take into account broader developments 
of EC instruments (e.g. MDG Contract).
The Commission agrees and is convinced  —
that a sound health policy and strategy 
framework is highly desirable for effec-
tive health system development. It will 
continue to promote the development  and adoption of well-defined health poli-
cies with all the complementary inter-ventions foreseen by its policy.
65
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan AfricaINTRODUCTION
1.
Sub-Saharan Africa lags behind in the  
achievement of most MDGs and notably  of health-related ones.
Progress on health-related MDGs is linked to 
improvements on various fronts (education, water and sanitation, food security, etc.).  Hence, supporting progress towards bet-
ter health outcomes calls for a comprehen-sive strategy tackling existing constraints  
through the most appropriate instruments 
and through division of labour with other  
donors.
OBSERVATIONS ON ALLOCATION 
AND DISBURSEMENT OF RESOURCES TO THE HEALTH SECTOR
7.
The Commission wishes to put the audit  of EC development assistance to health serv-
ices in sub-Saharan Africa into the perspec-
tive of its overall approach to development 
assistance.
The Commission policy recognises that sup-
porting progress towards better health out-comes calls for a comprehensive strategy  tackling existing constraints through the  most appropriate instruments and division of labour with other donors. Thus ‘at coun-
try level the Community will employ a range of complementary interventions including: 
macroeconomic support linked to improved 
health outcomes; support to sectors that  
have a wider impact on health outcomes and direct support to the health sector’ (health and poverty reduction communication).While the Commission has indeed made  
strong commitments on health, it has never 
formally set a target in term of percentage of resources allocated to health for the EDF. 
Moreover, the Commission is of the opinion 
that targets based on financial inputs are  increasingly ill-suited to reflect the current commitments within the framework of the  
aid effectiveness agenda and the real impact 
the Commission has on policies of partner  countries.
The Commission’s basic development  
approach focuses on poverty alleviation  
and, within this context, on improvements within the social sectors. Thus, the Commis-
sion concentrates on achieving development 
results as measured by performance indica-
tors. Whether these results/indicators are  
reached with higher or lower, direct or indi-
rect financial inputs is secondary.
The Commission agrees that there is no rec-
ognised method for attributing GBS assist-
ance to specific sectors. Accordingly, the  
Commission takes note of the audit’s meth-
odology and its ensuing results. The Com-mission, however, would like to underline  
that because of fungibility of funds, both  targeted and untargeted budget support  contributes to financing the entire budget and not solely a part of it. Their imputed con-tribution to health sector financing should 
therefore be the same. Given the absence  of an internationally recognised method  
for attributing GBS assistance to specific  
sectors, the Commission does not address  
specific findings on financial resources but intends to work towards a reporting meth-odology which would focus on performance indicators and aid effectiveness in line with Accra Agenda for Action and the Paris prin-
ciples (ownership, alignment, harmonisa-tion, managing for development results and 
mutual accountability).
66
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa12.
(b)
The Commission notes that the ‘70%’ share the Court extracts from the IEO (Independent 
Evaluation Office)/IMF study only refers to 
the utilisation of additional aid but regard-less of modalities and sectors. This share  therefore does not relate to the total amount 
of budget aid or total aid flows. Budget  
support is always taken into account when determining public expenditures, includ-
ing for health, and their optimal financing. 
When this implies reducing public debt or  
increasing reserves, the aid which is not  
immediately spent raises future spending  capacity including in the health sector.
15.
The Commission notes that there is a short-
age of international assistance for devel-
oping countries, in particular sub-Saharan  
Africa. This affects all areas, including health systems.
Donors’ programming choices increasingly 
reflect internationally agreed principles  
of aid effectiveness such as country owner-ship and division of labour among donors. 
Excessive fragmentation of aid increases  administrative costs by making the manage-ment of aid particularly complex and under-mines partner country systems.
The Commission and the Member States have 
taken a strong policy commitment on divi-
sion of labour, reflected in the 2007 EU Code 
of Conduct on Complementarity and the  
Division of Labour in Development Policy.Programming of EDF funds is done jointly  
with the partner country and in consultation 
with the Member States: country strategies for the 10th EDF were presented to the EDF 
committee and considered by the Member  
States relevant responses to the problems  of the partner countries in consideration  of support provided by other development 
partners. Furthermore, in the context of the 
24 June 2008 European Council conclusions on the EU agenda on MDGs, the EU col-
lectively has committed to increase — in  
relation to the prospects of increased EU  
ODA — the EU support to health (8 billion 
euro by 2010, 6 billion euro for sub-Saharan Africa). In this respect, the convening role 
of the EC in the division of labour applied  
to health will play a key role.
16.
The Commission will provide direct support 
to the health sector under the 10th EDF to 15 SSA countries of which eight are affected 
by situations of fragility. The number of such 
countries which receive direct support from 
the Commission to their health sector has  
slightly increased from seven in the ninth  to eight in the 10th EDF.
17.
The global partnerships (e.g. Global Fund,  GAVI / Global Alliance for Vaccines and  Immunization) have indeed attracted sig-
nificant funding, sometimes at the expense of national health systems strengthening  
(HSS).
It has nevertheless contributed to a mas-
sive supply of medicines, vaccines and other preventive / curative commodities to fight AIDS as well as highly prevalent diseases  such as, for example, malaria, tuberculosis or measles.
67
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan AfricaIn addition to its contribution to the Global 
Fund, the Commission has also supported  
HSS, through various actions to lessen the HRH crisis, to improve the availability and  
affordability of essential medicines or to  
enhance health financing. In the countries in which ‘health’ is a sector supported by  the national indicative programme, HSS is  
of course the central objective of EC sup-
port, preferably through a SWAp.
18.
Where the Commission is indirectly involved 
in the health sector, notably through GBS  
linked to the social sectors or budget lines and intra-ACP funding, silent partnerships  
have to be agreed with other (EU) donors in 
the spirit of the code of conduct on comple-
mentarity and division of labour, and coor-
dination within the budget support donor  
group ensured.
Delegations may also be supported by head-
quarters (HQ). The Relex family services have 
regrouped its health expertise around health 
teams in DG Development and the EuropeAid 
Co-operation Office. This has substantially contributed to improved technical support 
to delegations, in the policy dialogue with partner countries as well as in the identi-fication / formulation / implementation  of health interventions.
(a)
Not only to support Global Fund ‘operations’ 
but also to exhort the Fund to integrate  
its activities into national policies and to  
strengthen health systems.(d)
In countries where the HIV infection is  
highly prevalent, delegations are taking  measures to ensure that all professionals  
dealing with any project / programme, are 
able to ‘mainstream’ HIV/AIDS in his/her area of expertise, even if he/she is not a health specialist. As an example, the EC Delegations 
in southern Africa are completing a guide  
on ‘Mainstreaming HIV and AIDS in sectors and programmes’. Several delegations (e.g. 
Botswana) have already carried out specific 
training for their staff on mainstreaming  
HIV/AIDS.
20.
The Commission explores to what extent the 
division of labour will give opportunities for 
joint utilisation of expertise. The problem  
is that EU Member States are also reducing 
their sectoral expertise and that they might 
be reluctant to enter into formal and bind-ing agreements.
Whereas an increased cooperation with  
ECHO health advisors is desirable, there are 
limits to their utilisation in policy develop-ment, because their professional profile usu-
ally requires them to manage humanitarian aid in emergencies, which is different from the professional profile of a health policy  analyst and advisor to support health sys-tems strengthening.
24.
The Commission welcomes the Court’s  
remark on the speed and predictability  
of GBS funding under the ninth EDF. It notes that under the 10th EDF, it is planning to  further improve the predictability of its GBS instrument through the provision of ‘MDG  Contracts’ where conditions allow.
68
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa25.
(a)
The Commission will continue to strengthen health information systems in partner coun-
tries (e.g. Zambia) to increase their capaci-
ties in collecting data linked to result-based disbursements.
(b)
Eligibility conditions can affect the predicta-bility of budget support but offer fundamen-
tal guarantees in terms of the effectiveness 
of budget support. Disbursement of SBS  
funds when a GBS programme is delayed  
or temporarily suspended is only possible  when a deterioration of the macroeconomic 
framework constitutes a breach of GBS eligi-
bility but is not viewed by the Commission 
as putting sector objectives at risk.
Finally out of 26 GBS programmes financed 
under the ninth EDF, 19% were affected by delays or suspensions.
29.
The fact that only a minority of applications 
submitted to the Global Fund are selected, does not facilitate coordination of the assist-
ance provided by the donor community. As the Court noticed in Lesotho, the Global  Fund granted, on its seventh round, USD  33 million to assist OVC (orphans and vul-nerable children) while the Lesotho coun-
try strategy paper had already earmarked a significant support to them (at a time when 
there was no guarantee that the application 
to the Fund would be successful).
31.
The Commission welcomes the Court  acknowledgement that budget support has the potential to play a key role in improving health services.The differences between GBS and SBS are  
clearly identified in the existing interna-
tional definition given by the OECD (Office for Economic Cooperation and Develop-
ment) / DAC (Development Assistance Com-
mittee). While this definition is not always applied consistently by everyone every-where
1, EC guidelines and practice are fully 
in line with it.
32.
A relatively new aid modality, SBS started  
under the ninth EDF, with first commitments 
in 2003, after the publication of guidelines 
on GBS (2002) and on support to sector pro-grammes (2003). While it is true that so far 
health Sector Budget Support is limited to 
a small number of countries, available evi-
dence for Africa
2 shows that the Commission 
is the largest user of Sector Budget Support 
across all sectors.
Given the deep technical engagement in  
sector policy design and implementation  
within a focused dialogue with a broad  
range of stakeholders required by SBS,  
the Commission believes that focal sec-tors are the ones where such a demand-
ing effort to use SBS should focus. Where,  however, resources were available, SBS has also already been used in non-focal sectors (Ghana, Mozambique).
33.
GBS can be additional to the focal sectors  
because it provides a unique opportunity to 
have a dialogue on the overall policy priori-
ties of the partner country. SBS is a modality for the implementation of a focal or non-focal sector support.
1 Strategic partnership with Africa, Survey of budget 
support 2007.
2 Ibid.
69
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa34.
There is one clear Commission view (and  
practice) on the relation between GBS and social sector support. This is clearly stated in 
the current guidelines which do not lessen 
the relevance of social sector dimensions
3. 
The Commission is promoting increased staff awareness about the link between budget  support and social services.
35.
Having contributed to the evaluation  
approach conceived and used for the DAC  
joint evaluation (2006), the Commission  
is now working with other budget sup-port donors within the DAC to develop  
an improved methodology that takes into  
account lessons learned.
3 ‘In a GBS programme designed to support a national 
policy and strategy, there will nevertheless be key sectors or areas where particular attention will be given. These 
sectors will be those judged to be of particular importance 
to the support to the national strategy. In those countries 
where support is being given to PRSPs (poverty reduction 
strategy paper) it is normal to focus on the social sectors of education and health as being key elements in reducing 
income and non-income poverty’ (Guidelines page 50/51).36.
In any given year, budgetary decisions in  
terms of total expenditures, their sector allo-cation, the level of the deficit and the com-
position of its financing take into account  
current and future macroeconomic con-straints and the expected level and distribu-tion of all flows of aid. Normally, therefore, 
there neither will nor should be a one-to-
one relation between increased budget sup-port and increased health expenditures in  
any given year. With time, however, budget 
grants support the creation of the fiscal  
space necessary for increased expenditures. 
Through its dialogue and conditions, EC  budget support has also often pushed for  
higher budget allocation towards health.  
This, however, was not always regarded as 
the most urgent priority as when budget  
execution problems would impair the impact 
of higher allocations. For reasons like this, 
the Commission generally prefers to focus  on outcome indicators that capture improve-
ments at the level of beneficiaries.
37.
By fostering the strengthening of public  financial management systems, the Commis-
sion ‘dynamic interpretation’ of eligibility  which applies to both GBS and SBS sup-ports local efforts to improve the effective use of budgetary funding. In this way GBS  supports a sustainable answer to inefficient 
and ineffective public spending (in health as elsewhere) that will benefit all aid modali-
ties used in the partner country.
Public expenditure tracking surveys are very 
illustrative but have proved to be of limited use as tools to engage country authorities’ in a programme of PFM reform.
70
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa38.
GBS programmes address the risks men-
tioned by the Court in several ways.
The first is the regular implementation  
of PEFA (public expenditure and financial  accountability) diagnostics that comprises indicators on primary level expenditure in  
health and education (Performance indicator 
No 23). The second is the progressive inclu-sion of decentralised and deconcentrated  
expenditure in the programmes of reform  
of public financial management. In agree-
ment with other budget support donors,  
the Commission is ready to use financial  audits and compliance tests when these are 
regarded as the most useful tools to spur  
the process of public finance management 
(PFM) reform.
In any case, the ways in which the Commis-
sion manages these risks must be compat-ible with the fact that once transferred to  
the national treasury, Commission funds  
are mixed with national resources, cannot  
be specifically traced and audited. This is  
true for both GBS and SBS which are both  untargeted.
In SBS attention is given to the entire result-
chain and to the allocation and execution  of the sector budget. This can be supported by dialogue or conditionality according to 
the context and the specific objectives of a given SBS programme.
39.
GBS supports the strengthening of the glo-bal policy and institutional framework nec-essary for a sustainable and comprehensive improvement in the provision of health  services. The Commission agrees that the  
existence of well-defined health policies  increases the effectiveness of all types of aid 
to the sector and has actively supported the 
establishment of health policies since the  
1990s (Senegal, Zambia, Ghana, etc.).However, SWAps, national health policies  
and their relation with GBS should not be  
confused. Swaps are arrangements that har-monise donors support to an existing health 
policy. Although usually not fully aligned to 
country systems as budget support, Swaps are a positive development but should not be a pre-condition for GBS. As a matter  
of fact, when matched with adequate policy 
dialogue, the former can trigger the estab-lishment of SWAPs (e.g. Madagascar).
Finally, by focusing at PRSP (poverty reduc-
tion strategy paper) level, GBS also promotes 
progress towards the MDGs by creating a  demand for better defined sector policies.  
Out of the 22 SSA countries that have regu-
larly implemented EC GBS under the ninth  
EDF, as many as 14 carry out regular joint  
health sector reviews whose results are then 
taken into account during the GBS joint  
annual review. In the remaining countries  these are progressively being developed.
40.
The 2007 GBS guidelines do not prohibit  
the use of GBS capacity development funds to support sectoral ministries. However,  
in order to avoid excessive fragmentation, GBS capacity development funds are mainly used to strengthen PFM systems and PRSP  monitoring frameworks. Importantly, how-ever, this can include decentralised public 
financial management systems, in many  countries directly relevant for health serv-
ice delivery.
Broader technical assistance to the health  
sector is delivered in the frame of sector  programmes by the donors active in the  sector.
71
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa41.
The Commission welcomes the Court finding 
that the large majority of delegations directly participate in health sector dialogue.
(a)
Where the Commission is indirectly involved in the health sector, notably through GBS  linked to the social sectors, silent partner-
ships have to be agreed with other (EU)  donors in the spirit of the code of conduct 
on complementarity and division of labour, 
and coordination within the budget support 
donor group ensured. Delegations may also 
be supported by the health experts avail-able at HQ.
(b)
An increasing number of countries man-
age GBS through performance assessment  
frameworks (eight in 2006, 12 in 2008).  
These jointly agreed matrices clearly define the benchmarks used to assess country per-
formance, including in the health sector. It 
is for each delegation to decide the depth 
and extent of its involvement in sector pol-
icy dialogue. See also paragraph 39 above  for articulation between GBS and sectoral  
reviews.
(c)
The value added of GBS is in encouraging  sector dialogue to link policy, technical and financial inputs to critical sector outcomes. Accordingly, the Commission will continue its efforts to ensure that GBS outcome indi-cators are properly integrated into sector  dialogue and processes. However, discus-sions on actual outcomes need to balance  this objective with the need to ensure an  exhaustive verification of disbursement  conditions.43.According to the Commission’s data on  138 scored health targets covering disburse-ment decisions over 2003–07, 83 targets  
were fully achieved (i.e. 60%).
In addition, in a further 15% of cases targets 
were partially met.
Overambitious targets may also have con-
tributed to these results.
44.
(a)
The financial weight attached to individual targets is only one of the ways through which 
budget supports aims to foster improved  
performance, others being monitoring, pol-
icy dialogue and domestic accountability.
(b)
The Commission uses some input indicators (typically financial allocation and execution) 
but mainly focuses on outcome indicators  
(assisted deliveries).
While these are not under direct government 
control, they are still under indirect govern-ment control. Unlike input or output indica-tors (number of hospitals), they capture the objectives of government policies and their effects on beneficiary populations.
(c)
Although data reliability is a constraint, by 
using existing data the Commission pro-
motes and supports their improvement.
72
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa(d)
The identification of ambitious and realistic 
targets is difficult and can only be satisfac-torily achieved after several years of prac-
tice in management by results when sector 
processes are properly mastered. Improv-ing partner countries capacity to manage  by developing results is one of the objec-
tives of the Commission approach to budget 
support.
(e)
Efforts are being made to better take quality 
of care into consideration. As an example,  
the indicator on delivery attendance has  progressively evolved from ‘institutional’  
deliveries (while not everyone in a health  
centre has been trained to attend deliveries) 
towards ‘skilled’ attendance.
45.
Although the Court is correct in stating that indicators do not directly target the poorest 
of the poor, it should be noted that:
the definition of some indicators reflects  —
a poverty dimension (e.g. assisted deliv-
eries in basic health centres);poverty rates in countries beneficiary   —
of budget support range between 30  and 60% of the population: targets for  most indicators have overtaken the share of non-poor population.
In addition there is an increasing tendency 
to use indicators disaggregated at the level 
of the poorest regions, marginal areas or by 
gender.
46.
It should be noted that other GBS objectives can have a positive indirect influence on the health sector.47.
Although the project (as an approach or as an 
implementation modality of a Sector Policy Support programme) is not the EC preferred 
form of aid implementation, it is clear that 
projects still remain a major instrument to carry out our development assistance.
For example, a first assessment of the ini-
tial allocations to the 10th EDF national  indicative programmes / Envelope A of SSA 
countries (South Africa excluded) shows that 
Budget Support (including GBS and SBS) rep-
resent approximately 48% of the amounts so 
far allocated. The remaining 52% are then  going to be spent mostly through projects.
48.
In order to monitor and draw lessons from 
the projects it funds and in addition to mid-
term and final evaluations, the Commission 
has established a results-oriented monitor-ing (ROM) system covering all regions and  
sectors of Community aid. The ROM system 
mainly focuses on quality of design, effi-
ciency and effectiveness to date, impact  
prospects and potential sustainability. The results obtained through ROM for EDF health 
interventions for the years 2001–07, indeed show an insufficient sustainability.
49.
(a)
The situation is now improving as the Com-mission endeavours to improve the ‘link  
(between) relieve, rehabilitation and devel-
opment’ (LRRD).
73
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa(c)
Following the Court’s special report on  
the ‘Effectiveness of the TA in the context  of capacity development’ (2007), the Com-
mission will finalise by the end of Novem-
ber 2008 its new ‘Guidelines on technical  cooperation and programme implementa-tion arrangements’; the aim being to pro-
vide quality technical cooperation that  
supports country-led programmes as well  as support through partner-owned project 
implementation arrangements, with a sub-
stantial reduction in the use of parallel  
project implementation units. This should  
contribute to better quality of the technical cooperation, ownership and strengthened  
capacity.
(e)
Most countries in SSA have developed  
national health policies with the support  
of the WHO and of the whole donor commu-nity, the EC included. However, often there 
needs to be a better fit between policies  
and resources (budget allocated to health, 
human resources for health, etc.).
The Commission contributes to the improve-
ment of these health policies through  projects (e.g. the EUR 25 million ‘ Programme  
de soutien au secteur de la santé ’ in Angola), 
‘Sector Policy Support programmes’ (e.g.  health Sector Budget support in Zambia and Mozambique) or even through its participa-tion in ‘joint annual health sector reviews’ (e.g. Benin, Madagascar, Mozambique,  Zambia).
(f)
See replies to paragraphs VI (third indent)  and 18.50.
(b)
The delegations are kept informed about the centralised projects that are affecting their 
countries. It is useful in view of streamlining 
the EC interventions and avoiding possible overlaps between actions implemented at  country or regional level and those imple-
mented at intra-ACP level. In addition, EC  
delegations are regularly informed of cen-trally managed programmes when regional 
seminars are held. For more information,  
they also have access to CRIS (EuropeAid  
information system) and to the EuropeAid  
intranet.
(c)
The UN–EC joint guidelines on reporting are 
intended to overcome these difficulties.
53.
(a)Usually, these general budget lines health  
projects proposed and implemented by  
NGOs and other non-state actors are funded 
by the Commission only if they are suffi-
ciently compatible with the health policies and plans of the countries in which they are 
implemented. These projects are often car-ried out in cooperation with the local health system.
(b)
Between 2004 and 2005, the Commission  held four thematic seminars (Addis Ababa, 
Dakar, Maputo and Bangkok) with contract 
beneficiaries, civil society organisations and 
other partners such as the WHO, to discuss and share lessons learned from the actions financed under the thematic health budget lines.
(c)
The innovative nature and the potential for 
scale-up interventions, applies not only to 
the national health programmes in the given country but also other countries facing simi-
lar challenges and global initiatives financ-
ing health interventions in those areas.
74
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa54.
The calls for proposals (CfP) under health  thematic budget lines are targeted at least 
developed, other low and lower middle  
income countries and, within these coun-
tries, at the most disadvantaged population 
groups. It is recognised that poor and mar-
ginalised population groups even in more  advanced developing countries need sup-
port; this particularly applies to HIV/AIDS  
and reproductive health needs of groups  
such as injecting drug users, migrants work-
ers, refugees, sex workers, men having sex 
with men, etc. Furthermore, the CfP evalu-
ation process takes into account the rele-vance of the action proposed to the needs 
and constraints of the country / region /  
population concerned.
58.
Following the Court’s audit, the Commis-
sion has decided to establish a specific Inter 
Service Group with the following tasks:
to define the role and responsibilities   —
an EC delegation should have in relation 
to the Global Fund (e.g. participation  
in the CCM, reporting, etc.). Different  types of delegations could be identified 
according to criteria such as, for exam-
ple, the level of HIV prevalence in the  
country, the fact that ‘health’ is or not a focal sector in the CSP, etc.;find out how delegations will fulfil their  —
new tasks taking their limited resources into account and;
determine how delegations may be sup- —
ported by HQ and how both Develop-
ment DG and EuropeAid Co-operation  
Office will cooperate to carry out their  
assistance to the delegations.(c)
The capacity of countries to prepare good  quality proposals is generally improving. The 
last round of CfP (launched on 1 March 2008) 
has seen the highest amount requested so 
far (USD 6,1 billion), but it has also the high-
est ever rate of proposals recommended by 
the technical review panel: 54%.
The Commission is currently exploring with 
UNAIDS the ways to build capacity of coun-
tries in the fight against AIDS (development 
and implementation of a ‘capacity building’ 
plan of action).
60.
Efficient health systems are able to convert 
Global Fund and PEPFAR (US President’s  
Emergency Plan for AIDS Relief) support into 
health services to the population affected by HIV/AIDS, tuberculosis and malaria.
The Commission also supports health system 
main elements such as human resources for 
health (HRH). The DCI / ‘Investing in peo-
ple’ has earmarked EUR 40 million for HRH 
in the period 2007–13. The EDF supports  HRH activities and programmes in Angola,  
Mozambique, Uganda, Zambia and Zimba-
bwe and HRH indicators are now used in GBS 
and health SBS variables tranches. The Com-mission also works with the WHO in support-ing pharmaceutical policies (EUR 25 million) and improved health planning and budget-
ing (EUR 25 million) in ACP countries.
62.
The Commission is aware that significant  
disease specific programmes such as the  
Global Fund need efficient health systems  
to be productive. In order to better under-stand this relationship, Development DG is 
currently working on strategic and technical 
guidelines on how such disease specific pro-
grammes could strengthen health systems.
75
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa64.
The Commission notes that the issue may  be first and foremost when a combination  
of GBS and a health focal sector  is required 
and only secondly when SBS is an appropri-
ate implementation tool for the health focal 
(or non-focal) sector.
The Commission considers that a well-
defined health policy and a health sector  programme supported by donors, not neces-
sarily a Commission financed SBS, are desir-
able to improve the effectiveness of GBS  
contribution to health outcomes.
65.
In line with its belief concerning instruments 
complementarity, the Commission agrees  
with the Court that projects can reinforce  
budget support but notes that the opposite is also very much true.
66.
Complementarity is not easy with the Glo-
bal Fund. The predictability is weak (accord-
ing to the Court, only 39% of proposals for 
rounds 1–7 CfP have been granted by the  Fund). In addition the time scale to plan and 
prepare an intervention for both the Com-
mission and the Global Fund is completely 
different.
67.
The Commission agrees that there are poten-
tial synergies that could be better exploited 
by both budget support donors and the Glo-
bal Fund.
68.
As a rule, if there is a sector programme
4 in 
a country and if the Commission is involved 
in the health sector of this country, the Com-
mission will support its implementation.
4 As a result of following a SWAp, a government 
progressively develops a sector programme . A sector 
programme has three components: a sector policy and 
strategy , a sector budget and its medium-term perspective 
and a sector coordination mechanism.To reaffirm its position, the Commission  
signed in September 2007 the ‘international health partnership’ (IHP) which relaunched 
the sector wide approach in the health sector. 
Following this, the Commission delegations 
of Ethiopia and Mozambique have recently 
co-signed with governments and develop-
ment partners, an ‘IHP compact’ (modalities to apply IHP in a specific country).
69.
The Commission actively promotes the  
development and implementation of a sec-
tor programme, through a SWAp, mainly  
in the countries in which it supports the  health sector. So far, the Commission has  
been involved in several sector programmes 
(e.g. Ghana, Mozambique, Senegal, Uganda, 
and Zambia).
70.
In order to provide SBS to the health sector, 
the following criteria have to be satisfied:
the inclusion of support to health in the 1. 
CSP, as focal or non-focal sectors in the 
context of country ownership and divi-
sion of labour;SBS eligibility conditions are satisfied  2. 
(well-defined sector policy, sector coor-
dination mechanism, macroeconomic  
stability and PFM improvement).
However, in many sub-Saharan Africa coun-
tries these conditions are not currently  
met.
72.
The policy / strategy frameworks have  
improved a lot in SSA countries over the  last decade, with the support of the WHO  
and of all other major development partners. 
However, these policies need to be con-
stantly improved (for example, better links 
between health needs and resources). Joint 
annual health sector reviews in which the  
Commission is often involved, is an exercise which often result in new developments in 
the health policy / strategy frameworks.
76
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan AfricaCONCLUSIONS 
AND RECOMMENDATIONS
73.
In line with its policy commitments the Com-
mission has maintained its direct financing to health at country level, increased general 
budget support and its contribution to glo-
bal initiatives.
The 20% commitment (‘The Commission  
will endeavour to ensure that a benchmark 
of 20% of its allocated assistance under coun-try programmes covered by the DCI will be 
dedicated, by 2009, to basic and secondary 
education and basic health, through project, 
programme or budget support linked to  
these sectors , taking an average across all 
geographical areas…’ Article 5 of the Devel-
opment Cooperation Instrument) does not  
apply to ACP countries.
74.
Efficient health systems are able to convert 
Global Fund and PEPFAR support into health services to the population affected by HIV/
AIDS, tuberculosis and malaria.
The Commission also supports health system 
main elements such as human resources for health (HRH). The DCI / ‘Investing in people’ 
has earmarked EUR 40 million for HRH in the period 2007–13. EDF supports HRH activities and programmes in Angola, Mozambique,  Uganda, Zambia and Zimbabwe. HRH indica-tors are now used in GBS and health SBS vari-
ables tranches. The Commission also works with the WHO in supporting pharmaceuti-
cal policies (EUR 25 million) and improved 
health planning and budgeting (EUR 25 mil-
lion) in ACP countries.75.
The observation of the Court is noted by the 
Commission which will try to find solutions in view of having additional expertise, either 
in-house or through agreements, for exam-
ple, with Member States aid offices present in the countries.
RECOMMENDATIONS
ON RESOURCE ALLOCATIONS
No 1: The Commission will consider sectoral 
allocations according to the guidelines to  
be established for the 10th EDF mid-term  review. These are likely to stress country-
level objectives, results achieved and the  
principles of country ownership and divi-
sion of labour. They will also take into  
account the fact that results on the health  
MDGs can be attained through various  
ways, including investments outside the  health sector (water and sanitation, edu-
cation, rural development, governance,  
etc.) and not solely through direct suport  
to health services.
(a) While recognising the scope to expand  
the attention to health in fragile States,  often health donor orphans, the Com-mission already provides or will provide  direct support to the health sector under  the 10th EDF to 15 SSA countries of which  
eight are affected by situations of fragility  (Burundi, Chad, Congo, Democratic Republic 
of the Congo, Guinea, Côte d’Ivoire, Liberia  
and Zimbabwe). The number of countries  
affected by situations of fragility whose  health sector is supported by the Commis-
sion has increased from seven in the ninth  
to eight in the 10th EDF.
77
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa76.
The Commission welcomes the Court’s obser-
vation on the improved speed of implemen-tation of EDF health interventions, under the 
ninth EDF, and agrees with the Court that  
this is partly due to devolution.
77.
The results of the first five-year ongoing  
evaluation of the Global Fund will be avail-able by the end of this year. They will pro-
vide detailed information and analysis on the 
actual implementation of proposals funded 
by the Fund. The Commission carefully fol-
lows this evaluation and will take into con-sideration its conclusions. The Commission 
will also follow up on the conclusions of the 
Court’s audit.
78.
The Commission agrees that greater predict-
ability of funding would increase the effec-tiveness of aid. Accordingly, starting with  
the 10th EDF, the EC has developed the MDG 
Contract precisely to increase predictabil-
ity of budget support in performing partner 
countries. The Commission notes, however, that volatility in aid is justified when the  
preconditions for aid effectiveness are no  longer present as when budget support eli-gibility elapses.No 2: During the mid-term review of the  
10th EDF, the Commission will review the  balance of its funding to best reflect its  
policy priorities in health as in other sec-
tors in the light of the first years of imple-mentation of the 10th EDF. Health system  strengthening (HSS) is indeed among its  
priorities.
No 3: Though acknowledging the limits  
of resource allocation decision as concerns  
overall staff, the Commission is exploring  
ways to ensure a better access to public  
health expertise in delegations. Where the  Commission is indirectly involved in the  health sector, notably through GBS linked  to the social sectors or budget lines and  
intra-ACP funding, silent partnerships have 
to be agreed with other (EU) donors in the  
spirit of the code of conduct on comple-
mentarity and division of labour, and coor-dination within the budget support donor  
group ensured. Where health is a focal sec-
tor, the Commission will look into ways to  
provide the delegation with the adequate  
expertise.
(a) The possibility of establishing health  
expertise in regional delegations has been  under consideration for some time. There  is a need for the Commission to better bal-
ance the advantages and disadvantages  
of such a recommendation before reach-ing any decision.
(c) Cooperation with the WHO, which is  
already important, could indeed be rein-forced with its country offices whenever  this is possible.
78
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa79.
The Commission welcomes the Court’s  acknowledgement that GBS can be an impor-
tant instrument to support better health  
policies. Nevertheless, the Commission  
underlines that the effectiveness of gen-
eral budget support is better assessed in  
the longer term since progress in outcomes at national level takes time as it requires  
improvements in large systems and thus can-
not be compared to progress in outputs in 
smaller and targeted groups of the popu-
lation. Further improvements are targeted  
during the 10th EDF implementation, thanks 
to the introduction of MDG Contract and the preferred use of SBS for the implementation 
of programmed sector support. The Commis-
sion continues its efforts to increase the  
effectiveness of its BS instruments (includ-
ing through increased used of indicators  disaggregated at the level of the poorest  
regions, marginal areas or gender).
80.
The project approach — as stand alone  
project or as implementing modality of a  
SPSP — will continue to be an important ele-ment of EC support to the health sector. The 
Commission continuously tries to improve  
the selection of multi-country projects.
81.
The implication of the delegations also  depends on their capacity in sectoral  
matters.
Following the Court’s report, a specific Inter 
Service Group has been established to define 
what the Commission should do at country 
level to ensure a more efficient use of the  
Global Fund’s financial resources.RECOMMENDATIONS
ON SPEED AND PREDICTABILITY
No 4: The Commission is currently explor-
ing with UNAIDS the ways to build capac-
ity of countries in the fight against AIDS  
(development and implementation of a  ‘capacity building’ plan of action).
No 5: Under the 10th EDF, the Commission  
is seeking to make its GBS more predict-
able through the launch of MDG Contract  
in performing countries. The Commission  
believes that the threat of suspending pay-ments is an incentive to preserve eligibility: 
this would be undermined if the recourse  
to alternative instruments to preserve the  
flow of funds was automatic. The need to  
avoid unnecessarily punishing the poor,  
however, is one of the key factors deter-
mining Commission’s decisions under this  case-by-case approach.
79
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan AfricaRECOMMENDATIONS 
ON MANAGEMENT AND 
EFFECTIVENESS OF INSTRUMENTS
No 6: The Commission is committed to  
make the greatest use possible of SBS for  
focal and non-focal sector health interven-tions when conditions allow it. As per its  programming guidelines, the Commission  regards GBS as complementary to focal sec-
tor interventions, including when these are  
implemented through SBS.
No 7 (a): The Commission will continue its  
efforts to use GBS performance indicators  
and the linkages between GBS and sectoral  
dialogue (including joint sector reviews and 
ongoing dialogue where there is a SWAP) so 
as to encourage countries to achieve their  
health MDGs and other targets in a sustain-
able manner. This will imply using what in  each individual country case is regarded as  
the most appropriate mix of outcome and  
input indicators (such as budget shares and 
execution rates). A technical assistance  
facility could be included in General Budget Support operations to respond to specific  
needs regarding sectors with GBS indica-
tors (e.g. health information systems).
(b) At sector level annual reviews typi-
cally focus on the implementation of the  sector policy and the execution of the sec-
tor budget. Results of public expenditure  
reviews and expenditure tracking surveys  
are also taken into account when available. 
Out of the 22 SSA countries that have regu-
larly implemented EC GBS under the ninth
 
EDF, as many as 14 carry out regular joint  
health sector reviews whose results are then 
taken into account during the GBS joint  
annual review. In the remaining countries  
these are progressively being developed  
and encouraged in the context of GBS dia-
logue. Howevers the Commission will gen-erally prefer to use GBS and any attached  
safeguard as a means to strengthen more  
systemic components of partner pub-
lic financial management and also build  
capacities in the area of management  of human resources. Thus it would prefer  to strengthen domestic accountability bod-ies’ capacities to carry out reviews like the  ones suggested rather than carrying them  out directly. Such an approach has the  potential to maximise the impact of GBS,  
reduces the risks of overburdening the tool  
and embodies a design more proportionate 
to the multiple objectives of GBS.
(c) See above (point b of this box).(d) Within the overall limits of its human  
resource budget and the evolving status  
of division of labour exercises, the Com-
mission will do its utmost to improve the  
quality of input into health sector dialogue  as suggested above.
(e) The improvement of the indicators  
utilised in its budget support operations  
is a continuous preoccupation of the  
Commission.
No 8: The Commission has decided to estab-
lish a specific Inter Service Group, with the  
following tasks:
(1) to define the role and responsibilities an 
EC delegation should have in relation to the 
Global Fund (e.g. participation in the coun-
try coordinating mechanism, reporting,  
etc.). Different types of delegations could  be identified according to criteria such as,  for example, the level of HIV prevalence in  the country, the fact that health is or not  
a focal sector in the CSP, etc.;
(2) find out how delegations will fulfil their  
new tasks taking their limited resources  
into account;
(3) determine how delegations may be sup-
ported by HQ and how both Development  
DG and EuropeAid Co-operation Office will  
cooperate to carry out their assistance to  
the delegations.
In addition, The Commission is currently  
examining with UNAIDS the ways to build  
capacity of countries in the fight against  
AIDS (development and implementation  
of a ‘capacity building’ plan of action).
80
Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa82.
The Commission will further improve the  way in which it seeks to exploit synergies  between its interventions, starting with the 
ongoing review of health guidance.
83.
To support the implementation of secto-
ral programmes, the Commission in 2007  updated its 2003 guidelines on EC support to sector programmes and organised a whole series of trainings related to this implemen-tation modality. It has also launched and  
managed together with Denmark and the  Netherlands the joint learning programme  
on sector-wide approaches, an initiative  
highly regarded by the donor community.  
The Commission will continue to support the establishment and implementation of sec-
tor programmes, directly in the countries  
where health is part of its cooperation strat-
egy, and indirectly through GBS perform-
ance assessment and joint review processes 
elsewhere.No 9: Although the project (as an approach  
or as an implementation modality of a sec-tor policy support programme) is not the  
EC preferred form of aid implementation,  
it is clear that projects still remain a major  instrument to carry out our development  assistance. For example, a first assessment  
of the initial allocations to the 10th EDF  
national indicative programmes / Envelope A of SSA countries (South Africa excluded)  
shows that budget support (including  
GBS and SBS) represent approximately  
48% of the amounts so far allocated. The  
remaining 52% are then going to be spent  mostly through projects and earmarked  programmes. However, the Commission  cannot agree with the recommendation  
to use project support ‘to provide health-
care in poorer regions not adequately cov-
ered by health care services’ since in at  
least 30 developing countries, access to  health services is limited; but the adequate  
response to the challenge is sufficient, pre-
dictable and aligned health ODA; rather  
then the proposed NGO financing.RECOMMENDATIONS ON COHERENT 
USE OF INSTRUMENTS
No 10 (a): In the light of accumulating expe-
rience, the Commission will assess whether  there is need to review the indications about when to use GBS and SBS, and how best to  
use the two together, which are currently  
contained in the Commission’s guidelines  for programming, GBS and SBS.
(b) The guidance on the specific use of the  
various instruments in relation to the health 
sector (including projects), as well as on  their use in combination, will be reviewed  in the ‘health programming guidelines’  which are currently being updated to bet-
ter take into account broader developments 
of EC instruments (e.g. MDG Contract).
(c) The Commission’s new Interservice  
group on cooperation with the Global Fund 
will address ways to achieve greater com-
plementarity with Global Fund taking into  
account predictability issues in relation to  
Global Fund operations and the different  timeframes for Commission and Global  
Fund operations.
No 11: The Commission is committed to  
use SBS as its preferred implementation  modality for health interventions whenever conditions such as, among the others, the  existence of a well-defined sector policy.
No 12: The EC will continue to support the  
establishment and implementation of sec-tor programmes, directly in the countries  where health is part of its cooperation  strategy, and indirectly through GBS per-
formance assessment and joint review  
processes elsewhere.


European Court of Auditors
Special Report No 10/2008
EC development assistance to health services in sub-Saharan Africa
Luxembourg: Office for Official Publications of the European Communities2009 — 80 pp. — 21 × 29,7 cmISBN 978-92-9207-095-3doi: 10.2865/21515

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2008
EC DEVELOPMENT ASSISTANCE
TO HEALTH SERVICES IN SUBSAHARAN AFRICAEUROPEAN COURT 
OF AUDITORS
Special Report  No 10SPECIAL REPORT ‘EC DEVELOPMENT ASSISTANCE TO HEALTH SERVICES IN SUB
SAHARAN AFRICA’ EXAMINES WHETHER THE FINANCIAL AND HUMAN RESOURCES ALLOCATED TO THE HEALTH SECTOR REFLECTED THE EC’S POLICY COMMITMENTS, 
AND WHETHER THE COMMISSION HAS SPEEDED UP THE IMPLEMENTATION OF 
THIS AID AND USED THE VARIOUS TYPES OF FINANCING EFFECTIVELY. THE REPORT MAKES A SERIES OF RECOMMENDATIONS AIMED AT IMPROVING THE EFFECTIVENESS OF EC ASSISTANCE IN CONTRIBUTING TO IMPROVING HEALTH SERVICES IN SUBSAHARAN AFRICA.
EUROPEAN COURT OF AUDITORS
EN
QJ-AB-08-010-EN-C
ISBN 978-92-9207-095-3