Special Report No 10/2008#EC Development Assistance to Health Services in Sub-Saharan Africa
Date: 2008-11-19
Institutions: European Court of Auditors
Subjects: World Health Organisation, health care, health policy, health service, opinion of the Court of Auditors, public health, right to health, sub-Saharan Africa, the EU's international role, third country

SPECIAL  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.

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EUROPEAN COURT 
OF AUDITORS

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EN

EUROPEAN COURT OF AUDITORS

EC DEVELOPMENT ASSISTANCE
TO HEALTH SERVICES 
IN SUBSAHARAN AFRICA

ISBN 978-92-9207-095-3

 
 
 
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Special Report No 10  

 2008

EC DEVELOPMENT ASSISTANCE 
TO HEALTH SERVICES 
IN SUBSAHARAN AFRICA

(pursuant to Article 248(4), second subparagraph, EC)

EUROPEAN COURT OF AUDITORS

2

EUROPEAN COURT OF AUDITORS
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E-mail: euraud@eca.europa.eu
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Special Report No 10  

 2008

More information on the European Union is available on the Internet (http://europa.eu).

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

doi: 10.2865/21515

© European Communities, 2009

Reproduction is authorised provided the source is acknowledged.

Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa

Printed in Belgium

CONTENTS

GLOSSARY

 EXECUTIVE SUMMARY

INTRODUCTION

AUDIT SCOPE AND APPROACH

 OBSERVATIONS ON ALLOCATION AND DISBURSEMENT OF RESOURCES 
TO THE HEALTH SECTOR

RESOURCES ALLOCATED BY THE COMMISSION TO THE HEALTH SECTOR
FINANCIAL RESOURCES
HUMAN RESOURCES

SPEED OF EC FUNDING TO THE HEALTH SECTOR
EDF HEALTH SECTOR INTERVENTIONS
GENERAL BUDGET SUPPORT
GLOBAL FUND

MANAGEMENT AND EFFECTIVENESS OF INSTRUMENTS

BUDGET SUPPORT
THE USE OF BUDGET SUPPORT BY THE COMMISSION
EFFECTIVENESS OF GENERAL BUDGET SUPPORT IN IMPROVING HEALTH SERVICES

PROJECTS
EDF PROJECTS
INTRAACP PROJECTS
GENERAL BUDGET LINE HEALTH PROJECTS

GLOBAL FUND
THE COMMISSION’S MANAGEMENT OF ITS SUPPORT TO THE GLOBAL FUND
EFFECTIVENESS OF THE GLOBAL FUND

COHERENT USE OF INSTRUMENTS AND INTEGRATION IN SECTORWIDE APPROACHES
COHERENT MANAGEMENT OF INSTRUMENTS BY THE COMMISSION
INTEGRATION OF INTERVENTIONS INTO SECTORWIDE APPROACHES

CONCLUSIONS AND RECOMMENDATIONS

RESOURCES
MANAGEMENT AND EFFECTIVENESS OF INSTRUMENTS

Paragraph 

IVI 

13 

46 

729 

720 
817 
1820 

2129 
2223 
2425 
2629 

3072 

3146 
3134 
3546 

4755 
4849 
50 
5155 

5662 
5658 
5962 

6372 
6467 
6872 

7383 

7378 
7983 

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 Africa

GLOSSARY

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 Africa

EXECUTIVE 
SUMMARY

I.
T h e   o b j e c t i v e   o f   t h e   a u d i t   w a s   t o   a s s e s s 
h o w   e f f e c t i v e   E C   a s s i s t a n c e   h a s   b e e n   i n 
c o n t r i b u t i n g   t o   i m p r o v i n g   h e a l t h   s e r v i c e s 
in  sub-Saharan  Africa  in  the  context  of  the 
EC’s commitments to poverty reduction and 
the millennium development goals (MDGs). 
T h e   a u d i t   e x a m i n e d   w h e t h e r   t h e   f i n a n -
c i a l   a n d   h u m a n   r e s o u r c e s   a l l o c a t e d   t o   t h e 
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 
C o m m i s s i o n   h a d   u s e d   v a r i o u s   i n s t r u m e n t s 
to  assist  the  health  sector,  notably  budget 
s u p p o r t ,   p r o j e c t s   a n d   t h e   G l o b a l   F u n d   t o 
f i g h t   A I D S ,   t u b e r c u l o s i s   a n d   m a l a r i a   ( G l o -
bal Fund).

II.
Overall, EC funding to the health sector has 
n o t   i n c r e a s e d   s i n c e   2 0 0 0   a s   a   p r o p o r t i o n 
of  its  total  development  assistance  despite 
t h e   C o m m i s s i o n ’ s   M D G   c o m m i t m e n t s   a n d 
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 
C o m m i s s i o n   h a s   h a d   i n s u f f i c i e n t   h e a l t h 
e x p e r t i s e   t o   e n s u r e   t h e   m o s t   e f f e c t i v e   u s e 
of health funding (paragraphs 18 to 20).

III.
The Commission has accelerated the health 
a s s i s t a n c e   i t   m a n a g e s   i t s e l f .   W h i l e   t h e 
G l o b a l   F u n d   h a s   m o b i l i s e d   a   l a r g e   v o l u m e 
of funding, its rate of disbursement has been 
slower  than  for  the  European  Development 
F u n d s   ( E D F ) .   T h e r e   i s   s c o p e   f o r   i m p r o v i n g 
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).

Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa

IV.
The Commission has made little use of Sec-
t o r   B u d g e t   S u p p o r t   i n   t h e   h e a l t h   s e c t o r 
a l t h o u g h   t h i s   i n s t r u m e n t   c o u l d   m a k e   a n 
important contribution to improving health 
services. It has used General Budget Support 
much more widely but its links to the health 
s e c t o r   a r e   l e s s   d i r e c t   a n d   t h e   C o m m i s s i o n 
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.
T h e   C o m m i s s i o n   h a s   n o t   p a i d   s u f f i c i e n t 
a t t e n t i o n   t o   e n s u r i n g   t h e   d i f f e r e n t   i n s t r u -
ments  are  used  together  coherently.  When 
choosing which instruments to use, it could 
a l s o   t a k e   m o r e   a c c o u n t   o f   t h e   s i t u a t i o n   i n 
i n d i v i d u a l   c o u n t r i e s ,   i n   p a r t i c u l a r   w h e t h e r 
t h e y   h a d   a   w e l l - d e f i n e d   h e a l t h   s e c t o r   p o l -
icy. Given their importance to the effective-
ness of each instrument, there is a need for 
t h e   C o m m i s s i o n   t o   c o n t r i b u t e   m o r e   t o   t h e 
development of such policies and to ensure 
i t s   i n t e r v e n t i o n s   a r e   i n t e g r a t e d   i n t o   t h e m 
(paragraphs 63 to 72). 

7

EXECUTIVE 
SUMMARY

VI.
The report’s main recommendations are that 
the Commission should:

 –

 –

 –

 –

 –

 –

 –

 –

consider increasing its aid to the health 
s e c t o r   d u r i n g   t h e   1 0 t h   E D F   m i d - t e r m 
review to support its commitment to the 
health MDGs;

review  how  its  assistance  to  the  health 
sector  is  distributed  to  ensure  it  is  pri-
m a r i l y   d i r e c t e d   t o   i t s   p o l i c y   p r i o r i t y 
of health systems support;

e n s u r e   e a c h   d e l e g a t i o n   h a s   a d e q u a t e 
h e a l t h   e x p e r t i s e   e i t h e r   i n   t h e   d e l e g a -
tion or through drawing on the resources 
of other partners;

make more use of Sector Budget Support 
i n   t h e   h e a l t h   s e c t o r   a n d   f o c u s   i t s   G e n -
eral Budget Support more on improving 
health services;

c o n t i n u e   t o   u s e   p r o j e c t s ,   e s p e c i a l l y 
f o r   s u p p o r t   t o   p o l i c y   d e v e l o p m e n t   a n d 
c a p a c i t y   b u i l d i n g ,   p i l o t   i n t e r v e n t i o n s 
and assistance to poorer regions; 

work more closely with the Global Fund 
in beneficiary countries;

establish clearer guidance on when each 
i n s t r u m e n t   s h o u l d   b e   u t i l i s e d   a n d   h o w 
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 Africa

INTRODUCTION

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.

1. 

2. 

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 
t h e   M D G s   w h i c h ,   o v e r   t h e   p e r i o d   2 0 0 0 – 1 5 ,   a r e   i n t e n d e d   t o   b e   t h e 
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 
a n d   o t h e r   d i s e a s e s .   H o w e v e r ,   t h e   U n i t e d   N a t i o n s   2 0 0 7   m i d - t e r m 
r e v i e w   o f   p r o g r e s s   t o w a r d s   t h e   M D G s 1  r e p o r t e d   t h a t   t h e   p r o j e c t e d 
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).

In 2000 the Commission made poverty reduction the overarching goal 
o f   i t s    d e v e l o p m e n t   p o l i c y 2  a n d   a l s o   c o m m i t t e d   i t s e l f   t o   a s s i s t i n g 
d e v e l o p i n g   c o u n t r i e s   a c h i e v e   t h e   M D G s .   T h e   2 0 0 5   ‘ E u r o p e a n   c o n -
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.

(a) 

In 2000 it launched a policy to accelerate action targeted at HIV/
AIDS, malaria, and tuberculosis 3. 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 
i m p r o v e m e n t   o f   h e a l t h   s y s t e m s ;   t h e r e   i s   a l s o   a   n e e d   f o r   s i m u l -
t a n e o u s   a c t i o n s   b e y o n d   t h e   t r a d i t i o n a l   h e a l t h   s e c t o r ’ .   H e n c e , 
the  Commission  proposed  new  partnerships  and  faster  delivery 
mechanisms and this initiative contributed to the creation of the 
Global Fund in 2001.

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 Africa

 
 
9

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.

(b) 

(c) 

While the 2000 policy initiative was focused on HIV/AIDS, malaria 
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 
i n   t h e   a r e a s   o f   p r o m o t i n g   p u b l i c   h e a l t h ,   s t r e n g t h e n i n g   h e a l t h 
s y s t e m s ,   p r o - p o o r   s y s t e m s   o f   h e a l t h   f i n a n c i n g ,   c o m m u n i c a b l e 
diseases, and reproductive and sexual health and rights.
These two policies have remained the main basis for Commission 
interventions  in  the  health  sector  with  the  2000  communication 
being updated in 2004 to cover the period 2007–11. The main addi-
t i o n a l   i n i t i a t i v e ,   d i r e c t e d   a t   h e a l t h   s y s t e m s   s t r e n g t h e n i n g ,   w a s 
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.

Source: ECA.

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 Africa

 
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Channels

Instruments

Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
AUDIT SCOPE AND APPROACH

11

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:

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.

(a) 

(b) 

(c) 

(d) 

Has the amount of resources allocated by the Commission to the 
health sector reflected its policy commitments?
Has  the  Commission  accelerated  its  funding  of  assistance  to  the 
health sector?
H a s   t h e   C o m m i s s i o n   u s e d   t h e   i n d i v i d u a l   i n s t r u m e n t s   a v a i l a b l e 
effectively to contribute to improving health services?
Has the Commission used the range of instruments available coher-
ently to effectively contribute to improving health services?

5. 

T h e   m a i n   a u d i t   w o r k   c a r r i e d   o u t   t o   a n s w e r   t h e s e   q u e s t i o n s   w a s   a s 
follows:

(a) 
(b) 

(c) 

(d) 

(e) 

a review of documentation on EC health assistance policy;
a review of EDF, general budget line and Global Fund health sec-
tor commitments and disbursements;
o n - t h e - s p o t   m i s s i o n s   t o   K e n y a ,   L e s o t h o ,   M a l a w i ,   M a l i   a n d 
Swaziland;
d e s k   r e v i e w s   o f   h e a l t h   i n t e r v e n t i o n s   i n   B u r u n d i ,   C ô t e   d ’ I v o i r e 
and Ethiopia;
a   s u r v e y   o f   a l l   4 1   E C   d e l e g a t i o n s   i n   s u b - S a h a r a n   A f r i c a   o n   E C 
assistance to the health sector 5. 

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. 
I t   a l s o   e x c l u d e d   t h e   a u d i t   o f   h e a l t h   i n t e r v e n t i o n s   b y   t h e   E u r o p e a n 
Community Humanitarian Office (ECHO).

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 Africa

 
 
 
OBSERVATIONS ON ALLOCATION 
AND DISBURSEMENT OF RESOURCES 
TO THE HEALTH SECTOR

7. 

8. 

9. 

RESOURCES ALLOCATED BY THE COMMISSION 
TO THE HEALTH SECTOR

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.

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.

FINANCIAL RESOURCES

The Commission has made strong policy commitments 
to the health sector 

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 
p o p u l a t i o n   i n t e r v e n t i o n s   o v e r   t h e   n e x t   f i v e   y e a r s   ( 2 0 0 2 – 0 6 ) 6.   S u b -
s e q u e n t l y ,   t h e   2 0 0 3   p r o g r e s s   r e p o r t   o n   t h e   p r o g r a m m e   f o r   a c t i o n 7 
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.

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 
i s   p r o v i d e d   t h r o u g h   G e n e r a l   B u d g e t   S u p p o r t   f o r   w h i c h   t h e r e   i s   n o 
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. 

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.

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Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa

 
 
 
13

Overall 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 directly 11 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.

11 Excluding General Budget 

Support (see paragraph 12).

T A B L E   2

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

Total EDF commitments

Type of health support

Health in country 
programmes

Health in regional 
programmes

Health in intra-ACP funded 
interventions

Eighth EDF

9 787,0

Ninth EDF

13 930,7

Amount 
of EDF health 
commitments

% of total EDF 
commitments

Amount 
of EDF health 
commitments

% of total EDF 
commitments

369,3

3,8 %

351,2

2,5 %

13,1

47,6

0,1 %

0,5 %

4,4 %

19,7

0,1 %

399,7

770,6

2,9 %

5,5 %

Total

430,0

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 
p a r a g r a p h   2 ) .   L o w   h e a l t h   c o m m i t m e n t s   w e r e   n o t   c o m p e n s a t e d   f o r 
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.

Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa
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14

T A B L E   3

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 

Total EDF country programmes

Health in country programmes

Education in country programmes

Total health and education 
in country programmes 

Eighth EDF

7 268,6

Ninth EDF

9 793,8

369,3

175,5

544,8

5,1 %

2,4 %

7,5 %

351,2

255,8

607

3,6 %

2,6 %

6,2 %

12. 

Apart from the direct funding to the health sector, an assessment of the 
C o m m i s s i o n ’ s   s u p p o r t   t o   t h e   h e a l t h   s e c t o r   i n   s u b - S a h a r a n   A f r i c a 
should  also  take  General  Budget  Support  into  account,  although  in 
practice it is very difficult to quantify.

12 The IMF and Aid to sub-Saharan 

Africa. Independent Evaluation 

Office of the IMF, 2007.

(a) 

(b) 

(c) 

Under the seventh and eighth EDFs, 3 240 million euro were com-
m i t t e d   b y   t h e   C o m m i s s i o n   t o   b u d g e t a r y   s u p p o r t   p r o g r a m m e s . 
U p   u n t i l   2 0 0 0 ,   c o u n t e r p a r t   f u n d s   a r i s i n g   f r o m   t h e   p r o g r a m m e s 
were directly allocated to national health and education budgets, 
an  estimated  800  million  euro  (80  million  euro  per  annum;  35  % 
o f   c o u n t e r p a r t   f u n d s )   b e i n g   p r o v i d e d   t o   t h e   h e a l t h   s e c t o r   o v e r 
the period 1990–99.
U n d e r   t h e   n i n t h   E D F ,   G e n e r a l   B u d g e t   S u p p o r t   c o m m i t m e n t s 
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-
m a t e d   t h a t   i t   w a s   l o w e r   t h a n   u n d e r   t h e   t w o   p r e v i o u s   E D F s .   I f 
i t   i s   a s s u m e d   t h a t   c o u n t r i e s   s p e n d   t h e   G e n e r a l   B u d g e t   S u p p o r t 
t h e y   r e c e i v e   i n   l i n e   w i t h   t h e   r e l a t i v e   s h a r e s   o f   s e c t o r   b u d g e t s , 
t h i s   w o u l d   m e a n   t h a t   a p p r o x i m a t e l y   2 0 0   m i l l i o n   e u r o   w a s   u s e d 
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.
F o r   t h e   1 0 t h   E D F ,   G e n e r a l   B u d g e t   S u p p o r t   o f   a p p r o x i m a t e l y 
3  300  million  euro  has  been  programmed.  While  this  represents 
a n   i n c r e a s e   c o m p a r e d   w i t h   t h e   n i n t h   E D F ,   i t   i s   u n l i k e l y   t o   l e a d 
t o   a s   m u c h   r e s o u r c e s   b e i n g   c h a n n e l l e d   t o   h e a l t h   a s   u n d e r   t h e 
seventh and eighth EDFs.

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 Africa

 
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.

15

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 
r e c o g n i s i n g   t h e   l i m i t a t i o n s   o f   a   p u r e l y   i n p u t   b a s e d   a p p r o a c h ,   t h e 
Court’s analysis pointed to an indicative figure of 1 100 million euro 
t o   1   2 0 0   m i l l i o n   e u r o   b e i n g   a l l o c a t e d   t o   t h e   h e a l t h   s e c t o r   i n   s u b -
S a h a r a n   A f r i c a   o v e r   t h e   p e r i o d   o f   t h e   n i n t h   E D F   i n c l u d i n g   G e n e r a l 
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 
w a s   a   m o r e   t h a n   4 0   %   i n c r e a s e   i n   t o t a l   c o m m i t m e n t s   f o r   t h e   n i n t h 
E D F   c o m p a r e d   w i t h   t h e   e i g h t h   E D F   t h e   p e r c e n t a g e   o f   E C   f u n d i n g 
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 
a r e   e s t i m a t e d   a t   a p p r o x i m a t e l y   t h e   s a m e   a m o u n t   a s   f o r   t h e   n i n t h 
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.

15. 

There is a shortage of international assistance 
for strengthening health systems

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-
a g e m e n t   p r i n c i p l e ,   i t   d o e s   n o t   e n s u r e   t h a t   a d e q u a t e   r e s o u r c e s   a r e 
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. 

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1616

15 Council of the European Union 

Note 9558/07, Brussels, 

15 May 2007. 

16. 

The  2007  EU  Code  of  Conduct  on  Complementarity  and  the  Division 
of  Labour  in  Development  Policy 15  stresses  the  need  to  address  the 
problem  of  donor  orphans,  which  are  often  fragile  States  and  post-
c r i s i s   c o u n t r i e s .   A n   E C   c o m p a r a t i v e   a d v a n t a g e ,   r e c o g n i s e d   i n   b o t h 
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 
o f   i t s   r o l e   i n   s u p p o r t i n g   r e h a b i l i t a t i o n   a n d   d e v e l o p m e n t   a f t e r   t h e 
end  of  relief  operations  managed  by  ECHO.  Since  a  significant  part 
of ECHO’s interventions are health-related, there is a particular need 
t o   a s s u r e   f o l l o w - u p   h e a l t h   i n t e r v e n t i o n s .   I n   o n l y   a   l i m i t e d   n u m b e r 
o f   s u c h   c o u n t r i e s   w a s   h e a l t h   s e l e c t e d   a s   a   f o c a l   s e c t o r   u n d e r   t h e 
10th EDF (Angola, Burundi, Côte d’Ivoire, Democratic Republic of the 
Congo, Liberia and Zimbabwe).

B O X   1

KEY ISSUES IN THE OVERALL LEVEL AND DISTRIBUTION OF HEALTH FUNDING

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 worse17.

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. 

Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa

 
1717

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.

17. 

The relatively large Commission funding for disease-specific interventions 
compared to that for health systems (see paragraph 10) reflected the 
f a c t   t h a t   o v e r   t h e   p e r i o d   2 0 0 0 – 0 5   i t   i n v e s t e d   s i g n i f i c a n t   e f f o r t s   i n 
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 
h e a l t h   s e c t o r 2 0,   t h e   C o u r t   f o u n d   t h a t   t h i s   p r o b l e m   p e r s i s t s   a n d   a 
human resource strategy to address it has not been developed. Of the 
3 7   d e l e g a t i o n s   i n   s u b - S a h a r a n   A f r i c a   w h i c h   r e p l i e d   t o   t h e   C o u r t ’ s 
s u r v e y ,   1 3   d e l e g a t i o n s   h a v e   i n   t o t a l   1 8   s t a f f   w i t h   u n i v e r s i t y - l e v e l 
qualifications  in  health-related  fields 21.  Only  four  of  these  are  per-
manent  officials,  of  which  just  one  works  full-time  on  health 22.  The 
Court identified several issues during its on-the-spot audit work (see 
B o x   2 ) .   N o t   o n l y   i s   i t   e s s e n t i a l   f o r   d e l e g a t i o n s   i n   c o u n t r i e s   w h e r e 
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:

(a) 

(b) 
(c) 

(d) 

t o   m a n a g e   t h e   h e a l t h   a s p e c t s   o f   G e n e r a l   B u d g e t   S u p p o r t 
programmes;
to support and monitor Global Fund operations in the country;
to better supervise the health general budget line and intra-ACP 
projects;
to ensure HIV/AIDS issues are integrated into all EC interventions.

B O X   2

STAFFING ISSUES IDENTIFIED DURING THE COURT’S AUDIT MISSIONS

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.

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19. 

Commission headquarters does not have sufficient expertise to provide 
a d e q u a t e   b a c k u p   t o   t h e   d e l e g a t i o n s   i n   s u b - S a h a r a n   A f r i c a .   I n   D G 
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 
l a c k   o f   h e a l t h   e x p e r t i s e   a t   d e l e g a t i o n   l e v e l   w a s   t h e   a p p o i n t m e n t 
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 
f o r   d e l e g a t i o n s   t o   c o o p e r a t e   m o r e   i n   p o s t - c o n f l i c t   c o u n t r i e s   w i t h 
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.

21. 

22. 

SPEED OF EC FUNDING TO THE HEALTH SECTOR

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

The speed of implementation of ninth EDF health sector interventions 
in sub-Saharan Africa has significantly increased compared with the 
e i g h t h   E D F   ( s e e   T a b l e   4 ) .   A   m a j o r   f a c t o r   e x p l a i n i n g   t h e   a c c e l e r a -
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.

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T A B L E   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

Year 2

Year 3 

Year 4

Year 5

0 %

1 %

3 %

8 %

18 %

1  Excluding transfers to Global Fund (see paragraph 26).

0 %

3 %

13 %

25 %

39 %

23. 

24. 

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

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.

T A B L E   5

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

Year 2

Year 3 

Year 4

Year 5

12 %

22 %

31 %

55 %

71 %

5 %

18 %

38 %

57 %

74 %

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25. 

However, the Court found that speed and predictability were reduced 
by:

(a) 

(b) 

delays in countries making eligible payment requests, mainly due 
to their problems in collecting data for the performance indicators 
(e.g. Burundi, Kenya, Mali);
some countries losing their eligibility for General Budget Support, 
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, 
h a v e   a c c e l e r a t e d   t h e   s p e e d   w i t h   w h i c h   t h e   C o m m i s s i o n   d i s b u r s e s 
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.

B O X   3

BUDGET SUPPORT TO ETHIOPIA

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.

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T A B L E   6

EFFECT 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 EDF

Ninth EDF

Ninth EDF

(excluding Global 
Fund)

(including Global 
Fund)

Year 1

Year 2

Year 3 

Year 4

Year 5

0 %

1 %

3 %

8 %

18 %

0 %

3 %

13 %

25 %

39 %

22 %

24 %

31 %

46 %

55 %

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 
w h i c h   t h e   G l o b a l   F u n d   d i s b u r s e s   i n   s u b - S a h a r a n   A f r i c a n   c o u n t r i e s 
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.

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T A B L E   7

COMPARISON OF CUMULATIVE RATE OF DISBURSEMENT OF GLOBAL FUND 
AND EDF HEALTH INTERVENTIONS IN SUBSAHARAN AFRICA 

Year 1

Year 2

Year 3

Global Fund

EDF health interventions

2 %

13 %

26 %

1 %

25 %

36 %

28. 

Besides the Global Fund’s legitimate emphasis on performance-based 
f u n d i n g ,   w h i c h   m e a n s   i t   r e d u c e s   d i s b u r s e m e n t s   t o   l e s s   e f f e c t i v e 
grants,  two  further  factors  affecting  the  rate  of  disbursement  have 
been:

(a) 

(b) 

difficulties  of  some  recipients  of  Global  Fund  support  in  estab-
l i s h i n g   f i n a n c i a l ,   p r o c u r e m e n t   a n d   m o n i t o r i n g   s y s t e m s   o f   t h e 
standard  required  by  the  Global  Fund  and  in  quickly  disbursing 
the funding; 
n e w   f u n d i n g   s o u r c e s   s u c h   a s   P E P F A R   e n t e r i n g   c o u n t r i e s   d u r -
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-
i n g   w i l l   b e   a p p r o v e d   a n d   f o r   w h a t   a m o u n t .   T h u s ,   o v e r   t h e   f i r s t   s i x 
years  of  the  Global  Fund  only  39  %  of  grant  applications  submitted 
for financing were actually approved. 

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MANAGEMENT AND EFFECTIVENESS 
OF INSTRUMENTS

23

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. 

30. 

The Court examined the three main instruments used to improve health 
s e r v i c e s :   b u d g e t   s u p p o r t ,   p r o j e c t s ,   a n d   t h e   G l o b a l   F u n d .   T h i s   s e c -
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.

31. 

BUDGET SUPPORT

THE USE OF BUDGET SUPPORT BY THE COMMISSION 

Budget support has the potential to play a key role 
in improving health services

Budget support has the potential to play a key role in improving health 
s e r v i c e s   b y   i n c r e a s i n g   f u n d s   a v a i l a b l e   t o   g o v e r n m e n t s   f o r   t h e i r 
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 
t e c h n i c a l   a s s i s t a n c e .   T h e   C o m m i s s i o n ,   w h i c h   i s   o n e   o f   t h e   b i g g e s t 
providers  of  budget  support,  defines  it  as  ‘the  transfer  of  financial 
r e s o u r c e s   o f   a n   e x t e r n a l   f i n a n c i n g   a g e n c y   t o   t h e   n a t i o n a l   t r e a s u r y 
o f   a   p a r t n e r   c o u n t r y ,   f o l l o w i n g   t h e   r e s p e c t   b y   t h e   l a t t e r   o f   a g r e e d 
conditions  for  payment’ 23.  Although  it  classifies  budget  support  as 
G e n e r a l   B u d g e t   S u p p o r t   o r   S e c t o r   B u d g e t   S u p p o r t ,   i n   p r a c t i c e   t h e 
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 
B u d g e t   S u p p o r t   o p e r a t i o n s   w h i c h   i n c l u d e   s o m e   m a c r o   a n d   c r o s s -
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-
t i a l   f o r   a s s i s t i n g   t h e   h e a l t h   s e c t o r .   H o w e v e r ,   a l t h o u g h   i t   h a s   b e e n 
Commission policy since 2000 to increase its use, in practice only two 
s u b - S a h a r a n   A f r i c a n   c o u n t r i e s   ( M o z a m b i q u e   a n d   Z a m b i a )   r e c e i v e d 
h e a l t h   s e c t o r   b u d g e t   s u p p o r t   u n d e r   t h e   n i n t h   E D F .   O n e   r e a s o n   f o r 
t h i s   i s   t h a t   t h e   C o m m i s s i o n   h a s   g e n e r a l l y   o n l y   u s e d   h e a l t h   s e c t o r 
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.

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33. 

34. 

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 
s u p p o r t ,   t h e   C o m m i s s i o n   a l l o w s   i t s   u s e   i n   a d d i t i o n   t o   f u n d i n g   t w o 
f o c a l   s e c t o r s .   F u r t h e r m o r e ,   m o r e   c o u n t r i e s   a r e   e l i g i b l e   f o r   G e n e r a l 
Budget  Support  since  an  overall  national  policy,  rather  than  a  spe-
c i f i c   s e c t o r a l   p o l i c y ,   i s   a n   e l i g i b i l i t y   r e q u i r e m e n t   e v e n   t h o u g h   t h e 
e f f e c t i v e n e s s   o f   n a t i o n a l   p o l i c y   t o   a   c o n s i d e r a b l e   d e g r e e   d e p e n d s 
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 
s e c t o r a l   d i m e n s i o n   ( s e e   p a r a g r a p h   3 1 ) .   T h i s   h a s   t r a d i t i o n a l l y   b e e n 
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.

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-
c e i v e d   i m p r o v i n g   h e a l t h   s e r v i c e s   a s   a   k e y   o b j e c t i v e   o f   t h e   i n s t r u -
m e n t   ( s e e   T a b l e   8 ) .   O n   t h e   o t h e r   h a n d ,   t h e   r e v i s e d   2 0 0 7   G e n e r a l 
Budget  Support  manual  considerably  reduced  the  instrument’s  sec-
toral dimension compared to the previous 2002 manual, lessening its 
focus on improving health services.

T A B L E   8

DELEGATIONS’ PERCEPTION OF THE IMPORTANCE 
OF GENERAL BUDGET SUPPORT OBJECTIVES 

1

1

1

1

1

1

1

1

3

2

1

0

1

2

0

4

4

5

3

1

1

3

4

8

5

6

0

4

7

10

11

14

12

8

8

9

5

18

16

12

7

7

10

9

10

N/O

Average

GBS objectives

2

2

2

2

2

2

2

3

4,43

4,43

4,14

3,86

3,86

3,79

3,71

3,67

Reducing poverty 

Improving public ﬁ nance management

Providing macroeconomic stability

Harmonising aid procedures

Increasing predictability of funding

Improving health services

Improving education services

Reducing aid transaction costs

(1 = Not important, 5 = Highly important, N/O = No opinion)

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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. 

EFFECTIVENESS 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 
C o m m i s s i o n   i s   s t i l l   w o r k i n g   t o   e s t a b l i s h   a n   a p p r o p r i a t e   e v a l u a t i o n 
methodology. In its assessment of the instrument’s effectiveness the 
Court focused on the following aspects 25:

(a) 

(b) 

(c) 

(d) 

w h e t h e r   t h e   f i n a n c i a l   i n p u t s   p r o v i d e d   w e r e   a s s o c i a t e d   w i t h 
increased allocations to and disbursements from national health 
b u d g e t s   a n d   w h e t h e r   t h e   i n p u t s   w e r e   l i k e l y   t o   b e   u s e d   f o r   t h e 
intended purpose; 
whether the policy and institutional framework in the health sec-
tor was conducive to the effective delivery of services;
w h e t h e r   d e l e g a t i o n s   w e r e   i n v o l v e d   i n   h e a l t h   s e c t o r   p o l i c y   d i a -
logues which would contribute to the more effective use of Gen-
eral Budget Support; 
w h e t h e r   h e a l t h   p e r f o r m a n c e   i n d i c a t o r   t a r g e t s   s e l e c t e d   a s   p a r t 
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 

The Court found that in most countries examined General Budget Support 
d i d   n o t   l e a d   t o   i n c r e a s e d   r e s o u r c e s   b e i n g   c h a n n e l l e d   t h r o u g h   t h e 
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.

36. 

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37. 

The Commission’s ‘dynamic interpretation’ of eligibility 
for General Budget Support puts at risk the effective use 
of funding for improving health services 

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 
s t i l l   b e   e l i g i b l e   f o r   G e n e r a l   B u d g e t   S u p p o r t ,   l e a d i n g   t o   a   h i g h   r i s k 
of  inefficient  and  ineffective  public  spending.  Funds  channelled  to 
the health sector are at particular risk since resource flows to front-
l i n e   s e r v i c e   p r o v i d e r s   a r e   c o m p l e x ,   g e n e r a l l y   p a s s i n g   t h r o u g h   s e v -
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. 

B O X   4

GENERAL BUDGET SUPPORT AND ITS EFFECT ON HEALTH BUDGETS

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.

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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.

38. 

39. 

General Budget Support programmes have not adequately addressed 
these risks. The 2002 General Budget Support manual foresaw finan-
c i a l   a u d i t s   a n d   c o m p l i a n c e   t e s t s ,   p a r t i c u l a r l y   i n   t h e   s o c i a l   s e c t o r s , 
during the course of programme implementation, in addition to the 
initial  appraisal  of  the  quality  of  public  finance  management.  Such 
c o n t r o l s   a r e   p a r t i c u l a r l y   n e c e s s a r y   w h e r e   t h e   c a p a c i t y   o f   n a t i o n a l 
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. 
T h i s   s t a t e s   t h a t   o n c e   t h e   C o m m i s s i o n   h a s   t r a n s f e r r e d   r e s o u r c e s   t o 
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 
t h e   r e s u l t s   c h a i n   f r o m   ‘ i n p u t s ’   t o   ‘ o u t p u t s ’   t o   ‘ r e s u l t s / o u t c o m e s ’ 2 7. 
T h e   C o u r t   s h a r e s   t h e   v i e w   o f   t h e   E u r o p e a n   P a r l i a m e n t   t h a t   t h i s   i s 
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 

The  Court  found  that  in  two  countries  visited,  Malawi  and  Mali,  the 
e f f e c t i v e n e s s   o f   G e n e r a l   B u d g e t   S u p p o r t   c h a n n e l l e d   t o   t h e   h e a l t h 
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.

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The 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 
s u r v e y ,   t h e   g r e a t   m a j o r i t y   o f   d e l e g a t i o n s   d i r e c t l y   p a r t i c i p a t e d   i n   a 
h e a l t h   s e c t o r   d i a l o g u e ,   t h e   C o u r t   f o u n d   w e a k n e s s e s   i n   t h e   q u a l i t y 
and depth of this dialogue:

(a) 

(b) 

(c) 

the limited health expertise in delegations (see paragraph 18) is 
not conducive to contributing to high-quality dialogue. The Com-
mission has sought to find economic expertise to work on General 
B u d g e t   S u p p o r t   b u t   h a s   n o t   f o r m e d   w i d e r   t e a m s   f o r   s u c h   p r o -
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);
i t   i s   u n c l e a r   w h a t   d e p t h   o f   s e c t o r a l   d i a l o g u e   d e l e g a t i o n s   a r e 
e x p e c t e d   t o   g o   i n t o   i n   t h e   c o n t e x t   o f   G e n e r a l   B u d g e t   S u p p o r t 
(see paragraph 34);
discussions on the achievement of performance indicator targets 
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. 

43. 

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. 

The Court examined how far the health sector performance indicator 
t a r g e t s   c o n t a i n e d   i n   t h e   C o m m i s s i o n ’ s   f i n a n c i n g   a g r e e m e n t s   h a d 
b e e n   a c h i e v e d .   I t   f o u n d   t h a t   o v e r a l l   o n l y   5 0   %   o f   t h e   h e a l t h   i n d i -
c a t o r   t a r g e t s   h a d   b e e n   m e t .   T h i s   r a i s e s   i s s u e s   a b o u t   t h e   e f f e c t i v e -
ness of General Budget Support programmes in helping bring about 
improvements in health services.

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44. 

The Court found several factors concerning the way health performance 
i n d i c a t o r s   w e r e   u s e d   w h i c h   a l s o   r e d u c e d   t h e   e f f e c t i v e n e s s   o f   G e n -
e r a l   B u d g e t   S u p p o r t   i n   c o n t r i b u t i n g   t o   i m p r o v e m e n t s   i n   h e a l t h 
services.

(a) 

(b) 

(c) 

(d) 
(e) 

The incentive value of performance targets may be reduced both 
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.
G o v e r n m e n t s   a l s o   h a d   l e s s   i n c e n t i v e ,   a n d   t h e   l i n k   t o   G e n e r a l 
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 
to be sure whether a target had been achieved or not, particularly 
w h e n   i n d i c a t o r s   w e r e   m e a s u r e d   o v e r   r e l a t i v e l y   s h o r t   1 2 - m o n t h 
periods, which meant changes were sometimes hard to detect.
Targets set were sometimes under- or overambitious.
I n d i c a t o r s   d i d   n o t   s u f f i c i e n t l y   a d d r e s s   q u a l i t a t i v e   a s p e c t s 
of healthcare.

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. 
M o r e o v e r ,   t h e   C o m m i s s i o n ’ s   h e a l t h   p e r f o r m a n c e   i n d i c a t o r s   r a r e l y 
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.

The Court’s survey asked delegations how they perceived the effective-
ness  of  General  Budget  Support  in  improving  health  services  and  in 
m e e t i n g   o t h e r   o b j e c t i v e s .   T h e i r   r e p l i e s   c o n f i r m e d   t h e   C o u r t ’ s   c o n -
cerns about the effectiveness of General Budget Support, as currently 
i m p l e m e n t e d ,   i n   i m p r o v i n g   h e a l t h   s e r v i c e s .   O n   a   s c a l e   o f   1   ( l o w ) 
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).

45. 

46. 

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T A B L E   9

SUBSAHARAN EC DELEGATIONS’ PERCEPTION OF THE EFFECTIVENESS 
OF GENERAL BUDGET SUPPORT IN IMPROVING HEALTH SERVICES 

1

1

0

1

2

1

1

1

3

2

1

0

1

1

5

7

7

8

3

5

6

5

6

7

6

8

4

4

8

15

13

10

9

6

4

5

5

9

3

5

5

3

2

2

2

N/O

Average GBS objectives

5

5

4

5

4

7

7

7

3,96

3,88

3,80

3,63

3,32

3,05

2,95

Providing macroeconomic stability

Improving public ﬁ nance management

Harmonising aid procedures

Reducing aid transaction costs

Increasing predictability of funding

Reducing poverty 

Improving education services

2,77

Improving health services

(1 = Not important, 5 = Highly important, N/O = No opinion)

47. 

PROJECTS

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 

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examined  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.

(a) 

(b) 

(c) 

(d) 

(e) 

(f) 

Projects tended to be too ambitious, particularly in post-conflict 
situations, both because of the wide range of activities and geo-
graphical  coverage  of  some  projects  and  because  too  much  was 
e x p e c t e d   o f   w h a t   p r o j e c t s   c o u l d   a c h i e v e   w i t h o u t   t h e   s u p p o r t 
of other instruments. 
The  project  implementation  timeframe  was  generally  too  short, 
f i r s t l y   b e c a u s e   o f   l o n g   p r o c u r e m e n t   a n d   a p p r o v a l   p r o c e s s e s 
(see  paragraph  23),  and  secondly  because  time  was  required  for 
c h a n g e s   i n t r o d u c e d   b y   t h e   p r o j e c t s   t o   t a k e   h o l d   i n   b e n e f i c i a r y 
organisations and become sustainable.
The quality of the technical assistance contracted for these projects var-
ied greatly and this had a considerable influence on project results.
Capacity both to deliver health services and work with EDF projects 
also varied, especially at provincial and district level. 
The lack of a sound country health policy reduced project effective-
ness, and particularly the prospects for achieving sustainability.
D e l e g a t i o n s   o f t e n   d i d   n o t   h a v e   t h e   h e a l t h   e x p e r t i s e   a n d ,   m o r e 
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-
i s f a c t o r y ,   i n   t w o   c a s e s   a s   p a r t i a l l y   s a t i s f a c t o r y   a n d   i n   t w o   c a s e s   a s 
u n s a t i s f a c t o r y .   F a c t o r s   i n   t h e   m a n a g e m e n t   o f   t h i s   t y p e   o f   p r o j e c t 
which led to their generally modest performance included:

(a) 

(b) 

(c) 

the design of the projects, which generally involved a large number 
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 
m a n a g e d   p r o j e c t s   a n d   t h e   d i f f i c u l t y   C o m m i s s i o n   h e a d q u a r t e r s 
h a d   i n   a d e q u a t e l y   m o n i t o r i n g   p r o j e c t s   w h i c h   f r e q u e n t l y   c o v e r 
numerous countries;
difficulties in agreeing planning and reporting modalities between 
the Commission and UN bodies and subsequent problems for the 
UN bodies in complying with these modalities.

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30 Appraisal of the two legal bases 

on health, AIDS and population, 

Ecorys Research and Consulting, 

November 2006. 

32

GENERAL 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 
i n   K e n y a ,   M a l a w i   a n d   M a l i .   T h e   e f f e c t i v e n e s s   o f   t h r e e   p r o j e c t s   w a s 
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:

(a) 

(b) 

(c) 

(d) 

they were targeted on poverty-related issues and often provided 
basic  services  in  remoter  areas  where  government  services  were 
less present;
i n   s e n s i t i v e   a r e a s   s u c h   a s   H I V / A I D S   m a n y   p e o p l e ,   p a r t i c u l a r l y 
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-
m i s s i o n   t o   s u p e r v i s e ,   a n d   h e n c e   l e s s   p r o n e   t o   d e l a y ,   s i n c e   a l l 
project activities came under one NGO contract;
the projects provided high visibility for relatively low funding.

53. 

In general, as noted in a recent evaluation of the health budget lines 30, the 
weak  point  of  such  projects  is  their  sustainability  and  wider  impact 
because:

(a) 

(b) 

(c) 

a l t h o u g h   t h e   r e g u l a t i o n s   g o v e r n i n g   t h e   h e a l t h   g e n e r a l   b u d g e t 
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;
t h e   C o m m i s s i o n   h a s   n o t   e s t a b l i s h e d   a   s y s t e m   t o   e n s u r e   t h a t 
t h e   l e s s o n s   l e a r n e d   f r o m   s u c c e s s f u l   p r o j e c t s   a r e   s y s t e m a t i c a l l y 
disseminated;
although successful projects could have been scaled up using EDF financ-
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. 

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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 
f r o m   b o t h   t h e   d i f f i c u l t y   N G O s   h a d   i n   i m p l e m e n t i n g   o f t e n   c o m p l e x 
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.

B O X   5

GLOBAL FUND OPERATING PRINCIPLES

• 

• 

• 

• 

• 

• 

• 

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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31 Evaluation of the organisational 

effectiveness and efficiency 

of the Global Fund to fight 

AIDS, tuberculosis and malaria’. 

October 2007 (Macro Consultancy). 

34

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). 
T h i s   r e p r e s e n t e d   8 , 1   %   o f   t o t a l   c o n t r i b u t i o n s   t o   t h e   G l o b a l   F u n d , 
making  the  Commission  the  fourth  biggest  contributor.  However,  a 
recent  evaluation  of  the  management  of  the  Global  Fund  has  noted 
t h a t   t h e   G l o b a l   F u n d   m a y   e x p e r i e n c e   d i f f i c u l t i e s   i n   a b s o r b i n g   t h e 
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-
n i s m s   ( C C M )   a n d   h e l p   s t r e n g t h e n   t h e m :   a c c o r d i n g   t o   t h e   C o u r t ’ 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)  r e p o r t i n g   o n   a s p e c t s   o f   t h e   G l o b a l   F u n d   f u n c t i o n i n g   i n   c o u n t r y : 
according to the Court’s survey, just 8 % of delegations reported 
regularly  to  Commission  headquarters,  59  %  reported  occasion-
a l l y   w h i l e   o n e   t h i r d   h a d   n e v e r   r e p o r t e d .   W h i l e   t h e   C o m m i s s i o n 
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)  p r o v i d i n g   t e c h n i c a l   a s s i s t a n c e   f o r   d e v e l o p i n g   g r a n t   p r o p o s a l s 
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 
t h e   n e e d   f o r   t h e   i n t e r n a t i o n a l   c o m m u n i t y   t o   p r o v i d e   t e c h n i c a l 
assistance in sub-Saharan Africa to address this problem, but the 
Commission has not responded to this need.

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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. 

35

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 
s u p p o r t e d - p r o g r a m m e s ’ . T h e s e   i n d i c a t o r s   i n c l u d e   o u t p u t s   n o t   o n l y 
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 
p r o v i n g   d i f f i c u l t   b e c a u s e   o f   s t a f f i n g   s h o r t a g e s   a n d   c u l t u r a l   i s s u e s . 
S o m e   m a l a r i a   g r a n t s   e x p e r i e n c e d   p r o c u r e m e n t   d e l a y s   f o r   I T N s   a n d 
A C T s .   M o r e   d e t a i l s   o f   G l o b a l   F u n d   i n t e r v e n t i o n s   e x a m i n e d   b y   t h e 
audit are given in Annex III.

T A B L E   1 0

GLOBAL FUND PERFORMANCE INDICATORS 
FOR ITS THREE SUBSAHARAN AFRICAN REGIONS AT 31 DECEMBER 2007 

HIV/AIDS

% 
of target

Activities

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)

Support to orphans

Tuberculosis

DOTS treatment 

Malaria

Insecticide treated nets (ITN)

Anti-malarial treatment (ACT)

Other indicators

Care and support

People trained

Source: Global Fund.

64 %

116 %

100 000 HIV positive pregnant received a 
full course of prevention of mother-to-child 
transmission

2 million orphans provided with care and 
support

86 %

800 000 people on treatment

63 %

43 %

107 %

105 %

35 million nets distributed

37 million malaria treatments delivered

1,7 million people received care and support

1,8 million people trained to deliver services

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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.

36

60. 

61. 

62. 

63. 

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.

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 
r e f l e c t s   m o r e   t h e   d i s e a s e   b u r d e n   i n   t h e s e   a r e a s   t h a n   t h e   o v e r a l l 
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 
i n   t h e   p o o r e r   r e g i o n s   o f   c o u n t r i e s   w h i c h   a r e   l e s s   w e l l - c o v e r e d   b y 
government health services. 

The role of the Global Fund in health system strengthening and poverty 
reduction are issues which have not received adequate attention from 
t h e   C o m m i s s i o n ,   a t   e i t h e r   b o a r d   o r   c o u n t r y   l e v e l .   T h i s   r e f l e c t s   t h e 
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

The Commission’s overall health policy gave budget support a leading 
r o l e   i n   i t s   s t r a t e g y   f o r   a s s i s t i n g   t h e   h e a l t h   s e c t o r   b u t   s t r e s s e d   t o o 
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   n a t i o n a l   f r a m e w o r k   i s   n o t   i n   p l a c e ,   t h e   C o m m u n i t y   w i l l   f a c i l i t a t e 
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. 

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64. 

65. 

66. 

67. 

COHERENT MANAGEMENT OF INSTRUMENTS 
BY THE COMMISSION

The Commission has not developed guidance for coherently 
managing the different instruments in the health sector

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 
n u m b e r   o f   h e a l t h   S e c t o r   B u d g e t   S u p p o r t   p r o g r a m m e s   f i n a n c e d   b y 
the Commission in sub-Saharan Africa has reduced the effectiveness 
of its General Budget Support (see paragraphs 36 to 46).

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).

The 2002 health policy, while emphasising the complementary role of dif-
f e r e n t   i n s t r u m e n t s ,   d o e s   n o t   a c t u a l l y   m a k e   r e f e r e n c e   t o   t h e   l i n k s 
between the Global Fund and the instruments managed by the Com-
mission. The Court found that the lack of involvement of delegations 
i n   G l o b a l   F u n d   o p e r a t i o n s   ( s e e   p a r a g r a p h   5 8 )   h a d   l e d   t o   t h e   C o m -
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.

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. 
H o w e v e r ,   t h e   G e n e r a l   B u d g e t   S u p p o r t   i n s t r u m e n t   h a s   n o t   w o r k e d 
with the Global Fund in these areas and its financing agreements do 
not generally make reference to the Global Fund. 

B O X   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.

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INTEGRATION 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. 

69. 

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 
c o u n t r y   t o   c o u n t r y :   1 0   c o u n t r i e s   a l r e a d y   h a d   S W A p s ,   1 0   c o u n t r i e s 
were preparing SWAps, while in 14 countries delegations found health 
policies to be inadequate. 

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 
t h e   C o u r t ’ s   s u r v e y ,   i n   o n l y   e i g h t   d e l e g a t i o n s   ( 2 2   % )   h a d   n i n t h   E D F 
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. 

72. 

A key concern with the project approach is projects’ sustainability (see 
p a r a g r a p h s   4 8   a n d   5 3 ) .   G i v e n   t h a t   t h i s   i s   d e p e n d e n t   o n   t h e i r   i n t e -
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.

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 
i n   j u s t   t w o   c o u n t r i e s ,   M a l a w i   a n d   M o z a m b i q u e   b u t   i t s   2 0 0 7   s t r a t -
e g y   s i g n a l l e d   i t s   i n t e n t i o n   t o   e n g a g e   m o r e   i n   s u c h   f u n d i n g   w h e r e 
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. 

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CONCLUSIONS 
AND RECOMMENDATIONS

39

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. 

74. 

75. 

Financial allocations to the health sector in sub-Saharan Africa have not 
increased since 2000 as a proportion of its total development assist-
a n c e   d e s p i t e   t h e   C o m m i s s i o n ’ s   M D G   c o m m i t m e n t s   a n d   t h e   h e a l t h 
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. 

The Commission has mobilised significant additional funding to con-
t r i b u t e   t o   t h e   G l o b a l   F u n d   a g a i n s t   A I D S ,   t u b e r c u l o s i s   a n d   m a l a r i a . 
However,  the  Commission  has  focused  on  tackling  these  three  dis-
eases  rather  than  on  support  to  health  systems,  which  is  its  policy 
priority. 

The Commission does not have sufficient health expertise to adequately 
i m p l e m e n t   i t s   h e a l t h   p o l i c y   a n d   h a s   n o t   m a d e   s y s t e m a t i c   a r r a n g e -
ments to draw on alternative sources of expertise. 

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R E C O M M E N D A T I O N S   O N   R E S O U R C E   A L L O C A T I O N S

No 1:  In the context of its policy of supporting the achievement of the 
M i l l e n n i u m   D e v e l o p m e n t   G o a l s ,   t h e   C o m m i s s i o n   s h o u l d   c o n s i d e r 
increasing  its  support  to  the  health  sector  during  the  10th  EDF  mid-
term review, particularly in:

(a) 

(b) 

(c) 

 fragile  States,  as  the  Commission  is  considered  to  have  a  com-
parative advantage in these countries;
 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;
 countries which have been found to be health donor orphans.

No 2:  T h e   C o m m i s s i o n   s h o u l d   r e v i e w   t h e   b a l a n c e   o f   i t s   f u n d i n g   t o 
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 
a n d   p l a y   a n   e f f e c t i v e   r o l e   i n   h e a l t h   s e c t o r   d i a l o g u e .   T o   t h i s   e n d   i t 
should,  as  a  minimum,  ensure  that  all  delegations  where  health  is  a 
focal  sector  have  health  specialists.  It  should  assess  how  far  the  fol-
l o w i n g   o p t i o n s   a r e   f e a s i b l e   f o r   e n s u r i n g   a d e q u a t e   s u p p o r t   t o   o t h e r 
delegations:

(a) 

(b) 

(c) 

(d) 

 establishing health expertise in regional delegations to support 
delegations without health specialists;
 working more closely in post-conflict countries with ECHO health 
advisers;
 f o r m i n g   c l o s e r   p a r t n e r s h i p s   w i t h   W o r l d   H e a l t h   O r g a n i s a t i o n 
country offices to draw on their expertise;
 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.

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THERE 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. 

77. 

78. 

There has been a significant improvement in the implementation rate 
for EDF interventions, at least partly because of devolution.

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.

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.

R E C O M M E N D A T I O N S   O N   S P E E D   A N D   P R E D I C T A B I L I T Y

No 4:  T h e   C o m m i s s i o n   s h o u l d   w o r k   m o r e   c l o s e l y   w i t h   t h e   G l o b a l 
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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MANAGEMENT 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 
p o o r e r   s e c t i o n s   o f   t h e   p o p u l a t i o n .   S e c t o r   B u d g e t   S u p p o r t ,   w h i c h 
f o c u s e s   o n   t h e   h e a l t h   s e c t o r ,   h a s   b e e n   l i t t l e   u s e d   b y   t h e   C o m m i s -
sion in sub-Saharan Africa.

80. 

81. 

Although weaknesses exist with the project instrument, notably in rela-
t i o n   t o   s u s t a i n a b i l i t y ,   p r o j e c t s   h a v e   m a d e   a   u s e f u l   c o n t r i b u t i o n   t o 
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.

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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R E C O M M E N D A T I O N S   O N   M A N A G E M E N T 
A N D   E F F E C T I V E N E S S   O F   I N S T R U M E N T S

No 6:  Greater use should be made of Sector Budget Support. The gen-
e r a l   r e q u i r e m e n t   t h a t   i t   c a n   o n l y   b e   u s e d   i f   h e a l t h   i s   a   f o c a l   s e c t o r 
should be reviewed and the Commission should reconsider its current 
distribution of resources between Sector Budget Support and General 
Budget Support.

No 7:  T h e   s e c t o r a l   d i m e n s i o n   o f   G e n e r a l   B u d g e t   S u p p o r t   s h o u l d   b e 
strengthened by:

(a) 

(b) 

(c) 

(d) 

(e) 

 u s i n g   p e r f o r m a n c e   i n d i c a t o r s   a n d   h e a l t h   s e c t o r   d i a l o g u e   t o 
e n c o u r a g e   c o u n t r i e s   t o   r e s p e c t   t h e i r   c o m m i t m e n t   t o   m o v e 
towards  allocating  15  %  of  their  national  budget  to  health  and 
to fully implement their national health budget;
 c a r r y i n g   o u t   o p e r a t i o n a l   a n d   f i n a n c i a l   r e v i e w s   t o   e s t a b l i s h 
w h e t h e r   h e a l t h   b u d g e t   r e s o u r c e s   a r e   b e i n g   u s e d   f o r   t h e i r 
intended purpose;
 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;
 improving  the  quality  of  input  into  the  health  sector  dialogue 
b y   i n c r e a s i n g   t h e   l e v e l   o f   h e a l t h   e x p e r t i s e   i n   t h e   C o m m i s s i o n 
services or by using other donor expertise based on clear written 
mandates;
 giving  g r e a t e r   a t t e n t i o n   t o   e n s u r i n g   t h a t   p e r f o r m a n c e   i n d i c a -
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 
F u n d   a t   c o u n t r y   l e v e l .   A s   w e l l   a s   g i v i n g   b e n e f i c i a r y   c o u n t r i e s   m o r e 
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), 
t o   f i n a n c e   p i l o t   i n t e r v e n t i o n s   ( h e a l t h   g e n e r a l   b u d g e t   l i n e   p r o j e c t s ) 
and  to  provide  healthcare  in  poorer  regions  not  adequately  covered 
by healthcare services (NGO budget line projects). The role of general 
b u d g e t   l i n e   p r o j e c t s   c o v e r i n g   a   n u m b e r   o f   c o u n t r i e s   a n d   i n t r a - A C P 
projects should be reconsidered.

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THE 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. 

83. 

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.

Given the importance of sound sector-wide approaches to the effec-
t i v e n e s s   o f   a l l   i n s t r u m e n t s ,   t h e r e   i s   a   n e e d   t o   r e i n f o r c e   t h e   e f f o r t s 
t o   s u p p o r t   c o n t r i b u t i n g   t o   t h e   d e s i g n   a n d   i m p l e m e n t a t i o n   o f   s u c h 
approaches.

R E C O M M E N D A T I O N S   O N   C O H E R E N T   U S E   O F   I N S T R U M E N T S

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) 

(b) 

(c) 

 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;
 p r o v i d i n g   f o r   i n c r e a s e d   a n d   m o r e   e f f e c t i v e   u s e   o f   t h e   p r o j e c t 
instrument to support Budget Support and Global Fund interven-
tions in the health sector;
 taking  a c c o u n t   o f   G l o b a l   F u n d   o p e r a t i o n s   w h e n e v e r   t h e   C o m -
m i s s i o n   p l a n s   a   h e a l t h   s e c t o r   i n t e r v e n t i o n ,   i n c l u d i n g   t h r o u g h 
General Budget Support.

No 11: The choice of instruments to be used should take more specific 
a c c o u n t   o f   t h e   s i t u a t i o n   o f   t h e   c o u n t r y   a n d   i n   p a r t i c u l a r   w h e t h e r   i t 
has a well-defined sector policy.

N o   1 2 :   T h e   C o m m i s s i o n   s h o u l d   m o r e   c l o s e l y   a l i g n   i t s   h e a l t h   s e c t o r 
i n t e r v e n t i o n s ,   i n c l u d i n g   G l o b a l   F u n d   i n t e r v e n t i o n s ,   w i t h   S W A p s .   I n 
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

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Source: ECA.

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A N N E X   I

MILLENNIUM DEVELOPMENT GOALS: 2007 PROGRESS CHART 

Goals and targets

Africa

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 enrolment

moderate 
enrolment

GOAL 3 

|  Promote gender equality and empower women

Equal girls’ enrolment in primary school 

close to parity

almost close to 
parity

parity

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 parliaments

very low 
representation

low representation

moderate 
representation

low representation

low representation

very low 
representation

GOAL 4 

|  Reduce child mortality 

Reduce mortality of under-ﬁ ve-year-olds 
by two thirds

low 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 quarters

moderate 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 prevalence

very high 
prevalence

low prevalence

low prevalence

moderate 
prevalence

low 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 cover

medium forest 
cover

medium forest 
cover

high forest cover

medium forest 
cover

low forest cover

Halve proportion without improved 
drinking water

high 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-dwellers

moderate 
proportion 
of slum-dwellers

very high 
proportion 
of slum-dwellers

high proportion 
of slum-dwellers

moderate 
proportion 
of slum-dwellers

high proportion 
of slum-dwellers

moderate 
proportion 
of slum-dwellers

GOAL 8 

|  Develop a global partnership for development

Youth unemployment

very high 
unemployment

high 
unemployment

low unemployment

high 
unemployment

moderate 
unemployment

very 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.

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Goals and targets

Oceania

Latin America and 
Caribbean

Commonwealth of Independent States

Europe

Asia

GOAL 1 

|  Eradicate extreme poverty and hunger

Reduce extreme poverty by half

—

moderate poverty

low poverty

low poverty

Reduce hunger by half

moderate hunger

moderate hunger

very low hunger

high hunger

GOAL 2 

|  Achieve universal primary education

Universal primary schooling

moderate 
enrolment

high enrolment

high enrolment

high enrolment

GOAL 3 

|  Promote gender equality and empower women

Equal girls’ enrolment in primary school 

close to parity

parity

parity

parity

Women’s share of paid employment

medium share

high share

high share

high share

Women’s equal representation 
in national parliaments

very low 
representation

moderate 
representation

low representation

low representation

GOAL 4 

|  Reduce child mortality

Reduce mortality of under-ﬁ ve-year-olds 
by two thirds

moderate mortality

low mortality

low mortality

moderate mortality

Measles immunisation

low coverage

high coverage

high coverage

high coverage

GOAL 5 

| 

Improve maternal health

Reduce maternal mortality 
by three quarters

high mortality

moderate mortality

low mortality

low mortality

GOAL 6 

|  Combat HIV/AIDS, malaria and other diseases

Halt and reverse spread of HIV/AIDS

moderate 
prevalence

moderate 
prevalence

moderate 
prevalence

low prevalence

Halt and reverse spread of malaria

low risk

moderate risk

low risk

low risk

Halt and reverse spread of tuberculosis

moderate mortality

low mortality

moderate mortality moderate mortality

GOAL 7 

|  Ensure environmental sustainability

Reverse loss of forests

high forest cover

high forest cover

high forest cover

low forest cover

Halve proportion without improved 
drinking water

low coverage

high coverage

high coverage

moderate coverage

Halve proportion without sanitation

low coverage

moderate coverage moderate coverage moderate coverage

Improve the lives of slum-dwellers

moderate 
proportion 
of slum-dwellers

moderate 
proportion 
of slum-dwellers

low proportion 
of slum-dwellers

moderate 
proportion 
of slum-dwellers

GOAL 8 

|  Develop a global partnership for development

Youth unemployment

low unemployment

high 
unemployment

high 
unemployment

high 
unemployment

Internet users

low access

high access

moderate access

moderate access

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A N N E X   I I

EXTRACT FROM BRUSSELS DECLARATION 
BY ACP MINISTERS OF HEALTH, OCTOBER 2007

‘N.  Re c ognis ing  c ur r en t  c hallenges  of  h ealt h   mana ge men t   in   ACP 
S t a t e s   i n c l u d i n g ,   i n t e r   a l i a ,   t h e   l a c k   o f   h u m a n   r e s o u r c e s ,   w e a k -
nes se s of d is ease  ale rt  a nd su r vei llan ce s y s te ms , i nade qua te he alt h 
infor m atio n  m anagem e nt  sy ste ms   for   de ci s i on  ma ki ng,   p oor   q ual-
i t y   o f   h e a l t h c a r e ,   e s p e c i a l l y   u n i v e r s a l   p r e c a u t i o n s ,   b l o o d   t r a n s f u -
s i o n   a n d   l a b o r a t o r y   c a p a c i t y ,   l o w   l e v e l   o f   i n d i g e n o u s / o p e r a t i o n a l 
r e s e a r c h   a n d   d e v e l o p m e n t   ( R   &   D )   i n   e n d e m i c ,   a n d   c o m m u n i c a -
bl e  d ise ases   su ch  as  H IV  an d  AIDS ,  t uberculo s is   an d  mal ar ia ,  and 
chron i c  di sea se s s uch  as d iab e t es ,  h y pert en s io n,  a s th ma,  a s  w ell  as 
those arising out of violence, trauma and accidents, limited prepar-
edne ss and m anagem e nt of e pidemic s  s uch  a s  E bo la amon g ot h ers , 
e x o r b i t a n t   p r i c e s   o f   d r u g s   a n d   p h a r m a c e u t i c a l s   a n d   t h e   n e e d   t o 
ade qua te ly financ e  the  h e alth s ect or  f rom  a nn ual  budge ts ;

O .   S t r e s s i n g   t h e   i m p o r t a n c e   o f   h e a l t h   s y s t e m s   i n   A C P   S t a t e s   t o 
a d d r e s s   t h e   p r e v e n t i o n ,   t r e a t m e n t   a n d   m a n a g e m e n t   o f   n e g l e c t e d 
tropical diseases within the epidemiological context, such as human 
t r y p a n o s o m i a s i s   ( s l e e p i n g   s i c k n e s s ) ,   d e n g u e ,   l e p r o s y ,   f i l a r i a s i s , 
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, 
rabi e s, a s w ell as  m e ntal i lln es s, neurol ogi ca l i ll nes s es ,  huma n cer -
eb ral me ningi ti s,  i nte stinal w or ms ,  and i nf ant i le di ar rho ea,  a mo ng 
othe r s;’

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A N N E X   I I I

COUNTRY SUMMARIES

SWA ZILA ND

OVERVIEW OF  HEALT H SITUAT ION

Swa zi land  has t he  wo rst H IV/AIDS  pr ev al ence ra t e in  t he  w or l d at 
34 %  o f the popu lati on . Clos e ly  r e la t ed t o th is ,  i t al s o h as  th e h ig h -
est TB pr evale nce ra te , ca ses  r is i ng f rom 85 6  p er  100  0 0 0 pe opl e  in 
200 0  to  1   1 82   pe r   1 00   0 00  in  200 6.  L i fe  ex pecta ncy  h as   f al le n  f r om 
6 0   y e a r s   i n   1 9 9 8   t o   j u s t   3 1   y e a r s   i n   2 0 0 4 .   T h e r e   a r e   a n   e s t i m a t e d 
130  00 0 or phans and  vuln e r able  c hi ldre n ( OV C ) in  a to tal  pop ula-
tion  of  one  m illio n.

Both infant and under-five mortality have increased since 1997, ris-
ing fr om  78  and 1 06  p er  1 00 0 li ve bi rt h s  r e s pecti ve ly in  1 997 to  8 5 
and 120 in 2006. HIV/AIDS is the cause of 47 % of under-five deaths. 
Ther e  has  b ee n  a   r api d   r is e   i n  mat er na l  mor tal it y  fr om  2 30  de ath s 
per  10 0 000  live  bi r th s i n  19 99  t o 37 0  in  2006 ,  th e  pr in cip al c aus es 
b e i n g   n o t   o n l y   H I V / A I D S   b u t   a l s o   t h e   l i m i t a t i o n s   o f   t h e   h e a l t h 
s y s t e m .   H e a l t h   s e r v i c e s   a r e   i n c r e a s i n g l y   s t r u g g l i n g   t o   c o p e   w i t h 
t h e   h u g e   n e w   d i s e a s e   b u r d e n   w h i c h   i s   a d d e d   t o   b y   a   r i s e   i n   n o n -
com m un i cab le  di se ases  w hi c h r ecei ve l it tl e  att en ti on . 

EDF  PROJEC TS

HI V/ AID s pr ev ent ion  and   c are  prog ram me  (H A PA C)

HAPAC I (2001–05; 2,25 million euro) largely achieved its objectives 
in re la tio n to  deve lo pi ng n e w  VC T  s erv ic es ,  bui ldi ng up th e  h ome-
based care network in one of Swaziland’s four regions and support-
ing  m e asur es  to  st re ng th e n  the  tr eat ment   of  S T Is .   T he  main   r es ul t 
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 
f o r e s e e n   f o r   t h i s   f o l l o w - u p   p r o j e c t   h a v e   o n l y   b e e n   a c h i e v e d   t o   a 
lim it ed   deg re e.   H APAC  II   w as  fi na nced  becaus e  th e   sus t ain ab il ity 
of  H AP AC  I   h ad  not  ye t   b e en   as sure d  b ut  s us t ai nab il ity   r emai ns   a 
maj or  pr ob lem an d so m e VC T cent re s  we re  e xpe ct ed t o cl os e  at  th e 
end of the project, in 2008. Better coordination by the Commission 
with   t he  G lobal  F u nd  c ou ld  ha ve  a ll ow ed  th e  G lo bal  Fund  to   tak e 
over  o per atio ns  cove re d  b y th e p ro je ct  at   th e  end  of  HAPA C  I.

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A N N E X   I I I

NGO  C O FINANCING GENER A L BU DG ET L I NE

Inte gra t ed HIV/ AIDS a nd  liv elih ood proj e ct

T h i s   p r o j e c t   i s   i n t e n d e d   t o   a s s i s t   p e r s o n s   l i v i n g   w i t h   H I V / A I D S 
and orphans and vulnerable children through home-based care and 
h e l p i n g   t h e m   i n c r e a s e   f o o d   s e c u r i t y   t h r o u g h   g r o w i n g   t h e i r   o w n 
f o o d .   T h e   p r o j e c t   w a s   s t i l l   a t   a n   e a r l y   s t a g e .   W h i l e   v e r y   r e l e v a n t , 
t h e   o b j e c t i v e s   a p p e a r e d   t o   b e   t o o   a m b i t i o u s   f o r   a   p r o j e c t   o f   l i t t l e 
mor e  th an  thre e  ye ar s. 

GLOBAL F UND

Swaziland has so far received the highest per capita support from the 
Global Fund in the world (105 million USD, approximately 100 USD 
p e r   c a p i t a ) .   T h e   g r e a t   m a j o r i t y   o f   t h e   f u n d i n g   h a s   b e e n   f o r   H I V /
AID S.T he   low   am o un t  of  fu ndi ng  fo r   tub er cul os i s   do es   n o t  r e fl ec t 
the  sc ale  of  the  pr ob le m . 

The results of Global Fund-supported programmes are rather mixed. 
C a r e   a n d   s u p p o r t   t o   f a m i l i e s   a n d   c o m m u n i t i e s   a f f e c t e d   b y   H I V /
AID S, VCT ser vic es  and  ho me - ba s ed car e c omp on en ts  h av e g en er -
ally progressed well. On the other hand, parts of the components on 
A R V   t r e a t m e n t   a n d   m o n i t o r i n g ,   P M T C T   s u p p o r t ,   a n d   p r e v e n t i o n 
work amongst youth have been less effective. Global Fund reporting 
r e q u i r e m e n t s   h a v e   b e e n   a   c a t a l y s t   f o r   i m p r o v i n g   m o n i t o r i n g   a n d 
evalua ti on s yst em s and   dat a r e li abi li t y.

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A N N E X   I I I

LE SO T HO

OVERVIEW OF  HEALT H SITUAT ION

L e s o t h o ’ s   H I V / A I D S   p r e v a l e n c e   r a t e   o f   2 3   %   i s   o n e   o f   t h e   h i g h -
e s t .   C l o s e l y   a s s o c i a t e d   w i t h   t h i s   i s   t h e   e x t r e m e l y   h i g h   p r e v a l e n c e 
o f   t u b e r c u l o s i s .   H I V / A I D S   a n d   T B   a r e   t h e   m a i n   r e a s o n s   w h y   l i f e 
e x p e c t a n c y   h a s   p l u m m e t e d   s i n c e   t h e   m i d - 1 9 9 0 s   f r o m   6 0   y e a r s   t o 
just   41  year s.  Th er e   are   an  e sti mate d  1 8 0  00 0   o rp ha ns   and  vul ne r -
able children, approximately 10 % of the population. While malaria 
doe s n o t e xist in L es ot ho, othe r  co ncern s  in clude th e gr ow in g l e ve l 
of n on- co mm unic ab le  d isea ses .

P a r t l y   a s   a   r e s u l t   o f   H I V / A I D S ,   i n f a n t   m o r t a l i t y   h a s   c o n s i d e r a b l y 
i n c r e a s e d ,   f r o m   a n   a v e r a g e   o f   7 5   p e r   1   0 0 0   l i v e   b i r t h s   o v e r   t h e 
p e r i o d   1 9 9 5 – 9 9   t o   9 1   o v e r   t h e   p e r i o d   2 0 0 0 – 0 4 .   A t   t h e   s a m e   t i m e , 
maternal mortality has risen dramatically from 282 per 100 000 live 
b i r t h s   i n   1 9 9 3   t o   7 6 2   i n   2 0 0 4 .   T h e   d e t e r i o r a t i o n   o f   h e a l t h   i n d i c a -
tors also reflects the decline in health services, which are struggling 
to  c ope   w ith  t he   hi g he r   di se ase  bur den.   Budget ar y  res o ur c es   ha ve 
n o t   i n c r e a s e d   t o   a d d r e s s   t h i s   s i t u a t i o n   a n d   a r e   a l l o c a t e d   d i s p r o -
p o r t i o n a t e l y   t o   s e c o n d a r y   a n d   t e r t i a r y   c a r e   a n d   t o   u r b a n   a r e a s . 
The c ou nt ry i s los ing  he alth w orke rs  to  o th er coun tr i es  an d due  to 
HIV/ AI D S-re lated   de at hs .

GE NER AL  BU DGET  SUPPORT

G e n e r a l   B u d g e t   S u p p o r t   h a s   n o t   b e e n   a n   e f f e c t i v e   i n s t r u m e n t   f o r 
imp ro ving   he alth  ser vi c es.  The  e ig ht h   EDF  p ro gr amme   was   h al t ed 
by the Commission because of the government’s lack of commitment 
to public finance management reform and the programme also faced 
d i f f i c u l t i e s   i n   p r o v i d i n g   r e l i a b l e   d a t a   f o r   p e r f o r m a n c e   i n d i c a t o r s . 
For these reasons support under the ninth EDF, although originally 
prog r am me d,   was  not  g rante d .

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A N N E X   I I I

EDF  PROJEC TS

The e ig hth E D F pro j ec t ‘Su pport  to  h eal th  s ec to r r efo rm’  ( 1,8  mi l-
l i o n   e u r o )   m a d e   a n   i m p o r t a n t   c o n t r i b u t i o n   t o   t h e   h e a l t h   s e c t o r 
decentralisation process in Lesotho, both in its support to the over-
a l l   p l a n n i n g   o f   t h e   p r o c e s s   a n d   i t s   p i l o t i n g   o f   d e c e n t r a l i s a t i o n   i n 
three districts, even if the pilot phase of nine months was too short. 
The G o ver nm ent of L esot ho  has  s ubs eq uent l y ex te nded dec en tr ali -
s a t i o n   t o   a l l   1 0   d i s t r i c t s ,   a l t h o u g h   s e r i o u s   c a p a c i t y   a n d   r e s o u r c e 
const ra ints e xi st .

NGO  C O FINANCING PRO JE CT:  H O ME BA SE D CA RE 
FOR  PEOPLE  LIVING  WITH HI V/A IDS  OR  TE R MIN AL 
ILL NESSES AND  OVC S

Over all , thi s i s a suc c e ssfu l pr oje ct  wit h 600  p eopl e tr ain ed as  ca re 
provi d e rs, ea ch  wit h an ave rag e of  1 0 cl ie nt s  alt hough o nl y l imi ted 
sup po rt  i s d e liver e d  to  or phan s a nd v ulne rabl e ch il dre n . A f ol l ow -
u p   p r o j e c t   h a s   b e e n   l a u n c h e d   w h i c h   a d d r e s s e s   f o o d   s e c u r i t y   a n d 
i n c o m e - g e n e r a t i n g   a c t i v i t i e s   t o   m a k e   t h e   p r o j e c t   s u s t a i n a b l e ,   b u t 
the  thr ee -ye ar pr oj e c t  d ur a ti on  may  be  t oo  s h ort   to  ac h iev e  th i s . 

GLOBAL F UND

U n d e r   t h e   m a i n   g r a n t   i m p l e m e n t e d   s o   f a r   ( H I V / A I D S ,   R o u n d   2 ) 
m o r e   t h a n   1 5   0 0 0   p e o p l e   a r e   r e c e i v i n g   A R V   t r e a t m e n t ,   c o m p a r e d 
w i t h   a   t a r g e t   o f   1 2   5 0 0 ,   a s   a   r e s u l t   o f   a p p r o x i m a t e l y   e q u a l   s h a r e s 
of  G lo ba l  F und  and   gove rnm e nt  f in an ci ng.   H owe ver ,  t he   mon it or -
ing syst em  m ay inc lud e pe opl e w h o ha ve dro ppe d out  o f tr e atme nt 
and   tho se   w ho  have   d i ed   w hi lst  on  tr e atme nt .  O nly   a ppr ox imat el y 
30  %   o f  t ho se  ne ed i ng  A R Vs   a re  r ecei vi ng  t h em.   T h e re   ha s   b ee n  a 
large expansion of VCT sites but the number of people being tested 
for  H IV  is  20  %   les s  th an  fo r e seen.   T h is   r ef lect s   ge ner al   pr ob le ms 
i n   t h e   i m p l e m e n t a t i o n   o f   L e s o t h o ’ s   ‘ K n o w   y o u r   s t a t u s ’   c a m p a i g n . 
For   the   c ar e  and   su ppo r t  for   OV C s   it  w a s   no t  c lear ly  de fi ne d  wh at 
the su ppor t pac kag e  w ould  i n cl ude a nd i t  was  di ff icul t t o e s ta bl is h 
what the OVCs had received. Condom distribution targets have been 
e x c e e d e d   b u t   o n l y   p a r t l y   d u e   t o   G l o b a l   F u n d   f i n a n c i n g   a n d   t h e r e 
was a n ee d to ensu r e  th at the  c on doms  di s tr ibut ed t o an d av ail abl e 
in health centres were then actually obtained and used by the youth. 
S o m e   p r o g r e s s   h a s   b e e n   m a d e   o n   y o u t h   e d u c a t i o n   f o r   H I V / A I D S 
p r e v e n t i o n .   P M T C T   s u p p o r t   w a s   t h e   m o s t   p r o b l e m a t i c   a r e a ,   w i t h 
onl y o ne o f the si x ind i ca tor  targ et s  b ei ng  a ch ie ve d. T hi s  i s  in  par t 
the  c on sequ enc e  o f sh or tage s o f h e alt h  pe rs on ne l.

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A N N E X   I I I

KEN YA

OVERVIEW OF  HEALT H SITUAT ION

A l l   t h e   m a j o r   h e a l t h   i n d i c a t o r s   d e c l i n e d   i n   t h e   1 9 9 0 s   a n d   h e a l t h 
i n d i c a t o r s   c o n t i n u e d   t o   s h o w   a   d o w n w a r d   t r e n d   u n d e r   t h e   f i r s t 
national health sector strategic plan (1999–2004). Thus, there was an 
incre ase  in und e r-fi ve  m or ta lity fro m 1 1, 2  % to  11, 5  %.  W h il e it  i s 
difficult to establish the maternal mortality ratio, indicators do not 
poin t to  an  im pro vem e n t. The  on l y a rea of  cle ar imp ro ve me nt  was 
in H I V  pr e va lenc e,  w hi ch  fe ll fro m 13   %  in  199 4  t o  6  %  in  20 05.

The d e te ri ora tio n in m aj o r he alt h  in dica to rs  re fl ect s de cl in in g  us e 
o f   s e r v i c e s   i n   p u b l i c   h e a l t h   f a c i l i t i e s ,   s h o r t a g e s   o f   h e a l t h   w o r k e r s 
a n d   t h e i r   u n e v e n   d i s t r i b u t i o n   b e t w e e n   u r b a n   a n d   r u r a l   a r e a s   a n d 
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 w or k  a nd  fund ing ’,   is  at te m pt i ng t o  re ver s e  th is   decl in e .

GE NER AL  BU DGET  SUPPORT

In view of the still relatively low expenditure on health, weaknesses 
in he alt h and  g e ne r al pu b li c fi nanc e man ag eme nt  s ys t ems ,  and t h e 
f a c t   t h a t   o n l y   o n e   o f   t h e   f o u r   p e r f o r m a n c e   i n d i c a t o r   t a r g e t s   w a s 
a c h i e v e d ,   G e n e r a l   B u d g e t   S u p p o r t   c a n n o t   b e   c o n s i d e r e d   t o   h a v e 
bee n ve ry  e ffe c ti ve   i n K e nya  in  i mprov in g  heal th  s e r vi ce s . 

EDF  PROJEC TS

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 pe ople m or e at r is k and on  t h e communi ti es .  H ow ev er , h ad th e 
project timeframe been longer than the three years foreseen and not 
redu ce d  b y d e lays , r e sults  woul d h av e  be en  s t i ll  bet te r. 

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A N N E X   I I I

GE NER AL  BU DGET  LINE  PRO JEC TS

Ado le s c ent  sex ua l a nd  re prod ucti ve  h ea lth (A SRH )  i ni ti a ti ve

This project was making significant progress in improving the access 
to H IV/ AI DS  pr eve nti on and  car e s e rvi ces  for t h e most  vul n er abl e 
a n d   m a r g i n a l i s e d   y o u t h   b y   t h e   u s e   o f   y o u t h - f r i e n d l y   m o b i l e   V C T 
s e r v i c e   d e l i v e r y   a n d   i n c r e a s i n g   c o m m u n i t y   a w a r e n e s s   a b o u t   t h i s 
init iat ive .

Acce s s  to  a nd  u se of  qua lit y  b as ic and  c omp reh ens ive 
obs t et r ic  ca r e se rv ic es

T h e   p r o j e c t   s e e k s   t o   i m p r o v e   a c c e s s   f o r   w o m e n   a n d   c h i l d r e n   t o 
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  i nc r e ase  in t he  p ro por ti on  of de li ver ies   at t ended  by  mi dw iv es .

Compr ehe nsive  a pproac h   t o rea ch i ng  thos e m ost  a t  ris k  f rom 
an d  a f f ec te d  by  HIV/AIDS

T h e   p r o j e c t   s e e k s   t o   b u i l d   t h e   c a p a c i t y   o f   M a r i e   S t o p e s   K e n y a   t o 
c o n t r i b u t e   t o   t h e   K e n y a   n a t i o n a l   A I D S   s t r a t e g i c   p l a n   ( 2 0 0 5 – 1 0 ) . 
Initi a l pr og re ss h as  be e n g ood . 

Uza zi  B ora  — Mot h er  and  infant serv ice s — H IV act iv i ti es

T h e   a i m   o f   t h e   p r o j e c t   w a s   t o   i m p r o v e   P M T C T ,   a n t e n a t a l ,   i n t r a -
p a r t u m   a n d   p o s t n a t a l   c a r e   s e r v i c e s   i n   t w o   d i s t r i c t s .   T h e   p r o j e c t 
objectives were partially achieved, the main shortfall being in rela-
tion  to  po stn atal  se rvic e s.

GLOBAL F UND

Alth oug h  K enya  i s  a  m aj or   b e ne fi cia ry   o f  t h e  Gl obal   Fund,   g ran ts 
have been implemented with serious delays, with the result that the 
m o s t   t a r g e t s   w i l l   n o t   b e   r e a c h e d   a n d   b u d g e t s   h a v e   b e e n   r e d u c e d 
aft er   Phase  I .

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A N N E X   I I I

MA LAWI

OVERVIEW OF  HEALT H SITUAT ION

Malawi has one of the highest HIV/AIDS prevalence rates (approxi-
mate ly 14  % ) i n th e  wo rld . The h i gh  HI V/AI DS p re va len ce  ra te  has 
led to a major increase in tuberculosis, the number of cases doubling 
f r o m   1 9 9 4   t o   2 0 0 4 .   I t   a l s o   s u f f e r s   g r e a t l y   f r o m   m a l a r i a ,   i t   b e i n g 
the m os t c om mo nly r e por te d  caus e o f mo rt ali ty  bo th  i n  adul ts  and 
children. Even if there has been an improvement since 2000, Malawi 
s t i l l   a l s o   h a s   o n e   o f   t h e   h i g h e s t   m a t e r n a l   m o r t a l i t y   r a t e s   i n   t h e 
wor ld  at  984  per  100 0 00 li ve  bir th s .  S imil ar ly wh il e s o me pr o gr e s s 
h a s   b e e n   m a d e   i n   r e l a t i o n   t o   c h i l d   m o r t a l i t y ,   w h i c h   h a s   f a l l e n   t o 
76  pe r   1  00 0  live   b i r ths,  th is   too  r emai ns   a   maj or  ar ea   o f  c on ce r n. 
Malaw i   he alth  se r vi c es   h ave  been  gr os s l y   un der -r e sour ce d  t o  co pe 
w i t h   t h e s e   p r o b l e m s ,   w i t h   t h e   v e r y   l i m i t e d   n u m b e r   o f   h e a l t h   s t a f f 
he avi ly  c onc e ntra te d  in  ur ban  ar ea s . 

GE NER AL  BU DGET  SUPPORT

General Budget Support was not considered to have had a significant 
effec t on im pro ving  he alth ser v ices  by  mi d- 200 7 . Si nce 2005 , w he n 
General Budget Support was restarted, the government had focused 
on  us ing   b udg e tar y  su ppor t  to  he lp   buil d  up   a  s oun d  t r ack   r e co rd 
i n   f i s c a l   m a n a g e m e n t   r a t h e r   t h a n   e x p a n d i n g   p r o - p o o r   b u d g e t a r y 
expenditure. However, through the leverage of General Budget Sup-
port,  the  C omm is si on has c on tri but ed t o e ns ur in g th at  t he  go ve r n-
ment maintains its health budget allocation at a minimum of 10,7 % 
of the overall national budget. With the HIPC completion point now 
r e a c h e d ,   g r e a t e r   d i s c r e t i o n a r y   e x p e n d i t u r e ,   i n c l u d i n g   f o r   h e a l t h , 
will  b ec o me  pos si ble . 

EDF  PROJEC TS

T h e   e i g h t h   E D F   p r o j e c t   h a d   c r e a t e d   a   n a t i o n a l   b l o o d   t r a n s f u s i o n 
se rv ic e   w hic h  was   cove ri n g  b et w een   a  th ir d  a nd  a  ha lf   o f  na tio n al 
need s.  While  thi s w as le ss t han  w ha t w as  s pecif ie d in  th e  fi na nc ing 
agree me nt, i t st ill r e pr e sente d  c on s idera ble prog re s s  g iv en  th e dif-
ficult cultural, as well as organisational, challenges which have had 
to b e  o ver c ome  b y  the   pro j ec t.

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A N N E X   I I I

GE NER AL  BU DGET  LINE  PRO JEC TS

Scal ing  up of  se xual  a nd  rep r od uc ti ve  h ea lth  ( SR H ) and  H I V /
AI DS  ser v ice s f or  y oung   people

The  pro j ec t  aim s   to  i ncr e ase   th e  ut i li s at i on   o f  yo uth -f r ie ndl y  SRH 
services and the adoption of safer sex practices by working through 
NG Os  and  youth c lu b s. G i ve n in it i al  delay s , i t ma y n ot  be  po s s ib le 
to a ch ie ve  all pr oj e c t  ob j ect ives .

Pro mot ion of  be h av iour  c h ang e  and inc rea se  of  a cce ss  to  SR H 
servic e s  in T hyol o  dis t ric t

T h e   p r o j e c t   w a s   m a k i n g   a   v a l u a b l e   c o n t r i b u t i o n ,   p a r t i c u l a r l y   i n 
i m p r o v i n g   a c c e s s   t o   a   c o n t i n u u m   o f   H I V   c a r e ,   s u p p o r t   a n d   t r e a t -
m e n t ,   P M T C T   s e r v i c e s   a n d   V C T   s e r v i c e s   i n   t h i s   p o o r   d i s t r i c t 
of so uth er n M alaw i.

You t h  and  chil dr en’ s h ea l th   in  t he  c entral and  s outhern  reg i ons 
of Ma l a wi

The project is producing good results, with an increase in the number 
of y ou th un d erg o ing  VC T in th e t ar ge te d y out h an d h ea lt h  ce n tr es 
and   a d e c re ase  i n pr eg nanc i es  am on g  s ch ool  g ir ls . 

GLOBAL F UND

Overall, the Global Fund is producing significant results, most nota-
b l y   i n   e n a b l i n g   a   h u g e   s c a l i n g - u p   o f   A R V   p r o v i s i o n ,   f r o m   j u s t   a 
few  thou san d  in  2004  to  11 0  00 0  by   mi d- 200 7 .  Mo s t  ot he r   c ompo -
nents of the Round 1 HIV/AIDS project, after some delays, were on 
thei r way to  i mpor tant ac hi e ve men ts ,  i ncludin g th e  h ea lt h s y s te ms 
sup po rt  c o mpone nt, w hi c h w as a s s is ti ng  i n tr ain in g la rg e n umb er s 
of personnel, particularly at the level of community health workers. 
The  ma in pr ob le m  ar ea   was  the  P MT C T  co mpo nen t.

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A N N E X   I I I

MA LI

OVERVIEW OF  HEALT H SITUAT ION

M a l i   h a s   a   v e r y   h i g h   m a t e r n a l   m o r t a l i t y   r a t i o   ( 1   2 0 0   p e r   1 0 0   0 0 0 
l i v e   b i r t h s )   a n d   c h i l d   m o r t a l i t y   r a t e   ( 2 1 9   p e r   1   0 0 0   i n   2 0 0 4 ) .   T h e 
HIV/AIDS prevalence rate is relatively low (1,9 %) but tuberculosis 
is wi d es pr e ad (5 78 ca se s per  10 0 0 00 p op ulat i on)  an d mal ar ia co n-
tinue s t o b e one o f th e ma i n c a us es  of  c hi ld mort a li ty . Ot h er  maj o r 
i l l n e s s e s   i n c l u d e   a c u t e   r e s p i r a t o r y   i n f e c t i o n s ,   d i a r r h o e a ,   G u i n e a 
w o r m ,   s c h i s t o s o m i a s i s   a s   w e l l   a s   g r o w i n g   p r o b l e m s   w i t h   c h r o n i c 
il lnes ses  suc h as  d i abe te s  an d  hea rt  di se as e .

While significant investments have been made in health infrastruc-
t u r e   a n d   a c c e s s   t o   h e a l t h   s e r v i c e s   h a s   g l o b a l l y   i m p r o v e d ,   s e r i o u s 
p r o b l e m s   r e m a i n .   T h e r e   i s   n o   a d e q u a t e   h u m a n   r e s o u r c e   p o l i c y , 
resulting in low availability, inappropriate geographical allocation, 
a n d   i n a d e q u a t e   s k i l l s ,   m o t i v a t i o n   a n d   e t h i c a l   s t a n d a r d s   o f   s t a f f . 
The d ec e ntra li sat io n pr oce s s ha s n ot  be en ac co mpan ie d by  a s uffi -
cient transfer of human and financial resources. Overall, the quality 
of he al th ser vi ce s  r e m ains  lo w  and h ea lt h s e rvi ces  a re  unaf f or dabl e 
for  the  po or est. 

GE NER AL  BU DGET  SUPPORT

Con tr ar y  to  the  c om m i tm e nt  made  i n  t he  Gen er al   Budg et   Suppo r t 
f i n a n c i n g   a g r e e m e n t ,   t h e   g o v e r n m e n t   d i d   n o t   i n c r e a s e   t h e   s h a r e 
of the  he alth b u dge t,  wh ile  pu bli c funds  con ti nue to  be  in e quit abl y 
allocated between regions. In addition, public finance management 
r e m a i n s   w e a k ,   w i t h   a   h i g h   f i d u c i a r y   r i s k   a n d   l o w   e f f i c i e n c y   a n d 
effec ti ven es s  of  pub li c  spe nd i ng.

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A N N E X   I I I

EDF  PROJEC TS

T h e   e i g h t h   E D F   P A S S   p r o j e c t   h a s   c o n t r i b u t e d   t o   i t s   o b j e c t i v e 
of  str e ngthening   th e   c apaci ty  o f  t he   Mi ni s t r y  of   He al th   b ut  n ot   t o 
it s o the r  ob j ect ive  of i m pr ovi ng t h e q uali t y  of  he al th  s er v ic es . T h e 
project was not in a position to bring about such improvements since 
this  r eq uir ed   the  a dopt io n of  major  s t ruct ura l  re for ms .

GE NER AL  BU DGET  LINE  PRO JEC TS

Impr ov em ent  of  w ome n’s  r eprodu cti ve  he alth i n nort he rn M ali

The project contributed significantly to improving training of health 
wor k er s  an d  pr ovi di ng  e qu i pment   but   th e   p ro je ct   wa s   to o  s h or t  to 
mak e  a  r eal  im pac t  on  m a te r n al  mo rt ali ty . 

Acti on  Biom a li

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 
t h e r e   w e r e   d e l a y s   i n   t r a i n i n g   p e r s o n n e l   o n   h o w   t o   u s e   t h e   e q u i p -
m e n t   s u p p l i e d .   M o n i t o r i n g   o f   t h e   i n c r e a s e   i n   d e t e c t i o n   r a t e s   w a s 
prob le ma tic . 

Part ic ip at or y  appr oac h  t o  imp rovi ng  ac ce ss  to he althc a re 
for  T B  pa t ient s

This  r e gio nal  pr oj e c t,   also  c over i ng   B en in ,  Bur ki na   Fas o   an d  S en -
e g a l ,   w a s   c o n t r i b u t i n g   t o   a n   i m p r o v e m e n t   i n   t h e   d e t e c t i o n   o f   T B 
and   sub seq uent  follo w-u p.

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A N N E X   I I I

Stre ngt he ning  l oc al  c a pac it y  to fi g ht H IV / AID S

This  pr o je ct,   wh ic h  i s  s ti ll  at  an  e arly   s t age,   a i ms   t o  r e duc e  s e xual 
a n d   m o t h e r - t o - c h i l d   t r a n s m i s s i o n   i n   p o o r e r   r e g i o n s   o f   n o r t h e r n 
Mali through greater involvement of civil society and by improving 
the  qua li ty  of  he alth  s e rvic e s.

GLOBAL F UND

T h e   m a l a r i a   g r a n t   h a d   c o n t r i b u t e d   t o   t h e   s u p p l y   o f   b e d n e t s   a n d 
t r a i n i n g   t o   h e a l t h   p e r s o n n e l .   T h e   H I V / A I D S   g r a n t   c o n t r i b u t e d   t o 
the nu m ber  of pe ople  o n AR Vs in cr ea s in g f rom 60 0  to  12 80 0 ov er 
t h e   p e r i o d   2 0 0 5 – 0 7 .   F o r   t h e   T B   g r a n t ,   t h e   t r e a t m e n t   c o m p o n e n t 
w a s   m o r e   s u c c e s s f u l   t h a n   t h e   p r e v e n t i o n   o n e .   T h e   h e a l t h   s y s t e m s 
strengthening component was experiencing some difficulties, nota-
b l y   i n   r e l a t i o n   t o   t h e   c o n s t r u c t i o n   a n d   e q u i p p i n g   o f   t h e   n a t i o n a l 
labor a tor y.

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A N N E X   I V

LIST OF PROJECTS EXAMINED

Country

Project title

Project amount

Rating

EDF PROJECTS

Support programme to the health sector

25,0 Unsatisfactory

Support to the health sector

10,2

Partially satisfactory

Angola

Benin

Burundi

Chad

Kenya

Lesotho

Malawi

Mali

Côte d’Ivoire

Emergency and rehabilitation programme Phase 1

Transitional support to the health sector (PATSBU)

Support to health policy

District health services and systems development

Support to the health sector reform

Malawi blood transfusion service

4,1 Unsatisfactory

42,0 Unsatisfactory

34,0

Satisfactory

15,0

Satisfactory

1,8

Partially satisfactory

9,4

Partially satisfactory

Support programme to the health sector

10,5

Partially satisfactory

Sierra Leone

Health sector support programme

28,0 Unsatisfactory

Swaziland

Uganda

8 countries

14 countries

41 countries

22 countries

3 countries

HIV/AIDS prevention and care programme

4,3

Partially satisfactory

Development of human resources for health

17,0

Satisfactory

INTRA-ACP PROJECTS

EC/ACP/WHO partnership on health MDGs

WHO polio eradication programme

25,0

Partially satisfactory

26,8

Partially satisfactory

EC/ACP/WHO partnership on pharmaceutical policy

24,6 Unsatisfactory

EC/ACP/UNFPA/IPPF sexual and reproductive health 

32,0

Satisfactory

Development of malaria vaccine multi- centre trials

7,0 Unsatisfactory

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A N N E X   I V

Country

Project title

Project amount

Rating

HEALTH GENERAL BUDGET LINE PROJECTS

Adolescent sexual and reproductive health initiative 

2,6

Partially satisfactory

Increased access to and use of quality basic and comprehensive 
obstetric care services

2,2

Satisfactory

Comprehensive approach to reaching those most at risk and aﬀ ected 
by HIV/AIDS

4,4

Partially satisfactory

Uzazi Bora — Mother and infant services — HIV activities

1,3  Partially satisfactory

Scaling up sexual and reproductive health and HIV/AIDS services for 
young people 

2,25

Partially satisfactory

Promotion of behaviour change and increased access to sexual and 
reproductive health services

1,35

Satisfactory

Improving reproductive health services in northern Mali

1,6

Satisfactory

‘Action BioMali’

Participatory approach for improving the quality and access to health 
care for TB patients

3,6

Partially satisfactory

4,5

Partially satisfactory

Fight against AIDS programme

2,0 Unsatisfactory

Kenya

Kenya

Kenya

Kenya

Malawi

Malawi

Mali

Mali

Mali

Burundi, Kenya, 
Mozambique

Burundi, Guinea,
Haiti

Mutual 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/AIDS

Benin,
Dem. Rep. of the Congo

Programme to develop integrated HIV care for TB patients living with 
HIV/AIDS

Zambia, South Africa

Building local capacity and ownership of HIV vaccines in southern 
Africa

3,9

Partially satisfactory

4,3 Unsatisfactory

3,0 Unsatisfactory 

Malawi, South Africa

Increasing prevention and treatment of TB

4,5

Partially satisfactory

NGO CO-FINANCED BUDGET LINE HEALTH-RELATED PROJECTS

Lesotho

Mali

Malawi

Home-based care for people living with HIV/AIDS or terminal illnesses 
and for orphans

0,7

Partially satisfactory

Strengthening local capacity to ﬁ ght HIV/AIDS

1,0

Partially satisfactory

Youth and children’s health in the central and southern regions 
of Malawi

0,75

Satisfactory

Swaziland

Integrated HIV/AIDS and livelihood project

0,75

Partially satisfactory

Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa

REPLY
OF THE COMMISSION

EXECUTIVE SUMMARY

I.
The Commission thanks the European Court 
o f   A u d i t o r s   f o r   i t s   w o r k   o n   t h e   E C   d e v e l -
o p m e n t   a s s i s t a n c e   t o   h e a l t h   s e r v i c e s   i n 
s u b - S a h a r a n   A f r i c a   ( S S A ) .   I t   p r o v i d e s   a n 
i n t e r e s t i n g   a n a l y s i s   w i t h   f i n d i n g s   a n d   l e s -
sons learnt that gives an opportunity for the 
C o m m i s s i o n   t o   c l a r i f y   a   n u m b e r   o f   i s s u e s 
stemming from the Court audit work.

II.
The Commission policy recognises that sup-
porting progress towards better health out-
c o m e s   c a l l s   f o r   a   c o m p r e h e n s i v e   s t r a t e g y 
t a c k l i n g   e x i s t i n g   c o n s t r a i n t s   t h r o u g h   t h e 
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 
h e a l t h   o u t c o m e s ;   s u p p o r t   t o   s e c t o r s   t h a t 
have a wider impact on health outcomes and 
direct  support  to  the  health  sector’  (health 
and poverty reduction communication).

I n   l i n e   w i t h   i t s   p o l i c y   c o m m i t m e n t s   t h e 
C o m m i s s i o n   h a s   remained  sensitive  to  the 
i m p o r t a n c e   o f   h e a l t h   s y s t e m s   s t r e n g t h e n -
ing  by  maintainingd  its  direct  financing  to 
h e a l t h   a t   c o u n t r y   l e v e l ,   i n c r e a s e d   g e n e r a l 
budget support and its contribution to glo-
bal initiatives.

Health  expertise  in  the  Commission  is  kept 
w i t h i n   t h e   l i m i t s   o f   r e s o u r c e   a l l o c a t i o n 
d e c i s i o n s .   H o w e v e r ,   m e c h a n i s m s   s u c h   a s , 
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.

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The  health  policy  /  strategy  framework  has 
i m p r o v e d   a   l o t   i n   S S A   c o u n t r i e s   o v e r   t h e 
l a s t   d e c a d e ,   w i t h   t h e   s u p p o r t   o f   t h e   W H O 
(World Health Organization) and of all other 
m a j o r   d e v e l o p m e n t   p a r t n e r s   ( C o m m i s s i o n 
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.
T h e   C o m m i s s i o n   w i l l   c o n s i d e r   s e c t o r a l 
a l l o c a t i o n s   a c c o r d i n g   t o   t h e   g u i d e l i n e s   t o 
b e   e s t a b l i s h e d   f o r   t h e   1 0 t h   E D F   m i d - t e r m 
review. These will stress country-level objec-
t i v e s ,   r e s u l t s   a c h i e v e d   a n d   t h e   p r i n c i p l e s 
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.

T h e   C o m m i s s i o n   w i l l   c o n t i n u e   t o   s u p p o r t 
health systems, where possible with support 
t o   s e c t o r   p r o g r a m m e s .   D e v e l o p m e n t   a n d 
r e t e n t i o n   o f   ‘ h u m a n   r e s o u r c e s   f o r   h e a l t h ’ 
(HRH) as well as health system financing are 
issues that the Commission will follow care-
fully and assist.

III.
T h e   C o m m i s s i o n   c o n t i n u e s   i t s   e f f o r t   t o 
i m p r o v e   t h e   s p e e d   a n d   t h e   p r e d i c t a b i l i t y 
o f   i t s   a s s i s t a n c e   t o   t h e   h e a l t h   s e c t o r :   t h i s 
i n c l u d e s   p r i v i l e g i n g   s e c t o r - w i d e   a p p r o a c h 
(SWAp), Sector Budget Support (SBS) where 
c o n d i t i o n s   a l l o w   b u t   a l s o   a   m o r e   p r e d i c t -
a b l e   l o n g e r - t e r m   t y p e   o f   G e n e r a l   B u d g e t 
Support (GBS) (‘MDG Contract’) in perform-
ing countries.

IV.
The Commission shares the Court’s view on 
t h e   p o t e n t i a l   r o l e   o f   S B S ,   a   r e l a t i v e l y   n e w 
aid modality of which the Commission is the 
largest user in Africa, according to available 
evidence. The Commission has already used 
S B S   t o   s u p p o r t   h e a l t h   s e c t o r s   i n   M o z a m -
bique, Zambia and South Africa.

T h e   C o m m i s s i o n   v i e w s   G B S   a s   a   c o m p l e -
ment  to  health  focal  or  non-focal  interven-
tions  and  is  committed  to  further  enhance 
t h i s   t o o l ’ s   e f f e c t i v e n e s s   i n   g e n e r a l   a n d 
i n   r e l a t i o n   t o   s e c t o r a l   i s s u e s .   H o w e v e r , 
t h e   C o m m i s s i o n   n o t e s   t h a t   t h e   e f f e c t i v e -
n e s s   o f   g e n e r a l   b u d g e t   s u p p o r t   i s   b e t t e r 
assessed  in  the  longer  term  since  progress 
in  outcomes  at  national  level  takes  time  as 
i t   r e q u i r e s   i m p r o v e m e n t s   i n   l a r g e   s y s t e m s 
a n d   t h u s   c a n n o t   b e   c o m p a r e d   t o   p r o g r e s s 
i n   o u t p u t s   i n   s m a l l e r   a n d   t a r g e t e d   g r o u p s 
of the population.

V.
I n   a   c o u n t r y   s t r a t e g y   p a p e r   r e l a t e d   t o   a 
c o u n t r y   i n   w h i c h   h e a l t h   i s   s u p p o r t e d ,   t h e 
C o m m i s s i o n   a r t i c u l a t e s   d i f f e r e n t   t y p e s 
of support, foreseen in its policy to improve 
h e a l t h   o u t c o m e s ,   i n   r e s p o n s e   t o   c o u n t r y 
specificities.  The  Commission  will  continue 
t o   s t r e n g t h e n   s y n e r g i e s   b e t w e e n   d i f f e r e n t 
interventions at country level.

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C a p a c i t y   b u i l d i n g ,   a c c o r d i n g   t o   t h e   ‘ A c c r a 
Agenda for Action’ (September 2008), should 
increasingly be implemented through pooled 
f u n d s   t o   s t r e n g t h e n   n a t i o n a l   c a p a c i t i e s , 
maximising the use of local expertise.

 —

 —

 —

F o l l o w i n g   t h e   C o u r t ’ s   a u d i t   a   s p e c i f i c 
Inter Service Group has been established 
t o   d e f i n e   w h a t   t h e   C o m m i s s i o n   s h o u l d 
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 
v a r i o u s   i n s t r u m e n t s   i n   r e l a t i o n   t o   t h e 
health  sector,  including  on  their  use  in 
c o m b i n a t i o n ,   w i l l   b e   r e v i e w e d   i n   t h e 
‘health  programming  guidelines’  which 
a r e   c u r r e n t l y   b e i n g   u p d a t e d   t o   b e t t e r 
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 
c o n t i n u e   t o   p r o m o t e   t h e   d e v e l o p m e n t 
and adoption of well-defined health poli-
c i e s   w i t h   a l l   t h e   c o m p l e m e n t a r y   i n t e r -
ventions foreseen by its policy.

 —

 —

T h e   C o m m i s s i o n   a g r e e s   t h a t   a d e q u a t e 
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. 
P r a g m a t i c   w a y s   s u c h   a s   E U   p o o l i n g 
of experts might also be considered.

S B S   w i l l   i n c r e a s e   f r o m   n e a r l y   9 %   u n d e r 
t h e   n i n t h   E D F   t o   1 6 %   u n d e r   1 0 t h   E D F 
across  all  sectors  of  cooperation.  When 
c o n d i t i o n s   a r e   s a t i s f i e d   i t   w i l l   b e   t h e 
p r e f e r r e d   m o d a l i t y   i n   c o u n t r i e s   t h a t 
have programmed support to the health 
s e c t o r .   T h e   C o m m i s s i o n   w i l l   c o n t i n u e 
t o   s t r i v e   t o   m a k e   i t s   G B S   i n s t r u m e n t 
more effective in its achieving its goals, 
including through the launch of the MDG 
Contract.

 —

T h e   C o m m i s s i o n   w i l l   c o n t i n u e   t o 
u s e   p r o j e c t s   i n   o r d e r   t o   d e v e l o p   a n d 
s t r e n g t h e n   h e a l t h   s y s t e m s ,   e s p e c i a l l y 
i n   c o u n t r i e s   a f f e c t e d   b y   s i t u a t i o n s 
of fragility.

In countries with a SWAp environment, sup-
p o r t   t o   p o l i c y   d e v e l o p m e n t   i s   a l s o   g i v e n 
through sector policy dialogue (involvement 
i n   s p e c i f i c   w o r k i n g   g r o u p s ;   p a r t i c i p a t i o n 
i n   j o i n t   g o v e r n m e n t – d o n o r   h e a l t h   s e c t o r 
reviews) as well as projects.

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INTRODUCTION

1.
S u b - S a h a r a n   A f r i c a   l a g s   b e h i n d   i n   t h e 
a c h i e v e m e n t   o f   m o s t   M D G s   a n d   n o t a b l y 
of health-related ones.

Progress on health-related MDGs is linked to 
improvements on various fronts (education, 
w a t e r   a n d   s a n i t a t i o n ,   f o o d   s e c u r i t y ,   e t c . ) . 
H e n c e ,   s u p p o r t i n g   p r o g r e s s   t o w a r d s   b e t -
ter  health  outcomes  calls  for  a  comprehen-
s i v e   s t r a t e g y   t a c k l i n g   e x i s t i n g   c o n s t r a i n t s 
through  the  most  appropriate  instruments 
a n d   t h r o u g h   d i v i s i o n   o f   l a b o u r   w i t h   o t h e r 
donors.

OBSERVATIONS ON ALLOCATION 
AND DISBURSEMENT OF RESOURCES 
TO THE HEALTH SECTOR

7.
T h e   C o m m i s s i o n   w i s h e s   t o   p u t   t h e   a u d i t 
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-
c o m e s   c a l l s   f o r   a   c o m p r e h e n s i v e   s t r a t e g y 
t a c k l i n g   e x i s t i n g   c o n s t r a i n t s   t h r o u g h   t h e 
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 
h e a l t h   o u t c o m e s ;   s u p p o r t   t o   s e c t o r s   t h a t 
have a wider impact on health outcomes and 
direct  support  to  the  health  sector’  (health 
and poverty reduction communication).

W h i l e   t h e   C o m m i s s i o n   h a s   i n d e e d   m a d e 
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 
t h a t   t a r g e t s   b a s e d   o n   f i n a n c i a l   i n p u t s   a r e 
increasingly ill-suited to reflect the current 
c o m m i t m e n t s   w i t h i n   t h e   f r a m e w o r k   o f   t h e 
aid effectiveness agenda and the real impact 
t h e   C o m m i s s i o n   h a s   o n   p o l i c i e s   o f   p a r t n e r 
countries.

T h e   C o m m i s s i o n ’ s   b a s i c   d e v e l o p m e n t 
a p p r o a c h   f o c u s e s   o n   p o v e r t y   a l l e v i a t i o n 
and,  within  this  context,  on  improvements 
within the social sectors. Thus, the Commis-
sion concentrates on achieving development 
results as measured by performance indica-
t o r s .   W h e t h e r   t h e s e   r e s u l t s / i n d i c a t o r s   a r e 
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-
a n c e   t o   s p e c i f i c   s e c t o r s .   A c c o r d i n g l y ,   t h e 
Commission takes note of the audit’s meth-
o d o l o g y   a n d   i t s   e n s u i n g   r e s u l t s .   T h e   C o m -
m i s s i o n ,   h o w e v e r ,   w o u l d   l i k e   t o   u n d e r l i n e 
t h a t   b e c a u s e   o f   f u n g i b i l i t y   o f   f u n d s ,   b o t h 
t a r g e t e d   a n d   u n t a r g e t e d   b u d g e t   s u p p o r t 
contributes  to  financing  the  entire  budget 
and not solely a part of it. Their imputed con-
tribution  to  health  sector  financing  should 
t h e r e f o r e   b e   t h e   s a m e .   G i v e n   t h e   a b s e n c e 
o f   a n   i n t e r n a t i o n a l l y   r e c o g n i s e d   m e t h o d 
f o r   a t t r i b u t i n g   G B S   a s s i s t a n c e   t o   s p e c i f i c 
s e c t o r s ,   t h e   C o m m i s s i o n   d o e s   n o t   a d d r e s s 
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-
c i p l e s   ( o w n e r s h i p ,   a l i g n m e n t ,   h a r m o n i s a -
tion, managing for development results and 
mutual accountability).

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12.
(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-
l e s s   o f   m o d a l i t i e s   a n d   s e c t o r s .   T h i s   s h a r e 
therefore does not relate to the total amount 
o f   b u d g e t   a i d   o r   t o t a l   a i d   f l o w s .   B u d g e t 
support  is  always  taken  into  account  when 
d e t e r m i n i n g   p u b l i c   e x p e n d i t u r e s ,   i n c l u d -
ing  for  health,  and  their  optimal  financing. 
W h e n   t h i s   i m p l i e s   r e d u c i n g   p u b l i c   d e b t   o r 
i n c r e a s i n g   r e s e r v e s ,   t h e   a i d   w h i c h   i s   n o t 
i m m e d i a t e l y   s p e n t   r a i s e s   f u t u r e   s p e n d i n g 
capacity including in the health sector.

15.
The Commission notes that there is a short-
a g e   o f   i n t e r n a t i o n a l   a s s i s t a n c e   f o r   d e v e l -
o p i n g   c o u n t r i e s ,   i n   p a r t i c u l a r   s u b - S a h a r a n 
Africa. This affects all areas, including health 
systems.

Donors’  programming  choices  increasingly 
r e f l e c t   i n t e r n a t i o n a l l y   a g r e e d   p r i n c i p l e s 
of aid effectiveness such as country owner-
ship  and  division  of  labour  among  donors. 
E x c e s s i v e   f r a g m e n t a t i o n   o f   a i d   i n c r e a s e s 
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 
o f   C o n d u c t   o n   C o m p l e m e n t a r i t y   a n d   t h e 
Division of Labour in Development Policy.

P r o g r a m m i n g   o f   E D F   f u n d s   i s   d o n e   j o i n t l y 
with the partner country and in consultation 
with the Member States: country strategies 
for the 10th EDF were presented to the EDF 
c o m m i t t e e   a n d   c o n s i d e r e d   b y   t h e   M e m b e r 
S t a t e s   r e l e v a n t   r e s p o n s e s   t o   t h e   p r o b l e m s 
o f   t h e   p a r t n e r   c o u n t r i e s   i n   c o n s i d e r a t i o n 
of  support  provided  by  other  development 
partners. Furthermore, in the context of the 
24 June 2008 European Council conclusions 
o n   t h e   E U   a g e n d a   o n   M D G s ,   t h e   E U   c o l -
l e c t i v e l y   h a s   c o m m i t t e d   t o   i n c r e a s e   —   i n 
r e l a t i o n   t o   t h e   p r o s p e c t s   o f   i n c r e a s e d   E U 
O D A   —   t h e   E U   s u p p o r t   t o   h e a l t h   ( 8   b i l l i o n 
euro by 2010, 6 billion euro for sub-Saharan 
A f r i c a ) .   I n   t h i s   r e s p e c t ,   t h e   c o n v e n i n g   r o l e 
o f   t h e   E C   i n   t h e   d i v i s i o n   o f   l a b o u r   a p p l i e d 
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 
t h e   C o m m i s s i o n   t o   t h e i r   h e a l t h   s e c t o r   h a s 
s l i g h t l y   i n c r e a s e d   f r o m   s e v e n   i n   t h e   n i n t h 
to eight in the 10th EDF.

17.
T h e   g l o b a l   p a r t n e r s h i p s   ( e . g .   G l o b a l   F u n d , 
G A V I   /   G l o b a l   A l l i a n c e   f o r   V a c c i n e s   a n d 
I m m u n i z a t i o n )   h a v e   i n d e e d   a t t r a c t e d   s i g -
nificant funding, sometimes at the expense 
o f   n a t i o n a l   h e a l t h   s y s t e m s   s t r e n g t h e n i n g 
(HSS).

I t   h a s   n e v e r t h e l e s s   c o n t r i b u t e d   t o   a   m a s -
sive supply of medicines, vaccines and other 
preventive  /  curative  commodities  to  fight 
A I D S   a s   w e l l   a s   h i g h l y   p r e v a l e n t   d i s e a s e s 
such  as,  for  example,  malaria,  tuberculosis 
or measles.

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In addition to its contribution to the Global 
F u n d ,   t h e   C o m m i s s i o n   h a s   a l s o   s u p p o r t e d 
H S S ,   t h r o u g h   v a r i o u s   a c t i o n s   t o   l e s s e n   t h e 
H R H   c r i s i s ,   t o   i m p r o v e   t h e   a v a i l a b i l i t y   a n d 
a f f o r d a b i l i t y   o f   e s s e n t i a l   m e d i c i n e s   o r   t o 
enhance  health  financing.  In  the  countries 
i n   w h i c h   ‘ h e a l t h ’   i s   a   s e c t o r   s u p p o r t e d   b y 
t h e   n a t i o n a l   i n d i c a t i v e   p r o g r a m m e ,   H S S   i s 
o f   c o u r s e   t h e   c e n t r a l   o b j e c t i v e   o f   E C   s u p -
port, preferably through a SWAp.

18.
Where the Commission is indirectly involved 
i n   t h e   h e a l t h   s e c t o r ,   n o t a b l y   t h r o u g h   G B S 
linked  to  the  social  sectors  or  budget  lines 
a n d   i n t r a - A C P   f u n d i n g ,   s i l e n t   p a r t n e r s h i p s 
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-
d i n a t i o n   w i t h i n   t h e   b u d g e t   s u p p o r t   d o n o r 
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 
p a r t n e r   c o u n t r i e s   a s   w e l l   a s   i n   t h e   i d e n t i -
f i c a t i o n   /   f o r m u l a t i o n   /   i m p l e m e n t a t i o n 
of health interventions.

(a)
Not only to support Global Fund ‘operations’ 
b u t   a l s o   t o   e x h o r t   t h e   F u n d   t o   i n t e g r a t e 
i t s   a c t i v i t i e s   i n t o   n a t i o n a l   p o l i c i e s   a n d   t o 
strengthen health systems.

(d)
I n   c o u n t r i e s   w h e r e   t h e   H I V   i n f e c t i o n   i s 
h i g h l y   p r e v a l e n t ,   d e l e g a t i o n s   a r e   t a k i n g 
m e a s u r e s   t o   e n s u r e   t h a t   a l l   p r o f e s s i o n a l s 
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 
i n   s o u t h e r n   A f r i c a   a r e   c o m p l e t i n g   a   g u i d e 
on  ‘Mainstreaming  HIV  and  AIDS  in  sectors 
and programmes’. Several delegations (e.g. 
Botswana) have already carried out specific 
t r a i n i n g   f o r   t h e i r   s t a f f   o n   m a i n s t r e a m i n g 
HIV/AIDS.

20.
The Commission explores to what extent the 
division of labour will give opportunities for 
j o i n t   u t i l i s a t i o n   o f   e x p e r t i s e .   T h e   p r o b l e m 
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.

W h e r e a s   a n   i n c r e a s e d   c o o p e r a t i o n   w i t h 
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 
t h e   p r o f e s s i o n a l   p r o f i l e   o f   a   h e a l t h   p o l i c y 
a n a l y s t   a n d   a d v i s o r   t o   s u p p o r t   h e a l t h   s y s -
tems strengthening.

24.
T h e   C o m m i s s i o n   w e l c o m e s   t h e   C o u r t ’ s 
r e m a r k   o n   t h e   s p e e d   a n d   p r e d i c t a b i l i t y 
of GBS funding under the ninth EDF. It notes 
t h a t   u n d e r   t h e   1 0 t h   E D F ,   i t   i s   p l a n n i n g   t o 
further improve the predictability of its GBS 
i n s t r u m e n t   t h r o u g h   t h e   p r o v i s i o n   o f   ‘ M D G 
Contracts’ where conditions allow.

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25.
(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 
o f   b u d g e t   s u p p o r t .   D i s b u r s e m e n t   o f   S B S 
f u n d s   w h e n   a   G B S   p r o g r a m m e   i s   d e l a y e d 
o r   t e m p o r a r i l y   s u s p e n d e d   i s   o n l y   p o s s i b l e 
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 
t h e   C o u r t   n o t i c e d   i n   L e s o t h o ,   t h e   G l o b a l 
F u n d   g r a n t e d ,   o n   i t s   s e v e n t h   r o u n d ,   U S D 
3 3   m i l l i o n   t o   a s s i s t   O V C   ( o r p h a n s   a n d   v u l -
n e r a b l e   c h i l d r e n )   w h i l e   t h e   L e s o t h o   c o u n -
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.
T h e   C o m m i s s i o n   w e l c o m e s   t h e   C o u r t 
acknowledgement that budget support has 
the potential to play a key role in improving 
health services.

T h e   d i f f e r e n c e s   b e t w e e n   G B S   a n d   S B S   a r e 
c l e a r l y   i d e n t i f i e d   i n   t h e   e x i s t i n g   i n t e r n a -
tional  definition  given  by  the  OECD  (Office 
f o r   E c o n o m i c   C o o p e r a t i o n   a n d   D e v e l o p -
ment) / DAC (Development Assistance Com-
mittee).  While  this  definition  is  not  always 
a p p l i e d   c o n s i s t e n t l y   b y   e v e r y o n e   e v e r y -
where 1, EC guidelines and practice are fully 
in line with it.

32.
A   r e l a t i v e l y   n e w   a i d   m o d a l i t y ,   S B S   s t a r t e d 
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.

G i v e n   t h e   d e e p   t e c h n i c a l   e n g a g e m e n t   i n 
s e c t o r   p o l i c y   d e s i g n   a n d   i m p l e m e n t a t i o n 
w i t h i n   a   f o c u s e d   d i a l o g u e   w i t h   a   b r o a d 
r a n g e   o f   s t a k e h o l d e r s   r e q u i r e d   b y   S B S , 
t h e   C o m m i s s i o n   b e l i e v e s   t h a t   f o c a l   s e c -
t o r s   a r e   t h e   o n e s   w h e r e   s u c h   a   d e m a n d -
i n g   e f f o r t   t o   u s e   S B S   s h o u l d   f o c u s .   W h e r e , 
however,  resources  were  available,  SBS  has 
also already been used in non-focal sectors 
(Ghana, Mozambique).

33.
G B S   c a n   b e   a d d i t i o n a l   t o   t h e   f o c a l   s e c t o r s 
because it provides a unique opportunity to 
have a dialogue on the overall policy priori-
ties of the partner country. SBS is a modality 
f o r   t h e   i m p l e m e n t a t i o n   o f   a   f o c a l   o r   n o n -
focal sector support.

1  Strategic partnership with Africa, Survey of budget 

support 2007.

2  Ibid.

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34.
T h e r e   i s   o n e   c l e a r   C o m m i s s i o n   v i e w   ( a n d 
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 
a w a r e n e s s   a b o u t   t h e   l i n k   b e t w e e n   b u d g e t 
support and social services.

35.
H a v i n g   c o n t r i b u t e d   t o   t h e   e v a l u a t i o n 
a p p r o a c h   c o n c e i v e d   a n d   u s e d   f o r   t h e   D A C 
j o i n t   e v a l u a t i o n   ( 2 0 0 6 ) ,   t h e   C o m m i s s i o n 
i s   n o w   w o r k i n g   w i t h   o t h e r   b u d g e t   s u p -
p o r t   d o n o r s   w i t h i n   t h e   D A C   t o   d e v e l o p 
a n   i m p r o v e d   m e t h o d o l o g y   t h a t   t a k e s   i n t o 
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).

69

36.
I n   a n y   g i v e n   y e a r ,   b u d g e t a r y   d e c i s i o n s   i n 
terms of total expenditures, their sector allo-
cation, the level of the deficit and the com-
p o s i t i o n   o f   i t s   f i n a n c i n g   t a k e   i n t o   a c c o u n t 
c u r r e n t   a n d   f u t u r e   m a c r o e c o n o m i c   c o n -
straints and the expected level and distribu-
tion of all flows of aid. Normally, therefore, 
t h e r e   n e i t h e r   w i l l   n o r   s h o u l d   b e   a   o n e - t o -
one relation between increased budget sup-
p o r t   a n d   i n c r e a s e d   h e a l t h   e x p e n d i t u r e s   i n 
any given year. With time, however, budget 
g r a n t s   s u p p o r t   t h e   c r e a t i o n   o f   t h e   f i s c a l 
space necessary for increased expenditures. 
T h r o u g h   i t s   d i a l o g u e   a n d   c o n d i t i o n s ,   E C 
b u d g e t   s u p p o r t   h a s   a l s o   o f t e n   p u s h e d   f o r 
h i g h e r   b u d g e t   a l l o c a t i o n   t o w a r d s   h e a l t h . 
This,  however,  was  not  always  regarded  as 
t h e   m o s t   u r g e n t   p r i o r i t y   a s   w h e n   b u d g e t 
execution problems would impair the impact 
of  higher  allocations.  For  reasons  like  this, 
t h e   C o m m i s s i o n   g e n e r a l l y   p r e f e r s   t o   f o c u s 
on outcome indicators that capture improve-
ments at the level of beneficiaries.

37.
B y   f o s t e r i n g   t h e   s t r e n g t h e n i n g   o f   p u b l i c 
financial management systems, the Commis-
s i o n   ‘ d y n a m i c   i n t e r p r e t a t i o n ’   o f   e l i g i b i l i t y 
w h i c h   a p p l i e s   t o   b o t h   G B S   a n d   S B S   s u p -
ports  local  efforts  to  improve  the  effective 
u s e   o f   b u d g e t a r y   f u n d i n g .   I n   t h i s   w a y   G B S 
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.

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38.
G B S   p r o g r a m m e s   a d d r e s s   t h e   r i s k s   m e n -
tioned by the Court in several ways.

T h e   f i r s t   i s   t h e   r e g u l a r   i m p l e m e n t a t i o n 
o f   P E F A   ( p u b l i c   e x p e n d i t u r e   a n d   f i n a n c i a l 
a c c o u n t a b i l i t y )   d i a g n o s t i c s   t h a t   c o m p r i s e s 
i n d i c a t o r s   o n   p r i m a r y   l e v e l   e x p e n d i t u r e   i n 
health and education (Performance indicator 
No 23). The second is the progressive inclu-
s i o n   o f   d e c e n t r a l i s e d   a n d   d e c o n c e n t r a t e d 
e x p e n d i t u r e   i n   t h e   p r o g r a m m e s   o f   r e f o r m 
o f   p u b l i c   f i n a n c i a l   m a n a g e m e n t .   I n   a g r e e -
m e n t   w i t h   o t h e r   b u d g e t   s u p p o r t   d o n o r s , 
t h e   C o m m i s s i o n   i s   r e a d y   t o   u s e   f i n a n c i a l 
audits and compliance tests when these are 
r e g a r d e d   a s   t h e   m o s t   u s e f u l   t o o l s   t o   s p u r 
the  process  of  public  finance  management 
(PFM) reform.

In any case, the ways in which the Commis-
s i o n   m a n a g e s   t h e s e   r i s k s   m u s t   b e   c o m p a t -
i b l e   w i t h   t h e   f a c t   t h a t   o n c e   t r a n s f e r r e d   t o 
t h e   n a t i o n a l   t r e a s u r y ,   C o m m i s s i o n   f u n d s 
a r e   m i x e d   w i t h   n a t i o n a l   r e s o u r c e s ,   c a n n o t 
b e   s p e c i f i c a l l y   t r a c e d   a n d   a u d i t e d .   T h i s   i s 
t r u e   f o r   b o t h   G B S   a n d   S B S   w h i c h   a r e   b o t h 
untargeted.

In SBS attention is given to the entire result-
c h a i n   a n d   t o   t h e   a l l o c a t i o n   a n d   e x e c u t i o n 
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 
i m p r o v e m e n t   i n   t h e   p r o v i s i o n   o f   h e a l t h 
s e r v i c e s .   T h e   C o m m i s s i o n   a g r e e s   t h a t   t h e 
e x i s t e n c e   o f   w e l l - d e f i n e d   h e a l t h   p o l i c i e s 
increases the effectiveness of all types of aid 
to the sector and has actively supported the 
e s t a b l i s h m e n t   o f   h e a l t h   p o l i c i e s   s i n c e   t h e 
1990s (Senegal, Zambia, Ghana, etc.).

H o w e v e r ,   S W A p s ,   n a t i o n a l   h e a l t h   p o l i c i e s 
a n d   t h e i r   r e l a t i o n   w i t h   G B S   s h o u l d   n o t   b e 
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 
b e   a   p r e - c o n d i t i o n   f o r   G B S .   A s   a   m a t t e r 
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 
p r o g r e s s   t o w a r d s   t h e   M D G s   b y   c r e a t i n g   a 
d e m a n d   f o r   b e t t e r   d e f i n e d   s e c t o r   p o l i c i e s . 
Out of the 22 SSA countries that have regu-
l a r l y   i m p l e m e n t e d   E C   G B S   u n d e r   t h e   n i n t h 
E D F ,   a s   m a n y   a s   1 4   c a r r y   o u t   r e g u l a r   j o i n t 
health sector reviews whose results are then 
t a k e n   i n t o   a c c o u n t   d u r i n g   t h e   G B S   j o i n t 
a n n u a l   r e v i e w .   I n   t h e   r e m a i n i n g   c o u n t r i e s 
these are progressively being developed.

40.
T h e   2 0 0 7   G B S   g u i d e l i n e s   d o   n o t   p r o h i b i t 
the use of GBS capacity development funds 
t o   s u p p o r t   s e c t o r a l   m i n i s t r i e s .   H o w e v e r , 
in  order  to  avoid  excessive  fragmentation, 
GBS capacity development funds are mainly 
u s e d   t o   s t r e n g t h e n   P F M   s y s t e m s   a n d   P R S P 
monitoring  frameworks.  Importantly,  how-
ever,  this  can  include  decentralised  public 
f i n a n c i a l   m a n a g e m e n t   s y s t e m s ,   i n   m a n y 
countries  directly  relevant  for  health  serv-
ice delivery.

B r o a d e r   t e c h n i c a l   a s s i s t a n c e   t o   t h e   h e a l t h 
s e c t o r   i s   d e l i v e r e d   i n   t h e   f r a m e   o f   s e c t o r 
p r o g r a m m e s   b y   t h e   d o n o r s   a c t i v e   i n   t h e 
sector.

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41.
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 
i n   t h e   h e a l t h   s e c t o r ,   n o t a b l y   t h r o u g h   G B S 
linked  to  the  social  sectors,  silent  partner-
s h i p s   h a v e   t o   b e   a g r e e d   w i t h   o t h e r   ( E U ) 
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 
b e   s u p p o r t e d   b y   t h e   h e a l t h   e x p e r t s   a v a i l -
able at HQ.

(b)
A n   i n c r e a s i n g   n u m b e r   o f   c o u n t r i e s   m a n -
a g e   G B S   t h r o u g h   p e r f o r m a n c e   a s s e s s m e n t 
f r a m e w o r k s   ( e i g h t   i n   2 0 0 6 ,   1 2   i n   2 0 0 8 ) . 
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-
i c y   d i a l o g u e .   S e e   a l s o   p a r a g r a p h   3 9   a b o v e 
f o r   a r t i c u l a t i o n   b e t w e e n   G B S   a n d   s e c t o r a l 
reviews.

(c)
T h e   v a l u e   a d d e d   o f   G B S   i s   i n   e n c o u r a g i n g 
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-
c a t o r s   a r e   p r o p e r l y   i n t e g r a t e d   i n t o   s e c t o r 
d i a l o g u e   a n d   p r o c e s s e s .   H o w e v e r ,   d i s c u s -
s i o n s   o n   a c t u a l   o u t c o m e s   n e e d   t o   b a l a n c e 
t h i s   o b j e c t i v e   w i t h   t h e   n e e d   t o   e n s u r e   a n 
e x h a u s t i v e   v e r i f i c a t i o n   o f   d i s b u r s e m e n t 
conditions.

43.
A c c o r d i n g   t o   t h e   C o m m i s s i o n ’ s   d a t a   o n 
138 scored health targets covering disburse-
m e n t   d e c i s i o n s   o v e r   2 0 0 3 – 0 7 ,   8 3   t a r g e t s 
were fully achieved (i.e. 60%).

In addition, in a further 15% of cases targets 
were partially met.

O v e r a m b i t i o u s   t a r g e t s   m a y   a l s o   h a v e   c o n -
tributed to these results.

44.
(a)
The  financial  weight  attached  to  individual 
targets is only one of the ways through which 
b u d g e t   s u p p o r t s   a i m s   t o   f o s t e r   i m p r o v e d 
performance, others being monitoring, pol-
icy dialogue and domestic accountability.

(b)
The Commission uses some input indicators 
(typically financial allocation and execution) 
b u t   m a i n l y   f o c u s e s   o n   o u t c o m e   i n d i c a t o r s 
(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 
u s i n g   e x i s t i n g   d a t a   t h e   C o m m i s s i o n   p r o -
motes and supports their improvement.

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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.

F o r   e x a m p l e ,   a   f i r s t   a s s e s s m e n t   o f   t h e   i n i -
t i a l   a l l o c a t i o n s   t o   t h e   1 0 t h   E D F   n a t i o n a l 
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 
f a r   a l l o c a t e d .   T h e   r e m a i n i n g   5 2 %   a r e   t h e n 
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-
i n g   ( R O M )   s y s t e m   c o v e r i n g   a l l   r e g i o n s   a n d 
sectors  of  Community  aid.  The  ROM  system 
m a i n l y   f o c u s e s   o n   q u a l i t y   o f   d e s i g n ,   e f f i -
c i e n c y   a n d   e f f e c t i v e n e s s   t o   d a t e ,   i m p a c t 
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-
m i s s i o n   e n d e a v o u r s   t o   i m p r o v e   t h e   ‘ l i n k 
(between) relieve, rehabilitation and devel-
opment’ (LRRD).

(d)
The identification of ambitious and realistic 
targets is difficult and can only be satisfac-
t o r i l y   a c h i e v e d   a f t e r   s e v e r a l   y e a r s   o f   p r a c -
tice  in  management  by  results  when  sector 
p r o c e s s e s   a r e   p r o p e r l y   m a s t e r e d .   I m p r o v -
i n g   p a r t n e r   c o u n t r i e s   c a p a c i t y   t o   m a n a g e 
b y   d e v e l o p i n g   r e s u l t s   i s   o n e   o f   t h e   o b j e c -
tives of the Commission approach to budget 
support.

(e)
Efforts are being made to better take quality 
o f   c a r e   i n t o   c o n s i d e r a t i o n .   A s   a n   e x a m p l e , 
t h e   i n d i c a t o r   o n   d e l i v e r y   a t t e n d a n c e   h a s 
p r o g r e s s i v e l y   e v o l v e d   f r o m   ‘ i n s t i t u t i o n a l ’ 
d e l i v e r i e s   ( w h i l e   n o t   e v e r y o n e   i n   a   h e a l t h 
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);
p o v e r t y   r a t e s   i n   c o u n t r i e s   b e n e f i c i a r y 
o f   b u d g e t   s u p p o r t   r a n g e   b e t w e e n   3 0 
a n d   6 0 %   o f   t h e   p o p u l a t i o n :   t a r g e t s   f o r 
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.

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(c)
F o l l o w i n g   t h e   C o u r t ’ s   s p e c i a l   r e p o r t   o n 
t h e   ‘ E f f e c t i v e n e s s   o f   t h e   T A   i n   t h e   c o n t e x t 
of  capacity  development’  (2007),  the  Com-
m i s s i o n   w i l l   f i n a l i s e   b y   t h e   e n d   o f   N o v e m -
b e r   2 0 0 8   i t s   n e w   ‘ G u i d e l i n e s   o n   t e c h n i c a l 
c o o p e r a t i o n   a n d   p r o g r a m m e   i m p l e m e n t a -
t i o n   a r r a n g e m e n t s ’ ;   t h e   a i m   b e i n g   t o   p r o -
v i d e   q u a l i t y   t e c h n i c a l   c o o p e r a t i o n   t h a t 
s u p p o r t s   c o u n t r y - l e d   p r o g r a m m e s   a s   w e l l 
as  support  through  partner-owned  project 
implementation  arrangements,  with  a  sub-
s t a n t i a l   r e d u c t i o n   i n   t h e   u s e   o f   p a r a l l e l 
p r o j e c t   i m p l e m e n t a t i o n   u n i t s .   T h i s   s h o u l d 
contribute to better quality of the technical 
c o o p e r a t i o n ,   o w n e r s h i p   a n d   s t r e n g t h e n e d 
capacity.

(e)
M o s t   c o u n t r i e s   i n   S S A   h a v e   d e v e l o p e d 
n a t i o n a l   h e a l t h   p o l i c i e s   w i t h   t h e   s u p p o r t 
of the WHO and of the whole donor commu-
nity, the EC included. However, often there 
n e e d s   t o   b e   a   b e t t e r   f i t   b e t w e e n   p o l i c i e s 
and  resources  (budget  allocated  to  health, 
human resources for health, etc.).

The Commission contributes to the improve-
m e n t   o f   t h e s e   h e a l t h   p o l i c i e s   t h r o u g h 
projects (e.g. the EUR 25 million ‘Programme 
de soutien au secteur de la santé’ in Angola), 
‘ S e c t o r   P o l i c y   S u p p o r t   p r o g r a m m e s ’   ( e . g . 
health Sector Budget support in Zambia and 
Mozambique) or even through its participa-
tion  in  ‘joint  annual  health  sector  reviews’ 
( e . g .   B e n i n ,   M a d a g a s c a r ,   M o z a m b i q u e , 
Zambia).

(f)
S e e   r e p l i e s   t o   p a r a g r a p h s   V I   ( t h i r d   i n d e n t ) 
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 
o v e r l a p s   b e t w e e n   a c t i o n s   i m p l e m e n t e d   a t 
c o u n t r y   o r   r e g i o n a l   l e v e l   a n d   t h o s e   i m p l e -
m e n t e d   a t   i n t r a - A C P   l e v e l .   I n   a d d i t i o n ,   E C 
delegations  are  regularly  informed  of  cen-
trally  managed  programmes  when  regional 
s e m i n a r s   a r e   h e l d .   F o r   m o r e   i n f o r m a t i o n , 
t h e y   a l s o   h a v e   a c c e s s   t o   C R I S   ( E u r o p e A i d 
i n f o r m a t i o n   s y s t e m )   a n d   t o   t h e   E u r o p e A i d 
intranet.

(c)
The UN–EC joint guidelines on reporting are 
intended to overcome these difficulties.

53.
(a)
U s u a l l y ,   t h e s e   g e n e r a l   b u d g e t   l i n e s   h e a l t h 
p r o j e c t s   p r o p o s e d   a n d   i m p l e m e n t e d   b y 
NGOs and other non-state actors are funded 
b y   t h e   C o m m i s s i o n   o n l y   i f   t h e y   a r e   s u f f i -
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)
B e t w e e n   2 0 0 4   a n d   2 0 0 5 ,   t h e   C o m m i s s i o n 
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.

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54.
T h e   c a l l s   f o r   p r o p o s a l s   ( C f P )   u n d e r   h e a l t h 
thematic  budget  lines  are  targeted  at  least 
d e v e l o p e d ,   o t h e r   l o w   a n d   l o w e r   m i d d l e 
i n c o m e   c o u n t r i e s   a n d ,   w i t h i n   t h e s e   c o u n -
tries, at the most disadvantaged population 
groups.  It  is  recognised  that  poor  and  mar-
g i n a l i s e d   p o p u l a t i o n   g r o u p s   e v e n   i n   m o r e 
a d v a n c e d   d e v e l o p i n g   c o u n t r i e s   n e e d   s u p -
p o r t ;   t h i s   p a r t i c u l a r l y   a p p l i e s   t o   H I V / A I D S 
a n d   r e p r o d u c t i v e   h e a l t h   n e e d s   o f   g r o u p s 
such as injecting drug users, migrants work-
ers,  refugees,  sex  workers,  men  having  sex 
with  men,  etc.  Furthermore,  the  CfP  evalu-
a t i o n   p r o c e s s   t a k e s   i n t o   a c c o u n t   t h e   r e l e -
vance  of  the  action  proposed  to  the  needs 
a n d   c o n s t r a i n t s   o f   t h e   c o u n t r y   /   r e g i o n   / 
population concerned.

58.
F o l l o w i n g   t h e   C o u r t ’ s   a u d i t ,   t h e   C o m m i s -
sion has decided to establish a specific Inter 
Service Group with the following tasks:
 —

t o   d e f i n e   t h e   r o l e   a n d   r e s p o n s i b i l i t i e s 
an EC delegation should have in relation 
t o   t h e   G l o b a l   F u n d   ( e . g .   p a r t i c i p a t i o n 
i n   t h e   C C M ,   r e p o r t i n g ,   e t c . ) .   D i f f e r e n t 
types of delegations could be identified 
according  to  criteria  such  as,  for  exam-
p l e ,   t h e   l e v e l   o f   H I V   p r e v a l e n c e   i n   t h e 
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-
p o r t e d   b y   H Q   a n d   h o w   b o t h   D e v e l o p -
m e n t   D G   a n d   E u r o p e A i d   C o - o p e r a t i o n 
O f f i c e   w i l l   c o o p e r a t e   t o   c a r r y   o u t   t h e i r 
assistance to the delegations.

 —

 —

74

(c)
T h e   c a p a c i t y   o f   c o u n t r i e s   t o   p r e p a r e   g o o d 
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 
G l o b a l   F u n d   a n d   P E P F A R   ( U S   P r e s i d e n t ’ 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 
h e a l t h   ( H R H ) .   T h e   D C I   /   ‘ I n v e s t i n g   i n   p e o -
ple’  has  earmarked  EUR  40  million  for  HRH 
i n   t h e   p e r i o d   2 0 0 7 – 1 3 .   T h e   E D F   s u p p o r t s 
H R H   a c t i v i t i e s   a n d   p r o g r a m m e s   i n   A n g o l a , 
M o z a m b i q u e ,   U g a n d a ,   Z a m b i a   a n d   Z i m b a -
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.
T h e   C o m m i s s i o n   i s   a w a r e   t h a t   s i g n i f i c a n t 
d i s e a s e   s p e c i f i c   p r o g r a m m e s   s u c h   a s   t h e 
G l o b a l   F u n d   n e e d   e f f i c i e n t   h e a l t h   s y s t e m s 
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.

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T o   r e a f f i r m   i t s   p o s i t i o n ,   t h e   C o m m i s s i o n 
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 
c o - s i g n e d   w i t h   g o v e r n m e n t s   a n d   d e v e l o p -
ment partners, an ‘IHP compact’ (modalities 
to apply IHP in a specific country).

69.
T h e   C o m m i s s i o n   a c t i v e l y   p r o m o t e s   t h e 
development  and  implementation  of  a  sec-
t o r   p r o g r a m m e ,   t h r o u g h   a   S W A p ,   m a i n l y 
i n   t h e   c o u n t r i e s   i n   w h i c h   i t   s u p p o r t s   t h e 
h e a l t h   s e c t o r .   S o   f a r ,   t h e   C o m m i s s i o n   h a s 
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:
1. 

the inclusion of support to health in the 
CSP,  as  focal  or  non-focal  sectors  in  the 
context  of  country  ownership  and  divi-
sion of labour;
S B S   e l i g i b i l i t y   c o n d i t i o n s   a r e   s a t i s f i e d 
(well-defined sector policy, sector coor-
d i n a t i o n   m e c h a n i s m ,   m a c r o e c o n o m i c 
stability and PFM improvement).

2. 

However, in many sub-Saharan Africa coun-
t r i e s   t h e s e   c o n d i t i o n s   a r e   n o t   c u r r e n t l y 
met.

72.
T h e   p o l i c y   /   s t r a t e g y   f r a m e w o r k s   h a v e 
i m p r o v e d   a   l o t   i n   S S A   c o u n t r i e s   o v e r   t h e 
l a s t   d e c a d e ,   w i t h   t h e   s u p p o r t   o f   t h e   W H O 
and of all other major development partners. 
H o w e v e r ,   t h e s e   p o l i c i e s   n e e d   t o   b e   c o n -
stantly  improved  (for  example,  better  links 
between health needs and resources). Joint 
a n n u a l   h e a l t h   s e c t o r   r e v i e w s   i n   w h i c h   t h e 
Commission is often involved, is an exercise 
which  often  result  in  new  developments  in 
the health policy / strategy frameworks.

64.
T h e   C o m m i s s i o n   n o t e s   t h a t   t h e   i s s u e   m a y 
b e   f i r s t   a n d   f o r e m o s t   w h e n   a   c o m b i n a t i o n 
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.

T h e   C o m m i s s i o n   c o n s i d e r s   t h a t   a   w e l l -
d e f i n e d   h e a l t h   p o l i c y   a n d   a   h e a l t h   s e c t o r 
programme supported by donors, not neces-
sarily a Commission financed SBS, are desir-
a b l e   t o   i m p r o v e   t h e   e f f e c t i v e n e s s   o f   G B S 
contribution to health outcomes.

65.
In line with its belief concerning instruments 
c o m p l e m e n t a r i t y ,   t h e   C o m m i s s i o n   a g r e e s 
w i t h   t h e   C o u r t   t h a t   p r o j e c t s   c a n   r e i n f o r c e 
budget support but notes that the opposite 
is also very much true.

66.
C o m p l e m e n t a r i t y   i s   n o t   e a s y   w i t h   t h e   G l o -
bal Fund. The predictability is weak (accord-
ing  to  the  Court,  only  39%  of  proposals  for 
r o u n d s   1 – 7   C f P   h a v e   b e e n   g r a n t e d   b y   t h e 
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.

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CONCLUSIONS 
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.

T h e   2 0 %   c o m m i t m e n t   ( ‘ T h e   C o m m i s s i o n 
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, 
p r o g r a m m e   o r   b u d g e t   s u p p o r t   l i n k e d   t o 
these  sectors,  taking  an  average  across  all 
geographical areas…’ Article 5 of the Devel-
o p m e n t   C o o p e r a t i o n   I n s t r u m e n t )   d o e s   n o t 
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 
a n d   p r o g r a m m e s   i n   A n g o l a ,   M o z a m b i q u e , 
Uganda, Zambia and Zimbabwe. HRH indica-
tors are now used in GBS and health SBS vari-
ables  tranches.  The  Commission  also  works 
w i t h   t h e   W H O   i n   s u p p o r t i n g   p h a r m a c e u t i -
c a l   p o l i c i e s   ( E U R   2 5   m i l l i o n )   a n d   i m p r o v e d 
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 
b e   e s t a b l i s h e d   f o r   t h e   1 0 t h   E D F   m i d - t e r m 
r e v i e w .   T h e s e   a r e   l i k e l y   t o   s t r e s s   c o u n t r y -
l e v e l   o b j e c t i v e s ,   r e s u l t s   a c h i e v e d   a n d   t h e 
p r i n c i p l e s   o f   c o u n t r y   o w n e r s h i p   a n d   d i v i -
s i o n   o f   l a b o u r .   T h e y   w i l l   a l s o   t a k e   i n t o 
account the fact that results on the health 
M D G s   c a n   b e   a t t a i n e d   t h r o u g h   v a r i o u s 
w a y s ,   i n c l u d i n g   i n v e s t m e n t s   o u t s i d e   t h e 
h e a l t h   s e c t o r   ( w a t e r   a n d   s a n i t a t i o n ,   e d u -
c a t i o n ,   r u r a l   d e v e l o p m e n t ,   g o v e r n a n c e , 
e t c . )   a n d   n o t   s o l e l y   t h r o u g h   d i r e c t   s u p o r t 
to health services.

(a)  While  recognising  the  scope  to  expand 
t h e   a t t e n t i o n   t o   h e a l t h   i n   f r a g i l e   S t a t e s , 
o f t e n   h e a l t h   d o n o r   o r p h a n s ,   t h e   C o m -
m i s s i o n   a l r e a d y   p r o v i d e s   o r   w i l l   p r o v i d e 
d i r e c t   s u p p o r t   t o   t h e   h e a l t h   s e c t o r   u n d e r 
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 
a n d   Z i m b a b w e ) .   T h e   n u m b e r   o f   c o u n t r i e s 
a f f e c t e d   b y   s i t u a t i o n s   o f   f r a g i l i t y   w h o s e 
health sector is supported by the Commis-
sion has increased from seven in the ninth 
to eight in the 10th EDF.

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77

76.
The Commission welcomes the Court’s obser-
vation on the improved speed of implemen-
tation of EDF health interventions, under the 
n i n t h   E D F ,   a n d   a g r e e s   w i t h   t h e   C o u r t   t h a t 
this is partly due to devolution.

77.
T h e   r e s u l t s   o f   t h e   f i r s t   f i v e - y e a r   o n g o i n g 
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-
t i v e n e s s   o f   a i d .   A c c o r d i n g l y ,   s t a r t i n g   w i t h 
the 10th EDF, the EC has developed the MDG 
C o n t r a c t   p r e c i s e l y   t o   i n c r e a s e   p r e d i c t a b i l -
ity of budget support in performing partner 
countries. The Commission notes, however, 
t h a t   v o l a t i l i t y   i n   a i d   i s   j u s t i f i e d   w h e n   t h e 
p r e c o n d i t i o n s   f o r   a i d   e f f e c t i v e n e s s   a r e   n o 
longer present as when budget support eli-
gibility elapses.

N o   2 :   D u r i n g   t h e   m i d - t e r m   r e v i e w   o f   t h e 
1 0 t h   E D F ,   t h e   C o m m i s s i o n   w i l l   r e v i e w   t h e 
b a l a n c e   o f   i t s   f u n d i n g   t o   b e s t   r e f l e c t   i t s 
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 
s t r e n g t h e n i n g   ( H S S )   i s   i n d e e d   a m o n g   i t s 
priorities.

N o   3 :   T h o u g h   a c k n o w l e d g i n g   t h e   l i m i t s 
of resource allocation decision as concerns 
overall  staff,  the  Commission  is  exploring 
w a y s   t o   e n s u r e   a   b e t t e r   a c c e s s   t o   p u b l i c 
health expertise in delegations. Where the 
C o m m i s s i o n   i s   i n d i r e c t l y   i n v o l v e d   i n   t h e 
health  sector,  notably  through  GBS  linked 
t o   t h e   s o c i a l   s e c t o r s   o r   b u d g e t   l i n e s   a n d 
intra-ACP funding, silent partnerships have 
to be agreed with other (EU) donors in the 
s p i r i t   o f   t h e   c o d e   o f   c o n d u c t   o n   c o m p l e -
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 )   T h e   p o s s i b i l i t y   o f   e s t a b l i s h i n g   h e a l t h 
expertise in regional delegations has been 
u n d e r   c o n s i d e r a t i o n   f o r   s o m e   t i m e .   T h e r e 
is a need for the Commission to better bal-
a n c e   t h e   a d v a n t a g e s   a n d   d i s a d v a n t a g e s 
o f   s u c h   a   r e c o m m e n d a t i o n   b e f o r e   r e a c h -
ing any decision.

( c )   C o o p e r a t i o n   w i t h   t h e   W H O ,   w h i c h   i s 
a l r e a d y   i m p o r t a n t ,   c o u l d   i n d e e d   b e   r e i n -
f o r c e d   w i t h   i t s   c o u n t r y   o f f i c e s   w h e n e v e r 
this is possible.

Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa

RECOMMENDATIONS
ON SPEED AND PREDICTABILITY

No  4:  The  Commission  is  currently  explor-
ing  with  UNAIDS  the  ways  to  build  capac-
i t y   o f   c o u n t r i e s   i n   t h e   f i g h t   a g a i n s t   A I D S 
( d e v e l o p m e n t   a n d   i m p l e m e n t a t i o n   o f   a 
‘capacity building’ plan of action).

No 5: Under the 10th EDF, the Commission 
i s   s e e k i n g   t o   m a k e   i t s   G B S   m o r e   p r e d i c t -
able  through  the  launch  of  MDG  Contract 
i n   p e r f o r m i n g   c o u n t r i e s .   T h e   C o m m i s s i o n 
believes that the threat of suspending pay-
ments is an incentive to preserve eligibility: 
t h i s   w o u l d   b e   u n d e r m i n e d   i f   t h e   r e c o u r s e 
to  alternative  instruments  to  preserve  the 
flow  of  funds  was  automatic.  The  need  to 
a v o i d   u n n e c e s s a r i l y   p u n i s h i n g   t h e   p o o r , 
h o w e v e r ,   i s   o n e   o f   t h e   k e y   f a c t o r s   d e t e r -
mining  Commission’s  decisions  under  this 
case-by-case approach.

78

79.
T h e   C o m m i s s i o n   w e l c o m e s   t h e   C o u r t ’ s 
acknowledgement that GBS can be an impor-
t a n t   i n s t r u m e n t   t o   s u p p o r t   b e t t e r   h e a l t h 
p o l i c i e s .   N e v e r t h e l e s s ,   t h e   C o m m i s s i o n 
u n d e r l i n e s   t h a t   t h e   e f f e c t i v e n e s s   o f   g e n -
e r a l   b u d g e t   s u p p o r t   i s   b e t t e r   a s s e s s e d   i n 
the longer term since progress in outcomes 
a t   n a t i o n a l   l e v e l   t a k e s   t i m e   a s   i t   r e q u i r e s 
improvements in large systems and thus can-
not  be  compared  to  progress  in  outputs  in 
s m a l l e r   a n d   t a r g e t e d   g r o u p s   o f   t h e   p o p u -
l a t i o n .   F u r t h e r   i m p r o v e m e n t s   a r e   t a r g e t e d 
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-
s i o n   c o n t i n u e s   i t s   e f f o r t s   t o   i n c r e a s e   t h e 
effectiveness  of  its  BS  instruments  (includ-
i n g   t h r o u g h   i n c r e a s e d   u s e d   o f   i n d i c a t o r s 
d i s a g g r e g a t e d   a t   t h e   l e v e l   o f   t h e   p o o r e s t 
regions, marginal areas or gender).

80.
T h e   p r o j e c t   a p p r o a c h   —   a s   s t a n d   a l o n e 
p r o j e c t   o r   a s   i m p l e m e n t i n g   m o d a l i t y   o f   a 
SPSP — will continue to be an important ele-
ment of EC support to the health sector. The 
C o m m i s s i o n   c o n t i n u o u s l y   t r i e s   t o   i m p r o v e 
the selection of multi-country projects.

81.
T h e   i m p l i c a t i o n   o f   t h e   d e l e g a t i o n s   a l s o 
d e p e n d s   o n   t h e i r   c a p a c i t y   i n   s e c t o r a l 
matters.

Following the Court’s report, a specific Inter 
Service Group has been established to define 
what  the  Commission  should  do  at  country 
l e v e l   t o   e n s u r e   a   m o r e   e f f i c i e n t   u s e   o f   t h e 
Global Fund’s financial resources.

Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa

79

RECOMMENDATIONS 
ON MANAGEMENT AND 
EFFECTIVENESS OF INSTRUMENTS

N o   6 :   T h e   C o m m i s s i o n   i s   c o m m i t t e d   t o 
m a k e   t h e   g r e a t e s t   u s e   p o s s i b l e   o f   S B S   f o r 
focal and non-focal sector health interven-
t i o n s   w h e n   c o n d i t i o n s   a l l o w   i t .   A s   p e r   i t s 
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 
e x e c u t i o n   r a t e s ) .   A   t e c h n i c a l   a s s i s t a n c e 
facility could be included in General Budget 
Support  operations  to  respond  to  specific 
n e e d s   r e g a r d i n g   s e c t o r s   w i t h   G B S   i n d i c a -
tors (e.g. health information systems).

( b )   A t   s e c t o r   l e v e l   a n n u a l   r e v i e w s   t y p i -
c a l l y   f o c u s   o n   t h e   i m p l e m e n t a t i o n   o f   t h e 
sector policy and the execution of the sec-
t o r   b u d g e t .   R e s u l t s   o f   p u b l i c   e x p e n d i t u r e 
r e v i e w s   a n d   e x p e n d i t u r e   t r a c k i n g   s u r v e y s 
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 
t a k e n   i n t o   a c c o u n t   d u r i n g   t h e   G B S   j o i n t 
annual  review.  In  the  remaining  countries 
t h e s e   a r e   p r o g r e s s i v e l y   b e i n g   d e v e l o p e d 
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 
s y s t e m i c   c o m p o n e n t s   o f   p a r t n e r   p u b -
l i c   f i n a n c i a l   m a n a g e m e n t   a n d   a l s o   b u i l d 
c a p a c i t i e s   i n   t h e   a r e a   o f   m a n a g e m e n t 
o f   h u m a n   r e s o u r c e s .   T h u s   i t   w o u l d   p r e f e r 
to strengthen domestic accountability bod-
ies’ capacities to carry out reviews like the 

ones  suggested  rather  than  carrying  them 
o u t   d i r e c t l y .   S u c h   a n   a p p r o a c h   h a s   t h e 
p o t e n t i a l   t o   m a x i m i s e   t h e   i m p a c t   o f   G B S , 
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 )   W i t h i n   t h e   o v e r a l l   l i m i t s   o f   i t s   h u m a n 
r e s o u r c e   b u d g e t   a n d   t h e   e v o l v i n g   s t a t u s 
o f   d i v i s i o n   o f   l a b o u r   e x e r c i s e s ,   t h e   C o m -
m i s s i o n   w i l l   d o   i t s   u t m o s t   t o   i m p r o v e   t h e 
quality of input into health sector dialogue 
as suggested above.

( e )   T h e   i m p r o v e m e n t   o f   t h e   i n d i c a t o r s 
u t i l i s e d   i n   i t s   b u d g e t   s u p p o r t   o p e r a t i o n s 
i s   a   c o n t i n u o u s   p r e o c c u p a t i o n   o f   t h e 
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-
t r y   c o o r d i n a t i n g   m e c h a n i s m ,   r e p o r t i n g , 
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 
n e w   t a s k s   t a k i n g   t h e i r   l i m i t e d   r e s o u r c e s 
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.

I n   a d d i t i o n ,   T h e   C o m m i s s i o n   i s   c u r r e n t l y 
examining  with  UNAIDS  the  ways  to  build 
c a p a c i t y   o f   c o u n t r i e s   i n   t h e   f i g h t   a g a i n s t 
A I D S   ( d e v e l o p m e n t   a n d   i m p l e m e n t a t i o n 
of a ‘capacity building’ plan of action).

Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa

80

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 
s e c t o r   ( i n c l u d i n g   p r o j e c t s ) ,   a s   w e l l   a s   o n 
their  use  in  combination,  will  be  reviewed 
i n   t h e   ‘ h e a l t h   p r o g r a m m i n g   g u i d e l i n e s ’ 
which  are  currently  being  updated  to  bet-
ter take into account broader developments 
of EC instruments (e.g. MDG Contract).

( c )   T h e   C o m m i s s i o n ’ s   n e w   I n t e r s e r v i c e 
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 
G l o b a l   F u n d   o p e r a t i o n s   a n d   t h e   d i f f e r e n t 
t i m e f r a m e s   f o r   C o m m i s s i o n   a n d   G l o b a l 
Fund operations.

N o   1 1 :   T h e   C o m m i s s i o n   i s   c o m m i t t e d   t o 
u s e   S B S   a s   i t s   p r e f e r r e d   i m p l e m e n t a t i o n 
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-
t o r   p r o g r a m m e s ,   d i r e c t l y   i n   t h e   c o u n t r i e s 
w h e r e   h e a l t h   i s   p a r t   o f   i t s   c o o p e r a t i o n 
s t r a t e g y ,   a n d   i n d i r e c t l y   t h r o u g h   G B S   p e r -
f o r m a n c e   a s s e s s m e n t   a n d   j o i n t   r e v i e w 
processes elsewhere.

No 9: Although the project (as an approach 
or as an implementation modality of a sec-
t o r   p o l i c y   s u p p o r t   p r o g r a m m e )   i s   n o t   t h e 
E C   p r e f e r r e d   f o r m   o f   a i d   i m p l e m e n t a t i o n , 
it is clear that projects still remain a major 
i n s t r u m e n t   t o   c a r r y   o u t   o u r   d e v e l o p m e n t 
assistance. For example, a first assessment 
o f   t h e   i n i t i a l   a l l o c a t i o n s   t o   t h e   1 0 t h   E D F 
national indicative programmes / Envelope 
A of SSA countries (South Africa excluded) 
s h o w s   t h a t   b u d g e t   s u p p o r t   ( i n c l u d i n g 
G B S   a n d   S B S )   r e p r e s e n t   a p p r o x i m a t e l y 
4 8 %   o f   t h e   a m o u n t s   s o   f a r   a l l o c a t e d .   T h e 
remaining  52%  are  then  going  to  be  spent 
m o s t l y   t h r o u g h   p r o j e c t s   a n d   e a r m a r k e d 
p r o g r a m m e s .   H o w e v e r ,   t h e   C o m m i s s i o n 
c a n n o t   a g r e e   w i t h   t h e   r e c o m m e n d a t i o n 
to  use  project  support  ‘to  provide  health-
care in poorer regions not adequately cov-
e r e d   b y   h e a l t h   c a r e   s e r v i c e s ’   s i n c e   i n   a t 
l e a s t   3 0   d e v e l o p i n g   c o u n t r i e s ,   a c c e s s   t o 
health services is limited; but the adequate 
response to the challenge is sufficient, pre-
d i c t a b l e   a n d   a l i g n e d   h e a l t h   O D A ;   r a t h e r 
then the proposed NGO financing.

82.
T h e   C o m m i s s i o n   w i l l   f u r t h e r   i m p r o v e   t h e 
w a y   i n   w h i c h   i t   s e e k s   t o   e x p l o i t   s y n e r g i e s 
between its interventions, starting with the 
ongoing review of health guidance.

83.
T o   s u p p o r t   t h e   i m p l e m e n t a t i o n   o f   s e c t o -
r a l   p r o g r a m m e s ,   t h e   C o m m i s s i o n   i n   2 0 0 7 
updated  its  2003  guidelines  on  EC  support 
to sector programmes and organised a whole 
series of trainings related to this implemen-
t a t i o n   m o d a l i t y .   I t   h a s   a l s o   l a u n c h e d   a n d 
m a n a g e d   t o g e t h e r   w i t h   D e n m a r k   a n d   t h e 
N e t h e r l a n d s   t h e   j o i n t   l e a r n i n g   p r o g r a m m e 
o n   s e c t o r - w i d e   a p p r o a c h e s ,   a n   i n i t i a t i v e 
h i g h l y   r e g a r d e d   b y   t h e   d o n o r   c o m m u n i t y . 
The Commission will continue to support the 
e s t a b l i s h m e n t   a n d   i m p l e m e n t a t i o n   o f   s e c -
t o r   p r o g r a m m e s ,   d i r e c t l y   i n   t h e   c o u n t r i e s 
where health is part of its cooperation strat-
e g y ,   a n d   i n d i r e c t l y   t h r o u g h   G B S   p e r f o r m -
ance assessment and joint review processes 
elsewhere.

Special Report No 10/2008 — EC development assistance to the health services in sub-Saharan Africa

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 Communities

2009 — 80 pp. — 21 × 29,7 cm

ISBN 978-92-9207-095-3

doi: 10.2865/21515

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SPECIAL  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.

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EUROPEAN COURT OF AUDITORS

EC DEVELOPMENT ASSISTANCE

TO HEALTH SERVICES 

IN SUBSAHARAN AFRICA

ISBN 978-92-9207-095-3