WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR AFRICA
ORGANISATION MONDIALE DE LA SANTE BUREAU REGIONAL DE L’AFRIQUE
ORGANIZAÇÃO MUNDIAL DE SAÚDE ESCRITÓRIO REGIONAL AFRICANO
REGIONAL COMMITTEE FOR AFRICA
AFR/RC55/8 17 June 2005
Fifty-fifth session Maputo, Mozambique, 22–26 August 2005 Provisional agenda item 8.2
ORIGINAL: ENGLISH
COUNTRY COOPERATION STRATEGIES: IMPLEMENTATION, LESSONS LEARNT AND WAY FORWARD IN THE AFRICAN REGION Report of the Regional Director EXECUTIVE SUMMARY 1. This document gives a report of the follow-up actions on the orientation given at the fifty-first session of the Regional Committee to develop Country Cooperation Strategies in all the forty-six Member countries. It also provides an indication on how the process has evolved, lessons learnt and the way forward for maximizing the gains of the CCS process. 2. WHO has a country presence in the 46 Member States of the African Region and from 2001 has developed CCSs in 45 of the countries through extensive reviews and consultations with ministries of health, other relevant government agencies, development partners, nongovernmental organizations and WHO teams at the three levels of the organization. The strategies are aimed at making WHO more strategic and country-focused while streamlining WHO support to countries for more measurable impacts. The CCSs are aligned to national, subregional and regional objectives and plans such as the Poverty Reduction Strategy Papers, Millennium Development Goals and the New Partnership for Africa’s Development. CCSs are also in line with United Nations and other development agency country-level platforms and processes such as the Common Country Assessment and United Nations Development Assistance Framework. 3. The 45 CCSs have been analysed to obtain regional programmatic trends based on countries’ expressed priority health needs. The Member States and WHO therefore face the challenge of transforming the strategies into feasible work plans through a systems approach to institutionalize effective coordinated health action and improved performance at country level. 4. The Regional Committee is invited to note the progress made and lessons learnt in implementing the CCSs within the African Region; recognize the CCS as a key element of the WHO managerial process for implementing the Programme Budget and biennial workplans at country and regional levels and support the proposed way forward.
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CONTENTS Paragraphs BACKGROUND .............................................................................................................................. 1–6 IMPLEMENTATION ..................................................................................................................... 7–24 LESSONS LEARNT .................................................................................................................... 25–32 THE WAY FORWARD ............................................................................................................... 33–35 MONITORING AND EVALUATION ........................................................................................ 36–37 CONCLUSION ............................................................................................................................. 38–39
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BACKGROUND 1. The increasing complexity of the health sector in the presence of dwindling resources in Africa combined with the international commitment to achieving the Millennium Development Goals by 2015 and the growing number of actors with various health agendas have led to an increasing search for better coordination mechanisms at the country level. The need for effective WHO presence in Africa which adequately responds to the priority health needs of countries and supports ministries of health in their coordination roles has never been greater. 2. The Country Focus Initiative was introduced in 2001,1 as part of the reform throughout the organization. The Country Cooperation Strategy (CCS), a core component of the WHO Country Focus Policy of 2003, is a country-specific, adaptable and medium-term framework for cooperation between countries and WHO. The Country Focus Policy also concerns core competencies and capacities of country teams; coherent programmatic and technical support from regional offices and headquarters; functions of country offices; information; cooperation with United Nations and other development partners. 3. The Country Cooperation Strategy defines a strategic agenda for WHO work in and with individual countries and the implications of such agenda for the whole Organization. CCS priorities are based on extensive systematic assessment of country health needs; existing health partnerships; and WHO values, principles and directions. The CCSs also have very close linkages with existing national, regional and global objectives, plans, platforms and processes such as the Poverty Reduction Strategy Papers; Millennium Development Goals; Common Country Assessment; United Nations Development Assistance Framework; and the health strategy of the New Partnership for Africa’s Development. 4. The main objectives of the Country Cooperation Strategy are to: increase WHO effectiveness and efficiency in countries through well-led and adequately-skilled country teams, make WHO more responsive to country needs; ensure better internal consistency of WHO support to countries; facilitate access of governments, partners and WHO staff to reliable, timely information; and provide a mechanism for WHO to work with governments, development partners and other stakeholders on a wider development agenda that is based on human rights 5. The fifty-first session of the Regional Committee in 2001 reviewed the potential benefits of country-specific strategic frameworks which would form the basis of biennial workplans. It endorsed the development of Country Cooperation Strategies in all 46 Member States of the WHO African Region.2 6. The aim of this document is to report on the implementation of Country Cooperation Strategies; it also describes the lessons learnt and proposes the way forward in the African Region.
1
WHO, Improving WHO performance at country level: The Country Focus Initiative Consultation Document, Geneva, World Health Organization, 2002. 2 WHO, Fifty-first session of the WHO Regional Committee for Africa, Brazzaville, Republic of Congo, 27 August to 1 September 2001, Final Report. Brazzaville, World Health Organization, Regional Office for Africa, 2002 (AFR/RC51/18) p. 48.
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IMPLEMENTATION 7. The implementation of Country Cooperation Strategies is guided by the following principles: (a) (b) (c) (d) (e) Unity across WHO levels and programmes to ensure coherence of technical support to countries; Programmes based on the comparative advantage of WHO; Improved efficiency and effectiveness to ensure maximum health benefits to countries from WHO contributions; Decentralization of resources to regions and countries with corresponding increased delegation of authority to WHO representatives to expedite decision-making; Effective partnership coordination and dialogue for improved health resources and results at country level.
The process 8. Prior to the Country Focus Policy, programme priorities were determined at headquarters and handed down to regions and countries for use in developing biennial workplans. Many country offices then revealed weak alignment of activities with country priorities, limited resources for the many areas of work, in the POA, fragmented technical assistance and weak dialogue with ministries of health. 9. The formulation of Country Cooperation Strategies enabled WHO to undertake extensive consultations at country level with ministries of health as well as their national, bilateral and international partners. This helped to determine countries’ main health and development priorities for planning and intervention. 10. CCS guidelines were developed and used to ensure uniformity and consistency in the CCS formulation process undertaken by trained officers. Quality of CCS documents was assured through peer review by the Management Development Committee at the Regional Office and headquarters staff members led by the Regional Director. Progress to date 11. The Regional Office for Africa established the Country Analysis and Support Unit in 2001 to coordinate the entire CCS formulation process; it was also to promote and monitor the effective implementation of the Country Focus Policy. 12. Country Cooperation Strategies were developed in five countries in 2001, 18 in 2002, 14 in 2003 and eight in 2004. The collected information has been documented, analysed and made available on the WHO web site as a reference database for country profiles and health development programming at country, regional and global levels.
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13. The key priority health needs obtained from the analysis of the CCS documents include strengthening national health systems; scaling up integrated interventions to control both communicable and noncommunicable diseases; improving maternal, adolescent and child health; improving environmental health; and strengthening comprehensive health promotion. 14. Countries also expect WHO support for provision of timely, coherent and quality technical advice; harmonization of tools and guidelines; facilitation and coordination of partnerships; quality assurance of health development assistance of partners; advocacy; resource mobilization; engagement with macroeconomics and health; and strengthening health information use to facilitate policy analysis, dialogue, strategy development and decision-making. 15. The regional priority health needs identified from the CCS analysis compared very well with the priorities of the fifty-first session of the Regional Committee. However, many of the priorities included new emerging areas such as macroeconomics and health. The Country Cooperation Strategies are now being used by WHO to inform country, regional and global priorities, mediumterm and operational plans, resource allocation, programme budgets and the 11th General Programme of Work for the period 2006–2015. 16. Some WHO country offices are gradually reducing the number of selected areas of work in their biennial plans. While some offices have compiled profiles for selected agenda components, others have embarked on innovative extrabudgetary resource mobilization drives to fund capacity building and areas of intervention. Progress is also noted in pro-active partnership building through technical reviews, information sharing and consultations with stakeholders. 17. For the 2004–2005 biennium, the Country Office Operations area of work was changed to WHO’s Presence in Countries with a broader scope aimed at improving WHO performance at country level and networking among country support units. The new area of work covers development and analysis of CCSs, use of the CCS as a basis for programme development and resource allocation, CCS contributions to United Nations frameworks such as Common Country Assessment and United Nations Development Assistance Framework, and use of CCS to promote WHO input into national development platforms such as Povety Reduction Strategy Papers and sector-wide approaches. 18. In addition, the SCC Area of Work provides backup services to WHO country offices, securing technical and managerial support to ensure progress, monitoring WHO performance at country level and strengthening WHO capability to assess and respond to country needs and realities. Headquarters and Regional Office support to country offices has improved through promotion of learning approaches across countries and regions, and management of information. 19. The CCS analysis also identified some weaknesses in the WHO country offices, and these are now being addressed. As a result, some country offices are experiencing improved consultations, dialogues and relationships with ministries of health as well as greater assertiveness of technical health leadership at country level. The working environment is also being improved, with 20 country offices connected to the global communication network. Thirty-nine countries have the activity management system for better programmed management. Six countries have individual web sites linked to the WHO web site for more effective information dissemination.
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20. Recently, the WHO Regional Office for Africa, in its efforts to be more responsive and relevant to the needs of Member States, embarked on a systematic region-wide strengthening of WHO support using a five-element strategic framework. This framework which builds on the complementary strengths of country, regional and global expertise is aimed at strengthening the WHO country offices to enable them to provide high-quality, well-coordinated strategic technical support in a coherent manner at country level. 21. The five components of the strategic framework are as follows: (a) (b) Country Cooperation Strategy: re-stating the priorities of WHO through close interaction with government, health and development partners; Integrated health systems development: identifying how the country office can best be positioned among partners to strengthen national health systems for delivery of better health services; Re-profile of the country team: strengthening the country office team to ensure that proper competencies are available to WHO to carry out the core functions derived from the Country Cooperation Strategy and maintain technical leadership in health at country level; Strong administrative, financial and knowledge management capacities: enabling the country office to carry out its core functions; One Country Plan and budget: ensuring that WHO work planned at the three levels to support national health development and WHO normative work is adequately coordinated at country level.
(c)
(d) (e)
Challenges 22. The Country Cooperation Strategies have far-reaching implications for Member States and WHO operations in countries. Key challenges are: (a) (b) (c) (d) (e) (f) (g) (h) capacity to transform the strategies into consistent actions to improve performance and health outcomes at country level; continued preparedness to recognize the CCS as the basis for planning, defining expected results and resource allocation, considering the many other competing interests; effective coordination of the many activities, actors and agendas in the health sector, taking special account of SWAps, PRSPs, and national health plans; pragmatic integration of vertical programmes within the national health system to achieve coherent health service delivery and better results; WHO technical leadership at country level in the presence of dwindling regular budget resources for funding core country focus activities; region-wide CCS implementation, particularly aligning the organizational structures of the country and regional offices to reflect the identified programmatic shifts; full integration of CCS into the WHO managerial process and effective resource decentralization to the country offices; streamlining WHO managerial processes with the demands of United Nations reforms, especially with regard to joint collaborative activities between the United Nations agencies and the country team.
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Opportunities 23. The existing opportunities that could be explored to maximize the contribution of the CCS to improving WHO services to countries in the African Region include active advocacy by Member States for strengthening national health systems, re-evaluation of the contribution of vertical health programmes to sustainable health development, adoption of a systems approach in health programme delivery and changing modalities for programme funding at country level, with more donors tending towards sector-wide approaches and direct budget support. 24. A supportive environment exists to assist WHO to move the CCS agenda forward in the African Region. It includes the increasing priority given to health in the regional and global agendas, key partners who are calling for a shift from programme to coordinated strategic support to countries, the WHO international mandate, on-going reform and a management that is highly committed to change. LESSONS LEARNT 25. It was clearly learnt during the CCS formulation process that extensive consultations with various groups of people and exchange of information at country level were crucial for successful implementation of the developed CCS. In particular, the effective participation of representatives from ministries of health ensured both coherence and alignment between national and WHO priorities and orientations. 26. The involvement of all members of the WHO country office in the entire CCS process enhanced the quality of the process and document as well as ownership. The constant consultation and collaboration between country, regional and HQ offices reinforced the culture of “One WHO” and added value to the formulation processes. 27. The slow reduction of the large number of areas of work in biennial workplans in accordance with the CCS strategic agenda by some countries was linked to the limited understanding of the strategic objectives of WHO Areas of Work and their inter-relatedness. As a result, budgets were thinly spread and the impact of WHO support at country level was reduced. 28. Member States and health actors at country level recognize and are quite appreciative of the comparative strengths and professional neutrality of WHO. However, they want WHO technical and advisory support to be less fragmented, better coordinated and more strategic. 29. Inadequately coordinated planning across the three levels of the Organization and across programmes led to inefficient duplication of efforts and inconsistencies at country level. Technical clusters and divisions in HQ and the Regional Office need to work together to provide joint crossdepartmental support to clusters at country level to make them functional. 30. The recorded improvement in the key health indicators in countries is not commensurate with the number of players in the health sector and the fragmentation of health actions. Promotion of a more integrated health care delivery system and effective coordination of health actors are crucial to achieving better health impact.
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31. As WHO continues to negotiate with partners to act as their executing agency at country level, corresponding support systems must be put in place to strengthen the capacity of country offices to monitor performance, ensure accountability and show greater competence than other agencies in health matters. 32. In spite of the existing clear management commitment towards putting countries at the heart of WHO work, consistent advocacy is still required at programme level to fully integrate the CCS into the WHO managerial process. THE WAY FORWARD 33. The WHO Regional Office for Africa has systematically strengthened support for better health outcomes in three countries using the five-element strategic framework of the Country Focus Policy. It is also committed to implementing the policy in all 46 countries of the Region. It also aims to promote full integration of the CCS in the managerial processes in country offices. Another priority is facilitation of effective technical backstopping to enable country offices to offer more strategic integrated support to the attainment of the Millennium Development Goals. 34. The ultimate effectiveness of the Country Cooperation Strategies depends on the commitment of Member States, partners and WHO to implement the follow-up actions. Member States, working in collaboration with partners at the country level, have the responsibilities: (a) (b) (c) to ensure that the Country Cooperation Strategies form the basis of biennial workplans and dialogue on the WHO technical programme of cooperation; to support the alignment of the CCS strategic agenda with relevant areas of work and functions to avoid spreading programme funds too thinly; to consider the CCS process of determining priority health needs through consultations as an adoptable good practice to make national health plans more realistic and owned by all stakeholders. In addition, integration of technical programmes for more effective delivery of health services should be promoted.
35. The World Health Organization has responsibilities: (a) (b) (c) (d) (e) to ensure wide dissemination and full integration of the CCS into its managerial process; to provide coherent, strategic technical assistance to countries based on the CCS and promote integrated service delivery at country level; to ensure the systematic strengthening of WHO support to countries for better health outcomes using the five-component framework; to institutionalize requisite structural arrangements to support effective management and sustainability of the country focus approach at all levels; to work in collaboration with ministries of health and other relevant partners to develop appropriate supporting systems and tools to respond to the priority health needs of countries; to support the coordination and implementation of international health initiatives at the country level such as the MDGs within the context of the United Nations reforms;
(f)
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(g)
to monitor the implementation of the Country Focus Policy and overall performance of WHO at the country level.
MONITORING AND EVALUATION 36. Progress in the implementation of the above-stated priority actions will be monitored through the WHO managerial process while a performance and accountability framework will be developed to monitor the overall performance of WHO at the country level, its influence with key partners on the public health agenda and its contribution with relevant stakeholders to the health-related outcomes of Member States. 37. The CCS will form the basis of the biennial plans of action within a stipulated period and be subjected to review and evaluation to accommodate changes in the health and development situation in the country. Regular biennial reports shall be submitted to the Regional Committee. CONCLUSION 38. Despite the constraints encountered, especially in relation to complex emergency situations in some countries, marked progress has been made in implementing the country cooperation strategies within the African Region. However, country ownership and effective transformation of the CCS strategic agenda into concrete actions with measurable impact is central to the success of the Country Focus Policy. The various reforms aimed at strengthening the WHO country offices are meant to enhance complementarity and better technical support to countries rather than weaken the stewardship functions of the ministries of health. The support of WHO management structures at three levels is paramount for sustainability of the CCS process. 39. The Regional Committee is invited to note the progress and lessons learnt and support the proposed way forward for action.