Mozambique & Tanzania – Health Cluster Evaluation 2008-2013

Synthesis Report

Acknowledgements

This evaluation was undertaken by a team that included evaluation officers from Global Affairs Canada – Denis Marcheterre and Joanne Nowak – as well as consultants from Baastel and Interalia – Margot Rothman, Luc Gilbert and Philippe Bâcle, in collaboration with Brigitte Bagnol, Esmeralda Mariano, Sabas Kinboka and Roberto Esposito. Denis Marcheterre led the data collection field missions in both countries, as well as the writing of the final report. Consultants performed sectoral data collection, provided sectoral expertise, and contributed to the writing of the final report.

We would like to thank all who have contributed to this evaluation, including Country Program staff at headquarters and in the field who provided the documentation and participated in interviews. Many other stakeholders made themselves available for meetings, interviews and project site visits, including Government officials, donor representatives, implementing partners, numerous civil society organisations, and individual consultants who were generous with their time and provided the evaluation team with valuable insights into their programs and projects.

David Heath
Head of Development Evaluation
Global Affairs Canada

Executive Summary

The objectives of the evaluation were to take stock of the results achieved by the Mozambique and Tanzania Country Programs in the health sector over the five-year period 2008-2009 to 2012-2013, and to assess the Programs’ overall management performance in achieving these results. Data was gathered during the spring/summer of 2014 from program-level planning and reporting documentation, a sample of projects, and documentation on other program-related activities. Findings, conclusions, and recommendations are based on this body of evidence. The evaluation examined the Programs’ effectiveness, efficiency, sustainability and relevance.

Main Messages

Both Programs made a significant contribution to the health sectors in Tanzania and Mozambique. There were notable achievements in long-term HIV/AIDS programming in both countries. In addition, there was a successful effort to improve water and sanitation, featuring community involvement and multi-stakeholder engagement, through a long-term intervention in Mozambique. Global Affairs Canada health sector programming provided significant support to supply-side improvements in both countries, but attention to demand-side factors affecting health service access and outcomes has been relatively recent, with results only beginning to emerge. Challenges remained in the enabling environment affecting results achievement, particularly with regard to government accountability, health systems strengthening and women’s/maternal health.

Both Programs were aligned with the health sector priorities and needs of Tanzania, Mozambique and Global Affairs Canada. Given that needs and challenges remain significant in the health sectors of both countries, Canada’s presence in this sector continued to be relevant.

Global Affairs Canada was active in policy dialogue bodies throughout the evaluation period. These efforts contributed to strengthening health systems in both countries. However, the absence of tools and guidance to develop an internal policy dialogue plan, around which cohesion among Program staff could be built, limited the potential benefits of policy dialogue efforts in both countries.

Financial resources and fiduciary risks in Tanzania and Mozambique were managed diligently, although monitoring of operational and developmental risks can improve. Some corporate tools and processes, such as project approvals and performance measurement tools, hindered Program efficiency.

Challenges integrating cross-cutting themes into Program activities existed and were the result of limited expertise and diminishing human resources in these areas. This, in turn, reduced the Programs’ ability to effectively operationalize environment, gender equality and governance as cross-cutting themes.

For the period under review, both Programs successfully supported Muskoka projects, in spite of a limited timeframe for designing and implementing these investments. The achievement of results in health often requires time. The need to design health projects and achieve results in a short time-frame, in particular for Maternal Newborn and Child Health (MNCH), should consider sustainability over the long term.

Global Affairs Canada’s large programming and financial presence in the health sectors of both Tanzania and Mozambique would strongly benefit from managing interventions as a coherent health program rather than a collection of health projects. To manage operations as a program, a more rigorous analysis of complementarities across investments and across delivery channels, a systematic use of performance indicators to monitor and report on investments at sector level (not project level) and a more strategic use of policy dialogue, are needed.

The two Programs would benefit from considering how to include the cross-cutting themes more strategically, including pro-actively exploring opportunities for their integration that are outside of current practices and beyond current corporate trends. Both Programs could strengthen their impact by ensuring all projects have explicit outcomes related to the integration of cross cutting themes. Global Affairs Canada could contribute positively by ensuring the Programs receive adequate guidance and/or training, and have sufficient resources and time (both in the field and at HQ) to achieve such objectives.

A policy dialogue plan would help clarify what Programs seek to achieve through current or future dialogue structures, ensure better understanding and cohesion among staff, and allow the Programs to capitalize on the increased visibility resulting from the Muskoka Initiative. However, without adequate departmental tools and guidance and time set aside to undertake this analytical work, it will be challenging for the Programs to design and implement an organized policy dialogue plan.

Global Affairs Canada’s large programming and financial presence in the health sectors of both Tanzania and Mozambique require that the two Programs manage their interventions as a health program, rather than a collection of health projects. Beyond individual disbursements, a clearer strategic vision of the Programs’ leadership role in MNCH would be valuable in both countries. At a departmental level, a more flexible timeframe for designing and implementing MNCH projects, and a more efficient approval process, would enhance synergies among projects.

Management Response

In addition to the concrete program-level commitments for each recommendation, the Mozambique and Tanzania Programs have identified corporate and program-level considerations that would enable the implementation of the actions identified in their management responses. These considerations are included under each concrete commitment below.

This management response reflects the departmental priorities as expressed at the end of the evaluation period. Going forward, management responses will reflect new Departmental priorities as they evolve.

Recommendations

Recommendation 1

• Recommendation: Both Programs should regularly update their approach to cross-cutting themes, relying on in-depth sectoral analysis, as well as consider a more pro-active implementation of cross-cutting issues in their everyday work.

• Commitments and Action: Agreed. Both Programs will develop, in consultation with local and HQ specialists, program-level strategies to promote better integration of cross-cutting issues in investments, ensuring full consideration of the country context.

  Considerations

  Program-level: The two Programs need to consider how they strategically use cross-cutting themes. They should pro-actively explore opportunities, outside current practices and beyond current corporate trends. Both Programs could strengthen their impact by ensuring all projects have explicit objectives related to the integration of cross cutting themes.

  Corporate-level: Global Affairs Canada could contribute positively by ensuring the Programs receive adequate guidance and/or training, and have sufficient resources and time (both in the field and at HQ) to achieve such objectives.

• Responsibility Centre: ADM, Sub-Saharan Africa Branch

  Director, Tanzania and Mozambique Programs, supported by Program Deputy Directors, program officers

• Completion Date: Summer 2016

Recommendation 2

• Recommendation: Both Programs should develop policy dialogue plans that set clear objectives, desired policy outcomes and target audiences, identify the skills required to manage policy dialogue at political and technical levels, as well as report on them.

• Commitments and Action: Agreed. Both Programs will develop policy dialogue strategies and objectives, in line with Global Affairs Canada priorities and partner country needs and priorities. Both Programs will review and report on progress on their policy dialogue objectives as part of the annual country reporting cycle.

  Considerations

  Program-level: A plan would help clarify what Programs seek to achieve through current or future dialogue structures, ensure better understanding and cohesion among staff, and allow the Programs to capitalize on the increased visibility resulting from the Muskoka Initiative.

  Corporate-level: Without adequate guidance from the department, and time/resources set aside to undertake this analytical work, it will be challenging for the Programs to design and implement an organized policy dialogue plan.

• Responsibility Centre: ADM, Sub-Saharan Africa Branch

  Director, Tanzania and Mozambique Programs, supported by Program Deputy Directors and analysts

• Completion Date: March 31, 2016.

  To be documented in 2015-2016 reporting cycle and annually reviewed through program work planning and country reports

Recommendation 3

• Recommendation: Both Programs should ensure that health sector programming is guided by a program approach, within Global Affairs Canada’s corporate framework for MNCH, with a particular emphasis on how multidimensional health determinants for MNCH are interrelated.

• Commitments and Action: Agreed. Both Programs will develop, in consultation with specialists and relevant Global Affairs Canada bureaus, a health strategy aligned with their respective (draft) Country Bilateral Development Strategies and Global Affairs Canada’s corporate MNCH framework.

  Considerations

  Program-level: Global Affairs Canada’s large programming and financial presence in the health sectors of both Tanzania and Mozambique require that the two Programs manage their interventions as a health program, rather than a collection of health projects. Beyond individual disbursements, a clearer strategic vision of the Programs’ leadership role in MNCH would be valuable in both countries.

  Corporate-level: A more flexible timeframe from Global Affairs Canada for designing and implementing MNCH projects, and a revised approval process, would contribute to enhance synergies between projects.

• Responsibility Centre: ADM, Sub-Saharan Africa Branch

  Director, Tanzania and Mozambique Programs, supported by Program health teams and analysts

• Completion Date: By Summer 2016

Introduction

Evaluation Objectives^{Footnote 1}

The evaluation had three objectives: (1) take stock of the results achieved by the Tanzania and Mozambique Country Programs^{Footnote 2} in the health sector over the five-year period 2008-2009 to 2012-2013; (2) assess the bilateral Programs’ overall management performance in achieving these results; and, (3) document findings and formulate recommendations to improve performance.^{Footnote 3}

This evaluation examined the extent to which:

• The Programs contributed to/or achieved expected results,^{Footnote 4} including in policy dialogue and the integration of cross-cutting themes (Effectiveness);
• The use of resources were reasonable for the outcomes achieved, in light of the program context and priorities (Efficiency);
• The operations increased the probability of continued benefits from the portfolio of Global Affairs Canada development investments (Sustainability); and
• The objectives were consistent with beneficiary needs, country priorities, as well as Global Affairs Canada corporate policies and strategies; in addition to a retrospective assessment of the appropriateness of the program design, and continued need for the Program (Relevance).

The body of the document outlines the findings from data collection and analysis for both countries. The conclusions and recommendations are in the final section of the report.

In June 2013, the Department of Foreign Affairs and International Trade (DFAIT) and the Canadian International Development Agency (CIDA) were amalgamated into Foreign Affairs, Trade and Development Canada (Global Affairs Canada). The department has subsequently been renamed Global Affairs Canada. This evaluation covers a period during which Canada's development assistance was primarily delivered through CIDA. This report refers to CIDA in relation to decisions made prior to the amalgamation, and to Global Affairs Canada to describe ongoing or post-amalgamation decisions or situations.

Overview of Global Affairs Canada’s Priorities in Health^{Footnote 5}

Since 2006, Canada has made health sector investment a priority, increasing its financial commitments and the prominence of its efforts.^{Footnote 6} At the 2006 G-8 Summit in Russia, the Government of Canada committed $450 million over 10 years to support country-level efforts to strengthen health systems in sub-Saharan Africa. The Africa Health Systems Initiative (AHSI) aimed to improve health outcomes and advance Millennium Development Goals (MDGs) 4 and 5 by making health care more accessible for the most vulnerable, particularly women and children. AHSI efforts focused on training, equipping and deploying new/existing health workers, strengthening health information systems, as well as increasing equity in health service delivery.

In 2009, the Canadian government focused its development efforts on five thematic priorities, one of which was Children and Youth. The former CIDA launched its Children and Youth Strategy as part of an effort to focus interventions within this thematic priority. This Strategy emphasized: 1) access to quality education; 2) safe and secure futures for children and youth; and, 3) child survival, including maternal health. The latter targeted improving access to maternal health care, investing in child-specific health interventions (such as immunization and clean water), investing in the prevention of diseases (such as HIV/AIDS and malaria), and strengthening sustainable health systems.

At the Muskoka Summit in 2010, the G-8, led by Canada, announced an effort to galvanize global attention on maternal, newborn and child health (MNCH) due to the lack of progress on the related MDG5 (the Muskoka Initiative). The Government of Canada committed $2.85 billion over 2010-2015 to this new commitment, of which $1.1 billion was new funding and $1.75 billion represented ongoing spending in MNCH programming. The Initiative focused on three paths – strengthening health systems; reducing leading diseases affecting mothers and children; and improving nutrition – which served to amplify the child survival priority within CIDA’s Children and Youth Strategy. The Muskoka Initiative also built on AHSI by expanding the range of health priorities covered and the types of partnerships sought, including an increased focus on multilateral and global actors.

Tanzania and Mozambique were countries of focus in the context of both the AHSI and Muskoka commitments. During the 2008-2013 period, Global Affairs Canada’s disbursements (in all sectors) in Tanzania totalled roughly $564 million with 203 projects, and $483 million with 132 projects in Mozambique. The proportion of spending devoted to the health sector was roughly 38% for Tanzania and 44%^{Footnote 7} for Mozambique. This was mostly delivered through program based approaches.^{Footnote 8}

Canada was the 6^th largest donor in the health sector in Tanzania between 2008 and 2012 (in terms of disbursements), ranking behind the United States, the Global Fund, Germany, Denmark, and the World Bank. In Mozambique, Canada was the 3rd largest donor between 2008 and 2012, following the United States and European Union institutions.^{Footnote 9}

The launch of the Children and Youth Strategy and subsequent Muskoka Initiative had a significant impact on the allocation of Canada’s health funding in both countries. In Mozambique, bilateral health funding increased dramatically in the latter part of the evaluation period, growing fourfold from roughly $32 million between 2008 and 2010, to $127 million between 2010 and 2013. Health programming also grew in Multilateral and Partnership Branches, though to a lesser degree. The impact of this was also visible at the sub-sector level. Figure 1 illustrates how Canada’s health programming significantly increased in basic health care across all delivery channels after 2010, alongside more modest increases in the areas of HIV/AIDS and infectious disease control.

Figure 1: Mozambique - Total Disbursements for Key Investments in Health across Programming Branches between FY2008/09-2009/10 and FY2010/11-2012/13, by Sub-Sector (CDN$)

Bilateral programming in Tanzania increased more than fivefold from roughly $27 million between 2008 and 2010, to $144 million between 2010 and 2013. Multilateral programming also grew considerably, tripling from just under $10 million to roughly $30 million during the same period. Although Partnership programming in each country was of a lower value, this channel followed the same positive trend.

Figure 2 outlines the shifts in health programming at the sub-sector level across the three programming branches in Tanzania. The most significant overall increases, before and after 2010, were in basic health care, health policy and administrative management, basic health infrastructure, health personnel development, and basic nutrition. Only one sub-sector, HIV/AIDS, saw a relative decrease in funding in Tanzania over the evaluation period.

Figure 2: Tanzania - Total Disbursements for Key Investments in Health across Programming Branches between FY2008/09-2009/10 and FY2010/11-2012/13, by Sub-Sector (CDN$)

Most of the health funding in Tanzania and Mozambique was delivered through three types of partners: (i) national governments via pooled fund mechanisms to support the health sector (as well as HIV/AIDS in Tanzania); (ii) multilateral organisations; and (iii) civil society organisations. Pooled fund mechanisms and grants to multilateral partners accounted for more than 80% of all health disbursements in both countries, as shown in Table 1 below.

In 2009, bilateral programs developed Country Strategies and a companion Country Development Programming Framework (CDPF). These documents set out the bilateral Programs’ direction and were informed by partner country needs and priorities, as well as corporate policy. The expected outcomes outlined in the Country Strategies (see Annex C) are referenced in the discussion of the results. These figures represent the majority of the total health disbursements in Tanzania (over 95%) and Mozambique (over 95%); however, they do not include long-term institutional support to multilateral organizations or regional programs.

Findings

Effectiveness

In both Tanzania and Mozambique, important gains were made on many key health indicators for the period under review. While direct attribution of results is challenging in harmonized aid environments such as these, both Programs contributed to the realization of these results through their investments.^{Footnote 10}

Canada’s support to the respective national health strategies through sector-wide approaches represented the largest share of program investment in each country. Substantial increases in Canada’s support to multi-donor pooled funds in both countries allowed it to play an important role in supporting health system strengthening and the expansion of health service delivery. Both Tanzania and Mozambique have seen an expansion of health services, improvement in productivity and an increase in health care personnel during the period under review. However, coverage between regions in each country remained uneven, as did the quality of services provided, the deployment and retention of skilled healthcare personnel and the provision of commodities.

In terms of accountability, public financial management in the health sector was a concern for stakeholders in both countries, particularly relating to the efficiency and transparency of the budget process. The two Programs exercised influence through policy dialogue as a result of their leading role in supporting the health sector in each country. The most notable gains in health indicators for both Mozambique and Tanzania were made in the areas of child health and disease control, largely through targeted vertical programs, including vaccination, malaria control, tuberculosis and nutritional supplements programming. Global Affairs Canada has invested significantly in all of these areas.

Progress was evident but more modest for reproductive, neonatal and maternal health indicators; advances in Tanzania were more significant than those in Mozambique. Generally, experts observe that progress in maternal and neonatal health is more dependent on general health service availability, expansion and quality – all areas where significant challenges remain in both countries, and areas in which investments take time to produce results. While maternal health service delivery expanded, this did not necessarily translate into proportional increases in service utilization. As such, there is increasing recognition by donors that demand-side barriers must be addressed if maternal and reproductive health indicators and health access for women are to be improved.

HIV/AIDS represented a significant part of programming in Mozambique between 2003 and 2008, after which Canada gradually phased out its support. By the end of 2014, the last HIV/AIDS project funded under Multilateral and Global Program Branch came to an end; multilateral institutional funding to the Global Fund for AIDS, Tuberculosis and Malaria and UNAIDS continued. According to the Joint Annual Assessment of the Health Sector and the Programs’ Annual Country Reports, improvements in the prevention and treatment of HIV/AIDS were continuous. Furthermore, results achieved surpassed targets.^{Footnote 11} For instance, by 2012, over 297,000 HIV positive adults (the majority being women) were receiving antiretroviral treatments, surpassing the target of 185,000. The number of children receiving antiretroviral more than doubled between 2009 and 2012, while the prevalence of HIV/AIDS in the population of 15-49 year olds dropped slightly from 12.5% to 11.1%. Canada’s main intervention in this sector was support for the National AIDS Council, which was responsible for coordinating HIV/AIDS operations with donors.

Canada supported the Tanzania Commission for AIDS in its coordination and implementation of the national multi-sectoral strategy for HIV/AIDS. The majority of Global Affairs Canada funding was provided for activities at the district level encompassing prevention, care, treatment and impact mitigation. Canada’s funding for HIV/AIDS programming in Tanzania will end in 2016. Country-level data demonstrated that the prevalence of HIV/AIDS in the population of 15-49 year olds reduced from 6.2% to 5.1% during the period under review. Infected women receiving antiretroviral therapy (ARVT) increased from 69% to 71%, while babies born to HIV-infected mothers receiving ARVT increased from 17% to 56%.

In Mozambique, the Program funded a project in water, sanitation and hygiene in the province of Inhambane since 2003. This initiative emphasized community involvement and encouraged government, non-governmental organisations, and the private sector to develop sustainable, rural water supply and sanitation service delivery. Provincial directorates of public works and housing, health, education, in addition to provincial and local authorities and community leaders, were all involved and the approach was expanded to all districts of the province. This project supported ownership at the local level and reinforced planning and implementing capacities at the provincial level while also being complementary to other projects in the health sector. It also created awareness in communities of the link between clean water and sanitation and vulnerability to diseases. Furthermore, the dynamics introduced by the water committee and sub-committees changed attitudes and behaviors in target communities. As a result of the project, 66 out of 117 target communities and 76 schools out of 100 were certified as “open defecation-free”. This initiative had a multiplier effect on the surrounding communities, which started building their own latrines. The National Water program is now using the community approach developed by the Inhambane project and will expand it to all districts of the province.

Women’s equal participation with men in decision-making was effectively promoted by the project during community consultation around the location of water points, membership of water and sanitation committees, as well as management and maintenance of water points. As a result, women began holding leadership positions in water and sanitation committees at the community level (roles of president and treasurer); women were perceived as influencing decisions at these committees; and women in the community reported satisfaction with the location and management of water points.^{Footnote 12}

Mozambique has faced shortages in skilled health providers. The deployment and retention of health workers, particularly in under-served provinces, remains a key area to improve in the Ministry of Health’s management of the health system.

Support to human resources for health (HRH) became a central pillar of health sector programming in Mozambique in the Africa Health System Initiative. The Program supported HRH in a variety of ways, including through general support to the national health sector strategic plan (PROSAUDE). Beyond that, Global Affairs Canada’s multilateral program support to the World Bank, as well as bilateral support in Mozambique to Save the Children, UNICEF and One UN, resulted in the establishment of eight community outreach teams and the training of thousands of community health workers. Based on this experience, the Program collaborated with other donors involved in training community health workers to gather a body of evidence on the value of these workers and present a unified position to the government of Mozambique on the need to revitalize their role and integrate these workers more formally into the public health system. As a result, a national strategy for community health workers is being developed for inclusion in a new national health sector strategy.

In Mozambique Global Affairs Canada also supported the University of Saskatchewan’s partnership with the Ministry of Health’s Massinga Training Center through partnership programming and then bilateral programming. This support was crucial to HRH as Massinga was singled out as one of the top healthcare training centres in the country and had begun disseminating its community-based health model across other training centres.

In Tanzania, despite the expanded availability of health workers and health facilities, the country’s health system has struggled to keep up with rapid population growth. Progress towards Tanzania’s third Health Sector Strategic Plan targets has been slower than anticipated. Canada worked to strengthen human resources for health (HRH) starting with the Africa Health Systems Initiative in 2006. The Program promoted the creation of a pooled fund separate from the health basket fund to increase the numbers of trained health care workers, to support health worker training institutions and to develop a national supervision and accreditation system. Four bilateral projects were approved in 2010 for a total of $47 million of the new maternal, newborn and child health (MNCH) funding. Together these projects aimed to train hundreds of community health workers and health care providers at various governmental levels, in four regions of Tanzania, in MNCH, family planning and basic emergency obstetric care.

The Program also supported a Tanzanian non-governmental organization, Sikika, to conduct studies and campaigns on government deployment practices in HRH and how these practices have resulted in inefficiencies and inequalities in health service delivery. Through funding to One UN, Canada supported a national midwifery workforce assessment and provided support to midwife training schools. Another project, the “Health Workforce Initiative”, unfortunately suffered various delays by the Tanzanian government and did not progress as intended.

In Tanzania and Mozambique, women were not going to health facilities for reproductive health services and deliveries due to: the cost, distance and quality of care; the training of and treatment by health workers; and, the lack of basic infrastructure, equipment and medical supplies. Global Affairs Canada’s health sector programming focused on these supply-side constraints in its efforts to strengthen the health system in each country.

While health service availability was expanding in Tanzania and Mozambique, there was increasing recognition that this was not necessarily translating into proportional increases in health service utilization, particularly by women. Since 2011, both Programs have begun addressing demand-side constraints in a more comprehensive way.

In Mozambique, the Program supported several initiatives executed by the World Bank, UNICEF, Save the Children and the University of Saskatchewan, which reinforced the outreach of the public health system to the community level through the mobilization of community health workers (APE program) and mobile health units. However, support for the APE was fragmented and uncoordinated and included no investment by the partner government. In response, the APE program collaborated with other donors to get the APE included as a formal component of the national health strategy. In doing so, the Community-Based Health Training and Practice program more than doubled the capacity of the Massinga Centre to train health workers and disseminate training materials nationwide. The results from Global Affairs Canada’s investments in the network of community health workers were being gathered and used effectively in policy dialogue with the government. Although recognized as a good model, the approach had yet to be replicated by the government or other donors.^{Footnote 13}

The Mozambique Country Program also initiated a partnership with the British Department for International Development (DfID) on the implementation of a study and pilot project to address social and economic barriers that limit institutional deliveries and referrals for women. However, it was too early to assess results achieved.

The Tanzania Country Program invested in numerous projects with Canadian NGOs to address community outreach and demand-side constraints to maternal, newborn and child health (MNCH) service access and outcomes. Projects run by Plan International Canada, Amref Health Africa and CARE Canada trained community health workers and traditional birth attendants to address constraints in access to information, as well as the distance and cost of accessing health services. Plan International developed standard guidelines for the training of community health workers that addressed gender inequalities and the demand-side constraints facing women in the family and in the community; these guidelines were then shared with the other projects. The Aga Khan Foundation Canada piloted the development of community transport funds to address cost and distance-related constraints. This project also undertook a study on the socio-cultural determinants that limited post-natal care for new mothers in Morogoro. All projects worked with community leaders and men to improve access to information on MNCH and the important role that men can play in ensuring access to maternal and child health care. Amref Health Africa radio and TV spots, for example, addressed gender inequalities in MNCH and encouraging the involvement of men.

All of these Tanzanian initiatives came on-stream in 2011-2012. Since social and cultural attitudes take time to shift, preliminary results are only now beginning to emerge on these projects.

There were challenges to fully examining the results of cross-cutting issues given that the evaluation focused on the health sector. For instance, governance initiatives can be government-wide rather than sector specific, rendering the identification of specific results in any one sector difficult. Also, the intent and design of program-based approaches is to improve the host government’s capacity for any of the three cross-cutting issues and for accountability, although this is often difficult to measure and report on. Despite this, certain gender equality and governance results were demonstrated by both Country Programs.

Gender equality

Global Affairs Canada’s gender equality policy includes 3 key objectives. Programming in Mozambique and Tanzania emphasised the following two: supporting girls and women to fully exercise their human rights and reducing the gap between women and men’s access to and control over resources and the benefits of development. Programming in both Mozambique and Tanzania supported women in the realization of their health rights and in their access to the benefits of development. While health systems strengthening under the Africa Health Systems Initiative generated results for women’s health on the supply-side, the Muskoka Initiative expanded programming to address demand-side barriers, such as inequalities in health access and outcomes for women.

On the supply-side, the scale and type of public health care services available to women increased in both Mozambique and Tanzania. There were increases in trained MNCH health workers, maternity beds, maternity waiting homes, health facilities equipped for basic emergency obstetrical care and fistula care. Initiatives to improve access to information for women and men on reproductive health, as well as strengthen the standards of training for health care workers, including modules on gender sensitivity and male involvement, were also supported by both Programs. In addition, Global Affairs Canada supported One UN in their efforts to reduce gender-based violence and early marriage, which are important determinants of women’s health outcomes.

The balance of supply-side support to the health sector was provided through pooled funding to support the national health strategy in each country. Canada participated in donor-government fora established for the health sector and advocated for increased gender equality objectives. However, despite consistent efforts in this regard, challenges existed, including: the capacity and commitment of the ministries of health in both countries to gender was weak; there were many competing priorities; donors had varying levels of interest in promoting gender equality; representatives in these groups were often health, rather than gender, specialists; and, discussions were often dominated by budget and fiduciary issues.

In all of its projects, Global Affairs Canada required a gender analysis and strategy to achieve gender equality results. While the majority of bilateral Muskoka projects in Tanzania and one project funded with DfID in Mozambique examined gender dynamics in the household and community, it was not possible to gather evidence of results through this evaluation given they started in 2011-2012.

Global Affairs Canada’s remaining gender equality policy objective – promoting the equal participation of men and women in decision-making – received less attention from the two Programs. For example, findings and recommendations from the most recent Mid-Term Review (MTR) of the Health sector Strategy (2013) focused on the lack of participation by women in health-care decision-making at all levels of the health system and the need for both donors and the Government of Tanzania to support women’s voice and influence in health care policy and programming. This was echoed in the MTR’s associated Community Perspectives Report, where women expressed their dissatisfaction with the type, quality and availability of health services. In Mozambique, there has been no specific programming aiming to increase women’s influence in the establishment of health care priorities and budgets, including what services are offered, how, where, when and at what cost.

Governance

As a cross-cutting theme, Global Affairs Canada’s corporate priorities for governance include human rights, rule of law, and strengthening civil society. Both Country Programs focused on public financial management (PFM), largely as a risk mitigation strategy but also as a foundation for good governance and service delivery in the context of program-based approaches. In internal annual country reports for both countries, the analysis of governance and related results was largely confined to donor coordination, aid architecture and PFM.

Beyond its contribution to PFM, however, the Tanzania Country Program provided strategic support to strengthen the governance of two civil society organisations in the health sector. Sikika and Comprehensive Community Based Rehabilitation in Tanzania (CCBRT) received funding for the implementation of their strategic plans thereby enabling them to develop their strategic vision and internal capacities in a more sustainable way. Sikika is the largest advocacy non-governmental organisation (NGO) in the health sector and is credited with policy analysis that has led to institutional improvement in national health sector budgeting, human resource allocation formulas and procurement for essential medicines. CCBRT undertakes advocacy for inclusion, service delivery for disabled populations in health and is establishing a model maternity facility. This approach by the Tanzania Program is an illustration of good practice for Global Affairs Canada in strengthening civil society as these two organisations play important roles in policy analysis and promoting participation and accountability in the health sector. The innovative provision of core support allowed these two local NGOs the stability to build a sustainable organizational vision, goals and capacity.

Environment

The Global Affairs Canada Policy for Environmental Sustainability requires that Programs “assess all of their development assistance activities for potential risks and apply appropriate mitigation measures and ongoing monitoring where necessary”.^{Footnote 14} In both Programs, staff created opportunities to integrate environment as a cross-cutting theme through its interactions with civil society organisations, donor coordination groups, as well as partner-governments. However, it was unclear if this was done systematically in all projects.

This evaluation could not effectively explore intersections between health and environmental issues or the sharing of experiences among projects, except for projects in water and sanitation, due to a lack of evidence.^{Footnote 15} The projects that did take environmental determinants of health into account included the University of Saskatchewan’s project in Mozambique to train preventive medicine technicians within communities and a few select projects in Tanzania that had biomedical waste management components.

General

Mainstreaming cross-cutting themes at the Country Program level takes time, capacity and appropriate tools. Human and financial resources devoted to cross-cutting themes decreased over the period under review. From 2009-2012, Global Affairs Canada headquarters reduced the number of gender equality specialists and gender equality advisors housed in both program support units left their positions. Global Affairs Canada staff in Tanzania reported having difficulty recruiting a new advisor given the salary levels and an uncertain Program Support Unit structure, while Mozambique was testing a new advisor on a part-time basis at the time of the evaluation.

In spite of this, at the project level, both Country Programs demonstrated reasonable attention to mainstreaming cross-cutting themes into project plans and progress reporting. For example, both Programs complied with the required analysis in relation to environmental sustainability and corporate checklists were properly completed. Planning documents included the concept of environmental sustainability and some of the Annual Country Reports briefly described progress achieved in a few projects.

At the level of Country Program strategies and development frameworks, however, Global Affairs Canada did not appear to have the tools or capacity to undertake effective analysis and mainstreaming of cross-cutting themes. Expertise was limited both internally within the Programs and externally among implementing partners. These constraints, coupled with an increase in the size of health programming over a short timeframe, gradually reduced the Programs’ ability to operationalize cross-cutting themes.

The Tanzania Country Program contributed to several policy dialogue successes in the health sector over the evaluation period. During Canada’s time as coordinator of the Health Basket pooled fund, the percentage of basket funding going directly to Districts increased from 55% to 71%, contributing to the goal of improving access to health services.^{Footnote 16} In addition, during its tenure as Chair of the Donor Policy Group on HIV/AIDS, Canada successfully advocated for the development of a Trust Fund to leverage domestic funds and increase the sustainability of funding, which was being established in 2014.^{Footnote 17} The Tanzania Program also took on leadership roles in other key policy dialogue bodies, such as Chair of the main donor coordination forum and the Donor Policy Group-Gender, where health issues were discussed.

The Tanzania Program complemented its own policy dialogue work with support to civil society organisations to strengthen their capacity to engage in policy dialogue and strengthen accountability in the health sector. These efforts were also in line with the Program’s focus on public financial management across all sectors.

In Mozambique, the Program assumed the role of Chair in the Health Partners Group (2012-2013) (HPG) and the Health Sector Finance and Audit sub-working group. Canada’s policy dialogue efforts focused on transparency, accountability and improving financial management in the health system and service delivery. For instance, as Chair of the HPG, the Program facilitated the adoption of a new structure for the Health Sector Wide Approach with the aim of improving dialogue and coordination. In addition, Canada led policy discussions that resulted in an Institutional Reform Action Plan (2012-2013) in the health sector. These policy dialogue efforts contributed to the Country Strategy’s desired goal of improving the Government’s health system management.

Canada also worked successfully with other donors to convince the Government of Mozambique to formally recognize community health workers in their 2014-2019 health sector strategy. Lastly, Canada’s role as a consensus-maker and facilitator was also recognized by other donors and partners in Mozambique. Reference was made by stakeholders to Canada’s role in brokering a coordinated donor and government response to a critical audit of the Global Fund in 2012.

While both Programs remained active in policy dialogue in health throughout the evaluation period, towards the end of this timeframe they began to move away from leadership roles (though this was less pronounced in Mozambique). Policy dialogue was reported by Global Affairs Canada and other donors to have been increasingly seen as time-consuming and process-oriented, with few concrete outcomes. Further, there were limited tools and internal guidance related to policy dialogue during the evaluation period.

In Tanzania, this was exemplified by a duplication of working groups, varying levels of participation by government and donors, and frequent discussions on process and technical solutions, rather than results or follow-through on recommendations. The 2013 Joint Evaluation of Budget Support to Tanzania^{Footnote 18} confirmed these findings at a general level, noting that the quality of policy dialogue was undermined by limited government ownership, transaction costs and weaknesses in performance monitoring.

The challenges in Mozambique included a lack of donor coordination, difficulty putting forward a common donor agenda to the government and a tendency to focus on process and accountability at the expense of substantive health issues. This was corroborated in the 2014 Independent Evaluation of Budget Support in Mozambique, which reported a ‘lowered’ degree of productivity in health sector dialogue.^{Footnote 19}

Internally, both Programs referenced policy dialogue in their key planning documents. However, these descriptions were mostly brief and high-level in nature and often consisted of a listing of the health working groups in which Canada would be involved. Priority areas were not articulated in a coherent and formal policy dialogue strategy for the health sector as a whole.

The Mozambique Program identified transparency, accountability and public financial management as its focus for policy dialogue across all sectors, including health as articulated in the Program’s Health Sector Strategy document (2011-2012). No specific policy dialogue priority areas were identified in the Country Strategy, nor were they outlined in the draft Performance Management Framework beyond a count of working groups. More information on policy dialogue was available at the project level.

In terms of reporting, the Programs completed a policy dialogue section in their Annual Country Reports. However, the content was often descriptive, again listing the various working groups in which Canada was active, and outlining a few exemplar results. There were few links made between the chosen policy dialogue successes and the expected outcomes in the health sector.

Efficiency

Interviews revealed that both Programs had committed and skilled staff whose expertise generally responded to operational needs. At the individual level, Canadian and locally-engaged staff had significant development program/project management experience and sound analytical skills. In addition, the division of labour and level of communication between the field and Headquarters was clear and timely.

Former and current field staff from both Programs underlined the importance of having at least one health expert on the team – specifically, a specialist in maternal, newborn and child health given the amount of programming in this sector. Staff underlined that a formal background in health and longer field postings contributed to higher quality project planning, monitoring and policy dialogue. The Tanzania Program had one staff member with health expertise. In contrast, the Mozambique Country Program had limited health expertise among its field representatives throughout the evaluation period.^{Footnote 20} However, the Canadian Cooperation Office (CCO)^{Footnote 21} in Mozambique hired health professionals through different channels during most of the evaluation period. The Mozambique Program benefited from having an analyst posted in the field for four years, strengthening the relationship with partners and the strategic focus of policy dialogue activities. Fluency in Portuguese was also highlighted as essential for effective policy dialogue with government and partners in Mozambique. However, this was not a prominent staffing criteria.

The management model for CCOs has been changing. In Mozambique, the CCO was privatized and has been able to attract skilled technical experts. In Tanzania, the CCO often provided expertise unavailable among Global Affairs Canada field staff. However, the future of CCO services is uncertain. They had lost several senior sector experts and had difficulty attracting talented staff during the evaluation period.

Whereas an in-depth analysis of corporate trends was outside the mandate of this Country Program Evaluation, interviews at Headquarters and in the field revealed the following challenges in implementing health programming: constrained corporate capacity to guide or support Programs; uncertainties regarding corporate priorities in health; lengthy corporate approval processes;^{Footnote 22} changes and a lack of clarity around planning and reporting processes. These perceived corporate constraints impact the efficiency of program management.^{Footnote 23}

The tools provided to report on Program achievements were found to be challenging to use effectively. Program staff indicated that reporting templates were not designed to easily aggregate or compare results across projects. Data at lower levels did not necessarily aggregate to higher levels in ways that aided decision-making. There were also inconsistencies in the completion of performance measurement tools. Statement of immediate, intermediate, and ultimate outcomes across Country Program and project logic models were not always completed or consistent. Further, baselines, indicators and data sources were often missing. Constraints of this nature diminished the Programs’ ability to monitor and report on expected development results.

Financial resources and fiduciary risks were well managed in both countries. These risks, alongside mitigation measures, were well identified in planning documents and closely monitored and discussed by management in both Programs. Diversity in the use of delivery channels and of partners contributed to mitigating risks (see Table 1). The two Programs also drew on relevant human resource expertise to reduce risk. A particular strength in the Tanzania Program was the hiring of a highly skilled public finance management (PFM) expert, who provided technical support to the Program, the Government of Tanzania, and other donors where needed. In Mozambique, the Country Program had a Canadian PFM expert who worked in Mozambique and provided support to the Education Ministry to strengthen its PFM processes. Consideration was being given to hiring a similar expert for the health sector.

Despite noted strengths, an emphasis on the management of fiduciary risks may come at the expense of analysing operational and developmental risks. Global Affairs Canada’s current guide on results-based management includes four components of integrated risk management: development of a program risk profile; establishment of an integrated risk-management framework; practicing integrating risk management at all levels; and, ensuring continuous risk-management learning.^{Footnote 24} An analysis of all types of risk was present in planning documents for both Programs. However, beyond project monitoring reports that underlined a few lessons and risk mitigation measures, little data was available to determine whether there was systematic implementation of “practicing integrating risk management at all levels” and “ensuring continuous risk-management learning”, for operational and developmental risks.

While there was no evidence of a formal monitoring plan for either Program, health partners and the Ministry of Health in Mozambique hold a joint annual review where discussions on processes and results in the health sector occurs. Systematic monitoring was done by both Programs at the project level, often jointly with other donors. Individuals met during project visits conducted as part of this evaluation in Mozambique underlined the quality of the working relationship with Global Affairs Canada field representatives. A similar situation was present in Tanzania.

Sustainability

Limited institutional capacity of government partners, such as skills in the management of finances, planning, budgeting, results-based monitoring and evaluation, represented a significant challenge to obtaining sustainable development results in both Tanzania and Mozambique. The lack of government personnel and capacity, particularly at district and provincial levels, prevented the full observance of rules and regulations, proper management of resources in the health system and adequate delivery of services. In both countries, it was uncertain whether the Programs’ current government partners would be able to sustain outcomes should the donor community decrease their support to the sector.

In Tanzania, there was a reduction in the size of public health expenditure relative to overall government expenditure during the period under review. The share of total public expenditure devoted to health was 8.7% in 2013-2014, representing a decline from the previous two years where health spending was roughly 9.5% of total spending.^{Footnote 25} In Mozambique, public expenditure on health as a proportion of the total government expenditure also declined over the period under review; after reaching roughly 14% in 2005, the percentage of total expenditure dedicated to health was roughly 7.5% in 2011, 11.8% in 2012, and 7.1% in 2013.^{Footnote 26} Overall, both countries appeared to be moving away from their commitments, leading to concerns among donors around aid dependency and the sustainability of health sector results.^{Footnote 27} An Independent Evaluation of Budget Support in Mozambique from 2013 commented that, “The health sector is highly donor dependent and some commentators suggest that it is unsustainably so.”^{Footnote 28}

Donor interest in sector and general budget support also appeared to be in decline as risk tolerance diminished and the need to demonstrate concrete, attributable results to domestic audiences remained. The 2013 Rapid Budget Analysis in Tanzania confirmed a decrease in the health basket/pooled fund, as well as a potential trend to move away from sector support in favour of project-based modalities and donor pooled funds, which are less predictable sources of funding.^{Footnote 29} In both Mozambique and Tanzania, some donors have pulled out of general and/or sector budget support modalities, some due to dissatisfaction with policy dialogue and partner governments’ accountability, others for what they perceived as a lack of results achievement.^{Footnote 30} For its part, Global Affairs Canada has been seeking a balance between aid modalities. The Tanzania Program is also redesigning the health basket fund to focus further on performance and results.

In 2010, the Tanzania and Mozambique Programs received additional health funding through the Muskoka Initiative – the Tanzania Program received an additional $153 million and the Mozambique Program received an additional $163 million. Both Programs succeeded in identifying potential partners and recommending a set of initiatives for approval within nine months, which was considered to be faster than would normally be the case, in order to achieve results within a project implementation cycle of approximately three years. Absorbing this volume of international assistance in a short time period was recognized as a challenge given the limited institutional capacity of the public health systems of Tanzania and Mozambique. Considerable leadership and program planning was exercised to be able to develop programming in such a short period of time.

In Tanzania, the Country Program divided Muskoka funding between the health basket (40% of available funds), support to One UN and agencies of the United Nations (26%), and responsive bilateral projects executed by Canadian non-governmental organisations (33%). A small number of Canadian execution agencies submitted proposals to Global Affairs Canada on maternal, newborn and child health, of which three were selected and received contributions. In Mozambique, approximately 80% of the Muskoka funding went to health sector support: the national health sector strategic plan, PROSAUDE, received an additional $125 million (77% of available funds), and health sector support to the province of Zambezia received $5 million (or 3%). In addition, 17% of Muskoka funding went to One UN and agencies of the United Nations, and the remaining 3% was directed to bilateral projects. National governments and UN partners were seen as having the capacity to absorb a large volume of funding in a relatively quick period of time.

The shortened lead time for the planning and implementation of Muskoka-related projects was at odds with work in the health sector, which requires time and a focus on sustainability. In Tanzania, Plan International Canada (with its partners Jhpiego and Africare) began implementing the “Standard Based Management and Recognition” (SBMR), a program to improve the quality of services provided by local health facilities, in 2011. The baseline of the project involved 22 health centers whose quality of services were rated between 0% and 17% of optimal at the start of the project in 2011; in 2014, the project measured results of 40% towards full quality of services. While positive growth was achieved, a health facility must reach 80% of the standard to be considered “quality” and recognized as such by the Ministry of Health. It was likely that Muskoka funding would end before capacity building activities at the local level were sufficiently mature to produce results sufficient to enable the certification by the Ministry of Health as a ‘quality’ service.

Relevance

The Tanzania and Mozambique Country Programs were aligned with Global Affairs Canada’s Children and Youth Strategy, the Muskoka Initiative on Maternal, Newborn and Child Health Strategy, bilateral Country Program Strategies, as well as partner government health priorities (see Annex C). In addition, operations in the health sector were aligned with the two countries’ systems through general and sector budget support modalities. Global Affairs Canada’s overall development objective to reduce poverty and improve the quality of people’s lives in developing countries was in line with current needs in Tanzania and Mozambique.^{Footnote 31}

There has been a significant need for international development assistance in Mozambique and Tanzania, particularly in relation to maternal, newborn and child health and strengthening health systems. Mozambique was on track to meet many Millennium Development Goal (MDG) 4 targets on child health and Tanzania has already achieved them all.^{Footnote 32} However, MDG 5 targets on maternal and reproductive health were not within reach for either country.

The Evaluation of the Paris Declaration (2011) underlined good practices to enhance the relevance of assistance programs, including: prioritise the needs of the poorest; strengthen institutional capacities; improve the mix of aid modalities; and, intensify concrete actions to combat corruption.^{Footnote 33} The two Programs appeared to have effectively used a variety of delivery channels, programming tools (projects, pooled funds, policy dialogue) and partners, to create a multi-pronged approach that contributed to improving the health systems in Tanzania and Mozambique.

The Muskoka Initiative assisted Global Affairs Canada in aligning the efforts of different branches and aid delivered through different partners around a common purpose, set of results, indicators and language. This had the potential to facilitate dialogue and coordination between branches and partners for planning and reporting purposes. However, the review of administrative documents and interviews revealed that the two Programs made genuine efforts to promote synergies and complementarity among its projects (for example, community health workers for Mozambique or Muskoka civil society groups projects in Tanzania). However, these efforts tended to be ad hoc rather than planned programmatic strategies, which would have contributed to shaping development interventions into a program that was greater than the sum of its parts.

Conclusions

Effectiveness

The two Programs contributed to important results in the health sectors of Tanzania and Mozambique for the period under review, particularly in HIV/AIDS, water and sanitation, as well as supply-side health sector improvements. The Programs provided successful, long-term HIV/AIDS programming in both countries, which contributed to a reduction in new infection rates and substantial increases in antiretroviral treatment provision to adults and children. In addition, there was a successful effort to improve water and sanitation, featuring community involvement and multi-stakeholder engagement in a long-term intervention in Mozambique. Since promising results were emerging and water and sanitation are part of future Maternal, Newborn and Child Health programming areas, lessons learned from this project warrant consideration going forward. The Programs also provided significant support to supply-side improvements in both countries, but attention to demand-side factors affecting health service access and outcomes is relatively recent, with results only beginning to emerge. Challenges remain in the enabling environment affecting results achievement, particularly with regard to government accountability, health systems strengthening and women’s/maternal health.

The most notable gains for both Mozambique and Tanzania have been made in the areas of child health and disease control, largely through targeted vertical programs including vaccination, malaria control, tuberculosis and nutritional supplements programming. Canada has invested significantly in these areas. Progress was evident, but more modest for reproductive, neonatal and maternal health indicators; advances in Tanzania were more significant than in Mozambique. However, there is recognition by donors that demand-side barriers must continue to be addressed if maternal and reproductive health indicators and health access for women are to be improved.

In both Country Programs, an examination of experiences across health projects to identify lessons learned related to addressing demand-side constraints and promoting community outreach and engagement would be beneficial. The Tanzania Program planned to conduct thematic evaluations of these projects, in addition to a stocktaking assessment of good practices in MNCH.

Efficiency

In order to ensure efficiency in the implementation of health sector programming, specific technical expertise among Canada-based staff in the health sector is essential.

Financial resources and fiduciary risks in Tanzania and Mozambique were managed with diligence, although the monitoring of operational and developmental risks should become more systematic. However, the Programs did not have access to adequate tools and systems/processes to efficiently manage their operations in the health sector. Corporate processes contributed to inefficiencies in operations.

Sustainability

Partner government’s institutional capacity in the health sector remained limited, putting the sustainability of the donor community’s efforts at risk without continued donor support to health systems. Further, while promising results were emerging at the project level from Muskoka interventions in both countries, their potential sustainability may be at risk without a longer-term engagement. The achievement of results in health requires time; however, the need to design and implement projects in a short timeframe is part of today’s development landscape. Programs may need to adjust the way they plan and implement projects so that they can deliver results under short timelines, while also taking the sustainability of results over the long term into account. While the objectives of delivering quick results and sustainability can be challenging to pursue simultaneously, they are not inherently mutually exclusive. More could have been done to support field-based staff to program Muskoka funding in a sustainable manner.

Relevance

Both Programs made a significant contribution to the health sectors in Tanzania and Mozambique and, consequently, to Global Affairs Canada’s development objectives over the evaluation period. Global Affairs Canada’s operations were relevant and aligned with country needs and priorities. For these two countries, needs and challenges remained significant. Therefore, Canada’s presence in the health sector continues to be relevant.

Recommendations

The two Programs should consider how to be more strategic in their use of cross-cutting themes in projects. They should pro-actively explore opportunities outside current practices and beyond current corporate trends. Program impact would be strengthened by ensuring that all projects have explicit objectives related to the integration of cross cutting themes. Ideally, a plan related to the integration of cross-cutting themes at the Country Program level would be developed and go beyond a list of country issues related to the sector. It could also provide a contextual analysis of key challenges with a view to defining Global Affairs Canada’s vision, role, expected results on individual cross cutting themes and the programming tools at its disposal to advance those results.^{Footnote 34} There is currently no corporate expectation to undertake this kind of strategic analysis and no proposed corporate tools to help the Programs in this regard.

The challenges faced by the Programs when integrating cross-cutting themes into health activities were noticeable and led to uneven results. Program staff neither had a comprehensive understanding of how to integrate cross cutting themes at the operational level, nor a clear sense of current corporate expectations for doing so. The Department could contribute positively by ensuring Programs receive adequate guidance and/or training, and have sufficient resources and time (in both the field and HQ) to achieve such objectives. Furthermore, a review or discussion of the extent to which Programs can advance Global Affairs Canada’s cross-cutting themes in a multi-donor funding environment, such as program-based approaches, would also be helpful to shape reasonable goals and expectations.

Both Programs were active in policy dialogue bodies throughout the evaluation period; however, towards the end of 2014, both Programs began to move away from leadership roles in policy dialogue in the health sector (although this was less pronounced in Mozambique). Overall, the Programs’ strong policy dialogue efforts contributed to strengthening health systems in both countries. However, despite having achieved results, the absence of specific tools and guidance to create an internal policy dialogue plan, including an identification of challenges in donor coordination and duplication, may have limited the impact of policy dialogue efforts in both countries. Such a plan would contribute to clarifying what the Programs seek to achieve through current or future dialogue structures, ensure better understanding and cohesion among staff, and allow Programs to more fully leverage the increased visibility resulting from the Muskoka Initiative. Guidance from the Department and time/resources to undertake this analytical work is necessary for the Programs to convey clear policy dialogue messages, commonly understood and used by all staff.

Global Affairs Canada’s large programming and financial presence in the health sectors of both Tanzania and Mozambique require that the two Programs manage their interventions as a health program, rather than a collection of health projects. Beyond individual disbursements, a clearer strategic vision of the Programs’ leadership role for MNCH would be valuable. In line with a program approach, determinants of health could be the subject of in-depth analysis. Program planning documents could explicitly link each of these determinants to the chosen issues, projects, and policy dialogue areas, as well as describe how these links are expected to lead to expected results from both policy dialogue initiatives and project investments.^{Footnote 35} The implementation phase could include options about partnering with other like-minded donors or actors to promote any of these determinants. Monitoring and reporting would determine the extent to which the Programs have incorporated learning into programming related to the management of these determinants.