Social sectors

This presentation is taken from the outcome assessment of the results and lessons learned of Swedish development cooperation with Nicaragua 2001 – 2008 – for full text and detailed references see document Outcome Assessment 2001-2008.

Summarising the results reported in social sectors, it can be concluded that there has been substantial progress in the programs supported by Sweden. In most cases, these results have been in line with the plans and set targets, although in the case of the Health Sector Support, some results seemed to have been somewhat more modest than expected. Summing up, the programs have definitely contributed to the “development of new models and better governance in local institutions that can increase choice and opportunities for the poor”.

Swedish cooperation in this area has mainly been concentrated to the health sector through the Ministry of Health (MINSA). However, support has also been given to UNICEF’s Country Program, which includes activities related to water and sanitation and education, as well as to the Fund for Social Investment (FISE). In this section, the following programs are summarised and assessed:

PROSILAIS III (2000 – 2005)

Health Sector Program Support (2005 – 2009)

UNICEF’s Country Program (2003 – 2010)

Training Program for Midwives (2005 – 2010)

FISE (2000-2003)

PROSILAIS III

(2000 – 2005; 93 MSEK)

The overall aim of the program was to improve the health situation of the population in six departments through strengthened capacities of the decentralised health care system, with a special focus on vulnerable groups and areas with special health problems. The program supported the primary health care organisation (SILAIS) in six out of 17 departments in the country, with MINSA as counterpart and PAHO and UNICEF as channels for the support and technical advisors. Sweden had supported the program in three phases since 1992. The total amount contributed 2000-2005 was 93 MSEK.

The Draft Outcome Assessment made in 2007 notes that planned results of the program were achieved to a high degree and seems to have had an impact on the health situation in the areas receiving support. Maternal mortality and death caused by malaria decreased in five of the departments and infant mortality in four departments, with three of them reaching levels below the national average. Important results of the program are the strengthened institutional framework for planning, implementation, monitoring and financial follow-up of the services, and improved coordination between the health services, local governments and civil society.

The positive results demonstrate the possibilities of a decentralised primary health care system. The program has served as a model at the national level and as an important input into the National Health Plan 2005-2015. Another result with national implications is the institutional strengthening of the Ministry of Health, which was important for the establishment of the Sector Program Support in 2005. The results and experiences gained have been instrumental for the development of national planning and guidelines, which strengthens the sustainability of the achievements.

Health Sector Program Support

(2005-2009; 216 MSEK)

The aims of the Health Sector Program/Five-Year Health Plan are to 1) increase the quality and access to health services; 2) strengthen the network of services in targeted areas; and 3) improve governance, build institutional capacities and strengthen decentralization and participation.

Support to the Five-Year Health Plan is given by several donors through a pool funding mechanism (FONSALUD), where participating donors transfer their contributions to a national Treasury Account. The monitoring of the implementation of the Health Plan take place within the framework of the health sector round table, which includes the government, civil society organisations, private sector entities and the donors. Donors supporting the Five-Year Health Plan through the FONSALUD follow joint procedures for financial monitoring and related issues. The total amount contributed by Sweden is 216 MSEK.

The Midterm Evaluation of the Five-Year Health Plan (2008) notes, regarding the main indicators of impact, that maternal and infant mortality has decreased in general, although not quite to the target levels set in the plan. There were substantial variations among departments, but the decrease in most of the prioritised departments (12 out of 17) was greater than in the non-prioritised departments. The percentage of births taking place at institutions increased above the target (76% as compared to a target of 60%)

The Midterm Evaluation concludes that the first main objective of the Plan has been achieved to a higher degree than the two other objectives. However, the Plan is still not perceived as an effective guiding instrument for the work of the health sector by the different actors outside the central functions of the Ministry of Health. The interaction between the Ministry and other actors is not sufficient (i.e. NGOs participate in implementation but not in the planning of activities). There is also a lack of progress in decentralisation (especially in relation to capacities in Atlantic Regions) and deficiencies in the information and management systems (lack of coherence between planning and budgeting).

The Evaluation of the Processes of Appropriation, Alignment and Harmonisation of the international cooperation (2008) notes that there is some progress in these processes in the health sector but that they need to be further strengthened. There are still great variations in the view and understanding of the sector program approach among the actors in the sector. With regard to ownership (appropriation), it is noted that the Ministry of Health has improved its role as leader of the sector program process also after the change of government in 2007.

However, further development of institutional capacities is needed, as well as improved linkages between planning and budgeting. With regard to alignment and harmonisation, it is noted that national systems and procedures are being increasingly utilised, although the major multilateral agencies still use there own procedures and do not form part of the joint fund (FONSALUD).

It should be noted that the health sector was affected by a five months strike of the medical staff in 2006 and by policy changes introduced by the newly elected government in 2007 (i.e. universal rights to health services free of charge). Although the process of sector program support and cooperation seems to be slow, there have been advances, especially in terms of quality and access to health services.

A study in 2009 summarising 30 years of Swedish support to the health sector in Nicaragua confirms the important role of the Swedish support for the development of public health in the country. This refers especially to the introduction of new models of basic services, planning and community participations at the local level, but also to the fact that Sweden has been actively promoting the donor coordination and establishment of a sector program support. The Swedish support for organisations promoting sexual and reproductive health and rights and for the training of midwives are also considered important contributions to the development of the health sector.

UNICEF’s Country Program

(2003-2010; 80 MSEK)

The overall aim of the program was to advocate and contribute to the progressive consolidation of a culture that respects the rights of children, adolescents and women.

The Swedish support to the program was directed at strengthening national and local health systems, water and healthy environment and education for citizenship.

A Draft Outcome Assessment made in 2007 notes that UNICEF reports mainly give information regarding the implementation of activities, but do not present an analysis of the of results or problems encountered. The Country Report 2008 notes that planned activities have been implemented to a high degree and that the objectives set for the different components were in general reached. The monitoring team contracted by Sida notes that the program covered a wide range of needs within the sectors of health, education, sanitation and social protection in municipalities highly affected by poverty, that the program was well received, and that it had managed to establish effective inter-institutional collaboration and coordination. What was needed however was an improvement of the formulation of objectives, results, effects and indicators.

Training Program for Midwives

(2005-2010; 27 MSEK)

The program aim is to give 540 midwives a one year training course. The target group is nurses who have already graduated from seven nursing schools. Upon completion of the training course the midwives are expected to return to their respective health centres for at least two years. The training is organised in cooperation between the Ministry of Health and the university UNAN-Managua. The total amount to be contributed by Sweden is 27 MSEK.

The Midterm Evaluation (2008) concluded that the program had strengthened capacities both for the training of midwives in the nursing schools and for the maternal health services in the health centres. Most of the midwives who had received training had returned to their health centres as expected. The evaluation points out that there were weaknesses in the organisation of the practical work of the students during the training, as well as in terms of monitoring and communication of activities and results of the program. The Midterm Evaluation concludes that the first years of the program had established a basis for the training of midwives, but that financing would have to be secured and different modalities of training promoted. By mid-2008, 265 midwives had graduated from the program.

FISE

(2000-2003; 28 MSEK)

The aim of the Social Investment Fund (FISE) has been to meet the demands of the poor population through financing of basic social infrastructure in education (school buildings), health (health centres), water and sanitation (water pipes, latrines). Sida has supported FISE in two phases since 1995. The specific aim of the Swedish support 2000-2003 was to strengthen the decentralisation of planning, implementation and follow-up of the investments to the municipalities and the communities, which had been initiated during the previous period. The planning procedures was influenced by the positive experiences of participatory planning in the program for local development PRODEL (see 4.5.1 below). The amount contributed 2000-2003 was 28 MSEK.

The Final Report from FISE 2004 notes that the support 2000-2003 had financed 35 investment projects in eight municipalities benefitting 17,000 persons living in poverty, and had created 2,500 jobs. The support had also helped FISE to change its procedures and working methods, i.e. by involving communities in the planning of the projects and increasing the responsibilities of the municipalities in planning and implementation.