Working Paper Series
The Effectiveness o
Policies mid I'rofira
Case S
Table of Contents
Pages
Introduction 1
I. Methods to Assess the Effectiveness of Projects 3
II. Best Practices in the Health Sector 5
(a) Onchocerciasis - Riverblindness 5
(b) Lymphatic Filariasis: The scourge of elephantiasis 7 (c) SECALINE and CNP: Community nutrition projects 8 (d) IMCI - Integrated management of childhood
illness AFRICA 8
(e) The Roll Back Malaria Partnership
(WB, Findings no. 144 Oct. 99) 9
(f) Programme: Malaria and Anemia prevention
among Tanzanian infants 10
(g) Improving family health in the Gambia
Cote d'lvoire: Action research for better health (Findings 10
III. Best Practice in the Education Sector 12
(a) Improving the Quality of Primary Education
Regional Study on managing Schools for Effectiveness
(Findings, No.3, April 1996) 12
(b) Improving the Quality of Primary Education
Regional Study on managing Schools for Effectiveness
(Findings, No.3, April 1996) . 13
(c) Girls' Education and the Role of the Community.
(Findings; 168, Oct 2000) 14
IV. Best Practice in Other Sector 15
(a) MASAF - The Malawi social action fund
(Findings, No 30, July 1998) 15
(b) AGETIP-Senegal 16
(c) ACEP (Senegal) 16
(d) Water for the rural people:
A winner in Mali (RWSP/KBK) 17
(e) Traditional Energy in Sub-Saharan Africa 18
V. Best Practice in Policy: In Various Sectors 18 (a) Early Childhood Development in Sub-Saharan
Africa: Policy and Programmes (Findings
No. 101. Dec. 1997 19
(b) Leadership role in the fight against HIV/AIDS 20 (c) Zambia: Listening to farmers: Participatory Assessment
of Policy Reform in the Agricultural Sector
(Findings no. 1998) 21
VI. Conclusion and Recommendation 21
References (Section 2) 23
Annex 1 26
Annex 2 27
T
Introduction
he incidence and depth of poverty is a major concern of all developing countries. In particular, in Sub-Saharan Africa, the incidence has become a grave concern given the increase in the population below the poverty line in recent periods.
2. Moreover, the rural sector of Africa is also characterized by a highly unequal distribution of expenditure as evidenced by a Gini coefficient of 48 per cent (ECA, 2000:iii). In urban Africa the condition indicates an increase both in the number and severity of poverty.
3. Recent reports showed increase in the number of poor people which brought up Africa's share of the world's absolute poor in the 1990s from 25 per cent to 30 per cent
(World Bank, 2000:10).
4. Poverty in Africa is manifested in a number of ways. But, the most significant are those that deal with the capability of its population in terms of health and education. On average, 157 out of 1000 children die before the age of 5, and in many countries the mortality rate exceeds 200, which compares with 53 in East Asia and 9 in high Income countries. Mainly due to the AIDS pandemic life expectancy has declined in many African countries. Between 1980 and 1993, enrollment rates declined on average from 80 per cent to 70 per cent. In the 1990s, primary enrollment rates among the poor and rural females were only 24% and secondary enrollment among this group was just 7%. (see Ali, 2000).
In addition to war and civil conflict, Africa also suffers from the burden of low levels of human capital: its populaiuwi a not ruultK1 nor, is it sufficiently schooled. More than 23 million Afrtons Hvu with, HIV/AIDS; almost 14 million have died alioxlv. With.moit- than 70 per cent of the world's total number of jKople livingsith HIV/AIDS, Africa's economy is being serious!^jhrBdteUB*b\Whc-.
panclemic. It is estimated that over the next 20 ye An. if unchecked, HIV/AIDS wilt reduce the economies of SSA U ■» '«»urrb ift'A.
2000, Economic Report on Africa 2000, p(xv) dn"P.
5. Although the causes of poverty may differ from country to country, in general, the following causal factors are responsible for the worsening condition and the increasing number of poor in Sub-Saharan Africa:
1st cause - Slower growth in world trade;
2nd cause - Low level of economic performance that was insufficient for bringing about a decline in the number of poor people;
3rd reason, While a small number of countries that are undertaking reform programs have experienced declines in poverty, - for example Cote d'lvoire, Ghana, Mauritania, Uganda-, others have experienced sharp increases (for example Nigeria and Zimbabwe). Even though there is no reliable data on those countries engulfed in conflict, poverty has certainly increased;
4th reason: Lack of peace and stability continues to wreck havoc on lives and livelihoods. The evidence from participatory assessments conveys the anxiety of the poor regarding conflicts and its implications for their lives and that of their children.
When the uncertainties triggered by lack of security is compounded by uncertainties due to the vagaries of the weather, many households face the threat of starvation.
The problem is exacerbated by lack of safety nets such as public employment
programs;
5th reason: The gap in human development between Africa and the rest of the world is widening. Educational achievement has not advanced in the region, and may even have declined in the 1990s. The HIV/AIDS pandemic threatens to reduce gains made in life expectancy and reduction in child mortality;
6lh reason-The trends mentioned above are creating significant disparities across countries. There are a group of fairly stable countries that enjoy civil order, political openness and sound economic management, which led to improved economic performance and better outcomes for the poor (Ghana, Mauritania, Tanzania and Uganda). Others have slipped into turmoil that led to a breakdown of the state and civil liberty, which has profound effects on the economy and society (Sierra Leone, Somali, Burundi, Rwanda, etc.). The immediate challenge is to help direct the future of countries in the middle of this divide-countries like Ethiopia, Nigeria, Kenya, Cameroon, and Chad - so that they can achieve more secure and prosperous futures for their people. (World Bank, 1999a:lM2 ).
6. In the 1990s, socioeconomic trends have impacted either negatively or positively on the African economies. Thus in what follows this paper will attempt to present the lessons learnt from the programmes and social policies undertaken to rectify the problems.
7. There is abundant literature on poverty analysis and hence this paper will not dwell on the situation of poverty in Africa. The main objective of this paper is to share best practices in the design of programmes and policies adopted by governments or projects that have been implemented and which have contributed in some way to make a dent in poverty reduction. It is hoped that this attempt will stimulate countries to share experiences, replicate similar programmes and benefit from already tried and proven projects, innovative practices and most of all in promoting the practice of monitoring on-going projects with a view to assessing their effectiveness in addressing poverty.
8. The literature indicates that little has been done to measure the impact of projects on the poor, especially those projects undertaken by the World Bank. However, the Bank has also found it difficult to move from the policy generalities of the 1990 strategy towards country assistance strategies, which address specific social and structural constraints to broad-based growth. Insufficient attention has been paid to ensuring that lending for social services actually benefits the poor, and to the integral role of social safety nets in managing risk and vulnerability to shocks. Overall, the Bank's implementation of the strategy was insufficiently focused on measuring and monitoring results linked to Bank assistance.
(World Bank 2000a :v )
9. In most cases, such built-in evaluation mechanisms were not incorporated in the design phase of projects which should have been based on pre-project surveys and anticipated post- project surveys. While it might not always be feasible to implement such measures, these types of mechanisms tend to generate reliable empirical evidence, help avoid wastage of resources as well as limit leakages to the non-poor.
10. The paper will attempt to draw on some of the best practices by sector as well as effective policies that have been implemented by some countries. One lesson learnt is that a holistic approach is more effective in reaching the poor. Thus the main objective of this study is to derive some lessons of best practices that have applicability in a large number of
African countries.
11. As indicated in the foregoing, poverty in Africa has been on the rise in recent years and in due course became dynastic, as few people managed to escape its stronghold. What is essential for Africa is to improve the condition of its human capital to reverse the persistence of poverty and improve the quality of life in the continent.
12. The next sections attempt to shed light on some good practices that have made an impact on the poor. It is hoped that by highlighting the good practices countries with similar problems can duplicate or learn from the experience of others in solving similar problems under matching conditions. This paper in no way claims to be exhaustive, but rather selective in the examples presented and it does not also mean that there are no other more worthy programmes undertaken in the fight against the conditions of the poor.
13. An attempt is made to present as many examples of good practices as possible in diverse sectors, but the main emphasis is on the health and education sectors. The countries chosen are purely arbitrary and almost all projects chosen are or were executed by the World Bank.
14. Following this brief introduction, the rest of the paper is organized as follows: Section two will review basic concepts of poverty and various methods used to measure the effectiveness of projects. Sections three, four and five highlight best practices in the health, education and other sectors. Section six presents some best practices in policy and the last section consists of conclusions and recommendations. The annex provides a summary list of best practices (World Bank) in various sectors and countries for reference purposes.
; I. Methods to Assess the Effect!veness^fen.; ■
of Projects ^x«F
To understand the issue of poverty and to assess if projects designed to alleviate the conditions of the poor have been effective we must first know who the poor are.
Then, to know how much of problem poverty is, we need to know how many people are poor. The two issues can be summarized as identification and aggregation. First, to identify the poor, traditionally in the money-metric approach, we use a minimum income threshold -the poverty line. Any person whose income is below this threshold is considered poor. Second, to obtain an aggregate figure for a population, we add the
number poor and divide it by the total population. We thus obtain the head-count ratio (H).1
15. The next issue to address is how we can assess whether a program has been effective in reducing poverty. There are several methods available, all with methodological intricacies and complications.
16. A seemingly straight forward macro-approach may be to look at the national head- count {NH) before and after a particular program (or policy) is put into effect. This method is attractive for its simplicity; however, it has at least two major drawbacks. First, very few developing countries have reliable NH measures. Because lack of resources, and/or political sensibility, not many countries systematically observe what portion of the population is poor.2 Second, such a crude and aggregated measure as the NH is invariably affected by more than one single policy or program. In light of many confounding factors, we cannot easily ascribe changes in NH to a particular program.
17. One way to address the issue of confounding variables is to set up an experimental design with control and treatment groups, both of which would be affected by outside variables. There are, however, several problems with this approach. Among the most serious are the ethical and political aspects. It may be unethical to randomize when a life- saving treatment is being denied to a control group for the purposes of the analysis. It may be politically difficult to deny treat to a group and not to other.3
18. Cost-effectiveness analysis (CEA), more of a micro-nature, is a second approach to measure the impact of antipoverty programs. CEA has been widely used in the education and health sectors as more feasible methodological extension of the monetary-value-based cost-benefit analysis. In theory, we can establish a baseline indicator of poverty (say P2).
After a program is implemented, we can measure poverty again and obtain a post- intervention indicator (say, P2). We then can first see the change in poverty (P2- Pi). Or more importantly, for comparative analysis, we can construct a CE ratio that provides a per-unit of change cost. The major drawback with this approach is that not many programs can afford such detailed pre- and post-intervention information. An alternative is to use census-derived data but then we have again the issue of timing differences (national census surveys are not necessarily conducted before and after an antipoverty program is put in place). Another CEA alternative is to concentrate on sectoral projects (i.e., basic health, primary education, etc) and indirectly estimate an income effect.4
19. A third option to evaluate poverty reduction programs is to use computable general equilibrium (CGE) models.3 The drawbacks of this option are the assumptions underlying the model and the lack of a counterfactual. CGE models are based on algorithms that follow the neo-classical economic theory; however, it is well established in the literature that market inefficiencies are prevalent in most countries. Furthermore, the appropriate
1 There are several theoretical criticisms with respect to the rather crude H measure (see, for example. Watts 1968. Sen 1976 and 1981), but H in general is the more widely used approach.
2 The issue of timing is also relevant. Anti-poverty policies and programs do not change the income structure of a country overnight: thus, we need relatively long time-series, which are generally not available.
3 See Baker (1999) for a complete review of different impact evaluation methodologies.
4 For an example in the education sector, see Tan, Lane and Lassibille (1999); for a CEA in basic health see Phillips, Sanghvi, et al (1996).
_ _j. r-\_ nx_:_ c. l i j— t_i /i non\
comparison is the counterfactual — what would have happened in the absence of the program?— which is usually not constructed in a satisfactory manner.
20. Another option is to use just a part of a CGE model. For instance, by using social accounting matrices (SAMs), the structural components of CGE models, we can look at how growth in a particular sector affects the poor.6 The complications with this approach are the weighting scheme, static analysis, and paucity of disaggregated data. There is a measure of value judgement that is necessary to construct an appropriate weighting scheme giving more important to income gains accruing to poor people. The analysis, given the usual assumptions, is limited to partial equilibrium, linear modeling and fixed prices. Finally, disagreggated data, which is crucial for this type of analysis, is not readily available for most countries (Khan 1999 mentions the lack of calorie-income elasticities for the non-white population in South Africa, for example).
21. Qualitative methods also have drawbacks. First, we have the subjectiveness of the analyst. Then these studies are not necessarily representative since often they have ad hoc samples. The validity and reliability of the analysis is dependent on the skill, sensitivity and knowledge of the interviewer.
22. We have presented this summary review of methods for reference only. In this study, we do not intend to evaluate a particular program or set of policies. We will only review the outcomes of a selected number of anti-poverty programs. We believe that this analytical investigation can be useful for policy makers and program managers.
II. Best Practices in the Health Sector
Even though there is some progress in the health condition in many African countries since the 1960's the continent as a whole lags behind all developing countries. Poor health is a common consequence of poverty and poverty can be a consequence of poor health. Maternal mortality is twice as high as in other low-income developing countries. Malaria is becoming more prevalent and tuberculosis is on the rise.
AIDS/HIV threatens to create an enormous economic and social burden in some countries ( World Bank, 1994).
24. There is major focus by the international community and governments that have good health strategies that the health of the poor must be urgently addressed. Financing and provision of health services (also in other sectors) to the poor is not always easy, due to problems of targeting. One way of easy targeting could be to address those diseases that are prevalent among the poor. Communicable diseases, such as tuberculoses and malaria are good examples.
25. Malaria and Tuberculosis impact has grown recently in the Africa region. At the turn of the 20th century, Africa saw 223 deaths a year from malaria per 100,000 people. By 1970 the rate had fallen to 107 in Africa, compared with only 7 in other regions.. .the death rate soared again in Africa to 165 per 1000,000. (World Bank, 2000 ).
26. In undertaking any project to benefit the poor or the poorest percentile of the population an important element that must be considered is how to target the poor and
6 See Thombecke and Junq (1996) and Khan (1999).
minimize or avoid leakage to other sectors of the society. Reviewing the literature on targeting in the health sector to effectively reach the poor, there is a suggestion that two broad-based categories can be used. One is that to target by priority age-group (Table 1).
That is to assess the death-rate for each age group and to see in what group the prevalence is high. Globally it was found out that in the poorest 20 percent of the population the death rate was highest for the age-group 0-14. The second criteria is to target by disease, i.e. to concentrate on those diseases that are most prevalent in the poorest segment of the population. Here again it has been shown (see box..) that communicable diseases cause more death among the poor. "Communicable diseases cause over 11 times as many deaths among the poor as among the rich. Non-communicable diseases, on the other hand, kill only somewhat more than half as many poor as rich. (Gwatkin, D.R, 2000, draft P- 20.)
Table 1: Percentage of Deaths by Age
Age Group Under 15 15-59 Over 60 Total
Population Group Global Poorest 20%
15.7%
24.5%
24.8%
100.0%
Global Average 29.9%
24.2%
45.9%
100.0%
Global Richest 20%
3.9%
17.8%
78.3%
100.0%
Source: Gwatkin, D.R, 2000, draft p. 16.
Table 2: Percentage of Deaths by Age: Typical High-Mortality (African) Developing Country
Age Group 0-14
15-44 45-64
65+ |
Total
Least Healthy 10-20%
of Population 56.5
16.5 12.2 14.8 100.0
Healthiest 10-20% of Population 35.0
15.5 17.0 32.5 100.0
Ratio * (Col.2/Col.3) 1.6:1.0
1.1: 1.0 0.7: 1.0 0.5: 1.0
* Least healthy to healthiest.
Source: Gwatkin, D.R, 2000, draft p. 16.
27. What matters most for the global poor is finishing the unfinished agenda, dealing effectively with such associated conditions as maternal health and malnutrition, and combating those reemerging diseases, like tuberculosis, which spread particularly among the needy. .." (D.Gwatkin and M. Guillot 2000, p.26)
28. "At present, while noncommunicable diseases cause more death and disability than communicable diseases in the world as a whole, communicable and related diseases remain the leading cause of death and disability among the global poor. The population group for which non-communicable diseases matter most is the rich, among whom such diseases are overwhelmingly dominant." (D.Gwatkin and, M. Guillot, 2000, p.25)
In almost any developing country setting, as well as for the world as a whole, ill health in poor population growth is concentrated among the young. Poor infants, children, and youth suffer a significant higher proportion of total-ill health experienced by a poor population group than do the older members of that population group. And rich-poor differences in health status are much greater at younger than at older ages. Thus, cetens paribus. an age-targeted health program oriented toward the poor would wish to give highest priority to the young.
Source: Gwaikm, D.R^. 2000, The.current State of .Knowtetkje about. TARGETING HLALItt PROGRAMS TO REACH THE POOR draft, p.17.
29. Even though targeting is difficult especially where it is difficult to identify the poor some countries have used the PPA in establishing who the poor are before embarking on any project. Even though this approach has also its shortcomings, it is less time consuming and less costly than conducting household surveys.
30. The World Bank had been involved in many developing countries in projects aimed at alleviating the problems facing the health sector, these include policy formulation, financing the reform of the health sector running projects, and a wide variety of activities.
The following will just highlight some specific country projects that have born significant impact or result.
(a) Onchocerciasis - Riverblindness
31. This is one of the most applaudable programmes run in Africa that affects the lives of millions. The programme has 61 approved projects in 13 countries, treating 32 million people. It is a Global Partnership of 70 Developing Partners. A parasitic worm transmitted from person to person by a black fly, which causes blindness called Riverblindness. The social and economic impact that blindness causes is not hard to imagine. In about 30 countries in Africa about 120 million people are at risk and 20 million are infected. The treatment is taking two pills of a drug called Mectizan, once per year .The drug kills off microscopic worms with negligible side effects. It is given free for as long as may be needed by the manufacturer, Merck & Co.
32. The effect of the programme: 34 million people protected from the disease;
600,000 cases of blindness prevented; 15 million children are spared the disease and 25 million hectares of arable land freed up. The economic rate of return (ERR) of 20% is
calculated for the project.
33. The aim of the project is to eliminate Onchocerciasis throughout Africa, alleviating poverty for millions of Africans, strengthening community health care in rural areas and establishing a model of global partnership. This programme is considered one of the most effective means of combating the disease and rehabilitating the society.
(b) Lymphatic Filariasis: Elephantiasis
34. Mosquitoes transmit a parasite, these parasites develop into adult worms which block lymphatic channels. The disease causes:- kidney damage, physical disfigurement, severe disability, social ostracism, and economic hardship. In Africa 500 million Africans are at risk.
35. In SSA 43 million are infected in 37 countries. The burden causes almost US$2
billion in productivity losses each year.
36. The disease is controlled by taking a single dose of Vermectin (donated by Mereck
&Co) and Albendazole (donated by Smith Kline Beecham.) once a year which is effective in halting transmission of the disease. The suffering of those afflicted can be alleviated with simple local hygiene techniques. Integration of Lymphatic Filariasis control into the Onchocerciasis framework would be feasible and cost-effective. The Economic Rate of Return is 27%.
37. Eliminating Lymphatic Filariasis in Africa is not c^ly feasible and cost effective, but would greatly improve the lives of millions of the poore * of the poor.
(c) Community nutrition projects, SECALINE and CNP (Findings No.112, June 1998 )
38. The World Bank reviewed many projects it had assisted in nutrition in Africa and only 4 were considered success stories. The above 2 projects are part of the successful projects. SECALINE is the Madagascar Food Security and Nutrition Project, and CNP is the Senegal Community Nutrition Project. SECALINE has been in implementation since 1993 and CNP since 1995. The projects offers few standard nutrition services such as growth monitoring of children, nutrition education for the mothers food preparation demonstrations, home visits, and reference to health facilities for severely malnourished or sick children
39. SECALINE targets poor rural population and CNP targets the poor peri-urban population. Both projects are highly targeted by geographical area, by sex, by age, by self- targeting services.. The executing agency in Madagascar is SECALINE, while in Senegal it is AGETIP an NGO that uses delegated contract management to execute the project. The projects involves the community in some decision making, they are sensitized about the project and asked if they are interested, then they are asked to orgarvize themselves, they are given training and asked to deliver some of the services.
40. The impact has been that all services provided are well executed to the target groups, the projects are preventive some of the reasons for success are:
♦ The projects were designed based on other successful nutrition projects
♦ High level of political commitment
♦ Community involvement through social mobilization and involvement in
monitoring programme
♦ Service delivery by non-governmental entities who are contracted and are accountable for
♦ Use of national expert capacity for training, operation research, and management resulting in strong ownership.
(d) IMCI - Integrated Management of Childhood Illness AFRICA
41. As stated in the introduction many children die earl (12 million children in developing countries die before their fifth birthday). The cause of seven in ten deaths is due to acute respiratory infections, diarrhoea, measles, malaria or malnutrition - or any combination of these. Since there is an overlap in the diagnosis of these conditions a single approach will not suffice, hence the integration approach i.e. to treat the need to address the overall health of a child is necessary. The IMCI strategy was developed by various programmes of WHO and UNICEF.
42. The IMCI Strategy promotes the accurate identification of childhood illnesses, strengthens the counseling of caretakers and the provision of preventive services and speeds up the referral of severely ill children. Th programme treats the childhood diseases all at the same time and it trains a nurse or health worker on how to treat the diseases, so that they are able to handle all kinds of situations that may arise. An integrated approach is cost-effective, saves time and lives of children at the same time. The details of the programme can be easily adopted in all African countries and the modalities are available in the offices of the health sector of the World Bank.
(e) The Roll Back Malaria partnership (Findings No.144, 1999)
43. Malaria kills over one million and causes 300-500 million to fall ill each year. The majority of the 3.000 deaths each day and ten new cases every second occur in Africa. The disease impedes development and has high economic impact. The poor are affected most, because they have less access to information and means of protection and the have no or minimal option in changing living or working in Maiaria-affected areas.
44. A new discovery for the spread of the disease is that the breeding place has not been effectively sprayed. An interesting factor is that one of the ideal breeding places for the malaria mosquito is inside old tires, which is not sprayed and the moisture is always there and these old tires are always around poor neighborhoods.
45. What is alarming is that Malaria is on the rise, recent epidemics indicate a resurgence of the disease in what were considered low-risk areas. Due to drug and pesticide resistance affordable prevention and treatment of malaria is reduced. New tools are available to combat malaria such as rapid diagnostic tests, combination drug therapy, residual spraying, insecticide treated materials etc. But malaria needs to be effectively controlled within a
broader health sector development.
46. Thus there was need to call for concerted action, which was the global Roll Back Malaria (RBM) effort in response to the request from the OAU and announced by the heads of WHO, UNICEF,UNDP and the World Bank in November 1998. The aim of RBM is to reduce global malaria mortality by 50 percent by the year 2010. The RBM partnership consists of malaria-affected countries. UN agencies, the private sector, industry, OECD countries, development banks. NGOs, research entities, and the media. There are six strategies to achieve this goal:(l) early detection;(2) rapid treatment;(3) multiple means for prevention; (4) well-coordinated action; (5) a dynamic global movement; and (6) focused
research.
47. The RBM which has a multi-sectoral approach will be cost effective and create a basis for other partnerships such as combating HV/AIDS. Research initiatives will benefit all
participating countries as well as potential gains in economies of scale due to production, supply, research and training. The programme will also gain from funds donated from the various partners.
48. Specifically progress has been made in Ethiopia, Eritrea, Tanzania, and Mozambique, where the Malaria team within the Africa Region works with Country Teams to develop innovative approaches to address malaria, and employing the Bank's comparative advantages within the Partnership. It is hoped that the partnership will capture and disseminate the lessons learned in these "spotlight countries" and will also be working in other sectors as well.
(f) Malaria and Anemia prevention among Tanzanian infants (WHO, Bulletin, 2000:97)
49. Malaria is transmitted by the malaria mosquito and results in death if not treated.
Anemia is iron deficiency. Most of the burden of mortality and morbidity from malaria accounts for over 85% of the disability-adjusted life years (DALYs) in Africa. In developing countries as a whole, over half the children suffer from anemia. To treat these two conditions the project targeted the infants in the Tanzanian village. The treatment was preventive, i.e. the infants were given daily iron supplements and weekly malaria chemoprophylaxix. The preventive measures helped to strengthen the infants from being weak, due to iron deficiency, which can result in weakening them and makes them suitable targets to acquire any infectious diseases. Prevention against malaria was also effective because in Malaria infected areas weak infants die quickly from it. The project was cost effective because when the infants come for the treatment of one they get preventive treatment for two.
(g) Sexually Transmitted Infection Project (Uganda) (Findings.No. 127.Jan,1999)
50. In Uganda an estimated 2.73 million have been infected by sexually transmitted diseases since 1984. of those 1.9 million have developed AIDS and 1.8 million have died.
In Uganda HIV/AIDS prevalence is very high, at the same time it is one of the countries where due to strong government intervention coupled with the joint effort of donors and NGOs where the prevalence shows sustained steady decline especially in the 15-29 age group for women.
51. The Ugandan government has provided one of the strongest political leadership and established one of the most comprehensive HIV/AIDS program in Africa. In 1985 it setup the National Committee for Prevention of AIDS, then the AIDS Control Program (ACP) was established in the Ministry of Health. In 1988 it was decided to have a multi-sectoral approach thus the Uganda AIDS Commission was established. In 1993 a multi-sectoral National Operation Plan (NOP) for prevention of HIV infection and mitigation of health and socioeconomic impact of HIV/AIDS was adopted.
52. In 1994 the World Bank assisted project started. It is the largest project in the National Operational Plan for HIV/AIDS control, some of the main features of the project
are:
♦ Prevention of Sexual transmission of HIV. the STIP promotes safe sexual behavior through information, education and communication (IEC); provides
and promotes the use of condoms; care seeking of STD is promoted as well as the provision of care.
♦ The personal impact of AIDS is supported by the project by focusing on the development of treatment guidelines, training of health workers on how to mange AIDS patients, provides medicine for the treatment of opportunistic infections associated with AIDS. To reduce bed-occupancy by AIDS patients at hospitals, the organization supports NGO and community -based organizations and home-based care. It also provides counseling, nutrition and income generation activities by NGOs.
♦ Institutional Development: The project supports the management of HIV/AIDS program by capacity building in planning and management as well as in monitoring and evaluation. It has a wide range of activities and support for projects at different levels, such as central government and district level offices.
It also supports research activities.
♦ Gender: The project has mainstreamed gender in its activities and taken into account the behavioral differences between men and women in seeking health
care.
♦ Global partnerships: Through the national and district level planning effective collaboration of the various donors and government coordination is carried
out.
53. Even though there is room for improvement the program has shown a positive impact in combating HIV/AIDS. Some of the main achievements are listed below:
♦ General awareness level has improved especially in the urban areas.
♦ Changes in sexual behaviour has taken place -there is drop in non-regular partnership and casual sex across all age groups, especially in the 15-19 age
group.
♦ Delay in sexual debut - survey shows that between 1989 and 1995, males in the 15-19 age group reporting that they "never had sex" has risen from 31% to 56%, females has increased from 26% to 46%.
♦ HIV prevalence in young pregnant women aged 15-29 years has declined from 32% - 54%. in some urban areas, between 1992 and 1996. This is quite representative of the population and it is considered an important achievement because "a reduction in HIV/AIDS in this group will contribute significantly to economic productivity and social welfare in the country as this group constitutes a large proportion of the economically productive population group."
♦ The political commitment and involvement of the government coupled with the local ownership of the programs has made an impact to bring about the above mentioned successes.
54. In the health sector of Africa, speedy and effective health service and coverage to all the population is not feasible in the near future, due to the enormous financial requirements of the sector. In the meantime African countries, by pursuing a policy of greater collaboration and exchange of information among themselves, will be able to solve some of the health problems by turning to long used and proved effective traditional
medicine.
Greater collaboration between traditional healers and other health care providers could lead to stronger ties with the community. More than 20 African countries have established associations of traditional healers.
However, more emphasis could be placed on training traditional healers to increase their skills. For example, appropriate training for traditional birth attendants would give them greater role in the community health care systems. In Ghana, Nigeria, and Zimbabwe traditional healers have learned practices such as oral rehydration and HIV/AIDS prevention.
(Source: (World Bank, Action for Better Heafeli in Africa, 1994 p. 9). - ^
The next section presents best practices in the education sector. Both the health and education sectors are considered fundamental in changing the capability of the poor to lead a better life.
HI. Best Practices in the Education Sector
To increase the capability of any society education is fundamental. In the case of Africa the picture is very dismal. As stated in the introduction of this paper, enrollment rates have declined especially for primary education. At a time when most nations are on the verge of attaining universal primary education the majority of African countries are lagging behind. iMost of the adult population especially in the rural areas is illiterate and the case for the female population is worst. Thus it is important that African countries learn from each other on how to increase their enrollment rates and to also improve on the quality of education offered in their schools. Because without a healthy and an educated population any gains in other sectors will be unfruitful or
unequitable.
(a) Improving the Quality of Primary Education
Regional Study on managing Schools for Effectiveness (Findings, No.3, April 1996)
55. Through five workshops in Africa the study's approach and methodology were widely disseminated. The objective of the study was to assist governments in introducing school-focused programming into reforms of primary education, which included, (a) an assessment of how well 26 World Bank -assisted project designs for primary education met criteria for educational effectiveness; (b) the preparation of user-friendly framework of factors that determine school effectiveness; and (c) the development of a methodology for helping African educators define and priotrize school-based definitions and indicators of
educational effectiveness.
56. The impact of the study can be assessed by the fact that several African countries used the study such as:
♦ Madagascar: used the approach to develop a reform program of primary education. Which "centered on the child, based at the school, with a bottom-
up approach"i.e a negotiating process between the Ministry of Education and the community. This process will be applied nation wide because of a successful pilot application.
♦ Swaziland: the study's approach was used to prepare a national "Plan for improving the quality of Primary Education".
♦ Senegal: the study's approach used as a guide in the pilot implementation and monitoring of a Fond de Developpement Scolaire (FDS). Some 70- school communities received funds for school improvement projects.
♦ Guinea, Comoros, Togo, Zimbabwe, and Malawi: as a result of their participation in the study's workshops these countries have focused on school-level changes. The workshops have helped train senior educators to use the study's methodology, from the above countries as well as from Namibia, Lesotho, Zambia, Mauritania and Benin.
57. It has been observed that inspite of some best practices that are used as examples, many studies have shown that subsidies directed to the education and health services are not well targeted to the poorest. In the long-run the strategy must be to encourage private providers so that the public subsidy can be directed more effectively at services used mostly by the poor. There are also instruments that could improve targeting in the short and medium term. (Castro-Leal, Julia Dayton, Lionel Demery, Kalpana Mehra , 1999)
(b) Equity and School Improvement Project. (Guinea) (Findings.No.93.August 1997)
58. The government of Guinea's national Education for All Program, adopted in 1990, aimed to expand the gross primary enrollment rate by 2000 from 28% to 53%. Because it believed that an effective instrument to combat poverty especially in the rural areas is by expanding primary education. The Education Sector Policy, which embodies improvement of the quality of education, efficient use of resources and increasing government support for basic education. The program is multi-donor sector program, the USAID and World Bank being the major donors.
59. Project objectives: increase primary enrollment rate from 40% to 53%, increase rural student participation from 20% to 40%, increase girls enrollment rate from 29% to 42%;
quality of primary and secondary education to be improved; develop capacity within the ministry of Pre-University Education, and manage the sector outputs in a sustainable manner. The project design took into consideration poverty and gender issues. An assessment that was taken in 1997 showed that gross primary enrollment rose from 40%
to 44% and easily will reach target. Girls enrollment rate reached 36% at the time of the reporting and will surpass the target. Classrooms have been constructed. Quality of education has been enhanced, with monitoring system from the Ministry through tests. Text book distribution is fairly widespread by use of private distribution systems and co-bidding, and working with the communities.
60. The project also incorporates Health and Nutrition component, it distributes vitamin supplements including vitamin A and de-worming tablets, to enhance the learning capacity of students.
61. The educational system management, such as data collection, has been strengthened, with the school mapping process has been computerized with links with the main ministry. Data is decentralized by regions, this will eventually lead to budget decentralization.
Lessons Learned
62. The Equity and School Improvement Project is considered a best practice, because it set out long-term objectives and followed through until the objectives or targets were obtained. The project benefited by high level beneficiary involvement, coupled with use of quantitative and qualitative research of pertinent issues. Donors had close coordination and open communication, thus the project benefited from speedy decision and action.
(c) Girls' Education and the Role of the Community.
(Findings; 168, Oct 2000)
63. In four west African countries, Burkina-Faso, Guinea, Mali and Mauritania a research was carried out to find out the success criteria for girls education. It was found out that a number of factors contributed to the success the main one being the role of the community.
64. The parents association (Association des Parents d'Eleves-APE) and the mothers' association (Association des Meres d'Eleves-AME) are crucial to solving the dilemma of girls education. Guinea - the communities participated in building the library and helped in resolving issues of salaries of contract teachers. Burkina-Faso - the community gives material or financial support to the schools to enable it meet its material shortcomings such as text books, sports material and sometimes the community also builds additional classrooms. Mali - communities are very active at the school level. The community of Koubewel-Koundia opened its own community school, with help of an international NGO, and pays teachers' salaries. The community pays tax, part of which is withheld to cover the needs of the school. The community actively helps in the enrollment of girls and monitors the equality between girls and boys.
65. The study in the four countries revealed that the role of APEs is fundamental in girls' education. The AMEs which is a recent innovation of Burkina Faso it will have a big role to play in the education of children especially girls.
The activities of Parents Associations (APEs)
♦ Participation in the construction of classrooms and/or supply of construction materials;
♦ Maintenance and rehabilitation of school equipment and infrastructure
♦ Contribution to the financing of school canteens;
♦ Coordination and resolution of problems that arise between the school administration and parents;
♦ Organization and monitoring of evening classes;
♦ Search for exterior financing to develop the school;
♦ Awareness-raising among parents as to the advantages of girls' education;
♦ Monitoring of the transparency of school tests.
66. An example of special assistance to girls is found in Irelli and Madougou in Mali.
When a girl passes the entrance exam for the seventh or tenth grade and needs assistance because the girls have leave school to continue their studies the APE finds housing for them and members visit the girl students.
The Association of Students Mothers (AMEs)
67. Burkina-Faso - in 1992 an association of students' mothers in a region called Sissili was formed. The women wanted to participate more actively in the education of their children, more than what the APE were able to contribute. The association contributed more especially in the girls' schooling. Their objectives are:
♦ Increase the rates of enrollment, especially of girls;
♦ Improve the retention and the access of all students;
♦ Enable more young girls to finish their studies;
♦ Prepare girls' integration into their environment while giving them the skills to
manage their lives;
♦ Enable women to work together in order to ensure their full participation in the education of their children, particularly of their daughters.
68. The AMEs have complementary role with the APEs and have enabled more to participate in school meetings. Most important the AMEs have changed parents mentality towards girls' education as well as parents-school relation.
69. The findings of the study concludes that the community should be encouraged to participate more in school activities other than the benefit of helping out in the financial constraints of schools. The community and its evaluation is very important for human development especially in the education of girls.
IV. Best Practice in Other Sectors
Many activities are carried out that benefit the poor or the disadvantaged, the choice to present these best practices was difficult. The following three projects were chosen because they had unique feature that could be of interest to many countries. As stated in the introduction the purpose is to present best practices that have relevance to the society at large and the poor in particular. Ways and means of evaluation are difficult in such projects, but it is not difficult to judge projects that are effective or that
have relevance to the society.
(a) MASAF - The Malawi Social Action Fund (Findings, No 30, July 1998)
71. The project was proposed by the government as a quick-disbursing poverty alleviation facility targeted to the poor rural communities. The project was designed to promote change in the way the government and all development agencies would work with other stakeholders. Either in the form of cash, or labour or materials the communities were required to contribute 20 per cent in the total cost. Communities where therefore required to participate in the design of projects. The impact had been as follows:
72. The norms of the project was established very clearly through the mass media, like radios, posters etc. so that all stakeholders are aware of their responsibilities when
participating in the project.
♦ The access to information made a change of attitude of poor communities towards the NGOs and the government. Thus communities were able to
choose projects, i.e they made decisions not the donors. They were also able to control the whereabouts of the funds and assured its proper implementation, thus minimizing misuse of fund and corruption by officials.
♦ The project encouraged gender-focus and this was widely communicated, thus women became active committee members.
♦ The free flow of information created better working relationships between stakeholders and encouraged new trust and respect among the various actors.
(b) AGETIP-Senegal *
73. Is an innovative public works and employment programme that became known as
AGETIP- Agence pour /'Execution de Trauaux d'Interet Public contre le Sous-emploi.
AGETIP became operational end of 1989 it is a non-governmental and non-profit making
organization. It was launched as part of the framework of the Public Works and Employment project a four-year project that cost US$33 million financed jointly by the World Bank and ADB. The goal was to create short-term employment for the unemployed youth, to improve the quality of life of the urban poor by targeting projects with significant social' impact, and provide business opportunities, training, and advisory services to workers and managers of small and medium enterprises. The role of AGETIP is based on
the concept of delegated contract management- one that allows governments or municipalities to delegate the provision of public infrastructure or services to private-jqencies. The agency was created in the hope of reducing obstacles to the efficient implementation of those large-scale public works program that had the potential to reduce
unemployment. The agency receives authority from national or local governments tocontract out. coordinate and supervise the execution of a public works program composed of sub-projects in construction, rehabilitation or maintenance of urban infrastructure, and
provision of services. It manages the whole process from design and bidding toimplementation.
(c) ACEP (Senegal)
74. ACEP is a project in Senegal that gives credit to the unfunded. About 90 percent of the work force is employed in the informal sector which generates about 60 percent of all
economic activity in the country. " ...the informal sector and micro-enterprises itencourages are now seen as an important tool in the effort to reduce poverty and
unemployment in urban areas. "
75.
76. ACEP- the Alliance de credit et d'epargne pour la production - began in 1985 as a credit component of a USAID-supported Community Enterprise development as a small
loan program in the groundnut-producing basin of Senegal. In 1990, the credit unit wasestablished as an independent entity under its current name, by 1993 when the USAID project ended it was able to start lending from its own sources. The ACEP credit caters only
to expanding businesses and excludes star-up. It only lends to existing micro-enterprises,the majority of which employ less than 10 people The main objective was to grant working capital loans and investment to informal small and medium-size enterprises that had no access to formal credit. Credit is based on the evaluation by an ACEP representative and
on personal knowledge. Main objectives:
♦ Provide credit and savings services to Senegalese entrepreneurs to support growth of their companies as well as the social and economic development of Senegal:
♦ Develop a network of financial services; and
♦ Manage activities on the basis of principles of cooperation.
77. The success of the project is reflected by the fact that:
♦ Some 4,000 micro-enterprises currently receive ACEP credits, for about 2.5 billion CFA(about US$5 million) .
♦ Recovery rate is 99 percent.
♦ ACEP has reached financial sustainability
♦ Quality of management and staff are recognized in the country and it has become a reference in the business.
♦ It has an efficient organization of management ( low fixed costs, centralized credit management, focus on credit, and no interference from government).
78. Thus ACEP can be considered as a good practice in the micro-finance that encourages the private sector for job creation and gainful employment that can help to
alleviate poverty.
(d) Water for the Rural people ( Mali) { RWSP/KBK)
79. Mali's Kita-Bafoulabe-Kenieba Rural Water Supply Project (RWSP/KBK) is a successful development project. The project took about ten years to implement by the World Bank 1983-1993. As is well known most of sub-Saharan Africa does not have access to safe water in fact fetching water is one of the most burdensome and time consuming tasks faced by women especially in the rural areas. In Mali still about 75 percent of the rural population does not have reliable source of drinking water. The RWSP/KBK was designed to deal with three districts that had low population density and poor infrastructure.
80. The objective of the project was to drill 340 productive bore-holes equipped with hand-pumps. One of the criteria for site selection was the link that about 60 percent of diseases in the Kayes region were linked to a deficit in the quantity and quality of the water supply. The project was implemented with the full participation of the population. The community contributed cash to cover the cost of a pump which amounted to about US$1.20 per person. A water management committee was responsible for managing the water point and maintenance. A network of area mechanics was trained for the purpose and spare parts are also stocked. Even though water is supplied free of charge the community is responsible for paying for spare-parts and maintenance services.
81. The project provides about 481,000 people with water in some 860 villages, they provide an estimated 25 liters per person per day.
82. The economic value in terms of time spent in fetching water and the absence of water borne diseases is not hard to imagine, thus such kind of projects are valuable to the rural poor, especially for women and girls who are usually responsible for fetching water for
the household.
(e) Traditional Energy in Sub-Saharan Africa
83. There is a looming crisis in the supply of traditional fuels such as fuelwood and charcoal, because many countries are running out of these. About 60 to 85 percent of energy consumed in most African countries consists of traditional fuels. While rural communities use woodfuels the urban dwellers obtain them in the form of charcoal. Low - income urban dwellers can only afford to use traditional fuels.
84. The crisis has now been felt in depleting resources. In order to assist African Governments deal with the problem of the "silent crisis " the World Bank and Dutch government agreed in 1993 to establish the Regional Program for the Traditional Energy Sector (RPTES). Because the problem was most acute in the Sahelian countries a group of five countries from the region were selected namely, Burkina Faso, The Gambia, Mali, Niger and Senegal. The pilot phase was concluded in 1995. Then an additional seven countries were added, Benin, Ethiopia, Guinea, Guinea-Bissau, Mauritania, Mozambique
and Togo.
85. The program encourages exchange of information and experiences among countries while it provides tailored assistance to each participating country. (pl2-13) RPTES emphasized the "nexus' approach to the sector. It recognizes that the development of the energy sector can lead to environmental sustainability, desertification mitigation, rural poverty alleviation, energy and economic efficiency and gender. There is a clear need for technology and alternative sources of energy to free up we m's time. The programme helps in the formation of national teams comprised of key g^ ,emment officials ( such as the ministries of energy, environment, forestry, women affairs etc.), NGO, regional agencies, s and other concerned parties. Following the constitution of the national teams the Program provides technical and consultant support (on request) and the transfer of analytical methodologies. The team conducts the national Policy review. After the national policy consensus has been established the Program assists the national team in preparing a sectoral investment project for government and donor financing.
86. The success of the project is reflected in the experience of Senegal. The RPTES team is now implementing a $US 20 million project to bring 300,000 hectars of natural forests under the direct community management and control for the sustainable production of woodfuels for Dakar and other urban markets.
87. A similar project in Burkina Faso is expected to result in the sustainable production of about 70 percent of the woodfuel needs of the towns and cities in the country.
Mozambique is also in the process of a similar project, which has resulted in the introduction of new economic and employment opportunities such brick making and improved carbonization techniques.
V. Best Practices in Policy: In Other Sectors*'
Poverty reduction- in the world or in a particular region or country - depends primarily on the quality of economic policy. Where we find in the developing world good environments for households and firms to save and invest, we generally observe poverty reduction. Foreign aid can accelerate the process. It can assist the government and the society to provide public services, including critical ones needed by poor households to participate in the market economy.( Collier and Dollar, 1999, First
Draft, p26). Poverty reduction is a challenge, it is multi-dimensional and multi-sectoral. It is the interaction of policies that sustain long-term growth, by improving the stock and distribution of human capital, curb corruption and enhance the social and physical capital of the poor( World Bank, 2000a:49)
88. Policy changes that impact on the poverty reduction should be carefully thought out and implemented, but this process is both time consuming and requires some guidelines.In order for Africa to halve poverty by 2015, it has been estimated that an average growth rate of 8 per cent is required. This will require tremendous effort for the majority of African countries given their present level of growth. It will also require renewed effort by African governments to implement some policy changes such as the promotion of good governance, enahncing the efficiency of public expenditure, deeper economic reforms, expansion of exports, regional integration, access to information technology, and further improvements in the level and productivity of investments in human, as well as physical capital and to also provide an environment for the private sector to grow. Gender equity, such as access to basic assets of land, credit and education, employment and all other social services should be enforced.( G8 Okinawa Summit ,July 2000, p.5-6) Thus the purpose of this desk study is to distill some good practices on polices that have been implemented by African countries so that sharing of information can help in duplicating the process. Most African countries share similar initial conditions , thus with minor adjustments policies and programmes can easily be shared and implemented in similar scenarios.
(a) Early Childhood Development (ECD) in Sub-Saharan Africa: Policy and Programs (Findings No. 101. Dec. 1997)
89. Investment in Early Childhood Development (ECD) in Sub-Saharan Africa is becoming increasingly important due to persistent poverty, fast population growth and dwindling traditional family support system. ECD is an institutional and social policy issue that cuts across health, education and other social sectors. It cuts across all levels of government, non-government and local institutions, i.e the macro, meso and micro levels.
90. The investment in childhood development must begin from birth up to primary school and encompass the health, nutrition, and attention to cognitive and social development of children. Countries who aspire social and economic development must invest in young children's survival and development.
91. The programs and policies differ from case to case, but the main feature is that a range of possibilities exist for an integrated response to the physical, socio-emotional, cognitive, economic and cultural dimensions of young children's development. The various programs objectives also includes parents and others that contribute to children's socialization and growth. The program focuses directly on children, households and the
community.
Case studies of some effective programs:
♦ Angola - A Mobile Trauma Team combines traditional culture and healing rites with recent scientific evidence child development, trauma and healing. In order to interact with children in refugee camps, children's homes, schools and street children, professional paraprofessional, parents and youth leaders are
given training.
♦ Botswana - The Child-to-Child program for basic health education is adopted into a school readiness activity to help young children in primary prepare younger siblings for entry .
♦ Zimbabwe - Using the integrated community development project (Kushanda) in commercial farming communities, the project began with skill training, material and financial inputs. It was also used for ECD as well as adult education, literacy and extension training for health and nutrition.
♦ Ghana, Mali and Burkina Faso - Women's joint liability credit associations developed a curriculum on maternal health and Child care, they also analyzed problems of child development and produced appropriate action to be taken.
♦ Kenya, Uganda and Zanzibar - The Madrasa Preschool Programs in these countries require co-financing and community management to be eligible for access endowments for continuious funding for the preschools. The Resource Center trains women from the community, who are appointed by the local management committees, as ECD workers.
♦ National development policy - it has been found that grassroots organizations can make an effective impact in bringing about development policy. Community groups and local NGOs in South Africa led to the establishment of the National ECD Congress. Similar local initiatives and small pilot experiences in Kenya, Zimbabwe and Mauritius have led to long term commitments and in some cases to national programs.
92. In conclusion it must be sated that these ECD programs have incorporated African traditions and culture, and multi-sectoral policy frameworks which some countries have constructed for the protection and development of young children.
(b) Leadership role in the fight against HIV/AIDS
93. The recent ADF 2000 conference on 'Aids The Greatest Leadership Challenge", brought about a gathering of many that had a stake in this great challenge. One of the highlights at the opening of the conference was the statement made by the President of Ethiopia when he officially declared War on HIV/AIDS. This was a touching moment of great sense of achievement for Africa. Ethiopia has called upon all its people, the military , youth, medical personnel, women etc to rise and fight HIV/AIDS in their capacity and the government will turn its resources as much as it can to fight this pandemic.
94. Some other countries that are exemplary are: Presidents of Uganda, who has long put in place the necessary policy guidelines and is personally involved in this matter of national importance. Uganda has completed the 200-2005 National Strategic Framework for HIV/AIDS Activities. Uganda being the hardest hit by the pandemic took decisive political leadership and now is quoted as an example of best practice in the continent.
95. Botswana- there is commitment and follow up from the President. Ghana: The first Lady of Ghana put public awareness about the plight and effect of HIV/AIDS, to ease the women to take charge of their situation.
96. These are only a few examples to show the importance that African leaders are taking, but the large majority of African countries need to fully react to fight the pandemic.
(c) Zambia: Listening to farmers: Participatory assessment of policy reform in the agricultural sector. (Findings no.105.Feb. 1998).
97. In Zambia's agricultural sector several policies of liberalization and privatization as well as institutional changes have taken place since 1991. The Agricultural sector Investment Program {ASIP) with the assistance of the World Bank integrates fragmented projects and programs in the sector and provides continuing development of policies.
98. ASIP - all stakeholders such as the private, public and non-governmental sectors, participate actively in program design and implementation. Using methods such as Participatory Rural Appraisal (PRA) and Beneficiary Assessment (BA), ASIP has a systematic and regular feedback between policy makers' service providers and program beneficiaries. This enables the program to have feedback and improve implementation of
the program as well as promoting active participation.
99. The outcome of the consultations have resulted in the recommendations that led small farmers to benefit from improved quality and equity of services provided by the public and private sectors. Some of the main needs of the fanners were: improved infrastructure as well as the effective regulation of the private sector; need for more information on markets for their produce; access to more flexible credit facilities and wanted advice on storage methods and subsistence crops.
100. ASIP has shown that participatory assessments capture the diversity and complexity of the agricultural sector. It also gives ownership and participation of the stakeholders.
Combining qualitative and quantitative assessments can help in understanding that rural development needs a holistic approach. Future scope will involve the assessment of the social and distributional impact of policies.
VI. Conclusion and Recommendation
The World Bank has been implementing various projects in Africa, most of which are related, directly or indirectly to poverty alleviation. Even though it has not been possible to empirically prove the effectiveness of such projects in affecting directly the lives of the poor, it has been shown that the best practices reviewed in this study have played positive role in improving their lives. It is noted that in future there is need to improve the effectiveness of projects by designing simple, and easy to manage projects that are client oriented and responsive to the needs of the poor. Along with this it is also important to incorporate in the design of projects to include measures of outcomes that can be used in evaluating results.
102. The projects reviewed in this paper have been carefully selected, because not all projects carried out have successful results, thus as much as possible those that have good results, or those projects or programmes that have innovative approaches are sited.
103. The most tangible results are reported in the area of health related services. Even though there are still many gaps to be filled, many of the best practices shown have helped many of the disadvantaged in several countries. The lessons to be Ieamt from this paper is that to there are many on-going projects in various fields, that countries in several African countries can learn from and even duplicate the same projects in their own counties.
Government policies and actions, it must be noted, it must be noted, are detrimental in ensuring equitable distribution of benefits to the poor and vulnerable in all sectors.
104. It is recommended that readers can leam from the examples sited in this report, and also benefit from the annex provided to choose from or learn about projects in any particular area or sector.
