STRENGTHENING AFRICAN HEALTH SYSTEMS

THE CONTRIBUTION OF DOCTORS WITH AFRICA CUAMMTO THE REALIZATION OF THE UNIVERSAL RIGHT TOHEALTH WITHIN THE MILLENNIUM AGENDA

DOCTORS WITH AFRICA CUAMM

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viaSanFrancesco12635121Padova Italy

t. 049.8751279f. 049.8754738

cuamm@cuamm.orgwww.doctorswithafrica.org su

pplementon.2aCuammSolidarietà6/2007-PosteItalianeSpA

-SpedizioneinA.P.-D.L.353/2003(conv.inL.27/02/2004n°46)art.1comma2-DCBPadova-“TaxePerçue”“TassaRiscossa”

Doctors with Africa Cuamm reaffirms its commitmentto the mission, principles, and values, that, for morethan fifty years, inspired its work, in Italy and in Africa.To ensure the effectiveness of our work, in 2006 westarted a complex process of analysis of the global en-vironment and of our programs, activities, managerialprocedures and external relations.This fascinating but difficult process lasted more thana year.All our personnel, the organization’s members, sup-porting groups, other individuals sharing our passionfor human rights and involved in promoting the univer-sal right to health, participated and contributed.The Strategic Plan 2008-2015, approved by the Ad-ministration Board on October 1st 2007, is the result ofthis process.It embraces the spirit and adopts the timeframe of theMillennium Agenda, with its milestones in fighting themost repugnant forms of poverty, such as the pre-ventable deaths, every year, of more than 10,000,000children and 500,000 pregnant women and the rav-ages of endemic and epidemic diseases like HIV/AIDS,Malaria and Tuberculosis.Our mission won’t be accomplished by 2015. The Mil-lennium Development Goals (MDGs) represent an im-portant, but still intermediate, goal in the long and diffi-cult path towards a global development based onuniversal human rights.Furthermore, the gains in health so far achieved inAfrica are still far from the objectives internationallyagreed. Without rapid and significant changes in fund-ing levels and modalities, in internal policies and inter-national relations, MDGS will not be achieved in Africa.This Strategic Plan goes through the fundamentalsteps of our history and acknowledges the constantstruggle to be faithful to our mission and our founders’spirit in a rapidly changing environment.Our history reveals ability of seeing things in advanceand coming up with innovations. This makes us confi-dent in facing today’s challenges.

> A first substantial innovation of this Plan is the shiftfrom a project approach (mainly due to financing op-portunities) to a country-based strategic planning.

> Other important issues dealt with are the need for anew managerial culture and the search for a greatercoherence between planning, advocacy, lobbyingand fund raising.

> All our planning, managerial, and communication ac-tivities will be based on human rights and scientificevidence and oriented towards the achievement ofmeasurable results.

> Our fundamental strategic objective is the gradualtransformation of our organization, through a deepchange in our being, doing and knowing, in a centerof reference for the strengthening of African healthsystems.

> Our traditional activities of support to district healthsystems and training will be strengthened by the ter-ritorial concentration of our interventions focused onthe four main components of health systems: gover-nance, management, equitable financing, and tech-nical know how.

> Community and family health activities will be an in-tegral part of our programs from the initial phase ofdata collection throughout the monitoring and evalu-ation process. They will also be part of our opera-tional research, an important component of all ourprograms, as already stipulated in our 2005 Guide-lines.

> Doctors with Africa Cuamm is committed to supportNational Health Systems and contribute to their eq-uity, quality, universal accessibility, and sustainability,all needed to ensure the universal right to health.

> Gender equality, economic opportunities, education,food security, environmental hygiene and access tosafe water are non-medical factors with a strong im-pact on the right to health.

> This Plan envisages strategic partnerships with orga-nizations sharing our values and competent in allthese health-related fields.

Summary

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> Strategic partnerships and alliances will not be limit-ed to field activities. They will include lobby, advoca-cy and management activities requiring economiesof scale.

> In line with our choice of “being with Africa” we willexpand our presence, from the current seven, tothree more countries in West Africa.

> In addition, given the huge challenges posed byrapid urbanization, we will start working with poorcommunities in urban slums

> The strengthening and expansion of our activities re-quire improved communication and fund raisingstrategies together with improved management ofhuman resources.

> Three-year operational plans and annual work-plansfor headquarters and country offices will be basedon this Strategic Plan.

Our objectives are ambitious. But they are consistentwith our mission and history and respond to today’sopportunities and challenges.This Plan is a very demanding tool requiring unity of ef-fort and great collaboration.The worthiness of our cause inspires and encourageus.We would like to dedicate this plan to all the individu-als, women and men, who spent their life faithful to ourvalues and who will continue to inspire the work ofDoctors with Africa Cuamm.

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INTRODUCTION

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In September 2000, the Governments and Heads ofState of 189 countries committed themselves toachieve, by 2015, an ambitious human developmentprogram1 articulated in eight ambitious objectives(Millennium Development Goals, MDGs)2.These objectives are the milestones guiding the col-lective effort against the extreme manifestations ofpoverty.In addition to the financial resources promised bygovernments, those provided by Foundations and bigprivate donors are more and more consistent.Many philanthropic Foundations have budgets biggerthan those of recipient countries, many United Na-tions (UN) Agencies and some donor countries.There is a vast consensus, among international pub-lic health experts, on a set of preventive and curativemeasures that, if universally available, could rapidlyreduce maternal and child morbidity and mortalityamong the poor and stop the epidemics that festeron poverty and lead to it.In spite of their increase in recent years, the funds forhealth cooperation, together with those invested inhealth by recipient countries, are still far below thelevel considered sufficient to guarantee universal ac-cess to essential health services to all.In addition, most funds coming from institutionaldonors and big private donors, go to vertical pro-grams, focused on specific diseases.This further weakens the fragile health systems ofpoor countries, with negative consequences for themost vulnerable groups of the population.For these reasons (according to the most authorita-tive international observers) the health related MDGswill not be achieved, by many Sub-Saharan Africancountries, at the current levels of investment and withthe current policies.

Doctors with Africa Cuamm strongly requests thatthe investments in health in Sub-Saharan Africancountries be consistent with the objectives agreed inthe Millennium Agenda and that the strategies toachieve them be reviewed and reoriented towardsstrengthening health systems and investing in humanresources.This has always been the strategy of choice of Doc-tors with Africa Cuamm: “systemic” interventions onHealth Units and their territory with special emphasison primary care and human resource training.

In this document, we state our vision, values, andstrategies, and our contribution to the world move-ment in support of the Millennium DevelopmentAgenda in terms of action and reflection.To adequately face future challenges and opportuni-ties, Doctors with Africa Cuamm intends to promoteand carry out a process of internal and externalchanges.This will strengthen our identity and commitment toour values and mission.To achieve our goals, we are committed to:1. better specify the nature of our programs and

activities with greater attention to results moni-toring and evaluation and to operational re-search;

2. rationalize our organizational structures to in-crease their efficiency;

3. become a learning organization able of gener-ating and spreading new knowledge and usingthe knowledge produced by others;

4. adopt an organizational culture oriented to-wards result-based management;

5. build strategic partnerships in the framework ofthe Millennium Development Goals.

Introduction

2 The Millennium Development Goals are: eradicate extreme poverty andhunger, achieve universal primary education, promote gender equalityand empower women, reduce children mortality, improve maternal health,combat HIV/AIDS, malaria and other diseases, ensure environmentalsustainability, develop a global partnership for development.

1 UN Millennium Declaration, September 18th 2000, New York.

Values, mission, strategies

The political, cultural, social, economic and techno-logical events of the last 20 years deeply changed theinternational context.More and more subjects, with different characteristics,objectives, policies, and operation modalities, appearand interact in this rapidly changing and complex sce-nario.The world is changing rapidly and so is the so called“aid system”.The new world order, created by the fall of the Berlinwall and the disintegration of the Soviet Union is stilldominated by the economic and political power of theUnited States.The recent enlargement of the European Union (UE) to27 countries has increased the international weight ofthis relatively new actor. New Asian powers, China andIndia in primis, are emerging thanks to an economicgrowth close to 10% a year. They are extending theirspheres of influence in Africa with the aim, among oth-ers, of accessing energy sources and raw materials.In this new international equilibrium, the concept ofsecurity has also changed. The attack to the TwinTowers, on September 11th 2001, has exacerbatedthe difficult cohabitation of different cultures and reli-gions and brought the problems of terrorism and se-curity to the core of international relations.Globalization, accelerated trade exchanges and thecirculation of knowledge, facilitate scientific and tech-nologic progress.Globalization is still a very asymmetric process.When it comes to benefits and risks, it works well forsome and badly for others.A clear example comes from pharmaceutical re-search: of the 1,223 new products developed be-tween 1975 and 1996, only 11 relate to diseases af-fecting the poor.International migration is unstoppable. It is not just amatter of brain drain. Huge numbers of people movein search of a better life. About 200 million migrants,half of them moving within poor countries, send home

remittances estimated at more than twice the value ofthe Official Development Aid (ODA).The speed and depth of change also reached rural ar-eas, even in the poorest countries.Human development and economic indicators showthat changes have not always led to improvements inthe quality of life and in the health status of the poor.The following few data, from the World Health Report2006, published by the World Health Organization(WHO), are significant.Sub-Saharan Africa has about 10% of the world pop-ulation and 24% of the global disease burden; it hasabout 2.8% of the health care manpower and ac-counts for about 1% of the world health expenditure.In 1985, 16% of the world’s poor lived in Africa, in1998, 31%.It is not surprising that the average life expectancy inAfrica is 47 years (it was 45 in 1970). Every year273,000 African women die during pregnancy, deliveryor puerperium and 3,500,000 African children die fromeasily preventable and curable diseases like Tubercu-losis, malaria, acute respiratory infections and diar-rhea. Sub-Saharan Africa also has the highest numberof people infected with HIV and dying from AIDS.African health systems, weak and ineffective, operatewithin state structures equally weak and ineffective. Inextremely poor countries, highly vulnerable to naturaldisasters, they lack the resources to ensure universalaccess to quality services, routinely available in otherareas of the world.Health expenditure in rich countries is about US$2,000 per person per year, while in Sub-Saharancountries is about US$ 37 per person per year (but inhalf of them is less than US$ 15 per person per year).This is insufficient to provide basic services to thewhole population. In addition, it is only partly coveredby governments and donors. The rest – in increasingproportions – is directly paid by citizens.In Burkina Faso, Burundi, Ethiopia, Nigeria, Sudan,and Uganda more than two thirds of health expendi-

1. Context analysis

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ture is paid by users. This is only one of the effects of“structural adjustment” programs imposed by theWorld Bank and the International Monetary Fund topoor and indebted countries, forcing them to drasti-cally cut public spending, including education andhealth.The effects of these policies are clear. Health systemshave been turned into an uncontrolled and chaoticmarket. Drug shops mushroomed in the absence ofregulation and controls: inadequate treatments, un-wanted side effects and decreasing effectiveness ofdrugs are unavoidable consequences.User fees are the most common source of health fi-nancing in Africa. They are the most inequitable formof payment for health services, since:> the poor and the sick, who are in greatest need, are

those who pay more, in proportion with their means;> the poor become poorer, as they are forced, by cat-

astrophic health events, to sell the little they have(like domestic animals and land) or to forego some-thing essential like their children’s education.

Equitable financing of health systems and accessibili-ty of services are among the main challenges facedby those involved in public health, development andhuman rights.WHO states that the fundamental tasks of health sys-tems are improving population’s health status byguaranteeing universal access to services through fairfinancing. This means that “the cost to every family offinancing a health system must be distributed accord-ing to how much it can pay, and not on the basis ofrisk disease; a fair financial system must protect every-body from a financial point of view” (World Health Re-port 2000).To redress the current process of economic globaliza-tion, making the rich richer and the poor poorer, astrong and organized response leading to the “global-ization of solidarity” is needed.Health systems of poor countries have serious prob-lems linked to human resources and suffer from an in-creasing migration of qualified health personnel fromrural to urban areas, from the public to the privatesector and to foreign countries.Their Health Management Information Systems(HMIS) supply few data, incomplete, late and oftenunreliable. The absence of functioning vital statisticsregistration makes things worse.Over the years, international aid has given differentanswers to the needs of African health systems andAfrican countries.

The international aid system engaged in fightingpoverty and promoting human development, hasbecome more and more a complex. In the ’40s, bi-lateral donors were less than a dozen. Today theyare more than 50. There are more than 15 UNAgencies acting as donors as well as implementers,the financial institutions born from the post-waragreements of Bretton Woods (World Bank, Interna-tional Monetary Fund), at least 40 bilateral coopera-tion agencies (many from the 22 DAC3 countries),the European Union, about 20 Global Health Initia-tives (such as the Global Fund against HIV/AIDS,TB and malaria, and PEPFAR – the President’sEmergency Plan for AIDS Relief), regional and na-tional initiatives (such as NEPAD – New Partnershipfor Africa’s development, UK Commission forAfrica, Poverty Reduction Policy), philanthropicfoundations (Bill and Melinda’s Gates, Clinton’s,Rockefeller’s) and a large number of NGOs, big andsmall, with very different ethics, styles, profession-alism, and efficiency.To increase the complexity of the system, donorschoose different approaches, financing specific pro-jects, supporting national budgets or specific sec-tors (health, education, transport, etc.).Often, the official acceptance of internationallyagreed principles of “good donorship” is contradict-ed by macro-economic policies negatively affectingpoor countries.Inefficiency and mismanagement of aid make thingsworse.The European Union (EU) is the most important actorin development because of its contribution to policyformulation and because of the amount of funds itprovides.Beside the European Union’s, each member statehas its own bilateral development policy.Italy’s cooperation is of marginal importance and in-strumental to her foreign policy. In 2006, with 0.20%of GDP allocated to development aid, Italy was atthe 19th place out of 22 DAC countries.The Italian Parliament is currently discussing a bill ona new cooperation policy, including the establish-ment of a Development Aid Agency.4

For the first time in history, the fight against poverty,meaning exclusion and marginalization, not only fi-nancial deprivation, is the official common goal of allnations.Governments promised to invest resources, under-take reforms, and measure progress to achieve theMDGs by 2015.

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3 Development Aid Committee - OECD (Organization for Cooperation andEconomic Development).

4 On April 5, 2007 the Cabinet approved a bill reforming the Law n. 49,1987, regulating Italian cooperation with developing countries.

2.THEHISTORY

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2.1 FROM THE ORIGINS TO THE YEAR 2000Doctors with Africa Cuamm was born 57 years agostarting its activities in Padova in 1950, 21 years be-fore the first Italian law on development cooperation,approved in 1971. It witnessed all the national andinternational social, political and religious, events ofthe second half of the XX Century.In particular, the decolonization and independenceprocesses of African countries, the Second VaticanCouncil, the movement that led to the Alma Ata Dec-laration had a direct impact on the organization’sstrategies, choices, and style. While remaining faith-ful to its founding principles, Doctors with AfricaCuamm evolved and changed.Its long presence in African Countries, sometimes indifficult and critical situations, taught the organiza-tion how to adapt to local situations, to understandand interact, credibly, with populations and authori-ties.At the same time the organization closely followedand analyzed events and developments in rich coun-tries to understand and interprete them for the bene-fit of the poor.Inspired by the Evangelical exhortation “euntes cu-rate infirmos”, (go and cure the ill) Doctors withAfrica Cuamm started its activity as a University Col-lege initiated by Professor Francesco Canova, a pio-neering missionary doctor and Monsignor GirolamoBortignon, then Bishop of Padova.The College was established to host and train med-ical students, from Italy and from abroad, intendingto spend a period of their professional life in mis-sionary hospitals in poor countries.In the ’50s and ’60s, Doctors with Africa Cuammstarted to recruit and send medical doctors to mis-sionary hospitals in different countries, still undercolonial rule, in Africa, Asia, Latin America and theMiddle East.Later on, as cooperation mechanisms became morearticulated and complex, the profile of the “Cuamm

doctor” went through deep changes. From the firstcharismatic doctors working in mission hospitals,great clinicians and teachers, like Francesco Cano-va, Anacleto Dal Lago and Giovanni Baruffa, to to-day’s doctors trained in health policy and manage-ment.From the end of the ’60s through the ’70s, the orga-nization went through a deep, critical analysis of itsidentity, goals, and activities, and of the role of a“mission doctor”.In 1968, at the congress of Nyeri in Kenya, it recog-nized the need to give mission hospitals a clearerand more integrated role within National Health Sys-tems, an efficient and clear administration. It alsosaw the opportunity of adding basic care and pre-vention to the hospital activities.Activities were no longer left to individual initiatives.They became part of “Projects” formulated andagreed with local communities and authorities topromote the development of the health system andimprove the population health status.This was a fundamental shift from an approachbased to mere assistance to one geared towardslong term development.In the following years the organization analyzed the is-sues linked to closer links with local health systemsand to the accessibility of mission hospitals to the poorand disadvantaged, especially women and children.A more structured discussion developed on cooper-ation projects, objectives to be achieved, resourcesneeded to achieve them.On this issue, Prof. Canova had the far sighted ideaof creating, within the Italian Church, a “Foundationfor Mission Hospitals” (Opera Ospedali Missionari),with the aim of financing these institutions. The ideawas presented to Propaganda Fide in 1958, unfortu-nately, without success.In 1972 Doctors with Africa Cuamm was recognizedby the Italian Ministry of Foreign Affairs as a qualifiedorganization for cooperation with developing countries.

2. The history ofDoctors with Africa Cuamm

This recognition allowed access to governmentfunds and implement programs supported by bilater-al agreements between the Italian government andcountries like Mozambique, Tanzania and Uganda.Doctors with Africa Cuamm decided to work moreclosely with the governments of the countries whereit was working, on the basis of “Country Programs”.This decision did not imply abandoning mission in-stitutions. On the contrary, it contributed to their in-tegration in the National Health Plans, avoiding therisk of their isolation and ensuring wider availabilityand accessibility of services for the whole of the lo-cal populations.The organization’s leading idea was, and still is, “de-velopment” in its widest meaning and various as-pects: overall, equitable development of the country,support to the poorest areas, training of local cadres,promotion of basic and integrated health services.In 1975, based on the experience gained, Doctorswith Africa Cuamm developed a milestone documentin its history: “Intervention Criteria in Health Cooper-ation”.This document contains the principles that inspiredthe Alma Ata Declaration, issued three years later.The ideas shaped at the end of the ’70s are still fun-damental for the understanding of health and theformulation of health policies.After a long period of experiences, analyses and re-flections, some basic principles were stated and ac-cepted. They confirmed health as a universal andfundamental human right, indicated as a governmentresponsibility ensuring equitable and accessiblehealth services, underlined the importance of pre-vention and primary care, and identified poverty asthe main cause of morbidity and mortality.In the following years, the number and size of inter-ventions of Doctors with Africa Cuamm, mainly fund-ed by the Italian Ministry of Foreign Affairs, increasedsteadily.Between the second half of the ’80s and the begin-ning of the ’90s, the Organization’s activities shrankbecause of the crisis of the Italian Cooperation, witha drastic reduction of public funds for developmentaid, and increasing problems in developing coun-tries, under the grip of structural adjustment policiesthat particularly hit the health sector.It became necessary to review objectives, strategies,and project sustainability. The search for newsources of funds became a crucial issue.The Organization increased its financing flows fromthe private sector and from institutions like the Euro-

pean Union and the Italian Episcopal Conference,more and more engaged in the fight against poverty.In this period of financial hardships, the Board ofGovernors decided to invest more in the “image” ofthe Organization and in its external relations.It was decided to add “Doctors with Africa” to theoriginal name Cuamm and to create a new logo. In2000, the NGO celebrated its Fiftieth anniversary.It was a symbolic and important chance to reflectand to assess activities, organizational structuresand management.The very low level of the Italian government fundingfor development aid (it reached its lowest of 0.13%of GDP in 2002), the complexity of international co-operation mechanisms, the need for a rigorous train-ing and selection of personnel, require greater in-volvement in research, better planning, increasedawareness and systematic documentation.

2.2 GUIDELINES. THE PATH FROM 2000 TO THEPRESENT2.2.1 The 2000 Policy DocumentDoctors with Africa Cuamm, over more than 50years, established a long-term presence and stronglinks with several countries in Sub-Saharan Africaworking in small dispensaries/maternity units, dioce-san and government hospitals, at district and region-al levels, and in universities.A Policy Document published in 2000, identified thepriorities for the organization: health systems acces-sibility and equitable financing, public-private part-nership, training of Human Resources for Health(HRH), fight against major diseases like AIDS, Tuber-culosis and Malaria.To promote greater accessibility and equitable fi-nancing of health systems the Organization main ac-tions were twofold:> to guarantee long-term support to hospitals and

public health services by contributing to cover re-current costs and supporting the development oflocal human resources.

> To promote equitable financing mechanisms basedon solidarity and risk pooling.

In addition, the Document suggested the promotionof contracting-out arrangements whereby PrivateNot For Profit (PNFP) health units receive govern-ment funds to carry out public health services andare accountable for activities and results.This form of collaboration ensures a greater utilization

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of PNFP units while maintaining their nature of privateservices of public interest by keeping user fees low.Another important point is the development of localhuman resources with high levels of technical andmanagerial competencies needed to strengthenhealth systems and increase their sustainability.The following operational guidelines stem from theseideas.

2.2.2 The 2005 Planning guidelinesThe 2005 “Planning Guidelines” were meant to helpthe transformation into activities of the priorities indi-cated in the Policy Document. The first priority wasto establish, in each country, a strong and lasting“conceptual framework” for our interventions. Thisallowed and will allow the structured introductionand implementation of integrated projects (training,Mother and Child Health -MCH-, disability, etc.) orvertical interventions (HIV/AIDS, Tuberculosis, Malar-ia, etc.).Doctors with Africa Cuamm is not an emergency or-ganization. Along the years, however, many of theareas where it worked were ravaged by war or otherhumanitarian crises. In these situations the organiza-tion maintained its presence, relieved the suffering ofpeople in the acute phase and started reconstructionand development programs as soon as the situationallowed it.Special emphasis is placed on monitoring and evalu-ation criteria for measuring equity, accessibility, ef-fectiveness, efficiency and quality.

This sort of documentation is essential not only forplanning and control but, also, for communicationand relations with donors.

2.2.3 A few dataSo far, Doctors with Africa Cuamm:> hosted and trained 270 students from 35 countries

of the southern hemisphere;> sent to developing countries 1,250 doctors and

300 nurses and health technicians;> implemented 150 programs with the support of

Italian Ministry of Foreign Affairs, the EuropeanUnion, and other International Agencies;

> worked in 34 countries in Asia, Latin America, theMiddle East and, especially, Africa

Currently, Doctors with Africa Cuamm:> is present in Angola, Ethiopia, Kenya, Mozam-

bique, Tanzania, Sudan and Uganda;> employs 92 professionals of which: 61 doctors, 15

paramedics, 16 technicians and administrators;> implements 56 health cooperation projects and

about 100 micro-realizations supporting:- 17 hospitals;- 25 districts (with activities ranging from training

to general public health, mother and child heath,control HIV/AIDS, TB, and Malaria);

- 3 physiotherapy centers;- 4 nursing schools;- 3 Universities (in Ethiopia, Mozambique and

Uganda).

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3.1 THE MISSIONThe mission of Doctors with Africa Cuamm’s stemsfrom the evangelical exhortation ”euntes curate infir-mos” adopted by the founder Francesco Canova in1950. With time, it was articulated in different waysin successive editions of the Organization’s Statute,in 1971, 1984 and 2003.

In 2006, the mission has been phrased as follows:Doctors with Africa Cuamm was the first NGOworking in the international health field to be recog-nized in Italy and is the largest Italian organizationfor the promotion and protection of health in Africa.It works with a long-term developmental per-spective.To this end, in Italy and in Africa, it is engaged intraining, research, dissemination of scientificknowledge, and ensuring the universal fulfillmentof the fundamental human right to health.

This mission is translated in two fundamental objec-tives:1. to improve the health status of African people.2. To promote a positive attitude and solidarity

towards Africa.

The principle inspiring our action is that health is not aconsumer good but a universal human right, hence,the access to health services cannot be a privilege.Equally important is the second objective: the duty ofpromoting, in western institutions and public opinion,interest and commitment to a better future for Africa.

3.2 VALUESThe reference values of the organization’s mission,its activities are:> christian inspiration and link to the Church: the

reference to Christian values and to the Gospel isexplicit.

> Commitment to Africa: the organization worksexclusively in Africa, with African people and maxi-mizes the value of local resources. The expression“with Africa” underlines the ideas of sharing, par-ticipation, exchange, and common effort. We workin a limited number of countries where we empha-size not only the needs and the problems but, also,local values and potentials, with a long-term devel-opmental perspective.

> Experience: Doctors with Africa Cuamm is proudof more than 50 years of uninterrupted work withdeveloping countries.

> Specific and exclusive competence in the healthfield.

> Discretion: we think that those in need and notthose who help deserve visibility and public atten-tion.

Our guiding principles engage us, in the spirit of theGospel, to work for international solidarity, justiceand peace, with a style characterized by sharing andbased on respect and dialogue.In line with our principles, we employ qualified andstrongly motivated people, able of establishing a truerelationship of collaboration and dialogue.The spirit of the Gospel expresses the core of ourmission: to help the poorest by providing quality ser-vices accessible to everybody, with discretion andhumility.Doctors with Africa Cuamm also employs non-Christians as long as they agree on its interventioncriteria and share values like dialogue, cooperation,voluntary service, friendship among peoples, de-fense of human rights, respect for life, personalsacrifice, commitment for the poor, and spirit ofservice.

3. Mission and values

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Our commitment to health, based on the evangelicalexhortation to cure the ill, was strengthened, duringthe last decades, by the growing awareness abouthuman rights.This commitment is also engaged by the challengeof the Millennium Agenda that makes health one ofthe pillars in the fight against poverty.A society based on individual freedom and collectiveresponsibility, a model of economic developmentproviding for the protection of the weak and of theenvironment are part of a virtuous circle where edu-cation and health are essential elements for individ-ual and global development.In today’s globalized world inequalities in health,measured by life expectancy, maternal and childmortality, are morally, economically, and politicallyunacceptable.The debate on the feasibility of improving the healthstatus in poor countries, before they achieved highereconomic levels, takes away momentum from goingto scale with a mix of medical technologies, relative-ly simple and able of saving millions of people if de-livered not to single individuals but to entire popula-tions.The majority of the 500,000 mothers dying everyyear would survive if correctly assisted by a trainedmidwife during pregnancy and delivery and if, incase of complications, essential obstetric care wereavailable.More than 10 million children die every year mostlyof preventable and curable diseases such as diar-rhea, respiratory infections, and malaria. HIV/AIDS isresponsible for less than 5% of children’s deaths.Most of the times, malnutrition, a contributing factorin half of children’s deaths, is not due to lack of foodbut to repeated infections and inadequate nutritionalpractices.Doctors with Africa Cuamm is not interested in asterile debate on the primacy of economy versus theneed to invest in health and education.

We prefer acting at two levels:> in Africa, we are determined to prove that experi-

ence, knowledge, and the tools to improve thehealth of the poor in a rapid, sustainable and mea-surable way, are available.

> At the international level, we want to promote theidea that security for the rich will be possible only ifthere is development for the poor. Peace and jus-tice are inseparable, universal, and achievable.

For the first time in history, the fight against povertyhas officially become the common goal of all nationsthat promised to invest resources, introduce reforms,measure and report progress and achieve the eightMDGs by 2015.Particularly relevant to Doctors with Africa Cuammare the MDGs related to malnutrition, maternal andchild mortality, and disease control.Our focus on public health goals doesn’t mean thatwe neglect the other ones. Fighting poverty and dis-crimination against women, promoting a more effi-cient and effective use of financial resources for de-velopment, pursuing universal education, are allessential elements for the achievement of betterhealth.Most public health experts agree on the effectivepreventive and curative technologies that, if univer-sally available and correctly utilized, will improve theepidemiological profile and the life expectancy of thepoorest populations.Furthermore, we know that the cost of a lifesavinghealth services package is around US$ 38 per per-son per year. This means that rich countries shouldinvest around US$ 20 per person per year for poorcountries until their national resources will enablethem to cover these costs.Although not a negligible amount of money, this iscertainly sustainable considering that the worldeconomy continues to generate wealth at rates andlevels never seen before. In addition, improvementsin health are, probably, the quickest and most con-

4. Vision for the future:Doctors with Africa Cuamm andthe Millennium Development Goals

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venient way out of the poverty trap in which billionsof people are caught.

4.1. THE ROLE OF DOCTORS WITH AFRICA CUAMMIN AFRICA

For more than fifty years Doctors with Africa Cuammworked with hospitals. It rehabilitated, equipped, andmanaged them to improve quality, efficiency, and ac-cessibility of their services. It supported curative,preventive, and rehabilitative services and trainedhealth professionals in Italy and in Africa. Recently, itengaged in activities financed by the Global Fundagainst Tuberculosis, AIDS and Malaria.In the coming years, we intend to use our experienceto prove that, by delivering an adequate mix of effec-tive services at hospital, peripheral unit, and commu-nity/family levels, it is possible to achieve and mea-sure a positive impact on people’s health.

4.2. HOSPITALS4.2.1. Technical componentEfficient, equitable and accessible hospitals are anessential element of any health system. We are com-mitted to strengthen the hospital technical compo-nents, particularly those services that cannot be de-livered at lower levels and have a direct impact onpublic health. The focus will be on maternal andchild health, disability treatment, promotive and pre-ventive activities.The correct and timely execution of caesarean sec-tions and the adequate treatment of HIV/AIDS areimportant indicators of a hospital technical ability tocarry out its institutional functions.Many efforts to reduce maternal mortality failed be-cause of inadequate investments in hospitals. Hospi-tals must, also, be able of preventing and correctingvescico-vaginal fistulae, tragic consequences of lackof assistance during delivery and condemning thou-sands of women to total marginalization. Thesepathologies, together with female genital mutilations,are dramatic examples of the unacceptable discrimi-nation against women and young girls.

4.2.2. Hospital managementEfficient and effective hospital management is one ofour main objectives, since managerial incompetencecompromises service quality and accessibility.Human and financial resources, equipment, build-ings, drugs, and any other input in health serviceproduction must be used efficiently and effectively tomaximize results and contain costs.

The hospital, district or regional, is comparable to asmall to medium size business enterprise and shouldbe managed by a professional manager. This profes-sional profile still very rare in the countries where wework.Support, development, and training of hospital man-agers will be one of our priorities in the forthcomingyears.

4.2.3. Hospital financingHospital services are more expensive than thoseproduced at lower level health units. They should belimited to those that cannot be provided morecheaply, at lower levels. The majority of African hos-pitals is underfunded, unable to deliver quality ser-vices and underutilized.This vicious circle is made worse by the introductionof user fees that make the hospital even less acces-sible and inequitable, as they affect the poor whenthey are more in need.The Global Health Initiatives (GHI) often exacerbateinequities introducing perverse incentives and distor-tions. Drugs for specific pathologies, provided byglobal initiatives, are often free while other equally ormore important therapies are available only in privatedrugstores at high prices.It is important to document these distortions andpropose corrective actions.It is necessary to promote and support new and eq-uitable health financing mechanisms, based on soli-darity and risk pooling, like health insurance plans,community financing schemes, etc.The institution of a global fund or a global insuranceto finance public and PNFP health units are impor-tant initiatives deserving to be developed and real-ized.In the short term, Doctors with Africa Cuamm willcooperate with existing insurance schemes coveringthe costs of catastrophic health events.

4.2.4. The Hospital Executive BoardLike any enterprise, the hospital needs a competentand well functioning governing body. This must en-sure that the owner, staff, and patients’ interestsare kept in the right balance and harmoniously re-spected.Hospital good governance is often overlooked. Con-sequently, serious distortions occur, especially in therespect of patient’s rights. Patients are denied thepossibility to influence strategic choices relevant totheir life.

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Doctors with Africa Cuamm believes that good gov-ernance requires the active participation of people’srepresentatives in supervising institutions of public in-terest and wants to invest in building the capacity ofhospital governing boards.The above elements are essential for hospitals to fulfilltheir role. They require, financial investments and hu-man resources, effort in, monitoring, evaluation, analy-sis and research.Maternal mortality ratio is, arguably, the most powerfulindicator of the effectiveness of a health system and, inparticular, of the ability of hospitals to play their publichealth role.

4.3. PERIPHERAL HEALTH UNITSPeripheral units, supplying a mix of quality serviceswithin a well identified geographical area, with preciseresponsibilities and measurable objectives, are thesecond important element of health systems.In many peripheral units services are poor for severalreasons: insufficient qualified staff, lack of drugs, littlesupervision.The four basic elements of good performance (gover-nance, management, financing, and technical skills)need the support of a district referral institution.The majority of interventions to prevent or treat themost common causes of morbidity and mortality canbe performed, at low cost, by peripheral health unitsclose to the population.For this reason Doctors with Africa Cuamm considersa priority to support district networks of peripheralhealth units.Vaccination coverage and the number of outpatientsvisits per person per year are good indicators of thefunctioning of peripheral units.In the forthcoming years we want to measure the trendin infant and child mortality. This should provide strongmotivation for a renewed effort to revitalize peripheralhealth networks and constitute an indicator of the de-gree of success of our interventions.

4.4 FAMILIESFamilies, within their communities and with their cul-ture, are the main actors and the best allies in thestruggle for better health.Poverty is heavily influences lifestyles and health sta-tus of individuals and families.It is essential to provide families with the resourcesneeded to adopt lifestyles conducive for better health,like hands washing, drinking safe water, using cleantoilets, breastfeeding, not smoking, drinking alcohol

with moderation, avoiding risky sexual behavior, sleep-ing under a treated mosquito net. All this affects indi-vidual and public health.Health systems alone won’t be able to achieve theMDGs. What is also needed is a significant invest-ments at family and community levels to promotehealthy lifestyles and to provide safe water, soap, treat-ed mosquito nets, DDT for internal residual spraying,and other goods needed for a healthy life.Efficient and reliable births and deaths registration isanother important public good. In many poor countriesthis does not exist or is unreliable. It should be quicklyintroduced so that everybody, authorities and citizens,can have a picture of the current situation, assess thesuccess of health initiatives and act consequently.One of the main obstacles to develop a strong initiativesupporting families is the lack of relevant experienceson a large scale and the lack of personnel trained forsuch a task.This challenge requires a new way of approaching lo-cal communities: a “rights based approach” with inno-vative measures aimed at enabling and empoweringfamilies to fully develop their potentialities.In particular, we must train and recruit semi-profes-sional operators not to take away workers from hospi-tals.The poor and disadvantaged, particularly women, chil-dren, and people with disabilities are our prioritygroups. This choice, at the foundations of the organi-zation, is fully in line the objectives of the MillenniumAgenda.

4.5 DOCTORS WITH AFRICA CUAMMAND HEALTH POLICIES

Health policies are often influenced by factors not re-lated to the needs and rights of women, children, andpeople with disabilities.With the advent of rich foundations and global funds,policy making became even more complex because ofthe fear of losing financial support, even when fundingconditions or country’s absorption capacities are notideal.There is often contradiction between the official com-mitment to achieve the MDGs and the adoption ofmacro-economic policies enforcing budget ceilingsfor social sectors. These ceilings are always lowerthan those needed to supply the health services re-quired to improve the health status of the poor. Doc-tors with Africa Cuamm wants to participate in thisimportant debate involving donors, internationalagencies and African governments.

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Our experience and knowledge, our values, and ourcommitment require that we participate in the policymaking process at all levels.Our fieldwork provides valuable insights on success-es and failures.To make the best use of our experiences, we mustanalyze them and share our knowledge with policymakers, nationally and internationally, through wide-ranging lobby and advocacy.Our participation in alliances and partnerships at na-tional, European, and global levels is of the utmostimportance.

4.6 THE CHALLENGE OF HUMAN RESOURCESFOR HEALTH (HRH)

We are fully aware of the complexities and obstaclesbetween our vision and its realization. The scarcity ofwell trained HRH, their maldistribution and misuse,are an extremely serious problem requiring urgent at-tention.Maldistribution of HRH, concentrated in urban areasand in hospitals is well known and documented.In recent years this problem has been made worseby the migration of trained health professionals frompoor countries to less poor countries, and then toEurope and North America.Among those who remain, many combine an oftensymbolic presence in the public sector with a full-time and lucrative job in the private one.Many of the best professionals are employed by in-ternational cooperation agencies and NGOs. Todayeverybody expects allowances to carry out dutiesthat, even if part of their job, are performed withinspecific projects.Only meetings where sitting allowances are paid areattended.Many health workers spend a good part of theirworking time in training courses, not always relevantor effective, but financially attractive.All this negatively affects people needing health ser-vices and discredits health professionals.Doctors with Africa Cuamm has always been com-mitted to human resource development and intendsto work towards new and better human resourcesmanagement policies and programs.

4.7 NON-MEDICAL DETERMINANTS OF HEALTHDoctors with Africa Cuamm only works within thehealth sector.

When looking for a measurable impact of our activi-ties, we cannot ignore the fundamental importanceof other determinants of health that are outside thehealth sector.Therefore, we plan to establish programmatic al-liances with partners competent and experienced inother sectors, like:> water and sanitation;> agriculture, food security and nutrition;> micro-financing, income generating activities, and

social security schemes;> information, Education and Communication.The integration and synergy of activities in all thesesectors will allow the improvement of health indica-tors in the intervention areas.

4.8 THE APPROACH OF DOCTORS WITH AFRICACUAMM

The primary responsibility to guarantee the right tohealth to their citizens rests with the African Govern-ments and Civil Society, although supported by in-ternational solidarity.The proliferation of actors and the fragmentation ofactivities in the cooperation field (and especially inthe health sector) often overwhelm the fragile admin-istrative structures of recipient countries.In this complex scenario, Doctors with AfricaCuamm supports African National Health Systemsas a facilitator and, when needed, as a temporarysubstitute.We look at the sustainability of the interventionsneeded to achieve the MDGs at national, local andinternational level.It will be possible to scale down the donors’ contri-bution only when the economy of African countrieswill be able to meet the costs to provide universalquality health services.Doctors with Africa Cuamm, convinced that health isa fundamental human right, is committed to the uni-versal delivery of the package of interventionsknown to be effective for the achievement of thehealth related MDGs.Therefore, we will continue, with great flexibility, torehabilitate health units, supply equipment anddrugs, provide funds, train and provide human re-sources.All this, not as a series of stand alone projects, butwithin a clear frame to help African governments andcommunities to reach the health related MDGs.

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5.1 MAIN OBJECTIVEDoctors with Africa Cuamm intends to become areference center for the strengthening of Africanhealth systems.Today the main challenge is to provide evidence tothe international community that effective, efficientand accessible health systems are necessary toachieve significant health improvements in Africaand that it is right, urgent and strategically importantto work in this direction.

5.2 STRATEGIC OBJECTIVES IN ITALY ANDAFRICA

To achieve its main objective, Doctors with AfricaCuamm has to work in several interrelated direc-tions. Therefore it intends:

> to strengthen its identity inside and outside theorganization.We want to serve African people and our civil soci-ety with our approach based on the protection ofthe right to health as a fundamental pillar of devel-opment.In rich countries, we must stress that the experi-ence, the knowledge and the means to improve,rapidly and sustainably, the health status of thepoor are available and must be put to use.In this perspective, it is important to promote aware-ness and understanding of development and healthissues, inside and outside the organization.This requires knowledge, financial and human re-sources.

> To shape our program activities along the linesof the MDGs, especially those related to health,testing new approaches to improve the healthstatus of African people.In September 2000, 189 countries, rich and poor,industrialized and not, committed themselves toincrease resources, review policies and join in a

partnership to keep the promises of the MillenniumAgenda, by 2015.Doctors with Africa Cuamm wants to take up thischallenge with its own approach to African healthproblems, characterized by long term commitmentin collaboration and coordination with governmentand non government actors.The organization also wants to build partnershipsnationally and internationally, to create synergiesand expand the scope of its interventions.

> To become an internationally respected centerof knowledge, research, documentation andscientific dissemination on African health.We will increase our investment in monitoring,evaluation, operational research, documentationand dissemination of knowledge and understand-ing.

5.3 OPERATIONAL OBJECTIVESWe want to build on our experience to improveAfrican health systems in terms of, effectiveness, ef-ficiency and accessibility, and to provide high qualitytraining in Italy and Africa.This will prove that, with a comprehensive approach,providing a combination of services at hospital, pe-ripheral health units, community and family levels,African health systems can significantly contribute toimprove the population health status.To obtain measurable results, Doctors with AfricaCuamm wants to achieve the following operationalobjectives:

> to establish a long term presence with relevantprograms, in rural and urban areas, in at leastten African countries, by expanding its action toat least three West African countries.

> To build programmatic partnerships with otherNGOs and International Organizations for inte-

5. 2008-2015 Objectivesand strategic projects

grated programs in the fields of health care, ed-ucation, water and sanitation, food security,agriculture, and micro-credit, in at least threeAfrican countries, achieving a measurable healthimpact.

> To participate in building a national and interna-tional consensus, on the urgent need ofstrengthening African health systems in termsof effectiveness, efficiency, equity, and accessi-bility.

> To influence, through lobbying and strategic al-liances, policy decisions on international coop-eration, at the level of the European Union, theAfrican Union and the Italian government.5

> To strengthen our training activities by institutinga Master Course on African Health Systems incollaboration with leading academic institutions.

> To improve our organizational managementthrough modern, transparent, collaborative, andefficient procedures, to increase accountabilityat all levels to be awarded international qualitycertification.

> To make the transparent and professional man-agement of human resources the cornerstoneof our organization.

> To increase financial resources by at least 15%per year.

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5 Focusing on the creation modalities of a Cooperation Agency.

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Our objectives are analyzed considering the cross-cutting strategies needed for their achievement.Some of the concepts below will be further dis-cussed in the Section on “Sector Strategies”.

6.1 STRATEGIES TO STRENGTHEN OUR IDENTITYTo strengthen the organization’s identity, internallyand externally, for a deeper awareness of its inspir-ing values, we intend:> to enhance unity and coherence among the vari-

ous headquarters sections, with clear and sharedprocedures and a better and transparent circula-tion of information.

> To enhance unity and coherence of thought andaction between headquarters and country offices.

> To increase and improve our investments in humanresources at headquarters and in country offices.

> To enhance the involvement of volunteers, associ-ate members, supporting groups and all those whoparticipate in the life of the organization.

> To enhance our activities of public education infor-mation and communication on important Africanissues.

6.2 STRATEGIES TO ADVANCE OUR KNOWLEDGETo be a reference center of knowledge on develop-ment and health in Africa we want:> to adopt a knowledge management system ensur-

ing the continuous production, flow and fruition ofcritical analysis and understanding within the orga-nization at all levels, at headquarters and in coun-try offices.

> To adopt a result oriented culture based on contin-uous monitoring of our activities, critical analysis oftheir effectiveness and wide circulation and dis-cussion of the findings.

> To expand and improve our activities of opera-tional research ensuring wide circulation of find-ings through publications on health issues inAfrica.

> To work with universities, research centers, nation-al and international organizations, to produce andcirculate new knowledge.

> To become a reference center for scientific docu-mentation and dissemination.

> To promote greater attention on important Africandevelopment and health issues.

> To contribute to the awareness that improvinghealth in Africa means not only fulfilling a funda-mental human right of African people but, also,giving an important contribution to global secu-rity.

6.3 STRATEGIES TO ENHANCE OUR ACTIONDoctors with Africa Cuamm, to face today’s chal-lenges and contribute to the fulfillment of the Millen-nium Agenda, intends:

internally:> to match our spirit of service, solidarity and dedi-

cation with high professionalism and competence.> To employ professionals able of responding to the

new needs and challenges.> To establish a permanent pool of professionals giv-

ing to the organization continuity and spirit of inno-vation.

> To enhance our talent management with a carefulmix of young and experienced professionals.

> To introduce and systematically use sound sys-tems of performance management and careerdevelopment for all cadres of our personnel,African and Italian, at headquarters and in coun-try offices.

> To increase the number of our supporting mem-bers and groups at all levels of civil society.

externally:> to explore and test new initiatives to help families

and communities to promote and maintain goodhealth.

6. Crosscutting strategies

> To focus our attention on the most vulnerable anddisadvantaged groups: women, children and peo-ple with disabilities.

> To strengthen our integrated approach (hospitals,peripheral units, communities and families) demon-strating that effectiveness, quality and equity aremandatory and achievable.

> To strengthen hospitals and peripheral units’ man-agement, governance, and financing.

> To enhance integration and coordination be-tween government and Private Not For Profit in-stitutions.

> To become an active part of the health systems inthe countries where we work.

> To expand our presence to francophone Africancountries.

> To be an advocate, nationally and internationally, ofAfrica’s health interest and influence political deci-sions on development cooperation.

> To build partnerships with NGOs and internationalorganizations to implement integrated activities inthe fields of health, education, water and sanitation,agriculture, food security and nutrition, micro-credit,economic opportunities, social security schemes.

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Currently, Doctors with Africa Cuamm works in sev-en countries: Angola, Ethiopia, Kenya, Mozambique,Sudan, Tanzania, and Uganda.In some of these countries, the first projects startedat the end of the ’50s, often responding to requestsfrom local churches. Activities continued over theyears in the same countries, in the initial and in dif-ferent areas.The changes of the aid system and policies, coupledwith the rapid transformations of African countries,require clear entry as well as exit strategies whenstarting new activities or entering a new country.Being “with Africa” suggests the opportunity to ex-pand our attention to countries where we are not yetpresent.This may or may not lead to our presence in a “new”country. It may also be limited to studying and un-derstanding issues and situations in countries wherewe don’t work.This will give us a better overall understanding ofAfrica and will be a cultural enrichment.Furthermore, this knowledge will be useful if andwhen we decide to start working in new countries.

7.1 ENTRY CRITERIAOur overall goal, stemming from the evangelical ex-hortation “go and cure the ill” is the satisfaction ofthe universal right to health.Our main strategy is geared at the development ofeffective, equitable and efficient health systems.We will engage in acute emergencies, should theyoccur in countries where we work, applying the fol-lowing entry criteria for countries in transition.We will set up a database with continuously updatedeconomic, social and health data of different Africancountries. To do this, we will use the most reliableand internationally trusted sources.From this database, we will get the informationneeded when pondering the decision intervene in acountry.

Entry criteria will be verified when preparing to inter-vene in new countries to define the objectives of theintervention, its possible duration, the needed hu-man, technical, and financial resources, organiza-tional and logistic support.On the basis of our mission and values, the decisionto intervene in a given area will be guided by the fol-lowing criteria:> the needs of each priority group: women, children,

and people with disabilities.> The contexts in which these needs occur, in rural,

underserved areas as well as in urban, degradedand overcrowded ones.

> The risk and vulnerability to epidemics and naturaldisasters.

> The potential for mobilizing financial resources.> The opportunities for partnerships.> The potential positive effects on population’s

health of our intervention.> The presence of minimum security conditions for

our personnel.

7.2 DISENGAGEMENT CRITERIADisengagement criteria are as necessary as entryones.Clear disengagement criteria, shared with our part-ners, contribute to the sustainability of results.Reasons to review a strategy and consider the op-portunity to leave a country may be represented by:> the achievement of the planned objectives.> The coming to an end of the conditions specified

in the entry criteria.> Significant changes in government priorities and

policies.

7.3 STRATEGIC AND OPERATIONAL CONSIDERATIONSGiven the enormity of health needs in Africa, we in-tend to find the resources to work in at least tencountries, including the seven where we are alreadypresent, to reach at least 5 million people by 2015.

7. Sector strategies: the countries

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In light of the general principles outlined above andwith special attention to women, children, and peo-ple with disabilities, the following strategic consider-ations are important:> we must strengthen our presence in the seven

countries where we currently work. We will extendour presence to new geographical areas throughpartnerships and in synergy with other organiza-tions. We will implement innovative strategies, al-ways considering the essential and complemen-tary levels: hospitals, lower level health units,families and communities.

> Given the degrading conditions of life in manyovercrowded urban slums, we will study the possi-bility to intervene in slums of Nairobi, Luandaand/or other towns.

> We will improve our preparedness to epidemics ornatural disasters in the areas where we alreadywork.

> In line with our will of being “with Africa” we willexpand our presence to at least three west Africancountries.

> For a greater impact on health and in line with theMDGs, we will operate in partnership with other or-ganizations to improve: safe water supply, nutri-tional status, education, gender equity, and eco-nomic conditions in the areas where we work.

> In line with our strategic objectives, three-year andone-year operational country-plans, will describe ob-jectives, activities, needed and available resources,implementation methodology and timeframe, andcontext evaluation of the intervention areas.

ANNEX IThe internal organization sector strategies

The continuous and rapid transformations of interna-tional cooperation require a deep, all embracingchange of our organizational culture, structure andmanagement.

8.1. STRATEGIC OBJECTIVETo turn Doctors with Africa Cuamm into an orga-nization based on result oriented management.The first step is a deep cultural change turning theorganization from one functioning on specific pro-jects accountability to one functioning on whole em-bracing, cross cutting, result oriented accountability,at headquarters and country levels.

8.2. STRATEGIESTo guarantee the success of this change, all thosewho work with the organization must understandand share the principles of result oriented manage-ment.All our working procedures, at headquarters and incountry offices, must be shared, harmonious, andtransparent to optimize time and resources.

8.3. PRESENT SITUATIONThe Administration Office is currently running manymanagerial tasks not related to the organization ac-tivities. It carries out administrative work for the SaintFrancis Foundation (an Institution of the Dioceses ofPadova of which Doctors with Africa Cuamm is part).In addition, it takes care of the management of theCollege, a commercial activity of the Foundation.Several of the tasks mentioned above are cross cut-ting and it is difficult to disentangle them.Up to not long ago, although with some difficulties,this complex managerial set up, evolved over time,has satisfied the organizational and administrativeneeds.The increased number of partners and the diversifi-cation of donors of Doctors with Africa Cuamm, callfor an urgent reorganization and strengthening in

terms of managerial setup, logistics, computer net-working and staff.The external audits required by institutional donors,with their tough requirements, provided useful, op-portunities to test the organization’s managerial ca-pacity and identify the areas requiring improvementand change.The current organizational and managerial setupguarantees the correct use of the resources receivedbut must be significantly improved as for standard-ization of procedures, control mechanisms andtransparency.Significant changes and improvements are needed,at all levels, to transform Doctors with Africa Cuamminto a modern and efficient organization.

8.4. THE OVERALL RE-ORGANIZATIONTo achieve our strategic objective we have to investheavily in building our capacity. The cost of this mustbe identified and the needed resources found.Therefore we need to:> substantially improve the management of space at

our headquarters to allow wide and comfortableoffice space for everybody.

> Adequately equip all of sections (especially when itcomes to electronic tools and information technol-ogy).

> Improve and update knowledge, skills and compe-tencies of all our personnel through a two-yeartraining program based on assessed trainingneeds followed by thoroughly planned, regular andfrequent updates.

> Make sure that all the Heads of Section are profi-cient in spoken and written English by providingadequate training to those who need it.

8.5. PLANNED INTERVENTIONS AT OURHEADQUARTERSThe Administration Section has crosscutting func-tions and is in charge of the overall management.

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The Head of the Administration Section delegatesoperational tasks to the heads of the other sections(Human Resource Management, Projects and Ac-counting).Each head of section must receive a clear mandateindicating responsibilities, scope of action and levelsof answerability.This will make the overall management more trans-parent and functional.The organizational setup will emerge from the proce-dures of each Section.These will be regularly monitored and updated whenneeded.General financial control and accountability functionswill be separated from those related to contractualcommitments with specific donors.The financial accountability of all the projects andthe general one will be integrated using reliable soft-ware compatible with the current needs.For several years the financial report of the Organiza-tion has been annually certified by one of the mostreputed auditing firms.We want it to be more thorough and give more mean-ingful information on our financial situation.Working with international donors requires that weimprove our procurement procedures.We adopted the European Union procurement guide-lines and already acquired some experience withthem.

8.6. PLANNED INTERVENTIONS IN OUR COUNTRYOFFICES

An overall managerial improvement is necessary inall our country offices.In the countries where the Organization owns build-ings and equipment, we will ensure regular monitor-ing and maintenance to preserve and, if possible, in-crease the value of our investments.In the countries where we want to strengthen ourpresence we will assess the opportunity to buy ouroffice premises.In particular, we will hire professional accountantsand administrators to relieve the workload of theCountry Representatives and to achieve the report-ing standards currently required.We have already started a thorough assessment ofthe financial reporting systems and the procurementprocedures of our Country Offices with the aim ofobtaining positive external financial audits.Headquarters will carry out thorough financial and pro-curement audits in all our Country Offices once a year.

8.7 AUDITINGThe strengthening and modernization of Doctorswith Africa Cuamm will be ensured by a regular andthorough auditing of financial, procurement and oth-er managerial procedures with reporting made di-rectly to the Director.

8.8 RISK ASSESSMENTAssessing the risks associated with our interventionsrequires specific know-how and expertise.Up until now, the size and nature of our operationsallowed Management to asses the financial and op-erational risks on the basis of previous experiences.In this respect, we will acquire the solid expertiseneeded to protect the organization at all levels andensure responsible and transparent choices.

8.9. QUALITYAdequate and transparent working procedures regu-larly and frequently monitored and evaluated, will al-low us to achieve the international quality standardscurrently required.

8.10. EMPLOYEES AND COLLABORATORSFor several years, since the organization is a branchof the Foundation “Opera di San Francesco Saverio”of the Padova Diocese, Doctors with Africa Cuammadopted, for its Headquarters personnel, the stan-dard contractual rules of the AGIDAE6 National Con-tract.For those employed in our projects and for othercontracted personnel, in Africa, we adhere to theFrame Agreement signed in 2004 between the Asso-ciation of Italian NGOs and the Labor Unions.We have internal regulations and related forms inte-grated in the national contracts that we adopted.We will continue to adhere to national agreements oncontractual relations with employees and collabora-tors.We must identify clear indicators of professionalism,skills and competence of our personnel and set upclear procedures to monitor and assess them.This will allow adequate recognition of merit in termsof professional advancement and pay raises.In the previous paragraphs, capacity building, edu-cation and training needs have been emphasized.As part of our organizational re-engineering and inline with recommendations of international auditors’,we will provide each employee with an articulatedjob description defining duties, autonomy and hierar-chical relations.

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6 Associazione Gestori Istituti Dipendenti dellʼAutorità Ecclesiastica: anorganization supporting the management of Church owned or relatedinstitutions.

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Human resources are our most precious asset.We will continue to request, from those with us, themost important commitment: to match the basic val-ues of Doctors with Africa Cuamm, such as the spiritof service, solidarity, and gratuity, with the highestprofessional standards.The professional profile of our collaborators is linkedto our overall strategy and to the strategic objectivesset in each country.We must work out a new recruitment strategy ex-panded to professional fields outside our traditionalone, like management, governance and financing.Considering the increasing complexity of internation-al health cooperation and the global lack of healthprofessionals, we must count on a limited, but signif-icant, number of experts who will spend their entireworking career within the organization.For short term assignments and consultancies, wehave to maximize the expertise of our former collab-orators, now back to their permanent job in Italy. Tothis aim, we will set up a detailed and updated data-base.We will keep to employ, for mid or long term tasks,experts and volunteers who, at the end of their workin Africa, will go back to their former occupations inItaly.Through a series of collaboration agreements withuniversities and other relevant institutions, we intendto identify a pool of experts for highly specialized butshort-term tasks.Given the global scarcity of qualified and competentprofessionals, we intend to improve our ability topromote the professional development of all thosewho worked, work and will work with us.We will pay particular attention to harmonize theirfamily needs with their human and professional aspi-rations.Not to loose their contribution, we will strengthen ourrelationship with those who worked with us in thepast.

So far, the great majority of our collaborators wereItalian. This will change and we will have to turnmore and more often to international recruitment, in-cluding African professionals.Doing this, we will carefully consider the conse-quences of our choices for the countries where wework and will endeavor not to worsen their alreadycritical situation when it comes to human resourcesfor health.This decision has important operational implications,like the communication language used within the or-ganization.Even more important are the cultural changes need-ed by the shift to international recruitment.

9.1. PROFESSIONAL ROLES IDENTIFICATION CRITERIAAiming at priorities:Hospital:> technical component (specialists, midwives, nurs-

es, technicians) to ensure primary care, mainly inthe maternal and child sectors and in HIV/AIDStreatment.

> Hospital management and administration (healthmanagers, administrators, logisticians for procure-ment and maintenance, human resources experts,health economists).

Territory:> peripheral network management (public health

specialists, health technicians);Community/family:> promotion of healthy lifestyles and improvement of

family environment (community and public healthexperts, experts in social sciences, anthropolo-gists);

Capacity building:> professionals in various fields with education ex-

pertise at all levels;Support to health policies:> technical assistance (experts in health policy mak-

ing and analysis).

9. Human resources

9.2. RECRUITMENT AND SELECTION STRATEGIES9.2.1. Recruitment of young professionalsYoung professionals are a vital resource for the futureof our organization.We intend to invest heavily on them.We will create a pool of competent professionals able toact as “agents of change” to promote the right to health.

Objectives:> to create a group of young professionals committed

to the Organization’s values, with different technicalprofiles and adequately plan their continuous profes-sional development and career path.

Actions:> to improve the selection process and invest in peo-

ple with the needed professional requirements andcommitted to the organization principles and values;

> to update continuously our training course for pro-fessionals at their first cooperation experience;

> to re-introduce on-the-job field training facilitated bya senior professional cadre with subsequent employ-ment into a project and, when relevant, enrolment in-to further training, for professional growth;

> to earmark adequate funds to these activities.

9.2.2. Recruiting personnel with previous coopera-tion experienceExperienced professionals are the majority of our staff.Investing in their continuous professional developmentand retention is vital for the organization.

Objective:> to create a permanent pool of experts for top man-

agerial and strategic functions at headquarters andin country offices.

These cadres will be recruited inside and outside thecurrent human resource pool of the organization.

Inside, the recruitment will take place among thosewho already worked with us, the trainers in our variouscourses, active members of the organization andmembers of our supporting groups.

Actions:> to verify availability for field work among those who

worked with us in the last ten years, our active mem-bers and our trainers;

> to select, among the immediately available, thosewith the characteristics needed for our forthcom-ing interventions;

> to identify specific training paths for those avail-able but without the required competences. Ade-quate financial resources must be earmarked tothis end;

> to enhance our motivation strategies;> to calculate the financial needs for these actions

on a three-year basis.

Outside the organization, recruitment and selectionwill concern professionals with relevant experience, inItaly or abroad, with NGOs, and international agencies.

Actions:> to employ, in collaboration with our Country Of-

fices, professionals already working in the field;> to advertise vacant positions in international and

national web-sites, magazines, etc.;> to create a network of Universities and other rele-

vant institutions where we will regularly advertiseour activities;

> to translate all our important documents in English,French and Portuguese to allow a wide dissemina-tion;

> to set up an adequate, articulated and transparentselection and recruitment process;

> to set up an induction and training process stress-ing the values of the Organization;

> to make sure that all our personnel is fluent in spo-ken and written English and in the main languagespoken in the country where they work (French,Kiswahili or Portuguese).

9.3. ADDING VALUE TO OUR HUMAN RESOURCESDuring the years most of our collaborators displayednot only high levels of competence but, also, extra-ordinary dedication, passion, and commitment tourvalues and mission.We intend to make this a distinctive trait of our orga-nizational culture.

Objective:> to ensure the continuous development of our hu-

man capital, in line with our values.

Actions:> to make sure that each position within the organi-

zation is occupied by the right person;> to reinforce our organizational culture through

shared information, debates, and other events. Co-herence with organizational culture shall be one ofthe elements of performance evaluation;

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> to outline and promote, for all cadres, a continuousprofessional and career development path;

> to elaborate, for all cadres, a clear salary scale in-cluding appropriate incentives;

> to elaborate and adopt, for all cadres, at Headquar-ters and in Country Offices, a thorough performancemanagement process.

9.4. CONTINUING EDUCATION AND TRAININGContinuing education and training are essential for in-dividuals and organizations.For many years we have been running various trainingcourses (a pre-employment and several higher levelones).We also organize frequent national and internationalconferences and debates on development issues.We will consolidate and expand our activities in thisfield.

Objectives:Through our training and cultural activities we intend:> to promote continuous professional development for

all our cadres;> to identify, recruit and select new candidates among

the best performers in our pre-employment and oth-er courses;

> to disseminate scientific knowledge on Africanhealth issues as part of the international develop-ment knowledge network;

> to gain recognition in the national and internationalacademic and scientific fields.

Actions:> to make sure that our internal training activities are in

line with the training needs of our personnel and ourstrategic objectives;

> to make sure that our current collaborations with var-ious Universities, in Italy and abroad, become formaland fruitful partnerships;

> to make sure that these partnerships contribute tothe continuous development of our cadres and pro-duce operational synergies;

> to promote greater awareness about African healthand development issues in Universities and othercultural institutions in Italy and abroad.

9.5. A GROUP OF EXPERTSThe implementation of our strategic plan requires the

work of a permanent group of experts at Headquartersand in Country Offices.

Objective:> to employ, full time, a group of experts in Public

Health and Public Health Services Management.

Actions:To describe the professional profile of two types of ex-perts:> experts in health services management: with exper-

tise in planning and management of human, financialand material resources in the health sector;

> experts in public health: with expertise in epidemiol-ogy, research and evaluation;

> to guarantee the presence, in each country, of a spe-cialist in health services management and one inpublic health;

> to recruit experts within the organization;> in the initial phase, for lack of professionals with the

needed profile, a suitable training path may be nec-essary;

> to define the experts’ roles within the organizationalstructure;

> to work out contracts allowing mobility and flexibility,including a set of adequate incentives and benefits.

9.6. AFRICAN PERSONNELInvesting in African health professionals is an effectivecontribution to the development of African Health Sys-tems.

Objective:> to contribute to African personnel’s development

promoting its retention within African Health Sys-tems.

Actions:> to contribute to the formulation of policies promoting

national human resources retention within AfricaHealth Sectors;

> to contribute to formal training at different levels(from nursing schools to universities) and on the jobtraining within projects supporting local national sys-tems;

> to build partnership with NGOs and internationalagencies to identify and implement policies of hu-man resources production and retention.

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Doctors with Africa Cuamm style is characterized bydiscretion, away from excessive media attention.This style doesn’t exempt from taking a clear andstrong position on issues concerning the universalright to health.To promote effectively the right to health, a high de-gree of visibility is important.Our technical activities must be complemented bysystematic communication, lobby and advocacy.For us, communication is not mere publicity to ouractivities, but a proposal of change towards a soci-ety that doesn’t just acknowledge but also realizesthe right to health.In line with our idea of “service”, we always present-ed our field personnel not as main actors but dis-crete facilitators and, when necessary, temporarysubstitutes.We avoid the false image of “heroic” field staff aswell as the despicable commercialization of pain.Our organization’s image must communicate our en-gagement in the global fight against poverty side byside with African governments.

1. GLOBAL COMMUNICATION STRATEGIESDoctors with Africa Cuamm will implement effectivecommunication strategies documenting its participa-tion to the global movement for the respect of humanrights in general and of the right to health in particular.

1.1. Internal CommunicationWe want all our personnel to have timely, accurateand complete information on our activities. This willencourage frank discussions and participation in de-cision making.The following communication means and documentswill be used:

General communication:> Internet site;> Intranet site;

> journals and other publications;> annual reports, strategic plans, operational plans,

work plans, monitoring and evaluation reports, op-erational research reports;

> timetable of our main activities.

Communication within the Headquarters:> Administration Board meetings;> Management Team meetings (Director and Heads

of Sections);> section meetings;> general meetings.

Communication within Country Offices:> Management Team (Country representative and

members);> annual general meetings (all our professionals in a

given country).

Communication between Headquarters and Coun-try Offices:> annual Country Representatives meeting at head-

quarters;> Dissemination of Management Team meetings

minutes;> visits from Country Offices to Headquarters;> visits from Headquarters to Country Offices.

All this shall ensure the timely, accurate, completeand transparent circulation of information. Throughit, all staff members should have a clear under-standing of what is being done, by whom, where,when, how, with what resources and why.

1.2. The Supporting GroupsHundreds of Italian professionals worked with us inthe field then came back to Italy.Many of them became members of our Assembly,an important organ of the Organization.Many also created Supporting Groups made of

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people interested in our activities and contributingto them in various ways, including financial contri-butions.We must provide these Groups with adequate infor-mation on our activities and technical support, sothat they can fully develop their potential.To this aim we plan:> to strengthen the sense of belonging of the

Groups while respecting their autonomy.> To ensure the coordination and integration of the

Groups activities with those of the Organization.We will support the creation of new SupportingGroups so that all those who work with us, whenthey go back to their communities, become ourambassadors within them.

1.3. External communicationWe will make a significant investment in communi-cation, in Africa and in Italy, for the achievement ofour strategic objectives.Our communication strategy will strengthen ouridentity, disseminate knowledge and inform on ouractivities. It will be addressed to the following sub-jects.

1.3.1. Italian institutionsThe main targets of our communication activitiesare national institutions, local authorities, politicaland advocacy groups.We intend to achieve the following objectives:> to create consensus on the importance of devel-

opment cooperation and for a greater Italian en-gagement in it;

> to promote a cooperation culture based on allembracing, long term development policies ratherthan on emergency, fragmented and not evaluat-ed interventions;

> to promote greater attention to and sensibility forthe African continent;

> to advocate for the respect, by the Italian Gov-ernment, of its international commitments like itsadhesion to the Millennium Agenda and thepromise to channel 0.7% of GDP to developmentaid;

> to advocate for a greater coherence between de-velopment goals and sector policies (like interna-tional trade, environmental protection, migrationetc.);

> to contribute to the ongoing formulation of a newlaw on development cooperation;

> to underline the importance of involving in this

process the civil society (NGOs, Universities, Lo-cal Governments, etc.).

1.3.2. International and European InstitutionsThe sustainability of development objectives mustbe considered globally.The commitment of the international community toensure the right to health is necessary in view ofdeveloping global health policies.To this aim we intend:> to contribute to the choice of priorities and function-

ing mechanisms of the main donors on the basis ofour more than 50 years of experience in Africa;

> to promote coherence and coordination betweendevelopment goals and national policies;

> to promote, in all the international institutions, co-operation mechanisms ensuring transparency,monitoring, and effectiveness of programs;

> to advocate for the sustainable establishment of aglobal system of social protection.

1.3.3. African InstitutionsAfrican Governments and civil societies, with thesupport of the international community, have theprimary responsibility of guaranteeing the right tohealth to their citizens.We intend to participate, with African Governmentsand the African Union, in formulating health policiesgeared towards the achievement of equitable andmeasurable health goals in Africa.To do this we intend:> to stress the key-role of better health in the fight

against poverty;> to influence national health policies on the basis

of our experience shared with the competent au-thorities.

1.3.4. Individuals and groupsThe involvement of civil society, in Italy and Europe,is necessary to put pressure on decision makers forthe realization of the right to health.To create greater awareness and participation, wewant:> to promote wider and better information, at global

level, on the right to health in Africa;> to promote debate and exchange of ideas to cre-

ate a global movement for the right to health;> to promote inter-cultural debates on development

to establish relationships based on common in-terests, reciprocal exchange, solidarity, justiceand peace.

1.3.5. The Health communityWe intend to circulate information, promote debates,and stimulate change within the health communitywith the following objectives:> to increase awareness, knowledge and under-

standing on issues related to the right to health;> to promote the introduction, in the Faculties of

Medicine curricula, of elective courses on globalhealth and health equity;

> to promote greater collaboration between Universi-ties and international health cooperation organiza-tions;

> to increase interest and commitment for the elabo-ration and implementation of equitable and effec-tive global health policies.

1.3.6. Business enterprises and foundationsBusiness enterprises and private foundations haveconsiderable influence on policy formulation and im-plementation.We intend to influence them with the following ac-tions:> to increase information and awareness on the right

to health and the need of equitable and effectivehealth policies at global level;

> to promote a greater involvement of business en-terprises and private foundations in developmentcooperation.

1.3.7. The MediaGiven the impact of media on public opinion andpolicy making, we intend to do the following:> to stimulate greater and constant attention, by

newspapers, televisions, and radios, on develop-ment in general and health development in particu-lar;

> to promote a more accurate and documentedknowledge of Africa, its problems and richness;

> to promote a greater involvement in developmentcooperation of the mass media.

1.3.8. The Catholic communityWe intend to increase the awareness of the Catholiccommunities, in Italy and in Europe on the issueslinked to our mission.In particular we want:> to contribute to the role played by the Catholic

Church in promoting African development;> to stimulate commitment to the realization of the

right to health through equitable and effectivehealth policies;

> to participate in the debate on Catholic health ser-vices management in Africa.

1.3.9. The third sectorWe want to strengthen our links and collaborationwith other development organizations, in Italy andEurope (Focsiv, Italian NGOs Association, MedicusMundi International, etc.), stimulating debates andcultural growth for a coordinated advocacy at politi-cal level.

To achieve this, we intend:> to collaborate in priorities setting and health plan-

ning in Africa;> to promote networking and the creation of partner-

ships to increase the impact of our work;> to increase, through partnerships and collabora-

tion, the weight of our advocacy nationally and in-ternationally.

1.3.10. Local communitiesTo achieve the MDGs it is important to support localcommunities.Poor, marginalized and not adequately informed,they, often, don’t have sufficient awareness of theirrights. Neither are they involved in the strategicchoices heavily impacting on their lives.In this respect we intend:> to promote an active role of community represen-

tatives in health policy making and implementa-tion;

> to increase information and awareness of the com-munities we work with, promoting their structuredparticipation in health services management andsupervision at hospital and lower levels;

> to increase awareness and participation of fami-lies, empowering them to interact effectively withthe authorities.

2. THE TOOLSTo promote uniformity of action and wide sharing ofvalues and goals, inside and outside the organiza-tion, we will develop communication strategies andactions to achieve the following:> brand positioning: we must solve the problems

linked to the shift from our old brand “Cuamm” tothe new one, “Doctors with Africa-Cuamm”, in althe operational languages we use.

> Basic brand dissemination strategy, in Italy andAfrica: the dissemination of our brand must takeplace in all our communications (headed letters,

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envelopes, documents, dossier or project presen-tations).

> Publications: our publications must support ourstrategic objectives and reflect our mission, valuesand style.

> Videos and DVDs: we must add other ways ofcommunication and other forms of expression likevideos and DVDs.

> WEB/Internet: given its enormous potential, wemust use the web for all our communication andfund raising activities. We must improve our web-site (www.doctorswithafrica.org), make it more dy-namic and continuously updated.

> Advertising: this must be of excellent quality.Based on our values, it must illustrate our historyas well as our original contribution.

> Cultural Events: they must strengthen our sense ofbelonging, display our specificity and prove ourability to link Africa and the West in a fruitful ex-change of experiences and ideas.

> Relationship with the Media: in Italy and in Africa,we must increase our work with the media (pressagencies, journals and newspapers, television, ra-

dio, internet) and make it more systematic and ef-fective.

In each field of work we have:> to plan communication activities, at different levels,

assessing needs and opportunities;> to support Country Offices to plan and monitor im-

plementation;> To ensure coordination of all actors, at all levels, to

ensure the greatest synergy among all activities;> To report fully on the progress made, the obstacles

met and the support needed.

Two levels of involvement deserve particular atten-tion since they illustrate our new approach:> all those participating in the formulation and im-

plementation of this plan are important actors ina communication work allowing to put the MDGsat the first place in political and health actionplans;

> human resources involved in projects and the con-cerned communities will be able of making theirvoice heard, thus leading to real change.

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For each “right” there is a “right bearer” (who shouldenjoy his/her right) and a “duty bearer” (responsiblefor the respect of that right).There is consensus that the responsibility for provid-ing the financial resources needed to ensure theright to health rests with local communities, govern-ments and the international community.Fund raising is essential to promote the respect ofthe right to health.We propose the possibility to accomplish this duty tonational and international institutions, to the civil so-ciety, business enterprises, private foundations andprivate citizens.On the basis of studies costing the production anddelivery of health services in Africa, we estimate that,to implement this Strategic Plan, our organizationneeds to increment its financial income of about15% per year, to achieve 30 million Euros by 2015.We consider this realistic and achievable for the fol-lowing reasons.The funds channeled to development aid will in-crease in the next eight years due to greater publicpressure to achieve the MDGs, especially in Africa,where progress is slower.The big Foundations, especially in North America,and the Global Health Initiatives, can mobilize in-creasing resources.The professional standards requested today to orga-nizations like our one imply investments in qualitythat would not make sense with activities worth lessthan 25 million Euros.Finally, it is important that adequate amounts ofmoney are channeled to organizations, like our one,having a long term, systemic approach, rather than avertical one.

1. STRATEGYMoving from the current financial situation to the de-sired one, requires all the changes described in thisdocument.

In particular:> partnerships: we are committed to work with other

national and international organizations sharing ourvalues and professionally qualified.

> Results: donors have the right to know what wasdone with their money. We have the duty toachieve the planned results, document our actionsand disseminate our reports. We must also de-scribe and explain possible failures.

> Catalytic role: we must support the implementationof local and national programs resulting in qualityservices, capacity building, and empowerment.

> MDGs: our supporters must be aware that helpingus means to participate in the achievement of theMDGs.

> Specific role and professionalism: we will maintainour identity and specificity while working within theframework of the the MDGs, with a facilitators’role, a passion for results, and a partnership cul-ture.

> Responsibility of mobilizing resources: needed topromote the right to health, this will be part of thejob description of all the organization’s staff.

> Groups: the Supporting Groups are precious forspreading our ideas and fund raising. We will pro-vide them with the support they need.

In 2006 our income was about 8 million Euros. Weintend to achieve 30 million Euros by 2015. Of thisamount, not more than 20% will be used for man-agement, administration and training. The remaining80% will be used in the countries where we work.Several international agencies, funds, and founda-tions have adopted decentralized funding strategies.Considering this, we think that about one third of thefunds we want to collect by 2015, that is, about 10million Euros, shall be raised by our Country Officeswith the support of the Headquarters.Of the remaining 20 million Euros, 60% shall comefrom the Italian government and the European Union(about 12 million Euros).

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The remaining 8 million Euros shall be collected fromfoundations, business enterprises and individuals, inItaly and abroad.The funds raised from private sources are particu-larly important as they are not tied to political orother considerations like those from institutionalsources. As such, they allow us more freedom ofaction in the choice of interventions and countries.

2 INSTITUTIONAL FINANCIAL MARKET:PUBLIC AID TO INTERNATIONAL HEALTHCOOPERATION

In recent years there has been renewed interest inhealth cooperation, with increasing funds channeledto the health sector.Official Development Assistance (ODA) funds to thehealth sector grew from US$ 2.2 billion in 1990 toUS$ 14 billion 2005. This is 13% of the whole ODAfunds in 2005 (WB, 2007).New donors, like Global Funds, Global Health Initia-tives (GAVI, GAIN, etc.) and big private foundations(Bill and Melinda Gates, Clinton, Soros, etc.) act,side by side, with the traditional, bilateral and multi-lateral donors.Africa is receiving increasing attention and funds.Europe, through the portfolio managed by Commis-sion for Development, is, today, the biggest donor toAfrica (European Commission for Development,2006).For the period 2008-2013, the European Commis-sion has budgeted, through the 10th European De-velopment Fund, 22.7 billion Euros for investments insocial sectors in Africa (including health).In the last G8 meeting, held in Heiligendamm, Ger-many, from June 6th to June 8th 2007, industrializedcountries reasserted their commitment to double aidto Sub-Saharan Africa by 2010.The major donors agree on the need to better coor-dinate the use of aid funds. Aid must be aligned withthe priorities of recipient countries, better coordinat-ed and show evidence of its effectiveness (OCSE,2005).More and more donors disburse their funds asGeneral Budget Support, Sector Wide Approaches,and supporting Poverty Reduction Strategic Pa-pers.Health policies recognize the central role of healthsystems and the crucial importance of human re-sources for health (WHO, 2007; DFID, 2007; GAVI,2007).Looking at these positive developments, however,

there are old and new challenges in the institutionalfund raising market:> after falling in early 2000, current aid to Sub-Saha-

ran Africa has since remained at about the samelevel as it was in 1990s;

> funds continue to be unreliable and not steady;> priority has been given only to the principal pro-

grammes to control illnesses such as HIV/Aids, Tu-berculosis, Malaria and other illnesses which canbe controlled through vaccination;

> the worrying lack of funds available to supporthealth systems and for primary care which runscounter to declared strategies and policies;

> the difficulty of the new international aid organisa-tions (CBS, SWAP, PRSP) to produce importantand sustainable results at the district level.

Another factor to keep in mind is the national and in-ternational multiplication of NGOs that offer them-selves as agencies, able to implement health pro-grammes and financed by the internationalfund-gathering market. In this case, access to fund-ing from the institutional market is linked: to the abili-ty to satisfy the technical and organizational require-ments linked by predefined standards; to presenttechnically valid and innovative programme propos-al; and to work in partnership with other organiza-tions.Italian Cooperation for Development deserves a sep-arate comment. After years of financial regressionand political disinterest in cooperation, the last doc-ument regarding economic-financial programminghas shown clear signs of a coming u-turn. Morespecifically, the document states that in order to ho-nour its international commitments, the Italian gov-ernment has drawn up a sort of road map setting outproposed increases in State Aid for development asfollows: 0.33% in 2008 (estimated as around a totalof 4.7 billion), 0.42% in 2009 (estimated at around atotal of 6.1 billion), rising to 0.51% in 2010 (estimat-ed at around a total of 7.5 billion).However, within this funding, priority must be givento Africa where, at the Gleneagles conference, Italymade a commitment to double the aid it provided(DPEF, 2007).Despite this development, which should be kept un-der close observation, it is still unclear how long it isgoing to take to pass the laws that will give Italy adevelopment agency that can function as an efficienttool for carrying out policies effectively.Furthermore, it is still not clear what criteria will beused to allocate resources and what the level of im-

portance given to the cooperation sector in the fieldof health will be.

2.1. How does Doctors with Africa Cuammintend to act within this market?To obtain financial resources adequate to its plans,Doctors with Africa Cuamm must have the followingdocuments for each Country where it works:> a Strategic Country Plan.> A three-year Country Plan with detailed Financial

Plan.> A one-year Country Plan with analytical Financial

Plan.The three-year planning will illustrate all the interven-tions that will be proposed to the main institutionaldonors, particularly to the European Commission andthe Italian Government, at central and country level.This mid-term planning approach should allow thetimely integration of our activities within donors pri-orities. It should also avoid having to run after spe-cific and fragmented projects tendered out.

3. BUSINESS, BUSINESS FOUNDATIONSAND BANK FOUNDATIONS

The basic values of corporate responsibility are illustrat-ed in the 2001 European Commission Green Book andreceive increasing attention by business enterprises.Numerous studies suggest that the financial perfor-mance of business enterprises is strongly linked tothe degree of corporate responsibility shown bythem and perceived by their stakeholders, includingthe general public.Governance issues and involvement in social caus-es, positively affect their financial performance andcompetitiveness of business enterprises.Available data refer only to the tax-deductible pay-ments (and not to those that come from organisationsin the non profit sector) made by Italian firms. In 2001,these payments amounted to 266 million Euro. [Font:Research IRS, Institution for the Social Research]

In Italy, business foundations are a recent but grow-ing phenomenon. Corporate philanthropy is becom-ing part of the culture of big business enterprises.Bank foundations are particularly important. At the endof 2004 they managed a total of about 88 billion Euros.Bank foundations, in 2004, donated about 1.274 bil-lion Euros [Font: X° Annual report ACRI].To be effective in this environment, we need:> a constant, systematic and accurate market analy-

sis.

> a rational optimization of the existing relationships.> a strong corporate program using the main forms

of fund raising:- partnership;- cause-related marketing;- grant giving;- joint fund raising;- licensing;- sponsorship;- membership.

The effectiveness of our fundraising, especially in itsinitial phase and for several years to come, will de-pend heavily on the involvement of all our members.To do this, as part of our communication strategies,we need a lively and engaging dialogue with all ourstakeholders.We must be able of communicating the goodness ofour cause, raise interest and stimulate participation.Ensuring the universal enjoyment of the right tohealth must become a project shared by our entiresociety.Fund raising is not just a tool to obtain financial re-sources but a strategy to create a chain of social re-lationships based on shared values.

3.1. The market of private citizensThis is a market in expansion as suggested by sev-eral studies on trends for the next decades. The do-nations from private citizens amount to 4.8 billioneuro [Font: Sole 24 ore, 07/12/24].Bequests represent 30% and cash 70% of the totalannual donations.An IRS study, from which come these data, forecaststhat, in 2020, private citizens donations will reachabout 8 billion Euros [Font: “The social and healthfund raising” A. Masacci, P.L. Sacco, Meltemi, 2006].Others (Consodata) estimate current donations tocome from 29 million people, equal to 62.7% of thewhole Italian population over twenty years of age.Finally, another study (IREF) found that every yearspontaneous donors decrease while those influ-enced by awareness campaigns increase.Fund raising strategies must be diversified and ad-dressed to different targets.Our main fund raising strategies, used in differentways for different targets, will be:> mailing> membership policies> cultural events> merchandising> internet site

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The strategy plan suggests increasing specialisationin fund raising efforts directed at the diverse marketsand should be presented as a model for achievingsustainable and global growth.The current trend in Italy is to seek to broaden the

overall panorama of methods used for fund raisingfor all social reasons, but especially in the area of in-ternational health provision, these different initiativeswill be used at all levels, in order to find the funds re-quired to carry out our mission.

ANNEX IICountry strategic programs

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Angola, with its immense natural resources, is poten-tially one of the richest states in the world.Despite this wealth, 70% of the population still liveon less than two dollars per day. Until 2002, the yearwhen the peace agreement was signed, the countryhad been locked in continuous Civil War for 40years.The infrastructure of the health service has been se-verely damaged by the long conflict and reconstruc-tion is going slowly and is faced with many prob-lems. The health system was decentralized in 2001as part of a vast government reform.The Angolan government invests 4.1% of the publicspending in the health system which is low whencompared with the average rate of investment inhealth (9.24%) practised by other countries in theSub-Saharan region (WHO 2005).

HISTORY AND ACTIVITIES OF DOCTORS WITH AFRICACUAMM IN THE COUNTRYDoctors with Africa Cuamm has been active in An-gola since 1997. It is currently active in the province

of Uige and of Cunene and in Luanda. Since 2004, ithas been collaborating with the central authorities ofthe Health Ministry and with the United Nations De-velopment Programme to support the national TBprogramme, and has become the main recipient ofGlobal Fund aid to Angola (2005).

STRATEGIC TARGETS FOR 2015In line with Millennium Development Objectives 4, 5and 6, Doctors with Africa Cuamm is seeking:1. contribute to improving the health of the poorer

sections of the population by reinforcing local ordistrict health systems; in particular it proposes tocontribute to reducing maternal and infant mortal-ity in the rural areas of the country:- Municipality of Damba and Maquela, Uige

Province (in the North of the country).- Municipality of Chiulo, Cunene Province (in the

South of the country).In particular it intends to develop the hospital atChiulo and make it a centre for clinic referralsand for training obstetricians and hospital man-agers; and also to make it a place for trying outnew models for public and private non profitfunding integration models and for funding atthe community level.

2. Support national programmes which aim to re-duce the endemic diseases (HIV, TB, Malaria)without ignoring the “neglected diseases”.In particular:- consolidate the partnership with the Ministry of

Health in its role as leading NGO in the field oftuberculosis prevention and cure;

- promote experimentation of new organizationalmodels such as the adoption of the Dots at thecommunity level and horizontal integration of TBservices in the districts (as regards the supply ofmedicines, training, communication system,etc.);

- verify the effectiveness and transferability of

Angola

such operations through evaluation and on-go-ing research.

3. Support the country’s strategies for improving theproduction, distribution, competencies and moti-vation of health service personnel at the rural lev-el by promoting the training centre at Uige.

4. Actively contribute to the development of newstrategies for the provision of health services inthe urban area of Luanda.

5. Reinforce the local information system in order tomonitor and evaluate health services and the sys-tem.

HUMAN RESOURCES REQUIRED IN ORDER TOACHIEVE OBJECTIVESAngola is one of the Sub-Saharan countries where thecrisis of local human resources in the health sector isclearest. Therefore each programme has been de-signed so as to employ a sufficient number and mix ofexpatriate health personnel each time, in order tomeet the objectives decided on with the local partner.To avoid harming the Angolan Health system, a listshowing how local health personnel are employed willbe drawn up, checked and published every year.It has been suggested that human resources shouldinclude 1 or 2 experts in hospital management; doc-tors and nurses for the clinic functions; administra-tors and logistics experts.

FINANCIAL RESOURCES REQUIRED TO ACHIEVEOBJECTIVESIn order to be able to operate best in the areas of in-tervention identified it has been estimated that about30 million Euro will be required for the period 2008-

2015, of which 40% should be found in loco, whilethe remaining 60% should come from the main of-fices /organisation /headquarters?

PARTNERSHIP ACTIVITIESIt would be helpful if there were to be official recog-nition on the part of CEAST, Conferenza Episcopaledi Angola e Sao Tomè (Episcopal Conference of An-gola and Sao Tomè) of the Doctors with AfricaCuamm which is a Catholic international organiza-tion operating in the country.At the diocesan level, there is a need to stipulatespecific agreements, or delegate responsibilities,regarding the management of the diocesan struc-tures in Damba (Uige province) and Chiulo (Cuneneprovince).Other important alliances are those with internationaland national NGOs, who already operate in thecountry and have similar missions and targets eventhough they may not necessarily be operating in thehealth sector.

COMUNICATION ACTIVITIES, FUND RAISING,LOBBYING AND ADVOCACYGiven the strategy presented here, and in order tostimulate the necessary changes to reach MDGs, itis crucial that lobbying and advocacy activities bepromoted at the level of the local Health Ministry, insynergy with the most important public and privateactors in the Angolan7 context and within nationalprogrammes such as that for Tuberculosis.At the level of international donors we propose de-veloping fund raising activities based on result basedmanagement.

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7 International agencies, UN, bilateral cooperation, government authorities,the Catholic Church and religious organizations.

ETHIOPIA

43

Ethiopia is country with key geopolitical importanceboth within the whole continent of Africa and, espe-cially, in the Horn of Africa. In 1993, the Federal Gov-ernment launched a National Health policy based onthe democratization and decentralization of thehealth system.A programme, based on 5-year periods, was startedin 1993 in order to develop the health sector alongthese lines.

HISTORY AND ACTIVITIES OF DOCTORS WITH AFRICACUAMM IN THE COUNTRYDoctors with Africa Cuamm has been present in thecountry since 1985, when the first doctor was sentto the hospital of Gambo. Today, we are well estab-lished in the Oromia region.

STRATEGIC TARGETS FOR 2015In line with the development targets of Millennium 4,5 and 6, Doctors with Africa Cuamm proposes to:1. contribute to improving health among poorer sec-

tions of the population by supporting the local

district Health Service; in particular it proposesworking to reduce maternal and infant mortality inthe rural areas of the country:- South West Showa Zone, province of Wolisso,

Oromia region.We intend to improve the St. Luke Hospital inWolisso to make it into an excellent clinical centrefor training obstetricians and hospital managers.We also intend to guarantee continuity in reha-bilitation services for mobility with the aim of re-ducing the impact of disabilities due to congeni-tal and acquired malformation in children belowthe age of five. Building on the hospital’s experi-ence (where there is private non profit – publiccollaboration); we intend to set up local pro-jects, for health and other reasons, working withother NGOs who operate in other sectors (water,hygiene, micro credit and community projects).

2. Promote and encourage, within the community,the capacities required to recognise problems re-garding health and to identify suitable solutions.

3. Support activities seeking to reduce the incidenceof endemic diseases (HIV, TB, Malaria) and alsothe neglected diseases.

4. Reinforce the local information networks and sys-tems used to monitor and evaluate health ser-vices.

5. Strengthen the role of the “Catholic Medical Bu-reau” in the Ethiopian Secretariat of the CatholicChurch in order to develop the way in whichdiocesan health structures are organised andmanaged and encourage greater integration be-tween public and private non profit organisations.St. Luke Hospital in Wolisso offers an example ofgood management of public-private partnershipand is the best practice example which could bereproduced at the Ethiopian Catholic Secretariat.Furthermore, we propose the introduction of ca-pacity building activities for local health staff atthe Catholic Medical Bureau, capitalizing on the

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experiences of Doctors with Africa Cuamm in thissector in Uganda. Within the wider field of activi-ties in support of the Catholic Health Bureau ofthe Ethiopian Catholic Church, where there arethe required technical, administrative and finan-cial conditions, other technical and financial sup-port activities could be considered which focuson specific health structures. In this case it wouldbe possible to add further, complementary activi-ties, for example: support for St. Mary Hospital atDubbo (Soddo Hosanna Dioceses) and the Burat-Geto Clinic (Emdibir Dioceses).

HUMAN RESOURCES REQUIRED TO ACHIEVEOBJECTIVESThe most important challenge will be that of manag-ing, over time, to replace the expatriate staff withqualified local staff. It has been calculated that thehuman resources needed should include 1 or 2 hos-pital management experts; doctors and nurses forclinical activities; administrative and logistics per-sonnel. There must also be some guarantee of sup-port for orthopaedics and physiotherapy services.

FINANCIAL RESOURCES REQUIRED TO ACHIEVEOBJECTIVESWe estimate that 15 million Euro will be required forthe period 2008-2015, of which 50% should be ob-tained in loco while the remaining 50% should comefrom headquarters.

PARTNERSHIP ACTIVITIESEthiopia is one of the most important examples ofplanning partnerships, set up in conjunction withother NGOs, in order to undertake integrated sup-port projects in the area even though they are not di-rectly concerned with health. In 2007, one such part-nership was started up with two NGOs, Cefa andLvia, in order to carry out integrated actions in theSouth West Showa area.

Cefa and Lvia work in sectors (water and hygiene,agricultural and earnings generating activities – Igas)that are complementary to the health sector whereDoctors with Africa Cuamm are. This partnership willcreate important synergies which will help us in ourwork in the area and improve the situation of thepopulation overall.In the Wolisso district, partnerships will be exploredin order to capitalize on all the varied competenciesand experiences present, to share results with otherinternational agencies and institutions operating inthe geographical area in question, amongst whichare UNICEF and UNFPA. The existing partnershipwith the Italian Ministry of Foreign Affairs will be rein-forced in the hope of being able to contribute todrawing up a country-wide plan on the lines of onethat the Utl in loco is currently trying out.

COMUNICATION ACTIVITIES, FUND RAISING,LOBBYING AND ADVOCACYIn the Addis Adeba coordination centre there is aneed to improve the local activities of lobbying, ad-vocacy and fund raising. In particular, consideringthat the office of the United Nations in Africa and ofthe African Union are in the Ethiopian capital, lobby-ing, advocacy and fund raising activities should beorganised systematically throughout the organiza-tion. The country’s management team intends to de-velop suitable communication strategies for di-vulging information: data, experiences and bestpractices (for bilateral support organizations andagencies, such as WHO and UNICEF, internationalNGOs, Italian Cooperation, local dioceses andCatholic health institutions), in order to improve localvisibility, support, lobbying and fund raising. Amongall the various communication strategies and meth-ods that could be used, those to be encouragedmost are annual reports, country information filesand brochures and the results of operational re-search.

MOZAM

BIQU

E

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In 1992, in Rome, after 16 years of civil war and 26of negotiations, an agreement was signed betweenthe representatives of the Mozambique Govern-ment and the Rebels and Mozambique officially en-tered a period of peace. Today there is a multipartydemocracy. Mozambique has shown clear improve-ments with respect to the dramatic post-war condi-tions in the country, thanks in part to the successfulimplementation of the First poverty reduction plan(Parpa I, 2001). The most recent human develop-ment indicator, the Undp (2006) puts Mozambique168th out of the 177 countries analyzed.As regards in the situation of the health sector inthe country, a primary services health system mod-elled on the Primary Health Care model suggestedby the WHO was introduced in the late 1970s. Forthe first time the poorer groups among the popula-tion had access to the health system, to healthcare.Despite this however, there is worrying data todayfrom the Mozambique Health Service system partic-ularly regarding access to health care.

Currently 12.8% of the State public spending goesto the health sector.

HISTORY AND ACTIVITIES OF DOCTORS WITH AFRICACUAMM IN THE COUNTRYThe first volunteers, members of Doctors withAfrica Cuamm went to Africa in 1978, in the periodwhen the colonial health system based on inequali-ty was being changed into one based on principlesof equality and free access.In 2002, after in depth analysis of whether to re-main there or leave the country, a new phase hasstarted up with many new projects launched withinthe provinces of Sofala and Nampula. Apart fromone project set up in collaboration with the Facultyof Medicine at the Catholic University of Mozam-bique at Beira, all these projects have been devel-oped within the public health service.

STRATEGIC ROLE AND OBJECTIVES FOR 2015Doctors with Africa Cuamm intends to guaranteethe right to health care, by organising support forsome sectors of the national health system inMozambique so as to contribute to achieving theMillennium objectives.We intend to:1. contribute to improving the health of poorer

groups among the population by reinforcing thedistrict health service and system (hospitals,health centres, community health); in particularwe aim to contribute to reducing maternal andinfant mortality in these rural areas:- Sofala Province (city and district Beira).- Napula Province (districts of Moma, Angosche

and Mongovolas).2. Support activities and interventions that aim to

increase access to primary care and improvenutrition among women and children in rural ar-eas.

3. Promote and encourage, within the community,

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the capacities required to recognise problemsregarding health and to identify suitable solutions.

4. Support interventions which focus on reducing en-demic diseases (AIDS, TB, Malaria) and neglecteddiseases.

5. Support local strategies that aim to improve pro-duction, distribution, competencies and motivationsof the medical health staff (University MedicalSchool of Beira).

6. Improve the Central Hospital of Beira and make it acentre for referrals for clinical help, training and re-search for the northern areas of the country.

7. Improve the local information systems used tomonitor and evaluate health services.

HUMAN RESOURCES REQUIRED TO ACHIEVE OBJECTIVESMozambique is one of the African Sub-Saharan coun-tries with the worst crises of human resources in thehealth system. Therefore, each programme is expect-ed to employ suitable expatriate professional healthoperators, enough, in numbers and competencies, tomeet the objectives have been set in conjunction withthe local partner.In order to avoid damaging the Mozambican healthsystem, each year a list will be drawn up and pub-lished of those employed in the local health service.Currently, the most pressing problem is the dispropor-tionately large number of projects and their manage-ment or organisational support.The human resources must include: 1 or 2 hospitalmanagement experts; 1 or 2 public health experts;doctors with experience both in surgery and in medi-cine; administrators and logistics experts.We believe it is important to continue to recruit bothhealth staff and non health staff whether they be for-eigners or not in loco, but without eliminating the roleof headquarters, and to guarantee adequate and suffi-cient training and up-dating for all.

FINANCIAL RESOURCES REQUIRED TO ACHIEVEOBJECTIVESThe budget forecast is around 20 million Euro, onethird of which should be found in loco.

PARTNERSHIP ACTIVITIESConsidering the situation it would appear crucial to in-crease both collaboration in loco and partnerships withagencies and NGOs which, on the one hand, will in-crease the weight and quality of the programmes to beimplemented and, on the other, permits multi-sectorialapproaches.

The partnership with Celim of Milan, with the ClintonFoundation and the local NGO Aro Moçambique willcontinue. Offers to work with the following localNGOs wil l be evaluated: Adpp (regardingHIV/women/children); the Malaria Consortium -working in the context of community education;Save the Children and the Elizabeth Glazer Founda-tion regarding HIV and paediatrics.Our presence in the University and the Hospital inBeira will continue to benefit from agreements drawnup between the Veneto Region/Sofala Province asdoes the collaboration with the Health Authority (USL)and University of Padua. There is a need to createnew partnerships with other agencies, foundationsand universities in particular, to help in research andtraining.Doctors with Africa Cuamm is a member of both theGNGO, coordinating group of most of the NGOs activein Mozambique, and the Naima+, a network of interna-tional NGOs which work together in the health sector(especially around HIV/Aids). If we were registered as aMozambique NGO would make partnership easierboth in different sectors and for the different activities.

COMUNICATION, FUND RAISING, LOBBYING ANDADVOCACY ACTIVITIESIn order to disseminate more information about ac-tivities there is a felt need for better organisation ofthe way data and other information are collected andheld. Reporting on activities requires that thereshould be an archive/library in each office and head-quarters, with updated documentation on the coun-try, about topics and health programmes and aboutthe organization and its projects.There should be an annual report on all activities ofeach project, which should be sent to local and na-tional counterparts, given to the Doctors with AfricaCuamm team in Mozambique and sent to the main of-fice /headquarters. The country’s Management Team(Mt) has a particularly important role to play in improv-ing internal levels of communication, and distributionof reports from other towns / countries and from localand national headquarters will encourage up-dating,better sharing of both information and objectives.Fund raising in loco will continue and there will be aserious attempt to obtain access to funds managedby Misau (Ministry of Health) which has been setaside for projects proposed by NGOs. Were Doctorswith Africa Cuamm to be registered as a Mozambi-can NGO, this would help in fund raising.

SUDAN

47

Sudan is the largest country in Africa and one of therichest in oil which is found mainly in the south of thecountry. But the health indicators and the human de-velopment index show it to be one of the poorestcountries in the world. It is politically divided betweenNorth and South. Because of the long years of war,the South now has almost no type of infrastructureleft intact and a serious shortage, if not total ab-sence, of local medical and paramedical staff.The 9th of January 2005, the comprehensive PeaceAgreement was signed, ending twenty years of CivilWar. The agreement provided for a period of transitionat the end of which, in 2011, there would be a referen-dum, monitored by the international community, to es-tablish whether the South should be independent orunited with the North.In the South of the country, where Doctors with AfricaCuamm is now active, the political-institutional reality isstill unstable and fragmented. In the health sector, the fewexisting structures, principally primary care health centresdirected by religious organizations, are not able to dealwith the huge demand for care from the population.

Furthermore, Health Service structures are still veryweak and there is a lack of any real programme for in-tervention and reconstruction of the Health Service.Notwithstanding the adoption of strongly decen-tralised health policies there has, so far, been no realdefinite decisions taken about who is responsible, theCentral Government or the Federal States, for provid-ing which competencies.

HISTORY AND ACTIVITIES OF DOCTORS WITH AFRICACUAMM IN THE COUNTRYDoctors with Africa Cuamm have been operating inSouth Sudan since October 2006 thanks to fundingfrom the Italian Government Civil Protection Depart-ment, which has made it possible to start up a supportproject for reopening Yirol Hospital, in Yirol County, inLakes State.

STRATEGIC ROLE AND OBJECTIVES FOR 2015In line with the development objectives of Millennium4, 5 and 6, Doctors with Africa Cuamm proposes to:1. contribute to improving health among poorer sec-

tions of the population by supporting the local dis-trict Health Service, in particular it proposes work-ing to reduce maternal and infant mortality in therural areas of the county:- Yirol County.

2. Support activities and interventions that aim to in-crease access to primary care and improve nutritionamong women and children in rural areas.

3. Support activities seeking to reduce the incidenceof endemic diseases (HIV, TB, Malaria) and also theneglected diseases.

4. Support local strategies that aim to improve pro-duction, distribution, competencies and motivationsof the medical health staff.

5. Improve the local information systems used tomonitor and evaluate health services. We willconcentrate our activities in the Yirol County, sup-porting the Hospital and its management, with the

Sudan

aim of reinforcing the Health Services in the area.We will progressively extend our field of interven-tions to at least at two other counties so long asconditions of peace and stability can be main-tained. We will set up an office to co-ordinate ac-tivities at a country-wide level.

HUMAN RESOURCES REQUIRED TO ACHIEVEOBJECTIVESIn order to achieve any of the objectives for South Su-dan, human resources must be provided which includeboth international and local professionals and expertsin hospital, clinic and public health management.There is also a need for administrators and personsspecialised in provisioning and procurement.

FINANCIAL RESOURCES REQUIRED TO ACHIEVEOBJECTIVESThe budget forecast is for around 16 million Euro by2015.

PARTNERSHIP ACTIVITIESIt is very important here to work in a multi-sectormanner in partnership with experts with differentcapacities, training and experience. For this rea-son, Doctors with Africa Cuamm proposes ex-ploring the possibilities of partnerships with otherinternational or local NGOs and to set up jointprojects to support the National Health Service,to integrate its members and to train health work-ers.

COMUNICATION, FUND RAISING, LOBBYING ANDADVOCACY ACTIVITIESDoctors with Africa Cuamm proposes to help publi-cise results and lessons learned from experienceboth inside and outside the country.It will compile periodic reports, evaluations of activi-ties and publish the results of applied research thatwill be used at national and international level for ad-vocacy and lobbying activities.

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TANZANIA

49

Tanzania was founded in 1964 from the union be-tween Tanganyika (independent since1961) andZanzibar (independent since 1963). Although it is in ahighly instable area it has managed to maintain ahigh level of internal cohesion and political8 stability.Notwithstanding a recent improvements in some in-dicators, the “Poverty and Human Development Re-port 2005” has highlighted Tanzania’s difficulties inachieving MGDs within the foreseen times. This re-port, published in 2006 by Undp, puts the country162nd out of the 177 cases analyzed.The country is heavily dependent on foreign aid. In2001, having reached “completion point”, it was ableto benefit from HIPC9 (High Indebted Poor CountriesInitiative) and its debt with the International MonetaryFund was cancelled. The latest health sector reformswere introduced in 1996 and, together with thoselaunched by local government (districts), have result-ed in the introduction of user fees and in a reductionin government subsidies to non profit organisationsand structures.Since 1998, Tanzania has decided to use internation-

al aid in the health sector according to the SectorWide Approach (SWAp) formula where partners areencouraged to finance the total Action Plan of thesector rather than just specific projects.

HISTORY AND ACTIVITIES OF DOCTORS WITH AFRICACUAMM IN THE COUNTRYDoctors with Africa Cuamm has been active in Tan-zania since 1968. Initially it worked within missionaryand diocesan health structures but, since 1977, ithas been supporting the Government health struc-tures as part of action supported by Italian Coopera-tion. Since 2002, we have worked with health coop-eration projects in many regions: Dar es Salaam,Pwani (in Mkuranga and Rufiji districts), Iringa (inIringa Rurale, Mafinga, Ludewa, Njombe and Maketedistricts) and in Morogoro (Kilosa district). These arecontiguous areas but are very different from the boththe geographical and social point of view, however,the areas do have very similar health and manage-ment problems, for example: insufficient access tohealth care services, HIV/AIDS, TB, Malaria, highmorbidity and maternal-infant mortality.

STRATEGIC OBJECTIVES FOR 2015In line with the development objectives of Millennium4, 5 and 6, Doctors with Africa Cuamm proposes to:1. contribute to improving health among poorer sec-

tions of the population by supporting the localdistrict health service. In particular it proposesworking to reduce maternal and infant mortality inthe seven districts of the regions of Iringa: IringaRural, Iringa Muncipal, Kilolo, Mufindi, Njombe,Ludewa and Makete.

2. Support activities and interventions that aim to in-crease access to primary care and improve nutri-tion among women and children in rural areas.

3. Support national programmes that focus on re-ducing endemic diseases (HIV, TB, Malaria) with-out omitting the neglected diseases.

Tanzania

8 The CCM (Chama Cha Mapinduzi, the Revolutionary Party) was created in1967 and has been in power since then. Initially it was the only party, butalthough other parties have been recognised since 1995, it has continued inpower as it is the strongest and most popular party in the country.

9 The “HIPC Initiative” (Heavy Indebted Poor Countries) was adopted in1966 at the G7 meeting in Lyon, as an attempt to render the foreigndebts of poorer countries more sustainable at least in the medium-longterm.

4. Promote quality in both health services and re-search at different stages of the health system re-inforcing Primary Heath Care in Iringa.

5. Contribute to upgrading the District Hospital ofthe Mikumi Health Service to make it top leveland equip it to become a centre for referrals formaternal-infant health care.

6. Support integration between the public healthservice and the private non profit sector.

7. Offer our services as support agent for imple-menting strategies elaborated with the health au-thorities for the different levels of the districthealth service (hospitals, health centres, commu-nity).

8. Offer our services as support agent within nationalpolicies, for management of the health structuresfrom the point of view of governance, of manage-ment, and of clinical and financial systems.

HUMAN RESOURCES REQUIRED TO ACHIEVEOBJECTIVESIn order to achieve any of the objectives for SouthSudan, human resources must be provided which in-clude both international and local professionals andexperts in hospital, clinic and public health manage-ment. There is also a need for administrators andpersonnel specialised in provisioning and procure-ment.

FINANCIAL RESOURCES REQUIRED TO ACHIEVEOBJECTIVESWe have estimated that by 1915, 18 million Euro willhave been necessary in order to continue and rein-force our activities in Tanzania. We estimate that 8million Euro could be provided locally while another10 million should come from headquarters.

PARTNERSHP ACTIVITIESDoctors with Africa Cuamm proposes to seek outpartnerships with other organizations in order to set

up integrated support projects in the districts, partic-ularly in areas which are not strictly concerned withtechnical and health problems. In 2007, one suchpartnership was started up with two NGOs, Cefa andLvia, in order to carry out integrated actions in theIriga region and, in the long term, in the Dodoma re-gion too. Both Cefa and Lvia work in sectors (waterand hygiene, agricultural and earnings generatingactivities – Igas) that are complementary to thehealth sector where Doctors with Africa Cuamm is.We intend firstly to intensify collaboration with theItalian Ministry of Foreign Affairs (MAAEE) and tostart collaborating with major international agencies(UNICEF and WHO), not only in order to obtain fund-ing but also as regards exchanges of experience,best practices and technical support. Partnershipswith Family Health International (Fhi), the ClintonFoundation and UsAid will be sought with regard tomanagement and aid for specific questions relatingto HIV/AIDS.Should there be another opportunity to work with theIstituto Spallanzani interventions should be made inareas where we are already active and set up on thebasis of the mission of each of the two organiza-tions. Collaboration with the dioceses will be rede-fined on the basis of the annual budget for each hos-pital.

COMUNICATION, FUND RAISING, LOBBYING ANDADVOCACY ACTIVITIES> Promote a strategy of divulgation of results and

lessons learned, both inside and outside the coun-try, through periodical reports, evaluating activitiesand making applied research results public.

> Reformulate the financial strategy for hospitals,taking into account annual agreements and coun-terparts’ support. In this area communicationstrategies must be made more effective in order tohelp support groups and foundations becomemore aware of the issues.

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UGANDA

51

Uganda is a democratic republic. Over the past tenyears the country has been subject to extraordinarychanges in all sectors: financial, political, and cultural.Decentralized administration, internal peace and de-velopment of modern politics in favour of foreign capi-tal investment and industrial development are key ele-ments of its current national policies. The targets andnational health strategies of Uganda were defined inthe second strategic Plan of the Health Sector (HSSPII 2005-2010) and in the Plan for Poverty Reduction.

HISTORY AND ACTIVITIES OF DOCTORS WITH AFRICACUAMM IN THE COUNTRYDoctors with Africa Cuamm has been operating inUganda since 1959. Over this long period it has setup a vast range of initiatives in the health sector, forexample: supporting public hospitals, missionary andhealth services, collaboration with central and periph-eral health systems and promotion of training pro-grams for the health personnel. Today we are active infour regions (West Nile, Central Region, Karamoja,Lango) and in the Uganda Martyrs University of Nkozi.

STRATEGIC TARGETS FOR 2015In line with the development targets of Millennium 4, 5and 6, Doctors with Africa Cuamm proposes to:1. contribute to improving health among poorer sec-

tions of the population by supporting the local dis-trict health service (hospitals, health care, commu-nity). In particular we propose working to reducematernal and infant mortality in the following re-gions.- West Nile.- Lango and Teso.- Region Central.- Karamoja.

2. Support activities and interventions that aim to in-crease access to primary care and improve nutri-tion among women and children in rural areas.

3. Promote and encourage, within the community, thecapacities required to recognise problems regard-ing health and to identify suitable solutions.

4. Support national programmes that focus on reduc-ing endemic diseases (HIV, TB, Malaria) withoutomitting the neglected diseases.

5. Promote quality performances in the health ser-vices, especially hospital services, and reinforceteaching, research and academic partnership ac-tivities in the Faculty of Health Sciences at theCatholic University of the Uganda Martyrs (UMU).

6. Support the coordination activities of the CatholicBureau in the area of integration between publicand non profit private.

7. Reinforce the local information systems for moni-toring and evaluating health services.

WEST NILEThe current activities of Doctors with Africa Cuamm,will continue until 2010, and concentrate on support-ing the district and diocesan health structures of Aruaand Nebbi.During 2008, Doctors with Africa Cuamm will supportprimary eye care interventions and initiatives aimed to

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help disabled people in the community, in healthstructures and in schools.The activities will be carried out in such a way as toencourage increased commitment and responsibilitytaking on the part of our Ugandan partner, so thatthey can carry on, manage, the activities in the fu-ture.

LANGO AND TESONorth Uganda has been torn by decades of CivilWar. The normalisation policies being promoted inthe area all highlight see the Lango and Teso regionsas high priority areas for reconstruction and develop-ment interventions in health care because of theirenormous health needs.

CENTRAL REGIONThe activities of Doctors with Africa Cuamm in theCentral Region are still directed towards completingand reinforcing administrative competencies at Nag-galama Hospital and of collaborating with the nation-al and international partner network, in particularwith those involved in the struggle against AIDS.

KARAMOJAThe Karamoja districts have the lowest health anddevelopment scores not only for Uganda but also forthe whole of east Africa, both because of the ex-treme poverty in the region and the unsafe, unstable,political and social situation. For these reasons theregion is at the centre of the national developmentpriority programmes. We consider it would be goodstrategy to strengthen and consolidate our long-run-ning collaboration with diocesan health structures,with particular attention paid to Matany Hospital, itsclinical services, its role both as coordinator in thesub-district and as promoter of community medi-cine, and its Nursing School.

HUMAN RESOURCES REQUIRED TO ACHIEVEOBJECTIVESHuman resources must be provided which includeboth international and local professionals and ex-perts in hospital, clinic and public health manage-ment, doctors for clinical and medical activities, ad-ministrators and personnel specialised in logistics.It is hoped that this process will also optimize the re-lationship between the expatriate and local person-nel through continuation of a policy of investing in lo-cal human resources, in order to train professionalswho will be both able and motivated to continue ac-

tivities thus ensuring the continuity and sustainabilityof interventions.

FINANCIAL RESOURCES REQUIRED TO ACHIEVEOBJECTIVESWe estimate that 25 million Euro will be required forthe period 2008-2015 if objectives are to be met. Ofthis, 40% should be obtained in loco while the re-maining 60% should come from headquarters.

PARTNERSHIP ACTIVITIESPartnerships are seen as key factors for success inimplementing wider-reaching initiatives that will havegreater impact and visibility. During the period 2008-2015 current and traditional partnerships will bestrengthened and new ones set up. The followingpartnerships will be reinforced:> partnership for obtaining financial support: UNICEF,

UE, Japanese Embassy, USAID, WHO, MildmayClinic.

> Partnership for development initiatives: AVSI, COOPI,ISP, Malaria Consortium, UMU (Uganda MartyrsUniversity), and Local NGOs.

> Project partnership: diocesan health structuresPNFP (private not for profit), districts, HSD (HealthSub-district), government structures, communities.

> Partnerships to reinforce the role of NGOs in nationalstrategy and policy: government ministries, local anddistrict authorities, WHO, UNICEF, OCHA/UNDPUCMB (Uganda Catholic Medical Bureau), UMU(Uganda Martyrs University), development alliances,GFI (Global Found Initiative).

COMUNICATION, FUND RAISING, LOBBYING ANDADVOCACY ACTIVITIESIn order to achieve objectives lobbying, advocacyand fund raising activities in general must be im-proved and developed coherently and transversally.The adoption of English as the only language ofcommunication, internal and external, will facilitatemany activities: communication in loco, event orga-nization, public relations promotion and contact withthe media. It will also be helpful in fulfilling one ofthe aims of Doctors with Africa Cuamm - to act as achannel for passing on, disseminating information -as it will encourage production of periodical reports,evaluations of activities and reports on applied re-search which can be published both at national andinternational levels in order to encourage compari-son and exchange, sharing and learning from oth-ers.