FOREWORD n both the past and present, and in virtually every allow a better understanding of the sector and thus pave I world region, widely varied religious actors play the way for an exploration of priorities and for crucial roles in health care. Nowhere is this more meaningful action. significant than in Sub-Saharan Africa. Today, in most African countries, faith institutions and groups run Frankly, the report found more solid information than clinics, hospitals, and facilities that support families, expected. However, much is in silos, inaccessible or orphans, handicapped people, the mentally ill, and older unknown to key actors. And it is patchy with notable people. In communities, leaders and individuals gaps. It also confirmed our rising appreciation for communicate vital messages about health and provide remarkably wide differences country to country and sustained, hands-on care for the sick. The devastating faith tradition to faith tradition. Thus, a key element is a HIV and AIDS pandemic has placed a powerful series of short, preliminary case studies of faith health spotlight on these networks and their impact. With care in five countries— Gabon, Ghana, Mozambique, ambitious contemporary global health goals—notably South Sudan, and Tanzania—that illustrate this combatting malaria, tuberculosis, and maternal deaths, diversity. but also making decent care for all a meaningful human The report’s principle author was Lynn Aylward, who right—faith leaders and communities can be vital allies. led a team of contributors comprised of Molly Brady Yet many international health institutions and some and Kari Nelson. The case studies were written by Lynn governments have paid scant attention to faith-inspired Aylward, Katherine Marshall, and Claudia Zambra, organizations (FIOs) and their potential impact has not with research and writing assistance by Elizabeth Bliss been tapped in any systematic fashion. This is in part and cover design and final edits for the WFDD edition the result of gaps in knowledge. The “mapping” of by Alana Tornello. The report was prepared under the faith-inspired work is patchy and even less is known leadership of Hahna Fridirici Kimbrough and Katherine about relative costs and effectiveness. The distinctive Marshall in close collaboration with the TBFF under challenges and assets of these actors rarely figure into Ian Linden and Jaclyn Andrasek. It was reviewed by a strategic thinking about public health challenges and distinguished expert panel and benefitted from the delivery of services. This forms part of a broader contributions of many colleagues active in the field. phenomenon: a gulf dividing faith and secular actors We hope the report will shed useful light on the roles plays out in many world regions and institutions. that faith instituions play, gaps in knowledge and These knowledge gaps matter and so do the unanswered action, and opportunities for creative partnerships. We questions. The Tony Blair Faith Foundation and the also hope it will spark a dialogue on why knowledge World Faiths Development Dialogue thus set out jointly gaps matter and what more can be done to enhance to review rigorously what is and what is not known collaboration. The goal is indeed to move purposefully with a view to defining both research and action towards the ideal of decent health care for all. agendas. This report presents the results. Its aim is to Katherine Marshall bring together current academic literature, data bases, and evaluation reports in an accessible form that will Executive Director, World Faiths Development Dialogue 1 EXECUTIVE SUMMARY aith-inspired organizations have been important pro- State of knowledge on FIOs’ engagement in health F viders of health care in Sub-Saharan Africa for over a century. For some thirty years, their work and all its im- Data are scattered across different disciplines, organiza- plications have been a topic of research and discussion. A tions, and databases; and are difficult to consolidate into substantial body of information is available on faith-in- a clear quantitative understanding of the various aspects spired organizations (FIOs) working in health, and inter- of FIOs and their health work. The data sets that do ex- national organizations show growing interest in working ist can be divided into two types: (i) international health with them. data not focused on FIOs per se but including some FIO data and (ii) FIO-focused datasets, often derived from Nonetheless, there is a lack of systematic, comprehensive in- mapping exercises. A strength of the former is that they formation on FIOs. Nor is there rigorous evaluation of their ef- represent high-quality contemporaneous data sets, com- fectiveness and purported distinctive strengths in health work. parable across countries; a notable example is the World The shortfall derives in part from the diversity of the tens of Health Organization Service Availability and Readiness thousands of faith-inspired organizations working in health. Survey (SAM or SARA). Weaknesses are that the data are Their great variation, in nature, size, and structure, has created only available with long lags and they do not provide much unresolved problems of definition and classification. Gaps in faith-specific data, though attempts have been made to ad- knowledge and understanding of FIOs’ health work and its ef- dress this omission. The strength of the FIO-focused data fectiveness generate uncertainties and stereotypes. These, in is that they are highly-detailed and sometimes capture the turn, impede health ministries, the international community, work of community-based organizations, which otherwise multilateral donors, and FIOs themselves, from making the tend to be overlooked; the weakness is that this work, often best choices to improve public health in Africa. (1.1) mapping exercises, provides snapshots at a given moment in time of a specific region, faith, type of FIO, or health This study provides an extensive literature review covering concern, covering a limited range of indicators, and hav- available information from data bases, academic literature, ing limited use for wider extrapolation about FIOs’ health international health organizations, FIOs, and evaluation re- work. (2.3) ports. The report includes a Main and Background Paper. The Main Paper focuses on two topics: (i) the state of knowledge State of knowledge: ten key parameters of FIOs’ and key knowledge gaps on FIOs and (ii) evidence concern- engagement in health in Africa ing their effectiveness and purported comparative advantages. The Background Paper presents four special topics in FIOs’ The information - data, literature, and other sources - on health work in Africa (Supplement 1) and five country case FIOs can be assessed by considering ten key parameters of studies (Supplement 2). A principal goal of the report is to the organizations: number, size, type, and faith affiliation; define an agenda and priorities for research on faith-inspired geographical distribution; health services provided; mar- health work in Africa. ket share and utilization; financing: health service costs; 3 and FIOs’ relations with governments, other stakeholders, over the last several decades. Given that only 3 percent of and each other. (2.4) funds disbursed by the Global Fund to Fight AIDS, Tuber- culosis, and Malaria in its first eight funding rounds went Information on number, size, and types of FIOs; faith directly to FIOs supports claims of bias. On the other hand, affiliation; and geographic distribution some large US faith-inspired organizations receive up to 70 percent of their funding from the US government. Further- Some 100,000 FIOs are working on health in Africa. A rela- more, African governments, at least partially, fund FIOs’ tively small number are faith-inspired large international health work in 75 percent of African countries, though of- nongovernmental organizations (INGOs). Many more are ten with shortfalls in promised reimbursements and delays regional, national, and community-based organizations, in payment. with the INGOs sometimes relying on the smaller organi- zations to implement INGO-led health programs. There Information on health service costs and user fees is great variation in the numbers and nature of FIOs pre- sent from one African country to the next, though coun- Questions about the financing structure of FIOs spill over tries with similar backgrounds share tendencies, e.g., FIOs into questions about user fees and health costs. Provider- tend to be more numerous and play larger roles in Eastern specific findings are mixed. Many faith-inspired health and Southern Africa than in other parts of the continent. providers in Africa charge user fees, and broadly, faith-in- Christian organizations predominate in many countries. spired providers are sometimes more expensive than pub- Organizations affiliated with Islam and other faiths do im- lic ones but generally less expensive than for-profit ones portant work and are probably undercounted. The implica- (though studies vary in taking quality of care into account). tions of the rapid growth of two diverse African Christian FIOs reportedly engage in “Robin Hood pricing,” charging movements, Pentecostalism and the African Independent those who can afford to pay medical costs one fee and us- Churches, for health work are not yet clear. (2.4.1-2.4.3) ing this revenue to cross-subsidize lower fees for the poor. (2.4.6-2.4.7) Information on health services and market share and utilization Information on FIOs’