There are many ways in which policy, program and project decisions can be "suggested" from outside the health system. One of the most common, and important, is when project designs are based primarily on donor policy rather than host country needs.

While there is justification in designing projects around the comparative advantages of donor agencies, this process should be Ministry of Health driven. If not, the result may be a motley of projects which do not provide the spectrum of assistance required to develop an integrated health system, and which probably concentrate assistance in a few easy to reach regions of the country. Possible ways to achieve better donor coordination are:

Coordination by level of the health system. Projects are designed to assist a specific level of the health system. An NGO which works at the community level is a good example. A population policy development initiative is another example. This approach provides the advantage of a concentration of effort at one level of the health system. The disadvantage is that such efforts are not integrated with the other health system levels.

Coordination by PHC component activity or by support component. Projects or programs assist one PHC component or support component. This approach provides the advantage of a concentration of effort on one component. The disadvantage of this strategy is that it does not develop an integration between support components or provide sufficient capacity building to sustain the system.

Coordination by geographic unit. Geographical coordination is usually defined in terms of health districts, and the assistance package required to develop it. Aid agencies are asked to support the development of "x" number of districts. Projects of this type usually assist the development of an entire health district including health centers, community development, referral hospital and support components. This approach provides the advantage of promoting integration of the health system components. The disadvantage is that it requires a comprehensive assistance package. This approach can also result in "balkanization".

Coordination by Comparative Advantage. Most partner agencies have areas of comparative advantage which are usually well known or can be identified by an inventory (see Box 5). The trick is to coordinate these advantages to provide the whole spectrum of development assistance required by the health system. The advantage of this approach is that it builds on the existing comparative advantage of aid agencies. The disadvantage is that it is extremely difficult to coordinate.

Coordination by Geographic Unit and Comparative Advantage. This is a hybrid strategy in which an aid agency supports a certain number of health districts with a comprehensive assistance package, but at the same time supports assistance to all health districts in an area of its comparative advantage. If there is a component of the health district assistance package which a partner can not provide, then they or the MOH must identify another agency which can provide this assistance. This approach combines the advantages of the geographic and comparative advantage approaches. This approach also decreases the tendency to "balkanize" since most agencies are supporting an activity across health districts.