Background: In the 1990s, as a response to rapid urbanization, there were a number of large, urban health initiatives in sub-Saharan Africa. Most tended to be comprehensive as opposed to selective in scope: they aimed at strengthening the health system as a whole, and placed emphasis on delivering improved services at the primary level, with increased community participation. A multi-dimensional approach is required to assess the achievements of such initiatives.
Methods: In 2000 an external evaluation of the Swiss-funded Dar es Salaam Urban Health Project, Tanzania, used 50 key informant interviews, 90 health facility exit interviews, 90 community resident interviews and document analysis to assess achievements over a 10 year period. The study considered achievements in terms of capacity building, improving quality of care, community involvement, inter-sectoral action and sustainability.
Results: Although the project achieved improvements in capacity building and in structural and technical quality of care, there were difficulties in generating inter-sectoral action and the concept of participation was limited. However, city-level 'ownership' of the activities was high, and, with the advent of sector-wide allocation of funds (SWAPs) in the health sector in Tanzania, the prospects for sustainability of the achievements made in the project appear to be good.
Conclusion: Both the multi-dimensional method of the evaluation and the findings can inform future urban health initiatives in sub-Saharan Africa and in other resource-constrained environments. The decentralization that occurred in Dar es Salaam and the general approach of the project provided a platform to test out various elements that are common to health sector reform across developing countries.