Governance and management arrangements for health Sector-Wide Approaches (SWAps) (WP8)

KNOWLEDGE HUBS FOR HEALTHStrengthening health systems through evidence in Asia and the Pacific

The Nossal Institute for Global Health

www.ni.unimelb.edu.au

HEALTH POLICY AND HEALTH FINANCE KNOWLEDGE HUB

WORKING PAPER SERIES NUMBER 8 | NOVEMBER 2010

Governance and management arrangements for health Sector-Wide Approaches

(SWAps): Examples from Africa, Asia and the Pacific

Joel Negin Sydney School of Public Health and Menzies Centre for Health Policy, University of Sydney

Krishna Hort Nossal Institute for Global Health, The University of Melbourne

WORKING PAPER SERIES HEALTH POLICY AND HEALTH FINANCE KNOWLEDGE HUB

Governance and management arrangements for health Sector-Wide Approaches (SWAPs): NUMBER 8 | NOVEMBER 2010Examples from Africa, Asia and the Pacific

ABOUT THIS SERIES This Working Paper is produced by the Nossal Institute for Global Health at the University of Melbourne, Australia.

The Australian Agency for International Development (AusAID) has established four Knowledge Hubs for Health, each addressing different dimensions of the health system: Health Policy and Health Finance; Health Information Systems; Human Resources for Health; and Women’s and Children’s Health.

Based at the Nossal Institute for Global Health, the Health Policy and Health Finance Knowledge Hub aims to support regional, national and international partners to develop effective evidence-informed policy making, particularly in the field of health finance and health systems.

The Working Paper series is not a peer-reviewed journal; papers in this series are works-in-progress. The aim is to stimulate discussion and comment among policy makers and researchers.

The Nossal Institute invites and encourages feedback. We would like to hear both where corrections are needed to published papers and where additional work would be useful. We also would like to hear suggestions for new papers or the investigation of any topics that health planners or policy makers would find helpful. To provide comment or obtain further information about the Working Paper series please contact; [email protected] with “Working Papers” as the subject.

For updated Working Papers, the title page includes the date of the latest revision.

Governance and management arrangements for health Sector-Wide Approaches (SWAps): Examples from Africa, Asia and the Pacific

First draft – November 2010

Corresponding author: Joel Negin Address: Sydney School of Public Health and Menzies Centre for Health Policy, University of Sydney, [email protected]

Other contributors: Kris Hort, The Nossal Institute for Global Health, University of Melbourne

This Working Paper represents the views of its author/s and does not represent any official position of The University of Melbourne, AusAID or the Australian Government.

ACKOWLEDGEMENTSThe author would like to thank World Bank staff in the Pacific region for their comments on an earlier draft of this paper.

HEALTH POLICY AND HEALTH FINANCE KNOWLEDGE HUB WORKING PAPER SERIES

NUMBER 8 | NOVEMBER 2010 Governance and management arrangements for health Sector-Wide Approaches (SWAPs):Examples from Africa, Asia and the Pacific 1

INTRODUCTIONThis Working Paper summarises the experience of Sector-Wide Approaches (SWAps) or similar arrangements in the health sector in seven countries in Africa, Asia and the Pacific. A SWAp is characterised by an emphasis on governments and development partners working together in a ‘whole-of-sector’ manner to support one agreed health plan, and a related monitoring and evaluation framework, in order to maximise the use of resources available to the sector. Some SWAps include pooled funding arrangements and aligned financial management, while non-pooled SWAps focus on harmonisation and improved aid effectiveness. According to Walt, Pavignani et al (1999), a SWAp provides a broad framework within which all resources in the health sector are coordinated in a coherent and well-managed way, in partnership and with recipients in the lead.

The impetus for this Working Paper came from World Bank colleagues in the Pacific region, where the Bank works closely with governments in developing systems to support various SWAp arrangements. An earlier version of the paper was shared with partners in the Pacific to contribute to discussions about management systems for SWAps.

This Working Paper follows three others on the topic of SWAps in the Pacific region by Joel Negin, with examples drawn from Samoa and the Solomon Islands. The three papers are:

• Sector-WideApproachesforhealth:anintroductiontoSWApsandtheirimplementationinthePacificregion.HPHF Knowledge Hub Working Paper No. 2, March 2010.

• Sector-WideApproachesforhealth:acomparativestudyofexperiencesinSamoaandtheSolomonIslands.HPHF Knowledge Hub Working Paper No. 3, March 2010.

• Sector-WideApproachesforhealth:lessonsfromSamoaandtheSolomonIslands.HPHFKnowledgeHubWorking Paper No. 4, March 2010.

The paper aims to provide examples of governance and management arrangements of health SWAps and similar arrangements in a number of countries. The purpose of the paper is to inform discussion of options for the Government of the Solomon Islands. It does not provide an assessment of the effectiveness or appropriateness of the arrangements, or endeavour to compare arrangements across countries.

Examples of SWAps and similar arrangements were identified through a literature search. Accepted evidence included National Ministry of Health and development partner reports, SWAp reviews, conference presentations and academic literature describing and/or evaluating SWAps. The seven country examples were selected on the basis of availability of relevant information and longevity, under the assumption that SWAps that have been in existence for five or more years are more likely to have more settled and tested management structures. The exception is the Samoan health SWAp, which is included as a Pacific regional comparator to the Solomon Islands.

The emphasis for inclusion of country-level SWAps was on identifying management structures and arrangements that might be relevant to the Government of the Solomon Islands. The establishment of various committees and working groups and their roles and interaction with government bodies, including during formal review processes, were extracted from relevant documents.

The main findings of this review were:

• AllSWApsareadaptedtolocalcircumstancesandlocalneeds;thereisnoone-size-fits-allapproach.

• ThemechanismspresentedherearemostlyfrommuchlargercountriesthantheSolomonIslands,withmany more development partners, and therefore suitability to the Solomon Islands will need to be assessed.

• MostSWApshaveformalisedgovernancearrangements,includingannualorbiannualsectorreviews,morefrequent sector coordination meetings and a SWAp secretariat of some kind. Most SWAps also have a formal Memorandum of Understanding (MOU) between development partners and the government.

• Thelargerannualsectorreviewsgenerallyhavewideparticipation.Theyreviewperformance,developaprogram of work for the upcoming year and provide a forum to agree on financial contributions.


Governance and management arrangements for health Sector-Wide Approaches (SWAPs): NUMBER 8 | NOVEMBER 2010Examples from Africa, Asia and the Pacific2

• Sectorcoordinationmeetingsgenerallytakeplaceapproximatelymonthlyandincludeatleastdevelopmentpartners and government and, in some cases, NGOs and private providers. All of the coordination committees are chaired by government representatives— most commonly from the Ministry of Health.

• AsmallernumberofSWApcountriesmaintainseparateformaldevelopment-partner-onlycoordinationgroups that report to the wider coordination meetings through a donor focal point.

• MostSWApsalsohavesubgroupsthatprovideforumsforin-depthdiscussionsoncertaintechnicaltopicsand that report to the SWAp management. Most SWAps include subgroups on technical issues related to SWAp functioning, such as human resources, monitoring, procurement or finance.

• Thepersistenceofdisease-specificcoordinationmechanismshasbeenanongoingchallengeforhealthsector coherence.

• Mostcountries’governanceandmanagementarrangementshavechangedovertimetorespondtoemerging challenges and shortcomings.



SWAp GOVERNANCE STRUCTURES: INTERNATIONAL EXAMPLESThe following table summarises information on the management and governance arrangements of seven SWAps or similar arrangements: four in African countries (Zambia, Malawi, Uganda, Mozambique), two in Asia (Cambodia and Bangladesh) and one in a Pacific Island country (Samoa).

In Cambodia the Ministry of Health has adopted sector-wide management or SWiM. Under the SWiM, some funds are pooled (especially from the World Bank through the Health Sector Support Project), and the pooled funds are used within project structures with a commitment to harmonisation and alignment of donor funding in support of the Ministry’s Health Strategic Plan. Despite the somewhat different mechanism and different name, the Cambodian SWiM represents a similar arrangement to SWAps (especially that of the Solomon Islands, which is more focused on harmonisation and alignment rather than pooled funding) and is therefore included in this paper.

The table provides information on key governance elements identified, such as the format of annual reviews, coordination meetings and subgroups. Following it are examples of governance mechanisms from three SWAp countries. The brief then provides more information on the various governance arrangements and other issues for consideration.

The countries with health SWAps and similar arrangements described here are generally larger in terms of population and established their SWAps considerably earlier than the Solomon Islands. Additionally, some of the countries reviewed have considerably more development partners and stakeholders active in the sector than the Solomon Islands. Therefore, caution should be taken in interpreting the examples.

WO

RK

ING

PA

PE

R S

ER

IES

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EA

LTH

PO

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ange

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ts fo

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ide

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hes

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ples

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Gov

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nce

and

man

agem

ent a

rran

gem

ents

for h

ealth

Sec

tor-

Wid

e A

ppro

ache

s (S

WA

Ps)

: Exa

mpl

es fr

om A

frica

, Asi

a an

d th

e Pa

cific

5

Cat

ego

ryS

amo

aZ

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pul

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mill

ion

15 m

illio

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mill

ion

15 m

illio

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mill

ion

162

mill

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Dat

e o

f est

ablis

hm

ent

of S

WA

p20

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arly

199

0s20

0419

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WiM

ado

pted

in 2

000

2000

1998

SW

Ap

sec

reta

riat

(c

om

po

siti

on

, fu

nd

ing)

SW

Ap

Coo

rdin

atio

n U

nit h

ouse

d an

d ru

n by

gov

ernm

ent.

Rep

orts

to C

EO o

f M

OH

. Com

pose

d of

co

ordi

nato

r, ac

coun

tant

, pr

ocur

emen

t spe

cial

ist

and

four

oth

er s

taff

(all

loca

l).

Dire

ctor

ate

of P

lann

ing

and

Dev

elop

men

t w

ithin

MO

H; d

onor

co

ordi

natio

n of

ficer

with

in M

OH

. E

stab

lishe

d on

ly in

20

03.

SW

Ap

secr

etar

iat i

n th

e P

lann

ing

Uni

t of M

OH

.Te

chni

cal W

orki

ng

Gro

up fo

r Hea

lth

secr

etar

iat h

as

repr

esen

tativ

es o

f MO

H

and

DP

s—fo

rmul

ates

M

&E

indi

cato

rs, a

nnua

l w

ork

plan

s.

Co

ord

inat

ion

com

mit

tees

Pro

gram

Ste

erin

g C

omm

ittee

.

Mem

bers

: Min

istri

es

of H

ealth

, Fin

ance

, S

ocia

l Dev

elop

men

t, D

Ps,

priv

ate

sect

or a

nd

NG

Os.

Func

tion:

pro

vide

hi

gh-le

vel o

vers

ight

for

impl

emen

tatio

n an

d ac

t as

foru

m fo

r vie

ws

and

conc

erns

of p

artn

ers.

Det

ails

: Mee

ts q

uarte

rly.

Cha

ired

by M

OH

or

Fina

nce.

Polic

y C

onsu

ltativ

e M

eetin

g (1

2 pe

r yea

r).

Mem

bers

: MO

H, D

Ps.

Func

tion:

add

ress

ge

nera

l hea

lth s

ecto

r-re

late

d is

sues

.

Det

ails

: pre

side

d ov

er

by th

e P

S.

Hea

lth S

ecto

r Rev

iew

G

roup

.

Mem

bers

: poo

led

and

non-

pool

ed p

artn

ers;

N

GO

s; p

rivat

e se

ctor

.

Func

tion:

revi

ew

impl

emen

tatio

n pr

ogre

ss a

nd a

nnua

l w

ork

plan

s.

Det

ails

: cha

ired

by

MO

H.

Sec

tor W

orki

ng G

roup

.

Mem

bers

: MO

H,

Fina

nce,

DP

s.

Func

tion:

set

bud

get

prio

ritie

s an

d ap

prov

e pr

ojec

ts.

Det

ails

: cha

ired

by P

S.

Hea

lth P

olic

y A

dvis

ory

Com

mitt

ee: m

embe

rs:

MO

H, F

inan

ce,

Educ

atio

n, lo

cal

gove

rnm

ent,

DP

s,

priv

ate

prov

ider

s.

Det

ails

: mee

ts m

onth

ly.

Tech

nica

l Wor

king

G

roup

for H

ealth

.

Mem

bers

: 74

(gov

ernm

ent,

NG

Os,

D

Ps)

.

Func

tion:

focu

s on

br

oade

r stra

tegi

es a

nd

heal

th s

yste

ms.

MO

H T

ask

Forc

e on

Dee

peni

ng

Har

mon

isat

ion

and

Alig

nmen

t.

Mem

bers

: MO

H

Dep

artm

ent o

f In

tern

atio

nal

Coo

pera

tion.

SW

Ap

Foru

m.

Mem

bers

: MO

H a

nd

exte

rnal

par

tner

s.

Det

ails

: Rec

ent p

ush

to

mak

e it

mor

e in

clus

ive

and

incl

ude

all D

Ps.

HN

PS

P C

oord

inat

ion

Com

mitt

ee.

Mem

bers

: MO

H a

nd

two

deve

lopm

ent

part

ners

who

re

pres

ent v

iew

s of

all

deve

lopm

ent p

artn

ers.

Func

tion:

revi

ew

impl

emen

tatio

n pr

ogre

ss (t

o da

te h

as

been

too

form

al a

nd n

ot

focu

sed

on d

etai

l).

WO

RK

ING

PA

PE

R S

ER

IES

H

EA

LTH

PO

LIC

Y A

ND

HE

ALT

H F

INA

NC

E K

NO

WLE

DG

E H

UB

4 G

over

nanc

e an

d m

anag

emen

t arr

ange

men

ts fo

r hea

lth S

ecto

r-W

ide

App

roac

hes

(SW

AP

s): E

xam

ples

from

Afri

ca, A

sia

and

the

Paci

fic

NU

MB

ER

8 |

NO

VEM

BE

R 2

010

HE

ALT

H P

OLI

CY

AN

D H

EA

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FIN

AN

CE

KN

OW

LED

GE

HU

B

WO

RK

ING

PA

PE

R S

ER

IES

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MB

ER

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VEM

BE

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010

Gov

erna

nce

and

man

agem

ent a

rran

gem

ents

for h

ealth

Sec

tor-

Wid

e A

ppro

ache

s (S

WA

Ps)

: Exa

mpl

es fr

om A

frica

, Asi

a an

d th

e Pa

cific

5

Cat

ego

ryS

amo

aZ

amb

iaM

alaw

iU

gan

da

Cam

bo

dia

Mo

zam

biq

ue

Ban

gla

des

h

Dev

elo

pm

ent p

artn

er

onl

y co

ord

inat

ion

foru

ms

Non

e.N

one.

Hea

lth d

onor

sub

grou

p re

port

s to

Hea

lth S

ecto

r R

evie

w G

roup

.

Hea

lth D

evel

opm

ent

Part

ners

Gro

up m

eets

m

onth

ly to

coo

rdin

ate.

O

ne a

genc

y se

rves

as

chai

r and

con

tact

poi

nt

with

MO

H.

Hea

lth P

artn

ers

Gro

up

(onl

y D

Ps)

.N

one.

Don

or c

onso

rtiu

m

mee

ting

incl

udes

all

DP

s.

Sep

arat

e m

eetin

g fo

r poo

led

fund

ing

part

ners

.

An

nu

al r

evie

ws

Hea

lth s

umm

it in

M

arch

and

join

t re

view

in S

epte

mbe

r ea

ch y

ear o

rgan

ised

by

gov

ernm

ent.

All

part

ners

invi

ted,

in

clud

ing

civi

l soc

iety

an

d pr

ivat

e se

ctor

.

Ann

ual c

onsu

ltativ

e m

eetin

g; s

ecto

r ad

viso

ry g

roup

mee

ting

(2 p

er y

ear).

Mul

ti-st

akeh

olde

r joi

nt

revi

ews

held

twic

e ea

ch y

ear w

ith a

ides

-m

emoi

res

aris

ing

from

re

view

s. C

oord

inat

ed b

y S

WA

p se

cret

aria

t.

Join

t rev

iew

s he

ld tw

ice

each

yea

r. P

rogr

ess

is re

view

ed a

nd p

lans

ar

e ag

reed

for c

omin

g si

x m

onth

s, in

clud

ing

prio

ritie

s an

d bu

dget

al

loca

tions

.

Con

duct

ed th

roug

h th

e ro

utin

e ac

tiviti

es o

f the

M

OH

; inc

lude

s an

nual

he

alth

con

gres

s an

d an

nual

ope

ratio

nal p

lan.

Sec

tor C

oord

inat

ion

Com

mitt

ee m

eets

tw

ice

a ye

ar, c

haire

d by

Min

iste

r of H

ealth

, in

clud

es M

OH

and

DP

s.

Ann

ual p

rogr

am re

view

in

clud

es jo

int fi

eld

visi

ts

and

revi

ew o

f pro

gres

s.

Sec

tora

l sub

gro

ups

Non

e.Ye

s, in

clud

ing

finan

cing

, hu

man

reso

urce

s,

proc

urem

ent a

nd

tech

nica

l are

as.

Tech

nica

l wor

king

gr

oups

incl

udin

g pr

ocur

emen

t, hu

man

re

sour

ces.

Incl

udes

D

Ps.

Eigh

t wor

king

gr

oups

, inc

ludi

ng

hum

an re

sour

ces,

in

frast

ruct

ure,

fina

nce,

m

onito

ring.

A n

umbe

r of

prog

ram

mat

ic a

nd

dise

ase-

spec

ific

tech

nica

l wor

king

gr

oups

.

SW

Ap

-rel

ated

them

atic

w

orki

ng g

roup

s—w

here

m

ore

in-d

epth

ana

lysi

s is

nee

ded

prio

r to

broa

der f

orum

s.

Non

e.

Mem

ora

nd

um

of

Un

der

stan

din

gA

join

t par

tner

ship

ar

rang

emen

t des

crib

es

the

prin

cipl

es o

f the

S

WA

p, ro

les

and

resp

onsi

bilit

ies

of D

Ps

and

gove

rnm

ent.

Hea

lth M

OU

and

Joi

nt

Ass

ista

nce

Stra

tegy

bo

th s

igne

d.

MO

U b

etw

een

DP

s an

d M

OH

. Ref

ers

to c

oord

inat

ion

and

mon

itorin

g, fi

nanc

ing

arra

ngem

ents

.

SW

Ap

MO

U.

Cur

rent

ly n

o S

WA

p M

OU

; the

pro

cess

op

erat

es a

s a

SW

iM

with

DP

and

MO

H

agre

emen

t.

Cod

e of

con

duct

that

se

ts th

e ba

sic

rule

s of

en

gage

men

t bet

wee

n th

e M

OH

and

par

tner

s.

Not

es:

1. S

WiM

: Sec

tor-

Wid

e M

anag

emen

t; D

P: D

evel

opm

ent P

artn

er; M

OU

: Mem

oran

dum

of U

nder

stan

ding

; MO

H: M

inis

try

of H

ealth

; NG

O: N

on-G

over

nmen

t Org

anis

atio

n; M

&E

: Mon

itorin

g an

d E

valu

atio

n; P

S: P

erm

anen

t Sec

reta

ry; H

NP

SP

: Hea

lth

Nut

ritio

n P

opul

atio

n S

ecto

r Pro

gram

2. T

he in

form

atio

n in

the

tabl

e w

as c

ompi

led

from

a re

view

of n

umer

ous

doc

umen

ts, a

ll lis

ted

in th

e “C

ited

refe

renc

es a

nd o

ther

sou

rces

” se

ctio

n. F

or s

impl

icity

, the

sum

mar

y he

re d

oes

not c

ite th

ese

sour

ces.



EXAMPLES OF SWAp MANAGEMENT STRUCTURESExamples of SWAp management structures and reporting lines in three countries are provided here in graphic form to demonstrate the variety of systems developed.

Malawi• SWApmanagementstructureisownedandcentredontheMinistryofHealth(MOH),withtheSWAp

secretariat housed within MOH and reporting to MOH management committees.

• HealthSectorReviewGroupincludesMOHanddevelopmentpartnersaswellasNGOsandprivatesectorand reports to MOH (and consults with SWAp secretariat). (DFID 2004)

Technical Working Groups

Financial Management and Procurement Working Group

Human Resources Working Group

Ad hoc groups

Cabinet Committee on Health Parliamentary Health Committee

Health Sector Review Groups

Co-chaired Ministry/Dxxxx, NGOs, private sector providers.

Health Sub- Groups

SWAp

Secretariat

Zonal Offices

Top Management Committee

Chair: Health Minister, also Treasury, Local Government, Economic Planning.

Departmental Meetings and Committees

Senior Management Committee

Chair: Principal Secretary of Health, Health Directors, Central Hospitals, Professional Councils.



Uganda• HealthPolicyAdvisoryCommitteemeetsmonthlyandincludesdevelopmentpartners,governmentand

private providers.

• HealthdevelopmentpartnersonlymeetmonthlyandreporttoHealthPolicyAdvisoryCommittee. (Hutton 2004)

Top Management Committee*

Sector Working Group*Health Policy Advisory Comittee*

Partnership Fund

Working Groups*

Office of the Minister

Permanent Secretary

Director General

MoH Structure

Inter-Agency Coordinating Committees*

Senior Management Committee*

Health Developement Partners* (HDP Group)



Bangladesh• MinistryofHealthanddevelopmentpartnersbothcontributetoannualprogramreview.

• Separatecoordinationforumsexistforpoolfundersandforalldevelopmentpartners (including non-pooled partners).

• RecentlyestablishedHealthNutritionPopulationSectorProgrammeCoordinationCommitteemeetsquarterly and includes two development partners who represent the wider donor consortium (Sundewall, Forsberg et al 2006)

Donor Consortium (All development partners)

Development Partners

HPSO Steering Committee (Pool funders)

Annual Programme Review/Policy Dialogue

Ministry of Health and Family Welfare

Directorate of Family Planning

Directorate of Health Services



SUMMARY OF GOVERNANCE AND MANAGEMENT ISSUESSWAp SecretariatsSome, but not all, countries with health SWAps have formally convened SWAp secretariats. Samoa, Zambia and Malawi—some of the countries with the strongest SWAps—have secretariats based within the MOH and reporting to the Minister of Health.

The SWAp secretariat manages the day-to-day functioning of the SWAp, including donor coordination, accounting and procurement related to SWAp funds and other management roles.

Zambia explicitly places its SWAp secretariat as the go-between for development partners and the government. In other countries, management functions are retained within regular MOH functions.

Coordination CommitteesThough named differently, ongoing coordination mechanisms between various health sector stakeholders exist in each SWAp country. All include development partners and government. Government representatives are generally from the central MOH but sometimes also include finance, education, social development and other relevant Ministries involved in the health sector response.

Most but not all include others, such as private providers and NGOs. Both pooled and non-pooled partners are included.

All of the coordination committees are chaired by government representatives—most commonly from the MOH but occasionally from other Ministries. These bodies variously review progress, develop work plans, support implementation and discuss issues as they arise.

In Bangladesh, coordination meetings, which included the full suite of development partners, were deemed to be too large to permit meaningful discussion.

Development-Partner-Only Coordination ForumsMost countries do not have formal coordination forums exclusively for development partners. Malawi, Bangladesh and Uganda, however, all maintain development-partner-only forums that then report a coordinated perspective to a wider meeting including the national government. The development partner forums generally share information about program planning and program assessments and seek to reduce transaction costs for both agencies and government.

Bangladesh’s recently established Health Nutrition Population Sector Programme Coordination Committee meets approximately quarterly and is made up of senior MOH officers and two development partners, the latter representing the views of the wider partner community.

Analysis of sector coordination in Zambia reveals that even without a formal development partner forum, informal gatherings of donors still occur. According to one report: ‘a number of issues get discussed “over a cup of coffee”’ and ‘… in the past the Ministry has expressed opposition to such gatherings, rejecting any need to exclude policy-makers in a climate of openness and consultation. However, their continued existence demonstrates the inevitability of donor-donor communication.’ Furthermore, ‘senior MOH officials welcome the opportunity for partners to present a common position’ (Lake and Musumali 1999).

In the 1990s, Mozambique tried appointing one donor as the focal point to interface between the MOH and the donor community to relieve the MOH of part of the burden of discussing every issue with each agency. This endeavour was ultimately abandoned, however, as it was felt by both the MOH and other development partners that the focal donor had become too influential (Pavignani and Durao 1999).



Annual ReviewsAll SWAp countries have annual or biannual processes to review performance, develop a program of work for the upcoming year and agree on financial contributions. Some countries go down to the level of a procurement plan for the upcoming year.

Development partners generally prepare detailed reports on what they have done over the past year and specific details on what they plan to do in the coming year. In this way, the development partners work around an agreed national calendar or timetable.

One document in Mozambique noted that ‘a serious concern has been the lack of systematic follow up’ by the MOH and development partners of the recommendations made in the annual review. The document lamented that the reports emerging from the review were ‘not followed by implementation plans’ that facilitated and directed action (Martinez 2006).

Sectoral SubgroupsMost SWAps, in addition to coordination mechanisms and reviews, have subgroups that provide forums for in-depth discussions on technical issues related to SWAp functioning such as human resources, monitoring, procurement and finance. A number of countries also maintain disease-specific technical working groups. All of these subgroups report back to the SWAp secretariat or coordination mechanism.

Memoranda of UnderstandingMost countries with SWAps have some sort of agreement between development partners and the government (though most do not include private sector organisations or NGOs).

Overall, MoUs set the basic rules of engagement between the government and development partners. MoUs can describe some combination of the principles of the SWAp, roles and responsibilities of the development partners and the government related to the SWAp, institutional and fiduciary arrangements, approach to capacity building, monitoring and evaluation, disbursement arrangements for contributions of the pooled partners, conflict resolution and steps for adding new partners to the pooled arrangement.

Involvement of Non-State ActorsA number of sector coordination mechanisms include only the government and development partners, to the exclusion of non-state actors such as faith-based organisations, NGOs and the private sector. Malawi and Uganda, however, in which private providers and NGOs deliver a significant percentage of health services, both include non-state actors in their ongoing coordination meetings. Most annual or biannual reviews include a wide range of the health sector, including NGOs and private/not-for-profit providers such as churches. Commentators have acknowledged that ‘the role of NGOs in the SWAp process has all along been ambiguous’ (Jeppsson 2002).

Separate HIV Coordination MechanismsA number of countries (such as Mali, Madagascar and Mozambique) that have well-developed coordination for the health sector maintain separate mechanisms for coordination of the HIV response. This is partly due to the Global Fund requirement to have a country coordinating mechanism with specific membership requirements.

Following from this, in a few countries, technical units of the MOH continue to operate in a vertical fashion, holding technical meetings with donors, arranging separate training workshops and generally not coordinating activities and plans centrally. In Mozambique, technical departments maintain close links with technical partners that hinder central coordination.

Technical Assistance to SWAp SecretariatsFor SWAps in Africa, donors including the World Bank and the UK Department for International Development (DFID) have provided technical assistance in the establishment and initial staffing of SWAp secretariats. Technical assistance is thus provided explicitly with a clear mentoring and capacity-building role to strengthen the government’s ability to manage the SWAp.



The Samoan SWAp secretariat has recently hired one adviser focused on procurement (of items as diverse as vehicles, civil works, pharmaceuticals and information technology equipment) and one on program management, who are both international advisers and are both donor funded. The technical assistance was in response to discussions between development partners and government on SWAp secretariat needs and skill gaps.

Documents describing the Malawi SWAp went into significant detail on technical assistance. The Malawi MOH and the SWAp donor group conducted a human resources needs assessment that included effective SWAp management. The technical assistance needs identified were to be funded through the SWAp and included procurement specialists, human resources management specialists, M&E specialists and financial management specialists.

The ten technical assistant (TA) posts in Malawi were recruited directly by the MOH through a competitive and open process facilitated by one of the SWAp partners, and the funds for the posts were provided by DFID. The advisers are managed and monitored by the MOH—this differed from the past, when technical assistants reported to the funding donor.

A review of past technical assistance in Malawi (Malawi MOH and Health SWAp Donor Group 2007) revealed that although the assistance was effective in terms of output, the impact of capacity building and skills transfer was often very poor due to lack of government counterparts for technical advisors or insufficient focus by the adviser. Improvement in capacity building is part of the commitment for new technical assistance, and the long-term objective of SWAp partners is to phase out technical assistance over a ten to fifteen year period.

The needs assessment in Malawi is to be conducted annually, with procurement of assistance to respond to needs identified. Technical assistance is funded from within the pooled funding.

CONCLUSIONThe various SWAps and similar arrangements have all adapted their management mechanisms to suit local circumstances and needs. Despite this, a few common trends appear, including formal annual or biannual sector reviews, monthly sector coordination meetings and a secretariat within the MOH that manages the day-to-day elements of the SWAp. In countries with many donors, some have tried separate donor coordination forums to allow for a coordinated donor perspective. Separate disease-specific coordination bodies have also been attempted, but the trend seems to be towards a more streamlined whole-of-sector approach. Importantly, most countries’ management arrangements have changed over time in response to challenges and shortcomings, suggesting that SWAp governance must be dynamic and must be evaluated frequently to ensure that it is functioning effectively.



CITED REFERENCES AND OTHER SOURCESBoesen, N. and D. Dietvorst. 2007. SWAps in motion: Sector wide approaches—from an aid delivery to a sector development perspective. http://www.swisstph.ch/fileadmin/user_upload/Pdfs/swap/swap456_Boesen_2007.pdf (accessed 14 January 2010).

Carlson, C., M. Boivin, A. Chirwa, Simon Chirwa, Fenwick Chitalu, Geoff Hoare, Mechtild Huelsmann, Wedex Ilunga, Ken Maleta, Andrew Marsden, Tim Martineau, Chris Minett, Albert Mlambala, Friedrich von Massow, Hatib Njie and Ingvar Theo Olsen. 2008. Malawi health SWAp mid-term review: Summary report. Norad Collected Reviews 22/2008. Oslo: Norwegian Agency for Development Cooperation.

Chansa, C. 2007. Zambian health SWAp revisited—has it made the intended effects? http://www.gtz.rhp.com/conferences/madagascar07/ChansaCollins_final.pdf (accessed 14 January 2010).

Chansa, C., J. Sundewall, D. McIntyre, G. Tomson and B.C. Forsberg. 2008. Exploring SWAp’s contribution to the efficient allocation and use of resources in the health sector in Zambia. Health Policy & Planning 23(4): 244-251.

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http://www.u4.no/themes/health/dfidmalawifinalreport.pdf (accessed 14 January 2010).

Hutton G. 2004. Case study of a successful’ sector-wide approach: the Uganda health sector SWAp. A lessons learned paper established in the frame of the SDC-STI SWAp Mandate 2003-4. http://www.sti.ch/fileadmin/user_upload/Pdfs/swap/swap351.pdf (accessed 14 January 2010).

International Health Partnership. 2008. Cambodia Taking Stock Report. http://www.internationalhealthpartnership.net/pdf/03_CAMBODIA_TSR_EN_FINAL.pdf (accessed 14 January 2010).

International Health Partnership. 2008. Madagascar Taking Stock Report. http://www.internationalhealthpartnership.net/pdf/05_MADAGASCAR_TSR_EN_FINAL.pdf (accessed 14 January 2010).

International Health Partnership. 2008. Mali Taking Stock Report. http://www.internationalhealthpartnership.net/pdf/06_MALI_TSR_EN_FINAL.pdf (accessed 14 January 2010).

International Health Partnership. 2008. Mozambique Taking Stock Report. http://www.internationalhealthpartnership.net/pdf/07_MOZAMBIQUE_TSR_EN_FINAL.pdf (accessed 14 January 2010).

International Health Partnership. 2008. Nepal Taking Stock Report. http://www.internationalhealthpartnership.net/pdf/08_TSR_Nepal_FINAL_July_2008.pdf (accessed 14 January 2010).

International Health Partnership. 2008. Zambia Update: Scaling-Up for Better Health. http://www.internationalhealthpartnership.net/pdf/IHP%20Update%2013/MINISTERIAL/Zambia.pdf (accessed 14 January 2010).

Jeppsson, A. 2002. SWAp dynamics in a decentralized context: experiences from Uganda. Social Science & Medicine. 55(11): 2053-2060.

Lake S., and C. Musumali. 1999. Zambia: The role of aid management in sustaining visionary reform. Health Policy & Planning 14(3): 254-263.

Malawi Ministry of Health and Malawi Health SWAp Donor Group. 2007. Human resources / capacity development within the health sector needs assessment study: Final report. http://www.jica.go.jp/cdstudy/library/pdf/c20071127_05.pdf (accessed 14 January 2010).

Martinez, J. 2006. Implementing a sector wide approach in health: the case of Mozambique. London: HLSP Institute.

Martinez, J. 2008. Sector wide approaches at critical times: the case of Bangladesh. London: HLSP Institute.



Örtendahl C., 2007. The Uganda health SWAp: new approaches for a more balanced aid architecture? London: HLSP Institute.

Pavignani, E. and J.R. Durao. 1999. Managing external resources in Mozambique: building new aid relationships on shifting sands? Health Policy & Planning 14(3): 243-253.

Sundewall, J., B.C. Forsberg and G. Tomson. 2006. Theory and practice—a case study of coordination and ownership in the Bangladesh health SWAp. Health Research Policy and Systems 16, 4: 5.

Sundewall, J. and K. Sahlin-Andersson. 2006. Translations of health sector SWAps—a comparative study of health sector development cooperation in Uganda, Zambia and Bangladesh. Health Policy 76(3): 277-287.

Walt, G., E. Pavignani, L. Gilson and K. Buse. 1999. Managing external resources in the health sector: are there lessons for SWAps (sector-wide approaches)? Health Policy and Planning 14(3): 273-284.

White, H. 2007. The Bangladesh health SWAp: Experience of a new aid instrument in practice. Development Policy Review 25(4): 451-472.

World Bank. 2008. Project appraisal document of the World Bank on a proposed credit in the amount of SDR 1.9M to the independent state of Samoa in support of health sector management project. http://www-wds.worldbank.org/external/default/wdscontentserver/wdsp/iv/2008/06/03/000333037_20080604000524/rendered/pdf/411300pad0p0861ly10ida1r20081017911.pdf (accessed on 14 January 2010).

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KNOWLEDGE HUBS FOR HEALTHStrengthening health systems through evidence in Asia and the Pacific

A strategic partnerships initiative funded by the Australian Agency for International Development

The Nossal Institute for Global Health

Governance and management arrangements for health Sector-Wide Approaches (SWAps) (WP8)

Documents

Transcript of Governance and management arrangements for health Sector-Wide Approaches (SWAps) (WP8)