Sector-wide approaches [SWAps] in health: an overview Tom Merrick, World Bank Institute.
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Transcript of Sector-wide approaches [SWAps] in health: an overview Tom Merrick, World Bank Institute.
Sector-wide approaches [SWAps] in health: an overview
Tom Merrick, World Bank Institute
Objective & issues to address:
Objective: provide an overview of SWAps
Issues to address: Emergence & popularity of SWAps What SWAps are, their core elements Readiness criteria for SWAps SWAp financing options Advantages & disadvantages of
SWAps
Why emergence, popularity of SWAps
Three key sets of underlying reasons: shift in macro-economic dialogue
from SAPs to public expenditure management
recognized need to ‘reform aid’
opportunities provided by sector reform programs
Why reform aid?Problems with ‘project modality’ :
• Distortion of sectoral policies & budgets
• Minimal national ownership
• Undermining existing national systems
• Burden on recipient governments
• High operating/transaction costs
• Inflexibility; one size fits all
• Varying standards of service provision
Objectives SWAp is expected to achieve
Address fundamental issues/problems of ‘project aid’ modality
Increase aid effectiveness Restore ideal DCG/donor relationships Establish greater coherence between
policies, programmes and budgets Demonstrate ‘programme approach’ Scale-up positive lessons learned
What then is SWAp?
Various definitions; new concept; understanding still evolving
aid coordination mechanism; aid modality
way of managing development assistance
partnership between govt. & donors approach to sectoral development integrated national programme for
policy reform in a sector, SDP (UNICEF)
Common definition A method of working b/w govt & DPs All significant funding for the sector supports a
single policy and expenditure program Govt. provides leadership Common management approaches applied
across the sector by all partners Programme progresses towards relying on
govt. procedures to disburse and account for all funds
Core elements/attributes of SWAps
sector-wide in scope agreed coherent policy framework &
strategy national government leadership all/most donors sign on common/joint work program common management arrangements:
– disbursement and accounting of funds– reviewing performance
move towards reliance on govt. procedures
Variations in sector aid arrangements
Sector reform program
Project type aid
Earmarked funds
Pooled funds
Budget support
Stand alone projects
Project Self-contained One implementing
agency, one or a few financiers
Projects have own support systems
Implementation by a project unit overseen by a management committee
Project has clear beginning and end
Sector Program Open-ended and
complex (covers many projects and activities)
Many implementing agencies, many financiers
Common support systems
Project unit/management committee model cannot cope with complexity of program
Program is a rolling process with continuous planning, implementation
Contrast Project and Sector ProgrammeContrast Project and Sector ProgrammeApproachesApproaches
What is the “health sector”?
How the “health sector” relates to the “health system”
Does the sector refer to public sector only, or public and private actors?
Health outcomes are influenced by forces inside and outside the health system — how does SWAp address factors beyond health care?
How wide is sector-wide?
Ideally, a SWAp should capture the full spectrum of activity, financing and participation in the health sector
In practice, most SWAps only capture public expenditures (approx. 50% of total sector expenditure)
However, as SWAps mature, planning and budgeting functions capture more fragments of existing programmes, and new investment
Risks/common concerns in SWAps
Reduced/static govt. spending on health
Weak government capacity to implement/manage programme
Inadequate ownership/participation of wider stakeholder group
Disruption of services [transition] Suitability in decentralized systems
Risks/common concerns (2)
Loss of focus/fungibility Weak accountability environment Loss of attribution Increased demands on government
performance Treatment of some issues
[RH,gender] No window on the poor Capacity of govt to deal with NGOs,
PS
Risk: support systems during transition
Projects often have own procurement, training, info. & communication systems
Sector-wide management often brings common arrangements
Well-functioning programs risk being undermined by poorer ones
Timing of shift to common support systems critical
Part of donor reluctance to abandon projects
Advantages of SWAps (1) Increases predictability of funding;
[govt./DPs] Places government squarely in charge,
guided by policy and planned with knowledge of available resources
Identifies priorities; improves financing base
Reduces transaction costs (arguably) Applies interventions equitably, avoiding
geographic disparities
Advantages (2)
Increases transparency of resource Improves accountability Increased value for money Easier to disburse funds More effective partnerships Employs performance monitoring and
uses an evidence-based approach DPs: greater influence over policies,
priorities, expenditure
When is SWAp most likely to succeed?Where:
public expenditure in sector is high donor contribution is large donor co-ordination could be a problem donors willing to harmonize procedures agreement on strategy b/w Govt. & DPs supportive macro budget environment good fin/accountability mechanisms institutional relationships manageable relatively adequate national capacities
SWAp financing options Pooled or basket funding [budget support]
– thru/managed by govt. [preferred]
– managed by a partner Pooled with earmarking Parallel funding [for activities in program]:
– traditional projects
– direct provision of goods & services Mixed [some donors do both] Example: Ethiopia: 3/4 channels
‘Pools’ vary: scope, operation, coverage
Zambia: district basket restricted to non-staff, non-drug costs
Tanzania: district pool prescribed by spending categories; ceiling set at 50 US cents per capita
Mozambique: operates a drugs procurement and distribution pool for all levels of service delivery in the country
Time sliced financing” in Bangladesh: WB reimburses part of govt sector expenditure
Advantages of Pooling Focuses on strengthening govt. systems Transfers control to govt. Lowers transaction costs; eliminates
duplication of financing Collective risk; govt. & DPs Improves predictability of long term financing Promotes transparency, flexibility Improves coordination for greater impact on
agreed priorities Easier to disburse funds
Problems with Pooling
Requires strong government systems for management and accountability
Requires harmonization of donor procedures
Donors lose attribution to specific activities and outcomes
Fungibility/diversion of funds
SWAps and health sector reforms
SWAps not synonymous with HSR SWAps one of several reform initiatives,
including the following: Decentralizing budgeting/management of SD Separating financing from provision of
services Introduction of new financing/payment
schemes Devolving ownership of tertiary-care facilities Shifting donor funds from projects to SWAps Reorganizing MOH; redefining roles of units
SWAps & other development initiatives
Poverty Reduction Strategies (PRSP) Local government reform/ decentralisation National Development Strategies and
Perspectives (e.g. CDF; Vision 2025;…) National ublic service reform programs Public Expenditure Reforms(e.g. MTEF) Macroeconomic growth or decline and debt
servicing (e.g. HIPC II)
New funding modes: sector-wide approaches (SWAps) Program vs. project funding Agreed sector policy framework, often as
part of broader reform process Government capacity to manage
integrated sector program is critical Donor roles and coordination: pooled (or
“basket”) vs. parallel funding Roles of specialized agencies
Risks and benefits of SWAps Reduced fragmentation of government
effort, more coherent focus on priorities Government “in the driver’s seat” Is government able to manage sector
programs effectively? -- transition issues Risks to priority programs that had project
support (e.g. problems with procurement and technical assistance)
Special challenges faced by UN agencies and NGOs
Country examples (experience to date is fragmentary, mixed):
Bangladesh: restructuring underway, capacity problems (procurement)
Ghana: already reforming, SWAp in tandem with other reforms
Ethiopia: innovative funding model, program disrupted by war
Zambia: one of the first, not enough involvement of key stakeholders