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Sector-wide approaches [SWAps] in health: an overview Tom Merrick, World Bank Institute.

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Presentation on theme: "Sector-wide approaches [SWAps] in health: an overview Tom Merrick, World Bank Institute."— Presentation transcript:

1 Sector-wide approaches [SWAps] in health: an overview Tom Merrick, World Bank Institute

2 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

3 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

4 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

5 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

6 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)

7 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

8 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

9 Variations in sector aid arrangements Sector reform program Project type aid Earmarked funds Pooled funds Budget support Stand alone projects

10 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 Programme Approaches

11 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?

12 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

13 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

14 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

15 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

16 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

17 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

18 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

19 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

20 ‘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

21 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

22 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

23 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

24 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)

25 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

26 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

27 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


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