«Silke Seco Javier Martínez November 2001 DFID Health Systems Resource Centre 27 Old Street London EC1V 9HL Tel: +44 (0)20 7253 2222 Fax: +44 (0)20 ...»
An overview of Sector Wide
Approaches (SWAPs) in health
Are they appropriate for aid-dependant Latin
DFID Health Systems Resource Centre
27 Old Street
London EC1V 9HL
Tel: +44 (0)20 7253 2222
Fax: +44 (0)20 7251 9552
DFID Health Systems Resource Centre 2001 1
CONTENTSAbbreviations 3 Executive Summary 4 1 Introduction 9
1.1 Overview 9
1.2 History and evolution of SWAPs in the health sector 10
1.3 Definition and components of SWAPs 11
1.4 Scope of SWAPs and their implications 13
1.5 Donor concerns 15 2 Review of experience 17
2.1 Country overview 17
2.2 Progress to date 21
2.3 Barriers to change 22 3 SWAPs and the health of poor people 28
3.1 Are SWAPs pro-poor? 28
3.2 Experience with SWAPs in poverty reduction 29 4 The case for SWAPs in Latin America 31
4.1 Is there a case for health SWAPs in Latin-America? 31
4.2 Scope of SWAPs in Latin America 34
4.3 Building SWAPs in Latin America – what are the key steps? 35 5 Selected bibliography 37 _________________________________________________________________________________
DFID Health Systems Resource Centre 2001 2 Abbreviations EPI Expanded Programme on Immunisation EU European Union DFID Department for International Development HIPC Highly Indebted Poor Countries IMF International Monetary Fund MoH Ministry of Health MoF Ministry of Finance MTEF Medium Term Expenditure Framework NGO Non-governmental organisation ODA Overseas Development Agency (now DFID) PAHO Pan American Health Organisation PRSP Poverty Reduction Strategy Paper SDC Swiss Development Cooperation SWAP Sector Wide Approach UNICEF United Nations International Children’s Fund WHO World Health Organisation _________________________________________________________________________________
DFID Health Systems Resource Centre 2001 3 Executive Summary This paper has been commissioned to provide background information on the concept of Sector-wide approaches – SWAPs- and their implementation. It is aimed at policy makers, donor agency staff and health professionals working in countries where SWAPs are either being considered or might be considered in the future. While the paper attempts to encapsulate the main conceptual and practical issues involved in SWAP development it does not pretend to be either a blueprint for implementation or to explain in detail the specific mechanisms, arrangements or steps that should be followed for establishing a SWAP. The authors draw mainly from unpublished literature, in the form or consultancy reports and evaluation studies. The Bibliography section provides information on all the documents used, so as to help those interested in pursuing more in depth reading.
In a sector-wide approach (SWAP) all significant funding for the sector supports a single sector policy and expenditure programme, under government leadership, adopting common approaches across the sector, and progressing towards a situation in which all funds are disbursed by governments, which are also accountable for the disbursement.
The rationale for SWAPs stems partly from a regognition of the problems inherent in traditional project and programme development funding. In contrast to a multiplicity of individual donor projects -with different and sometimes conflicting agendas and with their own planning and monitoring arrangements, SWAPs are seen as an opportunity for governments to oversee the entire health sector, develop policies and plans, and manage resources.
The core assumed advantages of a sector-wide approach are:
• greater efficiency and equity
• decreasing transaction costs
• sustainability of health policy and systems development.
At the heart of a sector-wide approach is a medium-term collaborative programme of work between governments and donors concerned with the
The Policy components A policy document that identifies and addresses major policy issues is the
starting point of a sector-wide approach. This entails:
• defining sectoral objectives
• setting strategies about resource allocation
• identifying the institutional changes required and
• specifying the roles of different health care providers.
DFID Health Systems Resource Centre 2001 4 The Expenditure components In a SWAP, a public expenditure programme is defined to reflect macroeconomic policy and sector priorities in a transparent manner. Expenditure
programmes are based on:
• medium-term projections of the resources available
• short-term budgets, which are reviewed annually and
• priority areas where spending should be protected The Institutional components The key objective of a SWAP is to build government capacity to lead the process of sectoral development. Accordingly, governments should gradually be
• take the lead in strategic planning and policy
• manage budgetary and financial analysis
• develop systems and incentives to manage the health system in line with national policies and
• establish common management arrangements and systems.
Decentralisation and SWAPs Designing sector programmes in decentralised political or health systems can be challenging. In particular, certain priority projects (vertical programmes) may be neglected as a result of shifting towards a sector approach. Earmarking sector priorities and ring fencing priority programmes can be a way of overcoming problems and concerns.
Types of SWAPs SWAPs are not an absolute, and different funding arrangements are possible.
In this document we use the terms ‘tight’ and ‘loose’ to r fer to the extent to e which financial resources from various donors are pooled together, even if these terms are not universally accepted and should be taken as the two poles of possible financial arrangements. In a ‘tight’ SWAP an agreed strategy and investment plan is delivered by government with pooled finance provided by government and external development partners. In a ‘loose’ SWAP there is a strategy agreed by donors and government but both may continue to fund separate programmes and projects. Funding agencies can provide their funding in one of these two ways, or using combinations of these extremes.
Although SWAPs are by definition sector oriented, they may initially focus on one or two subsectors (ie primary care or tertiary hospitals), or in specific programme areas (ie reproductive health or disease interventions), particularly in countries where capacity is low to manage the complexities of a whole sector.
Implications of SWAPs The development of SWAPs entails major changes in donor-government
• The recipient government takes a stronger leadership role in the design of programmes and the allocation of resources.
DFID Health Systems Resource Centre 2001 5
• Donors give up their right to decide which projects to finance in exchange for the right to have a voice in the process of developing a sectoral strategy and overall resource allocation.
• SWAPs will only succeed if there is partnership and commitment to agreed aims from government and the donor community. For this, partnership agreements and working arrangements are needed.
• The objective is that governments are eventually able to use pooled funding for procuring goods and services. This implies the need to relax restrictions about rules pertaining the origin of funds and tied aid.
SWAPs should be an incremental process, not a blueprint for a single type of programme. They must also be implemented at a pace appropriate for the recipient country.
Review of experience All current SWAPs have been started in low-income countries and have achieved very different degrees of success. Because implementation can be a long process the evaluation of SWAPs has only recently begun to shed some light on the pros and cons of adopting a SWAP, and this mainly in those countries where SWAPs were started in the early 90s such as Pakistan, Ghana and Zambia.
Most sector-wide approaches have concentrated on the role of the public sector within the health sector, and not on the health sector as a whole. All countries regard SWAPs as incremental processes, progressing towards more pooled financing as trust is built and experience develops. There are already some countries with common funding, although this tends to coexist in most countries with separate project funding. In these cases efforts are being made to ensure that project funding takes place only in priority areas identified through the SWAP process, and within the expenditure framework agreed for the SWAP.
Plans developed under SWAPs can be regarded as a success if they result in governments and donors looking at health problems and at health interventions together, around a table, improving the quality of the policy debate. In particular,
there have been positive achievements reported in:
• Developing coherent priorities and plans for the health sector, and setting up systems to monitor performance.
• Strengthening the role of governments and ministries of health in the health sector.
• Enabling greater focus and continuity in policy implementation that counteract the risks linked to political and policy shifts.
On the other hand, developing a sector-wide approach is a complex undertaking spreading over several years that can be overwhelming and can strain governmental capacity. Unless there is compromise in reaching a balance between what is ideal and what can be realistically achieved given r source e availability the process of preparing a policy document and a sector plan can be _________________________________________________________________________________
DFID Health Systems Resource Centre 2001 6 prohibitively long. Even when there is a clear statement of intent from governments, it is often necessary to develop government capacity to carry out the planning process itself. The main reported problems have been delayed planning and sector appraisals, in part caused by donors persistently using over-detailed procedures and in part due to the said limitations in government capacity. While the focus has often been on strategic details and implementation plans more attention is needed on actual implementation and on results.
Finally, the fundamental problem of balancing investments within the health sector, and between the health sector and competing sectors has not always been resolved following introduction of SWAPs. For a start, most governments undertaking SWAPs do not have the resources needed to expand their population coverage on a sustainable basis. Even if the efficiency and costeffectiveness of the health system were to improve considerably, most governments will continue to face resource shortages and depend on foreign aid in the medium to long-term.
SWAPs and the health of poor people SWAPs are not pro or anti-poor in themselves, since they are just a mechanism for planning and managing the sector. Whether SWAPs benefit the poor depends on the actual policies and the record achieved in their implementation.
Because SWAPs take place within broader health, public sector, social, economic and political contexts it can be predicted that SWAPs are more likely to have a positive impact on the poor in countries whose governments are committed to poverty reduction. In this sense, SWAPs could have a synergistic effect on poverty and the poor in countries where Poverty Reduction Strategies have been defined and condensed in so-called PRSPs, but PRSPs are too recent a feature to demonstrate such synergy in practice.
There is concern that sector-wide approaches can become too centralist and focused on macro-level policy and service provision issues that may take many years to cascade down the system and benefit service users, including the poor. In this regard, the choice facing donors is whether to channel development aid directly to those most vulnerable or to encourage the allocation of resources in ways that favour the poor in the negotiation of sector policies and strategies. In practice, both approaches can be followed simultaneously.
SWAPs are often said to have a negative impact on certain priority programmes in countries where these have been traditionally financed and implemented in a very vertical manner. Because priority programmes are often aimed at the poorest SWAPs have been said to have a potential negative impact on poor people. So far, there is no evidence of such effect actually taking place except, perhaps, for limited periods of time during early stages of implementation. Even in these cases other policies outside SWAPs, such as decentralisation or the introduction of new health financing arrangements, might have been responsible for the said negative effects. Besides, SWAPs can have a beneficial effect on certain priority programmes by standardising or streamlining _________________________________________________________________________________
DFID Health Systems Resource Centre 2001 7 certain procedures which are common to several programmes. One such example is SWAPs resulting in more effective and faster procurement arrangements.
Is there a case for SWAPs in Latin-America?