Sector wide approaches for health in small island states: lessons learned from the Solomon Islands

Sector Wide Approaches (SWAps) have increasingly been implemented in countries around the world as a mechanism for effective delivery of health sector funding from various sources. Despite the global focus on aid effectiveness, SWAps have been under-examined. In 2007, the Solomon Islands and development partners began discussing a health SWAp making the Solomon Islands one of the first fragile states globally to adopt a SWAp. This paper explores the establishment and implementation of a health SWAp in the Solomon Islands as a specific case study with lessons learned for the region as well as for aid architecture in fragile states more generally. Tensions between donors and the government impeded agreement and early implementation and country ownership of the SWAp idea was muted. Since mid-2009, however, the Solomon Islands SWAp has made strong progress with greater government ownership and with more focus on partnership and harmonisation rather than on funding mechanisms. The SWAp mechanism has been a challenge for the capacity-constrained Solomon Islands health sector and for development partners familiar with other aid modalities, but current momentum suggests that the SWAp will have a positive impact on adherence to agreed aid effectiveness principles.     

Has the Swap Influenced Aid Flows in the Health Sector?

The sector wide approach (SWAp) emerged during the 1990s as a mechanism for managing aid from the multiplicity of development partners that operate in the recipient country's health, education or agricultural sectors. Health SWAps aim to give increased control to recipient governments, allowing greater domestic influence over how health aid is allocated and facilitating allocative efficiency gains. This paper assesses whether health SWAps have increased recipient control of health aid via increased general sector‐support and have facilitated (re)allocations of health aid across disease areas. Using a uniquely compiled panel data set of countries receiving development assistance for health over the period 1990–2010, we employ fixed effects and dynamic panel models to assess the impact of introducing a health SWAp on levels of general sector‐support for health and allocations of health‐sector aid across key funding silos (including HIV, ‘maternal and child health’ and ‘sector‐support’). Our results suggest that health SWAps have influenced health‐sector aid flows in a manner consistent with increased recipient control and improvements in allocative efficiency. Copyright © 2015 John Wiley & Sons, Ltd.     

Health SWAps and external aid—a case study from Tajikistan

As it moves from a relief to a development phase, the Republic of Tajikistan (RT) needs to attract more external aid and to ensure adequate alignment of this aid with health systems development priorities. A potential response to these two needs is a Sector‐Wide Approach (SWAp), a method originating from post‐colonial Africa and Asia that is increasingly being introduced in new contexts. However, little is known about whether SWAps are appropriate in the context of the former Soviet Union (FSU). This paper explores SWAps using Tajikistan as a case study. A number of lessons are identified for the Tajik health system, for other FSU countries and for health SWAps in general, covering issues of practical relevance to national and international health policy‐makers. We conclude that context‐specific SWAps may be developed to suit Tajikistan, and other FSU countries. Tajikistan currently does not yet have all the key SWAp elements in place, but this should be seen as a motive for, rather than an impediment to, developing a SWAp. Other FSU countries have a more favourable environment for implementing health SWAps. Copyright © 2010 John Wiley & Sons, Ltd.     

SWAp dynamics in a decentralized context: experiences from Uganda

This paper examines the role of the Ministry of Health (MoH) in Uganda in the process of developing a Sector-Wide Approach (SWAp) within the health sector. Power dynamics are integral to any understanding of development assistance, and SWAps bring with them new opportunities for the deployment of influence. The SWAp process has changed the interaction between the donors and the Government, and the perspective of this interaction has shifted from various technical areas to the entire health sector. It is argued that although the decentralization of the public sector has transferred considerable responsibilities and duties from the central level to the districts, significant power, defined as a social construct, has been generated by the MoH in the very process of developing SWAps. The MoH has been able to exercise significant influence on defining the content and boundaries of the SWAp process, as well as the direction it is taking. This development has largely followed blueprints drawn by donors. Through the institutional framework associated with SWAps, the MoH has redefined the interaction between the central level and the districts as well as between the MoH and the donors. While the SWAp process is now moving from the planning to the implementation phase in Uganda, we see a number of new, changing, ambiguous and contradictory strategies emerging.     

The sector-wide approach in health: what is it? Where is it leading?

This paper describes early experience with the Sector-Wide Approach (SWAp), an emerging trend in development practice in low-income countries. The paper describes what a SWAp is, and why it is now being pursued. The SWAp is characterized as a sustained government-led partnership with donor agencies and other groups. By applying sector-wide policies to an expenditure framework and national implementation systems, explicit health sector reforms are undertaken to meet sectoral and national development objectives. The approach has changed the dynamic between governments and donor agencies, requiring systemic changes in policy-making and management in both governments and donor agencies. With the SWAp, ongoing joint assessment and negotiations around sectoral plans and review of performance replaces the old way of preparing and supervising projects. Early experiences in countries undergoing SWAps are discussed, including the problem of reconciling priority programs and old practices with broader health sector reforms and new ways of managing development assistance. The paper concludes by identifying some of the key challenges for the future of SWAps.     

District health programmes and health-sector reform: case study in the Lao People's Democratic Republic

The Lao People's Democratic Republic (Lao PDR) is classified by the World Bank as a low-income country under stress. Development partners have sought to utilize effective aid instruments to help countries classified in this way achieve the Millennium Development Goals; these aid instruments include sector-wide approaches (SWAps) that support decentralized district health systems and seek to avoid fragmentation and duplication. In Asia and the Pacific, only Bangladesh, Papua New Guinea and the Solomon Islands have adopted SWAps. Since 1991, a comprehensive primary health care programme in the remote Sayaboury Province of Lao PDR has focused on strengthening district health management, improving access to health facilities and responding to the most common causes of mortality and morbidity among women and children. Between 1996 and 2003, health-facility utilization tripled, and the proportion of households that have access to a facility increased to 92% compared with only 61% nationally. By 2003, infant and child mortality rates were less than one-third of the national rates. The maternal mortality ratio decreased by 50% despite comprehensive emergency obstetric care not being available in most district hospitals. These trends were achieved with an investment of approximately 4 million US dollars over 12 years (equivalent to US 1.00 US dollars per person per year). However, this project did not overcome weaknesses in some national disease-control programmes, especially the expanded programme on immunization, that require strong central management. In Lao PDR, which is not yet committed to using SWAps, tools developed in Sayaboury could help other district health offices assume greater planning responsibilities in the recently decentralized system. Development partners should balance their support for centrally managed disease-specific programmes with assistance to horizontally integrated primary health care at the district level.     

Exploring SWAp's contribution to the efficient allocation and use of resources in the health sector in Zambia

Zambia introduced a sector-wide approach (SWAp) in the health sector in 1993. The goal was to improve efficiency in the use of domestic funds and externally sourced development assistance by integrating these into a joint sectoral framework. Over a decade into its existence, however, the SWAp remains largely unevaluated. This study explores whether the envisaged improvements have been achieved by studying developments in administrative, technical and allocative efficiency in the Zambian health sector from 1990-2006. A case study was conducted using interviews and analysis of secondary data. Respondents represented a cross-section of stakeholders in the Zambian health sector. Secondary data from 1990-2006 were collected for six indicators related to administrative, technical and allocative efficiency. The results showed small improvements in administrative efficiency. Transaction costs still appeared to be high despite the introduction of the SWAp. Indicators for technical efficiency showed a drop in hospital bed utilization rates and government share of funding for drugs. As for allocative efficiency, budget execution did not improve with the SWAp, although there were large variations between both donors and year. Funding levels had apparently improved at district level but declined for hospitals. Finally, the SWAp had not succeeded in bringing all external assistance together under a common framework. Despite strong commitment to implement the SWAp in Zambia, the envisaged efficiency improvements do not seem to have been attained. Possible explanations could be that the SWAp has not been fully developed or that not all parties have completely embraced it. SWAp is not ruled out as a coordination model, but the current setup in Zambia has not proved to be fully effective.     

Are reproductive health NGOs in Uganda able to engage in the health SWAp?

This paper explores the ability for reproductive health (RH) non-governmental organizations (NGO) in Uganda to survive in the context of SWAp and decentralization. The authors argue that, contrary to the perceptions that this context may increase NGO's financial vulnerability, a SWAp and a decentralized system may provide an opportunity that should be embraced by NGOs to enhance their sustainability and effectiveness by reducing their current dependency on donor funding. The paper discusses the systemic weaknesses of many NGOs that currently make them vulnerable, and observes that unless these weaknesses are addressed, such NGOs will lose their space in the SWAp and decentralization arena. The authors suggest that NGOs need to recognize the opportunities that participating in public-private partnerships through a SWAp can offer them for long-term and significant funding. They need also to develop their capacity to pro-actively participate in a SWAp and decentralized context by becoming more entrepreneurial in nature, through re-orienting their organizational philosophies and strategic planning and budgeting so as to be able to partner effectively with the public sector in accessing funds made available through health sector reform.     

Player or referee? Aid effectiveness and the governance of health policy development: Lessons from Viet Nam

Viet Nam is one of the brightest stars in the constellation of developing countries. Its remarkable achievements in reducing poverty and improving health and education outcomes are well known, and as a result it has enjoyed generous aid programmes. Viet Nam also has a reputation for taking a strong lead in disciplining its donors and pushing for more efficient and effective forms of aid delivery, both at home and internationally.

This article discusses how efforts to improve the effectiveness of aid intersect with policy-making processes in the health sector. It presents a quantitative review of health aid flows in Viet Nam and a qualitative analysis of the aid environment using event analysis, participant observation and key informant interviews.

The analysis reveals a complex and dynamic web of incentives influencing the implementation of the aid effectiveness agenda in the health sector. There are contradictory forces within the Ministry of Health, within government as a whole, within the donor community and between donors and government. Analytical frameworks drawn from the study of policy networks and governance can help explain these tensions. They suggest that governance of health aid in Viet Nam is characterised by multiple, overlapping ‘policy networks’ which cut across the traditional donor–government divide. The principles of aid effectiveness make sense for some of these communities, but for others they are irrational and may lead to a loss of influence and resources. However, sustained engagement combined with the building of strategic coalitions can overcome individual and institutional incentives.

This article suggests that aid reform efforts should be understood not as a technocratic agenda but as a political process with all the associated tensions, perverse incentives and challenges. Partners thus need to recognise – and find new ways of making sense of – the complexity of forces affecting aid delivery.     

Translations of health sector SWAps--a comparative study of health sector development cooperation in Uganda, Zambia and Bangladesh

INTRODUCTION: Sector-wide approach, or SWAp, is an increasingly popular approach to development cooperation for many bilateral and multilateral development agencies. While much has been published about the SWAp model itself, there is still limited research conducted on how it is applied in practice. This study aims at showing how the SWAp is translated as it is adopted in different local settings and it shows how these translations trigger changed practice in different ways. METHODOLOGY: A three-layered comparative study of exemplary texts, country policies and interviews, was conducted in Uganda, Zambia and Bangladesh. An international literature review, comprising research articles, consultancy reports and government policy documents was undertaken. Also, a total of 64 interviews were conducted with representatives from the government, development partners and NGOs. Finally, 18 policy and donor meetings at national and district levels were attended and observed. RESULTS: The study showed that the definitions of the SWAp model are general and vague in character. Furthermore, it was observed that in all three countries, no serious effort has been made to define SWAp in country policies. Finally, the study revealed that partners in development translate SWAp differently in daily practice. The variations in understandings were found both between and within countries. CONCLUSIONS: The SWAp is a clear label with unclear content. The meaning of SWAp is formed by the recipient government and its development partners through an active process of translation as the SWAp is adopted in a specific context. The introduction of the SWAp has limited potential to transform standards for how development aid should be pursued and practiced as much of the administrative structures in each country are still formed in line with a project focused approach. It is concluded that in order to create change, partners in development must work, not only on defining SWAp, but also on influencing the context surrounding the SWAp.     

Theory and practice – a case study of coordination and ownership in the Bangladesh health SWAp

Background  

In the past decade the sector-wide approach (SWAp) model has been promoted by donors and adopted by governments in several countries. The purpose of this study is to look at how partners involved in the health SWAp in Bangladesh define ownership and coordination, in their daily work and to analyse the possible implications of these definitions.     

Stakeholder perceptions of aid coordination implementation in the Zambian health sector

In this study, we analysed stakeholder perceptions of the process of implementing the coordination of health-sector aid in Zambia, Africa. The aim of coordination of health aid is to increase the effectiveness of health systems and to ensure that donors comply with national priorities. With increases in the number of donors involved and resources available for health aid globally, the attention devoted to coordination worldwide has risen. While the theoretical basis of coordination has been relatively well-explored, less research has been carried out on the practicalities of how such coordination is to be implemented. In our study, we focused on potential differences between the views of the stakeholders, both government and donors, on the systems by which health aid is coordinated.A qualitative case study was conducted comprising interviews with government and donor stakeholders in the health sector, as well as document review and observations of meetings. Results suggested that stakeholders are generally satisfied with the implementation of health-sector aid coordination in Zambia. However, there were differences in perceptions of the level of coordination of plans and agreements, which can be attributed to difficulties in harmonizing and aligning organizational requirements with the Zambian health-sector plans. In order to achieve the aims of the Paris Declaration; to increase harmonization, alignment and ownership – resources from donors must be better coordinated in the health sector planning process. This requires careful consideration of contextual constraints surrounding each donor.     

Has donor prioritization of HIV/AIDS displaced aid for other health issues?

Advocates for many developing-world health and population issues have expressed concern that the high level of donor attention to HIV/AIDS is displacing funding for their own concerns. Even organizations dedicated to HIV/AIDS prevention and treatment have raised this issue. However, the issue of donor displacement has not been evaluated empirically. This paper attempts to do so by considering donor funding for four historically prominent health agendas--HIV/AIDS, population, health sector development and infectious disease control--over the years 1992 to 2005. The paper employs funding data from the Organization for Economic Cooperation and Development's (OECD) Development Assistance Committee, supplemented by data from other sources. Several trends indicate possible displacement effects, including HIV/AIDS' rapidly growing share of total health aid, a concurrent global stagnation in population aid, the priority HIV/AIDS control receives in US funding, and HIV/AIDS aid levels in several sub-Saharan African states that approximate or exceed the entirety of their national health budgets. On the other hand, aggregate donor funding for health and population quadrupled between 1992 and 2005, allowing for funding growth for some health issues even as HIV/AIDS acquired an increasingly prominent place in donor health agendas. Overall, the evidence indicates that displacement is likely occurring, but that aggregate increases in global health aid may have mitigated some of the crowding-out effects.     

中国卫生软援助：实践、问题与对策——以对外卫生人力资源合作为例

中国卫生软援助是中国对外援助的重要组成部分。以卫生人力资源援助为主的卫生软援助集中反映了中国对外援助的基本理念和创新机制,是南南合作的典范。本文回顾了包括派遣医疗队、医疗卫生官员培训和提供中国政府奖学金等形式的中国卫生人力资源援助的成功实践。同时指出中国卫生软援助缺乏战略规划,参与援助的主体单一,对卫生软援助的实践和研究总结不足等。建议加强战略规划,主体多元化,提升总结中国软援助的能力,从而不断提高软援助的有效性。     

A scoping review of the implementation of health in all policies at the local level

ObjectivesHealth in All Policies (HiAP) is an approach to public policies across sectors that systematically takes into account the health implications of decisions, seeks synergies, and avoids harmful health impacts in order to improve population health and health equity. HiAP implementation can involve engagement from multiple levels of government; however, factors contributing or hindering HiAP implementation at the local level are largely unexplored. Local is defined as the city or municipal level, wherein government is uniquely positioned to provide leadership for health and where many social determinants of health operate. This paper presents the results of a scoping review on local HiAP implementation.MethodsPeer reviewed articles and grey literature were systematically searched using the Arksey and O’Malley framework. Characteristics of articles were then categorized, tallied and described.Results23 scholarly articles and four government documents were identified, ranging in publication year from 2002 to 2016 and originating from 14 countries primarily from North America and Europe. A wide range of themes emerged relating to HiAP implementation locally including: funding, shared vision, national leadership, ownership and accountability, local leadership and dedicated staff, Health Impact Assessment, and indicators.ConclusionCommon themes were found in the literature regarding HiAP implementation locally. However, to better clarify these factors to contribute to theory development on HiAP implementation, further research is needed that specifically investigates the facilitators and barriers of HiAP locally within their political and policy context.     

Responses to donor proliferation in Ghana’s health sector: a qualitative case study

ObjectiveTo investigate how donors and government agencies responded to a proliferation of donors providing aid to Ghana’s health sector between 1995 and 2012.MethodsWe interviewed 39 key informants from donor agencies, central government and nongovernmental organizations in Accra. These respondents were purposively selected to provide local and international views from the three types of institutions. Data collected from the respondents were compared with relevant documentary materials – e.g. reports and media articles – collected during interviews and through online research.FindingsGhana’s response to donor proliferation included creation of a sector-wide approach, a shift to sector budget support, the institutionalization of a Health Sector Working Group and anticipation of donor withdrawal following the country’s change from low-income to lower-middle income status. Key themes included the importance of leadership and political support, the internalization of norms for harmonization, alignment and ownership, tension between the different methods used to improve aid effectiveness, and a shift to a unidirectional accountability paradigm for health-sector performance.ConclusionIn 1995–2012, the country’s central government and donors responded to donor proliferation in health-sector aid by promoting harmonization and alignment. This response was motivated by Ghana’s need for foreign aid, constraints on the capacity of governmental human resources and inefficiencies created by donor proliferation. Although this decreased the government’s transaction costs, it also increased the donors’ coordination costs and reduced the government’s negotiation options. Harmonization and alignment measures may have prompted donors to return to stand-alone projects to increase accountability and identification with beneficial impacts of projects.     

Managing external resources in the health sector: are there lessons for SWAps (sector-wide approaches)?

Drawing on the case studies presented in this issue, from Bangladesh, Cambodia, Mozambique, Zambia and South Africa, and examples from other countries, this paper asks what general conclusions can be drawn about the management of external resources, and specifically what lessons could inform the future implementation of sector-wide approaches (SWAps) in the health sector. Factors constraining the management of aid by ministries of health are grouped under three themes: context and timing, institutional capacities and the interplay of power and influence in negotiations over aid. Two factors, often underplayed, were found to be important in facilitating management of resources: the inter-relationship of formal and informal relationships, and the extent to which incremental changes are tolerated. The main conclusion is that coordination and management of external resources is inherently unstable, involving a changing group of actors, many of whom enjoy considerable autonomy, but who need each other to materialize their often somewhat different goals. Managing aid is not a linear process, but is subject to set-backs and crises, although it can also produce positive spin-offs unexpectedly. It is highly dependent on institutional and systemic issues within both donor and recipient environments. In promoting sector-wide approaches the key will be to recognize context-specific conditions in each country, to find ways of building capacity in ministries of health to develop and own the future vision of the health sector, and to negotiate a realistic package that is explicit in its agreed objectives. The paper ends with identifying crucial actions that will enable ministries of health to take the lead role in developing and implementing SWAps.     

Research capacity training for surveillance and response in the Indo-Pacific: a case study of implementation

SETTING:Surveillance and response workforce in the Indo-Pacific region, including Papua New Guinea (PNG), Solomon Islands, Fiji, Eastern Indonesia and Timor-Leste.OBJECTIVE:To evaluate the implementation of a modified WHO SORT IT research training programme which included a workplace-based research project. The training was designed for surveillance and response frontline workforce in the Indo-Pacific region.DESIGN:This was a programme evaluation using mixed methods. Fifty-three health and biosecurity workers from Fiji, Indonesia, PNG, Solomon Islands and Timor-Leste participated in the research training programme.RESULTS:Implementation of the programme was modified to reflect the context of participant countries. Work-place research projects focused on priority issues identified by local policy makers and in-country stakeholders. Self-reported research skills showed a significant increase (P < 0.01) after the completion of training. Participants reported high scores for satisfaction with training.CONCLUSIONS:This case study provides lessons learnt for future research training, and demonstrates that the SORT IT model can be modified to reflect the context of implementation without compromising purpose or outcomes.