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Can the SWAp support universal health coverage initiatives?

5/22/2012

12 Commentaires

 
In this blog, Vincent Okungu wonders whether Sector-wide Approach and Universal Health Coverage are friends or foes.

By
Vincent R. Okungu (Emerging Voice 2010, KEMRI-Wellcome Trust)

 
In the 1990s, a few European donors and partner developing country governments acknowledged that the traditional project approach to the delivery and management of aid was not effectively improving population health even though development assistance to the health sector in poor countries was increasing. The sector-wide approach (SWAp) to financing health care was then proposed to replace the project approach.

SWAp is a process of aid coordination that aims at pooling external and internal funds under recipient governments’ leadership and ownership such that donors and recipient governments work towards common goals and are accountable for the results. The SWAp process shares a lot with (and probably inspired) the Paris Declaration of Aid effectiveness (2005) and the Accra Agenda for Action (2008). It is meant to significantly improve population health through progress in the provision of accessible, equitable and sustainable health services. These three goals are also at the core of universal health coverage (UHC) agenda current across the globe.

In a previous blog post on Financing Health in Africa, Jurrien Toonen wondered whether performance-based financing (PBF) would survive UHC. Is the question not relevant also for the SWAp approach? Are SWAps and UHC friends or foes?

Universal health coverage is the ultimate goal of ongoing health system reforms globally. It aims at making health services accessible and equitable to all citizens regardless of socioeconomic status. UHC is strategic in fighting poverty and ill-health because an effective UHC system significantly reduces the incidence of impoverishment from out-of-pocket payments for health care.

The SWAp is a process. Its focus is on consolidating internal and external funds, and integrating and harmonizing donor projects into national health programmes. This is to strengthen the entire health system capacity, structures and finances, to deliver adequate and quality health services to target groups. The SWAp process therefore, could in theory very well support UHC by pooling funds and health system capacity development. Furthermore, under this view the SWAp process should not only be seen as an aid coordination tool but also a system management tool, to provide long-term capacity building that is essential for UHC.

On the flipside, many SWAps have been disappointing. Most are yet to deliver any tangible and measurable benefits to population health (even if such measurement would be difficult). In practice, many SWAps have poor quality and overambitious plans and expenditure frameworks; a number of countries are yet to translate SWAps into actions for national leadership and ownership.  Many donors and recipient governments have also reduced SWAps to a specific public expenditure programme funded by specific donors according to policy and budget structures set by the national government.

Ideally, SWAps should involve several actors who must work together to achieve required results. The practice of reducing SWAps to common planning and monitoring, when pooling funds is very limited, has not been conclusive, including in terms of providing accessible health services in an equitable and sustainable manner.

The objectives of greater coordination of aid actors, harmonization of rules and government ownership are relevant. The question then is to what extent UHC initiatives could benefit from these objectives, dear to the SWAp approach.

A first recommendation would be to understand well the logic of some donors: they simply refuse to support SWAps because they need to ensure visibility and profile of their agencies. Other projects are pilots of planned interventions in donor countries, and agencies carrying out these ‘pilot projects’ reject SWAps because they would not be able to evaluate and measure results of their interventions. However, one should not blame the donors only: weak government leadership over the health sector is to blame as it offers opportunities for donors to force their interests on the sector.  Locally, SWAps reduce chances for corruption and patronage and have often faced opposition from establishment bureaucrats.

Interestingly enough, this reluctance to work together is also a challenge for UHC. Indeed, fragmentation and multiplication of schemes is an obstacle to UHC (this was the main topic of the recent regional workshop organized by the PBF and Financial Access CoPs in Bujumbura and was much discussed also in Phnom Penh, as reported by the Emerging Voice Raoul Bermejo).

I believe actors involved in SWAps and those committed to UHC should work together. SWAps should be addressed under the agenda of universal coverage. Recipient governments and local stakeholders have to convince donors that managing a health system for UHC must be through long-term capacity building plans. Government policies ought to put the population’s universal health needs and expectations as the top priority agenda. This persuasion of donors should not go through ‘words’ but through ‘actions’: local leadership of SWAps should be improved with a specific department established and designated to lead the SWAp process.

SWAps can support UHC efforts but only as an all inclusive process with a strong, transparent and accountable recipient government leadership. 

Readers are encouraged to share specific country experiences with SWAps.

12 Commentaires
Jan Borg
5/23/2012 08:49:46 am

I never understood this kind of perceived competition between what in essence are not comparable entities (at least in spirit). E.g. that SWAp has deteriorated into an aid modality is regrettable. E.g. that SWAp is seen as diametrically opposing disease programmes is regrettable. E.g that SWAp is seen as leverage towards or indeed requiring capacity building is regrettable. E.g. that SWAp is equated with Paris is understandable but regrettable; Paris includes SWAp but entails more. E.g. that decentralization is seen as a prerequisite for SWAp is less regrettable, but not always true. Now, I know it is easier to explain what is not a SWAp than to give a clear inclusive definition. For me SWAp is an 'approach' that looks at health delivery systems as a whole and holistically in terms of both allocative and technical efficiency. This means that it should - not as an option - consider the political dimensions for reforms that are often (or always) necessary. SWAp is not a technical solution (again formulating what it is not, mea culpa), SWAp is not (meant as) a solution to health service delivery full stop! (Rather as part of an approach for effective and efficient aid delivery.) The SWAp and its requisite partnerships should permeate all our dealing with all health delivery (systems). It would therefore be detrimental and indeed damaging to the approach to think about 'SWAp implementation units' as in the last paragraph of the article.

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Vincent Okungu
5/24/2012 01:16:04 am

Jan Borg's definition of SWAps is in part what it is supposed to be but not what it is as has been operationalised. Again, the article discusses SWAp in relation to the health sector (not aid as a whole). Now if SWAp is "as an approach to effective and efficient aid delivery" as explained by Borg, surely if such effectiveness and efficiency is realized in the health sector, it has to result in effective delivery of health services, which is what donor support to the health sector is all about.
In the last paragraph (Borg doesn't agree with it), let me clarify that SWAps, to be operationalized into what its original intentions were, should have a distinct leadership within the health sector for effective coordination and implementation. This is what my experience as a citizen of a low-income country tells me. Forget the textbook definition of SWAps vis-a-vis health sector and lets focus on how it has been implemented.

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Jan Borg
5/24/2012 04:16:35 am

What I meant specifically was 'an approach to efficient and effective aid delivery for health (sector) development'. This is different from the formulation propoposed by Okungu where he talks about efficient and effective health service delivery. We should not forget that support to a health sector in a foreign country is also support to a health sector in a sovereign country (substitute the word 'health' by the word 'defense' and the implications become clear). In other words and returning to the political dimension of a SWAp, allocation of scarce resources (setting priorities) in the health sector of a recipient country falls within its own sovereignity and should be considered before engaging in SWAp partnerships (and is hopefully based on evidence, otherwise that might be a valuable entry point for developing SWAp partnerships). (Nb. nothing is static, reason why I speak in one of my later contribution of a leverage model.) That donor money is spent in a technical efficient and effective way is of a different order and absolutely important for the use of and accountability for donor money.

Just to provoke some thoughts on the boundaries of SWAp's influence and political dimension: What is the reader's opinion on spending public money on the obviously very efficient and effective conveyor belt cardiac surgery (that also obviously serves a public demand) set up my Dr. Shetty in India. (Acknowledging that India is not an aid dependent country and that this only serves as a thinking example.)

To come back to the leadership question: Based on the above I do fully agree that the 'recipient' country should lead the process of budgetting and planning for health, I take issue however of instituting implementation units for the purpose of this. I think that there are plenty of examples around in Africa of this type of project type implementation of programmes to prove my point. If any (pre-)condition can be put by a donor on entering a SWAp partnership it should be the mainstreaming of the one budget, one plan, one monitoring framework approach.

Finally, to refer to textbook definitions and implementation bottlenecks as an excuse to compromise, leads to a lazy attitude, repeating mistakes without learning from the past. (I believe the health sector in Zambia wil see its third forced revival of the SWAp experiment soon...)

Louis Rusa link
5/23/2012 11:36:52 am

I agree with you Vincent, SWAps avoid wastage of resources and effort and for sure help to focus on the real priorities of the beneficiaries. It also is in right line with UHC, because if there are resources saved, they can be used for UHC to allow all health programs be well financed and covered. However, what you need to know is that aid pass through cooperation and as such must be a win win mechanism.Why donors are criticising SWAps, is because a well applied sector wide approach dont lead to donor interests.The consequence will be a hundred of reasons for not continuing to finance trough that system. The better way is to progressively look the way of phasing out the aid. Especially for Africans who have a lot of resources: human, natural, environmental etc... This suppose to better manage what we have and fight corruption. The aid must be an international mechanism of helping the victims of war and natural catastrophs wherever they occur and Africans must be also contributing trough AU.

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jan Borg
5/23/2012 08:38:04 pm

I think that the reaction of Louis Rusa illustrates perfectly why it is flawed to see SWAp as an aid modality. The implicit distinction between beneficiaries and benefactors (donors) will automatically lead to measuring the success of SWAp in terms of what it does for the individual involved partners. I am therefore not surprised that it is, mutatis mutandis, concluded that SWAps don't serve donors interests. The increasing (quick) result orientation with ensuing rigid results frameworks (of donors) and a strong focus on output and outcome targets (e.g. MDGs) have only contributed to that believe. Yesterday I wrote that I find it difficult to define what I think is a SWAp. Today, I might try with a metaphor: Look upon the health sector (systems) as a balloon. A balloon that is inflated with resources by all partners jointly, once inside the balloon these resources have no label of providence. Now look at the balloon as a whole. Pushing one area of the balloon in will, without fail, not only change that area but also the rest of the surface of the balloon. I guess, that what I am trying to say in analogy is that we have to change the ways we are looking upon measuring cause and effect to fully appreciate the benefits of SWAps. I would see much mileage in refocussing the discussion on SWAps in terms of measuring attribution (benefactor-beneficiary model) versus contribution (leverage model). (Nb. the metaphor also holds for hot air.)

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Jan Borg
5/23/2012 10:57:13 pm

Reading my last contribution and thinking that my metaphor could be interpreted as rather vague, I would like to add that the act of pushing the balloon in a certain area would of course equate with shifting resources within the system... We would therefore have one budget (the resources inside the balloon), one strategy and plan (the balloon's surface) while looking to perfect the measurement methodology for one evaluation framework that looks at cause and effect in a different ways than the traditional one dimensional (logical framework) target oriented evaluation and monitoring approach.

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Roberto TALONGWA
5/24/2012 03:08:46 am

PBF is a good tool for SWAp

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Bruno Meessen
5/24/2012 05:44:19 am

I never participated actively to a SWAp and I am not very familiar with the strategy nor the literature.

A frustration I share probably with many is the lack of coordination among the major funders of the health services that national government and donors are.

The final destination we have to reach is pretty clear: citizens deciding on allocation of their pooled resources. The path is less clear, and depends a lot on the context.

What we may need is clearer views on a few possible paths and identify indicators for different steps. Then it would be good to have some independent observers to monitor to what extent actors' acts are in line with their words.

We have also to acknowledge that the recipient government is not a united entity. Donors rarely do interventions against the will of their partner country. They always find someone who will sign their project. It is clear also that some governmental actors (especially those above the sector, such as the president himself) do not always comply with coordination mechanisms (are they even aware of them?).

A neutral national aid watcher would maybe help all these actors to enforce their commitment to each other. I observe that in some countries, the implicit rule is "I do not comment on your infringement of the Paris Declaration, please do not bother me either".

SWAp seems an option for moving towards harmonisation, ownership and coordination, but they are other mechanisms (not necessary exclusive). What we mainly need is mechanisms with strong enforcement power.






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Jan Borg
5/24/2012 06:40:03 am

In the heat of reacting I probably forgot the question that was raised in the original article and got too much stuck into the definition and application of SWAp. Not being a health economist, I had to do some googling and web research to attempt to find a clear and unique definition of Universal Health Coverage (you think that should not be too difficult since Margaret Chan declared 'Universal Health Coverage as the single most powerful concept that public health has to offer'). I did not succeed. Maybe there is somebody out there that can help me?

As far as I now understand UHC is a generic container for financing mechanisms for health services that includes both equitable access to health services and risk protection for all, or as the business dictionary has it: "A form of health insurance that is provided to citizens of a country at no charge. The health care coverage is funded by taxes imposed on the citizens through taxation. People participating in universal health coverage do not have to pay any of their medical costs including fees for prescriptions. Opponents of universal health coverage suggest that it forces people to wait for extended periods of time for major procedures and places an unnecessary tax burden on the country. The United States currently does not have a universal health coverage plan in place."

Hopefully my input on SWAp has debunked the believe that SWAp is first and foremost an aid deployment mechanism, although the approach does make some demands on financing modalities. As UHC seems to increase the public finances for equitable (horizontally and vertically) health service provision and the financing part of the SWAp deals predominantly with increasing that same domestic financing stock, I believe there is no competition (which was highly unlikely, because the two entities are at very different levels of taxonomy) between UHC and SWAp but rather, as the author also remarks, plenty opportunities for synergy.

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Luc Geysels
6/4/2012 06:21:45 am

Having worked since 1997 in a SWAp environment in several countries, I would like to contribute to this discussion.

There still seems to be much confusion around SWAp, although the term was adapted already in 1997. But this is understandable as there is no single agreed definition of a SWAp. On the other hand, the existing definitions all have the same common themes. And these themes are well reflected in the description of the European Commission. EC defines SWAp as “… a way of working together between government and development partners. The aim is to broaden government ownership over public sector policy and resource allocation decisions within the sector, to increase the coherence between policy, spending and results and to reduce transaction costs. It involves progressive development of a comprehensive and coherent sector policy and strategy, of a unified public expenditure framework for local and external resources and of a common management, planning and reporting framework”.

For all clarity I summarise the common themes:
1. A single comprehensive plan, at national level (e.g. an overall strategic framework like PRSP, as well as at sector level, a (health) sector strategic plan, including an MTEF programme and an annual budget.
2. The country leadership and ownership, including a formulised government led process for donor coordination at sector level.
3. An increased reliance on the use of local systems and common government and management arrangements for the partners engaged in SWAp. This includes the use of a performance monitoring system that measures progress towards the achievement of policy objectives and results.
4. An agreed process for (moving towards) donor coordination and harmonisation of donor systems for reporting, budgeting, financial management and procurement.

So SWAp is “a way of working together”: it is a means, a process, a mechanism to handle partner support. It is not an objective on its own (some SWAp fanatics see it like that). SWAp is neither a financing mechanism or an aid modality. Partners in SWAp can do budget support (general or earmarked for a sector or a subsector). They can choose pooled “basket” funding. But also programmes or projects can be part of a SWAp as long as they are “integrated”. This means that donor projects not supporting the government budget should be planned and coordinated with the government, they should be directed at the priorities of the sector strategic plan, and they should make systems of finance, monitoring and planning as compatible with government systems as possible.

So let’s not mix SWAp and pooled funding or budget support (they are not included in the 4 common themes).

SWAp is about HOW to work together, and not about WHAT to do together (UHC is about what to do).

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Vincent Okungu
6/6/2012 05:45:32 am

So much has been said about SWAps since the original piece was published. As the author of that piece, let me make a few clarifications, particularly in response to the last comments Luc Geysels:
1. I referred to SWAps in relation to the health sector
2. SWAp is a model with no universal application. It may have clear general principles but whose applications are far from homogeneous. That might explain why more and more “SWAp experts” have varied interpretations of SWAps as developed from varied contexts;
3. What SWAps ought to be is not what they have become in many countries.
4. SWAps, to me, have SIX basic principles:
a. Government leadership of the sector;
b. A clear, nationally-owned, sector policy and strategy emanating from broad-based stakeholder consultation and involving all major donor agencies
c. A budget and expenditure framework, which reflects national sector policy
d. Shared processes and approaches for planning, implementing and managing sector strategy
e. A sector performance framework monitoring against commonly agreed targets
f. Commitment to move to greater reliance on government financial management and accountability systems

5. SWAp is actually WHAT to do together to address failures of Project approach to aid delivery. Its underlying principles constitute HOW to get this done. Universal coverage is HOW to deliver quality and equitable health care to all…. We can go on with the semantics without sounding like “I’m right and he’s wrong” or without developing “lazy attitudes” that Jan Borg referred to in his commentary.
6. SWAps and UHC are birds of the same feather: SWAp is a process within the health sector plan; the health sector plan has UHC as its top priority. SWAps therefore play a supportive role to achieve universal coverage.
7. A core target for UHC is pooling funds. The principle behind SWAps is very simple: to do away with the fragmentation occasioned by stand-alone health projects such that donors contribute to fund the entire health sector. The government is responsible for setting health priorities, which are funding by donors, not separately but collectively. This involves significant POOLING of both financial and technical resources that are essential for universal coverage.
8. I fully agree with Luc that “donor projects not supporting the government budget should be planned and coordinated with the government, they should be directed at the priorities of the sector strategic plan, and they should make systems of finance, monitoring and planning as compatible with government systems as possible.” However, this is easier said than done. How can this take place without duplication and wastages that SWAps seek to address? Why are they not supporting government budget in the first place?
9. Needless to over-emphasize: SWAp is an aid coordination tool much as it is “a way of working together” and a sticking issue has been how to POOL different donor funds alongside domestic funds under one budget. Here, put the following in your mantelpiece: fears of corruption and lower absorptive capacity in government, and specific donors’ desire for visibility and piloting projects.

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Jan Borg
6/6/2012 06:25:42 am

Many thanks, Vincent, for your agreeable summary of (the state of) SWAps. In my first contribution I was trying to make the point that having implementation units managing SWAp partnerships will be defying the purpose of SWAps itself. I did however also mention that SWAps and UHC might well be a synergistic, but not a required combination. In terms of the Harvard knobs for health sector reform (WB flagship course): SWAp pools inputs ( importantly finances) in the health system while UHC pools payment (risk pooling, cross subsidy). Although probably closely related, different interventions are necessary to implement reform in these two areas.

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