Useful for Public Health Students and Professionals

1. Sector-wide approaches
(SWAps) in health
Hari Krishna Bhattarai, MPH, MPA, M.Phil., IDHA
Nepal

2. origin
• With the end of the Cold War, there was a proliferation of international health donors and
initiatives that was increasing the fragmentation of national health programs,
• Most aid for health in developing countries comes in the form of projects. Each project—
whether it is for supporting essential health services in one district, such as for a national
immunization program, for strengthening health-care management, or for reproductive
health services—is separately developed and negotiated between the donor and the
national authorities concerned with implementation.
• Dominance of fragmentation, duplication and parallel programming

3. Origin
• Sector-wide approaches are a response to the limitations of other forms of
development assistance and a practical expression of the idea of
partnership between government and donors, in which all parties involved
have rights and responsibilities

4. Origin
• Sector-wide approaches (SWAps) in health were developed in the early 1990s In
response to widespread dissatisfaction with fragmented donor-sponsored projects
and prescriptive adjustment lending with the purpose of supporting government
led health sector policies, strategies and local institutional capacity to improve
health.
• In a number of countries, governments and development agencies were openly
discussing new modalities for support to the health sector (notably Zambia, Sierra
Leone, Ghana, Bangladesh and Pakistan), with organizations such as the World Bank
and Danish International Development Assistance

5. Origin
• Projects are by no means unsuccessful. Many externally funded initiatives
work well, but commonly because they operate only on a small scale, creating
islands of excellence in an otherwise underfunded sea.
• Both the World Bank- ‘sector investment programs’ and DANIDA explained
the ‘sector program support’.
• The term SWAp was eventually adopted by a wide group of development
agencies at a meeting held in Copenhagen in February 1997.

6. Origin
• During the 2000s, SWAps consistently featured on high-level international
policy discussions. For example, the 2003 Rome Declaration on Harmonization
endorsed SWAps as a key tool for improving aid effectiveness (Rome
Declaration on Harmonization 2003).
• The SWAp strongly influenced the 2005 Paris Declaration on Aid Effectiveness,
and the subsequent International Health Partnership 2007; Accra Agenda for
Action 2008).

7. SWAps- basics
• Leading actors - the sector ministry is the key actor, other government
agencies, such as ministries of finance, civil service, and local government,
become more involved in negotiations and reviews.
• A sector-wide approach is an approach to support a country-led program for a
coherent sector in a comprehensive and coordinated manner.
• sector-wide approaches (SWAps) to health as a means to increase donor
collaboration, consolidate local management of resources and undertake the
policy and systems reform necessary to achieve a greater impact on health
issues.

8. SWAps- basics
• SWAps have been related to increased government leadership, improved donor
coordination, more efficient and effective financial, planning and implementation
management and improved sector stewardship as well as to more coherent sector policy
(Hutton & Tanner, 2004; Shepard & Cabral, 2008), which donors have addressed on the basis
of capacity building measures, policy advisory services, by promoting dialogue and
advocacy and supporting the development of comprehensive health information systems.
• SWAps were intended to provide a more coherent way to articulate and manage
government-led sectoral policies and expenditure frameworks and build local institutional
capacity as well as offer a means to more effective relationships between governments and
donor agencies.

9. Definition
SWAp “An approach that involves all significant funding for the sector supporting
a single sector policy and expenditure program under government leadership,
adopting common approaches across the sector and progressing towards relying
on government procedures to disburse and account for all funds” (Cassells,
1997).

10. Outcome of SWAps
The basic ideas underlying this approach are straightforward.
Rather than selecting individual projects, international agencies contribute to the
funding of the entire sector. In exchange for giving up the right to select projects
according to their own priorities, donors gain a voice (but not a controlling
interest) in the process of developing national health policies, and in decisions
about how not only external but also domestic resources are allocated.

11. Outcome of SWAps
Negotiation of how the health sector should work becomes more important
than planning of separate donor-specific initiatives. The focus of evaluation
shifts from the performance of individual projects towards the performance of
the sector as a whole, particularly in relation to improvement of health
outcomes.

12. Outcome of SWAps
The architecture of development assistance in health has changed significantly
since SWAps were first introduced.
Global health initiatives, such as The Roll Back Malaria Partnership (created in
1998), Stop TB Partnership (started 2000), the Global Alliance for Vaccines and
Immunizations (GAVI) (started 2000), The Global Fund for AIDS, TB and Malaria
(started 2002) and the President’s Emergency Plan for HIV/AIDS (PEPFAR)
(started 2003) are each examples of global efforts and program focused on
priority diseases and interventions, and have all emerged since the first SWAps
were developed.

13. SWAps – a common spirit
• SWAps are intended to serve as a platform for bringing both old and new
actors together, in the spirit of
• Harmonization,
• Alignment,
• and transparency around country-led health policies and processes

14. Approaches of SWAps- GIZ (2013)
• Building individual human and institutional capacity to enhance the general
performance of planning and financial management mechanisms in SWAps by
facilitating government leadership
• Promoting dialogue and advocacy to enhance the general performance of
planning and financial management mechanisms in SWAps by establishing
more equitable partnerships and improve donor coordination

15. CONT
• Efficiency of policy advisory services to enhance the general performance of
planning and financial management mechanisms by improving sector
stewardship, national ownership and (financial) management
• Promoting knowledge production, enhancing the general performance of
planning and financial management mechanisms and supporting national
health information systems

16. CONT
• Supporting Health SWAps to improve population health (improved survival;
reduction in morbidity; improved nutrition; improved health equity; social and
financial risk protection; greater health equity)
• Supporting Health SWAps to improve health system functioning (Increased
services utilization and intervention coverage for essential health services;
responsiveness of health systems)

17. SWAps- Better than traditional project approach
• Increased health sector coordination,
• Stronger national leadership and ownership,
• Strengthened countrywide management and delivery systems.
• Reduce duplication,
• Lower transaction costs,
• Increase equity and sustainability,
• improve aid effectiveness and health sector efficiency.
• Furthermore, the SWAp has become an integral part of poverty reduction strategies, and
its ideology has enjoyed a growing acceptance from donor agencies as well as aid
recipients

18. The sector-wide approach: a blessing for public health?
Guy Hutton & Marcel Tanner
• Country leadership and ownership,
• Institutional and management capacity,
• flow of resources,
• and monitoring and evaluation

19. Country leadership and ownership- Problematic
• Limited leadership capacity (e.g. Rwanda),
• Poor relationship with the ministry of finance (e.g. Mozambique),
• Slow shift of ownership (e.g. Cambodia),
• Frequent change of senior management (e.g. Zambia),
• Little ministry of health leverage to secure additional funds (e.g. the United Republic
of Tanzania),
• and low priority of cross-sectoral collaboration.

20. Institutional and management capacity
SWAp emphasizes strengthened health sector management through the
development or adaptation of management tools, combined with
strengthening of implementation capacity. For example, under SWAps greater
attention is given to health sector planning, financial management, and
improved health information systems. SWAps also tend to emphasize
strengthening district level management capability within existing
decentralization policies (e.g. Ghana, Uganda and the United Republic of
Tanzania).

21. Flow of resources
• Under a SWAp, recipient governments and donors only fund activities in the
national health sector plan. Donor funds are pooled and earmarked for high
priority activities, such as essential health package (e.g. Uganda, Tanzania).
• Importantly, pooled donor funding supports government budgets, giving a
much needed boost to recurrent expenditures.
• Furthermore, donors are responsible for synchronizing their own planning,
review and monitoring processes with government systems, and give long-
term projections of aid pledges.

22. Monitoring and evaluation
• Monitoring and evaluation of the health sector become institutionalized under a
SWAp. The “one voice” of donors has strengthened their position to create
conditions.
• The once or twice yearly joint review meeting is an important instrument providing
an open forum to review the progress and performance of the health sector. These
large meetings are complemented by more frequent meetings with key
development partners.
• The success of these processes depends mainly on the people involved and their
experience, expertise and sensitivity to developing partnerships.

23. Conclusion
• Considering the opportunities and the challenges - in many of the countries where
SWAps are in progress, it may take 5–10 years of sustained implementation before
any sizeable impact on health outcomes can be demonstrated (Guy Hutton & Marcel Tanner)
• Strong government commitment is essential - the future of SWAps will depend on
stronger government oversight and innovative institutional arrangements to
support health strategies that address the need for both targeted initiatives and
stronger health systems to provide a wide range of public health and clinical
services
• Transparent negotiation by the donors /development partners

24. sectoral reform is context dependent
• SWAps is now strongly identified with the shift from coordination of donor
resources to the local management of all development resources for health
(Walt et al., 1999a).
• If the partnerships are not totally inclusive, if national leadership is
vulnerable and shared financial and management mechanisms are difficult
to implement, how can SWAps confidently be promoted as the ‘‘next
generation’’ approach to development assistance? (Walt et al.,1999)

25. Thank you !