Zambian Health SWAp revisited – has it made the intended effects?

Collins ChansaDonor CoordinatorMinistry of Health - Zambia

Outline of the Presentation

• Zambian Health SWAp

• Notable Developments

• Basic tenets of the Zambian Health SWAp

• Structures & Instruments in the SWAp

• SWAp Coordination Committees

• SWAp Joint Annual Reviews

• Major Achievements and Challenges

• Policy Reflections

Zambian Health SWAp 1

• During the late 80’s and early 90’s Zambia’s health sector was characterized by several fragmented donor projects

• Project support tended to undermine national efforts to develop the health sector in an holistic and comprehensive manner

Zambian Health SWAp 2

• GRZ perceived a need to integrate all the vertical programmes into a sectoral framework that would meet common national goals and objectives

• In 1993, Zambia was the first country in Africa to implement a health SWAp

Why was the SWAp Adopted?

• Increases predictability of funding

• Improve the financing base since priorities are identified in advance

• Reduce transaction costs and duplication

• Apply interventions equitably and to reduce geographic disparities

• Leadership & Stewardship. Place government in charge leading to institutional & financial sustainability

• Improved efficiency in resource allocation & use

MOH MOEC

MOF

PMO

PRIVATE SECTORCIVIL SOCIETYLOCALGVT

NACP

CTU

CCAIDS

INT NGO

PEPFAR

Norad

CIDA

RNE

GTZ

SidaWB

UNICEF

UNAIDSWHO

CF

GFATM

USAID

NCTP

NCTP

HSSP

HSSP

GFCCPGFCCPDAC

CCM

UNFPA

3/5

SWAPSWAP

UNTG

PRSP PRSP

Isn’t Donor Collaboration Wonderful?Isn’t Donor Collaboration Wonderful?

Source: WHO: Mbewe

Verticalization of Aid leads to Verticalization of Aid leads to Fragmentation and Poor Results: Fragmentation and Poor Results: Child HealthChild Health

Drug Use

Malaria

Nutrition HIV/AIDS

Health system

PMTCT

Maternal health

New born care

Safe and Supportive

Environment

Skilled birth attendance

Case management

Community

Management

Source: WHO: Mbewe

Notable Developments 1

1991 First National Consensus Conference

1992 National Health Policies and Strategies

1993 “Basket” funding to districts

1993 District & Hospital Management Boards

1994 National Health Strategic Plan (NHSP) 1995 - 1998

1994 Financial and Accounting Management System (FAMS) and Health Management Information System (HMIS)

1996 Central Board of Health (CBoH)

1997 NHSP 1998 - 2000

1999 Signing of the Memorandum of Understanding

2000 NHSP 2001 - 2005

Notable Developments 22000 Joint Investment Plan 2001-2005

2003 Establishment of a SWAp Secretariat

2003 Basket funding expanded to 2nd & 3rd level hospitals, CBoH & Ministry of Health

2003 Medium Term Expenditure Framework

2004 Basket funding expanded to statutory boards and training institutions

2005 Vision 2030 & National Development Plan 2006-2010

2005 NHSP 2006-2010

2006 Dissolution of the CBoH

2006 Shift to Direct Budget Support by some CPs

2006 Revised Memorandum of Understanding signed

Basic tenets of the Zambian Health SWAp

• GRZ stewardship & ownership

• Commitment to the Health Vision & the National Health Strategic Plan

• Support to a defined cost-effective Basic Health Care Package of interventions

• Support to a Common Basket where no distinction is made between Cooperating Partners’ funds and that from GRZ

• Joint systems for sector reviews, planning, procurement, disbursement of funds, reporting, accounting and audit

Structures & Instruments in the SWAp

• Memorandum of Understanding between MoH and CPs (Nov 1999 & June 2006)

• Formal GRZ led coordination process• Joint Annual Health Sector Reviews• 5 year National Health Strategic Plan• 5 year National Human Resources for Health

Strategic Plan• Rolling 3 year Medium Term Expenditure

Framework (MTEF)• Drug Supplies Budget Line • Agreed Resource Allocation Criteria

SWAp Coordination Committees

Sector Advisory Group (SAG) Committee

Policy Committee Consultative Committee

Procurement Technical

Working Group

Capital Technical Working Group

Human Resources Technical

Working Group

Monitoring & Evaluation Committee

Health Care Financing Technical

Working Group

Annual Consultative Committee

SWAp Joint Annual Reviews

• Zambia has conducted 5 independent joint reviews between 1992 and 2006.

• In 2004, routine Joint Annual Reviews (JARs) were also introduced

• The JAR is conducted annually and consists of 4 main phases: Literature Review; Key Informant Interviews; Field Visits; and Joint Annual Review meeting. (3 JARS done so far).

Major Achievements 1

• Implementation has developed gradually and consultatively = confidence + trust

• Operational basket funding for districts, hospitals, Training Institutions, Statutory Boards

• Operational Human Resources for Health (HRH) basket and a Drug Supplies Budget line

• Establishment of the SWAp Secretariat has intensified dialogue and communication

Day to Day Management of the SWAp Collaborative Process

Major Achievements 2

• Improvements in financial management and accountability

• Some vertical programmes also use the SWAp accounts for disbursements

• Contributed to promoting equity in the allocation of resources to districts

Major Achievements 3

• Increased GRZ Fiscal Space: High financial commitment by CPs both in terms of numbers & level of funding

• Financial disbursements to the basket increased from an annual average of US$ 6.7 million in 1995 to about US$ 70 million in 2005

• Proportion of grants as opposed to loans in MoH is the highest among the GRZ Ministries

Major Achievements 4

Predictable & sustainable funding:

• Agreement with CPs to make two disbursements per year

• Operationalisation of a 6-months buffer

• Supporting a set of common activities has increased financial sustainability. GRZ increases in the advent of partnership problems (1997-1999) and Volatility due to Ex. Rates (2005-2007)

Challenges 1

• Transaction costs are still high due to high frequency & comprehensiveness of meetings (SWAp & Non-SWAp)

• Several donors are still outside the SWAp and several funding modalities

• Use of parallel systems by some bilateral donors and Global Health Initiatives

• In 1998 about 22% of overall donor support was through the SWAp while in 2005, this figure increased to 29% but dropped to 17% in 2006

Challenges 2

• Several disease-specific projects on HIV/AIDS. 19% of overall donor support was for HIV/AIDS in 2005, increasing to 61% in 2006

• Overall level of funding to the health sector is still low. $US 18 available compared to the required $US 33 dollars per capita

Problems in Funding, Sustainable and Predictable Financing

Source: The World Bank. 2005. World Development Indicators. 2006.

THE (in USD) / Capita (at exchange rate)

$35/capita

Minimum level of investment

recommended by the Commission

on Macroeconomics and Health (CMH)

Challenges 3

• Inadequate support for cost items like drugs and human resources making it difficult to provide quality health care

• Fragmentised procurements for Vaccines, HIV/AIDS drugs, Family planning commodities etc

• Inability of the system to take care of sudden drastic losses in funding due to exchange rate fluctuations (2005-2006)

Harmonization, alignment and mutual Accountability

Ideally, for a SWAp to be effective, both govt. and donors have to re-align their working arrangements

In reality, emphasis is on re-aligning govt. systems and rarely donors’ working arrangements

No Mutual Accountability on the part of donors

Who’s in the driver’s seat?

Do donors really let government drive?

Question: what is the “health sector”?

• How the “health sector” relates to the “health system”, but not the same

• 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?

Lessons Learnt 1

• Establishment of formal structures and tools for managing the SWAp and having a strong secretariat can make a huge contribution

• CPs contributing to the basket are more committed to the SWAp process

• The SWAp can provide a framework for collaboration but might not create significant improvements in efficiency

Lessons Learnt 2

• A SWAp can benefit from a decentralized health system

• Aid coordination is a very complex process which develops slowly

• MTEF as a tool for strengthening mechanisms for aid management might not be very effective

Policy Reflections 1

• Devpt of effective support systems, ‘learning by doing’ and re-adjusting from experiences

• Create opportunities for the participation of various stakeholders (by taking cognizance of their respective constraints)

• There is need to estimate the full resource envelope & put all funding ‘on budget’

Policy Reflections 2

• Build confidence through transparency in resource allocation and use

• Exit of key CPs from the Health Sector in preference for Direct Budget Support shouldn’t affect the level of funding in the overall health sector

Does it Really work?

• No agreed framework for evaluating SWAps and other Aid modalities – Attempts by Walford, Paris Declaration, Hutton, and most recently Boesen and Dietvorst

• Thus, attributing health outcomes directly to the SWAp is difficult as the SWAp is not implemented in isolation

• SWAps should be seen as add on processes to vertical projects and ingredients of Direct Budget Support

END OF THE PRESENTATION