Zambian Health SWAp revisited – has it made the intended effects?
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Zambian Health SWAp revisited – has it made the intended effects?
Collins ChansaDonor CoordinatorMinistry of Health - Zambia
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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).
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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
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Day to Day Management of the SWAp Collaborative Process
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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
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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
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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)
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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
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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
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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)
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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)
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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
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Who’s in the driver’s seat?
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Do donors really let government drive?
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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?
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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
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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
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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’
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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
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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
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END OF THE PRESENTATION