|A Guide to Sector-wide Approaches for Health Development - Concepts, Issues and Working Arrangements (European Commission, 1997, 84 pages)|
Defining the sector
· Sub-sectoral programmes - usually at district level - offer one way of dealing with problems of financial accountability and performance monitoring in the early stages of programme development. In an integrated sector such as health, however, a focus on primary care' alone may fail to deal with intra-sectoral resource allocation, and so perpetuate chronic imbalances between major spending categories. Health SWAps should ultimately be concerned with the sector as a whole, and thus the entire network of public, private and voluntary institutions financed, managed or regulated by the ministry of health.
· Focusing on multiple sectors may be an effective way of increasing government spending on a range of priority social services, but may be less successful in influencing service quality in the individual sectors concerned. Furthermore, whilst there is a strong case for broadening the scope of health policies in recognition of the multiple determinants of ill health, this will be a matter for negotiation with national governments. Lastly, complementarity between interventions in more than one sector does not have to be achieved through the creation of new multi-ministerial structures or programmes.
· There is no reason in principle why political decentralisation should not be compatible with a sector-wide approach. In very large federal countries, the key issue is whether SWAps should be developed at national or state level. Most existing evidence points toward the latter as being the most appropriate level for intervention.
· In smaller countries, where a nation-wide approach is clearly desirable, difficulties arise when responsibility for different parts of the sector is divided between central and local government. If central government provides a block grant to local authorities, potential solutions include negotiating agreements between central and local government about the proportion of funds allocated to priority sectors. If funds for hospitals are controlled separately from those for primary care, sector-wide resource planning and disbursement through common management arrangements will be far more difficult.
· In middle income countries, external agencies will be more concerned with policy development, than with financial planning or the development of common management arrangements. Sector-wide approaches may have an important role in countries emerging from conflict, and those former command economies where development assistance play a significant role.
Priority health programmes
· Sector-wide approaches are concerned with improving health status and bring together work on health systems and health outcomes. Difficulties arise when there is a disagreement about priorities. Particularly if, in the judgement of donors or their technical advisers, funding the sector as a whole would result in insufficient resources being made available for tackling major causes of ill health.
· Negotiation about the proportion of funds allocated to addressing major health problems - particularly those that affect the poor - will be critical in designing a sector-wide approach. However, separate lines of funding should not be regarded as the default. Instead, agreement is needed on which areas of expenditure merit special protection, and when this is necessary, government mechanisms for ring-fencing funds should be used. Earmarking by donors and the establishment of separate programmes should only be used as a last resort.
· When separate funding is required, it will be important to pay careful attention to the institutional consequences of creating special programmes. It is essential to avoid the problems associated with maintaining separate budget lines, dedicated staff, and information systems. The need to introduce new technologies or practices, and to back these with the provision of drugs, equipment or technical advice, does not in itself justify the establishment of separate or special programmes.
· Indicators of sectoral performance will include targets in relation to health outcomes, the achievement of which will depend on the effective performance of a range of individual health programmes:, Whilst reviews of sectoral performance will not be concerned with monitoring individual programmes, they will assess whether systems are in place which make such monitoring possible.
Poverty and the health of poor people
· Reducing levels of poverty is a concern of most governments and the fundamental principle underlying the development assistance provided by donors. The choice facing donors is whether they should channel development assistance as directly as possible to those perceived to be most vulnerable or, through their involvement in the negotiation of sector policies and strategies, attempt to influence the way resources are allocated, in ways that favour the poor.
· Relying on the proportion of funding allocated to primary care and/or rural districts as an indicator of a concern for the poor is too simplistic. Effective negotiation requires a better understanding of the relationship between health care provision and poverty reduction, and the potential impact of different policy interventions. A particular concern in countries where the bulk of health spending takes place in the private sector, will be to ensure that policies adequately address the way that governments manage the private provision of health care - to avoid exacerbating inequity.
Ownership and incentives
· The viability and success of sector-wide approaches will depend on the degree of political support they receive from the major players involved. This in turn will be influenced by how interest groups within governments, donor agencies and civil society are affected by the introduction of SWAps.
· Most technical agencies, development banks and bilaterals support the idea of sector-wide approaches in principle. Issues which will influence whether principle translates into practice include: concerns about accountability and the political risks of being associated with corrupt or unproductive spending; the restricted technical scope of existing sector assistance policies; and the difficulty of maintaining levels of expenditure whilst introducing new practices and management systems.
· Government ownership is the sine qua non of a sector-wide approach. The risk is that donors will urge governments to take the lead, in situations where there is only limited capacity and interest in so doing. Whilst SWAps can and should increase national control over sectoral development, the incentives to do so are not always clear-cut. There is no certainty, for example, of increased levels of external investment, and SWAps inevitably result in greater external scrutiny and discussion of issues previously the sole preserve of national authorities.
· SWAps will also affect relationships between different parts of government. Within a ministry of health, they are likely to strengthen the hand of senior policy makers - particularly those that are perceived as "reformers" - but reduce the influence of other officials, notably those responsible for managing projects. Similarly, they will change the relationship between ministries of finance and spending ministries such as health, in ways that are not always predictable.