8 Country context

To date much of the thinking on SWAps has focused on low-income countries in Africa. There is no reason, however, why the principles of a sector-wide approach cannot be applied in a much wider variety of contexts. Three different situations are considered below: decentralised states, middle income countries, and countries emerging from conflict. A more complete review might also consider the relevance of sector-wide approaches to those countries in the Former Soviet Union in which development assistance plays a significant role.

Decentralised states

Whilst decentralisation can take many forms, two situations merit particular attention: large, federally-organised countries, where the key issue is whether SWAps should be developed at national or state level; and smaller countries where a nation-wide approach is clearly desirable, but in which managerial and financial responsibility for different parts of the sector is divided between central and local government.

In the first case, most of the interaction between government and donors has traditionally taken place at federal level. However, apart from those institutions supported from the national budget (such as referral hospitals and research institutions), the main link between financing and implementation (and thus in terms of the original definition "a coherent sector defined by an appropriate institutional structure and financing programme") is to be found at state level. From the perspective of constituent states, the federal level often acts in the same way as an external donor, providing funds and materials which supplement those available from state revenues or direct external contributions.

Overall, therefore, there is a strong case for suggesting that the state, rather than the federal level is the best starting point for a sector-wide approach. Developing a sector-wide approach at state level will be considerably easier in circumstances in which the federal level ministry of health provides un-earmarked support for state health budgets. If federal contributions (like donor funds) are linked to specific activities, channelled directly to districts thus bypassing state treasuries, or earmarked for "national" programmes, the development of coherent state-level sectoral policies and spending priorities will be far more difficult. This is the situation in India, for example, where it has been recognised that for a sector-wide approach to family welfare to succeed requires that the purpose, balance and composition of federal subsidies to the states be carefully reviewed.

The situation is no different in principle in smaller countries where district-level local government has a significant role in financing and managing health services. In practice, however, two sets of problems need to be considered. Firstly, if central government provides a block grant to districts to be allocated according to their own priorities, earmarking funds for health (or other sectors) by donors, or national government, will undermine local autonomy. At the same time donors, are likely to need some assurance that their funds are being spent on the purpose for which they were originally provided. The way forward lies in negotiated agreements between central and local authorities on the proportion of funds allocated to priority sectors.

A further challenge arises from the fact that very few governments in aid receiving countries actually do provide un-earmarked block grants to local authorities. Rather, the situation is more complicated, with some funds (often for hospitals or specific national programmes) still being retained by the national ministry of health, while funds for primary care are channelled directly from the treasury to local authorities. In these circumstances - well illustrated by the situation in Tanzania and Uganda - strategy development and financial planning for the sector as a whole will be problematic. More work is therefore needed in developing an approach to sectoral development in countries where local government has an increasingly important role.

Middle income countries

Many middle income countries in South East Asia, the Middle East and Latin America have a number of characteristics in common. These include: more mature institutions, multiple agencies involved in financing, purchasing and providing health care; active private and social insurance markets; significant levels of decentralisation to provinces and/or municipalities; active, and in some cases, advanced reform programmes affecting several different types of institutions. In most of these countries only a small proportion of health expenditure comes from external agencies.

Despite the limited role of donor investment in the health sector, many countries value external intellectual inputs into policy development. This may take the form of flexible technical and financial support for policy experiments or pilots; opportunities to evaluate the advantages and disadvantages of different health care systems, through contacts with colleagues in other countries: and, in some cases, provision of practical know-how in implementing new approaches to health care financing and management. SWAps in middle income countries are thus more likely to be concerned with policy development, than with greater external involvement in financial planning, or the development of common management arrangements.

Unstable situations and countries emerging from conflict

Experience of developing sector-wide approaches in countries emerging from conflict is limited. Whilst Mozambique is perhaps the best example, attempts in other countries, such as Sierra Leone, have been disrupted by continuing instability. Clearly, there are several potential pitfalls: limited capacity within newly-formed governments to develop sectoral policy and strategy; on-going political conflicts and divisions between rival factions; acute scarcity of national financial resources, exacerbated by heavy military spending: dysfunctional management and administrative systems; and the need to provide direct humanitarian assistance to those most at risk of disease or death, often involving a plethora of external agencies.

There is no reason in principle, however, why a sector-wide approach should not provide the basis for sectoral development - once basic humanitarian needs have been met. Rather than re-establishing planning and management systems around the needs of separate projects, the progressive establishment of systems which allow donors to support a common development programme, led by government, has much to recommend it.