Zambian Health SWAp revisited

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Zambian Health SWAp revisited has it made the
intended effects?

• Collins Chansa
• Donor Coordinator
• Ministry 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 80s and early 90s Zambias
  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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Isnt Donor Collaboration Wonderful?
INT NGO
WHO
CIDA
3/5
UNAIDS
GTZ
RNE
UNICEF
Norad
WB
Sida
MOF
USAID
UNFPA
UNTG
PMO
CF
DAC
GFCCP
PRSP
PEPFAR
HSSP
GFATM
MOEC
MOH
SWAP
CCM
NCTP
CTU
CCAIDS
NACP
PRIVATE SECTOR
CIVIL SOCIETY
LOCALGVT
Source WHO Mbewe
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Verticalization of Aid leads to Fragmentation and
Poor Results Child Health
Case management
Community Management
Skilled birth attendance
Drug Use
HIV/AIDS
New born care
PMTCT
Safe and Supportive Environment
Health system
Maternal health
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 2
2000 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
Annual Consultative Committee
Sector Advisory Group (SAG) Committee
Policy Committee Consultative Committee
Monitoring Evaluation Committee
Capital Technical Working Group
Procurement Technical Working Group
Human Resources Technical Working Group
Health Care Financing Technical Working Group
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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
THE (in USD) / Capita (at exchange rate)
35/capita ? Minimum level of investment
recommended by the Commission on Macroeconomics
and Health (CMH)
Source The World Bank. 2005. World Development
Indicators. 2006.
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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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Whos in the drivers 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 shouldnt
  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