Managing external resources in the health sector: are there lessons for SWAps?

Abstract

Drawing on the case studies presented in this issue, from Bangladesh, Cambodia, Mozambique, Zambia and South Africa, and examples from other countries, this paper asks what general conclusions can be drawn about the management of external resources, and specifically what lessons could inform the future implementation of sector-wide approaches (SWAps) in the health sector. Factors constraining the management of aid by ministries of health are grouped under three themes: context and timing, institutional capacities and the interplay of power and influence in negotiations over aid. Two factors, often underplayed, were found to be important in facilitating management of resources: the inter-relationship of formal and informal relationships, and the extent to which incremental changes are tolerated. The main conclusion is that coordination and management of external resources is inherently unstable, involving a changing group of actors, many of whom enjoy considerable autonomy, but who need each other to materialize their often somewhat different goals. Managing aid is not a linear process, but is subject to set-backs and crises, although it can also produce positive spin-offs unexpectedly. It is highly dependent on institutional and systemic issues within both donor and recipient environments. In promoting sector-wide approaches the key will be to recognize context-specific conditions in each country, to find ways of building capacity in ministries of health to develop and own the future vision of the health sector, and to negotiate a realistic package that is explicit in its agreed objectives. The paper ends with identifying crucial actions that will enable ministries of health to take the lead role in developing and implementing SWAps.

Power and Agenda-Setting in Tanzanian Health Policy: An Analysis of Stakeholder Perspectives

“…Although the Sector-Wide Approach has demonstrated some clear benefits in the objectives of ownership and alignment, donor-driven policy in Tanzania is still overwhelmingly present. 13,59 This idea is supported by a broad base of literature stating that significant aid flows from donor organizations largely influence the national strategies of recipient countries. 2,3,10,11,32,35,49,50 This does not necessarily mean that donors always have the largest say, or that they are the ones who make the final decisions, but there is clearly an imbalanced interplay between donor and recipient.…”

“…Despite this shift, the exact influence of foreign stakeholders on national policies remains inconclusive, and further research into this area is essential for determining how donors and collaborators can best approach low-income countries. 3,7 Numerous studies have described the economic and political factors involved in priority-setting [8][9][10] and donor influence and coordination [11][12][13][14] on policy-making in low-income countries. However, there remains a gap in understanding the provenance of power within the donor-recipient relationship, how it is employed by various actors, and whether there are factors that can increase transparency and accountability.…”

Translations of health sector SWAps—A comparative study of health sector development cooperation in Uganda, Zambia and Bangladesh

“…Angers describes SWAp as a transition from donor-led, project-dominated aid to a country-led national development strategy [35]. Walt et al present SWAps as the next generation approach to aid that aims to provide a broad framework within which all resources in the health sector are coordinated in a coherent and wellmanaged way, in partnership, with the partner government in the lead [36]. The Swedish International Development Cooperation Agency interprets SWAp as a form of long-term development assistance partnership that embraces a single sector policy and expenditure programme in order to achieve sector objectives and ensure national ownership [37].…”

“…The health sector has been defined as activities under the Ministry of Health [7], or simply as the health sector [8]. Increased ownership is achieved through placing the partner government in the lead of health sector development [7,36]. A SWAp is supposed to increase ownership by placing the government in the "driver's seat".…”

Between Intent and Achievement in Sector-Wide Approaches: Staking a Claim for Reproductive Health

“…Any examination of the impact of SWAps on reproductive health needs to acknowledge the highly politicised environment in which these reforms are being played out [10,11]. To continue with the metaphor, ''staking a claim'' for reproductive health requires attention both to the ends -the reformed health system that is being developed -and the means -the processes by which this may be attained.…”