Zambian Health SWAp revisited – has it made the intended effects? Collins Chansa Donor Coordinator Ministry of Health - Zambia

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

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

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

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

MOH MOEC MOF PMO PRIVATE SECTORCIVIL SOCIETYLOCALGVT NACP CTU CCAIDS INT NGO PEPFAR Norad CIDA RNE GTZ Sida WB UNICEF UNAIDS WHO CF GFATM USAID NCTP HSSP GFCCP DAC CCM UNFPA 3/5 SWAP UNTG PRSP Isn’t Donor Collaboration Wonderful? Source: WHO: Mbewe

Verticalization of Aid leads to Fragmentation and Poor Results: Child Health Verticalization of Aid leads to Fragmentation and Poor Results: Child 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

Notable Developments First National Consensus Conference 1992National Health Policies and Strategies 1993“Basket” funding to districts 1993District & Hospital Management Boards 1994National Health Strategic Plan (NHSP) Financial and Accounting Management System (FAMS) and Health Management Information System (HMIS) 1996Central Board of Health (CBoH) 1997NHSP Signing of the Memorandum of Understanding 2000NHSP

Notable Developments Joint Investment Plan Establishment of a SWAp Secretariat 2003Basket funding expanded to 2nd & 3rd level hospitals, CBoH & Ministry of Health 2003Medium Term Expenditure Framework 2004Basket funding expanded to statutory boards and training institutions 2005Vision 2030 & National Development Plan NHSP Dissolution of the CBoH 2006Shift to Direct Budget Support by some CPs 2006Revised Memorandum of Understanding signed

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

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

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

SWAp Joint Annual Reviews Zambia has conducted 5 independent joint reviews between 1992 and 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).

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

Day to Day Management of the SWAp Collaborative Process STAKEHOLDER IN THE HEALTH SECTOR MINISTRY OF HEALTH SWAp SECRETARIAT Sector Dialogue & Communication

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

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

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 ( ) and Volatility due to Ex. Rates ( )

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

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

Problems in Funding, Sustainable and Predictable Financing Source: The World Bank World Development Indicators THE (in USD) / Capita (at exchange rate) $35/capita  Minimum level of investment recommended by the Commission on Macroeconomics and Health (CMH)

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 ( )

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

Who’s in the driver’s seat?

Do donors really let government drive?

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?

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

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

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’

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

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

END OF THE PRESENTATION