By Vincent R. Okungu, Emerging voice 2010
In the 1990s, a few European donors and partner developing country governments acknowledged that the traditional project approach to the delivery and management of aid was not effectively improving population health even though donor assistance for the health sector was increasing. As a result, the sector-wide approach (SWAp) was proposed to replace the project approach.
SWAp is a process of aid coordination that aims at pooling external and internal funds under recipient governments’ leadership and ownership to provide accessible, equitable and sustainable health services. The SWAp process shares a lot with (and probably inspired) the Paris Declaration of Aid effectiveness (2005) and the Accra Agenda for Action (2008). The SWAP aims and objectives are shared with universal health coverage (UHC), currently a major global health agenda.
Despite their shared aims, one keeps wondering whether SWAps and UHC are friends or foes. As a crucial goal in the health reform agenda, UHC would make health services accessible and equitable for all citizens. If effective, it would also contribute to poverty reduction by reducing the incidence of out-of-pocket payments for health care.
By consolidating internal and external funds, and integrating and harmonizing donor projects into national health programmes, SWAps should strengthen the entire health system capacity, structures and finances. The SWAp process therefore, could in theory very well support UHC by pooling funds and long-term capacity building.
Many SWAps, however, have been disappointing. Most are yet to deliver any tangible benefits to population health. In practice, many SWAps have poor quality and overambitious plans and expenditure frameworks. Many donors and recipient governments have also reduced SWAps to a specific public expenditure programme funded by specific donors according to policy and budget structures set by recipient governments
Ideally, SWAps should involve several actors who must work together to achieve required results. The practice of reducing SWAps to common planning and monitoring, when pooling funds is very limited, has not been conclusive, including in terms of providing accessible health services in an equitable and sustainable manner.
The objectives of greater coordination of aid actors, harmonization of rules and government ownership are relevant. The question then is to what extent UHC initiatives could benefit from these objectives, dear to the SWAp approach.
A first recommendation would be to understand well the logic of some donors: they simply refuse to support SWAps because they need to ensure visibility and profile of their agencies. Other projects are pilots of planned interventions in donor countries, and agencies carrying out these ‘pilot projects’ reject SWAps because they would not be able to measure the results of their interventions. However, one should not blame the donors only because weak government leadership over the health sector offers opportunities for donors to impose their interests on the sector. Locally, SWAps reduce chances for corruption and patronage and have often faced opposition from establishment bureaucrats.
Interestingly enough, this reluctance to work together is also a challenge for UHC. Indeed, fragmentation and multiplication of schemes is an obstacle to UHC.
I believe actors involved in SWAps and those committed to UHC should work together. SWAps should be addressed under the agenda of universal coverage. The UHC agenda should emphasize long-term capacity building plans and policies that prioritize population universal health needs and expectations. A point of action would be to improve local leadership of SWAps with a department specific to the SWAp process. This way, SWAps can support UHC efforts as an all inclusive process with a strong, transparent and accountable recipient government leadership.